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canal were involved in 10 patients (83.3%), whereas the otic capsule was not involved in any patient. The diagnosis of EG was established after histopathologic examination. Histologically, the lesion was characterized by expanding, erosive accumulations of Langerhans cells within the medullar cavity of the bone. Histiocytes were variably admixed with eosinophils, lymphocytes, plasma cells, and neutrophils. The cells were immunoreactive for CD1 antigen and S-100 protein in all our patients, whereas Saliba et al15 found positivity for these immunohistochemical stains in only 80% of their patients. The LCH has an unpredictable course varying from a rapidly fatal progressive disease to spontaneous resolution.2 However, the usual prognosis of the disease affecting the temporal bone is good in patients having limited organ involvement, with a survival rate of more than 90%.1 Age at presentation, multisystem involvement, and vital organ dysfunction are the most relevant prognostic factors, with bad prognosis in children younger than 2 years.2 There are several treatment modalities for histiocytosis, including surgery, radiotherapy, and chemotherapy. These modalities can be used either alone or in combinations, depending upon the extent and the severity of the disease. Different treatment protocols were used in different clinical settings.18 In our institute, the treatment protocol of EG is to perform cortical mastoidectomy followed by postoperative radiotherapy; in our study, there was no recurrence in 83.3% of our patients. Even the 2 patients who developed recurrence were treated successfully, with limited surgical excision because the recurrent lesions were superficial. Because of the fact that there are no large series in the literature, the optimal treatment protocol of histiocytosis is not well established. This is particularly true for EG because most published cases are sporadic without a standard protocol for treatment. With accumulation of data in the literature, the treatment of temporal bone EG may be standardized in the future.3 Bayazit et al3 stated that the most preferable method for treatment of temporal bone EG is surgical excision, and radiotherapy can be used for residual tissues when complete excision is not achieved. However, some authors preferred the use of corticosteroids, either local or systemic; others used chemotherapy especially in systemic lesions.19,20 del Rı´o et al21 proposed a treatment of temporal bone histiocytosis with radiosurgery, through isodoses of 10 Gy, with a good therapeutic response after 2 years of follow-up. Saliba et al15 treated a case of EG in the temporal bone only with steroid injections (Triamcinolone) in the mastoid, external auditory canal, and orbital region; they achieved complete eradication of the lesion after 1 year. In addition, Rodrı´guez Rivera et al22 treated EG with bone curettage and intralesional corticosteroid therapy; they obtained good clinical and radiologic response, without local and systemic relapse after a 3 month follow-up. Finally, we conclude that children with temporal bone EG may present with features that mimic the features of chronic suppurative otitis media. However, CT shows characteristic lesions, and histopathologic examination is diagnostic. Cortical mastoidectomy together with postoperative radiotherapy is a successful method for treatment of EG of the temporal bone; however, a long follow-up is essential to detect any recurrence.
REFERENCES 1. Boston M, Derkay CS. Langerhans cell histiocytosis of the temporal bone and skull base. Am J Otolaryngol 2002;23:246Y248 2. Martini A, Aimoni C, Trevisani M, et al. Langerhans cell histiocytosis: report of a case with temporal localization. Int J Pediatr Otorhinolaryngol 2000;55:51Y56 3. Bayazit Y, Sirikci A, Bayaram M, et al. Eosinophilic granuloma of the temporal bone. Auris Nasus Larynx 2001;28:99Y102
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4. Zinkham WH. Multifocal eosinophilic granuloma: natural history, etiology and management. Am J Med 1976;60:457Y463 5. Irving RM, Broadbent V, Jones NS. Langerhans’ cell histiocytosis in childhood: management of head and neck manifestations. Laryngoscope 1994;104:64Y70 6. Skoulakis CE, Drivas EI, Papadakis CE, et al. Langerhans cell histiocytosis presented as bilateral otitis media and mastoiditis. Turk J Pediatr 2008;50:70Y73 7. Greinwald JH, Smith RJH. Langerhans’ cell histiocytosis. In: Jackler RK, Driscoll CLW, eds. Tumor of the Ear and Temporal Bone. Philadelphia: Lippincott Williams & Wilkins, 2000:417Y430 8. Nanduri VR, Pritchard J, Chong WK, et al. Labyrinthine involvement in Langerhans’ cell histiocytosis. Int J Pediatr Otorhinolaryngol 1998;46:109Y115 9. Marioni G, De Filippis C, Stramare R, et al. Langerhans’ cell histiocytosis: temporal bone involvement. J Laryngol Otol 2001;115:839Y841 10. McCaffrey TV, McDonald TJ. Histiocytosis X of the ear and temporal bone: review of 22 cases. Laryngoscope 1979;89:1735Y1742 11. Sweet RM, Kornblut AD, Hyams VJ. Eosinophilic granuloma in the temporal bone. Laryngoscope 1979;89:1545Y1551 12. Levy R, Sarfaty SM, Schindel J. Eosinophilic granuloma of the temporal bone. Two cases with bilateral involvement. Arch Otolaryngol 1980;106:167Y171 13. Campos MK, Viana MB, de Oliveira BM, et al. Langerhans cell histiocytosis: a 16-year experience. J Pediatr (Rio J) 2007;83:79Y86 14. Puranik KR, Murthy PS, Gopalakrishna R, et al. Unusually large mastoid antrum (mega antrum). J Laryngol Otol 1992;106:164Y165 15. Saliba I, Sidani K, El Fata F, et al. Langerhans’ cell histiocytosis of the temporal bone in children. Int J Pediatr Otorhinolaryngol 2008;72:775Y786 16. Nicollas R, Rome A, BelaBch H, et al. Head and neck manifestation and prognosis of Langerhans’ cell histiocytosis in children. Int J Pediatr Otorhinolaryngol 2010;74:669Y673 17. Azouz EM, Saigal G, Rodriguez MM, et al. Langerhans’ cell histiocytosis: pathology, imaging and treatment of skeletal involvement. Pediatr Radiol 2005;35:103Y115 18. Appling D, Jenkins HA, Patton GA. Eosinophilic granuloma in the temporal bone and skull. Otolaryngol Head Neck Surg 1983;91:358Y365 19. Fo¨rster U, Klingebiel R, Schulte Overberg U, et al. Langerhans cell histiocytosis: petrosal remodeling after chemotherapyVcase report and review of the literature. Laryngorhinootologie 2003;82:166Y170 20. Lallemant B, Fayoux P, Nelken B, et al. Management of head and neck Langerhan’s cell histiocytosis in children. Ann Otolaryngol Chir Cervicofac 2003;120:30Y39 21. del Rı´o L, Lassaletta L, Martı´nez R, et al. Petrous bone Langerhans cell histiocytosis treated with radiosurgery. Stereotact Funct Neurosurg 2007;85:129Y131 22. Rodrı´guez Rivera V, Lesmas Navarro MJ, de Paula Vernetta C, et al. Early start eosinophilic granuloma of the temporal bone. Acta Otorrinolaringol Esp 2010;61:315Y317
Functional Outcomes of Preauricular Underparotid Retrograde Approach for Mandibular Condyle Fractures O¨zgur Pilanci, MD, Karaca Basaran, MD, Fatih Ceran, MD, Samet Vasfi Kuvat, MD Abstract: Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Various approaches have been previously mentioned for the access to the mandibular condyle. The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures. This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Functional outcomes with this method were addressed in light of the results obtained in this clinical series. We suggest this method in the management of condylar fractures. Key Words: Mandibular condylar fractures, preauricular underparotid retrograde approach
T
he mandible is one of the most important bones for esthetic appearance of the face, contributing significantly to the shape of the lower face. The anatomic position renders the mandible susceptible to trauma. The rate of condylar fractures among all mandibular fractures ranges between 17.5% and 52%.1Y5 To make a more precise classification, condylar fractures can be practically divided into 3 types based on the anatomic level of the fracture: head (intracapsular), neck (extracapsular), and the subcondylar region.6 Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. Various approaches have been previously mentioned for the access to the mandibular condyle.7Y10 The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures.
MATERIALS AND METHODS This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Three of the patients were female. The mean age was 27 years (range, 16Y46). The fractures were caused by falls in 9, assaults by another person in 3, and car accidents in 4. All fractures were pathologically displaced. Four patients had bilateral fractures. The mean interval between the trauma and surgery was 3 days.
Preoperative Imaging After evaluating patient histories and physical examinations, radiologic imaging was performed to visualize the condyle and the ramus of the mandible. An orthopantomogram and a maxillofacial computed tomography were performed in all patients before the operation to assess the level, type, displacement, and angulation of the fracture.
From the Plastic, Reconstructive, and Aesthetic Surgery, Bagcilar Training and Research Hospital, Bahcelievler, Istanbul, Turkey. Received September 25, 2013. Accepted for publication October 28, 2013. Address correspondence and reprint requests to Øzgur Pilanci, MD, Eski Londra Asfalti, Emlak Konut Sitesi, A 5, Daire 21, Bahcelievler, Istanbul, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000514
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Preauricular Underparotid Retrograde Approach General anesthesia and nasotracheal intubation were used. The surgical area was covered with a drape to prevent contamination. A solution containing 1:200000 epinephrine was injected to the operative field to ensure a relatively bloodless field. Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. A gull wingYshaped incision was made on the preauricular crease; the incision was carried down to the subcutaneous tissues and superficial to the superficial musculoaponeurotic system (SMAS) anteriorly. The superficial temporal vessels were left intact. The facial nerve and branches were protected. An incision was made parallel to the zygomatic arch. A periosteal elevator was inserted beneath the periosteum of the lateral zygomatic arch. The dissection was carried out retrogradely underneath the parotid gland to the joint to expose the capsule of the temporomandibular joint (TMJ) (Fig. 1). The fracture segments were then exposed, and the fracture was reduced (Fig. 2). In all cases, rigid osteosynthesis was carried out with miniplates and screws (Trimed CoYUCMED Medical, Istanbul, Turkey). After the placement of the plate on the planned site, the screws were placed with the screw holder, and only 1 miniplate was used for each condyle. The wound was irrigated, the periosteum and the subcutaneous layers were closed with Vicryl, and the skin was closed with intradermic Prolene sutures. A minivac drain was placed. None of the patients underwent intermaxillary fixation after the operation.
Postoperative Care Postoperative antibiotics, analgesics, and anti-inflammatory medications were prescribed. The patients were instructed to have a soft diet for the first 3 weeks. Drains were removed 2 to 4 days after the operation. Imaging studies were repeated after the operation, using the same views as those in the preoperative studies. The other parameters including occlusal status, range of motion, and interincisal opening were evaluated and compared with preoperative values for functional assessment. In addition, postoperative complications including infection, facial nerve palsy, paresthesia, and hematoma were noted. The patients were reassessed regularly at 1, 3, 6, and 12 months after the operation.
Preoperative and Postoperative Evaluations The mean postoperative maximal interincisal distance was 46 mm (range, 40Y50 ). Six patients with interincisal distances of less than 46 mm had bilateral condyle fracture. Pain and tenderness during horizontal and vertical movements persisted for 3 months after the operation in all patients, which continued until the sixth month in the 6 patients with bilateral fractures. Four patients had lateral deflection to the side of the fracture being operated and to the contralateral side in the others. The preoperative range of the lateral deflections detected was between 1 and 6 mm. According to the preoperative measurements, the shortening of the ascending ramus ranged between 6 and 15 mm, which improved to a range of 1 to 5 mm 6 months after the operation. Preoperative fracture angulation was between 37 and 92 degrees, and postoperative angulation measured 6 months after the operation was
FIGURE 1. Intraoperative dissection.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 2. Reduction of fractured segments.
between 0 and 25 degrees. All measurements were carried out on the Philips Synapse Radiological Systems (Fujifilm Medical Systems, Stamford, CT).
Clinical Outcomes There were no hematomas. Only 1 of 16 patients developed local infections that were superficial to the SMAS and did not involve the TMJ; cultures remained sterile. In 8 patients, the operative sites were tender on palpation during the early postoperative period. Despite the traction from a long distance to achieve the fracture line for a considerably long time, only 1 patient had a transient facial palsy localized only to the frontal branch and that resolved without treatment in 6 weeks. There were no fractures or angulations in the miniplates. There were no postoperative salivary fistulae or transient auricular anesthesia/parasthesias. Two patients had minimal facial asymmetry. Postoperative preauricular scars were acceptable. Thirteen of the patients were very satisfied with regard to postoperative quality of life and masticatory functions, 2 patients who had minimal facial asymmetry were satisfied, and none were dissatisfied (Table 1).
DISCUSSION Although there are still controversies about the treatment of condylar fractures in adult patients, many surgeons favor open treatment of displaced condylar fractures because open reduction and rigid fixation allow for good anatomic repositioning and immediate function.11Y13 According to the advocates of surgical treatment, only precise open reduction and internal fixation can prevent unwanted long-term effects such as shortening of the mandibular ramus, facial asymmetry, arthrosis of the TMJ, and masticatory and articular dysfunction. Rehabilitation is quicker with surgical treatment, enabling faster return of the joint and the muscles of mastication to normal function.14Y16 Controversies in surgical treatment arise from
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its disadvantages such as complicated surgical procedure, possible injury to the branches of the facial nerve, difficulties in assessment of occlusion, mandibular deviation on mouth opening, and presence of infection.17Y22 Remodeling capacity of fractures is different for children. In children, the condyle has a great capacity to remodel; even a severely angulated condyle can remodel into a functionally adequate articular process.23Y25 Therefore, a conservative treatment consisting of a soft diet for 3 to 4 weeks and regular follow-up is often enough in children. In the presence of minimal occlusal disturbance or minimal angulation as in greenstick fractures, archbar and elastic traction can be used for 1 to 2 weeks. In adults, there is a limited remodeling capacity; the angulation and the shortening often leave the TMJ permanently distorted.23,25 All patients in our series were adults. Failure to accurately manage the joint results in joint dysfunction with difficult and painful mouth opening, deflection and angulation during mouth opening, arthrosis of the contralateral joint, facial asymmetry, and unfavorable mandibular motion. Zide and Kent26 advocated a narrow set of absolute indications in 1983. Eckelt and Rasse reported criteria such as medial angulation of the condyle of more than 30 degrees, shortening of the ramus of more than 5 mm, and loss of contact between fracture fragments.27,28 The criteria for surgical treatment in our patients included malocclusion, shortening of the ascending ramus of more than 5 mm, and fracture angulation of more than 30 degrees. Preoperative shortening of the ascending ramus was between 6 and 15 mm, which decreased to 1 to 5 mm. Preoperative fracture angulation ranged between 37 and 92 degrees, and postoperative residual angulation was between 0 and 25 degrees. The historical evolution of the indications for open reduction and internal fixation of condylar and subcondylar fractures of the mandible has changed significantly by the development of titanium miniplates and screws. As a consequence, this evolution widened the indications due to several factors such as the degree and direction of displacement, level of the fracture, position of the condylar head in relation to the glenoid fossa, patient’s age, dental status, accompanying fractures of the facial skeleton, potential to obtain a good occlusion, and the patient’s general condition.29 Open reduction includes several approaches that depend on fracture site and degree of bone fragment displacement. Fracture type, age of the patient, fractures in other locations, and dentition
TABLE 1. Patient Characteristics No. Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age/Sex
Etiology
Level of Fracture
Postoperative Complication
Satisfaction
46 M 16 M 16 M 18 M 33 F 30 M 28 M 29 M 29 F 17 M 28 M 23 M 34 M 22 M 28 F 32 M
Assault Accident Fall Fall Fall Fall Fall Assault Fall Accident Assault Accident Fall Accident Fall Fall
Condylar neck R and L condylar neck R condylar neck Condylar head L condylar neck L condylar head, R subcondylar region R and L condylar head R and L condylar neck L condylar neck L condylar region R condylar region R and L condylar neck L condylar neck, R subcondylar region R condylar region R condylar region L condylar region
None None None Local infection None Asymmetry None None Local infection None None Asymmetry None Transient facial palsy None None
Very satisfied Very satisfied Very satisfied Very satisfied Very satisfied Satisfied Very satisfied Satisfied Very satisfied Very satisfied Very satisfied Satisfied Satisfied Very satisfied Very satisfied Very satisfied
F, female; L, left; M, male; R, right.
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 2. Reduction of fractured segments.
between 0 and 25 degrees. All measurements were carried out on the Philips Synapse Radiological Systems (Fujifilm Medical Systems, Stamford, CT).
Clinical Outcomes There were no hematomas. Only 1 of 16 patients developed local infections that were superficial to the SMAS and did not involve the TMJ; cultures remained sterile. In 8 patients, the operative sites were tender on palpation during the early postoperative period. Despite the traction from a long distance to achieve the fracture line for a considerably long time, only 1 patient had a transient facial palsy localized only to the frontal branch and that resolved without treatment in 6 weeks. There were no fractures or angulations in the miniplates. There were no postoperative salivary fistulae or transient auricular anesthesia/parasthesias. Two patients had minimal facial asymmetry. Postoperative preauricular scars were acceptable. Thirteen of the patients were very satisfied with regard to postoperative quality of life and masticatory functions, 2 patients who had minimal facial asymmetry were satisfied, and none were dissatisfied (Table 1).
DISCUSSION Although there are still controversies about the treatment of condylar fractures in adult patients, many surgeons favor open treatment of displaced condylar fractures because open reduction and rigid fixation allow for good anatomic repositioning and immediate function.11Y13 According to the advocates of surgical treatment, only precise open reduction and internal fixation can prevent unwanted long-term effects such as shortening of the mandibular ramus, facial asymmetry, arthrosis of the TMJ, and masticatory and articular dysfunction. Rehabilitation is quicker with surgical treatment, enabling faster return of the joint and the muscles of mastication to normal function.14Y16 Controversies in surgical treatment arise from
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its disadvantages such as complicated surgical procedure, possible injury to the branches of the facial nerve, difficulties in assessment of occlusion, mandibular deviation on mouth opening, and presence of infection.17Y22 Remodeling capacity of fractures is different for children. In children, the condyle has a great capacity to remodel; even a severely angulated condyle can remodel into a functionally adequate articular process.23Y25 Therefore, a conservative treatment consisting of a soft diet for 3 to 4 weeks and regular follow-up is often enough in children. In the presence of minimal occlusal disturbance or minimal angulation as in greenstick fractures, archbar and elastic traction can be used for 1 to 2 weeks. In adults, there is a limited remodeling capacity; the angulation and the shortening often leave the TMJ permanently distorted.23,25 All patients in our series were adults. Failure to accurately manage the joint results in joint dysfunction with difficult and painful mouth opening, deflection and angulation during mouth opening, arthrosis of the contralateral joint, facial asymmetry, and unfavorable mandibular motion. Zide and Kent26 advocated a narrow set of absolute indications in 1983. Eckelt and Rasse reported criteria such as medial angulation of the condyle of more than 30 degrees, shortening of the ramus of more than 5 mm, and loss of contact between fracture fragments.27,28 The criteria for surgical treatment in our patients included malocclusion, shortening of the ascending ramus of more than 5 mm, and fracture angulation of more than 30 degrees. Preoperative shortening of the ascending ramus was between 6 and 15 mm, which decreased to 1 to 5 mm. Preoperative fracture angulation ranged between 37 and 92 degrees, and postoperative residual angulation was between 0 and 25 degrees. The historical evolution of the indications for open reduction and internal fixation of condylar and subcondylar fractures of the mandible has changed significantly by the development of titanium miniplates and screws. As a consequence, this evolution widened the indications due to several factors such as the degree and direction of displacement, level of the fracture, position of the condylar head in relation to the glenoid fossa, patient’s age, dental status, accompanying fractures of the facial skeleton, potential to obtain a good occlusion, and the patient’s general condition.29 Open reduction includes several approaches that depend on fracture site and degree of bone fragment displacement. Fracture type, age of the patient, fractures in other locations, and dentition
TABLE 1. Patient Characteristics No. Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age/Sex
Etiology
Level of Fracture
Postoperative Complication
Satisfaction
46 M 16 M 16 M 18 M 33 F 30 M 28 M 29 M 29 F 17 M 28 M 23 M 34 M 22 M 28 F 32 M
Assault Accident Fall Fall Fall Fall Fall Assault Fall Accident Assault Accident Fall Accident Fall Fall
Condylar neck R and L condylar neck R condylar neck Condylar head L condylar neck L condylar head, R subcondylar region R and L condylar head R and L condylar neck L condylar neck L condylar region R condylar region R and L condylar neck L condylar neck, R subcondylar region R condylar region R condylar region L condylar region
None None None Local infection None Asymmetry None None Local infection None None Asymmetry None Transient facial palsy None None
Very satisfied Very satisfied Very satisfied Very satisfied Very satisfied Satisfied Very satisfied Satisfied Very satisfied Very satisfied Very satisfied Satisfied Satisfied Very satisfied Very satisfied Very satisfied
F, female; L, left; M, male; R, right.
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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status should be considered. Injury of the facial nerve and vessels, esthetically unacceptable scars, and postoperative infections are the most pronounced disadvantages. The preauricular approach is useful for approaching high condylar fractures and also for exploring the TMJ and injured soft tissues. In particular, preauricular transparotid and retromandibular approaches have been postulated to provide easy reduction and rigid fixation for mandibular condyle fractures.8,30,31 This method has advantages of inconspicuous scar formation because the incision is made on the preauricular crease, and sufficient exposure of bone fragments in the upper part of the mandibular ramus is achieved. Risk for injury of the facial nerve and vessels is increased because of prolonged traction. Inevidently, the close relationship of the facial nerve branches and the parotid gland makes these procedures more demanding. The branches of the facial nerves have to be identified during incision and dissection. Dissection under minimal tension reduces facial nerve injury and transient nerve palsy. Intraoral, postauricular, submandibular, Risdon, and combined approaches are other choices to approach condyle fractures. Endoscopic technique, which is associated with less operative trauma, has recently become popular. Facial nerve injury and unacceptable scar risk are reduced by using this technique. This technique can be used in selected patients who have low subcondylar fractures. Another drawback of this technique is the requirement of special instruments.10 Prolonged retraction while using preauricular retromandibular approach for subcondylar fractures can cause transient facial nerve palsy. One patient among 16 in our series developed transient facial nerve palsies, which resolved spontaneously in 3 weeks. This result is comparable with other series.13Y16 We believe that the use of minivac drains and elastic bandages prevented postoperative hematoma formation. One of 16 patients had a local infection superficial to the SMAS. The infection did not involve the TMJ, and microbial agents were not isolated. According to our surgical experience, using a drape prevents local and surgical procedureYrelated infections. Carefully making a skin incision is important to have a less perceptible, camouflaged scar. In conclusion, in this report, we describe the technique called the preauricular underparotid retrograde approach, which provided a safer plan to encounter not only the frontal branch of the facial nerve but also underneath the parotid gland to not damage the gland anatomically and functionally. Neither salivary fistula nor hematoma was encountered. The underparotid retrograde approach to the condyle fractures is a straightforward and secure surgical option that provides adequate exposure for open reduction and internal fixation without leaving permanent nerve or parotid gland injury.
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1. Zachariades N, Papavassiliou D, Papademetriou I, et al. Fractures of the facial skeleton in Greece. A retrospective study covering 1791 cases in 10 years. J Maxillofac Surg 1983;11:142Y144 2. Bochlogyros PN. A retrospective study of 1,521 mandibular fractures. J Oral Maxillofac Surg 1985;43:597Y599 3. Zachariades N, Papavassiliou D. The pattern and aetiology of maxillofacial injuries in Greece. A retrospective study of 25 years and a comparison with other countries. J Craniomaxillofac Surg 1990;18:251Y254 4. Silvennoinen U, Iizuka T, Lindqvist C, et al. Different patterns of condylar fractures: an analysis of 382 patients in a 3-year period. J Oral Maxillofac Surg 1992;50:1032Y1037 5. Villarreal PM, Monje F, Junquera LM, et al. Mandibular condyle fractures: determinants of treatment and outcome. J Oral Maxillofac Surg 2004;62:155Y163 6. Lindahl L. Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and
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canal were involved in 10 patients (83.3%), whereas the otic capsule was not involved in any patient. The diagnosis of EG was established after histopathologic examination. Histologically, the lesion was characterized by expanding, erosive accumulations of Langerhans cells within the medullar cavity of the bone. Histiocytes were variably admixed with eosinophils, lymphocytes, plasma cells, and neutrophils. The cells were immunoreactive for CD1 antigen and S-100 protein in all our patients, whereas Saliba et al15 found positivity for these immunohistochemical stains in only 80% of their patients. The LCH has an unpredictable course varying from a rapidly fatal progressive disease to spontaneous resolution.2 However, the usual prognosis of the disease affecting the temporal bone is good in patients having limited organ involvement, with a survival rate of more than 90%.1 Age at presentation, multisystem involvement, and vital organ dysfunction are the most relevant prognostic factors, with bad prognosis in children younger than 2 years.2 There are several treatment modalities for histiocytosis, including surgery, radiotherapy, and chemotherapy. These modalities can be used either alone or in combinations, depending upon the extent and the severity of the disease. Different treatment protocols were used in different clinical settings.18 In our institute, the treatment protocol of EG is to perform cortical mastoidectomy followed by postoperative radiotherapy; in our study, there was no recurrence in 83.3% of our patients. Even the 2 patients who developed recurrence were treated successfully, with limited surgical excision because the recurrent lesions were superficial. Because of the fact that there are no large series in the literature, the optimal treatment protocol of histiocytosis is not well established. This is particularly true for EG because most published cases are sporadic without a standard protocol for treatment. With accumulation of data in the literature, the treatment of temporal bone EG may be standardized in the future.3 Bayazit et al3 stated that the most preferable method for treatment of temporal bone EG is surgical excision, and radiotherapy can be used for residual tissues when complete excision is not achieved. However, some authors preferred the use of corticosteroids, either local or systemic; others used chemotherapy especially in systemic lesions.19,20 del Rı´o et al21 proposed a treatment of temporal bone histiocytosis with radiosurgery, through isodoses of 10 Gy, with a good therapeutic response after 2 years of follow-up. Saliba et al15 treated a case of EG in the temporal bone only with steroid injections (Triamcinolone) in the mastoid, external auditory canal, and orbital region; they achieved complete eradication of the lesion after 1 year. In addition, Rodrı´guez Rivera et al22 treated EG with bone curettage and intralesional corticosteroid therapy; they obtained good clinical and radiologic response, without local and systemic relapse after a 3 month follow-up. Finally, we conclude that children with temporal bone EG may present with features that mimic the features of chronic suppurative otitis media. However, CT shows characteristic lesions, and histopathologic examination is diagnostic. Cortical mastoidectomy together with postoperative radiotherapy is a successful method for treatment of EG of the temporal bone; however, a long follow-up is essential to detect any recurrence.
REFERENCES 1. Boston M, Derkay CS. Langerhans cell histiocytosis of the temporal bone and skull base. Am J Otolaryngol 2002;23:246Y248 2. Martini A, Aimoni C, Trevisani M, et al. Langerhans cell histiocytosis: report of a case with temporal localization. Int J Pediatr Otorhinolaryngol 2000;55:51Y56 3. Bayazit Y, Sirikci A, Bayaram M, et al. Eosinophilic granuloma of the temporal bone. Auris Nasus Larynx 2001;28:99Y102
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4. Zinkham WH. Multifocal eosinophilic granuloma: natural history, etiology and management. Am J Med 1976;60:457Y463 5. Irving RM, Broadbent V, Jones NS. Langerhans’ cell histiocytosis in childhood: management of head and neck manifestations. Laryngoscope 1994;104:64Y70 6. Skoulakis CE, Drivas EI, Papadakis CE, et al. Langerhans cell histiocytosis presented as bilateral otitis media and mastoiditis. Turk J Pediatr 2008;50:70Y73 7. Greinwald JH, Smith RJH. Langerhans’ cell histiocytosis. In: Jackler RK, Driscoll CLW, eds. Tumor of the Ear and Temporal Bone. Philadelphia: Lippincott Williams & Wilkins, 2000:417Y430 8. Nanduri VR, Pritchard J, Chong WK, et al. Labyrinthine involvement in Langerhans’ cell histiocytosis. Int J Pediatr Otorhinolaryngol 1998;46:109Y115 9. Marioni G, De Filippis C, Stramare R, et al. Langerhans’ cell histiocytosis: temporal bone involvement. J Laryngol Otol 2001;115:839Y841 10. McCaffrey TV, McDonald TJ. Histiocytosis X of the ear and temporal bone: review of 22 cases. Laryngoscope 1979;89:1735Y1742 11. Sweet RM, Kornblut AD, Hyams VJ. Eosinophilic granuloma in the temporal bone. Laryngoscope 1979;89:1545Y1551 12. Levy R, Sarfaty SM, Schindel J. Eosinophilic granuloma of the temporal bone. Two cases with bilateral involvement. Arch Otolaryngol 1980;106:167Y171 13. Campos MK, Viana MB, de Oliveira BM, et al. Langerhans cell histiocytosis: a 16-year experience. J Pediatr (Rio J) 2007;83:79Y86 14. Puranik KR, Murthy PS, Gopalakrishna R, et al. Unusually large mastoid antrum (mega antrum). J Laryngol Otol 1992;106:164Y165 15. Saliba I, Sidani K, El Fata F, et al. Langerhans’ cell histiocytosis of the temporal bone in children. Int J Pediatr Otorhinolaryngol 2008;72:775Y786 16. Nicollas R, Rome A, BelaBch H, et al. Head and neck manifestation and prognosis of Langerhans’ cell histiocytosis in children. Int J Pediatr Otorhinolaryngol 2010;74:669Y673 17. Azouz EM, Saigal G, Rodriguez MM, et al. Langerhans’ cell histiocytosis: pathology, imaging and treatment of skeletal involvement. Pediatr Radiol 2005;35:103Y115 18. Appling D, Jenkins HA, Patton GA. Eosinophilic granuloma in the temporal bone and skull. Otolaryngol Head Neck Surg 1983;91:358Y365 19. Fo¨rster U, Klingebiel R, Schulte Overberg U, et al. Langerhans cell histiocytosis: petrosal remodeling after chemotherapyVcase report and review of the literature. Laryngorhinootologie 2003;82:166Y170 20. Lallemant B, Fayoux P, Nelken B, et al. Management of head and neck Langerhan’s cell histiocytosis in children. Ann Otolaryngol Chir Cervicofac 2003;120:30Y39 21. del Rı´o L, Lassaletta L, Martı´nez R, et al. Petrous bone Langerhans cell histiocytosis treated with radiosurgery. Stereotact Funct Neurosurg 2007;85:129Y131 22. Rodrı´guez Rivera V, Lesmas Navarro MJ, de Paula Vernetta C, et al. Early start eosinophilic granuloma of the temporal bone. Acta Otorrinolaringol Esp 2010;61:315Y317
Functional Outcomes of Preauricular Underparotid Retrograde Approach for Mandibular Condyle Fractures O¨zgur Pilanci, MD, Karaca Basaran, MD, Fatih Ceran, MD, Samet Vasfi Kuvat, MD Abstract: Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
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Various approaches have been previously mentioned for the access to the mandibular condyle. The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures. This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Functional outcomes with this method were addressed in light of the results obtained in this clinical series. We suggest this method in the management of condylar fractures. Key Words: Mandibular condylar fractures, preauricular underparotid retrograde approach
T
he mandible is one of the most important bones for esthetic appearance of the face, contributing significantly to the shape of the lower face. The anatomic position renders the mandible susceptible to trauma. The rate of condylar fractures among all mandibular fractures ranges between 17.5% and 52%.1Y5 To make a more precise classification, condylar fractures can be practically divided into 3 types based on the anatomic level of the fracture: head (intracapsular), neck (extracapsular), and the subcondylar region.6 Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. Various approaches have been previously mentioned for the access to the mandibular condyle.7Y10 The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures.
MATERIALS AND METHODS This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Three of the patients were female. The mean age was 27 years (range, 16Y46). The fractures were caused by falls in 9, assaults by another person in 3, and car accidents in 4. All fractures were pathologically displaced. Four patients had bilateral fractures. The mean interval between the trauma and surgery was 3 days.
Preoperative Imaging After evaluating patient histories and physical examinations, radiologic imaging was performed to visualize the condyle and the ramus of the mandible. An orthopantomogram and a maxillofacial computed tomography were performed in all patients before the operation to assess the level, type, displacement, and angulation of the fracture.
From the Plastic, Reconstructive, and Aesthetic Surgery, Bagcilar Training and Research Hospital, Bahcelievler, Istanbul, Turkey. Received September 25, 2013. Accepted for publication October 28, 2013. Address correspondence and reprint requests to Øzgur Pilanci, MD, Eski Londra Asfalti, Emlak Konut Sitesi, A 5, Daire 21, Bahcelievler, Istanbul, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000514
Brief Clinical Studies
Preauricular Underparotid Retrograde Approach General anesthesia and nasotracheal intubation were used. The surgical area was covered with a drape to prevent contamination. A solution containing 1:200000 epinephrine was injected to the operative field to ensure a relatively bloodless field. Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. A gull wingYshaped incision was made on the preauricular crease; the incision was carried down to the subcutaneous tissues and superficial to the superficial musculoaponeurotic system (SMAS) anteriorly. The superficial temporal vessels were left intact. The facial nerve and branches were protected. An incision was made parallel to the zygomatic arch. A periosteal elevator was inserted beneath the periosteum of the lateral zygomatic arch. The dissection was carried out retrogradely underneath the parotid gland to the joint to expose the capsule of the temporomandibular joint (TMJ) (Fig. 1). The fracture segments were then exposed, and the fracture was reduced (Fig. 2). In all cases, rigid osteosynthesis was carried out with miniplates and screws (Trimed CoYUCMED Medical, Istanbul, Turkey). After the placement of the plate on the planned site, the screws were placed with the screw holder, and only 1 miniplate was used for each condyle. The wound was irrigated, the periosteum and the subcutaneous layers were closed with Vicryl, and the skin was closed with intradermic Prolene sutures. A minivac drain was placed. None of the patients underwent intermaxillary fixation after the operation.
Postoperative Care Postoperative antibiotics, analgesics, and anti-inflammatory medications were prescribed. The patients were instructed to have a soft diet for the first 3 weeks. Drains were removed 2 to 4 days after the operation. Imaging studies were repeated after the operation, using the same views as those in the preoperative studies. The other parameters including occlusal status, range of motion, and interincisal opening were evaluated and compared with preoperative values for functional assessment. In addition, postoperative complications including infection, facial nerve palsy, paresthesia, and hematoma were noted. The patients were reassessed regularly at 1, 3, 6, and 12 months after the operation.
Preoperative and Postoperative Evaluations The mean postoperative maximal interincisal distance was 46 mm (range, 40Y50 ). Six patients with interincisal distances of less than 46 mm had bilateral condyle fracture. Pain and tenderness during horizontal and vertical movements persisted for 3 months after the operation in all patients, which continued until the sixth month in the 6 patients with bilateral fractures. Four patients had lateral deflection to the side of the fracture being operated and to the contralateral side in the others. The preoperative range of the lateral deflections detected was between 1 and 6 mm. According to the preoperative measurements, the shortening of the ascending ramus ranged between 6 and 15 mm, which improved to a range of 1 to 5 mm 6 months after the operation. Preoperative fracture angulation was between 37 and 92 degrees, and postoperative angulation measured 6 months after the operation was
FIGURE 1. Intraoperative dissection.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 2. Reduction of fractured segments.
between 0 and 25 degrees. All measurements were carried out on the Philips Synapse Radiological Systems (Fujifilm Medical Systems, Stamford, CT).
Clinical Outcomes There were no hematomas. Only 1 of 16 patients developed local infections that were superficial to the SMAS and did not involve the TMJ; cultures remained sterile. In 8 patients, the operative sites were tender on palpation during the early postoperative period. Despite the traction from a long distance to achieve the fracture line for a considerably long time, only 1 patient had a transient facial palsy localized only to the frontal branch and that resolved without treatment in 6 weeks. There were no fractures or angulations in the miniplates. There were no postoperative salivary fistulae or transient auricular anesthesia/parasthesias. Two patients had minimal facial asymmetry. Postoperative preauricular scars were acceptable. Thirteen of the patients were very satisfied with regard to postoperative quality of life and masticatory functions, 2 patients who had minimal facial asymmetry were satisfied, and none were dissatisfied (Table 1).
DISCUSSION Although there are still controversies about the treatment of condylar fractures in adult patients, many surgeons favor open treatment of displaced condylar fractures because open reduction and rigid fixation allow for good anatomic repositioning and immediate function.11Y13 According to the advocates of surgical treatment, only precise open reduction and internal fixation can prevent unwanted long-term effects such as shortening of the mandibular ramus, facial asymmetry, arthrosis of the TMJ, and masticatory and articular dysfunction. Rehabilitation is quicker with surgical treatment, enabling faster return of the joint and the muscles of mastication to normal function.14Y16 Controversies in surgical treatment arise from
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its disadvantages such as complicated surgical procedure, possible injury to the branches of the facial nerve, difficulties in assessment of occlusion, mandibular deviation on mouth opening, and presence of infection.17Y22 Remodeling capacity of fractures is different for children. In children, the condyle has a great capacity to remodel; even a severely angulated condyle can remodel into a functionally adequate articular process.23Y25 Therefore, a conservative treatment consisting of a soft diet for 3 to 4 weeks and regular follow-up is often enough in children. In the presence of minimal occlusal disturbance or minimal angulation as in greenstick fractures, archbar and elastic traction can be used for 1 to 2 weeks. In adults, there is a limited remodeling capacity; the angulation and the shortening often leave the TMJ permanently distorted.23,25 All patients in our series were adults. Failure to accurately manage the joint results in joint dysfunction with difficult and painful mouth opening, deflection and angulation during mouth opening, arthrosis of the contralateral joint, facial asymmetry, and unfavorable mandibular motion. Zide and Kent26 advocated a narrow set of absolute indications in 1983. Eckelt and Rasse reported criteria such as medial angulation of the condyle of more than 30 degrees, shortening of the ramus of more than 5 mm, and loss of contact between fracture fragments.27,28 The criteria for surgical treatment in our patients included malocclusion, shortening of the ascending ramus of more than 5 mm, and fracture angulation of more than 30 degrees. Preoperative shortening of the ascending ramus was between 6 and 15 mm, which decreased to 1 to 5 mm. Preoperative fracture angulation ranged between 37 and 92 degrees, and postoperative residual angulation was between 0 and 25 degrees. The historical evolution of the indications for open reduction and internal fixation of condylar and subcondylar fractures of the mandible has changed significantly by the development of titanium miniplates and screws. As a consequence, this evolution widened the indications due to several factors such as the degree and direction of displacement, level of the fracture, position of the condylar head in relation to the glenoid fossa, patient’s age, dental status, accompanying fractures of the facial skeleton, potential to obtain a good occlusion, and the patient’s general condition.29 Open reduction includes several approaches that depend on fracture site and degree of bone fragment displacement. Fracture type, age of the patient, fractures in other locations, and dentition
TABLE 1. Patient Characteristics No. Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age/Sex
Etiology
Level of Fracture
Postoperative Complication
Satisfaction
46 M 16 M 16 M 18 M 33 F 30 M 28 M 29 M 29 F 17 M 28 M 23 M 34 M 22 M 28 F 32 M
Assault Accident Fall Fall Fall Fall Fall Assault Fall Accident Assault Accident Fall Accident Fall Fall
Condylar neck R and L condylar neck R condylar neck Condylar head L condylar neck L condylar head, R subcondylar region R and L condylar head R and L condylar neck L condylar neck L condylar region R condylar region R and L condylar neck L condylar neck, R subcondylar region R condylar region R condylar region L condylar region
None None None Local infection None Asymmetry None None Local infection None None Asymmetry None Transient facial palsy None None
Very satisfied Very satisfied Very satisfied Very satisfied Very satisfied Satisfied Very satisfied Satisfied Very satisfied Very satisfied Very satisfied Satisfied Satisfied Very satisfied Very satisfied Very satisfied
F, female; L, left; M, male; R, right.
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 2. Reduction of fractured segments.
between 0 and 25 degrees. All measurements were carried out on the Philips Synapse Radiological Systems (Fujifilm Medical Systems, Stamford, CT).
Clinical Outcomes There were no hematomas. Only 1 of 16 patients developed local infections that were superficial to the SMAS and did not involve the TMJ; cultures remained sterile. In 8 patients, the operative sites were tender on palpation during the early postoperative period. Despite the traction from a long distance to achieve the fracture line for a considerably long time, only 1 patient had a transient facial palsy localized only to the frontal branch and that resolved without treatment in 6 weeks. There were no fractures or angulations in the miniplates. There were no postoperative salivary fistulae or transient auricular anesthesia/parasthesias. Two patients had minimal facial asymmetry. Postoperative preauricular scars were acceptable. Thirteen of the patients were very satisfied with regard to postoperative quality of life and masticatory functions, 2 patients who had minimal facial asymmetry were satisfied, and none were dissatisfied (Table 1).
DISCUSSION Although there are still controversies about the treatment of condylar fractures in adult patients, many surgeons favor open treatment of displaced condylar fractures because open reduction and rigid fixation allow for good anatomic repositioning and immediate function.11Y13 According to the advocates of surgical treatment, only precise open reduction and internal fixation can prevent unwanted long-term effects such as shortening of the mandibular ramus, facial asymmetry, arthrosis of the TMJ, and masticatory and articular dysfunction. Rehabilitation is quicker with surgical treatment, enabling faster return of the joint and the muscles of mastication to normal function.14Y16 Controversies in surgical treatment arise from
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its disadvantages such as complicated surgical procedure, possible injury to the branches of the facial nerve, difficulties in assessment of occlusion, mandibular deviation on mouth opening, and presence of infection.17Y22 Remodeling capacity of fractures is different for children. In children, the condyle has a great capacity to remodel; even a severely angulated condyle can remodel into a functionally adequate articular process.23Y25 Therefore, a conservative treatment consisting of a soft diet for 3 to 4 weeks and regular follow-up is often enough in children. In the presence of minimal occlusal disturbance or minimal angulation as in greenstick fractures, archbar and elastic traction can be used for 1 to 2 weeks. In adults, there is a limited remodeling capacity; the angulation and the shortening often leave the TMJ permanently distorted.23,25 All patients in our series were adults. Failure to accurately manage the joint results in joint dysfunction with difficult and painful mouth opening, deflection and angulation during mouth opening, arthrosis of the contralateral joint, facial asymmetry, and unfavorable mandibular motion. Zide and Kent26 advocated a narrow set of absolute indications in 1983. Eckelt and Rasse reported criteria such as medial angulation of the condyle of more than 30 degrees, shortening of the ramus of more than 5 mm, and loss of contact between fracture fragments.27,28 The criteria for surgical treatment in our patients included malocclusion, shortening of the ascending ramus of more than 5 mm, and fracture angulation of more than 30 degrees. Preoperative shortening of the ascending ramus was between 6 and 15 mm, which decreased to 1 to 5 mm. Preoperative fracture angulation ranged between 37 and 92 degrees, and postoperative residual angulation was between 0 and 25 degrees. The historical evolution of the indications for open reduction and internal fixation of condylar and subcondylar fractures of the mandible has changed significantly by the development of titanium miniplates and screws. As a consequence, this evolution widened the indications due to several factors such as the degree and direction of displacement, level of the fracture, position of the condylar head in relation to the glenoid fossa, patient’s age, dental status, accompanying fractures of the facial skeleton, potential to obtain a good occlusion, and the patient’s general condition.29 Open reduction includes several approaches that depend on fracture site and degree of bone fragment displacement. Fracture type, age of the patient, fractures in other locations, and dentition
TABLE 1. Patient Characteristics No. Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age/Sex
Etiology
Level of Fracture
Postoperative Complication
Satisfaction
46 M 16 M 16 M 18 M 33 F 30 M 28 M 29 M 29 F 17 M 28 M 23 M 34 M 22 M 28 F 32 M
Assault Accident Fall Fall Fall Fall Fall Assault Fall Accident Assault Accident Fall Accident Fall Fall
Condylar neck R and L condylar neck R condylar neck Condylar head L condylar neck L condylar head, R subcondylar region R and L condylar head R and L condylar neck L condylar neck L condylar region R condylar region R and L condylar neck L condylar neck, R subcondylar region R condylar region R condylar region L condylar region
None None None Local infection None Asymmetry None None Local infection None None Asymmetry None Transient facial palsy None None
Very satisfied Very satisfied Very satisfied Very satisfied Very satisfied Satisfied Very satisfied Satisfied Very satisfied Very satisfied Very satisfied Satisfied Satisfied Very satisfied Very satisfied Very satisfied
F, female; L, left; M, male; R, right.
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* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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status should be considered. Injury of the facial nerve and vessels, esthetically unacceptable scars, and postoperative infections are the most pronounced disadvantages. The preauricular approach is useful for approaching high condylar fractures and also for exploring the TMJ and injured soft tissues. In particular, preauricular transparotid and retromandibular approaches have been postulated to provide easy reduction and rigid fixation for mandibular condyle fractures.8,30,31 This method has advantages of inconspicuous scar formation because the incision is made on the preauricular crease, and sufficient exposure of bone fragments in the upper part of the mandibular ramus is achieved. Risk for injury of the facial nerve and vessels is increased because of prolonged traction. Inevidently, the close relationship of the facial nerve branches and the parotid gland makes these procedures more demanding. The branches of the facial nerves have to be identified during incision and dissection. Dissection under minimal tension reduces facial nerve injury and transient nerve palsy. Intraoral, postauricular, submandibular, Risdon, and combined approaches are other choices to approach condyle fractures. Endoscopic technique, which is associated with less operative trauma, has recently become popular. Facial nerve injury and unacceptable scar risk are reduced by using this technique. This technique can be used in selected patients who have low subcondylar fractures. Another drawback of this technique is the requirement of special instruments.10 Prolonged retraction while using preauricular retromandibular approach for subcondylar fractures can cause transient facial nerve palsy. One patient among 16 in our series developed transient facial nerve palsies, which resolved spontaneously in 3 weeks. This result is comparable with other series.13Y16 We believe that the use of minivac drains and elastic bandages prevented postoperative hematoma formation. One of 16 patients had a local infection superficial to the SMAS. The infection did not involve the TMJ, and microbial agents were not isolated. According to our surgical experience, using a drape prevents local and surgical procedureYrelated infections. Carefully making a skin incision is important to have a less perceptible, camouflaged scar. In conclusion, in this report, we describe the technique called the preauricular underparotid retrograde approach, which provided a safer plan to encounter not only the frontal branch of the facial nerve but also underneath the parotid gland to not damage the gland anatomically and functionally. Neither salivary fistula nor hematoma was encountered. The underparotid retrograde approach to the condyle fractures is a straightforward and secure surgical option that provides adequate exposure for open reduction and internal fixation without leaving permanent nerve or parotid gland injury.
7.
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1. Zachariades N, Papavassiliou D, Papademetriou I, et al. Fractures of the facial skeleton in Greece. A retrospective study covering 1791 cases in 10 years. J Maxillofac Surg 1983;11:142Y144 2. Bochlogyros PN. A retrospective study of 1,521 mandibular fractures. J Oral Maxillofac Surg 1985;43:597Y599 3. Zachariades N, Papavassiliou D. The pattern and aetiology of maxillofacial injuries in Greece. A retrospective study of 25 years and a comparison with other countries. J Craniomaxillofac Surg 1990;18:251Y254 4. Silvennoinen U, Iizuka T, Lindqvist C, et al. Different patterns of condylar fractures: an analysis of 382 patients in a 3-year period. J Oral Maxillofac Surg 1992;50:1032Y1037 5. Villarreal PM, Monje F, Junquera LM, et al. Mandibular condyle fractures: determinants of treatment and outcome. J Oral Maxillofac Surg 2004;62:155Y163 6. Lindahl L. Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and
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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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