Professional Documents
Culture Documents
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)
248
Chossegros et aL
249
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%).
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.
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
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
1. Blanc JL, Lagier JP, Gras R, Bremond D, Belloni D. Les sequelles des fractures condyliennes ~i travers l'experience du
service et l'expertise medicale. (Condylar fractures sequelae
through our clinical experience and medical expertise). Rev
Stomatol Chir Maxillofac 1985;86:29-31.
2. Hidding J, Wolf R, Pingel D. Surgical versus nonsurgical
treatment of the articular process of the mandible. J Craniomaxillofac Surg 1992;20:345-7.
3. Lachard J, Zattara H, Romette JM, Vitton J. Indications des
ost6osynth~ses dans les fractures s0us condyliennes basses.
(Osteosyuthesis indications in subcondylar fractures) Rev
Stomatol 1971;72:201-4.
4. Fernandez JA, Mathog RH. Open treatment of condylar fractures with biphase technique. Arch Otolaryngol Head Neck
Surg 1987;113:262-5.
5. Koberg WR, Momma W. Treatment of fractures of the man-
252
6.
7.
8.
9.
10.
11.
12.
13.
Chossegros e t al.
14.
15.
16.
17.
18.
Reprint requests:
Dr Cyrille Chossegros
Service du Pr Blanc
CHU Timone
13385 Marseille cedex 5
France