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The application of the Risdon approach for mandibular condyle fractures
© Nam et al.; licensee BioMed Central Ltd. 2013
Received: 27 August 2012
Accepted: 4 July 2013
Published: 6 July 2013
Many novel approaches to mandibular condyle fracture have been reported, but there is a relative lack of reports on the Risdon approach. In this study, the feasibility of the Risdon approach for condylar neck and subcondylar fractures of the mandible is demonstrated.
A review of patients with mandibular condylar neck and subcondylar fractures was performed from March 2008 to June 2012. A total of 25 patients, 19 males and 6 females, had 14 condylar neck fractures and 11 subcondylar fractures.
All of the cases were reduced using the Risdon approach. For subcondylar fractures, reduction and fixation with plates was done under direct vision. For condylar neck fractures, reduction and fixation was done with the aid of a trochar in adults and a percutaneous threaded Kirschner wire in children. There were no malunions or nonunions revealed in follow-up care. Mild transient neuropraxia of the marginal mandibular nerve was seen in 4 patients, which was resolved within 1–2 months.
The Risdon approach is a technique for reducing the condylar neck and subcondylar fractures that is easy to perform and easy to learn. Its value in the reduction of mandibular condyle fractures should be emphasized.
Of all the fractures of the facial skeleton, the choice of treatment modalities for mandibular condyle fractures is probably the most controversial . The controversy has regarded closed conservative management versus open surgical management of condylar and subcondylar fractures, which constitute 25-35% of all mandible fractures reported in the literature . Those who prefer conservative treatment argue that morbidity due to surgical treatment is much greater than the advantages gained, and that 3–4 weeks of intermaxillary fixation and early mouth opening exercises are enough to achieve good results. Those who advocate surgical treatment argue that only definite open reduction can prevent shortening of the ramus, facial asymmetry, and ankylosis of the temporomandibular joint (TMJ), while providing a shortened time for the recovery of mastication and TMJ function [2–4].
For cases where open reduction is necessary, the surgeon can make a choice between intraoral and extraoral approaches. Although intraoral reduction is generally accepted for symphyseal and parasymphyseal fractures, there is still some debate regarding the use of the intraoral approach to condylar neck and subcondylar fractures because of the surgical skills and associated hardware required . Although various methods of external approaches to the mandible have been proposed, there are no recent articles addressing the classic Risdon approach [6–11]. The authors have used the Risdon approach for open reduction and internal fixation of condylar fractures, in some cases combined with external threaded Kirschner wire fixation and rubber traction. The aim of this study was to determine the efficacy and safety of surgical treatment of condylar fractures using the Risdon approach, as well as to describe our clinical experience.
A retrospective review of the electronic charts of mandibular condyle neck and subcondylar fractures was performed for the period from March 2008 to June 2012 in the Department of Plastic and Reconstructive Surgery at Hanyang University Guri Hospital. Approval for the study was obtained from the institutional review board on human subjects research and the ethics committee, Hanyang University Guri Hospital (IRB No. 2011–033). Written informed consent for participation in the study was obtained from the participants or their parents if they were children. Mandibular condyle fractures were classified according to the height of the fracture. Mandibular neck fractures occur below the joint capsule attachment but above the sigmoid notch, and subcondyle fractures run from the sigmoid notch to the back edge of the mandibular ramus . According to the relationship between the proximal and the distal segments, the degree of condylar fracture is classified into non-displaced, deviated, or displaced fracture. A non-displaced fracture has no displacement of the fracture site, a deviated fracture is where fracture segments are displaced but some of them contact, and a displaced fracture is where the fracture fragments are separated and the proximal and distal segments do not contact each other. Considering the relationship between the proximal segment and the temporal fossa, a dislocated fracture is one in which the condylar head is deviated from the temporal fossa .
Using gentian violet, an incision line was marked 2–3 cm below the lower mandible border, between the angle and the facial notch of the mandible. The incision was normally 4–5 cm, but was extended in either direction in cases of inadequate exposure. After skin incision, dissection was carried out down to the platysma muscle. The muscle was bisected using blunt scissors, and the cervical fascia was cut with care not to damage the facial nerve, until the masseter muscle was exposed. The masseter was cut just above the lower mandible border and dissection was carried out to the periosteum. Reduction was done by the use of wire traction inserted into a drilled hole at the inferior border of the angle. The masseter muscle attached to the posterior border of the mandible ramus was dissected until adequate exposure for reduction was achieved. All patients underwent intermaxillary fixation using arch bars, and the upper and lower jaws were fixed with elastics.
Notably, we decided to operate on condylar neck fracture in children when there was extensive dislocation and no contact between the proximal and the distal fracture segments. In cases of condylar neck fracture in children, a threaded Kirschner wire was placed in the fractured segment percutaneously, and directly in view through the Risdon incision, the condyle head was reduced maximally. The end was then cut to an appropriate length and bent to form a hook. A rubber band was placed on the hook, and the threaded K-wire was pulled in the appropriate direction and fixed with a tongue depressor on a cup to maintain tension. This procedure was performed according to a technique previously described by the authors .
The patients’ age and sex
The etiology and the level of fractures
Slip or fall
The surgical methods according to the fracture types
Risdon approach + Trochar
Risdon approach + Kirschner wire
Various approaches have been described in the literature for the reduction of mandibular condyle fractures. The intraoral approach has the advantages of avoiding leaving a scar on the face, simultaneous control of the occlusion and repositioning of the fragments during the operation, and direct visualization of the occlusion during placement of the hardware. However, the intraoral approach requires special traction, lighting devices to better expose the fracture site, and more surgical time than the extraoral approach . Recently, an endoscopy-assisted approach has been widely reported in the literature. Besides requiring specialized instruments, surgeons need additional training to use endoscopic equipment and there is a surgical learning curve because the techniques involve indirect incision without allowing for extensive exposure .
Extraoral approaches to the mandibular condyle region can be divided into three major categories in terms of the height of the approach: high, middle and low . The high approach, involving the preauricular and perilobular approach, has been applied to the reduction of high condylar neck or condylar head fractures. These approaches have a very well camouflaged scar and achieve a much clearer and more direct exposure than the middle and low approaches. However, this technique requires the identification of the facial nerve trunk or its branches, at least two at a time, to allow for surgical access between these branches. This requires advanced dissection skills and confidence in the anatomy of the facial nerves in the buccal and mandibular region [10, 11]. Despite meticulous dissection, mild neuropraxia can persist up to 13 months postoperatively, and in cases of a transparotid approach, postoperative sialoceles and salivary fistulas can be a nuisance .
Middle height approaches to the mandible include the retromandibular approach. This approach allows better exposure of the mandibular condyle compared to the low approach. However, this approach involves identification of the buccal and marginal mandibular branches of the facial nerve so as to avoid possible facial nerve damage. Despite this careful identification of the facial nerve, this approach requires retraction of the parotid gland, which may lead to facial nerve injury .
In children with condylar neck fracture, only percutaneous threaded K-wire fixation and rubber traction without rigid fixation produced good results because children have a high capacity for bony union. Moreover, a threaded K-wire can easily be removed under local anesthesia after bony union. We previously reported on the percutaneous manipulation of condylar fractures under fluoroscopy . The fractured condylar segment can be manipulated by threaded K-wires inserted percutaneously under fluoroscopy, and with rubber traction during the postoperative period, reduction is well maintained. However, closed reduction using the threaded K-wire has a steep learning curve, and since the fractured segment is small, precise insertion of the threaded K-wire into the fractured segment is necessary for reduction so as not to comminute the segment. In our experience, inserting the threaded K-wire under direct vision through the Risdon approach allows for a smaller failure rate and a more exact reduction than under fluoroscopic vision alone.
In an era where novel and modified approaches are proliferating, it may be concluded that the Risdon approach is one good surgical approach to the reduction of mandibular condyle fractures on the basis of these clinical results.
Written informed consent was obtained from the patient or his parent if a patient is a child for publication of cases of this study and any accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal.
The authors have no financial interest in the products, devices, or drugs mentioned in this article.
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