Page 83 - Open versus closed Mandibular condyle fractures

Open treatment of condylar fractures: extraoral approaches
INTRODUCTION
Anatomical reduction and adequate fixation rely on good surgical exposure of the fracture site.1 Thus, the ideal approach should allow enough exposure to reduce the fracture and position the hardware, but also have the lowest rate of surgical complications, be the least invasive, result in the least conspicuous postoperatively scarring, and be performed easily and rapidly.2-4
The treatment of condylar fractures is a controversial subject in numerous scientific reports.5,6 Even when there is a clear indication for treating these fractures, the appropriate approach becomes another subject of debate. In order to achieve anatomic reduction, it is essential to obtain complete exposure of the surgical field for direct visualization of the fracture and mobilization of the displaced segment.7 To establish this, different approaches to the mandibular condyle are described; the three most used are the pre-auricular, retromandibular, and submandibular approaches.2,8 The choice of approach is often based on the level of fracture. Fractures are subdivided into condylar base, condylar neck (extracapsular), and condylar head (intracapsular) fractures.9-12
With respect to the level of the fracture, one could argue for using the pre-auricular or perilobular approach for high condylar fractures,13 the retromandibular approach for middle-height fractures,13-16 and the retromandibular, or a variety of submandibular approaches for low condylar fractures.13-17 Although the open approach is superior in terms of restoring anatomy, open treatment can potentially result in surgery- related complications. The greatest risk is damage to the facial nerve.
The approach dictates the exposure, but also the degree and number of complications, due to the layers of dissection and anatomical structures present, i.e., the facial nerve, the great auricular nerve, and the parotid gland. It is said that the choice of surgical approach is of vital importance in reducing postoperative complications.7 In this matter, the focus of debate is not on the skin incision, but rather the subcutaneous dissection.
The aim of this study was to provide an overview of the complications of extraoral approaches in the open treatment of condylar fractures to enable a well-founded choice for one or more approaches.
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