The purpose of this article is to review the basic indications for different treatments of condylar and subcondylar fractures. It also reviews the steps of different surgical approaches to access the surgical area and explains the pros and cons of each procedure.
Key points
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There is a role for both open and closed reduction in the treatment of condylar fractures.
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Using a thoughtful approach with an understanding of the pros and cons of each treatment option, applied individually to each patient fracture, leads to the best long-term outcomes while minimizing the sequelae associated with surgery.
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Careful unbiased critique of postoperative results with the goal of continually improving techniques and outcomes is, in the end, significantly beneficial to both patients and surgeons.
Overview
No area of facial trauma elicits as much debate as the treatment of fractures of the condylar region. Optimal treatment seems to vary as much by surgical subspecialty as by treating surgeons themselves. Some of this variability is derived from surgeon comfort with different surgical techniques and approaches as well as concern for vital surrounding structures. Earlier publications on the treatment of these types of fractures attempted to determine whether open or closed treatment is the optimal choice. Recent discussions have shifted, with the understanding that both treatments have their indications. What is open for debate is when each option should be used.
Condylar fractures account for 20% to 62% of all mandibular fractures. Traditionally, closed management has been the most advocated treatment. As new techniques were developed and a better understanding of the associated sequelae of closed reduction elicited, there was a trend toward more surgical reduction of the fracture. Rigid rules with fairly wide indications for the implementation of open approaches were proposed, but concerns arose regarding whether these rules were leading to unnecessary surgery, with increases in morbidity, surgical time, and risk to the facial nerve. A middle ground has developed, where there is an understanding of those patients who can be treated successfully with simple closed reduction and those better served with open reduction of their condylar fracture.
There are few absolute indications for the open treatment of condylar fracture. If adequate occlusion cannot be obtained through closed reduction, then open reduction is necessary. Most agree that condylar fractures in conjunction with significant comminuted midface fractures warrants condylar reduction. In difficult midface fractures, the intact mandible is used as a stable base from which to reset maxillary dentition, re-establish occlusion, and then rebuild the midface as a whole, in a bottom to top fashion. By recreating appropriate occlusion, proper maxillary projection and width can be re-established.
Ellis and colleagues maintain the need for open treatment in edentulous patients and in those missing significant posterior dentition. In these cases, closed reduction cannot adequately address the loss of vertical mandibular height that is normally re-established when appropriate posterior dentition is present. This loss of height leads to altered jaw mechanics with significant deviation toward the fractured side or, in the case of bilateral fractures, open bite deformity. The derived malocclusion is difficult to treat later with prosthesis. Bilateral condylar fractures is an area where treatment is more controversial. Ellis has found that 10% of patients in this cohort do not respond well to closed treatment. Unfortunately, which patients are recalcitrant to closed treatment is unclear. Some investigators have argued that significantly severe dislocation of the fractured condyle is an indication for open reduction and internal fixation. Studies have shown this not to be the case and that, through remodeling, appropriate occlusion can be re-established despite the visible alteration in jaw mechanics.
Overview
No area of facial trauma elicits as much debate as the treatment of fractures of the condylar region. Optimal treatment seems to vary as much by surgical subspecialty as by treating surgeons themselves. Some of this variability is derived from surgeon comfort with different surgical techniques and approaches as well as concern for vital surrounding structures. Earlier publications on the treatment of these types of fractures attempted to determine whether open or closed treatment is the optimal choice. Recent discussions have shifted, with the understanding that both treatments have their indications. What is open for debate is when each option should be used.
Condylar fractures account for 20% to 62% of all mandibular fractures. Traditionally, closed management has been the most advocated treatment. As new techniques were developed and a better understanding of the associated sequelae of closed reduction elicited, there was a trend toward more surgical reduction of the fracture. Rigid rules with fairly wide indications for the implementation of open approaches were proposed, but concerns arose regarding whether these rules were leading to unnecessary surgery, with increases in morbidity, surgical time, and risk to the facial nerve. A middle ground has developed, where there is an understanding of those patients who can be treated successfully with simple closed reduction and those better served with open reduction of their condylar fracture.
There are few absolute indications for the open treatment of condylar fracture. If adequate occlusion cannot be obtained through closed reduction, then open reduction is necessary. Most agree that condylar fractures in conjunction with significant comminuted midface fractures warrants condylar reduction. In difficult midface fractures, the intact mandible is used as a stable base from which to reset maxillary dentition, re-establish occlusion, and then rebuild the midface as a whole, in a bottom to top fashion. By recreating appropriate occlusion, proper maxillary projection and width can be re-established.
Ellis and colleagues maintain the need for open treatment in edentulous patients and in those missing significant posterior dentition. In these cases, closed reduction cannot adequately address the loss of vertical mandibular height that is normally re-established when appropriate posterior dentition is present. This loss of height leads to altered jaw mechanics with significant deviation toward the fractured side or, in the case of bilateral fractures, open bite deformity. The derived malocclusion is difficult to treat later with prosthesis. Bilateral condylar fractures is an area where treatment is more controversial. Ellis has found that 10% of patients in this cohort do not respond well to closed treatment. Unfortunately, which patients are recalcitrant to closed treatment is unclear. Some investigators have argued that significantly severe dislocation of the fractured condyle is an indication for open reduction and internal fixation. Studies have shown this not to be the case and that, through remodeling, appropriate occlusion can be re-established despite the visible alteration in jaw mechanics.
Treatment goals and planned outcomes
The principal goal of treatment is re-establishment of normal occlusion and mastication. Beyond this, restoration of baseline jaw mechanics and overall cosmesis are also given consideration. As discussed previously, the ideal surgical technique to obtain these goals is variable and based on individual injury while weighing the risk/benefit of surgery.
Preoperative planning and preparation
As with any other surgery, patient safety is of penultimate importance. Patient stability before surgery must be assessed with associated preoperative evaluation and laboratory work. Comorbid injuries are not unusual and need to be assessed in regards to urgency and triage of treatment. A surgical plan must be determined. Patients require adequate dentition or at least intact dentures to even consider closed reduction or mandibular–maxillary fixation. If endoscopic reduction is planned, appropriate equipment is necessary that may not be readily available. With external approaches, obtaining cervical spine clearance and removal of cervical collar allows the head to be turned, making surgery significantly easier.
Patient positioning
With either an open or closed approach, it is likely patients are placed in maxillary–mandibular fixation, if only intraoperatively. Therefore, nasotracheal intubation is used in most cases, with the circuit brought up over the head and secured with a head wrap. In cases where this is not a possibility, due to comorbid injuries or need for long-term ventilator support, then a tracheostomy must be considered. Regardless of treatment planned, the arms are tucked and the table is turned 180° to allow several surgeons and assistants access to the head.
Procedural approaches
Pediatric Condylar Fractures
Condylar fractures are the most common pediatric mandibular fracture and present bilaterally in 20% of cases. Prior to age 6, most fractures are intracapsular, whereas after that age they occur most frequently in the neck of the mandible. When normal occlusion is present, fractures of the condylar region are treated conservatively with close observation, soft diet, and pain medication. When there is malocclusion, a short course of maxillary–mandibular fixation is warranted. Limiting fixation to 7 to 10 days helps limit the chance of joint ankylosis, although postoperative physiotherapy may still be beneficial. Choice of technique is largely dependent on the age of the child and, more importantly, the quality and quantity of dentition. When possible, intradental wires with arch bars maybe placed. If not possible, intermaxillary fixation using 1-point circumandibular wiring should be used, attaching it to a wire wrapped around a hole drilled through piriform aperture. Due to the possibility of injuring nonerupted teeth, intermaxillary fixation screws should not be placed. It is important to discuss chin deviation during chewing and the possibility of long-term growth abnormalities of the jaw with patients’ parents.
Closed Reduction
Several approaches for closed reduction may be used. The authors have found that obtaining occlusion with elastic bands offers the same benefit as metal wiring but permits patients to subtly shift into natural occlusion while mobilizing earlier, which improves dietary intake and lowers the chance of joint ankylosis. If there are concerns about patient compliance with elastics, surgeons may elect to stay with the reliability of complete wire fixation.
Preauricular Approach
The preauricular approach is excellent to expose the temporomandibular joint (TMJ) and to remove displaced condylar fragments. The incision also hides well in the preauricular crease. It provides, however, poor exposure and visualization of the subcondylar region. If placing a fixation plate and screws is desired, it often requires inferior retraction on the facial nerve, potentially causing paresis ( Fig. 1 ).
The incision is marked in a skin crease in front of the pinna beginning at the superior pole of the helix and extending inferiorly to the inferior anterior edge of the tragus. The incision is carried through skin and subcutaneous tissues. Superior to the zygomatic arch, the temporoparietal fascia is incised to reach the superficial layer of the deep temporal fascia, with care taken to avoid damaging the superficial temporal vessels and auriculotemporal nerve. Inferior to the zygomatic arch, the dissection precedes to the same depth as the superior dissection, immediately anterior to the tragal cartilage. In the superior portion of the incision, the superficial layer of the deep temporal fascia is then incised starting at the anterior superior portion of the incision and running at a 30° angle to the long axis of the helix, toward the tragus. This exposes a layer of fat between the superficial and deep layers of the deep temporal fascia, and a periosteal elevator can be inserted in this incision deep to the superficial layer of the deep temporal fascia. The periosteal elevator can be used to free the periosteum off of the lateral zygomatic arch and create a tunnel inferior to the zygomatic arch. The intervening tissue can then sharply be divided posteriorly along the original axis of the vertical skin incision. This subperiosteal flap can then be reflected anteriorly from the root of the zygomatic arch, thus protecting the temporal branch of the facial nerve. Dissection proceeds anteriorly until the articular eminence and entire TMJ capsule should be revealed. To help locate and palpate this, the mandible can be opened and closed. Dissection and retraction can proceed inferiorly to reveal the subcondylar region.
Submandibular/Risdon Approach
The submandibular/Risdon approach provides good access to the ramus and lower subcondylar areas of the mandible but can be somewhat limited for high subcondylar or condylar fractures because the incision is positioned a long ways away from these fractures. The main complication is either paralysis or paresis of the marginal mandibular branch of the facial nerve either from direct injury or from retraction forces. The scar created is also visible on the neck.
The 4-cm to 5-cm incision is marked 1 to 2 fingerbreadths below the inferior border of the mandible near the angle ( Fig. 2 ). Care should be taken to hide the incision within a skin crease if possible. The dissection proceeds through skin and subcutaneous tissue until the superoinferiorly oriented fibers of the platysma muscle are identified. The platysma is divided to reveal the superficial layer of the deep cervical fascia, the submandibular gland in the anterior aspect of the incision, and often the facial artery and vein. The marginal mandibular branch of the facial nerve is located within or just deep to the superficial layer of the deep cervical fascia and sometimes are encountered running inferior to the border of the mandible, so care should be taken to preserve it. This can be done by identifying it directly, by only dividing tissue that has been dissected to reveal no nerve, by incising the fascia covering the submandibular gland at its inferior border and elevating it superiorly, or by ligating the facial vein and retracting this superiorly as the marginal mandibular branch is superficial to the facial vein ( Fig. 3 ). In many instances, however, the nerve is superior to the area of dissection and is not encountered.
