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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 55-60

The surgical sequencing and techniques in the management of multiple mandibular fractures involving the condyle: A review of 121 surgical cases


Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Web Publication29-Apr-2019

Correspondence Address:
Sunil S Nayak
Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Opposite Fortune Inn Hotel, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_312_18

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  Abstract 

Aims: Surgical management of patients presenting with multiple fractures of the mandible involving condylar segments can be a challenging proposition to the maxillofacial surgeon. These fractures can be double or triple mandibular fractures and may also be in association with panfacial fractures. Even though most authors suggest that the conventional approachof reduction and fixation of the mandibular symphysis/ parasymphysis fractures, prior to addressing the fractured condylar segment is appropriate, there exists another school of thought suggesting that the condylar segment must be reduced and fixed first. This article aims to review the outcomes of surgery when reduction and fixation of the fractured condyle is done prior to other associated mandibular fractures and looks into the various surgical approaches advocated for the same. Materials and Methods: 121 surgically treated patients with multiple (double/ triple) mandibular fractures including a condylar component were reviewed. The preauricular, periangular and the retromandibular (anterior parotid-transmasseteric) approaches were advocated to access the fractured condylar segments. Results: The fractured condyle was the first segment to be addressed during the sequencing of the surgical management, irrespective of the approach used. Good reduction and fixation with limited complications were achieved by addressing the condylar fracture first. Conclusion: Sequencing of multiple mandibular fractures, though the prerogative of the operating surgeon, addressing the condylar segment first, provides the operator with a viable alternative to the conventional technique.

Keywords: Condylar fractures, multiple mandibular fractures, periangular approach, preauricular approach, retromandibular approach


How to cite this article:
Kamath AT, Nayak SS, Shukla AD, Chatterjee A. The surgical sequencing and techniques in the management of multiple mandibular fractures involving the condyle: A review of 121 surgical cases. J Int Oral Health 2019;11:55-60

How to cite this URL:
Kamath AT, Nayak SS, Shukla AD, Chatterjee A. The surgical sequencing and techniques in the management of multiple mandibular fractures involving the condyle: A review of 121 surgical cases. J Int Oral Health [serial online] 2019 [cited 2019 Jul 16];11:55-60. Available from: http://www.jioh.org/text.asp?2019/11/2/55/257365


  Introduction Top


Mandibular condylar fractures range from 29% to 52% among all mandibular fractures.[1],[2] Earlier, closed reduction of condylar fractures was the most preferred technique which included the patients being subjected to maxillomandibular fixation for varying periods.[3] Due to the possibility of a wide range of complications such as facial asymmetry, pain, and ankylosis, that can occur in association with closed reduction, more and more surgeons now prefer the open surgical intervention of the fractured condyle.[3],[4]

A large number of reported condylar fractures are caused by indirect trauma, in which the external force applied to one particular location of the mandible will result in fracture at a different location.[5],[6] The kinetic energy of a direct trauma on the mandible can result in fracture of the bone lying directly beneath the impact site and also a contralateral indirect fracture in an area of weakness. Condylar fractures are mostly caused by indirect forces transferred to the condylar region in the event of trauma.[7] On considering multiple fractures associated with the lower jaw, the most commonly seen are those involving the symphysis with bilateral condylar fractures and also the parasymphysis with contralateral condylar fractures. The management of multiple fractures of the mandible associated with condylar segments involves perioperative care, surgical treatment as well as postoperative rehabilitation and can be a challenging proposition to the maxillofacial surgeon. These fractures can be double or triple mandibular fractures and may also be in association with panfacial fractures. Even though most authors suggest the conventional approach of anatomic reduction followed by a semi-rigid or rigid fixation of the mandibular symphysis/parasymphysis fractures before addressing the fractured condylar segment, there exists another school of thought suggesting that the condylar segment must be reduced and fixed first.[8],[9]

This article evaluates and reviews 121 cases of multiple (double/triple) mandibular fractures involving the condyle and the approaches employed with emphasis on the sequencing pattern employed in their surgical management. An honest effort to provide an alternative surgical sequencing option to the conventional approach has been addressed which may improve the surgical ease of the operation in the larger interests of the patients.


  Materials and Methods Top


A systematic review of 121 patients with multiple (double/triple) mandibular fractures, including a condylar component surgically treated at the Manipal College of Dental Sciences, Manipal, a constituent unit of Manipal Academy of Higher Education, in a 7-year period from December 2011 to November 2018 was carried out. The case reports of patients aged between 18 and 60 years were selected for the review. Maxillofacial trauma cases with associated neurosurgical component were not included in this review. The sequencing of the surgical treatment of multiple mandibular fractures was initiated from the fractured condylar segment. This sequencing method was followed in all the cases irrespective of the surgical approaches to the condyle. Different surgical approaches, such as retromandibular, periangular, and preauricular, were advocated to access the fractured condylar segments. The subcondylar fractures [Figure 1] were approached through the retromandibular incision and the high condylar fractures were addressed by the preauricular approach. The periangular approach was advocated for very low subcondylar fracture reduction and fixation.
Figure 1: Three-dimensional computed tomography scan showing bilateral subcondylar fractures and right parasymphysis fracture

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In the retromandibular approach [Figure 2], the transmasseteric anterior parotid approach was used to address the subcondylar fractures. The dissection was made through the skin, subcutaneous tissue, and platysma. The anterior margin of the parotid was identified and retracted posteriorly followed by incising the fibers of the masseter muscle. The condyle and the posterior ramal border were exposed, followed by reduction and fixation of fractures either with a minimum of two plates [Figure 3] or by a single three-dimensional (3-D) trapezoidal plating system [Figure 4]. After satisfactory fixation of the condylar segment, the symphysis fracture was reduced and fixed with two plates in accordance with the Champy's principles [Figure 3]. The periangular incision (Modified Risdon approach) was preferred for low subcondylar fractures. The incision was placed into the first cervical crease approximately 2-cm posterior and inferior to the mandibular gonion. Dissection was carried out through the superficial fascia, platysma, and the superficial layer of the deep cervical fascia. Blunt dissection was further carried out between the anterior border of the sternocleidomastoid muscle and the posterior border of the submandibular gland in an avascular plane. The periosteum over the mandibular angle was incised followed by stripping of the masseter muscle from the angle and posterior border of the mandible to expose the fractured fragments [Figure 5]. These fragments were then adequately reduced and fixation was done using Stryker/Biomet plating system. The intraoral vestibular incision was then used to access, reduce, and fix the parasymphysis fracture.
Figure 2: Retromandibular approach to the fractured condyle

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Figure 3: Postoperative orthopantomogram showing a minimum of 2-plate fixation of the condyle

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Figure 4: Left condylar fracture fixed with three-dimensional trapezoidal plate through a retromandibular approach

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Figure 5: Periangular approach

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Fractures of the condylar head and neck were addressed through the preauricular approach [Figure 6]. The incision was carried through the skin and subcutaneous tissues to reach the white glistening temporalis fascia. An oblique incision was placed parallel to the temporal branch of the facial nerve through the superficial layer of the temporalis fascia above the zygomatic arch. The periosteum was stripped off the lateral zygomatic arch and the temporomandibular joint capsule was exposed, which was incised and dissected to reach to the joint spaces. The fractured fragments were exposed, reduced, and fixed in their proper anatomical position with miniplates and screws [Figure 7]. Following this, the parasymphysis fracture was addressed through the intraoral vestibular incision to achieve reduction and fixation. A combination of two approaches was advocated for reduction and fixation of inaccessible fractured condyles. A Hegar dilator was sometimes used to facilitate retraction of the fibrosed tissue envelope [Figure 8].
Figure 6: Preauricular approach

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Figure 7: Fixation through the preauricular approach

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Figure 8: Combined preauricular and retromandibular approach facilitated by a hegar dilator

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In all the three approaches advocated, the fractured condylar segment was addressed first, followed by the reduction and fixation of other associated mandibular fractures. The condylar segment was either stabilized by two plates, one along the posterior border and the other below the sigmoid notch or by a single 3-D trapezoidal plate.


  Results Top


Out of 121 patients subjected to open reduction and internal fixation under general anesthesia, 89 of them were male and 32 were female [Table 1]. Road traffic accidents (RTAs) were the most common cause for injuries, with 91 patients, followed by history of fall with 24 patients and other causes with 6 patients [Table 2]. The condylar fractures were associated with 28 symphysis fractures, 51 parasymphysis fractures, 9 mandibular angle fractures, 27 mandibular body fractures, and 6 mandibular ramus fractures [Table 3].
Table 1: Gender distribution

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Table 2: Distribution of patients according to the etiology of trauma

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Table 3: Distribution of type of mandibular fractures associated with condylar fractures

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Bilateral condylar fractures accounted for 15 patients and only 6 of them underwent surgical management bilaterally. A total of 127 condylar fractures were managed by open reduction and internal fixation. A retromandibular approach was used in 57 cases, a periangular approach in 36 patients, and a preauricular approach in 34 cases [Table 4]. The incidence of temporary postoperative paresthesia was noted in 18 patients, with the preauricular approach accounting for 14 patients and the periangular approach accounting for four patients. No incidence of paresthesia was reported in the retromandibular approaches [Table 4]. The occlusal discrepancy was found to be present in only six patients overall. Two incidences of sialocele formation postoperatively were reported associated with the retromandibular approach.
Table 4: Distribution of type of surgical approaches to the fractured condyle and associated complications

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  Discussion Top


Studies have shown that 22%–52% of all mandibular fractures involve double/triple mandibular fractures.[10],[11] The male-to-female ratio was about 3:1 similar to that of other studies.[2],[5] RTAs are the most common cause for trauma in developing countries[5] which can be attributed to the geographic location and the economic status of the participants.

Although fractured condyles are accessible by a variety of approaches, studies have shown that the preauricular incision can be a cumbersome option to treat subcondylar fractures.[12] Preauricular incisions reported an incidence of facial nerve injury ranging from 3.2% to 42.9% as was found in our cases.[13] We used the preauricular incision only for condylar head fractures. Satisfactory exposure for most condylar fractures is provided by the retromandibular approach. In the traditional transparotid retromandibular approach, the chances of encountering the facial nerve branches and retromandibular vein in the substance of the parotid gland are high. Chances of a salivary fistula developing postoperatively is a possibility as the approach traverses the parotid.[14] The anterior parotid transmasseteric technique through the retromandibular incision counters the complications of the transparotid retromandibular approach. There was no incidence of nerve injury through this approach, and the occurrence of a postoperative sialocele was negligible [Table 4].

In this article, the surgical sequencing during the management of multiple mandibular fractures involving the condyle was initiated by addressing the condylar fracture first in all cases. Some studies were of the view that malpositioning of the condylar segment was a possibility if the condylar segment is fixed before the symphysis fracture.[15] A study by Orabona et al. had come to the conclusion that treating the fractures in the tooth-bearing areas primarily and later addressing nontooth bearing areas resulted in fewer complications. However, they also opined that fracture reduction and fixation were much easier to perform when prior treatment of the nontooth bearing fragment was carried out.[16] Prior fixation of the condylar plate can lead to it being subjected to higher forces of stress during reduction of the lingual cortex in the symphyseal region.[17],[18],[19],[20],[21],[22],[23],[24],[25] Some authors had contrasting views in this regard. The need for craniomandibular articulation in double mandibular fractures involving a condylar fracture has been emphasized by Cillo and Ellis. Following fixation of the symphysis fracture first, lack of craniomandibular articulation can lead to lateral flaring at the gonial angle and malpositioning of the posterior ramus component.[26] Reconstruction of panfacial fractures associated with double mandibular fractures inclusive of a condylar component is best initiated from the condyle. This helps in restoring both the mandibular width as well as the sagittal mandibular position.[27] Moreover, the posterior facial height is restored when the condylar fracture is reconstructed first, and this would immensely benefit in the surgical management of associated mandibular and midface fractures.[28] In cases with dislocated condylar fractures associated with a symphysis fracture, the first step is to correct the dislocation followed by reduction of the symphysis.[29] The same principle, involving fixation of the condylar fracture before the symphysis/parasymphysis fractures was followed in the cases reported here.

The photoelastic analysis by Meyer et al. put forth the view that tensile stress was distributed inferior and parallel to the sigmoid notch and compressive stresses were present along the posterior border of the ramus.[30] Two miniplates along these stress lines, one below the sigmoid notch, and one at the posterior border of the mandible are recommended.[31] A single 3-D trapezoidal plate instead of a single miniplate is also highly recommended as internal fixation failure is commonly reported in the single-plate fixation of the condyle.[32],[33] Moreover, when a single plate is used to fix the fractured condyle, reduction of a mandibular symphysis fracture after fixation of the condyle could adversely affect the condylar internal fixation.[34] In this review article, the condylar fractures were fixed either with two miniplates along the stress lines or by a single 3-D trapezoidal plate to achieve good stabilization [Figure 3] and [Figure 4].

Many authors have found the retromandibular transparotid approach to be a reliable technique for condylar fracture management.[35] This approach can sometimes be associated with complications like the formation of a sialocele.[36] In this review article, a slightly modified retromandibular approach was used. A surgeon friendly approach, the transmasseteric anteroparotid retromandibular approach, which according to various studies can be used by surgeons of varying grades[37] was advocated and was found to reduce complications such as sialocele formation and facial nerve injury. The surgical approach advocated is usually based on the surgeon's experience and convenience.[38]

The prevention of lateral flaring at the gonial angle, establishing proper mandibular width as well as the sagittal mandibular position, and restoring the correct posterior facial height are the advantages of reducing the condylar segment first before other mandibular fracture sites.


  Conclusion Top


Sequencing of multiple mandibular fractures involving the condyle is a unique challenge. Establishing the posterior facial height and the prevention of lateral flaring at the gonial angle can be best-taken care by addressing the fractured condylar segment first. Sequencing of multiple mandibular fractures, though the prerogative of the operating surgeon, addressing the condylar segment first, provides the operator with a viable alternative to the conventional techniques.

Acknowledgments

The authors would like to thank all the participants in this project.

Informed consent

Written informed consent for patient information and images published was obtained by the patients or a legally authorized representative.

Ethical approval consent

Present Study is containing retrospective data of treated cases of concern institute. Author had taken consent from legal authorities for same and presented review.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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