2017-18 HSC Section 3 Green Book

ORAL AND MAXILLOFACIAL SURGERY e10 Kotrashetti, Lingaraj and Khurana

April 2013

the results reported by Zide and Kent, 16 Vesnaver et al., 17 and Choi et al., 18 where they observed facial nerve palsy in 40%, 22%, and 20% of their patients, respectively. According to Vasconcelos et al., 19 facial nerve damage is caused chiefly by compression and/or stretching of nerve fibers, which resulted in neuro- praxia, and was caused by excessive or heavy handed retraction. Chossegros et al. 20 reported incidence of transitory auricular hypoesthesia for 3 weeks in 2 out of 38 cases of condylar fractures where ORIF was done through retromandibular approach. This is not consis- tent with our study, where none of our cases had auricular anesthesia when retromandibular approach was used. Two types of temporomandibular joint dysfunction were encountered in the present study, i.e., ipsilateral deviation on opening the mouth and pain on opening the mouth which was assessed subjectively by the pa- tients. Ipsilateral deviation of the mandible was noted in 2 cases treated by closed reduction (16.67%), whereas no deviation was seen in any of the cases treated by open reduction. Patients who complained of pain were treated symptomatically and were resolved completely in a period of 3-4 months. Postoperative physical therapy should be directed toward increasing condylar translation on the traumatized side, thus re- ducing deviation on opening and enabling the mandible to shift away from the site of previous injury. It will also allow reduction of compensatory movements of uninvolved joints. Widmark et al. 3 reported a 2.0-mm deviation of the TMJ toward the operated site in 30% of their cases and 7/19 patients experienced pain in rela- tion to the TMJ. According to Zide and Kent, 16 15% of all surgically treated patients had problems in the form of pain, dysfunction, and limitation of mouth opening or deformity, which is similar to our observation. 20 Dysfunction and degeneration of the TMJ occurred not only on the fractured side but also on the contralateral side. Dislocated fractures seem to cause more dysfunc- tion than nondisplaced fractures. Scar was assessed clinically and graded as con- spicuous, inconspicuous, or hypertrophic. In this study, out of 10 patients with open reduction, 1 had conspicuous scar (10%). We did not encounter any plate infection, plate fracture or any necessity for plate removal in any of the operated cases. Retro- mandibular approach has been the recommended method to approach the condyle for ORIF by many authors, because it is easier, is associated with min- imal complications, and provides better access. 3,4,6,7 The retromandibular approach used in the present study provides adequate accessibility, less risk of facial nerve damage. and minimal scarring.

ORIF of the condyle by an intraoral route, principally for low subcondylar fractures, and since then several techniques have evolved. Koberg and Momma 9 de- scribed the retromandibular approach for plate and screw fixation. Kitayama 10 described a method for the intraoral placement of a lag screw. With any interven- tion, the risks must be weighed against the benefits. If it is decided that the benefits of open reduction out- weigh the risks of the surgery, the surgeon must further consider the type of internal fixation desired and the risks of the particular approach against the potential benefits. For return of immediate function, plate and screw fixation was considered in the present study. The main risk of extraoral approaches is damage to the facial nerve. 11 In the present study of 22 patients, there was high male predominance (90.9%). Road traffic accidents ac- counted for 100% of the cases. When considering the associated injuries, fracture of parasymphysis was the most common associated injury (40%). The types of fracture were classified according to Spissel and Schroll. 12 A similar study was conducted by Schneider et al., 13 where out of 45 condylar fractures, 36 fractures were type II, 3 patients sustained type III fracture, and 7 cases were type IV fractures. Regarding the above- mentioned parameters, such as age, sex, type and side of the fracture, mechanism of injury, and incidence of associated injuries, no significant differences were ob- served between the 2 treatment groups. A similar result has been observed in a study conducted by Eckelt et al. 14 Considering the occlusal discrepancies, occlusion was deranged in all of the cases included in this study, which was also an indication of ORIF. All of the cases treated by closed reduction were managed postopera- tively with IMF using elastics for 2 weeks, whereas for those treated by open reduction, no postoperative IMF was done. In a study carried out by Hyde et al., 15 10% of the patients required elastic traction during the post- operative period for the first 10 days to achieve their premorbid occlusion. 9 In the closed reduction group, we could achieve mouth opening of 40 mm in 7/12 patients (58.33%) compared with 9/10 patients (90%) in the open reduction group. In the study conducted by Hyde et al., 15 where ORIF of fractured condyle was performed via retromandibular approach, they achieved an average mouth opening of 42 mm, which matches the results of our study. Widmark et al. 3 reported an average mouth opening of 51 mm using a retroman- dibular approach. 2 We encountered postoperative com- plications, such as facial nerve weakness, salivary fis- tula, and infection, in 1 patient treated by open reduction. The rate of neurologic complication rate found in this study was not significant compared with

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