Clinical Paper

Trauma

Int. J. Oral Maxillofac. Surg. 2009; 38: 835–839doi:10.1016/j.ijom.2009.04.008, available online at http://www.sciencedirect.com

Retromandibular approach forreduction and fixation ofmandibular condylar fractures:A clinical experienceV. Narayanan, R. Kannan, K. Sreekumar: Retromandibular approach for reductionand fixation of mandibular condylar fractures: A clinical experience. Int. J. OralMaxillofac. Surg. 2009; 38: 835–839. # 2009 International Association of Oral andMaxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This study evaluated the efficiency and safety of a retromandibularapproach to reduce and fix displaced condylar fractures. The study group included31 patients who had undergone surgery for 35 condylar fractures (8 bilateral, 23unilateral). Consultants and residents had performed the procedure. Inclusioncriteria were: patient’s choice for open reduction and fixation; displaced unilateralcondylar fractures with occlusal derangement; bilateral condylar fractures withanterior open bite. Restriction of lateral movement towards the unaffected side wasobserved preoperatively in all cases taken up. There was a difference in the lateralmovements towards the fractured side (mean 7.2) and unaffected side (mean 4.2)during the first postoperative review. Functional occlusion identical to thepreoperative occlusion and good reduction of the condyles was noted in all cases.Facial nerve was encountered in 6 cases (17%) intraoperatively. There was one case(3%) of temporary facial nerve weakness, which resolved within 2 weeks. Therewas no permanent facial nerve damage in any patient. The retromandibular-transparotid approach seems to be a safe and efficient method for reduction andinternal fixation of condylar fractures with little or no risk to the branches of facialnerve.

0901-5027/080835 + 05 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surge

V. Narayanan, R. Kannan,K. SreekumarDepartment of Oral and Maxillofacial Surgery,College of Dental Surgery, SaveethaUniversity, India

Keywords: condylar fractures; open reduction;retromandibular–transparotid approach.

Accepted for publication 14 April 2009Available online 20 May 2009

Fractures of the mandibular condyleaccount for 25–50% of all mandibularfractures17,18. The method of choice fortreating condylar fractures without displa-cement has been conservative, by immo-bilization of the mandible2. Theindications for surgical management havebeen controversial10. There is consensusthat the correct anatomical reconstructionof the condylar process is an important

prerequisite for re-establishing function2.The surgical methods include open reduc-tion and osteosynthesis with miniplates,wires or lag screws13,15. The risk of tran-sitory facial nerve palsy is one of the mainlimitations against surgical manage-ment5,9. Various approaches to the man-dibular condyle are described in theliterature. The retromandibular approachwas one of the techniques first described

by Hinds and Girotti in 1967 and modifiedby Koberg and Momma in 197811,13. Thisapproach was not carried out widelybecause of the proximity of the operativefield to the branches of the facial nerve,retromandibular vein and the parotidgland. When compared with the othermethods, the retromandibular approachoffers greater advantages because of theshorter working distance from the skin

ons. Published by Elsevier Ltd. All rights reserved.

836 Narayanan et al.

Fig. 1. Fixation of fracture site with mini plates.

incisions to the condyle, great access to theposterior border of the mandible and sig-moid notch, less conspicuous facial scarand easy reduction7.

The aim of this study is to evaluate theefficiency and safety of the retromandib-ular approach to reduce and fix displacedcondylar fractures in a series of 31patients.

Patients and methods

The study group included 31 patients whohad undergone surgery for 35 condylarfractures (8 bilateral, 23 unilateral). Thedistribution according to the pattern ofcondylar fractures was: 16 neck and 7subcondylar fractures in the unilateralgroup; 4 condylar head fractures, 9 con-dylar neck fractures and 3 subcondylarfractures in the bilateral group8. Amongthe 8 bilateral condylar fractures, 4 sites inthe bilateral group were not open reducedbecause they were found to be mediallydisplaced condylar head fractures thatwould have been difficult to reduce andfix. Operators of varying status (consul-tants and postgraduate trainees) performedthe procedure. The inclusion criteria werethe patient’s choice for open reduction andfixation, unilateral condylar fractures withocclusal derangement where it is impos-sible to achieve pretraumatic or adequateocclusion by closed reduction, in caseswhere conservative therapy has failedand in bilateral condylar fractures withresultant anterior open bite.

The surgical technique adopted was aretromandibular approach using a skinincision, about 3–4 cm long, parallel tothe posterior border of the mandible, com-mencing 0.5 cm below the earlobe. Thedissection was carried out in the subder-mal fat plane. The parotid capsule, whichappears as a white glistening layer, wasidentified. The parotid gland was enteredby incising the capsule. The gland wasblunt dissected in an anteromedial direc-tion towards the posterior border of themandible. This was done by inserting acurved haemostat and spreading it openparallel to the expected direction of thebranches of the facial nerve. The posteriorborder of the mandible was identified andthe pterygomasseteric sling was incised.The masseter was stripped along with theperiosteum from the angle of the mandiblealong the posterior border, as high aspossible, exposing the fracture site withthe help of suitable retractors. The frac-tures were reduced and fixation was car-ried out with miniplate osteosynthesis,using a 2 mm osteosynthesis system(Fig. 1). It was ensured that watertight

closure of parotid capsule was achieved.The incisions were closed in layers withresorbable sutures and skin closure withnon-resorbable sutures. Drains were notplaced in any of the cases. Rigid inter-maxillary fixation using stainless-steelwire was carried out for 3–4 days afterthe operation. Extracorporeal fixation ofthe condyle was done for 3 fracture sites,all of which were subcondylar fractureswith medial displacement and reductionwas not possible in vivo. Despite allattempts to reduce the condyle into anupright position it was difficult to do soand resulted in the lateral pterygoid mus-cle losing its attachment to the condylarneck, thus rendering it as a free graft. Itwas decided to remove the condyle fromthe wound and fix the miniplate andscrews in an extracorporeal manner onthe bench (Fig. 2). The distal segmentof the fracture site, namely the ramus,was then distracted inferiorly with aretractor to create the space to repositionthe condyle back in the glenoid fossa. Thecondylar segment was then reduced pre-cisely and good occlusion was obtainedbefore fixing the miniplate to the subcon-dylar portion of the ramus.

All patients were reviewed 2 weeks, 6weeks and 3 months postoperatively toassess: maximum mouth opening, lateralexcursion on the fractured and the oppo-site sides, deviation on opening the mouth,protrusive movement, occlusion, scar for-

mation, facial nerve weakness, and sali-vary leak.

Results

Among the 39 condylar fracture sitesincluded in the study were 8 bilateralcondylar fractures of which 4 sites inthe bilateral group were not open reducedbecause they were found to be condylarhead fractures that were medially dis-placed and would have been difficult toreduce and fix without rendering themavascular. Restriction of lateral movementtowards the unaffected side was observedpreoperatively in all cases with unilateralcondylar fracture. Maximum interincisalopening at the end of 3 months was 45 mm(mean) � 5 (SD). There was a differencein the lateral movements towards the frac-tured side (mean 7.2 � SD 3.1) and unaf-fected side (mean 4.2 � SD 2) during thefirst postoperative review. There were nodifferences in lateral movements duringthe 6 week and 3 month postoperativereviews. Protrusive movement at the endof 3 months was 6 mm (mean) � SD 2. Allthe cases with bilateral condylar fracturehad anterior open bite preoperatively andhad functional occlusion identical to thepre-injury occlusion postoperatively.Baseline data for these parameters werenot included because it was impossible torecord them preoperatively due to variousreasons, such as pain and discomfort in the

Retromandibular approach for mandibular condylar fractures 837

Fig. 2. Extra corporeal fixation of miniplates.

Fig. 3. Preoperative radiograph.

Fig. 4. Postoperative radiograph showing miniplate fixation.

orofacial region, asymmetrical movementof the mandible due to bilateral fractures,swelling of the lips, cheeks, open bite anddifficulty with jaw movements, and pre-operative endotracheal intubation of thepatient.

The facial nerve was encountered in 6cases (17%) intraoperatively. The buccalbranch was encountered in 4 cases, thezygomatic branch in one case and themarginal mandibular branch in one case.There was one case (3%) of temporaryfacial nerve weakness out of the 35 con-dyles; this resolved within 2 weeks. Therewas no permanent nerve damage in anypatient. No case of Frey’s syndrome wasencountered during the study.

Two patients had a chronic sinus at theincision site after 6 weeks but it had healedby the third postoperative review. Thesepatients had undergone extracorporealfixation of the condylar fracture. Extra-corporeal fixation of the condyle was car-ried out for 3 fracture sites, all of whichwere unilateral subcondylar fractures withmedial displacement and reduction wasnot possible in vivo. All the three con-dyles, which were fixed extracorporeally,showed resorptive changes radiographi-cally at the end of one year. The occlusionremained identical to that observed at theend of the third postoperative review. Allthe other patients had a barely perceptiblescar. Salivary fistulae were seen in four

incision sites, which resolved within 1week. Drains were not used for any ofthe cases. None of the patients requiredremoval of the fixation. Functional occlu-

sion identical to the preoperative occlu-sion and good reduction of the condyleswere noted in all cases. (Figs. 3 and 4).

Discussion

The management of fractured condyleshas always been controversial. A paperappeared in the first edition of the Journalof Oral and Maxillofacial Surgery thatreported 100 cases of subcondylar man-dibular fractures treated consecutively byclosed reduction and elastic tractionresulting in acceptable function in allbut two cases. The authors suggested thatsurgical intervention should not be usedfor routine cases3. There was no argumentto support surgical intervention. Consen-suses on the subject, at Budapest in 1995and in the Netherlands in 1998, suggestedthat a multicentre audit of randomizedcomparative clinical study between closedreduction and surgical intervention wasneeded4.

SILVENNOINEN et al observed that therewas a reduction in the height of the ramusand malocclusion following conservativemanagement19. AMARATUNGA et al foundthat there was no benefit following closedreduction of mandibular condylar frac-tures and they were not truly reduced1.Palmieri observed a reduction in condylarmovements following conservative man-agement16. ELLIS et al concluded that the

838 Narayanan et al.

condyle was medially tilted followingconservative management8. Few authorsfavoured the surgical management of con-dylar fractures. Worsae and Thorn con-cluded that surgical management wassuperior to non-surgical management22.

BAKER et al found that 57% of surgeonswould opt for open treatment when there isa displaced fracture of the condyle withaccompanying occlusal disturbance2. Thepresent authors used the open techniquewhen it was the patient’s choice for openreduction and fixation, for unilateral con-dylar fractures with occlusal derangementwhere it is impossible to achieve pretrau-matic or adequate occlusion by closedreduction, for cases where conservativetherapy has failed and in bilateral condylarfractures with resultant anterior open bite

They found that there was a restrictionof lateral movement towards the unaf-fected side preoperatively. There weredifferences in the lateral movementstowards the fractured side (mean 7.2)and unaffected side (mean 4.2) duringthe first postoperative review. There wereno differences in lateral movements dur-ing the 6 week and 3 month postoperativereviews.

Functional occlusion identical to thepreoperative occlusion and good reduc-tion of the condyles were noted in allcases, including the bilateral cases whereonly one condyle was fixed. Approxi-mately a quarter of the surgeons whowould prefer open reduction for fracturedbilateral condyles would opt to treat onlyone side2. It is thought that fixation of oneside combined with intermaxillary fixa-tion is effective in restoring posteriorfacial height2. This would probablyexplain the outcome in the authors’patients treated in this manner. There isconflicting opinion in that such a strategyis not always effective in the treatment ofbilateral condylar fractures with persis-tent and troublesome ramus shorteningobserved on the side not managed in anopen fashion2,18.

The authors encountered the facialnerve in 6 cases (17%) intraoperatively.The buccal branch was encountered in 4cases, the zygomatic branch in one caseand the marginal mandibular branch inone case. MANISALI et al reported thatthe branches of the facial nerve wereencountered in 30% of the cases14. In acadaveric study, using 30 facial halves (15fresh cadavers), branches of the facialnerve were encountered in 12 dissections(40%)14. There was only one case (3%) oftemporary facial nerve weakness out of the35 operated on condyles in the 31 patientsin the present series. This resolved before

the first postoperative review. There wasno permanent nerve damage in any of thecases. DEVLIN et al6 reported transientnerve weakness in 3 of 42 cases. CHOSSE-

GROS et al5 reported transient nerve weak-ness in 2 of 19 cases and ELLIS et al9

reported 3 of 52 cases of transient nerveweakness.

SVERZUT et al20 reported a case of Frey’ssyndrome after open reduction of condylarfracture. There was no case of Frey’ssyndrome in the present study.

Salivary fistulae were seen in four inci-sion sites in this series, which resolvedwithin 1 week. WILSON et al described thetransmasseteric antero-parotid technique,which seems to minimize the occurrenceof salivary fistula and facial nervedamage21.

Two patients whose fracture wasreduced and fixed using the extracorpor-eal method hd a chronic sinus for 6weeks, which resolved before the thirdpostoperative review. The three casesfixed using the extracorporeal methodwere medially displaced condyles andbecame avascular by losing their softtissue attachment during reduction.IIZUKA et al. described severe boneresorption in 10 patients who had under-gone open reduction and internal fixationof fracture dislocations with miniplatescarried out extracorporeally12. Thesechanges were more severe than thoseseen with wire osteosynthesis performedin a previous cohort of patients treated bythese authors. In the present series, all thethree condyles that were fixed extracor-poreally showed resorptive changesradiographically at the end of 1 year.The occlusion remained identical to thatobserved at the end of the third post-operative review.

The advantages of the retromandibularapproach include shorter working distancefrom the skin incisions to the condyle,greater access to the posterior border ofthe mandible and sigmoid notch, little riskof facial nerve damage, less conspicuousfacial scar and easy reduction.

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Address:Vinod Narayanan

Department of Oral andMaxillofacial Surgery

College of Dental SurgerySaveetha University No. 162Poonamallee High RoadChennai: 600077Tamil NaduIndiaE-mail: vinodnarayan@vsnl.net