Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible Samer George Hakim*, Thomas Trankle, Harald Kimmerle, Peter Sieg, Hans-Christian Jacobsen Department of Oral and Maxillofacial Surgery, University Medical Centre Schleswig-Holstein, Campus Luebeck, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 30 September 2013 Accepted 7 February 2014
Open reduction and internal fixation (ORIF) of subcondylar fractures of the mandible is a widely accepted treatment concept aimed at reconstruction of the vertical height of the mandibular ramus and restoration of occlusion. Here, we describe new instruments designed for ORIF via an intraoral approach using a single inverted y-miniplate. The special design allows sufficient visualisation of the fracture site and enables the establishment of a standardised procedure for the treatment of both dislocated and non-dislocated fractures. Several manoeuvres are described and some clinical cases are presented. Challenges frequently met during ORIF of subcondylar fractures via the intraoral approach such as limited exposure and visual control of fracture site can be overcome using the instruments-kit presented, which help to optimise this treatment. Ó 2014 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Condylar fracture Intraoral approach Miniplate osteosynthesis Open reduction and internal fixation
1. Introduction
2. Material and methods
Open reduction and internal fixation (ORIF) of low condylar fractures of the mandible represents a standard operative procedure for the treatment of facial trauma aimed at reconstruction of the vertical height of the mandibular ramus and restoration of habitual occlusion, as well as normal function of the temporomandibular joint (Schneider et al., 2008). In order to achieve sufficient osteosynthesis in this region, several surgical techniques have been introduced and reported to be valid for this indication (Asprino et al., 2006; Biglioli and Colletti, 2008; Gealh et al., 2009; Haim et al., 2011; Handschel et al., 2012; Meyer et al., 2006). Although the procedure has already become routine, there is still a need for specific instruments to allow sufficient exposure, visualisation and control of this region and to ensure anatomic reduction and placement of osteosynthesis. While many surgeons may not feel the need for additional tools to deal with such kinds of fracture, we believe that this new tool presented here facilitates and allows standardisation of such procedure.
Here, we describe a new instrument-set designed by the authors for the open reduction and internal fixation of low condylar fracture of the mandible. The tools were developed together with MediconÒ, Tuttlingen, Germany (Figs. 1e4). The main advantage of this set is the capability of dealing with different dislocation types associated with the fracture and the adaptation to specific reduction manoeuvres, as well as fixation using miniplates. It consists of the following elements:
* Corresponding author. Dept. Maxillofacial Surgery, University of Luebeck and University Medical Centre Schleswig-Holstein, Ratzeburger Allee 160, D-23562 Luebeck, Germany. Tel.: þ49 451 500 2266; fax: þ49 451 500 4188. E-mail address: [email protected] (S.G. Hakim).
1. Manipulation and reposition instruments, including one contraangled raspatory to encompass the dislocated condylar process and to luxate it from the infratemporal fossa (Fig. 1A) and a double-angled extension raspatory to assist reposition by pulling down the ramus at the incisura or at the retromolar trigone (Fig. 1B). An additional angled arrestable clamp enables ventral traction of the dislocated condylar fragment and facilitates placement of the miniplates (Fig. 1C). 2. Fixation tools including modified holding forceps to grasp the yplate at one branch and achieve miniplate fixation to the fragment with the opposite one (Fig. 2A). Further adaptation of the miniplate on bone may be obtained using an angled applicator with spherical head (Fig. 2B).
http://dx.doi.org/10.1016/j.jcms.2014.02.003 1010-5182/Ó 2014 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
2
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
Fig. 1. Manipulation and reposition instruments: A. A contra-angled raspatory to encompass the dislocated condylar process. B. A double-angled extension raspatory to assist reposition by pulling down the mandibular ramus. C. Angled arrestable forceps for ventral traction of the dislocated condylar fragment.
3. An illuminated double-angled retractor with a high-polished reflecting element (mirror) at the tip, which provides indirect visualisation of the fracture site and allows sufficient evaluation of anatomic reduction and fixation (Fig. 2C).
A recently introduced inverted y-miniplate, which was mainly developed for open reduction and fixation via the transoral approach, combines the advantage of the standard 2-plates design in the lower part, but works with one arm in the upper spongious
Fig. 2. Fixation tools: A. Holding forceps to grasp the y-plate at one branch and achieve miniplate fixation on the fragment with the opposite one. B. Angled applicator with a spherical head for additional adaptation of the y-miniplate. C. An illuminated double-angled retractor with a high-polished reflecting element at the tip, which provides indirect visualisation and control of the fracture site.
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
3
Fig. 3. Simulated reduction manoeuvres using the contra-angled raspatory to encompass the dislocated condylar fragment (A), the double-angled extension raspatory to pull down the mandibular ramus (B) and the angled arrestable forceps for ventral traction of the dislocated condylar fragment (C).
and gracile part of the condylar process. This y-miniplate is part of the new technique presented here and the instruments described have been optimised to work with this miniplate design in order to achieve sufficient results. Handling of the tools mentioned above during both reduction and fixation manoeuvres are simulated in Figs. 3 and 4. For the direct fixation of non-dislocated fractures, or those with minor displacement not requiring reposition, the y-plate can be adapted by the spherical head applicator and/or grasped at its
lower anterior branch by the holding forceps (Fig. 4A,B). The upper and lower posterior branch are thus free and fixation screws can be inserted. After accomplishing posterior fixation, the remaining two anterior screws are then fixed. If the condylar fragment is dislocated, it has to be tracked laterally and anteriorly. This can be facilitated by pulling down the ramus at the incisura or at the retromolar trigone by related instruments and grasped together with the lower hole of the upper branch of the y-miniplate by the holding forceps (Fig. 4C). The two
Fig. 4. Simulated fixation manoeuvres of the inverted y-miniplate using the angled applicator with a spherical head (A) and the holding forceps (B) or non-dislocated condylar fractures. For dislocated fractures, the condylar fragment is grasped together with the y-miniplate using the holding forceps (C). Visual control of reduction is provided via the illuminated double-angled retractor (D).
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
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S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
Fig. 5. Endoscopic views showing the ORIF of a dislocated subcondylar fracture via the new intraoral approach. After anterior pull with the clamp in the upper left image, the yminiplate is grasped and fixed with the condylar fragment using the holding forceps (lower left image). The upper right image shows inserted screws in the cranial part of the yminiplate and reposition of the condylar fragment controlled by the illuminated retractor. The final result of ORIF is shown in the lower right image. C: Clamp, CF: Condylar fragment, HF: Holding forceps, MP: y-miniplate, R: Illuminated retractor with a reflecting mirror, FL: Fracture line.
upper screws are inserted first so that the condylar fragment can be manipulated by the lower anterior branch of the y-miniplate allowing proper reposition under visual control, which is provided by the illuminated retractor (4D). Afterwards posterior fixation is accomplished and the anterior fixation follows when the fragment is stable and the holding forceps are removed (Fig. 5).
particular, the high rate of facial nerve lesion e albeit mostly of temporary nature e and conspicuous scar for preauricular and submandibular approaches, as well as constriction of the external acoustic meatus and auricle displacement for the retroauricular approach, have changed the paradigm and led to further development of the transoral approach, particularly for low subcondylar fractures.
2.1. Clinical reports Four patients, including one edentulous female presented with a dislocated subcondylar fracture of the mandible, shortening of the mandibular ramus and manifested malocclusion, were treated by ORIF using this approach. Operation time, excluding additional steps like tooth extraction or intermaxillary fixation, ranged from 30 to 78 min (mean 55.25 19.6 min). Endoscopic control using a 30 endoscope was only used for documentation of the operation steps. Postoperative radiographs showed sufficient anatomic reduction and fixation of the condylar fragment. In the long-term, stable results could be assessed after a follow-up period of 8e34 months (Fig. 6). 3. Discussion It is widely accepted that patients with condylar fractures associated with a considerable deviation or a shortening of the ramus benefit from ORIF (Kokemueller et al., 2012; Kyzas et al., 2012; Schneider et al., 2008), which can be achieved by various approaches. The concern of relatively high complication rates has characterised the operative management of condylar fractures in the last twenty years and has led to the development of minimallyinvasive treatment protocols and partially revived conservative management via mandibulomaxillary fixation for such injury. In
Fig. 6. Clinical case showing preoperative orthopantomogram of a patient with a dislocated right condylar fracture (upper image) and the postoperative result after ORIF via the intraoral approach presented (lower image).
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
One of the most challenging problems in the treatment of condylar fractures is the limited visualisation of the fracture site and a lack of adequate instruments for dealing with small and dislocated fragments. Although some innovations have recently been introduced in view of development of endoscopy-assisted control of fracture site as well as development of special clamps with tiny branches for reposition of the condylar fragment (Schon et al., 2002), a comprehensive set of surgical instruments for this indication has not yet been provided. The tool kit introduced here takes various aspects of ORIF into consideration, beginning with sufficient exposure and visualisation of the fracture site through facilitating reposition manoeuvres to finally provide adequate controlled fixation. The direct view of the fracture site without the endoscopic equipment allows better coordination of procedures in spite of the limited incision. 4. Conclusion In summary, condylar fractures associated with a considerable deviation or a shortening of the ramus are better treated by ORIF, which can be achieved via a transoral approach. The tool kit presented here enables sufficient visualisation of fracture site and allows adequate internal fixation using a y-miniplate via a minimally-invasive transoral approach. Conflict of interest statement Osteosynthesis material including miniplates and application instruments for testing the approach were provided by MediconÒ, Tuttlingen, Germany. SGH has also participated in the development
5
of various products for MediconÒ including the inverted y-miniplate and related tools. References Asprino L, Consani S, de Moraes M: A comparative biomechanical evaluation of mandibular condyle fracture plating techniques. J Oral Maxillofac Surg 64: 452e456, 2006 Biglioli F, Colletti G: Mini-retromandibular approach to condylar fractures. J Craniomaxillofac Surg 36: 378e383, 2008 Gealh WC, Costa JV, Ferreira GM, Iwaki Filho L: Comparative study of the mechanical resistance of 2 separate plates and 2 overlaid plates used in the fixation of the mandibular condyle: an in vitro study. J Oral Maxillofac Surg 67: 738e 743, 2009 Haim D, Muller A, Leonhardt H, Nowak A, Richter G, Lauer G: Biomechanical study of the delta plate and the TriLock Delta condyle trauma plate. J Oral Maxillofac Surg 69: 2619e2625, 2011 Handschel J, Ruggeberg T, Depprich R, Schwarz F, Meyer U, Kubler NR, et al: Comparison of various approaches for the treatment of fractures of the mandibular condylar process. J Craniomaxillofac Surg 40: e397ee401, 2012 Kokemueller H, Konstantinovic VS, Barth EL, Goldhahn S, von See C, Tavassol F, et al: Endoscope-assisted transoral reduction and internal fixation versus closed treatment of mandibular condylar process fracturesea prospective doublecenter study. J Oral Maxillofac Surg 70: 384e395, 2012 Kyzas PA, Saeed A, Tabbenor O: The treatment of mandibular condyle fractures: a meta-analysis. J Craniomaxillofac Surg 40: e438ee452, 2012 Meyer C, Serhir L, Boutemi P: Experimental evaluation of three osteosynthesis devices used for stabilizing condylar fractures of the mandible. J Craniomaxillofac Surg 34: 173e181, 2006 Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota RA, Rasse M, et al: Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg 66: 2537e2544, 2008 Schon R, Gutwald R, Schramm A, Gellrich NC, Schmelzeisen R: Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs. intraoral approach. Int J Oral Maxillofac Surg 31: 237e243, 2002
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible Samer George Hakim*, Thomas Trankle, Harald Kimmerle, Peter Sieg, Hans-Christian Jacobsen Department of Oral and Maxillofacial Surgery, University Medical Centre Schleswig-Holstein, Campus Luebeck, Germany
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 30 September 2013 Accepted 7 February 2014
Open reduction and internal fixation (ORIF) of subcondylar fractures of the mandible is a widely accepted treatment concept aimed at reconstruction of the vertical height of the mandibular ramus and restoration of occlusion. Here, we describe new instruments designed for ORIF via an intraoral approach using a single inverted y-miniplate. The special design allows sufficient visualisation of the fracture site and enables the establishment of a standardised procedure for the treatment of both dislocated and non-dislocated fractures. Several manoeuvres are described and some clinical cases are presented. Challenges frequently met during ORIF of subcondylar fractures via the intraoral approach such as limited exposure and visual control of fracture site can be overcome using the instruments-kit presented, which help to optimise this treatment. Ó 2014 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Condylar fracture Intraoral approach Miniplate osteosynthesis Open reduction and internal fixation
1. Introduction
2. Material and methods
Open reduction and internal fixation (ORIF) of low condylar fractures of the mandible represents a standard operative procedure for the treatment of facial trauma aimed at reconstruction of the vertical height of the mandibular ramus and restoration of habitual occlusion, as well as normal function of the temporomandibular joint (Schneider et al., 2008). In order to achieve sufficient osteosynthesis in this region, several surgical techniques have been introduced and reported to be valid for this indication (Asprino et al., 2006; Biglioli and Colletti, 2008; Gealh et al., 2009; Haim et al., 2011; Handschel et al., 2012; Meyer et al., 2006). Although the procedure has already become routine, there is still a need for specific instruments to allow sufficient exposure, visualisation and control of this region and to ensure anatomic reduction and placement of osteosynthesis. While many surgeons may not feel the need for additional tools to deal with such kinds of fracture, we believe that this new tool presented here facilitates and allows standardisation of such procedure.
Here, we describe a new instrument-set designed by the authors for the open reduction and internal fixation of low condylar fracture of the mandible. The tools were developed together with MediconÒ, Tuttlingen, Germany (Figs. 1e4). The main advantage of this set is the capability of dealing with different dislocation types associated with the fracture and the adaptation to specific reduction manoeuvres, as well as fixation using miniplates. It consists of the following elements:
* Corresponding author. Dept. Maxillofacial Surgery, University of Luebeck and University Medical Centre Schleswig-Holstein, Ratzeburger Allee 160, D-23562 Luebeck, Germany. Tel.: þ49 451 500 2266; fax: þ49 451 500 4188. E-mail address: [email protected] (S.G. Hakim).
1. Manipulation and reposition instruments, including one contraangled raspatory to encompass the dislocated condylar process and to luxate it from the infratemporal fossa (Fig. 1A) and a double-angled extension raspatory to assist reposition by pulling down the ramus at the incisura or at the retromolar trigone (Fig. 1B). An additional angled arrestable clamp enables ventral traction of the dislocated condylar fragment and facilitates placement of the miniplates (Fig. 1C). 2. Fixation tools including modified holding forceps to grasp the yplate at one branch and achieve miniplate fixation to the fragment with the opposite one (Fig. 2A). Further adaptation of the miniplate on bone may be obtained using an angled applicator with spherical head (Fig. 2B).
http://dx.doi.org/10.1016/j.jcms.2014.02.003 1010-5182/Ó 2014 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
2
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
Fig. 1. Manipulation and reposition instruments: A. A contra-angled raspatory to encompass the dislocated condylar process. B. A double-angled extension raspatory to assist reposition by pulling down the mandibular ramus. C. Angled arrestable forceps for ventral traction of the dislocated condylar fragment.
3. An illuminated double-angled retractor with a high-polished reflecting element (mirror) at the tip, which provides indirect visualisation of the fracture site and allows sufficient evaluation of anatomic reduction and fixation (Fig. 2C).
A recently introduced inverted y-miniplate, which was mainly developed for open reduction and fixation via the transoral approach, combines the advantage of the standard 2-plates design in the lower part, but works with one arm in the upper spongious
Fig. 2. Fixation tools: A. Holding forceps to grasp the y-plate at one branch and achieve miniplate fixation on the fragment with the opposite one. B. Angled applicator with a spherical head for additional adaptation of the y-miniplate. C. An illuminated double-angled retractor with a high-polished reflecting element at the tip, which provides indirect visualisation and control of the fracture site.
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
3
Fig. 3. Simulated reduction manoeuvres using the contra-angled raspatory to encompass the dislocated condylar fragment (A), the double-angled extension raspatory to pull down the mandibular ramus (B) and the angled arrestable forceps for ventral traction of the dislocated condylar fragment (C).
and gracile part of the condylar process. This y-miniplate is part of the new technique presented here and the instruments described have been optimised to work with this miniplate design in order to achieve sufficient results. Handling of the tools mentioned above during both reduction and fixation manoeuvres are simulated in Figs. 3 and 4. For the direct fixation of non-dislocated fractures, or those with minor displacement not requiring reposition, the y-plate can be adapted by the spherical head applicator and/or grasped at its
lower anterior branch by the holding forceps (Fig. 4A,B). The upper and lower posterior branch are thus free and fixation screws can be inserted. After accomplishing posterior fixation, the remaining two anterior screws are then fixed. If the condylar fragment is dislocated, it has to be tracked laterally and anteriorly. This can be facilitated by pulling down the ramus at the incisura or at the retromolar trigone by related instruments and grasped together with the lower hole of the upper branch of the y-miniplate by the holding forceps (Fig. 4C). The two
Fig. 4. Simulated fixation manoeuvres of the inverted y-miniplate using the angled applicator with a spherical head (A) and the holding forceps (B) or non-dislocated condylar fractures. For dislocated fractures, the condylar fragment is grasped together with the y-miniplate using the holding forceps (C). Visual control of reduction is provided via the illuminated double-angled retractor (D).
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
4
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
Fig. 5. Endoscopic views showing the ORIF of a dislocated subcondylar fracture via the new intraoral approach. After anterior pull with the clamp in the upper left image, the yminiplate is grasped and fixed with the condylar fragment using the holding forceps (lower left image). The upper right image shows inserted screws in the cranial part of the yminiplate and reposition of the condylar fragment controlled by the illuminated retractor. The final result of ORIF is shown in the lower right image. C: Clamp, CF: Condylar fragment, HF: Holding forceps, MP: y-miniplate, R: Illuminated retractor with a reflecting mirror, FL: Fracture line.
upper screws are inserted first so that the condylar fragment can be manipulated by the lower anterior branch of the y-miniplate allowing proper reposition under visual control, which is provided by the illuminated retractor (4D). Afterwards posterior fixation is accomplished and the anterior fixation follows when the fragment is stable and the holding forceps are removed (Fig. 5).
particular, the high rate of facial nerve lesion e albeit mostly of temporary nature e and conspicuous scar for preauricular and submandibular approaches, as well as constriction of the external acoustic meatus and auricle displacement for the retroauricular approach, have changed the paradigm and led to further development of the transoral approach, particularly for low subcondylar fractures.
2.1. Clinical reports Four patients, including one edentulous female presented with a dislocated subcondylar fracture of the mandible, shortening of the mandibular ramus and manifested malocclusion, were treated by ORIF using this approach. Operation time, excluding additional steps like tooth extraction or intermaxillary fixation, ranged from 30 to 78 min (mean 55.25 19.6 min). Endoscopic control using a 30 endoscope was only used for documentation of the operation steps. Postoperative radiographs showed sufficient anatomic reduction and fixation of the condylar fragment. In the long-term, stable results could be assessed after a follow-up period of 8e34 months (Fig. 6). 3. Discussion It is widely accepted that patients with condylar fractures associated with a considerable deviation or a shortening of the ramus benefit from ORIF (Kokemueller et al., 2012; Kyzas et al., 2012; Schneider et al., 2008), which can be achieved by various approaches. The concern of relatively high complication rates has characterised the operative management of condylar fractures in the last twenty years and has led to the development of minimallyinvasive treatment protocols and partially revived conservative management via mandibulomaxillary fixation for such injury. In
Fig. 6. Clinical case showing preoperative orthopantomogram of a patient with a dislocated right condylar fracture (upper image) and the postoperative result after ORIF via the intraoral approach presented (lower image).
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
S.G. Hakim et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
One of the most challenging problems in the treatment of condylar fractures is the limited visualisation of the fracture site and a lack of adequate instruments for dealing with small and dislocated fragments. Although some innovations have recently been introduced in view of development of endoscopy-assisted control of fracture site as well as development of special clamps with tiny branches for reposition of the condylar fragment (Schon et al., 2002), a comprehensive set of surgical instruments for this indication has not yet been provided. The tool kit introduced here takes various aspects of ORIF into consideration, beginning with sufficient exposure and visualisation of the fracture site through facilitating reposition manoeuvres to finally provide adequate controlled fixation. The direct view of the fracture site without the endoscopic equipment allows better coordination of procedures in spite of the limited incision. 4. Conclusion In summary, condylar fractures associated with a considerable deviation or a shortening of the ramus are better treated by ORIF, which can be achieved via a transoral approach. The tool kit presented here enables sufficient visualisation of fracture site and allows adequate internal fixation using a y-miniplate via a minimally-invasive transoral approach. Conflict of interest statement Osteosynthesis material including miniplates and application instruments for testing the approach were provided by MediconÒ, Tuttlingen, Germany. SGH has also participated in the development
5
of various products for MediconÒ including the inverted y-miniplate and related tools. References Asprino L, Consani S, de Moraes M: A comparative biomechanical evaluation of mandibular condyle fracture plating techniques. J Oral Maxillofac Surg 64: 452e456, 2006 Biglioli F, Colletti G: Mini-retromandibular approach to condylar fractures. J Craniomaxillofac Surg 36: 378e383, 2008 Gealh WC, Costa JV, Ferreira GM, Iwaki Filho L: Comparative study of the mechanical resistance of 2 separate plates and 2 overlaid plates used in the fixation of the mandibular condyle: an in vitro study. J Oral Maxillofac Surg 67: 738e 743, 2009 Haim D, Muller A, Leonhardt H, Nowak A, Richter G, Lauer G: Biomechanical study of the delta plate and the TriLock Delta condyle trauma plate. J Oral Maxillofac Surg 69: 2619e2625, 2011 Handschel J, Ruggeberg T, Depprich R, Schwarz F, Meyer U, Kubler NR, et al: Comparison of various approaches for the treatment of fractures of the mandibular condylar process. J Craniomaxillofac Surg 40: e397ee401, 2012 Kokemueller H, Konstantinovic VS, Barth EL, Goldhahn S, von See C, Tavassol F, et al: Endoscope-assisted transoral reduction and internal fixation versus closed treatment of mandibular condylar process fracturesea prospective doublecenter study. J Oral Maxillofac Surg 70: 384e395, 2012 Kyzas PA, Saeed A, Tabbenor O: The treatment of mandibular condyle fractures: a meta-analysis. J Craniomaxillofac Surg 40: e438ee452, 2012 Meyer C, Serhir L, Boutemi P: Experimental evaluation of three osteosynthesis devices used for stabilizing condylar fractures of the mandible. J Craniomaxillofac Surg 34: 173e181, 2006 Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota RA, Rasse M, et al: Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg 66: 2537e2544, 2008 Schon R, Gutwald R, Schramm A, Gellrich NC, Schmelzeisen R: Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs. intraoral approach. Int J Oral Maxillofac Surg 31: 237e243, 2002
Please cite this article in press as: Hakim SG, et al., A new non-endoscopic intraoral approach for open reduction and internal fixation of subcondylar fractures of the mandible, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.02.003
