TECHNICAL STRATEGY
Modified Submandibular Access for Open Reduction and Internal Rigid Fixation in Condylar Fractures Ricardo Augusto Conci, Msc,* Flávio Henrique Silveira Tomazi, Jr, DDS,* Rosana Kalaoun, Msc,* Guilherme Genehr Fritscher, PhD,* Greison Rabelo de Oliveira, PhD,† and Claiton Heitz, PhD* Purpose: The purpose of the present study was to describe a surgical technique for treatment of condylar fractures through the modified submandibular access, by means of a small incision in the mandibular angle that promotes a dissection between the parotideomasseteric and the transmasseteric fascia in a quick way and with low morbidity. Fixation may be made with plates and screws according to the technique prescribed by the surgeon. Methods: Owing to the high incidence and importance of condylar fractures, various therapeutic methods have been described and may be divided into conservative and surgical methods. Various open surgical techniques are recommended in the treatment of mandibular condylar fractures, and the methods of internal rigid fixation and surgical accesses vary. The techniques that offer an adequate treatment of these fractures with shorter surgical time very often remain matters of controversy among surgeons. The procedure must guarantee maximum safety for the facial nerve and must provide a good cosmetic outcome, besides providing a suitable surgical field. Results: A modified submandibular access is a safe and reproducible procedure providing excellent functional results. This procedure has been routinely performed in our department. Key Words: Condylar fractures, modified submandibular access, mandibular fractures (J Craniofac Surg 2015;26: 232–234)
C
ondylar fractures represent 20% to 30% of all mandibular fractures1,2 and differ from others because of the difficulty of clinical and imaging diagnosis.3 Owing to the high occurrence of these fractures, various therapeutic methods have been described4 and are divided into conservative and surgical methods. The conservative methods are indicated in cases of fractures with little or no displacement, fractures that occur during childhood, and intracapsular fractures, depending on the line of the fracture. Treatment consists in a maxilomandibular blockage from 10 to 14 days.1,2,5
From the *Pontifícia Universidade Católica do Rio Grande do Sul – PUC/ RS, Porto Alegre, RS, Brazil; and †Universidade Estadual do Oeste do Paraná – UNIOESTE, Paraná, Brazil. Received November 13, 2013. Accepted for publication May 8, 2014. Address correspondence and reprint requests to Ricardo Augusto Conci, Msc, Pontifícia Universidade Católica do Rio Grande do Sul – PUC/RS, Av. Ipiranga 6681, Bloco 6, 90619-900, Porto Alegre, RS, Brazil; E-mail: [email protected] The author reports no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001099
232
Indications for open treatments are as yet highly controversial, especially in the access of choice for the resolution of a clinical case.1,4,6 Condylar fractures are mostly reached through preauricular, submandibular, and retromandibular accesses; and it is important to consider associated mandibular fractures, the surgeon’s experience, and aesthetical aspects.1,7,8 Access by endoscopy affords a limited transoral incision with imperceptible scars, a minimal chance of facial nerve lesions, and no need for a dissection of the masseter muscle. However, this is a more complex surgical technique compared to others, for it requires more training and relatively longer surgical time.1,8 The objective of a surgical treatment is anatomical restoration and early mobilization of the mandible, with total functional recovery.1 The success of the treatment is related to the nonlimitation of mouth opening and mandibular movement, which should be similar to those previous to the trauma.1
Technical Surgery A modified submandibular access is indicated in all subcondylar fractures, with or without displacement. When they are associated to other types of mandibular fractures, they are also initially treated openly with monocortical plates and screws. The incision is made 0.5 cm below the mandibular angle, with an extension of 3 cm (Fig. 1). Subcutaneous dissection is made upon the upper portion of the platysma muscle and extends widely over the fascia parotideomasseterica, thus involving the anterosuperior and inferior portions of the parotid gland and the masseter muscle (Fig. 2). For this, a dissection in the upper direction of 2 cm and the lower end of 1 cm is required. Therefore, we can access the fractures correctly and we can install screws, which should occur perpendicular to the fracture. In cases of high condylar fractures, a blunt dissection is made along the fibers of the masseter muscle, between the higher and
FIGURE 1. Displaced left low subcondylar fracture of the mandible with severe occlusal problems.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Modified Submandibular Access
FIGURE 4. Good exposure of the fracture line and reduction of the fractures.
FIGURE 2. The modified submandibular acess: submandibular acess (*) and retromandibular acess (**).
lower buccal branches, and in the case of lower fractures, between the inferior marginal and inferior buccal branches of the facial nerve. As the dissection occurs parallel to the fibers of the masseter, there is no requirement to monitor the facial nerve, which can be easily visualized and inferiorly away during surgery, avoiding injuries that can cause functional and aesthetic damage to the patient (Fig. 3). The reduction occurs after the subperiosteal displacement of the region of the ascendant branch and of the condylar neck. The open reduction and internal fixation may be performed with one or two 2.0-mm miniplates or associating one 2.0-mm miniplate to a 1.5-mm miniplate, by means of special (hybrid) plates, or with a neck screw attached to the miniplate (Fig. 4). In this case, we chose the internal rigid fixation technique with two plates, with satisfactory resolution (Figs. 5 and 6). Since 2009, we have been performing this technique on more than 30 patients. The access to condylar fractures is satisfactory. No facial palsy, even if transient, has occurred to date. The mean duration of the procedure was 60 minutes. The technique is relatively easy and presents favorable aesthetic results,
FIGURE 3. Subcutaneous dissection over the platysma muscle. Fibers of the platysma muscle are cut to expose the masseteric fascia (*). Lower clearance of the facial nerve during surgical access.
with a discreet scar hidden beneath the inferior border of the mandible. It is therefore a viable alternative to other procedures.
DISCUSSION An open approach to the treatment of patients with dislocated condylar fractures is becoming the standard of care in an increasing number of institutions.9 The choice for surgical access depends on the selected fixation system and on the type of fracture. It is known, however, that the structure that is responsible for much hesitation in the choice of surgical access is the facial nerve. The 2 types of access that are most frequently used are the preauricular and the submandibular types, and they have a direct anatomic relation with auriculotemporal and mandibular-marginal branches, respectively.1,8,10 Moreover, one can resort to the retromandibular access.1,8 The marginal branch of the mandible is that which is most frequently affected in submandibular and retromandibular accesses. On the other hand, the preauricular approach often causes lesions of the temporal and zygomatic branches.11 For subcondylar fractures, the preauricular access is too high, whereas the submandibular access is too low. The retromandibular access, on the other hand, affords a complete visualization and alignment of the fractured fragments.1,8 The access to the line of the fracture is sometimes unsatisfactory in submandibular and retromandibular approaches, especially in high fractures, because the skin incision is made far from the fracture and the soft tissue retraction is not easy and may induce facial nerve damage.8,12 Paresthesia is the most frequent complication in this type of surgery, 30% to 48% being transitory and 1% definite.11 Another limitation to these accesses is that the plates and screws are generally inserted in an oblique direction in relation to
FIGURE 5. Internal fixation is performed with the use of 2 plates arranged obliquely.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
233
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Conci et al
FIGURE 6. Postoperative computed tomographic scan shows good reduction of fractures.
the surface of the bone. Under these conditions, stabilization is hard to perform and may be deficient.9,11,13 Although the transoral approach offers the best aesthetic results, it often needs a transbuccal screw by means of a trocar, which may also lead to injuries of the facial nerve.1,8,14 The intraoral approach and its endoscopically assisted modifications can offer the best cosmetic outcomes.8,10 Even with the assistance of an endoscope, the procedure requires specific instruments, professionals with special training, and longer surgical time. In addition, more serious complications may occur with the intraoral approach compared to extraoral approaches, such as the ill placement of the fragment, reabsorption of the condylar head, persistent postoperative malocclusion, and functional problems of the temporomandibular joint.2
REFERENCES 1. Kim BK, Kwon YD, Ohe JY, et al. Usefulness of the retromandibular transparotid approach for condylar neck and condylar base fractures. J Craniofac Surg 2012;23:712–715
234
2. Biglioli F, Colletti G. Transmasseter approach to condylar fractures by mini-retromandibular access. J Oral Maxillofac Surg 2009; 67:2418–2424 3. Gupta M, Iyer N, Das D, et al. Analysis of different treatment protocols for fractures of condylar process of mandible. J Oral Maxillofac Surg 2012;70:83–91 4. Valiati R, Ibrahim D, Abreu MER, et al. The treatment of condylar fractures: to open or not to open? A critical review of this controversy. Int J Med Sci 2008;5:313–318 5. Ellis E III, McFadden D, Simon P, et al. Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2000;58:950–958 6. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001;59:370–376 7. Knepil GJ, Kanatas AN, Loukota RJ. Classification of surgical approaches to the mandibular condyle. Br J Oral Maxillof Surg 2011;49:664–665 8. Yang L, Patil PM. The retromandibular transparotid approach to mandibular subcondylar fractures. Int J Oral Maxillofac Surg 2012;41:494–499 9. Trost O, El-Naaj IA, Trouilloud P, et al. High cervical transmasseteric anteroparotid approach for open reduction and internal fixation of condylar fracture. J Oral Maxillofac Surg 2008;66:201–204 10. Kheradpir AR, Chien AT, Julian RS III. Transoral osteosynthesis of subcondylar fractures of the mandible using a fenestrated Levassier-Merrill retractor. J Oral Maxillofac Surg 2011; 69:2006–2011 11. Wilson AW, Ethunandan M, Brennan PA. Transmasseteric antero-parotid approach for open reduction and internal fixation of condylar fractures. Br J Oral Maxillof Surg 2005;43:57–60 12. Bhavsar D, Barkdull G, Berger J, et al. A Novel surgical approach to subcondylar fractures of mandible. J Craniof Surg 2008;19:496–499 13. Trost O, Trouilloud P, Malka G. Open reduction and internal fixation of low subcondylar fractures of mandible through high cervical transmasseteric anteroparotid approach. J Oral Maxillofac Surg 2009;67:2446–2451 14. Nirvikalpa N, Narayanan V. Subankylotic ostectomy for release of TMJ ankylosis using the transmasseteric anterior parotid approach. J Craniof Surg 2011;22:2300–2303
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Modified Submandibular Access for Open Reduction and Internal Rigid Fixation in Condylar Fractures Ricardo Augusto Conci, Msc,* Flávio Henrique Silveira Tomazi, Jr, DDS,* Rosana Kalaoun, Msc,* Guilherme Genehr Fritscher, PhD,* Greison Rabelo de Oliveira, PhD,† and Claiton Heitz, PhD* Purpose: The purpose of the present study was to describe a surgical technique for treatment of condylar fractures through the modified submandibular access, by means of a small incision in the mandibular angle that promotes a dissection between the parotideomasseteric and the transmasseteric fascia in a quick way and with low morbidity. Fixation may be made with plates and screws according to the technique prescribed by the surgeon. Methods: Owing to the high incidence and importance of condylar fractures, various therapeutic methods have been described and may be divided into conservative and surgical methods. Various open surgical techniques are recommended in the treatment of mandibular condylar fractures, and the methods of internal rigid fixation and surgical accesses vary. The techniques that offer an adequate treatment of these fractures with shorter surgical time very often remain matters of controversy among surgeons. The procedure must guarantee maximum safety for the facial nerve and must provide a good cosmetic outcome, besides providing a suitable surgical field. Results: A modified submandibular access is a safe and reproducible procedure providing excellent functional results. This procedure has been routinely performed in our department. Key Words: Condylar fractures, modified submandibular access, mandibular fractures (J Craniofac Surg 2015;26: 232–234)
C
ondylar fractures represent 20% to 30% of all mandibular fractures1,2 and differ from others because of the difficulty of clinical and imaging diagnosis.3 Owing to the high occurrence of these fractures, various therapeutic methods have been described4 and are divided into conservative and surgical methods. The conservative methods are indicated in cases of fractures with little or no displacement, fractures that occur during childhood, and intracapsular fractures, depending on the line of the fracture. Treatment consists in a maxilomandibular blockage from 10 to 14 days.1,2,5
From the *Pontifícia Universidade Católica do Rio Grande do Sul – PUC/ RS, Porto Alegre, RS, Brazil; and †Universidade Estadual do Oeste do Paraná – UNIOESTE, Paraná, Brazil. Received November 13, 2013. Accepted for publication May 8, 2014. Address correspondence and reprint requests to Ricardo Augusto Conci, Msc, Pontifícia Universidade Católica do Rio Grande do Sul – PUC/RS, Av. Ipiranga 6681, Bloco 6, 90619-900, Porto Alegre, RS, Brazil; E-mail: [email protected] The author reports no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001099
232
Indications for open treatments are as yet highly controversial, especially in the access of choice for the resolution of a clinical case.1,4,6 Condylar fractures are mostly reached through preauricular, submandibular, and retromandibular accesses; and it is important to consider associated mandibular fractures, the surgeon’s experience, and aesthetical aspects.1,7,8 Access by endoscopy affords a limited transoral incision with imperceptible scars, a minimal chance of facial nerve lesions, and no need for a dissection of the masseter muscle. However, this is a more complex surgical technique compared to others, for it requires more training and relatively longer surgical time.1,8 The objective of a surgical treatment is anatomical restoration and early mobilization of the mandible, with total functional recovery.1 The success of the treatment is related to the nonlimitation of mouth opening and mandibular movement, which should be similar to those previous to the trauma.1
Technical Surgery A modified submandibular access is indicated in all subcondylar fractures, with or without displacement. When they are associated to other types of mandibular fractures, they are also initially treated openly with monocortical plates and screws. The incision is made 0.5 cm below the mandibular angle, with an extension of 3 cm (Fig. 1). Subcutaneous dissection is made upon the upper portion of the platysma muscle and extends widely over the fascia parotideomasseterica, thus involving the anterosuperior and inferior portions of the parotid gland and the masseter muscle (Fig. 2). For this, a dissection in the upper direction of 2 cm and the lower end of 1 cm is required. Therefore, we can access the fractures correctly and we can install screws, which should occur perpendicular to the fracture. In cases of high condylar fractures, a blunt dissection is made along the fibers of the masseter muscle, between the higher and
FIGURE 1. Displaced left low subcondylar fracture of the mandible with severe occlusal problems.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Modified Submandibular Access
FIGURE 4. Good exposure of the fracture line and reduction of the fractures.
FIGURE 2. The modified submandibular acess: submandibular acess (*) and retromandibular acess (**).
lower buccal branches, and in the case of lower fractures, between the inferior marginal and inferior buccal branches of the facial nerve. As the dissection occurs parallel to the fibers of the masseter, there is no requirement to monitor the facial nerve, which can be easily visualized and inferiorly away during surgery, avoiding injuries that can cause functional and aesthetic damage to the patient (Fig. 3). The reduction occurs after the subperiosteal displacement of the region of the ascendant branch and of the condylar neck. The open reduction and internal fixation may be performed with one or two 2.0-mm miniplates or associating one 2.0-mm miniplate to a 1.5-mm miniplate, by means of special (hybrid) plates, or with a neck screw attached to the miniplate (Fig. 4). In this case, we chose the internal rigid fixation technique with two plates, with satisfactory resolution (Figs. 5 and 6). Since 2009, we have been performing this technique on more than 30 patients. The access to condylar fractures is satisfactory. No facial palsy, even if transient, has occurred to date. The mean duration of the procedure was 60 minutes. The technique is relatively easy and presents favorable aesthetic results,
FIGURE 3. Subcutaneous dissection over the platysma muscle. Fibers of the platysma muscle are cut to expose the masseteric fascia (*). Lower clearance of the facial nerve during surgical access.
with a discreet scar hidden beneath the inferior border of the mandible. It is therefore a viable alternative to other procedures.
DISCUSSION An open approach to the treatment of patients with dislocated condylar fractures is becoming the standard of care in an increasing number of institutions.9 The choice for surgical access depends on the selected fixation system and on the type of fracture. It is known, however, that the structure that is responsible for much hesitation in the choice of surgical access is the facial nerve. The 2 types of access that are most frequently used are the preauricular and the submandibular types, and they have a direct anatomic relation with auriculotemporal and mandibular-marginal branches, respectively.1,8,10 Moreover, one can resort to the retromandibular access.1,8 The marginal branch of the mandible is that which is most frequently affected in submandibular and retromandibular accesses. On the other hand, the preauricular approach often causes lesions of the temporal and zygomatic branches.11 For subcondylar fractures, the preauricular access is too high, whereas the submandibular access is too low. The retromandibular access, on the other hand, affords a complete visualization and alignment of the fractured fragments.1,8 The access to the line of the fracture is sometimes unsatisfactory in submandibular and retromandibular approaches, especially in high fractures, because the skin incision is made far from the fracture and the soft tissue retraction is not easy and may induce facial nerve damage.8,12 Paresthesia is the most frequent complication in this type of surgery, 30% to 48% being transitory and 1% definite.11 Another limitation to these accesses is that the plates and screws are generally inserted in an oblique direction in relation to
FIGURE 5. Internal fixation is performed with the use of 2 plates arranged obliquely.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
233
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Conci et al
FIGURE 6. Postoperative computed tomographic scan shows good reduction of fractures.
the surface of the bone. Under these conditions, stabilization is hard to perform and may be deficient.9,11,13 Although the transoral approach offers the best aesthetic results, it often needs a transbuccal screw by means of a trocar, which may also lead to injuries of the facial nerve.1,8,14 The intraoral approach and its endoscopically assisted modifications can offer the best cosmetic outcomes.8,10 Even with the assistance of an endoscope, the procedure requires specific instruments, professionals with special training, and longer surgical time. In addition, more serious complications may occur with the intraoral approach compared to extraoral approaches, such as the ill placement of the fragment, reabsorption of the condylar head, persistent postoperative malocclusion, and functional problems of the temporomandibular joint.2
REFERENCES 1. Kim BK, Kwon YD, Ohe JY, et al. Usefulness of the retromandibular transparotid approach for condylar neck and condylar base fractures. J Craniofac Surg 2012;23:712–715
234
2. Biglioli F, Colletti G. Transmasseter approach to condylar fractures by mini-retromandibular access. J Oral Maxillofac Surg 2009; 67:2418–2424 3. Gupta M, Iyer N, Das D, et al. Analysis of different treatment protocols for fractures of condylar process of mandible. J Oral Maxillofac Surg 2012;70:83–91 4. Valiati R, Ibrahim D, Abreu MER, et al. The treatment of condylar fractures: to open or not to open? A critical review of this controversy. Int J Med Sci 2008;5:313–318 5. Ellis E III, McFadden D, Simon P, et al. Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2000;58:950–958 6. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001;59:370–376 7. Knepil GJ, Kanatas AN, Loukota RJ. Classification of surgical approaches to the mandibular condyle. Br J Oral Maxillof Surg 2011;49:664–665 8. Yang L, Patil PM. The retromandibular transparotid approach to mandibular subcondylar fractures. Int J Oral Maxillofac Surg 2012;41:494–499 9. Trost O, El-Naaj IA, Trouilloud P, et al. High cervical transmasseteric anteroparotid approach for open reduction and internal fixation of condylar fracture. J Oral Maxillofac Surg 2008;66:201–204 10. Kheradpir AR, Chien AT, Julian RS III. Transoral osteosynthesis of subcondylar fractures of the mandible using a fenestrated Levassier-Merrill retractor. J Oral Maxillofac Surg 2011; 69:2006–2011 11. Wilson AW, Ethunandan M, Brennan PA. Transmasseteric antero-parotid approach for open reduction and internal fixation of condylar fractures. Br J Oral Maxillof Surg 2005;43:57–60 12. Bhavsar D, Barkdull G, Berger J, et al. A Novel surgical approach to subcondylar fractures of mandible. J Craniof Surg 2008;19:496–499 13. Trost O, Trouilloud P, Malka G. Open reduction and internal fixation of low subcondylar fractures of mandible through high cervical transmasseteric anteroparotid approach. J Oral Maxillofac Surg 2009;67:2446–2451 14. Nirvikalpa N, Narayanan V. Subankylotic ostectomy for release of TMJ ankylosis using the transmasseteric anterior parotid approach. J Craniof Surg 2011;22:2300–2303
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
