Condylar Neck and Sub-Condylar Fractures: Surgical Consideration and Evolution of the Technique with Short Follow-Up on Five Cases

Abstract

Condylar neck and sub-condylar fractures of the mandible are a frequent occurrence in maxillofacial surgery. The indication for surgical treatment of these fractures has changed over time, and several techniques have been developed with different results in the attempt to avoid the most worrisome adverse event, i.e., facial nerve injury. In this study, we present a new technique that combines an intraoral and a cutaneous pre-auricular access, which allows for easy and safe access to the surgical site, preventing facial nerve injury and avoiding surgical scars in high-impact aesthetic areas of the neck. Five consecutive patients affected by condylar neck or sub-condylar fractures were treated at a single institution using a combined intraoral and pre-auricular access. Results were evaluated after three months from surgery in terms of mandibular mobility, occurrence of complications, and patient’s satisfaction. All five patients had good outcome, with complete healing of the fracture and no occurrence of complications, including no facial nerve palsy. A key point of the technique is the safe reduction of the two mandibular fragments realized by a combined intraoral and a cutaneous pre-auricular surgical access. The periosteal plan of the ramus can be widely and safely elevated with the intraoral approach and connected to the condylar bone plane by the pre-auricular cutaneous approach without any need for soft tissue dissection at the fracture rim, thereby avoiding facial nerve injuries. Wide ramus periosteum elevation creates an “optical space”, allowing fragment reduction and fixation under direct oblique view without any endoscopic need. Our results strongly suggest that with our technique it is possible to treat sub-condylar and condylar neck fractures safely, avoiding facial nerve injury, which is an unacceptable complication due to its heavy impact on a patient’s life.

New Minimally Invasive Intraoral Procedure for Condylar Fractures: Clinical Presentation and Considerations on Current Techniques

“…The main drawbacks include cutaneous scar formation due to skin incisions, possible facial nerve injury (FNI) during soft tissue dissection or traction near the posterior and lateral sides of the mandible, and a limited surgical field of view elevating FNI risk. Moreover, the deep procedures register a higher rate for FNI over that of the superficial techniques 5 …”

“…Moreover, the deep procedures register a higher rate for FNI over that of the superficial techniques. 5 At present, aesthetics, safety, and precise surgical results are mandatory, particularly for preserving the facial nerve and restoring the posterior ramus height.…”

“…Many review studies evaluated complications for different surgical techniques. 5,7,8 All the studies reported a higher prevalence of facial nerve injury for deep and posterior techniques than that of the superficial and anterior approaches. 7 Recently, researchers described conservative techniques for extracapsular condylar fractures and the combined minimally invasive technique (COMIT), based on a wide ramous periosteum elevation with intraoral and preauricular cutaneous access points.…”

“…4 Several surgical approaches to treat condyle fractures by open reduction and internal fixation (ORIF) have been described, classified in superficial techniques (trans-parotid, trans-masseter, and antero-parotid accesses), deep techniques (submandibular and retromandibular approaches), as well as transoral and preauricular accesses. 5 An endoscopic reduction via intraoral approach has also been recently described. 6 Open reduction and internal fixation is considered the treatment of choice in displaced fractures providing good alignment, also restoring facial symmetry, function, and anatomical alignment.…”

“…Many review studies evaluated complications for different surgical techniques 5,7,8 . All the studies reported a higher prevalence of facial nerve injury for deep and posterior techniques than that of the superficial and anterior approaches 7 …”