oral surgery oral medicine oral pathology wirh sections
on
oral and
and maxillofaciat radiology endodontics
oral surgery Editor: ROBERT
B. SHIRA,
DDS
School of Dental Medicine, Tufts University 1 Kneeland Street Boston, Massachusetts 021 I I
Open reduction and internal rigid fixation of subcondylar fractures via an intraoral approach Joachim L.uchner, DMD. MD,a Jerald T. Clanton, DMD, MD,b and Peter D. Waite, DDS, MD, MPH,’ Birmingham, Ala. DEPARTMENT
OF ORAL
AND
MAXILLOFACIAL
SURGERY,
UNIVERSITY
OF ALABAMA
AT
BIRMINGHAM
Extraoral open reduction and rigid fixation of mandibular subcondylar fractures is controversial among surgeons. An intraoral approach with a percutaneous trocar and miniplates demonstrated satisfactory reduction. This technique can be more easily performed than a preauricular or submandibular incision, and risk of facial nerve damage is diminished. Early function with proper vertical dimension was restored with minimal postoperative morbidity. (ORAL SURC ORAL MED ORAL PATHOL
T
1991;71:257-61)
he goal of treatment in facial fractures is achieving anatomic reduction and restoring function while increasing patient comfort and making postoperative care easier. Open reduction and fixation of mandibular body fractures with plate fixation is technically simple and well accepted. This method can avoid maxillomandibular fixation, improve healing, and restore early function. Surgical treatment of mandibular subcondylar neck fractures, however,generatescontroversy among most surgeons dealing with maxillofacial trauma. aFellow. bAssistant Professor. ‘Associate 7/12/23782
Professor.
Subcondylar fractures are defined as extracapsular fractures through the anatomic neck, extending obliquely downward and backward from the sigmoid notch to a point above the middle of the posterior ramus border.’ The purpose of this article is to present the results of a method for intraoral open reduction and internal fixation of subcondylar fractures with miniplates, with the use of a technically simple procedure associatedwith minimal morbidity and a high degree of precision. Many open reduction techniques for stabilization of subcondylar fractures are complicated, require a generousextraoral incision, risk facial nerve injury, and lead to insufficient stability.2-4 Using miniplates from a intraoral approach eliminates many of the disadvantages inherent with other techniques and makes it amenable to more patients. 257
258
Lachner, Clanton, and Waite
Fig. 1. Postoperative panoramic radiograph reveals good reduction with less than 2 mm gap.
Fig. 3. Distal segment is distracted inferiorly ulate proximal segment.
Table
to manip-
I. Type and association of trauma No. of patients (n = 14)
Bilateral subcondylar fracture Right subcondylar fracture Left subcondylar fracture Mandibular body angle fracture Midface fracture Fracture of coronoid process
Fig.
2. Postoperative Towne view reveals good reduction
and condylar position. The intraoral approach to the condyle was first described by Steinhluser.’ Since then the surgical technique has been further described with some modifications.6,’ To date, no follow-up studies demonstrating postoperative results with the useof this technique have been published. MATERIAL
AND METHODS
Fourteen patients (3 women, 11 men; average age 24 years, range 19 to 41 years) were surgically treated
4
5 5 7 4 1
with intraoral open reduction of subcondylar fractures. Most of the patients had other associatedmaxillary and mandibular fractures that were treated at the same time (Table I). The reduction was evaluated with immediate postoperative radiographs (panoramic and Towne projection; Figs. 1 and 2). All patients were followed up for at least 12 months after surgery with appropriate radiographs and clinical examinations. Initially, only displaced low subcondylar neck fractures were indicated for this intraoral open reduction internal fixation technique. With more experience all subcondylar neck fractures (extracapsular) were treated successfully. With the use of a general anesthetic, subcondylar fractures were first reduced and fixed and then the other mandibular fractures were treated. The condylar neck was approached through an incision over the anterior border of the ascending ramus. The periosteum and massetermuscle w-erereflected laterally to the posterior border. The mandibular notch was identified and a Bauer retractor
Volume 71 Number 3
Fig. 4. Bauer retractor is positioned in sigmoid notch, and fracture is reduced while patient is in maxillomandibular fixation. Miniplate is first fixed to proximal segment.
placed. The periosteum of the proximal segment was elevated only to the degree necessaryfor plate placement. If the proximal segment was displaced medially, the mandible was distracted inferiorly and the proximal segment positioned laterally (Fig. 3). A percutaneous trocar was placed through a horizontal stab incision in the preauricular region. A four-hole Wiirzburg miniplate (Walter Lorenz Surgical Instruments, Inc., Jacksonville, Fla.) was first attached to the proximal segment with one or two screws. The patient was then placed in maxillomandibular fixation and the fracture reduced. Attention was given to properly align the posterior border of the ramus. This was done by inspection and palpation of the fracture site with an instrument. The plate was then attached to the distal segment (Fig. 4). The incision was closed, and patients wore training elastics for 2 to 10 days. RESULTS
The reduction of the condyle was considered to be adequate if the condyle was in the fossa. This could be immediately evaluated in the operating room by articulation of the mandible. There was no significant deviation with opening. Eighty percent of the fractures radiographically demonstrated a good reduction ((2 mm). Functionally, all patients returned to within normal range of motion (37 to 43 mm) within 8 weeks (nor-
Intraoral
open reduction and rigid fixation
259
Fig. 5. A 35year-old white woman involved in motor vehicle accident sustained Le Fort I middle palatal split, bilateral subcondylar fractures, and symphyseal fracture. Initial treatment was symphyseal plate, resulting in loss of vertical dimension, poor function, and facial distortion.
ma1range 36 to 38 mm). & g A slight deviation to the traumatized side was noted on maximal opening in 23% of the patients. Lateral excursion was possible in all cases.Clicking occurred in four patients, two of whom had a history of clicking before the fracture. Fifty-three percent of the patients at 6 weeks had mild discomfort with heavy chewing but required no medication. Function further improved in all patients, and at 6 months no complaints required intervention. These results are generally better than similar fractures treated in a closed fashion with either early function or extended maxillomandibular fixation. DISCUSSION
No consistent treatment of subcondylar fractures has gained universal acceptance. The complications of external open reduction, such as facial nerve injury, large external scar, vascular compromise to the proximal segment, and technical difficulties, have led to reluctance to open and rigidly fix these fractures. Therefore many surgeons elect to treat subcondylar fractures conservatively. Treatment without reapproximating the fractured segmentsmay result in compromiseof function.‘* The most obvious malfunction is a reduction in lateral and
260
Lachner, Cianton, and Waite
ORAL SCRG ORAL MED ORAL. PATHOI
March 1991
Fig. 6. Definitive treatment for patient in Fig. 5 is correction of maxillary transverse width and establishing proper vertical dimension with new mandibular plate and intraoral subcondylar miniplates.
Fig. 8. Surgical treatment involved intraoral open reduction and rigid fixation with miniplates. Patient was first put in maxillomandibular fixation; subcondylar fracture was plated, then angle fracture.
Fig. 7. A 25-year-old white man involved in altercation sustained left angle fracture and right subcondylar fracture. Subcondylar fracture is displaced laterally.
protrusive movements.‘I Opening is affected only minimally but is frequently associatedwith deviation. Bilateral fractures frequently lead to loss of vertical dimension. Therefore the lowest subcondylar fracture or most distracted fracture is indicated for reduction. The presence of bilateral fractures does not complicate the technique but does indicate reduction to restore vertical dimension (Figs. 5 to 8). Extraoral plating of fractures achievesgood reduction but has the obvious disadvantages of a large external scar and a risk of facial nerve damage.12*I3 The accessibility of intraoral fracture reduction and technical improvements in percutaneous rigid fixation with the use of miniplates make this a favorable procedure for reduction and stabilization of subcondylar fractures. If the proximal segment is medial, it is easily positioned laterahy before maxillomandibular fixation is applied. Therefore it is not necessaryto detach the temporal muscle or coronoid process,as has been suggested.r4 The intraoral approach to subcondylar fractures has minimal morbidity and complication. Low subcondylar fractures that result in decreased vertical height of the mandible should be considered for this procedure. Complicated positioning of the fractured midfacial region may require proper articulation of the condyle. Reduction of the mandible first fre-
Volume 71 Number 3
quently helps determine the correct position of the maxilla. Open reduction should be considered for most low subcondylar fractures to facilitate treatment of concomitant maxillary fractures. However, surgical treatment of these fractures should be approached with caution in children and young adults becausesignificant remodeling is to be expected in the joint structures after trauma. REFERENCES 1. Haskell R. Applied surgical anatomy. In: Rowe NL, Williams JL. Maxillofacial injuries. New York: Churchill Livingstone, 1985:1-42. 2. Petzel J. Instrumentarium and technique for screw pin osteosynthesis of condylar fractures. J Maxillofac Surg 1982;10:8. 3. Fernandez JA, Mathog RH. Open treatment of condylar fractures with biphase technique. Arch Otolaryngol Head Neck Surg 1987;113:262-6. 4. Peters RA, Caldwell JB, Olsen TW. A technique for open reduction of subcondylar fractures. ORAL SURG ORAL MED ORAL PATHOL 1976;41:273-80.
5. Steinhiiuser E. Eingriffe am processus articularis auf dem oralen Weg. Dtsch Zahn Z 1964;19:694-700. 6. Niederdellmann H. Surgical treatment of fractures of the neck and base of the condylar process:compressionosteosynthesis. In: Kruger H, Schilli W, eds. Traumatology in maxillofacial surgery. Chicago: Quintessence, 1986:101-6.
Intraoral open reduction and rigid jixation
26 1
7. Jeter TS, Van Sickels JE, Nishioka GJ. Intraoral open reduction with rigid internal fixation of mandibular subcondylar fractures. J Oral Maxillofac Surg 1988;46:1113-6. 8. Carlsson GE, Svardstiom G. A survey of the symptomatology of a series of 299 patients, stomatognathic dysfunction. Swed Dent J 1971;64:889-99. 9. Landtwing K. Evaluation of the normal range of vertical mandibular opening in children and adolescentswith special reference to age and stature. J Maxillofac Surg 1978;6:157-62. 10. Raveh J, Vuillemin T, Liidrach K. Open reduction of the dislocated, fractured condylar process: indications and surgical procedures. J Oral Maxillofac Surg 1989;47:120-7. 11. Dahlstrom L, Kahnberg KE, Lindahl L. 15years’ follow-up on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18-22. 12. Koberg WR, Momma WG. Treatment of fractures of the artitular processby functional stable osteosynthesisusing miniaturized dynamic compression plates. Int J Oral Surg 1978;7:256-62. 13. Chuong R, Piper MA. Open reduction of condylar fractures of the mandible in conjunction with repair of discal injury. J Oral Maxillofac Surg 1988;46:257-63. 14. Lindahl L, Hollender L. Condylar fractures of the mandible. II. A radiographic study of remodeling processesin the temporomandibular joint. Int J Oral Surg 1977;6:153-65. Reprint requests to:
Peter D. Waite, DDS, MD, MPH Department of Oral and Maxillofacial Surgery University of Alabama at Birmingham 1919 Seventh Ave. South Birmingham, AL 35294
on
oral and
and maxillofaciat radiology endodontics
oral surgery Editor: ROBERT
B. SHIRA,
DDS
School of Dental Medicine, Tufts University 1 Kneeland Street Boston, Massachusetts 021 I I
Open reduction and internal rigid fixation of subcondylar fractures via an intraoral approach Joachim L.uchner, DMD. MD,a Jerald T. Clanton, DMD, MD,b and Peter D. Waite, DDS, MD, MPH,’ Birmingham, Ala. DEPARTMENT
OF ORAL
AND
MAXILLOFACIAL
SURGERY,
UNIVERSITY
OF ALABAMA
AT
BIRMINGHAM
Extraoral open reduction and rigid fixation of mandibular subcondylar fractures is controversial among surgeons. An intraoral approach with a percutaneous trocar and miniplates demonstrated satisfactory reduction. This technique can be more easily performed than a preauricular or submandibular incision, and risk of facial nerve damage is diminished. Early function with proper vertical dimension was restored with minimal postoperative morbidity. (ORAL SURC ORAL MED ORAL PATHOL
T
1991;71:257-61)
he goal of treatment in facial fractures is achieving anatomic reduction and restoring function while increasing patient comfort and making postoperative care easier. Open reduction and fixation of mandibular body fractures with plate fixation is technically simple and well accepted. This method can avoid maxillomandibular fixation, improve healing, and restore early function. Surgical treatment of mandibular subcondylar neck fractures, however,generatescontroversy among most surgeons dealing with maxillofacial trauma. aFellow. bAssistant Professor. ‘Associate 7/12/23782
Professor.
Subcondylar fractures are defined as extracapsular fractures through the anatomic neck, extending obliquely downward and backward from the sigmoid notch to a point above the middle of the posterior ramus border.’ The purpose of this article is to present the results of a method for intraoral open reduction and internal fixation of subcondylar fractures with miniplates, with the use of a technically simple procedure associatedwith minimal morbidity and a high degree of precision. Many open reduction techniques for stabilization of subcondylar fractures are complicated, require a generousextraoral incision, risk facial nerve injury, and lead to insufficient stability.2-4 Using miniplates from a intraoral approach eliminates many of the disadvantages inherent with other techniques and makes it amenable to more patients. 257
258
Lachner, Clanton, and Waite
Fig. 1. Postoperative panoramic radiograph reveals good reduction with less than 2 mm gap.
Fig. 3. Distal segment is distracted inferiorly ulate proximal segment.
Table
to manip-
I. Type and association of trauma No. of patients (n = 14)
Bilateral subcondylar fracture Right subcondylar fracture Left subcondylar fracture Mandibular body angle fracture Midface fracture Fracture of coronoid process
Fig.
2. Postoperative Towne view reveals good reduction
and condylar position. The intraoral approach to the condyle was first described by Steinhluser.’ Since then the surgical technique has been further described with some modifications.6,’ To date, no follow-up studies demonstrating postoperative results with the useof this technique have been published. MATERIAL
AND METHODS
Fourteen patients (3 women, 11 men; average age 24 years, range 19 to 41 years) were surgically treated
4
5 5 7 4 1
with intraoral open reduction of subcondylar fractures. Most of the patients had other associatedmaxillary and mandibular fractures that were treated at the same time (Table I). The reduction was evaluated with immediate postoperative radiographs (panoramic and Towne projection; Figs. 1 and 2). All patients were followed up for at least 12 months after surgery with appropriate radiographs and clinical examinations. Initially, only displaced low subcondylar neck fractures were indicated for this intraoral open reduction internal fixation technique. With more experience all subcondylar neck fractures (extracapsular) were treated successfully. With the use of a general anesthetic, subcondylar fractures were first reduced and fixed and then the other mandibular fractures were treated. The condylar neck was approached through an incision over the anterior border of the ascending ramus. The periosteum and massetermuscle w-erereflected laterally to the posterior border. The mandibular notch was identified and a Bauer retractor
Volume 71 Number 3
Fig. 4. Bauer retractor is positioned in sigmoid notch, and fracture is reduced while patient is in maxillomandibular fixation. Miniplate is first fixed to proximal segment.
placed. The periosteum of the proximal segment was elevated only to the degree necessaryfor plate placement. If the proximal segment was displaced medially, the mandible was distracted inferiorly and the proximal segment positioned laterally (Fig. 3). A percutaneous trocar was placed through a horizontal stab incision in the preauricular region. A four-hole Wiirzburg miniplate (Walter Lorenz Surgical Instruments, Inc., Jacksonville, Fla.) was first attached to the proximal segment with one or two screws. The patient was then placed in maxillomandibular fixation and the fracture reduced. Attention was given to properly align the posterior border of the ramus. This was done by inspection and palpation of the fracture site with an instrument. The plate was then attached to the distal segment (Fig. 4). The incision was closed, and patients wore training elastics for 2 to 10 days. RESULTS
The reduction of the condyle was considered to be adequate if the condyle was in the fossa. This could be immediately evaluated in the operating room by articulation of the mandible. There was no significant deviation with opening. Eighty percent of the fractures radiographically demonstrated a good reduction ((2 mm). Functionally, all patients returned to within normal range of motion (37 to 43 mm) within 8 weeks (nor-
Intraoral
open reduction and rigid fixation
259
Fig. 5. A 35year-old white woman involved in motor vehicle accident sustained Le Fort I middle palatal split, bilateral subcondylar fractures, and symphyseal fracture. Initial treatment was symphyseal plate, resulting in loss of vertical dimension, poor function, and facial distortion.
ma1range 36 to 38 mm). & g A slight deviation to the traumatized side was noted on maximal opening in 23% of the patients. Lateral excursion was possible in all cases.Clicking occurred in four patients, two of whom had a history of clicking before the fracture. Fifty-three percent of the patients at 6 weeks had mild discomfort with heavy chewing but required no medication. Function further improved in all patients, and at 6 months no complaints required intervention. These results are generally better than similar fractures treated in a closed fashion with either early function or extended maxillomandibular fixation. DISCUSSION
No consistent treatment of subcondylar fractures has gained universal acceptance. The complications of external open reduction, such as facial nerve injury, large external scar, vascular compromise to the proximal segment, and technical difficulties, have led to reluctance to open and rigidly fix these fractures. Therefore many surgeons elect to treat subcondylar fractures conservatively. Treatment without reapproximating the fractured segmentsmay result in compromiseof function.‘* The most obvious malfunction is a reduction in lateral and
260
Lachner, Cianton, and Waite
ORAL SCRG ORAL MED ORAL. PATHOI
March 1991
Fig. 6. Definitive treatment for patient in Fig. 5 is correction of maxillary transverse width and establishing proper vertical dimension with new mandibular plate and intraoral subcondylar miniplates.
Fig. 8. Surgical treatment involved intraoral open reduction and rigid fixation with miniplates. Patient was first put in maxillomandibular fixation; subcondylar fracture was plated, then angle fracture.
Fig. 7. A 25-year-old white man involved in altercation sustained left angle fracture and right subcondylar fracture. Subcondylar fracture is displaced laterally.
protrusive movements.‘I Opening is affected only minimally but is frequently associatedwith deviation. Bilateral fractures frequently lead to loss of vertical dimension. Therefore the lowest subcondylar fracture or most distracted fracture is indicated for reduction. The presence of bilateral fractures does not complicate the technique but does indicate reduction to restore vertical dimension (Figs. 5 to 8). Extraoral plating of fractures achievesgood reduction but has the obvious disadvantages of a large external scar and a risk of facial nerve damage.12*I3 The accessibility of intraoral fracture reduction and technical improvements in percutaneous rigid fixation with the use of miniplates make this a favorable procedure for reduction and stabilization of subcondylar fractures. If the proximal segment is medial, it is easily positioned laterahy before maxillomandibular fixation is applied. Therefore it is not necessaryto detach the temporal muscle or coronoid process,as has been suggested.r4 The intraoral approach to subcondylar fractures has minimal morbidity and complication. Low subcondylar fractures that result in decreased vertical height of the mandible should be considered for this procedure. Complicated positioning of the fractured midfacial region may require proper articulation of the condyle. Reduction of the mandible first fre-
Volume 71 Number 3
quently helps determine the correct position of the maxilla. Open reduction should be considered for most low subcondylar fractures to facilitate treatment of concomitant maxillary fractures. However, surgical treatment of these fractures should be approached with caution in children and young adults becausesignificant remodeling is to be expected in the joint structures after trauma. REFERENCES 1. Haskell R. Applied surgical anatomy. In: Rowe NL, Williams JL. Maxillofacial injuries. New York: Churchill Livingstone, 1985:1-42. 2. Petzel J. Instrumentarium and technique for screw pin osteosynthesis of condylar fractures. J Maxillofac Surg 1982;10:8. 3. Fernandez JA, Mathog RH. Open treatment of condylar fractures with biphase technique. Arch Otolaryngol Head Neck Surg 1987;113:262-6. 4. Peters RA, Caldwell JB, Olsen TW. A technique for open reduction of subcondylar fractures. ORAL SURG ORAL MED ORAL PATHOL 1976;41:273-80.
5. Steinhiiuser E. Eingriffe am processus articularis auf dem oralen Weg. Dtsch Zahn Z 1964;19:694-700. 6. Niederdellmann H. Surgical treatment of fractures of the neck and base of the condylar process:compressionosteosynthesis. In: Kruger H, Schilli W, eds. Traumatology in maxillofacial surgery. Chicago: Quintessence, 1986:101-6.
Intraoral open reduction and rigid jixation
26 1
7. Jeter TS, Van Sickels JE, Nishioka GJ. Intraoral open reduction with rigid internal fixation of mandibular subcondylar fractures. J Oral Maxillofac Surg 1988;46:1113-6. 8. Carlsson GE, Svardstiom G. A survey of the symptomatology of a series of 299 patients, stomatognathic dysfunction. Swed Dent J 1971;64:889-99. 9. Landtwing K. Evaluation of the normal range of vertical mandibular opening in children and adolescentswith special reference to age and stature. J Maxillofac Surg 1978;6:157-62. 10. Raveh J, Vuillemin T, Liidrach K. Open reduction of the dislocated, fractured condylar process: indications and surgical procedures. J Oral Maxillofac Surg 1989;47:120-7. 11. Dahlstrom L, Kahnberg KE, Lindahl L. 15years’ follow-up on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18-22. 12. Koberg WR, Momma WG. Treatment of fractures of the artitular processby functional stable osteosynthesisusing miniaturized dynamic compression plates. Int J Oral Surg 1978;7:256-62. 13. Chuong R, Piper MA. Open reduction of condylar fractures of the mandible in conjunction with repair of discal injury. J Oral Maxillofac Surg 1988;46:257-63. 14. Lindahl L, Hollender L. Condylar fractures of the mandible. II. A radiographic study of remodeling processesin the temporomandibular joint. Int J Oral Surg 1977;6:153-65. Reprint requests to:
Peter D. Waite, DDS, MD, MPH Department of Oral and Maxillofacial Surgery University of Alabama at Birmingham 1919 Seventh Ave. South Birmingham, AL 35294
