There is some consensus on the indication of open reduction and internal fixation for condyle fractures.1 If bilateral condylar fractures of the mandible are treated with a closed technique, often malocclusion and limitation of mouth opening take place. If bilateral condylar fractures are treated conservatively, 10 percent of cases require corrective orthognathic surgery.2 However, open reduction with internal fixation is technically difficult, leaves a visible external scar, and has the risk of facial nerve injury. In a situation that required open reduction and internal fixation, we treated the patient with open reduction and external fixation through an intraoral incision using a distraction osteogenesis device, and obtained a satisfactory result.
A 47-year-old man was referred for treatment of extensive facial bone fractures, including a palatal fracture, a mandibular parasymphysis fracture, and bilateral condylar fractures. The patient had a crossbite caused by the palatal fracture, and his lower incisor was extracted due to the mandibular parasymphysis fracture. He had a subcondylar fracture on the left side and a condylar neck fracture on the right; as a result, there was an anterior open bite and the height of the posterior ramus had been reduced (Fig. 1).
With the patient under general anesthesia and nasotracheal intubation, we internally fixed the palatal fracture and the parasymphysis fracture through a lower gingival sulcus incision. Then, after minimal subperiosteal dissection was performed through the intraoral incision, the fracture line of the bilateral condyles was examined and aligned as much as possible by manual reduction. For external fixation using distraction osteogenesis devices, we marked the fracture line on the skin and inserted two Kirschner wires into the condylar segment and the ramus, avoiding the path of facial nerves. The distraction osteogenesis devices were installed on both sides and alignment was achieved again through the intraoral incision, with adjustment of the hinge joint and the degree of distraction (Fig. 2). After the fractures on both sides had been reduced accurately, arch bars were applied to the maxilla and the mandible and intermaxillary fixation was achieved with elastic bands.
Three weeks after the operation, the intermaxillary fixation was released. When radiographs showed that the right-side fracture was out of line with mild open bite, we reduced it again by manipulating the right device. After another 2 weeks of external fixation, we removed the distraction osteogenesis devices. The open bite was aggravated temporarily and then improved spontaneously. At 3 months postoperatively, the patient's mouth opening was 3.8 cm, and no clinically significant malocclusion or facial asymmetry was observed.
By manipulating the devices intraoperatively and postoperatively, we maintained maximal bone-to-bone contact and appropriate ramus height. In mandibular condylar fractures that need to be treated with open reduction and internal fixation, the application of open reduction and external fixation through an intraoral incision using adjustable distraction osteogen-esis devices can give satisfactory results in mandibular motion, symmetry, and occlusion.
The authors have no financial conflicts to disclose. The treatment of mandibular condyle fracture is the most controversial part of facial bone fractures.
This work was supported by the SRC/ERC program of MOST/KOSEF (R11-2005-065) through the Intelligent Textile System Research Center at Seoul National University.
Yoonho Lee, M.D.
Kikap Kim, M.D.
Department of Plastic and Reconstructive Surgery
Seoul National University College of Medicine
1. Baker AW, McMahon J, Moos KF. Current consensus on the management of fractures of the mandibular condyle: A method by questionnaire. Int J Oral Maxillofac Surg.
2. Newman L. A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles. Br J Oral Maxillofac Surg.
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