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Fractures of the mandibular condyle - approaches and osteosynthesis

Fractures of the condyle account for one third of all the mandibular fractures. Different surgical approaches to the condyle described hitherto testify to the advantages and disadvantages of the different surgical techniques used for approaching the condyle in such cases of fractures. We have described and compared two of such surgical techniques in this study.

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The aim of this study is to compare the outcome of dealing with condylar fractures by two different surgical techniques: A prospective study of 31 patients who had suffered with mandibular condylar fractures was carried out. Of these, 26 patients had unilateral condylar fractures, and 5 patients had a bilateral fracture.

Further, 19 of these patients were treated by the mini retromandibular approach and 12 by the preauricular approach. The treated patients were followed up and evaluated for a minimum period of 1 year and assessed for parameters such as the maximum mouth opening, lateral movement on the fractured side, mandibular movements such as protrusion, dental occlusion, scar formation, facial nerve weakness, salivary fistula formation and time taken for the completion of the surgical procedure.

Dental occlusion was restored in all the cases, and good anatomical reduction was achieved.

  1. In order to avoid complications, the only fractures which should be treated intraorally are those which allow exact reduction even under the conditions of a limited view and reduced possibilities of surgical manipulation during reduction. Indian J Dent Res 2012;23.
  2. We now require methods that allow faster rehabilitation of the patient while maintaining a better quality of life with minimal or no complications. The fracture site on the posterior border of the mandible was identified and the pterygomasseteric sling was incised by diathermy.
  3. Fractures of the condyle account for one third of all the mandibular fractures.

The mean operating time was higher 63. Scar formation was satisfactory in almost all the cases.

Condylar fractures, mini retromandibular approach, preauricular approach How to cite this article: Kumaran S, Thambiah L J. Analysis of two different surgical approaches for fractures of the mandibular condyle. Indian J Dent Res 2012;23: Management of displaced condylar fractures in adults remains controversial with different techniques described by different authors.

Fractures of the mandibular condyle : approaches and osteosynthesis

The resultant morbidity from the surgical approach to the mandibular condyles and the time consumed in these techniques inhibit the surgeons from using these methods freely. Approaches described hitherto testify to the advantages and disadvantages of the individual techniques.

The critical factors in deciding the approach for surgical management include: There is a consensus amongst oral and maxillofacial surgeons that intra articular fractures are better managed conservatively with short term intermaxillary fixation IMF and intense rehabilitation. Conversely, there is little agreement on the management of extra-articular fractures in adults, protocols depending on the surgeon's experience and beliefs.

Recent accounts in publications hold that surgically treated condylar fractures yield better results in terms of occlusion, masticatory function, mouth opening and bone morphology.

However, the preference for conservative management is still prevalent, as surgical management is technically demanding and involves risks such as facial nerve injury and unsightly scars. The risk of facial nerve damage and unsightly scars is reduced in the intra oral approach; however, this method is technically difficult to expedite, and requires special training and dedicated instruments.

Further, external access does allows straightforward fracture reduction; however, the risk of facial nerve injury and visible scars cannot be ignored. In addition, there is a technique for the removal and replantation of the condylar segment through ramus osteotomy. Closed reduction does away with surgery; but however, carries its own disadvantages such as prolonged period of jaw immobility, limited mobility combined with dietary restrictions, decreased ability to maintain good oral hygiene especially lingually and transient periodontal damage.

These drawbacks do not make it the treatment of choice in this era of semi rigid and rigid osteosynthesis. We now require methods that allow faster rehabilitation of the patient while maintaining a better quality fractures of the mandibular condyle - approaches and osteosynthesis life with minimal or no complications.

These two approaches are also being followed at our centre. Materials and Methods 31 patients with 36 fractured condyles were included in the study group and treated by the preauricular and mini retromandibular appraches. The time frame of the study extended from June 2005 through June 2010.

One of the patients with bilateral condylar fracture with the associated parasymphysis fracture was operated only one side for medical reasons.

Routine hematological evaluation was done for all patients and all were within normal parameters in all. Radiographic investigations included orthopantomograms and posterior anterior PA view of the mandible.

  1. Radiographic investigations included orthopantomograms and posterior anterior PA view of the mandible. Informed consent was taken from every patient after explaining the merits and demerits and comparison of open and closed reduction methods of treating the condyle fracture.
  2. The mini retromandibular approach The mini retromandibular approach was used in 19 of 31 patients.
  3. Re-displacement and complications during osteosynthesis were the reasons. Forty patients with displaced or dislocated fractures of the mandibular condyle were re-examined.

Patients with a condylar fracture but no displacement, dislocation, or derangement of occlusion were treated by closed reduction via elastics or wire IMF. Informed consent was taken from every patient after explaining the merits and demerits and comparison of open and closed reduction methods of treating the condyle fracture.

The patients with the following criteria were included for open reduction: Post-operative recovery was uneventful in all the patients.

The mini retromandibular approach The mini retromandibular approach was used in 19 of 31 patients. The surgical technique adopted after the naso endotracheal intubation involved: This incision was made with a No. The deep dissection that followed was carried out using monopolar and bipolar diathermy, with blunt dissection of the parotid gland with a small curved hemostat. All the layers were clearly identified and undermined on either side of the incision to facilitate a tension free and easy closure.

The parotid capsule was incised and the gland was dissected anteromedially towards the posterior border of the mandible. The fracture site on the posterior border of the mandible was identified and the pterygomasseteric sling was incised by diathermy. The fractures were reduced and fixation was carried out with miniplate osteosynthesis using a 1.

The condylar fragment was plated first with the mouth wide open, followed by plating of the distal fragment while manually maintaining the optimum occlusion.

  • Approaches described hitherto testify to the advantages and disadvantages of the individual techniques;
  • Of these, 26 patients had unilateral condylar fractures, and 5 patients had a bilateral fracture;
  • Conversely, there is little agreement on the management of extra-articular fractures in adults, protocols depending on the surgeon's experience and beliefs;
  • Mini retromandibular approach - Incision;
  • Dental occlusion was restored in all the cases, and good anatomical reduction was achieved.

In some of the cases, a wire placed through the last hole on the plate helped to draw the fragment of the condyle into place [Figure 2]. Water-tight closure of the parotid capsule was ensured.

  • Management of displaced condylar fractures in adults remains controversial with different techniques described by different authors;
  • We now require methods that allow faster rehabilitation of the patient while maintaining a better quality of life with minimal or no complications;
  • While functionally stable osteosynthesis is a generally accepted method to treat all dislocated fractures of the skull, open reduction and rigid fixation of fractures of the mandibular condyle are still controversial;
  • Layered closure with resorbable sutures and skin closure with non resorbable sutures was carried out.

Layered closure with resorbable sutures and skin closure with non resorbable sutures was carried out. Suturing was done subcutaneously using a 4-0 nylon or 4-0 monofilament sutures.

Mini retromandibular approach - Incision.