Content uploaded by Alan Parbhoo
Author content
All content in this area was uploaded by Alan Parbhoo on Oct 14, 2017
Content may be subject to copyright.
British Journal of Oral and Maxillofacial Surgery 46 (2008) 167–169
A
vailable online at www.sciencedirect.com
Specialist review
Review of pertinent papers 2005—trauma
Simon Holmes ∗, Alan Parbhoo
Accepted 19 May 2007
Available online 25 October 2007
Hlawitschka M, Loukota R, Eckelt U. Functional
and radiological results of open and closed treatment
of intracapsular (diacapitular) condylar fractures of
the mandible. Int J Oral Maxillofac Surg 2005;34:597–
604.
This study was done to compare open and closed management
of intracapsular condylar fractures of the mandible.
Fifteen displaced fractures of the condylar head were
treated by open reduction and internal fixation over a 6-year
period. The results were then compared to ‘similar condy-
lar fractures’ treated by closed management. Patients in the
operated group had a better radiological outcome, better pos-
terior facial height, and less resorption of the condyle than
the closed group.
Clinically, both groups had signs of lateral deviation in
mouth opening and crepitus. A third of the closed treatment
group had occlusal disturbance, compared with none of the
operated group, and the mouth opening cycle in the closed
group was more irregular.
This paper supports the use of open reduction and internal
fixation (ORIF) in these injuries.
Comment
The paper is flawed in its case selection, so the results must
be interpreted with caution, but it is probably the best com-
parison of open compared with closed reduction in these
challenging injuries.
Previous papers have shown good results in patients who
have lost clinical and radiological posterior facial height, but
this paper adds weight to the ‘ORIF’ argument.
The approach to the head was by an auricular approach,
and fixation was with a combination of techniques including
titanium compression screw, titanium mesh, and a polylactide
screw. Coexisting Neff B fractures, on the other side, were
∗Corresponding author.
E-mail address: sbholmes1@mac.com (S. Holmes).
managed by 10 days’ IMF followed by 3 weeks’ functional
mobilisation.
The control group consisted of 29 patients with 34 frac-
tures of the condylar head. They were immobilised for 10
days, and then had 6–8 weeks’ functional treatment.
The ORIF group was examined at roughly 11 months, and
the closed group at about 20 months.
There were no operative complications, no failures of
osteosynthesis, and all patients were happy with the aesthetics
of the repair.
Analysis showed that the outcome in patients who had
open treatment was significantly better in terms of condy-
lar movement. Radiological examination showed increased
deformity in the closed group with respect to posterior facial
height and the shape of the condylar head.
Mandibular mobility was compromised with respect to
translation in the closed group, and rotation in the ORIF. The
paper suggests that physiotherapy should be customised to
take this into account.
Davis BR, Powell JE, Morrison AD. Free grafting
of mandibular condyle fractures: clinical outcomes in
10 consecutive patients. Int J Oral Maxillofac Surg
2005;34:871–6.
There is little doubt that diacapitular fractures of the
mandibular condyle are technically the most difficult to
repair. They are often the result of high-energy transfer and
are often bilateral.
The paper presents a review of 10 consecutive patients who
had their intracapsular fractures treated by ‘free grafting of
the condylar head’ with or without osteotomy of the posterior
ramus as an aid to reduction or fixation, or both.
Over a 6-year period, 11 patients were identified retro-
spectively, of whom 1 was lost to follow-up. This left 10
patients with 10 operated sites for evaluation, all of whom had
been operated on within 9 days. Access was by either a retro-
mandibular or submandibular approach, and they each had
an osteotomy of the posterior border ramus. Both fragments
0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.05.016
168 S. Holmes, A. Parbhoo / British Journal of Oral and Maxillofacial Surgery 46 (2008) 167–169
were then removed, fixed extracorporealy, and the fragments
returned to their anatomical position. Elastic IMF was used
for about of 1.6 weeks and patients were reviewed by clinical
and radiographic examination, and questionnaire.
The results showed excellent function in seven, but
condylar resorption in three cases required secondary recon-
struction with a costochondral graft. Ultimately all the
patients had a satisfactory result.
Of the three failures, one had a further assault, the
second had a refractory infection, and the third had a pre-
existing skeletal open bite. Eight had radiological resorption
up to 1 year, but none showed any deterioration after this
time.
Comment
Surgical management of this group of patients is problem-
atic for four reasons. First, the minor fragment is usually
displaced medially and inferiorly and is difficult to identify
and retrieve; secondly, the dissection and exposure transgress
the facial nerve; thirdly, the condylar head is challenging
to fix, and various methods may be used; and lastly there
are concerns about resorption, loss of fixation, and poor
outcome.
Surgical exposure of the fracture was achieved by either
a retromandibular or a submandibular approach, or both.
This is surprising, as the submandibular incision affords little
advantage in terms of exposure. The preauricular approach
combined with a retromandibular incision allows visualisa-
tion of both the head and the ramus.
The mandible may then be distracted downwards and for-
wards to aid exposure and retrieval of the minor fragment.
This is a difficult manoeuvre, and may be facilitated by a seg-
mental posterior ramus osteotomy. It is essential to pre-bend
the plates and fix them before osteotomy, as the reduction of
the postcondylar fixation fragment is difficult.
The timing of the operation is interesting, the usual time
being 2 days; six patients were operated on within a day. The
earlier these fractures are attempted, the more straightfor-
ward the manipulation. An incarcerated condylar head can
be difficult to mobilise, and this should be borne in mind
when a period of conservative management is allowed before
fixation.
The fragments may be fixed by several methods, depend-
ing on the line of fracture and the size of the fragment. In
the study, miniplates, microplates, and lag screws were used.
There is no doubt that the segmental osteotomy greatly sim-
plifies reduction and fixation, and allows a more accurate
assessment of the quality of fixation.
All patients had appreciable resorption but, apart from the
three complicated cases, returned to good function.
Of the three patients who required secondary recon-
struction, bony reduction was imperfect in two. There was
underlying pre-existing skeletal deformity in one, repeated
trauma in the second, and unexplained infection in the third.
All three were reconstructed with costochondral grafts with
good outcomes.
This paper supports the concept of free grafting of the
mandibular condyle, and the addition of an osteotomy of the
segmental posterior ramus may facilitate fixation, particu-
larly when the head cannot be stabilised in place.
Herford AS, Ying T, Brown B. Outcomes of severely com-
minuted (type III) nasoorbitoethmoid fractures. J Oral
Maxillofac Surg 2005;63:1266–77.
This paper presents a case series of 10 consecutive patients
with Markowitz type III fractures, all of whom had comminu-
tion of the central fragment with detachment of the canthal
tendons.
Access was by coronal, transconjunctival, or transoral
incisions. Transnasal canthopexy was done through a drill
posterior to the lacrimal crest. Nasal support was by a can-
tilevered cranial bone graft.
The series included six bilateral type III and four uni-
lateral type III/II fractures. All patients had successful
reconstructions, and there were no cases of postoperative
telecanthus, enophthalmos, or strabismus. The mean reduc-
tion in telecanthus was 6 mm. All patients had the nasal
bridge grafted.
Follow-up was short at 8–12 weeks, but the final results
will therefore not reflect the long-term facial appearance.
Comment
Naso-orbitalethmoid fractures are a diverse group of injuries
that vary greatly in complexity and therefore in treatment and
prognosis.
This paper deals with two aspects of management: the
canthal tendon and nasal projection. Markowitz III fractures
are the least common and the most difficult to treat.
Correct assessment of the nasal septum may be a major
cause of secondary facial deformity.
The successful reduction of the medial canthal ligament
depends on both medial and posterior placement of the ten-
don. This is a complex manoeuvre and the method described
in this article over-simplifies the technique, particularly when
there are extensive blow out fractures of the medial wall. After
localisation and capturing of the tendon, the paper describes
pre-drilling of the central fragment and the passage of a wire.
More recent developments in the form of the synthes canthal
tendon wire may simplify this part of the operation greatly.
This was achieved in all cases; two patients had ‘slight asym-
metry’.
A primary bone graft to the nasal dorsum was used in all
cases, and is an interesting concept. The assessment of the
size of the graft together with accurate placement requires
good judgement, and the results are impressive. Two of
10 patients were judged to have overprojection after the
graft, and one of the cases described in the paper does not
have perfect symmetry, emphasising the complexity of the
technique.
This well-illustrated paper shows that good results may be
achieved in these devastating injuries, but the techniques are
complex.
S. Holmes, A. Parbhoo / British Journal of Oral and Maxillofacial Surgery 46 (2008) 167–169 169
Pedemonte C, Basili E. Predictive factors in infraorbital
sensitivity disturbances following zygomaticomaxillary
fractures. Int J Oral Maxillofac Surg 2005;34:503–6.
Sensory disturbance of the trigeminal nerve is an almost
pathognomic sign in fractures of upper, middle, and lower
thirds of the maxillofacial skeleton. Patients in the outpatient
clinic often ask about the prognosis of this disturbance.
This paper attempts to answer this question, and to find
out if there are objective measurements of nerve recovery.
Ten patients with infraorbital nerve dysfunction were
assessed with a combination of touch detection thresholds
(Von Frey fibres), and warm/cold discrimination.
Warm/cold discrimination was found to be a significant
discriminator in the prediction of duration of time to tactile
recovery.
Comment
Numbness of the face is extremely common after facial
trauma, and is often of most concern to the patient, once the
initial symptoms of the injury and operations have resolved.
In contrast to pharmacologically blocked nerves, dam-
aged nerves have dysfunctional larger myelinated fibres,
so touch and proprioception are affected more often than
pain and temperature fibres. This is known as the ‘Lewis
theory’.
The authors therefore suggest that the nerves that maintain
temperature discrimination have a greater potential for earlier
recovery.
This theory is borne out by the results that showed that
patients with impaired thermal discrimination took three
times longer to recover tactile sensation (17 as opposed to
4.6 weeks).
The total time for nerves to recover is normally about 3–6
months. Anecdotally, some patients recover nerve function
within 18 months. Thermal discrimination would therefore
be a good prognostic indicator of a rapid return to function,
but impaired discrimination does not necessarily predict total
resolution after this time and may be associated with a more
permanent loss.