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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1733-1736  

Extracorporeal plating of high-level condyle fracture through retromandibular approach – A technical note


1 Associate professor, Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Chidambaram, Tamil Nadu, India
2 Professor, Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Chidambaram, Tamil Nadu, India
3 postgraduate student, Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Chidambaram, Tamil Nadu, India

Date of Submission18-Feb-2021
Date of Decision05-Mar-2021
Date of Acceptance12-Apr-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
R Murugan
Associate Professor, Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and hospital, Chidambaram, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.jpbs_86_21

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   Abstract 


The complex anatomy of the mandibular condyle makes its fracture management challenging and debatable. Apart from this, the approaches to condyle are also challenging as most of them depend on the surgical expertise. The retromandibular approach which was initially proposed for the vertical sub condylar osteotomies was later popularized for condyle fracture management. It is considered to be a gold standard approach in the management of low condylar fractures. Although it has its own demerits in managing high condylar fracture due to its poor access and visibility, the major complications of temporary facial nerve paresis and sialocele are very less compared to other approaches. However, modified extracorporeal plating combined with retromandibular approach proves to be effective in managing high condylar fracture. In this article, we discuss about a case of bilateral neck of condyle fracture that has been managed with the combined modified extracorporeal plating with retromandibular approach and has been followed with no complications for about 1 year.

Keywords: Condyle fractures, extracorporeal plating, retromandibular approach, temporary facial nerve paresis


How to cite this article:
Murugan R, Thiruneelakandan S, Manojprabhakar M, Srivatson V. Extracorporeal plating of high-level condyle fracture through retromandibular approach – A technical note. J Pharm Bioall Sci 2021;13, Suppl S2:1733-6

How to cite this URL:
Murugan R, Thiruneelakandan S, Manojprabhakar M, Srivatson V. Extracorporeal plating of high-level condyle fracture through retromandibular approach – A technical note. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Jun 26];13, Suppl S2:1733-6. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/1733/330149




   Introduction Top


Among the mandibular fractures, condylar fractures are more common because of their complex anatomy. Management of condylar fractures is still debatable because of the functional problems, approaches to the condyle, and complications associated with open reduction and internal fixation (ORIF).

In management using ORIF of the condyle, regular approaches such as hemicoronal, preauricular, and retromandibular approaches have their own merits and demerits. The retromandbular approach was designed for vertical sub condylar osteotomies as it gives exposure of the entire ramus of the mandible and hence it is considered to be a gold standard approach in the management of low condylar fractures. The retromandibular approach is considered to be a gold standard approach in the management of low condylar fractures. Although it has its own demerits in managing high condylar fracture due to its poor access and visibility, the major complications of temporary facial nerve paresis and sialocele are very less compared to other approaches.


   Case Report Top


A 45-year-old female reported to our outpatient department with an alleged history of self-fall from two-wheeler following which she had difficulty in mouth opening [Figure 1]. The patient was then subjected to investigations and diagnosed with a fracture bilateral neck of condyle [Figure 2]. Upon obtaining medical fitness, the patient was subjected to ORIF under general anesthesia (GA). The patient was planned for ORIF for bilateral condyle through retromandibular approach.
Figure 1: Mouth opening of the patient

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Figure 2: Orthopantomogram reveals bilateral condyle fracture

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Under nasotracheal intubation GA was administered, standard betadine painting and surgical draping was done. Incision marking was done for retromandibular/Hinds incision on right side layer-by-layer dissection was done. Fracture site was identified and exposed [Figure 3]. Reduction was done using 1.5 mm stainless steel continuous plate and 1.5 mm × 8 mm screws [Figure 4]. On the left side after marking for retromandibular incision, careful dissection was done by layers. The tail of parotid was identified and carefully retracted along with marginal mandibular branch of the facial nerve. Medially dislocated condyle was identified, after careful release from the attachments of lateral pterygoid muscle, the condyle was plated extraorally and repositioned into the fossa [Figure 5], [Figure 6]. Condyle positions were checked intraoperatively. Layer-by-layer closure was done using 3-0 Vicryl and 3-0 Ethilon.
Figure 3: Hinds incision placed on right side and fracture site exposed

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Figure 4: Fracture reduction and fixation done

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Figure 5: Condyle plating done extraorally

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Figure 6: Plated condyle repositioned into the fossa

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Follow-up

Immediate postoperative follow-up of the patient showed no complications. The patient was then followed up for 3 months, 6 months, and 1 year. At 3 months, the patient had mild restriction in mouth opening for which she had been advised for isotonic and isometric mouth opening exercises. At 6 months, the patient's mouth opening was improved and showed no complications. At 1 year, the patient's functional activity was completely restored and also confirmed radiologically [Figure 7] but was dissatisfied regarding her esthetics.
Figure 7: Postoperative orthopantomogram at 1-year follow-up

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No facial nerve weakness or sialocele was reported for the entire follow-up.


   Discussion Top


The mandibular condyle fracture accounts for 25%–35% of all mandibular fractures reported in the literature.[1],[2] The retromandibular approach was described in 1967 in relation to vertical subcondylar osteotomies[3],[4],[5] and was later popularized for the management of condylar fractures. To avoid encountering the facial nerve, retromandibular incision has many modifications. Intracapsular and high condyle fractures are best approached through pre- and postauricular incisions, whereas submandibular, retromandibular, and rhytidectomy approaches are indicated for low condylar neck fractures. The intraoral and endoscopic approach may offer better cosmetic results.[6],[7],[8] A coronal approach can provide access if there are other indications to use this approach.[3]

The retromandibular approach provides ease of access and visibility for addressing the entire ramus and neck of condyle. Facial nerve lies 2 cm deep to the posterior border of the mandible as it emerges from the stylomastoid foramen. It then runs obliquely forward to enter the substance of the parotid gland where it crosses retromandibular vein and external carotid artery. The skin incision is therefore placed between the superior and inferior division of the nerve.

The close proximity of the facial nerve makes preauricular and endaural approaches difficult for open reduction.[4],[6] Superior extension of the incision to the pterygomandibular sling in a retromandibular approach helps in adequate exposure for high level condyle fractures. Compromised vascular supply due to the stripping of lateral pterygoid muscle makes the fractured condyle act as a free graft. The retromandibular approach combined with modified extracorporeal reduction and fixation without detachment of the lateral pterygoid muscle allows for a safer reduction of neck of condyle fractures and subcondylar fracture. This surgical technique allows for a safer anatomic reduction of a mandibular condylar neck and subcondylar fracture. Avascular necrosis of mandibular condyle can be minimized as the attachment of lateral pterygoid muscle is retained. Marginal mandibular branch of facial nerve weakness was evident in 30% of cases.[9],[10] All of these were resolved within 3 months. There were no reported cases of permanent facial nerve weakness. Sensory nerve deficit and sialocele are some common complications noted in this approach.[10],[11],[12]

However, our patient did not show any of these complications, esthetic outcome was the only drawback due to scarring.


   Conclusion Top


Therefore the retromandibular approach combined with extracorporeal fixation proves to be promising for high condyle fractures as it helps us to overcome complications like facial nerve damage, as retraction is minimal and also intact fibers of lateral pterygoid muscle onto the fractured condyle maintain the vascularity. Future studies must be made on the muscle fiber reattachment that helps the surgeon understand and refine the technique to perform with more accuracy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Baker AW, McMahon J, Moos KF. Current consensus on the management of fractures of the mandibular condyle. A method by questionnaire. Int J Oral Maxillofac Surg 1998;27:258-66.  Back to cited text no. 1
    
2.
Chossegros C, Cheynet F, Blanc JL, Bourezak Z. Short retromandibular approach of subcondylar fractures: Clinical and radiologic long-term evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:248-52.  Back to cited text no. 2
    
3.
Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg Transplant Bull 1962;29:266-72.  Back to cited text no. 3
    
4.
Ellis E 3rd, McFadden D, Simon P, Throckmorton G. Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2000;58:950-8.  Back to cited text no. 4
    
5.
Hinds EC, Girotti WJ. Vertical subcondylar osteotomy: A reappraisal. Oral Surg Oral Med Oral Pathol 1967;24:164-70.  Back to cited text no. 5
    
6.
Kannadasan K, Shenoy KV, Kengagsubbiah S, Sathyabhama V, Priya V. Extra corporeal fixation of fractured mandibular condyle. J Clin Diagn Res 2014;8:ZD41-3.  Back to cited text no. 6
    
7.
Lachner J, Clanton JT, Waite PD. Open reduction and internal rigid fixation of subcondylar fractures via an intraoral approach. Oral Surg Oral Med Oral Pathol 1991;71:257-61.  Back to cited text no. 7
    
8.
Lee C, Mueller RV, Lee K, Mathes SJ. Endoscopic subcondylar fracture repair: Functional, aesthetic, and radiographic outcomes. Plast Reconstr Surg 1998;102:1434-43.  Back to cited text no. 8
    
9.
Liu CK, Liu P, Meng FW, Deng BL, Xue Y, Mao TQ, et al. The role of the lateral pterygoid muscle in the sagittal fracture of mandibular condyle (SFMC) healing process. Br J Oral Maxillofac Surg 2012;50:356-60.  Back to cited text no. 9
    
10.
Manisali M, Amin M, Aghabeigi B, Newman L. Retromandibular approach to the mandibular condyle: A clinical and cadaveric study. Int J Oral Maxillofac Surg 2003;32:253-6.  Back to cited text no. 10
    
11.
Kim MK, Kwon KJ, Kim SG, Park YW, Kim JY, Kweon H. Modified extracorporeal reduction of the mandibular condylar neck fracture. J Korean Assoc Maxillofac Plast Reconstr Surg 2014;36:30-6.  Back to cited text no. 11
    
12.
Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41:89-98.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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