2017-18 HSC Section 3 Green Book

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

Hackenberg et al

Nevertheless, the operative time can be prolonged because of the more technically challenging reduction of displaced segments com- pared with the open approach. Therefore, we see the main benefit of ERIF in replacing MMF in patients who cannot tolerate the prolonged fixation with closed reduction. This becomes pivotal in the trauma patient because concomitant injuries such as pneumothorax, flail chest, and other respiratory compromising conditions are frequently observed in maxillofacial fractures. 41 Reductions requiring ORIF are a potential source of injury to the facial nerve. Damage to this delicate structure may result in par- esthesia of the facial muscles ranging from mild to severe and from transient to permanent. The preauricular incision may lead to a dif- ficult reduction in which damage to the undissected facial nerve occurs through excessive tissue retraction. Our approach to managing the facial nerve is slightly differ- ent. The anteriorly placed incision (8 mm in front of the external auditory canal) necessitates dissection of the individual branches of the nerve, allowing direct visualization to avoid injury. Dissecting and separating the individual branches, if done properly under facial nerve monitoring, may actually reduce the probability of paresthesia through direct vision. However, this additional dissection effort comes with the great benefit of a perpendicular access to the fracture easing the difficulty of reduction in nearly every fracture pattern. The treatment of subcondylar mandible fractures remains a topic of debate. The discussion focused historically on whether open or closed reduction achieved better outcomes regarding premorbid form and function while minimizing morbidity associated with treat- ment. Recent technical advances within the field of endoscopic sur- gery have added yet another treatment modality, further challenging the surgeon to choose the best option for his/her patients. We conclude that the main benefits of ERIF are found in the replacement of MMF in selected patients. This is clinically sig- nificant when MMF is not a viable option for the patient or when there is a mild functional discrepancy that can be restored with ERIF but does not warrant ORIF. However, the duration of MMF should be 4 to 6 weeks when performing closed reduction on a true subcondylar fracture. When ORIF is necessary, surgeons should consider becoming familiar working with the facial nerve under monitoring to improve anatomic reduction. Lastly, in the era of shared decision making, patients' choices always need to be consid- ered. In general, an algorithm may inform or provide a structural ba- sis for this decision making to not only ensure the best outcome for our patients but also serve as a point of discussion in the manage- ment of this complex fracture pattern. REFERENCES 1. Smith H, Peek-Asa C, Nesheim D, et al. Etiology, diagnosis, and characteristics of facial fracture at a midwestern level I trauma center. J Trauma Nurs 2012;19:57 – 65 2. Kostakis G, Stathopoulos P, Dais P, et al. An epidemiologic analysis of 1,142 maxillofacial fractures and concomitant injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2012;114(suppl):S69 – S73 3. Kyrgidis A, Koloutsos G, Kommata A, et al. Incidence, aetiology, treatment outcome and complications of maxillofacial fractures. A retrospective study from northern Greece. J Craniomaxillofac Surg 2013;41:637 – 643 4. Villarreal PM, Monje F, Junquera LM, et al. Mandibular condyle fractures: determinants of treatment and outcome. J Oral Maxillofac Surg 2004;62:155 – 163 5. Brandt MT, Haug RH. Open versus closed reduction of adult mandibular condyle fractures: a review of the literature regarding the evolution of current thoughts on management. J Oral Maxillofac Surg 2003;61:1324 – 1332

TABLE 1. Conversion of MMF Into ERIF

displacement. In these cases, restoration of premorbid form and function is highly dependent on the approach taken by the surgeon. It is our experience that superior outcomes are achieved through the use of ERIF or ORIF rather than closed reduction. Although many surgeons advocate for closed reduction when possible, we believe that secondary healing of the fracture site can result in potential malunion, facial asymmetry, deviation on mouth opening, and chronic TMJ problems. Although there may be concerns regarding facial nerve injury, such complications are negligible in ERIF and mini- mized using the previously described surgical approach under facial nerve monitoring for ORIF. In fractures with minimal displacement and those that seem amenable to reduction via the endoscopic approach, ERIF should be considered the primary treatment option. Indications for ERIF include laterally displaced fractures in the coronal plane, fractures rotated anteriorly in the sagittal plane, and fractures with a minimal degree of medial displacement. In the latter case, reduction may be slightly more difficult and a threaded k-wire or condylar reduction tool should be available. Fractures with a low degree of displace- ment not amenable to ERIF should be treated with ORIF to best re- store premorbid form and function. Subcondylar fractures with a high degree of displacement are always treated with ORIF. As previously stated, ORIF results in su- perior fracture reduction of complex fractures not attainable through other surgical techniques. This approach regarding the use of ORIF is well established in both the literature and clinical practice. Lastly, the presence of a bilateral fracture does not necessar- ily influence the treatment plan. As long as both sides are non- displaced, MMF can still be applied. In the case of displacement with loss of vertical height, we recommend operating with ERIF or ORIF on the safer side — typically the fracture that is lower and provides a larger proximal segment for fixation. When considering internal fixation, the proximal segment should always be optimally large enough to place at least 2 screws superior to the fracture. Relative Contraindications for the Use of MMF Respiratory compromise (eg, due to trauma, flail chest, pneumothorax, infection, asthma, chronic obstructive pulmonary disease) Nutritional status Noncompliance, psychiatric comorbidity Oral health (eg, edentulous patient, gross periodontal disease, gross caries) Other comorbidities (eg, seizure disorder) CONCLUSIONS In cases in which closed reduction is the management tech- nique of choice, the duration of MMF varies between institutions. The main concern is finding a balance between attaining fracture re- duction and avoiding ankylosis of the TMJ. Given the anatomic location of a subcondylar fracture, we believe that fractures properly diagnosed as within this region are at low risk for ankylosis. In a subcondylar fracture, one will gener- ally not observe trauma to the joint capsule or the condylar head. As such, we recommend a period of MMF for at least 4 to 6 weeks, with an additional period of 2 to 3 weeks of guiding elastics in patients in whom closed fixation is possible. Compared with the rather short duration of 2 weeks, 5 a longer period of MMF works toward achieving maximal union and healing of the fracture. The endoscopic approach provides surgeons with a third via- ble option for treating subcondylar fractures. It combines the ben- efits of ORIF and MMF while minimizing their associated risks.

© 2014 Mutaz B. Habal, MD

5