Methods
In the period between 2003 and 2011, 40 patients visited our clinic for the surgical treatment of mandibular condyle fractures. The inclusion criteria for this study were as follows: adolescent or adult patients in good health, presence of neck and subcondylar mandibular fractures associated with post-traumatic dental malocclusion, and alteration of the temporomandibular joint functionality on radiological examination. Edentulous patients and patients below the age of 15 years were excluded. All the 40 patients were contacted by telephone and invited to volunteer for clinical and radiological examinations, but only 25 patients accepted our invitation and were finally included in this study. The study involved 18 males (72%) and 7 females (28%) (male/female ratio, 2.5/1), and the age at the time of injury ranged from 16 to 55 years (mean age, 27 years). The most frequent causes of injury were road traffic accidents (60%) followed by accidental falls (32%) and personal violence (8%). The mean follow-up duration was 3.67 years (range, 1–10 years).
The 25 patients reported a total of 28 mandibular condylar fractures: 22 (88%) unilateral condylar fractures and 3 (12%) bilateral condylar fractures of which 26 were surgically treated. The patients were evaluated by the authors according to a detailed protocol. The preoperative radiographic examinations comprised panoramic radiography and CT (high-definition 1-mm thickness, high-resolution 3D reconstruction) to determine the degree of condylar displacement. We used 2 different types of surgical approaches, retromandibular retroparotid or preauricular approach, depending on the severity of the fracture.
According to Lindahl's classification of mandibular condylar fractures, we used the preauricular approach in cases of condylar neck fractures and the retromandibular retroparotid approach in cases of subcondylar fractures.
The retromandibular retroparotid approach was performed through a 3- to 4-cm vertical incision that extended inferiorly from the tip of the mastoid, below the ear lobe, anterior to the sternocleidomastoid muscle. The incision was made in the anteromedial direction, beneath the parotid gland, toward the posterior border of the mandible until the incision reached the condylar fracture. The branches of the facial nerve were not encountered. The preauricular approach was performed through a 5- to 6-cm skin incision extending superiorly to the top of the helix leading to an anterior temporal extension. Then, the temporal fascia (superficial layer) was incised in the vertical direction, and a blunt dissection was performed, exposing the lateral part of the temporomandibular joint capsule.
The patients were trained to perform a set of exercises consisting of forced active and passive mouth opening. The training was aimed to correct the jaw's alignment to achieve a satisfactory range of movements. The patients treated for unilateral condylar fracture were instructed to stand in front of a mirror and apply gentle force using their fingers to open the mandible along a straight line, using the upper interincisive line as the reference line; in addition, the gradual recovery of the normal range of jaw movement was encouraged. Use of left and right laterality, with particular attention to the movement of the side contralateral to the fractured side, was recommended. Furthermore, the rehabilitation of protrusion as well as correction of lateral mandibular deviation of the fractured side was encouraged. The patients treated for bilateral condylar fracture received post-surgery physiotherapy in the same manner described above. We suggest particular attention be paid during protrusive mandibular movement. The patients were instructed to perform the exercises 3 times a day, with 10 minutes spent for each movement. In cases where the Balter's bionator was used, the device was built by taking the construction bite in maximum protrusive in case of bicondylar fracture and in contralateral laterality in the case of unilateral condylar fracture. The patients were recommended to use it for as long as possible every day.
The following post-operative clinical parameters were monitored: (1) dental occlusion, (2) facial nerve functionality according to the House-Brackmann Facial Nerve Grading System, (3) skin scarring according to the Vancouver Scar Scale (VSS) of Baryza, (4) postoperative temporomandibular joint functionality, and (5) postoperative symptomatology according to the Research Diagnostic Criteria for Temporomandibular Joint Disorders (RDC/TMD). Finally, the patient's satisfaction concerning the treatment received was evaluated. The degree of satisfaction was quantified by asking the patient to rate the treatment received using a score from 0 to 10.
Habitual occlusion recovery was assessed by asking the patient whether he/she perceived his/her occlusion to be the same as that experienced before the trauma.
The postoperative functionality of the facial nerve was evaluated using the House-Brackmann Facial Nerve Grading System. The House-Brackmann system is used to score the degree of damage in facial nerve palsy. The score is determined by measuring the upwards (superior) movement of the mid-portion of the top of the eyebrow and the outward (lateral) movement of the angle of the mouth. Each reference point corresponds to 1 point for each 0.25-cm movement, up to a maximum of 1 cm. The scores are then added to obtain the maximum score out of 8.
The VSS is the most widely used scar assessment instrument. This scale, originally developed to rate burn scars, is a standardized grading instrument based on the following 4 parameters: pliability, pigmentation, vascularity, and scar height, all of which are evaluated independently. The total score (range 0 to 13) was obtained by adding the scores for each of the 4 parameters. The lower the score the greater the resemblance of the scar tissue to normal tissue.
The RDC/TMD consists of 2 axes: axis I (clinical examination, evaluation, and diagnosis) and axis II (behavioral questionnaires). Axis I was carefully compiled after scrupulous measurements taken using a caliper of the maximum opening without pain, maximum opening, passive opening, overbite, right lateral movement, left lateral movement, protrusion, deviation from the midline, and opening pattern.
We completed a historical review by asking the patients whether they experienced any facial pain homolateral to the side of the fracture and the exact position of this pain. The presence of temporomandibular joint pain, facial muscular pain, and combination of such pain was taken into account. Axis II was completed by the patients but was not taken into account in this study.
The presence of postoperative complication such as Frey's syndrome, infection, salivary fistula, plate fracture, and permanent paralysis of the facial nerve were taken into account.
After surgery, the mandible, the correct anatomical restoration of the fractured site, and the possible presence of plate fracture or screw loosening were evaluated via orthopanoramic radiography and high-definition CT. The patients photographs before and after surgery were also evaluated.
All patients granted written specific consent for all photographs and personal data to be used in every medical pubblications, journal, textbook and electronic pubblications. The investigation was conducted according to the ethical principles of the 1975 Helsinki Declaration for biomedical research involving human subjects, as revised in 2004. The present work represents a retrospective study, so that it did not require ethical comitte approval; its design, inclusion and exclusion criteria, and treatment protocol were reviewed and approved by the Research Committee of senior attending surgeons of the department.