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Short retromandibular approach of subcondylar fractures

Clinical and radiologic long-term evaluation


Cyrille Chossegros, MD. DMD a Francois Cheynet. MD. DMD. a
Jean-Louis Blanc. MD. DMD, a and Znnbir Bourezak. b Marseille. France
TIMONE UNIVERSITY HOSPITAL CENTER

Objective. The classic technique for open reduction of subcondylar fracture is the submandibular approach, The aim of
this study was to evaluate long-term clinical and radiologic results of the short retromandibular approach to displaced
subcondylar fractures.
Material and methods. During a period of 66 months we performed a prospective study with a modified version of the
retromandibular approach in 38 patients with displaced subcondylar fractures. In this article we describe clinical and
radiologic results in 19 patients with follow-ups longer than 6 months Irange, 6 to 66 monthsl. Preoperatively all patients
had malocclusion and radiology demonstrated displacement.
Results. The retromandibular surgical approach was successful in all cases. Roughly 25 months after surgery, mouth
opening was 43 mm with symmetric laterotrusive movements. Permanent marginal nerve palsy was never observed.
Conclusions. Our findings indicate that the short retromandibular approach "s an easy and safe technique for displaced
subcondylar fractures.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82;248-52)

One third of all mandibular fractures involve the


condylar region. 1 There is a consensus that the
method of choice in cases without displacement is
conservative treatment by immobilization of the
mandible. Indications for surgical management in
adults are controversial. 2' 3 When surgery is indicated.
surgical methods include open reduction and osteosynthesis with a miniplate, wire, or lag-screw. 4-6 The
classic submandibular Ridson approach 7, * that we
used for several years achieves poor exposure of the
fracture and is associated with a high rate (30%) of
transitory facial nerve palsy. In an attempt to avoid
these problems we used a modified retromandibular
approach 8, 9 in a prospective series of 38 patients. The
aim of the present article was to describe clinical and
radiologic results in 19 patients with follow-ups
longer than 6 months.
PATIENTS A N D M E T H O D S

Between 1989 and 1994. 38 subcondylar fractures


with displacement but no dislocation were treated
surgically in the Department of Maxillofacial Surgery
at the Timone University Hospital Center in
Marseilles. At the time of writing 19 patients had follow-ups longer than 6 months and were included in
aOral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery.
bForeign resident.
Received for publication Nov. 9. 1995: returned for revision Dec.
14. 1995: accepted for publication Apr. 16. 1996.
Copyright 9 1996 by Mosby-Year Book, Inc.
1079-2104/96/55.00 + 0 7/12/74212

248

the study. The other patients had follow-ups that were


too short or were lost to follow-up. No early complication were observed or reported in any of the excluded patients.
Surgery via the retromandibular approach was performed as soon as possible. Surgical indications were
based either on clinical examination that found shortening of the ramus associated with ipsilateral molar
prematurity or edentulous posterior segment and radiologic findings that showed subcondylar fracture
with displacement (Figs. 1 and 2). The mean age ot
the 19 patients evaluated was 31 years: 68% were
men. Preoperative data such as pain, mouth opening,
and noise were not recorded. Mean duration ot
follow-up was 26 months. Follow-up consisted ol
clinical and radiologic evaluation. Clinical examination by an independent examiner included assessment
of the following factors: pain. mouth opening, laterotrusive movement, noise, facial nerve function, ear
sensitivity, intraocclusional relationship, and scar.
Radiologic examination included panoramic view
and facial and lateral teleradiographs.
Maxillomandibular fixation with elastics was
placed at the beginning of the procedure. Intubation
was done by the nasotracheal route, and the head was
not overly rotated. The incision is made in a natural
crease of the neck beginning from 1 cm under the
mastoid apex and running parallel to the anterior aspect of the sternocleidomastoid muscle (Fig. 3). The
length of the incision is between 3 and 4 cm. If the
fracture is located too high, the inferior part of the
parotid gland must be freed. After locating the angle

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Chossegros et aL

249

Volume 82, Number 3

Fig. 1. Part of panoramic view; right displaced subcondylar fracture.

Fig. 2. Panoramic view; postoperative view with miniplate fixation.

of the mandible the pterygomasseteric sling is released by making a 6 to 8 cm incision, and the masseter muscle is detached. The edge of the condylar
fragment is sharp and the surgeon must take care to
avoid self-injury. 1~ A towel clip is inserted in the
mandibular angle to facilitate fracture reduction after
placement of a periosteal elevator behind the condyle.
After positioning the miniplate (four holes with
bridge) and placing the upper two screws, the fracture
is then reduced with the towel clip before placement
of the lower two screws (Fig. 4). Placing the upper
screws before reduction provides a greater skin mobility. If the condyle has been displaced into the infratemporal fossa, the finger should be used to push
it from the deep portion of the ramus toward the glenoid fossa. The last step in the procedure is vacuum
drain placement with closure of the periosteum and
intradermal suture. In cases of single fractures, maxillomandibular fixation is removed after 1 week.
Normal food intake is not permitted until postoperative day 21. Physical exercise is prescribed only if
range of mouth opening is limited (4 of 19 cases or
21%).

Maximal mouth opening was greater than 35 m m in


all cases and greater than 40 m m in 13 (81%) of 16
patients with follow-ups longer than 10 months. Seventy-nine percent (15 of 19) presented sagittal opening movement. Laterotrusive movements ranged from
4 to 14 m m but were always symmetric. Constant
noise was reported on the contralateral side by one
patient (5%) and transient noise on the ipsilateral side
by six patients (32%). The interocclusional relationship was the same as before the procedure in 79% of
cases (15 of 19) and slightly different (deviation of the
incisors to the fractured side <1 ram) in 11% (2 of 19)
of cases. In two patients the interocclusional relationship was abnormal: angle class III in one patient
in whom subcondylar fracture was associated with
fracture of the body of the mandible and angle class
II (edge-to-edge occlusion) in o n e p a t i e n t in whom
subcondylar fracture was associated with four mandibular fractures and partial preoperative edentulism.
A prefracture interocclusional relationship was not
known in either o f these two patients. Chewing was
normal in 89% of cases (17 of 19) and unilateral in
the remaining two patients with occlusional abnormalities. Temporary facial palsy occurred in two
cases (2 of 19); it lasted for 3 weeks in one patient and
6 weeks in the other. Two patients had transitory auricular hypoesthesia for 2 to 3 weeks. Scar widening
(about 2 m m large) was noted in one case and slight
transient inflammation without infection in another.

RESULTS
All patients reported Satisfaction with the outcome
of the procedure. None complained of fatigue or pain
on chewing. Two patients complained of facial tenderness associated with chan~es in the weather.

250

Chossegros et al.

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY


September 1996

Fig. 3. Drawing (A) and photograph (B) of retromandibular approach show skin incision (arrow). Note incision is rather short (3 to 4 cm). (A, angle of mandible; M, mastoid apex)
In the remaining 17 cases (89%) healing was considered as excellent. Radiologic examination revealed
normal condyles in 15 patients, insufficient reduction
in 1 (5%), slight ipsilateral upper condylar flattening
(as a result of resorption (1 mm) of the anterosuperiot part of the condyle) in 2 (11%), and slight contralateral upper condylar flattening in 1 (5%).

DISCUSSION
Various techniques have been proposed for surgical treatment of displaced condylar fractures including the submandibular approach, 8 the preauricular
approach, 8 the rhytidectomy approach, 8, 11 or the intraoral approach. 12 For subcondylar fractures, the
submandibular approach is too low and the preauricular approach is too high. For this reason we chose the
retromandibular approach in most cases. Our technique is slightly different from the one proposed by
Ellis8; the approach is more posterior, the parotid
gland is not entered, the nerve branches are not
encountered, and the scar is slightly more conspicuous.
In all cases the retromandibular approach allowed
direct visual alignment of the fragments. Condylar
removal, 13 which seems to us to be a source of iatrogenic complications, 14, 15 is not needed. Reduction

was good in 95% of patients. Postoperative mouth


opening was over 40 m m in 81% of patients, but these
results cannot be compared with those of McArthm
et al. 7 with dislocated condyles (43% >35 mm). Neurologic complications in our series were minimal (i.e.,
11% of transient palsy). This is low in comparison
with previous reports: 48% (14 of 29) for Ellis and
Dean s with the retromandibular approach, 37% foi
Tasanen 16 with the Ridson approach, and 13% foi
Eckelt 6 with the lag-screw. The rate of 11% was perhaps due to the fact that we do not enter the parotid
gland. Long-term condylar resorption observed i~
five cases in our series (ipsilateral in two cases and
contralateral in three) underlines the fragility of the
condyle even in nondeviated fractures. Contralatera]
bone resorption without fracture observed in one patient (case 5) was due either to a microfracture oi
secondary osteonecrosis. Bone resorption is usual in
dislocated condyle 7' 14 but has not been frequently
reported in nondislocated condylar fracturesJ 7
Because the disk cannot be visualized with the retromandibular approach, preoperative magnetic resonance imaging is mandatory in patients with dislocated fractures 18 because of the remote possibility ot
separation of the disk from the condyle. If separatio~
is detected the disk must be sutured to the periosteunn

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Volume 82, Number 3

Chossegros et al.

251

Fig. 4. Operative view. Upper two screws are placed before reduction. With this technique the whole
miniplate cannot be seen through the incision at the same time. Note that the incision is short and that the
view is quite good.

of the posterior border of the c o n d y l e with a preauricular approach, a double approach (preauricular and
retromandibular), or a large cutaneous rhytidectomy
incision. After recovery we do not r e c o m m e n d the
r e m o v a l of c o n d y l a r miniplates because of the risk of
nerve and salivary gland injury associated with the
forces required o n the fibrous tissues for miniplate
removal. However, it should be m e n t i o n e d that successful r e m o v a l was performed in one patient who
c o m p l a i n e d of tenderness associated with changes in
the weather.

CONCLUSION
T r e a t m e n t of displaced s u b c o n d y l a r fractures
should be as n o n a g g r e s s i v e as possible. W h e n open
reduction and osteosynthesis are required, the retrom a n d i b u l a r approach is an effective and safe technique, especially for displaced s u b c o n d y l a r fractures
without deviation. Further study is needed to c o n f i r m

that the retromandibular approach is safer and easier


than s u b m a n d i b u l a r approach.
We thank Mr. A. Corsini and Dr. J. Conrath for their
translation and review of the manuscript.
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Reprint requests:
Dr Cyrille Chossegros
Service du Pr Blanc
CHU Timone
13385 Marseille cedex 5
France

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