CLINICAL STUDY

Transparotid Approach in the Treatment of Intracapsular Condylar Fracture Jun Shi, DDS, MD,* Feifei Jiao, MB,† Bing Xu, DDS, MD,* and Hongbo Yu, DDS, MD* Purpose: Open reduction and internal fixation of intracapsular condylar fractures is a great challenge due to the confined access. This study aims to explore the feasibility of transparotid approach in the treatment of intracapsular condylar fractures. Patients and Methods: Eight patients with intracapsular condylar fractures were enrolled in this study. A minimized preauricular incision and transparotid access was used. Blunt dissection was performed perpendicularly to the condyle. The reduction and fixation of intracapsular condylar fractures were performed. After confirming that the fracture was fixed rigidly, the articular disc was repositioned. Results: Using this incision, the condylar head and fracture stump were exposed perpendicularly. No extensive incision was needed and minimal invasion was realized. Postoperative CT scan showed that the condyle had been repositioned and fixed in the normal position. Occlusal disturbance, restriction of mouth opening, and lateral deviation were not found in the follow-up. Conclusions: Transparotid approach gave an optimal view of the bony field, which allowed surgeons to work perpendicularly to the fracture, and facilitated the reduction of medially displaced proximal stumps. It was regarded as an ideal and valuable alternative in this potentially complicated procedure. Key Words: Intracapsular condylar fracture, transparotid approach, reduction, fixation

Although in many cases good initial clinical results are achieved, serious late complications have been reported such as ankylosis, condylar necrosis, inhibition of mandibular growth, and occlusal disturbances. Mandibular deviation in mouth opening is another sequela due to the irreducible artistic disc in conservative treatment.3,4 In recent years, with the wide availability of plate and screw fixation systems, surgical treatments of intracapsular condylar fractures have attracted increasing interest. However, open reduction and internal fixation (ORIF) of intracapsular condylar fractures is always a challenge in such a confined space. There are various surgical approaches, each with advantages and disadvantages. The traditional preauricular incision allows adequate exposure, but risks facial nerve injury and results in visible facial scars.5,6 Because there are many important anatomic structures around the temporomandibular joint (TMJ), such as branches of the facial nerve and blood vessels, the access was restricted. Some surgeons tried the transoral access in the treatment of condylar neck or base fractures, which greatly reduced the risks of facial nerve damage and abstained facial scars.7,8 However, it is technically difficult for intracapsular condylar fractures. The ideal approach for intracapsular condylar fractures should allow an excellent view of the surgical field, facilitate handling of the fracture, while minimizing the risk to the facial nerve and leave the scar in a barely noticeable region. In this study, transparotid approach with minimal invasion was attempted in the treatment of intracapsular condylar fractures.

(J Craniofac Surg 2015;26: 495–497)

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ractures of the mandibular condyle are common and account for 25% to 50% of all mandibular fractures.1,2 Among them, intracapsular condylar fractures have their special characters. The chief symptoms are movement restriction and malocclusion caused by a dislocated fragment of fracture and shortened mandibular ramus. They are frequently treated using closed functional techniques.

From the *Department of Oral & Craniomaxillofacial Science, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai; and †China-Japan Friendship Dental Clinic, Shanghai Stomatological Disease Center, Shanghai, China. Received September 13, 2014. Accepted for publication December 23, 2014. Address correspondence and reprint requests to Hongbo Yu, DDS, MD, Department of Oral and Craniomaxillofacial Science, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, Zhizaoju Road, 200011, Shanghai, China; E-mail: [email protected] J.S. and F.J. contributed equally to this article. This study was supported by a grant from the National Natural Science Foundation of China (No. 81101131) and Research Fund of Medicine and Engineering of Shanghai Jiao Tong University (No. YG2013MS56). The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001524

PATIENTS AND METHODS Eight patients with intracapsular condylar fractures were enrolled in this study from January 2011 to December 2011. The patients (7 males and 1 female) had a mean age of 26.9 years (range 16–52). The inclusion criteria were as follows: adult patients with unilateral or bilateral type B intracapsular condylar fractures (Neff’s classification) concomitant with body or symphysis fractures, occlusal disturbance was caused by shortening of the condylar height, and the fragment of the fracture was single and big enough for fixation (Table 1).9 This study was approved by the Clinical Research Ethics Committee of Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine. Patient’s informed consent and the authorization of images which were used for illustrative purpose related to this study was obtained. All operations were performed under general anesthesia. A minimized preauricular incision from tragus to auricular lobule was used to approach the fracture (Fig. 1). To avoid damage of the facial nerve, the superficial temporal fascia was cut along the anterior border of the superficial temporal artery, and blunt dissection was performed perpendicularly to the condyle. In this procedure, retractors were used to keep the passageway. Facial nerve isolation was not needed, when the branches were exposed, paying attention to their protection. Further dissection was performed to expose the lateral side of the condylar stump and neck. The ramus was distracted inferiorly to widen the joint space. The fractured fragment was reduced gently to maximally preserve the attached lateral pterygoid muscle. After occlusion

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Shi et al

TABLE 1. Patients’ Characteristics Patient No.

Age

Gender

Etiology

Trauma History (d)

Type of Fractures

Concomitant Fractures

Follow-up (mo)

1

52 21 22 16 25 31 21 27 26.9

M F M M M M M M

Fall Fall RTA RTA Fall RTA Fall RTA

5 19 20 62 14 3 8 4 16.9

B, B B, B B A, B B, B B, B B B

Symphysis Symphysis, body Symphysis Symphysis, ZF-B, UAF Symphysis Symphysis, UAF LAF UAF, symphysis

19 17 15 14 13 13 12 12 14.4

2 3 4 5 6 7 8 Mean

RTA, road traffic accident; A, intracapsular condylar fracture type A; B, intracapsular condylar fracture type B; UAF, upper alveolar fracture; LAF, low alveolar bone fracture; ZF-B, zygomatic fracture type B.

rehabilitation and internal maxillomandibular fixation were performed, the fragment had been repositioned with a bicortical screw (Cibei Company, Ningbo, China) (Fig. 2). After confirming that the fracture was fixed rigidly, the articular disc was repositioned. Then the capsule was carefully sutured in position and the wound closed in layers. Other combined fractures were treated by rigid internal fixation. Postoperative clinical evaluation (3–5 days after surgery) consisted of CT scans, occlusion examination, and the evaluation of TMJ and facial nerve function. The reduction of the fragments and the location of the screws were checked by CT scans. Occlusion, mouth opening, protrusion, and lateral mobility of the mandible were evaluated 3, 6, and 12 months after surgery.

RESULTS The reduction and fixation of intracapsular condylar fractures were performed successfully via transparotid approach for all patients. Using this incision, the condylar head and fracture stump were exposed perpendicularly. No extensive incision was needed and minimal invasion was realized. In clinical follow-up carried out 3, 6, and 12 months postoperatively, there were no occlusal disturbances, no restrictions in mouth opening, and no lateral deviation. In all cases, we found a restoration of preinjury occlusion and a pain-free joint. All patients regained normal mandibular movements and had short and invisible scars at 12 months’ follow-up. Facial nerve function evaluation showed that 2 patients had temporary paralysis of the frontal muscle postoperatively, but recovered gradually within 3 months. All patients were satisfied with the outcomes. Postoperative CT scan showed the condyle had been replaced and fixed in the normal position, and the sizes of the bicortical screws were suitable with no injury to the articular cartilage or surrounding tissue. The height of the ramus on the fractured side was restored (Fig. 3).

DISCUSSION Patients with intracapsular condylar fractures display significantly poorer clinical, radiological, and axiographical results if the

FIGURE 1. Preauricular incision.

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fracture line runs through the lateral condylar pole and the displacement of the proximal fragment has resulted in a shortening of the mandibular ramus.10,11 Although no consensus has been established on whether open reduction is necessary, closed treatment cannot correctly reposition the dislocated fragment of the fracture and restore the mandibular ramus to its normal length. At the same time, the displaced articular disc cannot be reduced.12,13 ORIF was reported to be more efficient than closed treatment in restoring the function and shape of the TMJ for diacapitular condylar fracture.14–16 As we all know, not all intracapsular condylar fractures need surgical treatment. The indication for selecting open treatment of the intracapsular fractures should be based upon the age and fracture type. Adult patients with displaced, intracapsular mandibular fractures with a loss of vertical height of the mandibular ramus could be treated surgically.17 Schneider et al thought that condylar fractures with a deviation of 10° to 45° or a shortening of the ascending ramus more than 2 mm should be treated with ORIF, irrespective of the level of the fracture.18 At present, although some surgeons considered that the dislocated fragment was associated with serious complications (including ankylosis of the TMJ) and anatomical repositioning should be achieved in surgical ways, the surgical treatment was limited.17,19 It is partly due to the fear of potential pitfalls related to the access. Extraoral routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but is demanding technically, especially for higher neck fractures.20 In this study, transparotid access was attempted in the treatment of intracapsular condylar fractures. It has its special advantages. The incision was short and the scar was imperceptible. It gives surgeons an optimal view of the bony field and allows working perpendicularly to the fracture and thus facilitates the reduction of even medially displaced proximal stumps, which are very hard to manage with other approaches. It is technically easy and does not require special training. Furthermore, the articular disc and capsule can be repositioned, which is an undoubted advantage to postoperative function. Another advantage of the modified auricular approach is that the access is based on

FIGURE 2. Condylar fracture was fixed by titanium screw through transparotid approach.

© 2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015

FIGURE 3. Comparison between preoperative (A, B) and postoperative (C, D) CT scans.

the anatomical boundary of blood vessels and nerves and the scars are acceptable. None of our patients complained of the aesthetics of the access incision. Nonetheless, some disadvantages are intrinsic to this technique. In overweight patients with redundant cheek soft tissues, the procedure is somewhat arduous with a 20-mm-long incision. To expose the fracture, parotid fascia was identified and incision of the fascia and blunt dissection of the parotid tissue was then performed. The dissection of the parotid gland proceeded carefully to avoid damage of facial nerve. Incision of the articular capsule allowed good visualization of the fracture site and mobilization of the soft tissues. In this study, bicortical screws were used for fixation. Conventional internal fixation, using screws or titanium miniplates, or both, is difficult because the view from the lateral side of the condylar stump is confined. Kermer et al13 described that only intracapsular fractures with a single fragment can be repaired with the screw osteosynthesis. The rehabilitation of condylar process length was primarily determined by the results of repositioning and the remodeling process. Condylar fractures occur as both single and bilateral fractures, which can be concomitant with mandibular corpus or dentoalveolar injuries, especially mandibular symphysis. In these patients, widening of the mandible leads to the lateral pole of the condyle or the condylar stump to become displaced laterally or superolaterally, which can induce TMJ ankylosis.21 Therefore, it is indispensable to restore mandibular width, which facilitates the rehabilitation of condyle-fossa relation and occlusion.

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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Transparotid approach in the treatment of intracapsular condylar fracture.

Open reduction and internal fixation of intracapsular condylar fractures is a great challenge due to the confined access. This study aims to explore t...
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