Extracorporeal Plating of High-Level Condyle fracture Through Retromandibular Approach - A Technical Note.

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. Copyright:

INTRODUCTION

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

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

Figure 2

Orthopantomogram reveals bilateral condyle fracture

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 [Figures 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

Figure 4

Fracture reduction and fixation done

Figure 5

Condyle plating done extraorally

Figure 6

Plated condyle repositioned into the fossa

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

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

DISCUSSION

The mandibular condyle fracture accounts for 25%–35% of all mandibular fractures reported in the literature.[12] The retromandibular approach was described in 1967 in relation to vertical subcondylar osteotomies[345] 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.[678] 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.[46] 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.[910] 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.[101112]

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

CONCLUSION

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.

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Nil.

Conflicts of interest

There are no conflicts of interest.