The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
noma remains ambivalent and may be identified as a gingival mucosal infectious lesion, malnutrition, weak immune system, poor oral hygiene, and poor medical condition. Noma can further develop and exasperate by such diseases as measles and AIDS. Patients who suffered the disease often had maxillofacial disfigurement and functional disabilities such as difficulties in chewing and talking, presumably because of limited mouth opening. Thus, the adequate resolve the restriction of mouth opening is of great importance to improve the quality of life in these patients.3,4 Free forearm flap, which is widely used for reconstructive surgery,5 is soft with less subcutaneous fat, and suitable for soft tissue defect reconstructions. Advantages of the flap include high survival rate, easy to harvest, and well defined anatomy, etc. Flap in the current case was harvested in nondriving blood state, in which the blood supply of proximal end is easier to judge. Although more than half of the flap did not contain the artery perfusion, the flap still achieved stable and reliable blood supply after microvascular anastomosis in the recipient site. Timely and adequate treatment of pseudoankylosis of TMJ can significantly improve patients’ life quality, social communications. The free forearm flap is a viable and suitable flap option for the reconstruction in patients with pseudoankylosis of TMJ.
REFERENCES 1. Baraldi CE, Martins GL, Puricelli E. Pseudoankylosis of the temporomandibular joint caused by zygomatic malformation. Int J Oral Maxillofac Surg 2010;39:729–732 2. Yang GF, Chen PJ, Gao YZ, et al. Forearm free skin ap transplantation: a report of 56 cases. Br J Plast Surg 1981;50:162–165 3. Van Niekerk C, Khammissa RA, Altini M, et al. Noma and cervicofacial necrotizing fasciitis: clinicopathological differentiation and an illustrative case report of noma. AIDS Res Hum Retroviruses 2014;30:213–216 4. Wamba A. Causes and pathogenesis of noma in Zinder (Niger): a socio-anthropological study. Med Sante Trop 2013;23:287–293 5. Wirthmann A, Finke JC, Giovanoli P, et al. Long-term follow-up of donor site morbidity after defect coverage with Integra following radial forearm flap elevation. Eur J Plast Surg 2014;37:159–166
Observational Study of Surgical Treatment of Sagittal Fractures of Mandibular Condyle Chang-Kui Liu, MD,yz Cai-xia Jing,§ Wei Li, Jianzhong Wang, Hongzhi Zhou,jj Min Hu, BM, BS,y and Kai-Jin Hu, PhDjj Objective: This study was conducted to investigate the complications that occur after surgical treatment of sagittal fracture of the mandibular condyle (SFMC). Methods: A retrospective study was conducted on patients in whom SFMC was treated using surgical methods (87 patients, 105 sides) between January 1995 and December 2011 (79 sides were treated by rigid internal fixation and the remaining 26 sides were removed the condylar fragments). The longest follow-up was 17 years, and the shortest was 2 years. Follow-ups were conducted to assess mandibular activity, mouth opening, and computed tomography scans of condylar morphologic alterations. The postoperative complications were evaluated and the causes were analyzed. #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
Results: We observed 3 patients with joint ankylosis (all of them were removed the condylar fragments); 8, mouth opening less than 30 mm; 23, deviation on mouth opening at 6 months. At 4 weeks, 19 patients had facial nerve weakness, which was resolved within 6 months. The radiological investigation showed complete remodeling in 56.2% of the condyles (in the 59 sides, 57 sides were treated by rigid internal fixation and 2 sides were removed the condylar fragments); partial remodeling 27.6% condyles (in the 29 sides, 20 sides were treated by rigid internal fixation and 9 sides were removed the condylar fragments); poor remodeling, 16.2% condyles (in the 17 sides, 2 sides were treated by rigid internal fixation and 15 sides were removed the condylar fragments). Conclusions: Surgical treatment of SFMC is not perfect. There were some complications that occurred after the surgical treatment of SFMC. The findings also indicate that condylar anatomic reduction is the basis for functional recovery and, therefore, rigid fixation should be implemented. Furthermore, the removal of condylar fragments should be performed with caution, and if used, the fragments should be removed entirely. Key Words: Complication, mandible, sagittal fracture of mandibular condyle, surgical treatment
S
agittal mandibular condylar fracture (SFMC) is also called a type B intracapsular (diacapsular) condylar fracture. It presents as a fracture line that begins from the lateral pole of the condylar surface and leads up to the medial side of the condylar neck.1 Earlier, SFMC was not commonly detected in the clinical setting because it was easily missed on conventional radiographs.2,3 With the introduction of computed tomography (CT), the incidence of SFMC has increased gradually in recent years and was reported to comprise 9% to 29% of condylar fractures.4,5 Animal experiments and clinical observations show that compared with other condylar fractures, SFMC has an increased risk for ankylosis.6 –8 In particular, SFMC is noted for its susceptibility to temperomandibular joint (TMJ) ankylosis. Yao et al6 demonstrated an evident correlation between SFMC and TMJ ankylosis in an experimental study using miniature pigs. Moreover, He et al7 reported that 25 of 40 patients with TMJ ankylosis resulted from SFMC, and Ferretti et al8 revealed that SFMC is more likely to ankylose than other condylar fractures. Gu¨ven9 speculated that the reason for ankylosis was probably inadequate or late treatment of From the Department of Stomatology, 451th Hospital of the People’s Liberation Army, Xi’an; yDepartment of Somatology, General Hospital of the PLA, Beijing; zDepartment of Stomatology, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi; §Department of Pathogenic Biology of Medical College of Yanan University, ShanXi; and jjState Key Laboratory of Military Stomatology, Department of Oral Surgery, The Fourth Military Medical University, Xi’an, China. Received April 14, 2014. Accepted for publication January 8, 2015. Address correspondence and reprint requests to Kai-Jin Hu, PhD, Department of Oral Surgery, State Key Laboratory of Military Stomatology, The Fourth Military Medical University, Xi’an 710032, PR China; E-mail: [email protected] C.-k.L. and C.-x.J. contributed equally to this work. This work was supported by National Natural Science Foundation of China (81470726) and Beijing Natural Science Foundation of China (7112124). The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001791
e359
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The Journal of Craniofacial Surgery
TMJ fractures. Therefore, appropriate treatment of SFMC is highly important. Palmieri et al10 found that closed reduction of mandibular condylar fractures was not effective, and Ellis et al11 concluded that the condyle was tilted medially after the conservative management. Therefore, in the last decade, support for open surgical treatment has been steadily increasing.12– 14 At our hospital too, we have been using surgical management to treat SFMC since the 1980s. Some complications inevitably occur after the surgery, for example, temporary facial paralysis, infection, salivary fistulas, sialoceles, and seromas, as well as Frey syndrome in 1 case15– 18. Few reports were, however, available about the complications after surgical treatment of SFMC. The aim of this study is to investigate the complications that occur after surgical treatment of SFMC and to analyze their causes.
PATIENTS AND METHODS Patients Between January 1995 and December 2011, 87 patients (52 men and 35 women ages 14–62 years) with 105 SFMCs were treated using open surgery at the Department of Oral and Maxillofacial Surgery, General Hospital of the PLA. Diagnoses were made based on clinical and radiographic examinations, including orthopantomography and helical CT. Sixty-nine patients had unilateral fractures, 27 of which were on the left side and 42, on the right side. Eighteen patients had bilateral condylar fractures. Patients with any other fractures were excluded.
Treatment In 81 (99 condyles) of the 87 patients, a preauricular incision was made after induction of general anesthesia. The zygomatic arch and the surface of the TMJ capsule were exposed after elevation of the skin flap. Then, a T-shaped incision was made from the lateral adherence of the capsule to the neck of the condyle, and the stump of the condylar fracture was exposed. The condylar fragments were replaced their positions and were treated by rigid internal fixation in the 65 patients (79 sides). The condylar fragments were removed in the 16 patients (20 sides). The remaining 6 patients of the total 87 patients had unilateral fracture, intraoral incisions was made after induction of general anesthesia, and then the condylar fragments were removed in these patients. So, there were total 22 patients (26 sides) with removal of condylar fragment.
Clinical and Radiological Examination The clinical examination was primarily conducted to detect possible joint disorders, growth disturbances, and other complications at 4 weeks, 6 months, and 1 year after the operation. The patients with SFMC were studied clinically and radiographically for 2 to 17 years (average 9.8 years). The parameters evaluated clinically included limitation of mandibular mobility, occlusion disturbance, deviation on mouth opening, joint pain, joint clicking, and facial asymmetry. In addition, the patient’s subjective evaluation of joint clicking, joint pain when chewing, numbness, joint tenderness and symptoms of Frey syndrome was recorded, and examination for nerve palsy was conducted. The results of CT conducted using a GE (General Electric Company, Fairfield, CT) light-speed 32-slice CT scanner (120 kV, 80 mA, 0.8-second rotation time, and 0.2-mm slice thickness) were recorded every 6 months and every year. Three-dimensional reconstruction was performed to observe the shape of the TMJ (Figs. 1 and 2Figs. 1-2). The condyles were classified into 3 categories based on shape, namely, complete remodeling, partial
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Volume 26, Number 4, June 2015
FIGURE 1. Before treatment.
FIGURE 2. Removal of condylar fragments.
remodeling, and poor remodeling. Complete remodeling was characterized by complete recovery of the shape and height of the condyle with no difference from an intact condyle; partial remodeling, partial recovery of the shape and height of the condyle with slight difference from an intact condyle; and poor remodeling, deformity and shortness of the condyle with marked difference from an intact condyle.
Statistical Analyses To identify differences between the treatment groups, X2 frequency tables were used to compare the observers the shape of the TMJ (complete remodeling, partial remodeling, and poor remodeling). Statistical significance was defined at P < 0.05 for all statistical tests.
RESULTS Postoperative Complications The findings from the patients’ subjective evaluations are shown in Table 1. One patient (1.1%) had Frey syndrome after the operation; this patient had undergone rigid internal fixation via a preauricular incision. Other complications included wound infection, salivary fistula, and facial nerve palsy. Six patients (6.9%) developed infection after the operation, and 3 patients (3.4%) had salivary fistula; they were treated with occlusive pressure dressings and antisialogogues and they recovered within 3 weeks. Nineteen patients (21.8%) had facial nerve palsy at 4 weeks after the operation, but it was resolved within 6 months with some neurotrophic drugs.
Mandibular Function The mandibular functions evaluated were mouth opening, deviation of the mandible on mouth opening, protrusion, and lateral movements. Mean unassisted interincisal opening without pain was 14.5 mm (range 11.2–30.3 mm) before treatment (approximately 1 week after trauma) and 37.9 mm (range 5–43.5 mm) at 6 months after treatment. Eighty-four patients (96.6%) achieved normal mouth opening without limitations in daily life. Three patients, however, had ankylosis, and all 3 of these patients had undergone removal of condylar fragments via intraoral incision. The progression was shown on Figures 1–4Figures from 1 to 4. Lateral deviation on mouth opening was found in 23 patients (26.4%) at 6 months after the operation; rigid internal fixation was used in 9 of these patients, and the condylar fragments had been removed in 14 of them. Among the patients who were treated by removal of condylar fragments, 2 patients had mandibular retrusion; 3 patients, open bite of the front teeth; and 3 patients, ankylosis. In the patients who were #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
FIGURE 3. Initiation of fusion between the condyle and glenoid fossa at 6 months after operation.
FIGURE 4. Coronal plane image showing bone hyperplasia and adhesion between the condyle and glenoid bone.
treated by rigid internal fixation with titanium plate, 1 plate got loosened and 1 plate was fractured.
Shape of the Condyle The shape of the condyle was judged by three-dimensional reconstruction from CT scans taken at 1 year after treatment. Complete remodeling was found in 59 condyles; partial remodeling, 29 condyles; and poor remodeling, 17 condyles. Most patients with rigid internal fixation showed complete remodeling, whereas most patients with condylar fragment removal showed poor remodeling. The treatment and the findings from the radiological investigation are shown in Table 2.
DISCUSSION Sagittal fracture of the mandibular condyle is noted for its susceptibility to TMJ ankylosis .6–8 Gu¨ven9 speculated that the reason for ankylosis was probably inadequate or late treatment of TMJ fractures. In the last decade, support for open surgical treatment has been steadily increasing.12– 14 We have been using surgical management at our hospital too to treat SFMC since the 1980s. Some complications, however, inevitably occur after surgery, for example, temporary facial paralysis, infection, salivary fistulas, sialoceles, and seromas, as well as Frey syndrome in 1 case15– 18. The aim of this study was to investigate the complications after surgical treatment of SFMC and to analyze their causes as objectively as possible. TABLE 1. Incidence of Complications According to Surgical Technique Rigid Internal Fixation (n ¼ 65)
Removal of Fragments (n ¼ 22)
Complication
n
%
n
%
Joint clicking Joint pain Numbness Joint tenderness Frey syndrome
20 15 3 4 1
30.8 23.1 4.6 6.2 1.5
5 5 0 1 0
22.7 22.7 0.0 4.5 0.0
TABLE 2. Degree of Condylar Remodeling (105 Condyles) After Surgical Intervention Treatment Rigid internal fixation Removal of fragments P
#
Complete Remodeling
Partial Remodeling
Poor Remodeling
57 2
Volume 26, Number 4, June 2015
noma remains ambivalent and may be identified as a gingival mucosal infectious lesion, malnutrition, weak immune system, poor oral hygiene, and poor medical condition. Noma can further develop and exasperate by such diseases as measles and AIDS. Patients who suffered the disease often had maxillofacial disfigurement and functional disabilities such as difficulties in chewing and talking, presumably because of limited mouth opening. Thus, the adequate resolve the restriction of mouth opening is of great importance to improve the quality of life in these patients.3,4 Free forearm flap, which is widely used for reconstructive surgery,5 is soft with less subcutaneous fat, and suitable for soft tissue defect reconstructions. Advantages of the flap include high survival rate, easy to harvest, and well defined anatomy, etc. Flap in the current case was harvested in nondriving blood state, in which the blood supply of proximal end is easier to judge. Although more than half of the flap did not contain the artery perfusion, the flap still achieved stable and reliable blood supply after microvascular anastomosis in the recipient site. Timely and adequate treatment of pseudoankylosis of TMJ can significantly improve patients’ life quality, social communications. The free forearm flap is a viable and suitable flap option for the reconstruction in patients with pseudoankylosis of TMJ.
REFERENCES 1. Baraldi CE, Martins GL, Puricelli E. Pseudoankylosis of the temporomandibular joint caused by zygomatic malformation. Int J Oral Maxillofac Surg 2010;39:729–732 2. Yang GF, Chen PJ, Gao YZ, et al. Forearm free skin ap transplantation: a report of 56 cases. Br J Plast Surg 1981;50:162–165 3. Van Niekerk C, Khammissa RA, Altini M, et al. Noma and cervicofacial necrotizing fasciitis: clinicopathological differentiation and an illustrative case report of noma. AIDS Res Hum Retroviruses 2014;30:213–216 4. Wamba A. Causes and pathogenesis of noma in Zinder (Niger): a socio-anthropological study. Med Sante Trop 2013;23:287–293 5. Wirthmann A, Finke JC, Giovanoli P, et al. Long-term follow-up of donor site morbidity after defect coverage with Integra following radial forearm flap elevation. Eur J Plast Surg 2014;37:159–166
Observational Study of Surgical Treatment of Sagittal Fractures of Mandibular Condyle Chang-Kui Liu, MD,yz Cai-xia Jing,§ Wei Li, Jianzhong Wang, Hongzhi Zhou,jj Min Hu, BM, BS,y and Kai-Jin Hu, PhDjj Objective: This study was conducted to investigate the complications that occur after surgical treatment of sagittal fracture of the mandibular condyle (SFMC). Methods: A retrospective study was conducted on patients in whom SFMC was treated using surgical methods (87 patients, 105 sides) between January 1995 and December 2011 (79 sides were treated by rigid internal fixation and the remaining 26 sides were removed the condylar fragments). The longest follow-up was 17 years, and the shortest was 2 years. Follow-ups were conducted to assess mandibular activity, mouth opening, and computed tomography scans of condylar morphologic alterations. The postoperative complications were evaluated and the causes were analyzed. #
2015 Mutaz B. Habal, MD
Brief Clinical Studies
Results: We observed 3 patients with joint ankylosis (all of them were removed the condylar fragments); 8, mouth opening less than 30 mm; 23, deviation on mouth opening at 6 months. At 4 weeks, 19 patients had facial nerve weakness, which was resolved within 6 months. The radiological investigation showed complete remodeling in 56.2% of the condyles (in the 59 sides, 57 sides were treated by rigid internal fixation and 2 sides were removed the condylar fragments); partial remodeling 27.6% condyles (in the 29 sides, 20 sides were treated by rigid internal fixation and 9 sides were removed the condylar fragments); poor remodeling, 16.2% condyles (in the 17 sides, 2 sides were treated by rigid internal fixation and 15 sides were removed the condylar fragments). Conclusions: Surgical treatment of SFMC is not perfect. There were some complications that occurred after the surgical treatment of SFMC. The findings also indicate that condylar anatomic reduction is the basis for functional recovery and, therefore, rigid fixation should be implemented. Furthermore, the removal of condylar fragments should be performed with caution, and if used, the fragments should be removed entirely. Key Words: Complication, mandible, sagittal fracture of mandibular condyle, surgical treatment
S
agittal mandibular condylar fracture (SFMC) is also called a type B intracapsular (diacapsular) condylar fracture. It presents as a fracture line that begins from the lateral pole of the condylar surface and leads up to the medial side of the condylar neck.1 Earlier, SFMC was not commonly detected in the clinical setting because it was easily missed on conventional radiographs.2,3 With the introduction of computed tomography (CT), the incidence of SFMC has increased gradually in recent years and was reported to comprise 9% to 29% of condylar fractures.4,5 Animal experiments and clinical observations show that compared with other condylar fractures, SFMC has an increased risk for ankylosis.6 –8 In particular, SFMC is noted for its susceptibility to temperomandibular joint (TMJ) ankylosis. Yao et al6 demonstrated an evident correlation between SFMC and TMJ ankylosis in an experimental study using miniature pigs. Moreover, He et al7 reported that 25 of 40 patients with TMJ ankylosis resulted from SFMC, and Ferretti et al8 revealed that SFMC is more likely to ankylose than other condylar fractures. Gu¨ven9 speculated that the reason for ankylosis was probably inadequate or late treatment of From the Department of Stomatology, 451th Hospital of the People’s Liberation Army, Xi’an; yDepartment of Somatology, General Hospital of the PLA, Beijing; zDepartment of Stomatology, Ankang Hospital of Traditional Chinese Medicine, Ankang, Shaanxi; §Department of Pathogenic Biology of Medical College of Yanan University, ShanXi; and jjState Key Laboratory of Military Stomatology, Department of Oral Surgery, The Fourth Military Medical University, Xi’an, China. Received April 14, 2014. Accepted for publication January 8, 2015. Address correspondence and reprint requests to Kai-Jin Hu, PhD, Department of Oral Surgery, State Key Laboratory of Military Stomatology, The Fourth Military Medical University, Xi’an 710032, PR China; E-mail: [email protected] C.-k.L. and C.-x.J. contributed equally to this work. This work was supported by National Natural Science Foundation of China (81470726) and Beijing Natural Science Foundation of China (7112124). The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001791
e359
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The Journal of Craniofacial Surgery
TMJ fractures. Therefore, appropriate treatment of SFMC is highly important. Palmieri et al10 found that closed reduction of mandibular condylar fractures was not effective, and Ellis et al11 concluded that the condyle was tilted medially after the conservative management. Therefore, in the last decade, support for open surgical treatment has been steadily increasing.12– 14 At our hospital too, we have been using surgical management to treat SFMC since the 1980s. Some complications inevitably occur after the surgery, for example, temporary facial paralysis, infection, salivary fistulas, sialoceles, and seromas, as well as Frey syndrome in 1 case15– 18. Few reports were, however, available about the complications after surgical treatment of SFMC. The aim of this study is to investigate the complications that occur after surgical treatment of SFMC and to analyze their causes.
PATIENTS AND METHODS Patients Between January 1995 and December 2011, 87 patients (52 men and 35 women ages 14–62 years) with 105 SFMCs were treated using open surgery at the Department of Oral and Maxillofacial Surgery, General Hospital of the PLA. Diagnoses were made based on clinical and radiographic examinations, including orthopantomography and helical CT. Sixty-nine patients had unilateral fractures, 27 of which were on the left side and 42, on the right side. Eighteen patients had bilateral condylar fractures. Patients with any other fractures were excluded.
Treatment In 81 (99 condyles) of the 87 patients, a preauricular incision was made after induction of general anesthesia. The zygomatic arch and the surface of the TMJ capsule were exposed after elevation of the skin flap. Then, a T-shaped incision was made from the lateral adherence of the capsule to the neck of the condyle, and the stump of the condylar fracture was exposed. The condylar fragments were replaced their positions and were treated by rigid internal fixation in the 65 patients (79 sides). The condylar fragments were removed in the 16 patients (20 sides). The remaining 6 patients of the total 87 patients had unilateral fracture, intraoral incisions was made after induction of general anesthesia, and then the condylar fragments were removed in these patients. So, there were total 22 patients (26 sides) with removal of condylar fragment.
Clinical and Radiological Examination The clinical examination was primarily conducted to detect possible joint disorders, growth disturbances, and other complications at 4 weeks, 6 months, and 1 year after the operation. The patients with SFMC were studied clinically and radiographically for 2 to 17 years (average 9.8 years). The parameters evaluated clinically included limitation of mandibular mobility, occlusion disturbance, deviation on mouth opening, joint pain, joint clicking, and facial asymmetry. In addition, the patient’s subjective evaluation of joint clicking, joint pain when chewing, numbness, joint tenderness and symptoms of Frey syndrome was recorded, and examination for nerve palsy was conducted. The results of CT conducted using a GE (General Electric Company, Fairfield, CT) light-speed 32-slice CT scanner (120 kV, 80 mA, 0.8-second rotation time, and 0.2-mm slice thickness) were recorded every 6 months and every year. Three-dimensional reconstruction was performed to observe the shape of the TMJ (Figs. 1 and 2Figs. 1-2). The condyles were classified into 3 categories based on shape, namely, complete remodeling, partial
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Volume 26, Number 4, June 2015
FIGURE 1. Before treatment.
FIGURE 2. Removal of condylar fragments.
remodeling, and poor remodeling. Complete remodeling was characterized by complete recovery of the shape and height of the condyle with no difference from an intact condyle; partial remodeling, partial recovery of the shape and height of the condyle with slight difference from an intact condyle; and poor remodeling, deformity and shortness of the condyle with marked difference from an intact condyle.
Statistical Analyses To identify differences between the treatment groups, X2 frequency tables were used to compare the observers the shape of the TMJ (complete remodeling, partial remodeling, and poor remodeling). Statistical significance was defined at P < 0.05 for all statistical tests.
RESULTS Postoperative Complications The findings from the patients’ subjective evaluations are shown in Table 1. One patient (1.1%) had Frey syndrome after the operation; this patient had undergone rigid internal fixation via a preauricular incision. Other complications included wound infection, salivary fistula, and facial nerve palsy. Six patients (6.9%) developed infection after the operation, and 3 patients (3.4%) had salivary fistula; they were treated with occlusive pressure dressings and antisialogogues and they recovered within 3 weeks. Nineteen patients (21.8%) had facial nerve palsy at 4 weeks after the operation, but it was resolved within 6 months with some neurotrophic drugs.
Mandibular Function The mandibular functions evaluated were mouth opening, deviation of the mandible on mouth opening, protrusion, and lateral movements. Mean unassisted interincisal opening without pain was 14.5 mm (range 11.2–30.3 mm) before treatment (approximately 1 week after trauma) and 37.9 mm (range 5–43.5 mm) at 6 months after treatment. Eighty-four patients (96.6%) achieved normal mouth opening without limitations in daily life. Three patients, however, had ankylosis, and all 3 of these patients had undergone removal of condylar fragments via intraoral incision. The progression was shown on Figures 1–4Figures from 1 to 4. Lateral deviation on mouth opening was found in 23 patients (26.4%) at 6 months after the operation; rigid internal fixation was used in 9 of these patients, and the condylar fragments had been removed in 14 of them. Among the patients who were treated by removal of condylar fragments, 2 patients had mandibular retrusion; 3 patients, open bite of the front teeth; and 3 patients, ankylosis. In the patients who were #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
FIGURE 3. Initiation of fusion between the condyle and glenoid fossa at 6 months after operation.
FIGURE 4. Coronal plane image showing bone hyperplasia and adhesion between the condyle and glenoid bone.
treated by rigid internal fixation with titanium plate, 1 plate got loosened and 1 plate was fractured.
Shape of the Condyle The shape of the condyle was judged by three-dimensional reconstruction from CT scans taken at 1 year after treatment. Complete remodeling was found in 59 condyles; partial remodeling, 29 condyles; and poor remodeling, 17 condyles. Most patients with rigid internal fixation showed complete remodeling, whereas most patients with condylar fragment removal showed poor remodeling. The treatment and the findings from the radiological investigation are shown in Table 2.
DISCUSSION Sagittal fracture of the mandibular condyle is noted for its susceptibility to TMJ ankylosis .6–8 Gu¨ven9 speculated that the reason for ankylosis was probably inadequate or late treatment of TMJ fractures. In the last decade, support for open surgical treatment has been steadily increasing.12– 14 We have been using surgical management at our hospital too to treat SFMC since the 1980s. Some complications, however, inevitably occur after surgery, for example, temporary facial paralysis, infection, salivary fistulas, sialoceles, and seromas, as well as Frey syndrome in 1 case15– 18. The aim of this study was to investigate the complications after surgical treatment of SFMC and to analyze their causes as objectively as possible. TABLE 1. Incidence of Complications According to Surgical Technique Rigid Internal Fixation (n ¼ 65)
Removal of Fragments (n ¼ 22)
Complication
n
%
n
%
Joint clicking Joint pain Numbness Joint tenderness Frey syndrome
20 15 3 4 1
30.8 23.1 4.6 6.2 1.5
5 5 0 1 0
22.7 22.7 0.0 4.5 0.0
TABLE 2. Degree of Condylar Remodeling (105 Condyles) After Surgical Intervention Treatment Rigid internal fixation Removal of fragments P
#
Complete Remodeling
Partial Remodeling
Poor Remodeling
57 2
![[Outcome of endoscopically assisted surgical treatment of mandibular condyle fractures: a retrospective study of 22 patients].](/assets/img/hold.png)
