2017-18 HSC Section 3 Green Book

The Journal of Craniofacial Surgery • Volume 25, Number 1, January 2014

Subcondylar Mandible Fractures

with further clinical evaluation including the patient's medical his- tory and personal preferences, allowing the patient and the surgeon to arrive at a shared decision. Note that we have excluded children from the patient population discussed because different challenges are expected in a growing mandible and such considerations exceed the scope of this article. 15 If the patient presents with a preserved occlusion, we gener- ally opt to perform a closed reduction. Upon CT examination, a nondisplaced fracture may be treated with either 6 weeks of a soft diet or MMF for 4 to 6 weeks, depending on patient preference and normal findings from a functional examination. In a minimally displaced fracture, our decision is based upon further evaluation of functional status. When the patient shows no infringement re- garding the range of mandibular motion, deviation on opening, or intercuspation of the teeth, and when this patient can tolerate MMF, we recommend closed reduction. In the case of significant functional infringement such as loss of vertical height or if the pa- tient is unable to tolerate MMF, we choose to approach and repair the fracture endoscopically. It is our opinion that restoring any loss in vertical height is imperative in achieving premorbid form and function. In the case of a minimally displaced fracture, ERIF is technically simple, provides restoration of vertical height rela- tive to closed reduction, and allows us to avoid the operative morbidities associated with a facial nerve dissection. We assert that ERIF promises to replace MMF in 2 specific scenarios: one, when patients cannot tolerate a period of MMF because of poor dentition or comorbidities (Table 1), and two, when a fracture is displaced with significant functional impairment but not significantly enough to warrant ORIF. If the patient presents with his/her dentition not in functional occlusion, we expect the CT scan to show a low or high degree of

makes reduction technically more challenging and not always pos- sible. Therefore, we reserve this approach for laterally displaced fractures, fractures with minimal medial displacement, and fractures rotated anteriorly in the sagittal plane. It is of greater value in patients with no or minor displacements, who are not optimal can- didates for several weeks of MMF (Fig. 4). Although endoscopic approaches have shown benefits, they also have their limitations, namely, in cases with significant bony displacement we are now trending toward ORIF with facial nerve monitoring. of strengths and weaknesses, the general aim of fracture reduction is always to restore premorbid form and function without harming the patient. However, determining the optimal treatment for each case is not a simple task, and the aim of this article was to make an effort to clarify the best approach for each patient. The diversity of surgical techniques, materials, and perhaps more importantly fracture type and location challenges us to make the correct deci- sion for each individual patient. It is implicit in this article that with an open approach coupled with facial nerve monitoring, nearly all subcondylar fractures can be reduced effectively but at the cost of increased operative time and the need for additional facial nerve monitoring technology. Figure 5 outlines our treatment algorithm in approaching subcondylar fractures of the mandible. The figure is based on cur- rent literature and our clinical experience. We begin with the first assessment of the patient's functional occlusion and premature con- tact and correlate this occlusion with the amount of displacement on the computed tomographic (CT) scan. This information is coupled DISCUSSION Although the techniques mentioned above each have an array

FIGURE 5. Algorithm for the treatment of subcondylar fractures of the mandible in the adult patient.

© 2014 Mutaz B. Habal, MD

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