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National Journal of Maxillofacial Surgery
 
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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 491-494  

Is extracorporeal plating ideal for condylar fracture? A case report with a two-year follow-up study


1 Department of OMFS, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu, India
2 Department of Oral and Maxillofacial Surgery, Karpaga Vinayaga Institute of Dental Sciences, Tamil Nadu, India

Date of Submission21-Nov-2021
Date of Acceptance11-Mar-2022
Date of Web Publication10-Dec-2022

Correspondence Address:
Dr. Nathiya Balasubramaniyan
Assistant Professor, Department of Oral and Maxillofacial Surgery, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.njms_499_21

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   Abstract 


Management of condylar fractures includes the closed and open methods. The closed method, although is conservative, has disadvantages such as inadequate reduction, disturbances in occlusion, and a decrease in ramal height. To overcome these disadvantages, surgeons prefer open reduction and internal fixation. One of the methods used is extracorpeal fixation of condyle fractures. This method has a limiting factor of excessive condylar resorption and avascular necrosis. We report a two-year follow-up of a patient with condylar head resorption and fractured implant.

Keywords: Condylar fractures, condylar resorption, extracorpeal fixation


How to cite this article:
Balasubramaniyan N, Kumar GS, Bhagat M J, Muthulingam V. Is extracorporeal plating ideal for condylar fracture? A case report with a two-year follow-up study. Natl J Maxillofac Surg 2022;13:491-4

How to cite this URL:
Balasubramaniyan N, Kumar GS, Bhagat M J, Muthulingam V. Is extracorporeal plating ideal for condylar fracture? A case report with a two-year follow-up study. Natl J Maxillofac Surg [serial online] 2022 [cited 2023 Jan 26];13:491-4. Available from: https://www.njms.in/text.asp?2022/13/3/491/363082




   Introduction Top


Management of mandibular condylar fracture has reviewed more discussion and controversies in the field of maxillofacial trauma. Among mandibular fractures, the condylar region is the most frequent site, accounting for almost 25–35% of the cases. Motor vehicle accidents and falls are the major causes of the fracture. They cause occlusal disturbances, temporo-mandibular joint dysfunction, and facial deformities. Therefore, proper treatment of condylar fracture is essential to prevent such problems. Extracorporeal fixation of the condyle is used by several authors to describe a surgical procedure in which the fractured fragment is intentionally detached from the surrounding hard and soft tissues plated in vitro, and again, it was repositioned and fixed to the neck of the condyle.


   Case Report Top


A 23-year-old male patient came to our department with an alleged history of a road traffic accident of about 2 days prior to the presentation with the complaint of pain in the left side of the jaw. On examination, the young well-built and nourished male was conscious and well oriented and was able to recall the incident clearly. The face was asymmetrical because of extra-oral diffuse swelling seen in the left side of the face. On palpation tenderness over the left pre-auricular region, the condyle could not be elicited. The mandible was found to be deviated to the left side. On intra-oral examination, the mouth opening was restricted (13 mm). A posterior cross bite was present on the right side [Figure 1]. The orthopantomogram (OPG) shows the left condylar neck fracture displaced with anteromedial dislocation [Figure 2]. Patient routine blood investigation was normal. We planned to go for extracorpeal reduction and fixation of the condyle. After obtaining fitness, the patient was taken up for surgery under general anesthesia (GA). Right naso-endo-tracheal intubation was achieved. 2% lignocaine was administered in the left retro-mandibular region. Initially, retro-mandibular incision was placed. Layer-by-layer dissection was performed. We cannot reach the condylar segment because of medial wall displacement, so we extend to pre-auricular incision [Figure 3]. The fractured site is identified, and the condylar fragment was retrieved. The fragment was held manually and stabilized with a seven-hole bone plate and screws [Figure 4]. Since there was compromised vascular supply in the explanted segment, we chose to fix with a single-plate system. The assembled fragments were replaced in situ and fixed to the distal segment in the pre-determined position. The procedural time taken to complete the fixation of the plate was approximately 12 min. Layer-by-layer closure was performed with 3-0 vicryl and skin closure with 4-0 ethilion. Maxillomandibular fixation (MMF) was maintained for 1 week. This was followed by active jaw exercises. The patient was followed up for 2 weeks. The patient was asymptomatic, and the mouth opening was 35 mm. The patient was comfortable at rest. Erich's arch bar was removed after 4 weeks.
Figure 1: Posterior cross bite

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Figure 2: Pre-Op OPG

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Figure 3: Intra-Op surgical site exposure

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Figure 4: Condylar neck fracture fragment explanted plate fixed in vitro and again repositioned and fixed to the neck of the condyle

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Follow-up

The patient reported after 2 years with chief complaints of painful swelling in the left side of the face and was unable to eat because of a limited mouth opening of 15 mm. Facial asymmetry because of diffuse swelling was in the left lower third of the face. There was deviation of the jaw toward the left side during closing of the mouth, with occlusion intact. The post-operative complication noted was swelling in the left side of the face, implant fracture, and resorption of the condyle [Figure 5]. In the second stage of surgery, although the patient had implant plate fracture, there was no intra-oral discrepancy in occlusion [Figure 6]. OPG showed the resorption of the condyle in the left side with fracture of the implant [Figure 7]. The patient was advised for implant removal under GA. After obtaining anesthetic fitness, the patient was taken up for implant removal under GA. Right naso-endo-tracheal intubation was achieved. 2% lignocaine was administered in the left retro-mandibular region. Incision was placed through the existing scar in the retro-mandibular region. Layer-by-layer dissection was performed. Fractured implant site-exposed implants and screws were removed. Closure was performed with 3-0 vicryl and 3-0 ethilion.
Figure 5: Post-operative complication after 2-year follow-up with facial asymmetry because of diffuse swelling on the left side

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Figure 6: Intra-oral occlusion on the right and left sides

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Figure 7: OPG shows resorption of the condyle and fractured implant

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   Discussion Top


The prevalence of a mandibular condyle fracture is relatively high compared with other types of mandibular fractures. The treatments for mandibular condyle fractures have been controversial because of the anatomic position of this fracture and the influence of facial bone growth. A search of the PubMed database in August 2021 using a combination of the search terms “condyle fracture” and “extracorporeal” revealed only a few articles that specifically addressed this issue.

Park JM et al.[1] reported that patients who received extracorpeal reduction were 6.539 times more likely to have condyle resorption than those who received closed treatment. Post-operative condyle resorption was affected by the fracture type, the fracture site, and the displacement of the fragment, although the fracture type was the most significant predictor of post-treatment condylar resorption.

The treatment objectives for mandibular condyle fractures are 1) a pain-free mouth opening greater than 40 mm, 2) free mandibular movement in any direction, 3) restoration to the level of the original condition before injury, and 4) no facial asymmetry after reduction to the point that existed before reduction.[2],[3]

Extracorporeal reduction was introduced by Nam. The extracorporeal reduction technique has advantages that include easier reduction and anatomic restoration.[4] The mean severe resorption rate after the extracorporeal reduction of the mandibular condyle has been reported to be 27% to 89%.[5],[6] Boyne et al.[7] reported slight resorption, leading to flattening of the condyle in a follow-up period of 2 years.

One possible cause of the condyle resorption in this case is the loss of the periosteal blood supply in the explanted segments. Because the explanted fractured segment was not different from a free bone graft, excessive resorption was anticipated. The attachment of the lateral pterygoid muscle is important for the prevention of condyle resorption. The other factors, such as age, systemic disease, and/or fracture severity, may lead to the excessive resorption after the extracorporeal reduction. In our case, there was a 2-year follow-up in which the patient presented with a fractured plate and condylar resorption.

For the treatment of an excessively resorbed condyle, condylectomy and re-construction with a costochondral graft can be considered.[8] In our case, there was no disturbance in functional occlusion and we noticed that there was a complete resorption of the condyle and fractured implant. We performed implant removal under GA. Since the fractured condyle itself was used as a free graft, there are always possibilities of condylar resorption and avascular necrosis.[6] In our case, we experienced the same. It is difficult to consider the resorption rate but a viable option only in the case of a displaced condylar fragment.[9],[10]


   Conclusion Top


Although the exracorpeal fixation of the condyle seems to be a good option to achieve perfect alignment, it is difficult to achieve absolute maintenance of the vertical height and facial symmetry in the case of severely displaced condyle fracture. One of the main limiting factors taken into consideration is the possibility of condylar resorption and avascular necrosis, which we clearly experienced in our 2-year follow-up of a case. Therefore, we conclude that extracorpeal fixation can be considered as an option only if other treatment modalities fail.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Park JM, Jang YW, Kim SG, Park YW, Rotaru H, Baciut G, et al. Comparative study of the prognosis of an extracorporeal reduction and a closed treatment in mandibular condyle head and/or neck fractures. J Oral Maxillofac Surg 2010;68:2986-93.  Back to cited text no. 1
    
2.
Zachariades N, Mezitis M, Mourouzis C, Papadakis D, Spanou A. Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals. J Craniomaxillofac Surg 2006;34:421-32.  Back to cited text no. 2
    
3.
Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41:89-98.  Back to cited text no. 3
    
4.
Nam IW. The condylar head and upper condylar neck fractures treated by Dr Nam's method. J Korean Acad Oral Maxillofac Surg 1980;6:25.  Back to cited text no. 4
    
5.
Iizuka T, Lindqvist C, Hallikainen D, Mikkonen P, Paukku P. Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures. A clinical and radiologic study of thirteen patients. Oral Surg Oral Med Oral Pathol 1991;72:400-7.  Back to cited text no. 5
    
6.
Davis BR, Powell JE, Morrison AD. Free grafting of mandibular condyle fractures clinical out come in 10 consecutive patients. Int J Oral Maxillofac Surg 2005;34:871-6.  Back to cited text no. 6
    
7.
Boyne PJ. Free grafting of traumatically displaced or resected mandibular condyles. J Oral Maxillofac Surg 1989;47:228-32.  Back to cited text no. 7
    
8.
Jacobsen PU, Lund K. Unilateral overgrowth and remodeling processes after fracture of the mandibular condyle. A longitudinal radiographic study. Scand J Dent Res 1972;80:68-74.  Back to cited text no. 8
    
9.
Meng FW, Liu YP, Hu KJ, Kong L. Use of a temporary screw for alignment and fixation of sagittal mandibular condylar fractures with lateral screws. Int J Oral Maxillofac Surg 2010;39:548-53.  Back to cited text no. 9
    
10.
Gupta MV, Sahoo NK. Extracorporeal fixation of displaced mandibular condylar fracture: Viable option. Med J Armed Force India 2009;65:229-31.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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