Howlader Debraj, Ram Hari, Mohammad Shadab, Singh Vibha, Gamit Jagdish, John Rubin S
Senior Resident, Department of Oral & Maxillofacial Surgery, King George's Medical University, Lucknow, India.
Professor, Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, King George's Medical University, Lucknow, India.
J Oral Maxillofac Surg. 2019 May;77(5):1040.e1-1040.e9. doi: 10.1016/j.joms.2019.01.010. Epub 2019 Jan 14.
The optimal treatment for adult mandibular condylar fractures (MCFs) has largely shifted in favor of open reduction and rigid internal fixation. However, a sizeable portion of these injuries are still being treated in a closed manner based on old literature, convenience, results deemed acceptable, and lesser associated morbidity. Most MCFs with multiple associated facial traumas are appropriately treated under general anesthesia (GA). However, some selected isolated MCFs or those with minimal associated mandibular or low midfacial fractures can be treated optimally with patients under local anesthesia following a protocol presented in this article, thus expediting and simplifying their management. The purpose of this study was to develop a safe, sound, effective protocol for routine surgical management of mandibular subcondylar fractures under local anesthesia.
We carried out a prospective clinical study to assess the feasibility of operating on MCFs with patients under local anesthesia. Seven patients with MCFs and other associated facial fractures underwent surgery after careful case selection following our proposed protocol. The outcome variables were 1) duration of the procedure, 2) intraoperative pain assessed by a visual analog scale, 3) fracture reduction assessed by measuring the preoperative and postoperative average fracture gap, 4) presence of malocclusion preoperatively and postoperatively, 5) deviation on mouth opening, and 6) maximal mouth opening.
The mean duration of the procedure was 35.14 minutes, and the mean rating of intraoperative pain or discomfort was 0.57 as reported on the visual analog scale by the patients. Mean mouth opening improved from 17.1 to 40.5 mm, whereas deviation on opening improved from 4.4 to 0.28 mm. The average fracture gap was reduced from 6.32 to 0.97 mm.
The presented protocol is a straightforward, efficient, safe, cost-effective tool for operating on MCFs, avoiding GA with its attendant risks and complications, that can be used routinely, as well as in patients for whom GA is deemed unsuitable.
成人下颌髁突骨折（MCF）的最佳治疗方法在很大程度上已转向切开复位和坚固内固定。然而，基于旧文献、便利性、可接受的结果以及较低的相关发病率，仍有相当一部分此类损伤采用闭合方式治疗。大多数伴有多处相关面部创伤的MCF在全身麻醉（GA）下进行适当治疗。然而，一些选定的孤立性MCF或那些伴有最小下颌或低中面部骨折的患者，按照本文提出的方案在局部麻醉下可得到最佳治疗，从而加快并简化其治疗管理。本研究的目的是制定一种安全、合理、有效的方案，用于在局部麻醉下对下颌髁突下骨折进行常规手术治疗。
我们进行了一项前瞻性临床研究，以评估在局部麻醉下对MCF患者进行手术的可行性。7例MCF及其他相关面部骨折患者按照我们提出的方案进行仔细病例选择后接受手术。结果变量包括：1）手术持续时间；2）通过视觉模拟量表评估的术中疼痛；3）通过测量术前和术后平均骨折间隙评估的骨折复位情况；4）术前和术后错牙合的存在情况；5）张口偏斜；6）最大张口度。
手术平均持续时间为35.14分钟，患者在视觉模拟量表上报告的术中疼痛或不适平均评分为0.57。平均张口度从17.1毫米提高到40.5毫米，而张口偏斜从4.4毫米改善到0.28毫米。平均骨折间隙从6.32毫米缩小到0.97毫米。
所提出的方案是一种简单、高效、安全、经济有效的工具，用于对MCF进行手术，避免了GA及其伴随的风险和并发症，可常规使用，也适用于认为GA不适合的患者。
