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Table of Contents
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 9-13

Indications for transoral endoscopic-assisted methods in condylar process fractures

Department of Plastic Surgery, Selcuk University, Medical Faculty, Konya, Turkey

Date of Submission25-Jan-2019
Date of Acceptance13-Apr-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Osman Akdag
Selcuk University, Medical Faculty, 42030 Selcuklu, Konya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_9_19

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Objective: Endoscopic-assisted mandibular subcondylar fracture repair is a different way of performing open reduction internal fixation and also includes surgical equipment and manipulations other than those used in the classical methods. The criteria for patient selection should be different from that of the classical methods. Materials and Methods: Between April 2012 and June 2017, treatment protocols which were applied to 56 patients with mandibular subcondylar fracture were evaluated retrospectively. The first step of this study was to evaluate why patients with mandibular subcondylar fractures were not operated endoscopically. In 34 patients, methods other than endoscopic methods were used. Characteristics of these patients and fractures were demonstrated. Results: Twenty-four patients were followed conservatively. Twenty-two patients were treated with transoral endoscopic method while ten patients were treated with the conventional open surgery. This open surgical treatment was reported by determined the patient records for why the endoscopic method was not preferred. The determined criteria were; condyle with excessive medial deviation, patient age, fracture type, general condition/anesthesia risk, and time of injury. Conclusion: In accordance with clinical experience, some criteria have been defined for patient selection preoperatively in mandibular subcondylar fractures. It believes that with the right patient selection, it will be possible to achieve better results and reduce complications.

Keywords: Endoscopicassisted approach, intraoral treatments, mandibular subcondylar

How to cite this article:
Akdag O, Sutcu M, Yildiran GU, Bilirer A. Indications for transoral endoscopic-assisted methods in condylar process fractures. Turk J Plast Surg 2020;28:9-13

How to cite this URL:
Akdag O, Sutcu M, Yildiran GU, Bilirer A. Indications for transoral endoscopic-assisted methods in condylar process fractures. Turk J Plast Surg [serial online] 2020 [cited 2021 Oct 26];28:9-13. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/9/274447

  Introduction Top

Mandibular subcondylar fractures constitute roughly one-third of all mandibular fractures.[1],[2] Such fractures are treated primarily by either open reduction and internal fixation (ORIF) or conservative therapy. To date, surgeons do not agree on which is the most effective approach, because both methods can have serious drawbacks.[3],[4] Because the anatomic structure of the condylar area is highly complex, open surgery can result in extreme complications.[5],[6] Therefore, to minimize potential complications during open surgery, new approaches are being tried, which include preauricular, retroauricular, submandibular or retromandibular, and transoral surgery.[7]

Endoscopy is another surgical approach to repairing condylar fractures, which may have fewer complications than other procedures.[8],[9],[10] Because it is still a new approach, however, it is not used routinely at all surgery centers.[7] Which patients are most appropriate for the endoscopic approach and the indications for this approach have not yet been established. Appropriate patient selection is crucial for the success of endoscopic-assisted surgery, which results in minimal complications. The purpose of this study was to determine the best method for choosing the appropriate patient to undergo repair of subcondylar fracture using the endoscopic approach. Exclusion criteria were also established according to our clinical findings. Once inclusion and exclusion criteria were determined, the current literature was analyzed to assess the validity of these criteria. Certain exclusion or inclusion criteria have always been defined for the repair of maxillofacial traumas with a specific technique.[11],[12],[13],[14] Some authors have determined these criteria by considering their own personal experience.[15],[16]

  Materials and Methods Top

To determine the most important criteria affecting the treatment method for mandibular subcondylar fracture, between April 2012 and June 2017, patients with mandibular subcondylar fractures followed by the same surgeon were retrospectively analyzed. Endoscopic surgery was not performed, but patients who underwent open surgery were identified. Specific characteristics of these ten patients with open surgery were recorded. In line with these characteristics, some criteria were obtained.

  Results Top

During the 5-year period, 56 patients with subcondylar fracture who applied to our clinic were evaluated. Twenty-four patients were followed up conservatively because of their age and bilateral fractures. Twenty-two patients were treated with transoral endoscopic method. Ten patients were thought to have open surgery but not endoscopically. Three of these patients were pediatric patients, and one had poor condition due to general body trauma. Two patients had high-level condylar fractures with vertical extension. The three patients' condyles had medially angulations more than 45°. One patient was thought to have developed bone callus after 15 days of trauma and was treated with open surgery [Table 1].
Table 1: Distribution of number of patients according to treatment protocols

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Determination of criteria for patient selection

Some authors have already documented similar criteria used in their case series reported in the literature.[17],[18] However, the limitations of these criteria were not clearly specified. Considering these items, the literature was reviewed to determine the limitations in transoral endoscopic-assisted treatment of mandibular subcondylar fractures.

Patients with definite indications for open surgery were evaluated for endoscopic compliance according to the criteria shown in a Table [Table 2]. During patient selection, certain situations where technical repair is difficult and the rate of possible complications is increased were determined. According to this, patients with more than 45° of medial deviation of the condyle, pediatric patients with incomplete dental development, patients who could not tolerate the long operation time, and patients with a history of fracture longer than 10 days were not preferred for undergoing endoscopic methods. Endoscopic methods were also not the preferred approach for open mandibular fractures, intracapsular high condyle fractures, and panfacial fractures.
Table 2: Patient selection and conditions that increase the risk of complications

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  Discussion Top

The endoscopic approach is a minimally invasive technique practiced at many surgical centers for treating maxillofacial fractures.[17],[19] Compared with the traditional open surgical approach, an endoscopic procedure has many advantages.[17],[20],[21] Jacobovicz et al. were the first to successfully treat condylar fractures using the endoscopic-assisted intraoral approach in a single case in 1998.[22] This new approach is not a replacement for osteosynthesis to ORIF. Lauer et al. reported on their use of the transcutaneous approach for endoscopic-assisted condylar fracture repair, which is easier to perform and reduces operative time; however, its disadvantage is that it causes scarring.[23] Endoscopic-assisted mandibular condylar fracture repair, no matter whether intraoral or transcutaneous, is less invasive than traditional surgery.[13],[18]

Other classical repair methods include conservative treatments and surgical transcutaneous approaches that utilize different types of incisions in both surgical and nonsurgical techniques. Many studies have shown that surgical approaches provide better results than conservative treatments.[1],[3],[7],[24]

Indications for ORIF for mandibular condyle fractures can vary according to the time of the operation and the technological equipment available. The open surgical indications determined by Zide and Kent[11] were updated in 2003 by Brand and Haug who described ORIF as the gold standard method for mandibular condyle fractures.[4],[25] Later, Schneider et al. identified clearer indications for ORIF in their randomized prospective study and recommended ORIF repair of fractures with an angulation over 10° and a shortening of more than 2 mm, irrespective of the level of the fracture.[26]

ORIF is the best treatment currently available for mandibular condyle fractures.[3] Nevertheless, the most important factor that determines the indications for ORIF in condylar fractures is still the complications that can occur.[27],[28] In order to reduce the complications that can be seen with ORIF, several approaches in which incisions are made in different places have been developed.[12],[29],[30] Elis asked the following questions in a spectacular article: “which condylar process fractures should be treated using an open approach?” and another question, just as important, is “which do not require open treatment?“[14] Today, the answer to these questions can be provided in part. The question may be revised as follows: “which condylar process fractures should be/not be treated using transoral endoscopic-assisted methods?”

The transoral approach to endoscopic-assisted surgery is a different surgical method for treating ORIF; however, it is not a new idea. The benefit to patients and lower complication rates have been reported in numerous studies of endoscopic-assisted subcondylar fracture surgery.[10],[13],[19],[24],[31]

Patient selection must be performed properly to obtain successful results. Indications for open surgery are not appropriate for endoscopic applications. Some patients who are indicated for repair by open surgery may not be eligible for endoscopic repair. We used the following criteria in [Table 1] for patients who were not eligible for the endoscopic method and to find an answer to the question.

To repair condyles with medial displacement of more than 45° is a great challenge, especially if using the endoscopic technique [Figure 1]. In such cases with extensive displacement, the endoscopic reduction of the condyle is difficult.[32] In cases where reduction could not been achieved, it is obvious that successful fixation can also not be achieved and postoperative occlusion problems will arise.
Figure 1: Medial deviation of the left condyle more than 45°

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No mention is made of the importance of patient age and whether age is a criterion for patient selection in many case series of endoscopic repair of mandible subcondyle fracture. No pediatric patient groups under the age of 15 years are included in case series discussing endoscopic repair.[15],[16],[18],[19] Because conservative therapy is highly preferred in the pediatric population and also the technical equipment for endoscopic repair is mainly designed for adults may be the main reasons of this[32] [Figure 2].
Figure 2: Axial (a) and coronal (b) computed tomography images of 6-year-old patient show condylar fracture. New condyle formation without surgery on the right side can be seen on axial (c) and coronal (d) sections of computed tomography

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Some authors certainly do not recommend repair of intracapsular and high-grade fractures with ORIF[19],[33],[34] [Figure 3]. Conservative methods are generally preferred for these fractures. Similarly, endoscopic repair of these fractures is not recommended, and conservative methods should be preferred.[16],[31] Endoscopic fixation of the proximal part in high condylar fractures is technically very difficult. To ensure adequate fixation in the proximal part, a minimum of two holes is required for the plate to be placed.[35] The dissections to be performed in this area are also quite difficult which is the reason for strong capsule connections. Intensive bleeding of the joint capsule also makes the dissection difficult and negatively affects the field of vision.
Figure 3: Image of the intracapsular fracture of the right condyle on coronal section of computed tomography

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Open fractures were reported by Zide and Kent as a definite indication for ORIF.[11] It especially should not be forgotten that the open fractures on the skin may be contaminated, and it is suitable to use the existing incision if it is available. In addition, parotis can also be injured in open fractures of the skin, and it should not be forgotten that fistula and sialocele may develop in such fractures.[5] ORIF is recommended in some types of mandibular condyle fracture and panfacial fractures, but the rate of complication is increased in endoscopic interventions in such fractures.[34],[36]

The mandibular subcondylar repair with the transoral endoscopic method is different from conventional surgery because both the technique and equipment used are different. The learning curve is extensive.[13],[15],[20],[37] In this learning process, the biggest disadvantage of the transoral endoscopic repair is that the duration of the operation is long.[24],[32] In the literature, the reported mean duration of the surgery varies. In Kang et al.'s 26-case study, the mean duration of the operation was 200 min,[38] whereas the duration of surgery was 32 min in another study.[9] In an another study, although the mean duration of the surgery was reported to be <90 min including maxillomandibular fixation, it was reported to be up to more than 200 min in some cases in the same study in which the difficult work was performed.[19] It is very difficult to create a standard because operation times can be calculated in many different ways. However, the average duration of surgery is not clear in many studies. It has not been reported that another fracture could be present, and the time spent on, the intermaxillary fixation is not included.

The duration of surgery varies depending primarily on the experience of the surgeon then on patient-related issues and the condition of the technical equipment used. As the duration of the operation increases, necessary attention is dissipated, and it may be difficult to obtain quality images due to edema in the surgical area. It should not be forgotten that long operation times could bring about possible mistakes. In addition, care must be taken in patients who are unable to tolerate the medical condition for a long operation. Authors do not suggest endoscopic repair for patients with a high anesthesia risk score and in poor health. It has been shown in some studies where it may be possible to achieve a faster fixation with classical open surgery in this patient group.[13]

Some authors have reported that the rate of complications was reduced in early-onset operations, but more complications occurred with late-onset repair.[39],[40] In a retrospective study by Maloney etal., no infections occurred in 204 mandibular fractures during the first 3 days of surgery, whereas infection rates in select cases after the 3rd day were reported to be 4.4%.[39] Contrary to these studies, some studies report that neither early nor late surgery affects the complication rate.[41],[42] Although late-onset repair is not an additive effect on infection, excellent alignment cannot be intuitively achieved over a period of 10 days and more. Late-referral patients should undergo open surgery, and endoscopic methods are not recommended because perfect reduction will not be achieved.

As surgeons gain more experience, repair of mandibular subcondylar fractures with the endoscopic approach is becoming more accepted and more frequently practiced, because it is less invasive than traditional surgery. However, because of the learning curve, the endoscopic approach can involve the use of surgical equipment and manipulations that are unfamiliar to the surgeon, as well as many traps and complications such as occlusion problems and joint disorders, and persistent pain.[43] Before a decision is made about whether to perform endoscopic-assisted surgery, surgeons should carefully consider the medial deviation of the condyle, patient age, type of fracture, patient's general condition, and the time of the injury.

  Conclusion Top

Determining which patients would not be proper for transoral endoscopic-assisted treatment can be evaluated during the preoperative period. Patient selection is extremely important in reducing complications. Although criteria for open surgery in mandibular subcondylar fractures were determined many years ago, endoscopic-assisted open surgery should be remembered as a unique approach, and some criteria should be considered in this method.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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