Surgical Technique |

Endoscopically Assisted Repair of Subcondylar Fractures of the Mandible:  An Evolving Technique

Robert M. Kellman, MD
Arch Facial Plast Surg. 2003;5(3):244-250. doi:10.1001/archfaci.5.3.244.
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Published online

Objective  To review one surgeon's experience with the endoscopic approach to assist with reduction and rigid fixation of subcondylar fractures of the mandible.

Design  Chart review of all cases in which endoscopic techniques were used to assist with the reduction and, when possible, repair of these fractures. The numbers of fractures approached, successfully repaired with the use of plates and screws, and not successfully plated with this approach were documented.

Setting  All surgeries were performed in the operating room at a university hospital.

Patients  All patients who underwent endoscopic exploration of a single or bilateral subcondylar fractures of the mandible were included. Seventeen explorations were carried out in 12 patients (age range, 16-39 years). Associated mandibular and other facial fractures were noted.

Interventions  Endoscopic exploration via a transoral approach. A secondary port in the submandibular region was made in 13 of 17 fracture explorations, and this second port was used primarily for the application of downward traction on the angle of the mandible. Plates were introduced transorally, while screws were placed through a transbuccal trochar.

Main Outcome Measure  Success was judged by the successful reduction of the fracture and application of a rigid fixation plate by means of the limited, endoscopically assisted approach, a measure of the ability to accomplish the procedure, not an evaluation of functional results. (With these criteria, 9 of 10 successes had normal function at last follow-up, as did the 10th after revision.)

Results  Rigid plate fixation was completed endoscopically for 10 fractures, and 2 were plated after conversion to a full open approach. Four were reduced but could not be plated, and in 1 exploration, a bent plate was removed, but a new plate was not applied. Nine of the 10 fractures plated endoscopically resulted in normal occlusion and function. In the 10th case, a persistent malocclusion necessitated reexploration and refixation, resulting in a successful functional outcome with normal occlusion.

Conclusion  The endoscopically assisted approach for the repair of subcondylar fractures of the mandible is a feasible but challenging technique.

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Figure 1.

Some of the instruments in the prototype endoscopic subcondylar fracture fixation set.

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Figure 2.

A, Wire passed through the angle of the mandible. Inset, Inferior traction on the wire pulls the distal mandible inferiorly, allowing the fracture to reduce (see Figure 7). B, Retractor designed to fit over a screw placed into the angle of the mandible for inferior traction. Inset, Close-up view of the instrument tip. C, Retractor in place through a small submandibular incision.

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Figure 3.

Endoscopic forehead lift retractor used in these procedures.

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Figure 4.

Endoscopic view of a left subcondylar fracture near the completion of fixation with 2 plates. The solid arrow points to the Kocher clamp holding the transbuccal trochar, and the dashed arrow points to the trochar with the screwdriver passing through it. The end of the forehead-lift retractor is seen to the left of the Kocher clamp.

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Figure 5.

A, Introducer designed to hold a zygomatic plate. It allows for manipulation of the position of the plate in the wound. The screw on the end turns only 90°, allowing the blunt end to catch in a plate hole or release the plate. Inset, Close-up view of the instrument tip. B, Introducer (which is holding a plate over the fracture) protruding from the mouth.

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Figure 6.

A, Threaded fragment manipulator ("screw on a stick"). Inset, Close-up of the thread, which is fluted for self-drilling application. B, Endoscopic view of the manipulator passing into the cheek. C, Split-screen view of a manipulator passing through the left cheek. The manipulator is designed to screw into the bone (generally through the most proximal hole in the plate). Once in place, it can be used to manipulate the proximal fragment while screws are placed to fixate the fracture. The manipulator is then removed, and a screw is replaced in the hole that it occupied.

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Figure 7.

A, Frame of a coronal computed tomographic scan demonstrating a right subcondylar fracture with lateral overlap of the proximal fragment. B, Lateral overlap of the proximal fragment as seen through the endoscope. C, Artist's depiction of B. D, Wire through the angle of the mandible. Inset, Inferior traction on the distal fragment allows the proximal fragment to fall into a reduced position. E, Proximal fragment falling into place as inferior traction is applied. F, Artist's depiction of E. G, Threaded fragment manipulator being passed through the right cheek. H, The manipulator in position over the proximal fragment. I, Artist's depiction of the manipulator passing through the proximal plate hole into the proximal bone fragment. J, Endoscopic view of the reduced fracture after plate placement is complete.

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