|Year : 2022 | Volume
| Issue : 3 | Page : 405-410
Evaluation of efficacy 3Dimensional 4-hole trapezoid condyle plate for treatment of base of condyle fracture
Roger Paul1, Bharathi Suvvada2, Prasanna Polomarasetty2, Sai kumar Thumu3, PV Santosh4
1 Department of Oral and Maxillofacial Surgery, Lenora Institute of Dental Sciences, Rajanagaram, Rajamahendravaram, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Anil Neerukonda institute of Dental Sciences, Tagarapuvalasa, Vishakhapatnam, Andhra Pradesh, India
3 Department of Oral and Maxillofacial Surgery, Mallareddy Dental College for Women, Suraram, Hyderabad, Telangana, India
4 Department of Oral and Maxillofacial Surgery, Government Dental College, NTR Colony, Vijayawada, Andhra Pradesh, India
|Date of Submission||04-Dec-2021|
|Date of Acceptance||03-May-2022|
|Date of Web Publication||10-Dec-2022|
Dr. Sai kumar Thumu
Mallareddy Dental College for Women, Suraram, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of our study was to evaluate the effectiveness of open reduction and internal fixation of the base of condyle using a 3D 4-hole trapezoid condyle plate (4-HTCP).
Materials and Methods: A group of 25 subjects of an age range of 21-52 years (mean 32.7 ± 8.7 years) were treated of which, 7(28%) were female and 18 (72%), were male. All the patients were examined according to standard protocol. A retromandibular approach was used in all the patients.
Results: The time taken for operating on the condyle alone was recorded it was between 30 minutes to one hour in 5 (20%) patients, between one-two hours in 19 (76%) patients and greater than two hours in 1 (4%) patient. Time taken from reduction of fracture to placement of the last screw was recorded. In 15 (60%) patients the time taken was less than ten minutes, in 10 (40%) patients the time taken ranged from 10-15 minutes. 6 (24%) patients needed additional exposure to facilitate the procedure. Postoperatively all the patients were followed up for a minimum of 9 months and a maximum of 30 months (mean 19.5 ± 5.87 months). The range of mandibular movements was satisfactory. The maximum incisal opening was in the range of 25-37 mm (mean- 31.4 ± 3.38 mm)on the first post-operative day. 31.4 ± 3.4 mm 6 weeks postoperatively, 43.8 ± 4.3 mm 3 months postoperatively, 46.7 ± 2.9 mm 6 months postoperatively and 49.7 ± 4.5 mm 9 months postoperatively. Taking into consideration the transient hypofunction of the facial nerve (8%) and TMJ disorder (8%) the aggregate complication rate in our study was 16%.
Conclusion: Our study concludes that 4HTCP is a reliable and rigid choice of osteosynthesis for the base of condyle fractures.
Keywords: 3D condyle trapezoid plate, condyle fracture, subcondylar fracture
|How to cite this article:|
Paul R, Suvvada B, Polomarasetty P, Thumu Sk, Santosh P V. Evaluation of efficacy 3Dimensional 4-hole trapezoid condyle plate for treatment of base of condyle fracture. Natl J Maxillofac Surg 2022;13:405-10
|How to cite this URL:|
Paul R, Suvvada B, Polomarasetty P, Thumu Sk, Santosh P V. Evaluation of efficacy 3Dimensional 4-hole trapezoid condyle plate for treatment of base of condyle fracture. Natl J Maxillofac Surg [serial online] 2022 [cited 2023 Jan 27];13:405-10. Available from: https://www.njms.in/text.asp?2022/13/3/405/363083
| Introduction|| |
Fracture of mandibular condyle accounts for 20–45% of all mandibular fractures. Conventional wisdom has suggested closed reduction of mandibular condyle as a safe approach. However, a meticulous juxtaposition of open to close reduction divulges open reduction and internal fixation provide a better functional reconstruction of mandibular condyle when compared to that of closed reduction. Of late, the choice of osteosynthesis is being increasingly assessed. Succinctly, current literature suggests that the use of two plates rather than a single plate gives a more stable fixation.,, Nevertheless, the three-dimensional (3D) plating system complies with the osteosynthesis principles regarding functional stability.,, Our study aimed to analyze the efficiency of 3D 4-hole trapezoid condyle plate (4-HTCP) in open reduction and internal fixation of the base of condyle fractures.
| Materials and Methods|| |
This study was conducted in accordance with the Declaration of Helsinki and was approved from the Institutional ethical committee vide letter no 3/A/IEC-GDCH-VJA/2013 dated 28-1-14. Written informed consent was obtained from all subjects.
A total of 25 patients with an age range of 21 to 53 years (mean 32.7 ± 8.7 years) were included in the study of which, 7 (28%) were females and 18 (72%) were males. On presentation, the standard protocol was followed for all the patients, which included a detailed case history [Table 1], clinical examination, and a minimum of two radiographs that included an orthopantomogram (OPG) [Figure 1] and skull posteroanterior view (PA) view [Figure 2]. Additionally, computer tomography (CT) scans were performed if required. Fractures were classified according to the comprehensive Arbeitsgemeinschaft fur osteosynthesefragen craniomaxillofacial surgery (AOCMF) classification system [Figure 3]. Routine blood investigations were done. A medical assessment of the patient was done by the physician and anesthetist.
| Surgical Procedure|| |
All the procedures are performed under general anesthesia via nasotracheal intubation. The patient is positioned and draped conventionally. Erich's arch bars or intermaxillary fixation screws are placed to facilitate maxillomandibular fixation. Marking is done before administration of local anesthesia 0.5 cm below the lobe of the ear extending for 3 cm [Figure 4]. Following skin incision, the platysma and superficial musculoaponeurotic layer are incised and the parotid gland is retracted superiorly. The tissues are retracted anteriorly and posteriorly. A ribbon retractor is placed to retract the tissues medial to the mandible thereby exposing the pterygomassetric sling, which is later incised, and masseter muscle reflected to expose the fracture line. Fracture exposure [Figure 5] is facilitated by the placement of a channel retractor in the sigmoid notch.
The fracture was reduced under direct vision. Ramus is distracted downwards to facilitate fracture reduction. Following reduction of fracture segments, fixation was done using 1.5mm 3 4-HTCP with 6 mm monocortical screws [Figure 6]. Maxillomandibular fixation was released and occlusion checked. Layer wise closure of soft tissue was done using 3-0 vicryl (ETHICON-located at Raritan, New Jersey, United States) for deeper layers and 3-0 silk (ETHICON-located at Raritan, New Jersey, United States) for the skin [Figure 7].
Four parameters were assessed intraoperatively [Figure 8], namely, the time taken for surgery (TSX), time taken from the reduction of fracture till the placement of the last screw (TLS), the requirement for additional exposure, ease of hardware handling as rated by the operating surgeon which was graded as excellent, good, (or) bad.
Post-operative OPG [Figure 9] and PA view [Figure 10] was taken on the second post-operative day. Patients were discharged 3 days after surgery. Patients were recalled once a week during the first post-operative month following which they were recalled every month for a minimum period of 9 months post-operatively. Six parameters were assessed during the follow-up [Figure 11]: hardware failure (screw loosening, plate torquing, plate fracture, screw fracture), signs of infection, maximum incisal opening, facial nerve injuries according to House and Brackmann's classification, temporomandibular joint (TMJ) symptoms (clicking, jaw deviation, and tenderness), and malocclusion.
| Results|| |
A total of 25 patients of an age range of 21–52 years were (mean 32.7 ± 8.7 years) treated of which, 7 (28%) were females and 18 (72%) were males. The etiology of the fractures [Figure 12] included road traffic accidents 13 (52%), interpersonal violence 6 (24%), accidental falls 4 (16%), sports trauma 2 (8%). The fractures were classified according to the comprehensive level-3 AOCMF classification system [Figure 3]. All the fractures included in our study were classified as condylar base fractures. Based on “fragmentation,” 22 (88%) of the fractures were non-fragmented, and 3 (12%) showed minor fragmentation. Considering the “remaining contact,” it was absent in 4 (16%) and was partial in 21 (84%) of the cases. Confirming the “displacement,” 4 (16%) of the cases showed full condylar displacement in the anteromedial direction, and 21 (84%) showed partial displacement. Of which, 15 (60%) of the patients showed partial displacement in the anteromedial direction and 6 (24%) in the posterior direction.
Concomitant mandibular fractures [Figure 13] and non-mandibular fractures [Figure 14] were analyzed and recorded separately, irrespective of one or more fractures occurring in the same subject. Fifteen (60%) of the subjects suffered body fractures, 14 (56%) suffered parasymphysis fractures, 12 (48%) had angle fractures, 9 (36%) had symphysis fractures, and 7 (28%) suffered a bilateral condylar fracture.
The surgeries were performed by five different surgeons with different levels of surgical experience. All the patients were operated on using a retromandibular approach. The time taken for operating on the condyle alone was recorded [Figure 8]. It was between 30 min and 1 h in 5 (20%) patients, between 1 h and 2 h in 19 (76%) patients, and greater than 2 h in 1 (4%) patient. Time taken from reduction of fracture to placement of the last screw was recorded which also included the time taken for manipulation of osteosynthesis plate to ensure optimal adaptation. In 15 (60%) subjects, the time taken was less than 10 min, and in 10 (40%) patients, the time taken ranged from 10 min to 15 min. Six (24%) subjects needed additional exposure to facilitate the procedure.
Ease of plate handling [Figure 8] was graded as “excellent,” “good,” and “bad.” The same was recorded as expressed by the physician. In 21 (84%) subjects, it was rated as “excellent” and as “good” in 4 (16%) of the subjects.
Post-operatively, all the patients were followed up for a minimum of 9 months and a maximum of 30 months (mean 19.5 + 5.87 months). Five parameters were assessed during the follow-up period [Figure 11]. The given data depicts the results during 9 months follow-up period. According to House-Brackmann's classification, two (8%) subjects showed mild dysfunction of buccal and marginal mandibular branches of the facial nerve which are noticeable on close inspection (Grade II) and recovered within 6 months.
No failure of osteosynthesis plates was reported. None of the subjects had an infection at the surgical site. TMJ was examined for clicking, tenderness, and jaw deviation. Two (8%) subjects had TMJ clicking which lasted beyond 6 months follow-up period.
The range of mandibular movements was satisfactory. The maximum incisal opening was in the range of 25–37 mm (mean- 31.4 ± 3.38 mm) on the first post-operative day, 31.4 + 3.4 mm 6 weeks post-operative period, 43.8 + 4.3 mm 3 months post-operatively, 46.7 + 2.9 mm 6 months post-operatively, and 49.7 + 4.5 mm 9 months post-operatively.
Jaw deviation on opening towards the fractured side was 1.5+/-7.4 mm six weeks post operatively, -0.5+/-3.7 mm three months post operatively, -0.6+/-4.5 mm six months post operatively and -0.4+/-6.2 mm nine months post operatively.
Taking into consideration the transient hypofunction of the facial nerve (8%) and TMJ disorder (8%), the aggregate complication rate in our study was 16%.
| Discussion|| |
Osteosynthesis devices are applied mostly along the condylar neck axis, nevertheless, this is an area subject to compression stresses which apparently elucidated the failures encountered in the internal fixation of the condylar region. A practical way to achieve a stable fixation would be to extend the osteosynthesis device into the zone of tension located along the coronoid process or below the mandibular notch.
The design of trapezoidal 3D plates meets the above-mentioned requirements. Its anterior arm and the two connecting horizontal arms cross brace the tractional forces below the mandibular notch creating a stable internal fixation.
The minimum follow-up period in our study was 6 months during which osteosynthesis device failure was reported. Maximum bite force increases significantly from 6 weeks to 6 months. This implies that in our study trapezoidal 3D plates were able to withstand dynamic forces of the mandible when subjected to maximum bite force.
The range of mandibular movements in our study showed maximum improvement during the first 3 months post-surgery.
Bouchard et al. in a retrospective study conducted on 118 subjects with subchondral fracture treated through a retromandibular approach reported a 22% temporary paralysis of the facial nerve and 6.8% persistent partial facial paralysis. Similarly, Cortellazi et al. conducted a study in which the subcondylar fractures were treated using different osteosynthesis devices. In their study, they reported 17.7% transient facial palsy in patients who were treated through a retromandibular approach, which resolved spontaneously in a mean time of 3–4 weeks. In our study, we reported a transient partial facial nerve paralysis pertaining to buccal and marginal mandibular branches of the facial nerve, which resolved without intervention within 6 months follow-up period.
The infection rate in our study was 0%, which could be attributed to a minimal hospital stay as required, judicious use of antibiotics, restoring the patient to oral intake at the earliest, strict adherence to sterilization and disinfection protocol as well as regular monitoring of the patient.
Sikora et al. reported a TMJ complication rate of 11.5% which did not resolve within 6 months post-surgically. In our study, TMJ complications were reported in two subjects (8%). Both the subjects received delayed treatment. One of them had a neurologic intervention for a head injury, while in the second patient the delay was attributed to a lack of general awareness regarding maxillofacial injuries and their consequences.
| Conclusion|| |
3D 4-HTCP is a robust and reliable option for stable internal fixation of condylar base fractures. They occupy minimal space and their ease of adaptation in the condylar base region minimizes the surgical time. The design of these osteosynthesis devices aids in counteracting the class III lever forces of the mandible creating zones of traction below the mandibular notch region.
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
Conflicts of interest
There are no conflicts of interest.
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