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Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures
Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
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Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures Daniel Dalla Torre a, *, Doris Burtscher b, Gerlig Widmann c, Albina Pichler a, Michael Rasse a, Wolfgang Puelacher a a
Clinical Department of Craniomaxillofacial and Oral Surgery, Medical University of Innsbruck, (Head: Prof. DDr. Rasse Michael), Austria Clinical Department of Restorative and Prosthetic Dentistry, Medical University Innsbruck, (Head: Prof. DDr. Grunert Ingrid), Austria c Clinical Department of Radiology, Medical University Innsbruck, (Head: Prof. Dr. Jaschke Werner), Austria b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 29 January 2015 Accepted 22 April 2015 Available online xxx
Objective: Different modalities have been described regarding the treatment of mandibular condyle fractures. The most advantageous and safest one is still a topic of discussion. The present analysis describes the combination of a retromandibular, transparotideal approach combined to a triangularpositioned double-miniplate osteosynthesis, with a special regard for the patients' long term outcomes. Material and methods: Clinical data of 102 patients with 124 condyle fractures treated with the mentioned surgical procedure were evaluated. Functional parameters such as the maximal interincisal distance, deviations/deflections, facial nerve function, occlusion as well as complications regarding the parotid gland, osteosynthesis, and esthetics were evaluated 1 week, 2 weeks, 3 months, and 6 months postoperatively. Results: The mean maximal interincisal distance ranged from 38 mm after 1 week to 45 mm after 6 months. Deviations/deflections were seen in 22.5% of the cases 1 week postoperatively and decreased to 2% at 6 months postoperatively. A temporary facial palsy was diagnosed in 3.9% during the first followup, whereas no impairment was recorded after 3 or 6 months. At the same time, no patient had occlusional disturbances or complications regarding the parotid gland or the osteosynthesis 6 months postoperatively. Conclusions: Direct fracture visualization and a stable three-dimensional fracture stabilization are the main advantages of the presented combination of a surgical approach and osteosynthesis technique. Additionally, the absence of long-term complications confirms the safety of the procedure. Therefore, it may be considered as a successful treatment option for mandibular condyle fractures. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Condyle Fracture Retromandibular Transparotid Approach Osteosynthesis
1. Introduction Although mandibular condyle fractures represent 25%e50% of all mandibular fractures (Iida et al., 2001; Gassner et al., 2003; Brasileiro et al., 2006; Tang et al., 2009; Neff et al., 2014), the indication to perform surgical treatment is still a controversial issue. Multicenter studies have been able to demonstrate improved * Corresponding author. Jaufenstrasse 5, I-39049 Sterzing (BZ), Italy. Tel.: þ39 0472 767650; fax: þ39 0472 762427. E-mail address: [email protected] (D. Dalla Torre).
functional outcomes for surgical treatment compared to the “closed” conservative treatment (Eckelt et al., 2006; Schneider et al., 2008). The optimal conditions for complete functional rehabilitation of the patient include a correct fracture reduction and stabilization as well as the prevention of mouth opening limitations, ramus shortening, facial asymmetry, arthrosis of the temporomandibular joint, and functional difficulties in chewing, speaking, etc. (Silvennoinen et al., 1992; Vesnaver et al., 2005). The precise realignment and fixation of the bony fragments as the most important factor in fracture healing can be provided only by open reduction and a stable osteosynthesis.
http://dx.doi.org/10.1016/j.jcms.2015.04.019 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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D. Dalla Torre et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
The most advantageous and safest surgical approach still remains a topic of discussion. Different intraoral and extraoral approaches to the condylar area are used to perform open reduction of condyle fractures including submandibular, perimandibular, preauricular, and retromandibular approaches (Tang and Gao, 2009; Handschel et al., 2012). Several studies regarding the advantages and the complications of the retromandibular approach can be found in literature (Devlin et al., 2002; Biglioli et al., 2009; Narayanan et al., 2009; Girotto et al., 2012; Kim et al., 2012; Bhutia et al., 2014; Colletti et al., 2014). Despite the elevated number of investigations, publications with consistent case numbers of more than 50 patients are rare (Bouchard et al., 2014; Colletti and Battista, 2014). The goal of this study was to evaluate the functionality and complication rate of the retromandibular anterior transparotid (RAT) approach in combination with two triangular-positioned miniplates (triangular-positioned double-miniplate osteosynthesis [TDO]) in a cohort of more than 100 patients with 124 fracture sites. 2. Material and methods In a 5-year period, from 2007 to 2012, a total of 117 patients presenting with 146 mandibular condylar fractures were treated at the University Clinic for Craniomaxillofacial Surgery in Innsbruck, Austria, by open reduction and internal fixation (ORIF). Of these patients, 102 with a total of 124 fracture sites met the following inclusion criteria: >18 years of age; uni- or bilateral condylar base or neck fracture according to Loukota et al. (Loukota et al., 2005); retromandibular anterior transparotid (RAT) approach as surgical approach; triangular-positioned double-miniplate osteosynthesis (TDO) as fixation method; and completion of the follow-up examinations 1 week, 2 weeks, 3 months, and 6 months postoperatively. Beside clinical evaluations (occlusion, mouth opening, deviations/deflections, nerve injuries), orthopantomography and computed tomography (CT) scans were accomplished in all patients pre- and postoperatively (Figs. 4 and 5). Using this radiographic information, correct classification of the fracture level including fracture displacement and fragmentation were performed according to the classification of Loukota et al. (Loukota et al., 2005). All patients underwent surgery in general anesthesia via a nasotracheal intubation, to enable a maxillomandibular fixation and occlusion check during surgery. The retromandibular anterior transparotid approach was performed in the patient, to control the facial nerve function during the surgical approach by noninvasive nerve stimulation. The approach was marked and measured; the skin incision started 3e5 mm below the ear lobe in the caudal direction parallel to the posterior border of the ramus in the closed-mouth position. After the surgical identification of the parotid capsule respectively the superficial musculoaponeurotic system (SMAS) (Fig. 1), the incision of the parotid fascia was done in a more anterior part to prevent nerve injury. The parotid gland and the masseteric muscle were dissected bluntly until visualization of the condylar process. Close identification of the facial nerve branches was not performed; nevertheless they were retracted carefully if encountered using electrostimulation. The subperiosteal visualization of the condylar fracture site was performed under muscular relaxation followed by correct anatomical repositioning and osteosynthesis of the fracture under occlusal check (Fig. 2). Two 2.0-mm titanium miniplates were positioned in a triangular way, whereby the base of the triangle was located inferiorly (first plate position: parallel to posterior border; second plate position: caudal to the sigmoid notch, forming a three-dimensional “triangular” structure). During wound
Fig. 1. Identification of the parotid capsule respectively the superficial musculoaponeurotic system (SMAS).
closure, an accurate closure of the parotid capsule was performed, avoiding nerve damage (Fig. 3). A drain was inserted before skin closure and removed 1 day after surgery. The patients were placed on a soft diet for 1 week until removal of the stitches and were
Fig. 2. Visualization of the fracture reduction and the internal fixation.
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
D. Dalla Torre et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2015) 1e6
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Fig. 3. Meticulous suturing of the parotid capsule.
encouraged to practice mouth opening, latero- and protrusion 1 day after surgery. Follow-up examinations were performed 1 week, 2 weeks, 3 months, and 6 months postoperatively (Figs. 4, 5). The collected data comprised demographical indications, mechanisms of injury, radiological fracture classification, postoperative clinical measurement of the maximal interincisal distance, as well as postoperative complications (occlusion, deviation/ deflection, scar length and scar formation, facial nerve palsy, parotid fistula or sialocele). Statistical analysis was performed using SPSS 20 (IBM, Armonk, NY, USA). 3. Results A total of 102 patients presenting with 124 condylar fracture sites were evaluated. Of these, 80 patients (78.4%) had a unilateral condyle fracture and 22 patients (21.6%) had bilateral condyle fractures. In al, 65 patients (63.7%) were male and 37 (36.3%) female. The overall mean age was 33.6 years (range: 18e81 years); the gender-dependent mean age was 36.4 years for the men and 31.1 years for the women. The most common cause for the injury were sports (n ¼ 36, 35.3%) and traffic (n ¼ 33, 32.4%) accidents, followed by acts of violence (n ¼ 12, 11.8%), accidents at work (n ¼ 11, 10.8%), and accidents at home (n ¼ 6, 5.9%). Other miscellaneous causes were registered in 4 cases (3.9%). According to the classification of Loukota et al. (Loukota et al., 2005), 33 sites (26.6%) were condylar neck fractures, whereas 91 (73.4%) fractures were condylar base fractures. A total of 103 condyle fractures (83.1%) showed a displacement of more than 10 and/or a fracture fragment overlap of more than 2 mm, of which 84 fractures showed anterior and medial displacement of the condyle and 19 fractures a lateral displacement. The remaining 21 (16.9%) showed a minor displacement (Loukota et al., 2005). Baseline data are summarized in Table 1. Patients were seen at 1 week, 2 weeks, 3 months, and 6 months after surgery. The clinical parameters including occlusion, mouth
Fig. 4. Detail of a preoperative panoramic x-ray showing a left condyle fracture.
opening, deviation/deflection, scar length, facial palsy, parotid fistula, and sialocele are summarized in Table 2. Ten patients (9.8%) showed a malocclusion after 1 week (minor open bite at the operated side), which diminished to 5 patients (4.9%) after 2 weeks. Functional therapy was continued in these patients, achieving a correct, physiological occlusion in every case at the 3-month follow-up. Regarding the maximal interincisal distance as a measure for the maximal mouth opening, a minor impairment could be found at the 1-week follow-up with a mean distance of 38 mm (range 36e47 mm). Two weeks after surgery, a maximal interincisal distance of 44 mm on average (range 41e58 mm) could be recorded. After 3 and 6 months the interincisal distance was stable. Deviations or deflections were recorded in 23 patients (22.5%) after 1 week and in six patients (5.8%) after 2 weeks. Two cases (2%) of mandibular deviations were detected at the 3-month and the 6-month follow-up. All skin incisions were positioned in the mandibular shadow area, and the length was limited to a maximum of 30 mm. No complaints regarding esthetic impairment could be recorded at any time point during the follow-up. Regarding the function of the facial nerve, four patients (3.9%) presented with a unilateral weakness of the buccal branch of the facial nerve 1 and 2 weeks postoperatively. Thus, 3.2% of all approaches (4 f 124) showed a postoperative disturbance of the facial nerve. No impairment of the nerve function could be diagnosed at the 3-month follow-up or later in any patient. Seven patients (6.8%) experienced subcutaneous retention of saliva after 1 week in the region of the skin incision. However, all cases resolved within 2 weeks after drainage combined with a compression dressing. No parotid fistula or sialocele of the parotid gland could be diagnosed after 3 or 6 months.
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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occlusion did not appear to be clinically disturbed. Correspondingly, no significant radiological change in the condylar shape or the condylar head could be diagnosed despite the screw loosening. No fracture dislocation, condylar head resorption, or necrosis occurred during the observation period. The osteosynthesis material was removed successfully in 33 patients (32.3%) in the period from 10 to 18 months postoperatively. The main reasons for plate removal were complaints regarding the osteosynthesis (mainly weather sensitivity), patient wish, and all cases of screw loosening. 4. Discussion
Fig. 5. Detail of the postoperative panoramic x-ray after triangular-positioned doubleminiplate osteosynthesis (TDO).
No fractures or failures of the 2.0-mm thick titanium osteosynthesis plates were observed. In four patients (3.9%), screw loosening concerning the proximal, joint-bearing segment was seen radiologically at the 6-month follow-up, whereas the
Table 1 Baseline data of study patients. Condyle fractures (n¼patients, total n¼102) - Unilateral - Bilateral Gender - Male - Female Mean age (years) - Overall - Male - Female Mechanism of injury - Sports accident - Traffic accident - Acts of violence - Work accidents - Accidents at home - Other causes Fracture location (n¼fractures, total n¼124)a - Condylar neck - Condylar base Fracture dislocation (n¼fractures, total n¼124)a - Major displacementb - Minor displacementc a b c
80 (78.4%) 22 (21.6%) 65 (63.7%) 37 (36.3%) 31.1 (range 18e81) 36.4 33.6 36 (35.3%) 33 (32.4%) 12 (11.8%) 11 (10.8%) 6 (5.9%) 4 (3.9%) 33 (26.6%) 91 (73.4%) 103 (83.1%) 21 (16.9%)
According to Loukota et al., 2005. Displacement >10 and/or fracture fragment overlap of >2 mm. Displacement <10 and fracture fragment overlap of <2 mm.
Direct visualization of the fracture site as well as an optimal verification of the anatomical fracture realignment under occlusal control are prerequisites for a functional and stable condyle fracture stabilization. These advantages are important characteristics of the retromandibular transparotideal approach to the condylar neck and base. By this surgical access, the surgeon gains direct visibility of the posterior border of the mandibular ramus as well as the sigmoid notch, allowing an exact three-dimensional repositioning of the fracture fragments. Once the anatomic relations are recreated and stabilized, the optimal conditions for bony healing are achieved, minimizing at the same time the risk of long-term complications due to an incorrect union of the fracture fragments. In contrast to conservative therapy with intermaxillary fixation (IMF), a surgical approach of condylar fractures with stable osteosynthesis does not restrain patients' activities for weeks. The patients were encouraged to train their lower jaw immediately after surgery. By doing so, all patients were able to perform their daily life activities after 1 week. Most of the patients could even return to work after this initial recovery period. Additionally, the known complications of prolonged periods of IMF with trismus, inappropriate fracture healing, or a wrong occlusion could be avoided. For the whole period of an IMF, the oral hygiene of the patients is extremely restricted as is eating, with a possible compromise of body weight. Both limitations can be avoided by a surgical approach with rigid internal fixation of the fracture. The risk of facial nerve lesions performing a retromandibular approach has been a topic of research during the last decade. A temporary facial palsy as a possible complication has been described in 9%e20% of all treated patients (Girotto et al., 2012; Yang et al., 2012; Salgarelli et al., 2013; Bhutia and Kumar, 2014; Kanno et al., 2014). In the presented analysis using the retromandibular anterior transparotid (RAT) approach, 3.9% of all patients had a transient facial palsy, which resolved after a maximum of 12 weeks in all cases. The occurrence of nerve involvement may be lower in this study, because the authors used a nerve monitoring combined with an anterior transparotid approach, avoiding an exact visualization of the facial nerve branches at the same time. Additionally, since the single branches are left embedded in the surrounding connective tissue, problems regarding surgical damage or reduction of blood supply of the nerve may be avoided. Nevertheless, a temporary palsy may occur because of the necessary soft tissue retraction during surgery. The RAT approach to the condyle allows perfect visualization of the area of interest, representing the approach with the shortest distance between skin and the mandibular condyle. Beside possible esthetic disadvantages because of longer and more visible scars, the perimandibular or the submandibular approach are more time consuming. On another point of view, the preauricular approach has limitations concerning low condylar base fracture sites. In all three approaches (perimandibular, submandibular, and preauricular), a more forceful retraction of the soft tissues might be necessary because of the longer working distance, implying a
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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Table 2 Complications observed during 6 months after surgery. Complication
Malocclusion, n ¼ patients Mean maximal incisal distance, mm (range) Deviation/deflection, n ¼ patients Facial palsy, n ¼ patients Parotid fistula/sialocele, n ¼ patients
Timepoint (after surgery) 1 week
2 weeks
3 months
6 months
10 (9.8%) 38 (36e55) 23 (22.5%) 4 (3.9%) 7 (6.8%)
5 (4.9%) 44 (41e58) 6 (5.8%) 4 (3.9%) 0
0 44 (42e58) 2 (2%) 0 0
0 45 (42e58) 2 (2%) 0 0
higher risk of facial nerve disturbances. In contrast to extraoral approaches, an intraoral surgical access can be performed without any visible scars. Nevertheless, the fracture visualization, reduction, and its fixation are more difficult to perform in cases of higher condyle fractures, and should be performed under endoscopic assistance and control. Additionally, an angled bur and screw driver or a second transbuccal approach might be necessary. The complication of a salivary fistula or sialocele after a retromandibular transparotideal approach has been described by several authors (Ellis et al., 2000; Vesnaver and Gorjanc, 2005; Kanno and Sukegawa, 2014). Except for one patient, every case of salivary fistula described in the present analysis was recorded in the first 2 years. It may be supposed that the suturing of the parotid capsule has not been performed in a sufficient way in the first surgeries. By meticulous reunion of the capsule membrane during the interventions of the last years of the analysis, complications regarding the parotid gland could be avoided except in one patient. Therefore, the meticulous and exact reunion of the parotid capsule may be considered as the most important measure in the prevention of parotideal complications. No fracture of miniplates could be noticed during the observation period of 6 months. Other authors have described a failure of the internal fixation if only one miniplate was used for osteosynthesis (Hammer et al., 1997; Choi et al., 1999; Handschel and Ruggeberg, 2012). The reasons for considering a single osteosynthesis plate are principally two: the fear of a condylar head necrosis, and the (wrong) estimation of the fragment dimensions available for the osteosynthesis. In the present analysis, the stable insertion of two plates was possible in every case. At the same time, no condylar head necrosis was encountered. The triangular-positioned osteosynthesis guarantees a stable fracture fixation in all three dimensionsda crucial condition especially in condyle fractures because of the asymmetric design of the condylar head. Only by the correct fracture repositioning and the anatomical repositioning of the condylar head in the glenoid fossa can the patient recover physiologic mandibular function. For the mentioned reasons, the triangular-positioned double-miniplate osteosynthesis as a combination of one osteosynthesis plate at the posterior border of the ramus mandibulae and a second plate toward the region of the sigmoid notch can be declared a safe and successful option with a stable long-term outcome. The functionality and advantages of different three-dimensional plates have been investigated by various authors in the last few years (Lauer et al., 2007; Meyer et al., 2008; Kozakiewicz et al., 2014). All of them highlight the three-dimensional stability of the osteosynthesis. However, for the correct insertion of these plates, the corresponding surgical approach has to be of a certain width. In the authors' experience, the described RAT approach with a maximum length of 30 mm may render the use of threedimensional plates difficult or even impossible, whereas the insertion of two single plates does not present any “space” problem. By the triangular position of the two miniplates, the stability properties of the three-dimensional plates can partially be achieved as well as a functionally stable osteosynthesis, although via a
minimally invasive approach. In addition, the correct plate bending and positioning after the fracture reduction may be easier using two single plates compared to one large three-dimensional plate. Thus, a lower rate of secondary fracture displacement due to a better plate adaption can be achieved. 5. Conclusion Showing the efficacy and the safety of the retromandibular anterior transparotid approach in combination with triangular positioned double miniplate osteosynthesis using two titanium miniplates in 102 consecutive trauma patients presenting with 124 condylar fractures, this clinical procedure can be indicated as successful treatment option for mandibular condyle fractures. Conflicts of interest The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. References Bhutia O, Kumar L, Jose A, Roychoudhury A, Trikha A: Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach. Br J Oral Maxillofac Surg 52(3): 236e240, 2014 Biglioli F, Colletti G: Transmasseter approach to condylar fractures by miniretromandibular access. J Oral Maxillofac Surg 67(11): 2418e2424, 2009 Bouchard C, Perreault MH: Postoperative complications associated with the retromandibular approach: a retrospective analysis of 118 subcondylar fractures. J Oral Maxillofac Surg 72(2): 370e375, 2014 Brasileiro BF, Passeri LA: Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102(1): 28e34, 2006 Choi BH, Kim KN, Kim HJ, Kim MK: Evaluation of condylar neck fracture plating techniques. J Craniomaxillofac Surg 27(2): 109e112, 1999 Colletti G, Battista VM, Allevi F, Giovanditto F, Rabbiosi D, Biglioli F: Extraoral approach to mandibular condylar fractures: our experience with 100 cases. J Craniomaxillofac Surg 42(5): e186ee194, 2014 Devlin MF, Hislop WS, Carton AT: Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: surgical morbidity and informed consent. Br J Oral Maxillofac Surg 40(1): 23e25, 2002 Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota R, et al: Open versus closed treatment of fractures of the mandibular condylar processda prospective randomized multi-centre study. J Craniomaxillofac Surg 34(5): 306e314, 2006 Ellis 3rd E, McFadden D, Simon P, Throckmorton G: Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 58(9): 950e958, 2000 Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H: Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 31(1): 51e61, 2003 Girotto R, Mancini P, Balercia P: The retromandibular transparotid approach: our clinical experience. J Craniomaxillofac Surg 40(1): 78e81, 2012 Hammer B, Schier P, Prein J: Osteosynthesis of condylar neck fractures: a review of 30 patients. Br J Oral Maxillofac Surg 35(4): 288e291, 1997 Handschel J, Ruggeberg T, Depprich R, Schwarz F, Meyer U, Kubler NR, et al: Comparison of various approaches for the treatment of fractures of the mandibular condylar process. J Craniomaxillofac Surg 40(8): e397ee401, 2012 Iida S, Kogo M, Sugiura T, Mima T, Matsuya T: Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 30(4): 286e290, 2001 Kanno T, Sukegawa S, Tatsumi H, Nariai Y, Ishibashi H, Furuki Y, et al: The retromandibular transparotid approach for reduction and rigid internal fixation
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using two locking miniplates in mandibular condylar neck fractures. Int J Oral Maxillofac Surg 43(2): 177e184, 2014 Kim BK, Kwon YD, Ohe JY, Choi YH, Choi BJ: Usefulness of the retromandibular transparotid approach for condylar neck and condylar base fractures. J Craniofac Surg 23(3): 712e715, 2012 Kozakiewicz M, Swiniarski J: “A” shape plate for open rigid internal fixation of mandible condyle neck fracture. J Craniomaxillofac Surg 42(6): 730e737, 2014 Lauer G, Haim D, Proff P, Richter G, Pradel W, Fanghanel J, et al: Plate osteosynthesis of the mandibular condyle. Ann Anat 189(4): 412e417, 2007 Loukota RA, Eckelt U, De Bont L, Rasse M: Subclassification of fractures of the condylar process of the mandible. Br J Oral Maxillofac Surg 43(1): 72e73, 2005 Meyer C, Zink S, Chatelain B, Wilk A: Clinical experience with osteosynthesis of subcondylar fractures of the mandible using TCP plates. J Craniomaxillofac Surg 36(5): 260e268, 2008 Narayanan V, Kannan R, Sreekumar K: Retromandibular approach for reduction and fixation of mandibular condylar fractures: a clinical experience. Int J Oral Maxillofac Surg 38(8): 835e839, 2009 Neff A, Cornelius CP, Rasse M, Dalla Torre D, Audige L: The comprehensive AOCMF classification system: condylar process fracturesdlevel 3 tutorial. Craniomaxillofac Trauma Reconstr 7(Suppl. 1): S044eS058, 2014
Salgarelli AC, Anesi A, Bellini P, Pollastri G, Tanza D, Barberini S, et al: How to improve retromandibular transmasseteric anteroparotid approach for mandibular condylar fractures: our clinical experience. Int J Oral Maxillofac Surg 42(4): 464e469, 2013 Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota RA, Rasse M, et al: Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg 66(12): 2537e2544, 2008 Silvennoinen U, Iizuka T, Lindqvist C, Oikarinen K: Different patterns of condylar fractures: an analysis of 382 patients in a 3-year period. J Oral Maxillofac Surg 50(10): 1032e1037, 1992 Tang W, Gao C, Long J, Lin Y, Wang H, Liu L, et al: Application of modified retromandibular approach indirectly from the anterior edge of the parotid gland in the surgical treatment of condylar fracture. J Oral Maxillofac Surg 67(3): 552e558, 2009 Vesnaver A, Gorjanc M, Eberlinc A, Dovsak DA, Kansky AA: The periauricular transparotid approach for open reduction and internal fixation of condylar fractures. J Craniomaxillofac Surg 33(3): 169e179, 2005 Yang L, Patil PM: The retromandibular transparotid approach to mandibular subcondylar fractures. Int J Oral Maxillofac Surg 41(4): 494e499, 2012
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Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures Daniel Dalla Torre a, *, Doris Burtscher b, Gerlig Widmann c, Albina Pichler a, Michael Rasse a, Wolfgang Puelacher a a
Clinical Department of Craniomaxillofacial and Oral Surgery, Medical University of Innsbruck, (Head: Prof. DDr. Rasse Michael), Austria Clinical Department of Restorative and Prosthetic Dentistry, Medical University Innsbruck, (Head: Prof. DDr. Grunert Ingrid), Austria c Clinical Department of Radiology, Medical University Innsbruck, (Head: Prof. Dr. Jaschke Werner), Austria b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 29 January 2015 Accepted 22 April 2015 Available online xxx
Objective: Different modalities have been described regarding the treatment of mandibular condyle fractures. The most advantageous and safest one is still a topic of discussion. The present analysis describes the combination of a retromandibular, transparotideal approach combined to a triangularpositioned double-miniplate osteosynthesis, with a special regard for the patients' long term outcomes. Material and methods: Clinical data of 102 patients with 124 condyle fractures treated with the mentioned surgical procedure were evaluated. Functional parameters such as the maximal interincisal distance, deviations/deflections, facial nerve function, occlusion as well as complications regarding the parotid gland, osteosynthesis, and esthetics were evaluated 1 week, 2 weeks, 3 months, and 6 months postoperatively. Results: The mean maximal interincisal distance ranged from 38 mm after 1 week to 45 mm after 6 months. Deviations/deflections were seen in 22.5% of the cases 1 week postoperatively and decreased to 2% at 6 months postoperatively. A temporary facial palsy was diagnosed in 3.9% during the first followup, whereas no impairment was recorded after 3 or 6 months. At the same time, no patient had occlusional disturbances or complications regarding the parotid gland or the osteosynthesis 6 months postoperatively. Conclusions: Direct fracture visualization and a stable three-dimensional fracture stabilization are the main advantages of the presented combination of a surgical approach and osteosynthesis technique. Additionally, the absence of long-term complications confirms the safety of the procedure. Therefore, it may be considered as a successful treatment option for mandibular condyle fractures. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Condyle Fracture Retromandibular Transparotid Approach Osteosynthesis
1. Introduction Although mandibular condyle fractures represent 25%e50% of all mandibular fractures (Iida et al., 2001; Gassner et al., 2003; Brasileiro et al., 2006; Tang et al., 2009; Neff et al., 2014), the indication to perform surgical treatment is still a controversial issue. Multicenter studies have been able to demonstrate improved * Corresponding author. Jaufenstrasse 5, I-39049 Sterzing (BZ), Italy. Tel.: þ39 0472 767650; fax: þ39 0472 762427. E-mail address: [email protected] (D. Dalla Torre).
functional outcomes for surgical treatment compared to the “closed” conservative treatment (Eckelt et al., 2006; Schneider et al., 2008). The optimal conditions for complete functional rehabilitation of the patient include a correct fracture reduction and stabilization as well as the prevention of mouth opening limitations, ramus shortening, facial asymmetry, arthrosis of the temporomandibular joint, and functional difficulties in chewing, speaking, etc. (Silvennoinen et al., 1992; Vesnaver et al., 2005). The precise realignment and fixation of the bony fragments as the most important factor in fracture healing can be provided only by open reduction and a stable osteosynthesis.
http://dx.doi.org/10.1016/j.jcms.2015.04.019 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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The most advantageous and safest surgical approach still remains a topic of discussion. Different intraoral and extraoral approaches to the condylar area are used to perform open reduction of condyle fractures including submandibular, perimandibular, preauricular, and retromandibular approaches (Tang and Gao, 2009; Handschel et al., 2012). Several studies regarding the advantages and the complications of the retromandibular approach can be found in literature (Devlin et al., 2002; Biglioli et al., 2009; Narayanan et al., 2009; Girotto et al., 2012; Kim et al., 2012; Bhutia et al., 2014; Colletti et al., 2014). Despite the elevated number of investigations, publications with consistent case numbers of more than 50 patients are rare (Bouchard et al., 2014; Colletti and Battista, 2014). The goal of this study was to evaluate the functionality and complication rate of the retromandibular anterior transparotid (RAT) approach in combination with two triangular-positioned miniplates (triangular-positioned double-miniplate osteosynthesis [TDO]) in a cohort of more than 100 patients with 124 fracture sites. 2. Material and methods In a 5-year period, from 2007 to 2012, a total of 117 patients presenting with 146 mandibular condylar fractures were treated at the University Clinic for Craniomaxillofacial Surgery in Innsbruck, Austria, by open reduction and internal fixation (ORIF). Of these patients, 102 with a total of 124 fracture sites met the following inclusion criteria: >18 years of age; uni- or bilateral condylar base or neck fracture according to Loukota et al. (Loukota et al., 2005); retromandibular anterior transparotid (RAT) approach as surgical approach; triangular-positioned double-miniplate osteosynthesis (TDO) as fixation method; and completion of the follow-up examinations 1 week, 2 weeks, 3 months, and 6 months postoperatively. Beside clinical evaluations (occlusion, mouth opening, deviations/deflections, nerve injuries), orthopantomography and computed tomography (CT) scans were accomplished in all patients pre- and postoperatively (Figs. 4 and 5). Using this radiographic information, correct classification of the fracture level including fracture displacement and fragmentation were performed according to the classification of Loukota et al. (Loukota et al., 2005). All patients underwent surgery in general anesthesia via a nasotracheal intubation, to enable a maxillomandibular fixation and occlusion check during surgery. The retromandibular anterior transparotid approach was performed in the patient, to control the facial nerve function during the surgical approach by noninvasive nerve stimulation. The approach was marked and measured; the skin incision started 3e5 mm below the ear lobe in the caudal direction parallel to the posterior border of the ramus in the closed-mouth position. After the surgical identification of the parotid capsule respectively the superficial musculoaponeurotic system (SMAS) (Fig. 1), the incision of the parotid fascia was done in a more anterior part to prevent nerve injury. The parotid gland and the masseteric muscle were dissected bluntly until visualization of the condylar process. Close identification of the facial nerve branches was not performed; nevertheless they were retracted carefully if encountered using electrostimulation. The subperiosteal visualization of the condylar fracture site was performed under muscular relaxation followed by correct anatomical repositioning and osteosynthesis of the fracture under occlusal check (Fig. 2). Two 2.0-mm titanium miniplates were positioned in a triangular way, whereby the base of the triangle was located inferiorly (first plate position: parallel to posterior border; second plate position: caudal to the sigmoid notch, forming a three-dimensional “triangular” structure). During wound
Fig. 1. Identification of the parotid capsule respectively the superficial musculoaponeurotic system (SMAS).
closure, an accurate closure of the parotid capsule was performed, avoiding nerve damage (Fig. 3). A drain was inserted before skin closure and removed 1 day after surgery. The patients were placed on a soft diet for 1 week until removal of the stitches and were
Fig. 2. Visualization of the fracture reduction and the internal fixation.
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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Fig. 3. Meticulous suturing of the parotid capsule.
encouraged to practice mouth opening, latero- and protrusion 1 day after surgery. Follow-up examinations were performed 1 week, 2 weeks, 3 months, and 6 months postoperatively (Figs. 4, 5). The collected data comprised demographical indications, mechanisms of injury, radiological fracture classification, postoperative clinical measurement of the maximal interincisal distance, as well as postoperative complications (occlusion, deviation/ deflection, scar length and scar formation, facial nerve palsy, parotid fistula or sialocele). Statistical analysis was performed using SPSS 20 (IBM, Armonk, NY, USA). 3. Results A total of 102 patients presenting with 124 condylar fracture sites were evaluated. Of these, 80 patients (78.4%) had a unilateral condyle fracture and 22 patients (21.6%) had bilateral condyle fractures. In al, 65 patients (63.7%) were male and 37 (36.3%) female. The overall mean age was 33.6 years (range: 18e81 years); the gender-dependent mean age was 36.4 years for the men and 31.1 years for the women. The most common cause for the injury were sports (n ¼ 36, 35.3%) and traffic (n ¼ 33, 32.4%) accidents, followed by acts of violence (n ¼ 12, 11.8%), accidents at work (n ¼ 11, 10.8%), and accidents at home (n ¼ 6, 5.9%). Other miscellaneous causes were registered in 4 cases (3.9%). According to the classification of Loukota et al. (Loukota et al., 2005), 33 sites (26.6%) were condylar neck fractures, whereas 91 (73.4%) fractures were condylar base fractures. A total of 103 condyle fractures (83.1%) showed a displacement of more than 10 and/or a fracture fragment overlap of more than 2 mm, of which 84 fractures showed anterior and medial displacement of the condyle and 19 fractures a lateral displacement. The remaining 21 (16.9%) showed a minor displacement (Loukota et al., 2005). Baseline data are summarized in Table 1. Patients were seen at 1 week, 2 weeks, 3 months, and 6 months after surgery. The clinical parameters including occlusion, mouth
Fig. 4. Detail of a preoperative panoramic x-ray showing a left condyle fracture.
opening, deviation/deflection, scar length, facial palsy, parotid fistula, and sialocele are summarized in Table 2. Ten patients (9.8%) showed a malocclusion after 1 week (minor open bite at the operated side), which diminished to 5 patients (4.9%) after 2 weeks. Functional therapy was continued in these patients, achieving a correct, physiological occlusion in every case at the 3-month follow-up. Regarding the maximal interincisal distance as a measure for the maximal mouth opening, a minor impairment could be found at the 1-week follow-up with a mean distance of 38 mm (range 36e47 mm). Two weeks after surgery, a maximal interincisal distance of 44 mm on average (range 41e58 mm) could be recorded. After 3 and 6 months the interincisal distance was stable. Deviations or deflections were recorded in 23 patients (22.5%) after 1 week and in six patients (5.8%) after 2 weeks. Two cases (2%) of mandibular deviations were detected at the 3-month and the 6-month follow-up. All skin incisions were positioned in the mandibular shadow area, and the length was limited to a maximum of 30 mm. No complaints regarding esthetic impairment could be recorded at any time point during the follow-up. Regarding the function of the facial nerve, four patients (3.9%) presented with a unilateral weakness of the buccal branch of the facial nerve 1 and 2 weeks postoperatively. Thus, 3.2% of all approaches (4 f 124) showed a postoperative disturbance of the facial nerve. No impairment of the nerve function could be diagnosed at the 3-month follow-up or later in any patient. Seven patients (6.8%) experienced subcutaneous retention of saliva after 1 week in the region of the skin incision. However, all cases resolved within 2 weeks after drainage combined with a compression dressing. No parotid fistula or sialocele of the parotid gland could be diagnosed after 3 or 6 months.
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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occlusion did not appear to be clinically disturbed. Correspondingly, no significant radiological change in the condylar shape or the condylar head could be diagnosed despite the screw loosening. No fracture dislocation, condylar head resorption, or necrosis occurred during the observation period. The osteosynthesis material was removed successfully in 33 patients (32.3%) in the period from 10 to 18 months postoperatively. The main reasons for plate removal were complaints regarding the osteosynthesis (mainly weather sensitivity), patient wish, and all cases of screw loosening. 4. Discussion
Fig. 5. Detail of the postoperative panoramic x-ray after triangular-positioned doubleminiplate osteosynthesis (TDO).
No fractures or failures of the 2.0-mm thick titanium osteosynthesis plates were observed. In four patients (3.9%), screw loosening concerning the proximal, joint-bearing segment was seen radiologically at the 6-month follow-up, whereas the
Table 1 Baseline data of study patients. Condyle fractures (n¼patients, total n¼102) - Unilateral - Bilateral Gender - Male - Female Mean age (years) - Overall - Male - Female Mechanism of injury - Sports accident - Traffic accident - Acts of violence - Work accidents - Accidents at home - Other causes Fracture location (n¼fractures, total n¼124)a - Condylar neck - Condylar base Fracture dislocation (n¼fractures, total n¼124)a - Major displacementb - Minor displacementc a b c
80 (78.4%) 22 (21.6%) 65 (63.7%) 37 (36.3%) 31.1 (range 18e81) 36.4 33.6 36 (35.3%) 33 (32.4%) 12 (11.8%) 11 (10.8%) 6 (5.9%) 4 (3.9%) 33 (26.6%) 91 (73.4%) 103 (83.1%) 21 (16.9%)
According to Loukota et al., 2005. Displacement >10 and/or fracture fragment overlap of >2 mm. Displacement <10 and fracture fragment overlap of <2 mm.
Direct visualization of the fracture site as well as an optimal verification of the anatomical fracture realignment under occlusal control are prerequisites for a functional and stable condyle fracture stabilization. These advantages are important characteristics of the retromandibular transparotideal approach to the condylar neck and base. By this surgical access, the surgeon gains direct visibility of the posterior border of the mandibular ramus as well as the sigmoid notch, allowing an exact three-dimensional repositioning of the fracture fragments. Once the anatomic relations are recreated and stabilized, the optimal conditions for bony healing are achieved, minimizing at the same time the risk of long-term complications due to an incorrect union of the fracture fragments. In contrast to conservative therapy with intermaxillary fixation (IMF), a surgical approach of condylar fractures with stable osteosynthesis does not restrain patients' activities for weeks. The patients were encouraged to train their lower jaw immediately after surgery. By doing so, all patients were able to perform their daily life activities after 1 week. Most of the patients could even return to work after this initial recovery period. Additionally, the known complications of prolonged periods of IMF with trismus, inappropriate fracture healing, or a wrong occlusion could be avoided. For the whole period of an IMF, the oral hygiene of the patients is extremely restricted as is eating, with a possible compromise of body weight. Both limitations can be avoided by a surgical approach with rigid internal fixation of the fracture. The risk of facial nerve lesions performing a retromandibular approach has been a topic of research during the last decade. A temporary facial palsy as a possible complication has been described in 9%e20% of all treated patients (Girotto et al., 2012; Yang et al., 2012; Salgarelli et al., 2013; Bhutia and Kumar, 2014; Kanno et al., 2014). In the presented analysis using the retromandibular anterior transparotid (RAT) approach, 3.9% of all patients had a transient facial palsy, which resolved after a maximum of 12 weeks in all cases. The occurrence of nerve involvement may be lower in this study, because the authors used a nerve monitoring combined with an anterior transparotid approach, avoiding an exact visualization of the facial nerve branches at the same time. Additionally, since the single branches are left embedded in the surrounding connective tissue, problems regarding surgical damage or reduction of blood supply of the nerve may be avoided. Nevertheless, a temporary palsy may occur because of the necessary soft tissue retraction during surgery. The RAT approach to the condyle allows perfect visualization of the area of interest, representing the approach with the shortest distance between skin and the mandibular condyle. Beside possible esthetic disadvantages because of longer and more visible scars, the perimandibular or the submandibular approach are more time consuming. On another point of view, the preauricular approach has limitations concerning low condylar base fracture sites. In all three approaches (perimandibular, submandibular, and preauricular), a more forceful retraction of the soft tissues might be necessary because of the longer working distance, implying a
Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019
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Table 2 Complications observed during 6 months after surgery. Complication
Malocclusion, n ¼ patients Mean maximal incisal distance, mm (range) Deviation/deflection, n ¼ patients Facial palsy, n ¼ patients Parotid fistula/sialocele, n ¼ patients
Timepoint (after surgery) 1 week
2 weeks
3 months
6 months
10 (9.8%) 38 (36e55) 23 (22.5%) 4 (3.9%) 7 (6.8%)
5 (4.9%) 44 (41e58) 6 (5.8%) 4 (3.9%) 0
0 44 (42e58) 2 (2%) 0 0
0 45 (42e58) 2 (2%) 0 0
higher risk of facial nerve disturbances. In contrast to extraoral approaches, an intraoral surgical access can be performed without any visible scars. Nevertheless, the fracture visualization, reduction, and its fixation are more difficult to perform in cases of higher condyle fractures, and should be performed under endoscopic assistance and control. Additionally, an angled bur and screw driver or a second transbuccal approach might be necessary. The complication of a salivary fistula or sialocele after a retromandibular transparotideal approach has been described by several authors (Ellis et al., 2000; Vesnaver and Gorjanc, 2005; Kanno and Sukegawa, 2014). Except for one patient, every case of salivary fistula described in the present analysis was recorded in the first 2 years. It may be supposed that the suturing of the parotid capsule has not been performed in a sufficient way in the first surgeries. By meticulous reunion of the capsule membrane during the interventions of the last years of the analysis, complications regarding the parotid gland could be avoided except in one patient. Therefore, the meticulous and exact reunion of the parotid capsule may be considered as the most important measure in the prevention of parotideal complications. No fracture of miniplates could be noticed during the observation period of 6 months. Other authors have described a failure of the internal fixation if only one miniplate was used for osteosynthesis (Hammer et al., 1997; Choi et al., 1999; Handschel and Ruggeberg, 2012). The reasons for considering a single osteosynthesis plate are principally two: the fear of a condylar head necrosis, and the (wrong) estimation of the fragment dimensions available for the osteosynthesis. In the present analysis, the stable insertion of two plates was possible in every case. At the same time, no condylar head necrosis was encountered. The triangular-positioned osteosynthesis guarantees a stable fracture fixation in all three dimensionsda crucial condition especially in condyle fractures because of the asymmetric design of the condylar head. Only by the correct fracture repositioning and the anatomical repositioning of the condylar head in the glenoid fossa can the patient recover physiologic mandibular function. For the mentioned reasons, the triangular-positioned double-miniplate osteosynthesis as a combination of one osteosynthesis plate at the posterior border of the ramus mandibulae and a second plate toward the region of the sigmoid notch can be declared a safe and successful option with a stable long-term outcome. The functionality and advantages of different three-dimensional plates have been investigated by various authors in the last few years (Lauer et al., 2007; Meyer et al., 2008; Kozakiewicz et al., 2014). All of them highlight the three-dimensional stability of the osteosynthesis. However, for the correct insertion of these plates, the corresponding surgical approach has to be of a certain width. In the authors' experience, the described RAT approach with a maximum length of 30 mm may render the use of threedimensional plates difficult or even impossible, whereas the insertion of two single plates does not present any “space” problem. By the triangular position of the two miniplates, the stability properties of the three-dimensional plates can partially be achieved as well as a functionally stable osteosynthesis, although via a
minimally invasive approach. In addition, the correct plate bending and positioning after the fracture reduction may be easier using two single plates compared to one large three-dimensional plate. Thus, a lower rate of secondary fracture displacement due to a better plate adaption can be achieved. 5. Conclusion Showing the efficacy and the safety of the retromandibular anterior transparotid approach in combination with triangular positioned double miniplate osteosynthesis using two titanium miniplates in 102 consecutive trauma patients presenting with 124 condylar fractures, this clinical procedure can be indicated as successful treatment option for mandibular condyle fractures. Conflicts of interest The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. References Bhutia O, Kumar L, Jose A, Roychoudhury A, Trikha A: Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach. Br J Oral Maxillofac Surg 52(3): 236e240, 2014 Biglioli F, Colletti G: Transmasseter approach to condylar fractures by miniretromandibular access. J Oral Maxillofac Surg 67(11): 2418e2424, 2009 Bouchard C, Perreault MH: Postoperative complications associated with the retromandibular approach: a retrospective analysis of 118 subcondylar fractures. J Oral Maxillofac Surg 72(2): 370e375, 2014 Brasileiro BF, Passeri LA: Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102(1): 28e34, 2006 Choi BH, Kim KN, Kim HJ, Kim MK: Evaluation of condylar neck fracture plating techniques. J Craniomaxillofac Surg 27(2): 109e112, 1999 Colletti G, Battista VM, Allevi F, Giovanditto F, Rabbiosi D, Biglioli F: Extraoral approach to mandibular condylar fractures: our experience with 100 cases. J Craniomaxillofac Surg 42(5): e186ee194, 2014 Devlin MF, Hislop WS, Carton AT: Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: surgical morbidity and informed consent. Br J Oral Maxillofac Surg 40(1): 23e25, 2002 Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota R, et al: Open versus closed treatment of fractures of the mandibular condylar processda prospective randomized multi-centre study. J Craniomaxillofac Surg 34(5): 306e314, 2006 Ellis 3rd E, McFadden D, Simon P, Throckmorton G: Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 58(9): 950e958, 2000 Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H: Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 31(1): 51e61, 2003 Girotto R, Mancini P, Balercia P: The retromandibular transparotid approach: our clinical experience. J Craniomaxillofac Surg 40(1): 78e81, 2012 Hammer B, Schier P, Prein J: Osteosynthesis of condylar neck fractures: a review of 30 patients. Br J Oral Maxillofac Surg 35(4): 288e291, 1997 Handschel J, Ruggeberg T, Depprich R, Schwarz F, Meyer U, Kubler NR, et al: Comparison of various approaches for the treatment of fractures of the mandibular condylar process. J Craniomaxillofac Surg 40(8): e397ee401, 2012 Iida S, Kogo M, Sugiura T, Mima T, Matsuya T: Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 30(4): 286e290, 2001 Kanno T, Sukegawa S, Tatsumi H, Nariai Y, Ishibashi H, Furuki Y, et al: The retromandibular transparotid approach for reduction and rigid internal fixation
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Please cite this article in press as: Dalla Torre D, et al., Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures, Journal of Cranio-Maxillo-Facial Surgery (2015), http://dx.doi.org/10.1016/j.jcms.2015.04.019