Mandibular Subcondylar Fractures Research Articles

Comparative Evaluation of Conventional (Static) Versus Dynamic Elastic Therapy for Closed Treatment of Unilateral Mandibular Sub-Condylar Fractures: A Randomized Controlled Trial

Comparative Evaluation of Conventional (Static) Versus Dynamic Elastic Therapy for Closed Treatment of Unilateral Mandibular Sub-Condylar Fractures: A Randomized Controlled Trial

A Comparative Clinical Evaluation of Yang’s Keyhole Plate Versus Conventional Plate for Treatment of Mandibular Sub-Condylar Fractures

A Comparative Clinical Evaluation of Yang’s Keyhole Plate Versus Conventional Plate for Treatment of Mandibular Sub-Condylar Fractures

Which Factors Affect the Reduction Quality of Open Reduction Internal Fixation of Mandibular Subcondylar Fractures?

Open reduction internal fixation (ORIF) of mandibular subcondylar fractures (MSF) involves several variables that could affect decision making. There is insufficient data regarding factors influencing the outcomes of MSF ORIF. The purpose of this study was to investigate factors associated with quality of bony reduction of MSF and occlusion, after ORIF. We designed a retrospective cohort study of consecutively treated subjects for MSF ORIF, ages 18 to 64years, by University of Illinois' Department of Oral and Maxillofacial Surgery, between January 1, 2013, and January 26,2021. The primary predictor variable was the vertical level of MSF from the gonial angle. Secondary predictor variables included surgeon, fixation scheme (number and configuration of miniplate), surgical approach, time to surgery, mechanism of injury, vertical fragment overlap, overlying soft tissue thickness, presence of other mandibular fractures, and severity and direction of displacement. The primary outcome variable was the mean radiographic reduction score (RRS), rated by 2 blinded observers on a 1 to 5 scale. The secondary outcome variable was presence of postoperative malocclusion as documented in the medical records. Covariates were age and sex. Descriptive statistics were computed. To investigate the influence of the predictor variables on reduction quality, multifactorial analysis of variance with post hoc Tukey test was performed. For malocclusion, χ2 test was performed. The level of significance was set at P<.05. Thirty-eight MSF in 37 subjects were included. Mean age was 32.7years (range 18 to 64), and 83.8% were male. Mean RRS was 4.38 (standard deviation 0.77). Fixation scheme was the only variable that showed significant impact on RRS: single-straight miniplate had lower scores than double-straight (-1.50, P=.011), rhomboid (-1.29, P=.036), and ladder miniplates (-1.38, P=.048). There was 1 incidence of malocclusion (2.7%) which resolved without intervention. Favorable reduction (anatomic reduction to mild discrepancies) can be achieved without malocclusion using double-straight, or rhomboid-shaped or ladder-shaped miniplates, without influences from patient or injury-related factors. In contrast, single-straight miniplate fixation resulted in moderate discrepancies in reduction, although it did not lead to malocclusion.

Study of Facial Nerve Function Following Retromandibular Open Reduction of Mandibular Condylar Fracture

At least 1/3rd (26–40%) of all mandibular fractures occur in the condylar region, making it one of the most common fracture sites. They can further lead to morphological &amp; functional damage when undetected or poorly managed. Condylar fractures that are misdiagnosed or improperly treated can cause substantial functional impairment, such as malocclusion, decreased mouth opening due to jaw deviation, and restricted lateral mandibular motions. Objectives: The aim of the study was to examine facial nerve function following retromandibular trans parotid ORIF for mandibular sub-condylar fractures. Methodology: After receiving the necessary ethical approval, 50 patients who presented with unilateral condylar fractures, sub condylar fractures (36), &amp; neck fractures (14) (Ellis classification)5 were chosen. All of the research participants, who underwent open reduction using a retromandibular technique, provided informed consent. Results: All 50 patients were assessed and no patients were excluded. The healing went well, and no one experienced significant scarring or hardware infection. 7 (14%) individuals experienced transient buccal branch weakness, while 2 (4%) experienced transient zygomatic branch dimness Keywords: Condylar fracture, Open reduction, Retromandibular approach, Anatomical reduction

Comparative evaluation of open reduction and internal fixation using delta plate versus conservative treatment in management of mandibular subcondylar fractures in adults

The aim of the evaluative study was to compare the efficacy of standard conservative treatment and the open reduction internal fixation (ORIF) using the delta titanium plates in the mandibular subcondylar fractures in adults. Patients who diagnosed with mandibular subcondylar fracture in the department from January 2018 up to September 2019 were recruited into the study. The patients satisfying the inclusion criteria were randomly assigned to two groups in a 1:1 ratio (10 in each group). Group A comprised patients treated using delta titanium plates through open reduction and internal fixation and Group B comprised patients treated with closed reduction. Informed consent was taken for all the patients. All the patients of Group A underwent ORIF under GA via retromandibular approach. Pain was significantly higher in 1 and 3 month follow up in group B compared to group A. Comparison of mouth opening in both the groups show statistically significant difference at 3 and 6 month compared to baseline mouth opening. Deviation was more prevalent at 1 and 3 month follow up in group B compared to group A. Presence of mandibular deviation at 1, 3 and 6 month was statistically insignificant for both the groups.Our experience with 3D stable delta plate provides better treatment outcomes in terms of easy adaptation to the anatomy of the fracture site, better 3D stability and functional osteosynthesis.

Biomechanical Comparison of Titanium and Poly- L -Lactic Acid Trapezoidal Plates Applied in a Subcondylar Fracture Model.

Different types of plates are used in clinical practice for the management of subcondylar fractures. This study aimed to compare the performance of poly- L -lactic acid (PLLA) and titanium trapezoidal plates in the fixation of subcondylar mandibular fractures using finite element analysis. Titanium and PLLA trapezoidal plates and screws were placed on the virtual model obtained from computed tomography images of a patient with a subcondylar fracture to perform finite element analysis. The analysis included maximum tension distribution, maximum principal strain, displacement, and deformation of the bone, plates, and screws. The maximum tension distribution and maximum principal stress were found to be significantly higher on the titanium plate than on the PLLA plate and screws. Almost no difference was found between the trapezoidal and PLLA plates regarding the displacement of the fracture fragments at the fracture line. No difference was recorded regarding the displacement of the PLLA and titanium screws. The values of maximal principal strain between the PLLA and titanium materials showed no significant difference. The trapezoidal PLLA plates can be an alternative to trapezoidal titanium plates due to their functional stability and rigidity.

An Alternative Location for Fixation of Subcondylar Fractures With 2 Resorbable Plates.

Mandibular subcondylar fractures can be fixed with 2 titanium plates or 2 resorbable plates. However, when a wider resorbable plate is used, there might be insufficient space on subcondylar region. The authors have tested the back of the condyle as an alternative location for the wide resorbable plate. The fractured condyle was accessed through the preauricular approach. The first resorbable plate (4 hole plate, extended; 2mm Inion OTPSTM) was contoured around the posterior edge of the mandibular ramus. The upper and lower parts of the very resorbable plate were twisted into 2 different planes. The upper part was adapted and then fixed on the back of the condylar neck. And the lower part was fixed on the lateral surface of the posterior edge of the mandibular ramus. The second plate (4 hole plate; 2mm Inion OTPSTM) was put below the mandibular notch as usual. Postoperative computed tomography confirmed a stable anatomical reduction of condyle. One-year follow-up showed good fracture healing. The authors believe that the back of the condyle is particularly suitable for wider resorbable plate. And this alternative site on the back of the condyle is also feasible in cases where the conventional site is not available.

Simulating A Subcondylar Mandibular Fracture With Intraoral Open Reduction and Internal Fixation: A Novel Education Tool for Residents.

Face and content validation of a surgical simulation model. Open reduction and internal fixation in displaced subcondylar mandibular fractures is standard care. This requires an extraoral (eg: retromandibular, transparotideal) or intraoral approach. An intraoral approach requires further training since specialized instrumentation such as the 90° screwdriver system and endoscopes might be needed. Currently, no simulation models are available for training residents in intraoral reduction and fixation of subcondylar mandibular fractures. Therefore, we present a validated simulation model for intraoral treatment of subcondylar mandibular fractures. Based on a computer tomography data set, we designed and printed a 3D model of a mandible with a unilateral subcondylar fracture. To simulate intraoral work depth, it was positioned inside a dental phantom. We tested the model by a group of experts (n = 8), simulating intraoral reduction and fixation of a unilateral subcondylar fracture, using a 90° screwdriver system, a 1.0 subcondylar plate (lambda), and 5-6mm screws.We assessed Face and Content validity by survey. We provided an open-source printable fracture model. Printing costs were approximately US $10. Experts "Agreed" the model resembling the real scenario and its use for training intraoral reduction and fixation of subcondylar mandibular fractures. We developed a low cost, reproducible, open-source simulator for subcondylar mandibular fractures. Face and Content validity was achieved through evaluation by a group of experts.

Yang’s keyhole plate versus conventional plate for treatment of mandibular sub-condylar fractures

Objectives: The use of a keyhole plate vs two miniplates in the treatment of mandibular subcondylar fractures. Materials and methods:Twenty patients were randomized into two equal groups. Ten patients with subcondylar fractures were treated with two Yang's keyhole plates in Group I. Ten patients with subcondylar fractures were treated with two conventional miniplates in Group II. Maximum mouth opening (MMO), Protrusive excursive movement, Lateral excursive movement, and Time for reduction and fixation were all used to evaluate patients clinically vertical height of ramus, and antero-posterior condylar angulation are all measured radiographically. Results: There was a statistically non-significant difference between the study and control groups at all intervals regarding MMO, Protrusive excursive movement, Lateral excursive movement, vertical height of the ramus, antero-posterior condylar angulation, but was significant at time for reduction and fixation. Conclusion: reducing a mandibular condylar fracture using a YK-plate, the results were similar and the operating time was quicker than when utilizing a traditional mini plate fixation.

Endoscopic-Assisted Intraoral Approach for Osteosynthesis of Mandibular Subcondylar Fractures.

Introduction:The aim of this study is to follow-up and evaluate the treatment result of mandibular subcondylar (MSC) fractures by osteosynthesis via endoscopy-assisted intraoral approach.Materials and Methods:This is a prospective study, in which 47 patients with 51 sites of MSC fractures treated osteosynthesis via endoscopic-assisted intraoral approach at the Department of Maxillofacial Surgery, National Hospital of Odonto-Stomatology HoChiMinh City—Vietnam were followed-up and evaluated clinically and radiographically up to 6 months postoperative.Results:Before surgery, all of the patients were malocclusion, 15% of patients were isolated MSC fractures, the rate of concomitant midface fractures were 30%, 92.2% of fracture sites with moderate displacement, 7.8% of fracture sites with severe displacement, 5.9% of fracture sites with dislocation. After surgery, all of the patients had preinjured centric occlusion; no patient had facial paralysis; 6% of patients had surgical site infection within 1 week; pain frequency were 56.9% at 1 month, 35.3% at 2 months, 7.8% at 3 months, and 2.0% at 6 months with Visual Analog Scale (VAS) means of pain were 1.74±1.85 at 1 month, 0.55±1.12 at 2 months, 0.08±0.27 at 3 months and 0.02±0.14 at 6 months; 90% of fracture sites had precise anatomy at 1 week and 96% at 6 months; 96% fracture sites had no displacement the of correlation between condyle and articular fossa at 1 week and 98% at 6 months; 1 fracture site had screw loosening at 2 months; 88% fracture sites had stage-4 radiographic bone healing at 6 months.Conclusion:Endoscopic-assisted intraoral approach for osteosynthesis of MSC fractures have provided the esthetic and functional success and good bone healing.

P-61069874-222 - Antero-Parotid trans-massetric approach for reduction of mandibular subcondylar fractures; clinical tricks.

Sub-condylar fractures of mandible are a common occurrence in the trauma of the maxillofacial region both in children and adults. These fractures are treated by open reduction and internal fixation or by closed reduction according to the patient's age, his general condition and the facilities available in a particular healthcare setting. Use of the antero-parotid trans-massetric approach for treating mandibular subcondylar fractures has the least postoperative complications among other approaches for treating mandibular subcondylar fractures. Data was collected over seven years with a total of 245 fractures operated on 205 patients. Only minor complications were noticed during the 10 day post operative period, with mild temporary weakness of the buccal branches of facial nerve in 3.4% of cases while post operative unusual edema and trismus in 8.7% which resolved during the first ten days. No parotid leak/sialocele was found in any of these cases. Our aim is to give some clinical tricks after seven years experience in using this approach to treat subcondylar fractures and to achieve the best results with the least complications. The tricks include: the type of fractures which can be treated with this approach, to identify the access site, to deal with facial nerve branches in surgical site, the needfor perfect retraction and how to aid in reduction of fractures. We recommend this approach as it is rapid,easy, safe and effective for treating low subcondylar fractures.We suggest consideration of those clinical tricks to achieve the least complications and minimize surgical time.

Stability of single 3-D trapezoidal plate in condylar fracture in comparison to 2 Miniplates

Background: Condylar fractures account for one third of all mandibular fractures being in the range of 17.5–52%1, 2 of all mandibular fractures. The main goal in the treatment of condylar fractures is to predictably restore pre-injury anatomical form, with associated aesthetics and function. Aim: The aim of this study is to assess the efficacy and stability of single 3-D trapezoidal condylar plate and compare it with 2.0mm conventional miniplates in the Open Reduction and Internal Fixation of mandibular sub-condylar fractures. Methods: This study was conducted on 20 patients with subcondylar fracture.10 patients were allotted by random sampling in each Group. 3-D trapezoidal condylar plates were used in Group A and 2.0mm conventional minplates were used in Group B. The mini retromandibular surgical approach was common to both the groups. Function and stability was assessed post operatively at 1st, 3rd and 6th month respectively. Results: Intergroup analysis showed no statistically significant difference in results with respect to function and the stability of the fractured fragments. Conclusion: 3D trapezoidal condylar plates are more stable and structurally more efficient in reducing the torque forces leading to better osteosynthesis.

Reliability of a Trapezium Miniplate with Endoscope-Assisted Internal Fixation in Mandibular Subcondylar Fractures: A Three-Dimensional Analysis.

This study aimed to evaluate the reliability of a trapezium plate for open reduction and internal fixation (ORIF) of mandibular subcondylar fractures with the simultaneous use of an endoscope. We selected and retrospectively studied 18 patients (12 males and 6 females) with unilateral mandibular subcondylar fractures who visited the Wonju Severance Christian Hospital. The mean age of the patients was 43.43 ± 15.76 years. Patients underwent ORIF with trapezium miniplate application through an intraoral incision under general anesthesia. The clinical and radiographic findings of the fractured side were compared with those of the non-operated side at 6 months follow-up. All occlusions became stable, and transient functional disturbances disappeared within 6 months of periodic follow-up. Functional mandibular movement recovered within the normal range, with an average mouth opening of 41.5 mm, protrusion of 7.5 mm, and lateral excursion of 7 mm at 6 months. Radiographic controls and statistical analysis confirmed a decent anatomical reduction in all 18 cases. In conclusion, the use of a trapezium miniplate with endoscope-assisted ORIF in mandibular subcondylar fractures can be useful for fixation and functional recovery.

Two miniplates versus 3-dimensional plate in the management of mandibular subcondylar fractures: a retrospective analysis.

The aim of the present study was to evaluate the outcomes in patients withsubcondylar fracture of mandible treated with 2 single miniplates compared to a 3-dimensional (3D) plate. This is a retrospective study which included patients diagnosed and treated for mandibular subcondylar fracture from January 2015 to December 2019. Included patients were divided into two groups, group 1: 2 miniplate group and group 2: 3D plate group. The data was obtained from the patients' records and evaluated for various outcomes including occlusal stability, postoperative complications like plate fracture, non-union, plate or screw loosening, and plate or screw infection leading to implant removal, wound dehiscence, salivary fistula, and facial nerve paralysis. The statistical analysis was performed using chi square test and Student's t test. A total 58 patients (43 males and 15 females) were enrolled in the two groups ranging from 21 to 59 years. A total of 35 patients were recruited in group 1, whereas 23 patients were recruited in group 2. There was no statistically significant difference in the two groups with regard to the age range, gender, diagnosis, side of fracture, and accompanying fractures. Occlusal instability, wound dehiscence, and facial nerve paralysis was found in both the groups. Group 1 had 1 patient which required implant removal due to screw loosing, whereas group 2 had 2 patients which required plate removal due to plate fracture. One patient in group 2 required second surgery for fixation of fracture due to non-union. One patient in group 1 developed a sialocele postoperatively. However, there was no statistically significant difference in any of the variables assessed among the two groups (p > 0.05). The results of our study indicate that the 2 miniplates and 3D plate system are effective in the management of mandibular subcondylar fractures.

Retromandibular transparotid approach for subcondylar mandibular fracture: A retrospective study.

The retromandibular transparotid approach provides the shortest and the most direct access to mandibular sub-condylar fractures. However, this approach is less preferred due to the fear of facial nerve injury. The aim of this study was to evaluate the safety and morbidity of the retromandibular transparotid approach for open reduction and internal fixation of sub-condylar mandibular fractures. A retrospective cohort study of 29 patients with 35 sub-condylar mandibular fractures who underwent open reduction and internal fixation through the retromandibular transparotid approach was conducted. The primary study variable was facial nerve palsy, whereas the secondary variables were infection, sialocele, salivary fistula, stability of the fractured segments, post-operative malocclusion, Frey's syndrome, and unesthetic scar. All patients were followed up for 6months. Predictor variables included age, gender, side, location, displacement, etiology, concomitant maxillofacial fractures, and healing status. Fisher's exact test was calculated to find the association between primary variables and predictor variables. Out of 35 sub-condylar fractures (29 patients; 23 male, 6 female), four (11.42%) developed transient facial nerve palsy. Fractures at the condylar neck level (P=.045) and with displacement (P=.026) were significantly associated with the development of facial nerve palsy. Four patients (13.8%) developed slight malocclusion, two had surgical site infections, two developed sialoceles, and one had a salivary fistula. The retromandibular transparotid approach is safe and effective with rare major complications in the management of sub-condylar fractures of the mandible. Condylar neck fractures and displaced fractured segments are associated with an increased risk of development of facial nerve palsy.

Comparison of functional outcome after open and closed reduction of mandibular subcondylar fracture.

To compare open reduction with internal fixation of mandibular subcondylar fracture with closed reduction in terms of adequate mouth opening. The randomised clinical trial was conducted from March 2014 to February 2015 at the Oral and Maxillofacial Surgery Department, King Edward Medical University and Allied Hospitals, Lahore, Pakistan, and comprised patients who presented with unilateral subcondylar fractures. The patients were randomly divided into 2 groups. Group-A patients were treated with closed reduction and immobilisation and were discharged the same day, while Group-B patients were treated by open reduction with internal fixation and retained in ward for 1 day. Both were recalled for periodic follow-ups, and were compared in terms of achieving adequate mouth opening. Data was analysed using SPSS 20. Of the 70 patients, 35(50%) were in each of the two groups. The mean age in Group-A was 28.88±11.86 years compared to 28.22±10.80 years in Group-B (p>0.05). Mean mouth opening in the two groups were consistently positive, and significant at the last two follow ups(p<0.001). The difference in results of both treatment modalities was significant, indicating that open reduction and internal fixation should be the preferred treatment.

Does the Retromandibular Transparotid Approach Provide Quicker Access to Fracture of Mandibular Subcondyle Compared With the Retromandibular Transmasseteric Anterior Parotid Approach?

Limited studies are available in the literature comparing various surgical approaches for the management of condylar fractures, and those comparing different types of retromandibular approaches are even fewer in number. This study aimed to compare the efficacy of 2 variants of the retromandibular approach-retromandibular transmasseteric anterior parotid (RMTMAP) and retromandibular transparotid (RMTP) in terms of exposure time, blood loss, facial nerve palsy, sialoceles or parotid fistula formation, infection, and esthetics of scar tissue. A randomized controlled trial was designed in patients with mandibular subcondylar fractures requiring operative intervention. Patients were randomized into 2 groups based on a computer-generated randomization table. Group A included 37 cases, treated with the RMTMAP approach, and group B included 38 cases treated with the RMTP approach. The primary outcome variable was exposure time. Secondary outcome variables were blood loss during exposure, complications like facial nerve palsy, sialocele formation, surgical site infection, and scar esthetics. All patients were followed for 3months. Collected data were analyzed using the χ2 and analysis of variance tests. The mean exposure time for fractures treated with the RMTMAP approach and RMTP approach was 21.08±9.18 and 13.57±6.09, respectively (P<.05). The mean blood loss for RMTMAP and RMTP approach was 11.75±5.11 and 9.9±3.77mL, respectively (P=.078). No facial nerve injury was seen in patients treated with the RMTMAP approach, whereas 3 (7.8%) patients in the RMTP group had transient facial nerve injury (P=.08). This study concludes that the RMTP approach provides quicker access to the condyle as compared with the RMTMAP approach. However, the incidence of transient facial nerve injury was more in the RMTP approach. Except for reduced blood loss in the RMTP approach, all other parameters were comparable in both the approaches.

Clinical Assessment of Retromandibular Antero-Parotid Approach for Reduction of Mandibular Subcondylar Fractures: Report of 60 Cases and Review of the Literature.

This study assessed the efficacy of the retromandibular antero-parotid approach for open reduction and internal fixation (ORIF) of subcondylar fractures. Sixty patients with the mean age of 31.03 years underwent surgical reduction with a 20–25mm incision in the retromandibular area with an antero-parotid transmasseteric approach. All patients were followed between 6 to 12 months. At the end of the first week, six patients exhibited postoperative malocclusion. At the next visits, all patients had optimal occlusion. Maximal interincisal opening (MIO) of 56 patients (93.3%) was >37mm, and only four patients (6.7%) had MIO<37mm. In three patients (5%), weakness of the buccal branch of the facial nerve was noticed postoperatively. No salivary gland complications were seen. The surgical scar was hardly noticeable. Retromandibular access with transmasseteric antero-parotid approach is the technique of choice for treatment of high- and low-level subcondylar fractures with adequate visibility and direct access to the condylar area.

Does Dynamic Intermaxillary Fixation With Elastics Improve Outcomes Following Unilateral Condylar Fracture?

The use of rigid versus semi-rigid intermaxillary fixation (IMF) following subcondylar fractures is controversial. This study aims to investigate whether the "dynamic" elastic fixation technique improves the outcomes, compared to the rigid fixation technique for the treatment of displaced subcondylar fractures in adults. This nonblinded randomized clinical trial was performed on adult patients with unilateral displaced mandibular subcondylar fractures. Patients were randomly allocated into two groups (n=17). The primary predictor variable was wire versus elastic IMF. Changes in primary (mouth opening) and secondary (other clinical and radiological) outcomes were recorded. Data were analyzed with the t test and Mann-Whitney test with SPSS software version 20. P-value < .05 considered as significant. In this study 34 patients (with mean age of 33.03±1.79, 23.5% females & 76.5% males) in two groups (Elastics & Wire) followed up to 6months. The Elastics group showed significant improvement in mouth opening (primary outcome) after 1 month of follow-up, but the differences were not significant at the end of the study. In terms of secondary outcomes, the ramus height shortening compared to the opposite side revealed favorable improvement in the Elastics group in the period of study. The differences between the two groups in the lateral movement and protrusive movement were significant in favor of the Elastics group. The differences in pain, fracture displacement, and midline deviation between study groups were not significant at the end of the study. Just 1 case with malocclusion was observed in the Wire group. Patients were more satisfied with dynamic nonrigid IMF with elastics. The results of this study showed that using the dynamic IMF technique is more tolerable, and patients have better functional and clinical outcomes during and at the end treatment.

Management of Medially Displaced Sub-Condylar Mandibular Fractures in Pediatric Population Using Novel Atraumatic Approach.

The appropriate treatment of pediatric mandibular condyle fractures is subject to much debate and concern among surgeons, with improper treatment potentially resulting in a number of adverse outcomes. Such outcomes include the disruption of mandible growth, decreased posterior facial height, facial asymmetry, and temporomandibular joint ankylosis. Several surgical and nonsurgical approaches to these fractures have been described in the literature; however, each one carries its own risk of various complications. In this study, the authors illustrate a new atraumatic approach for mild to moderately displaced subcondylar fractures, with least possible complications and unexpected outcomes. In this study, 6 patients (2 female and 4 male) with unilateral medially displaced condylar base and neck fractures, angulated between 30 and 45 degrees, were treated using a novel intraoral approach. The follow-up period varied from 12 to 18 months. All patients achieved normal occlusion and had painless functioning of the temporomandibular joint with proper mouth opening (>35 mm) without any recurrence at long term follow up. This minimally invasive approach could eliminate the possibility of major complications and be considered a safe and feasible surgical technique for certain cases of pediatric mandibular condyle fracture.