Munoli Amarnath V, Mayekar Sarika, Mukati Prachir, Jagannathan Mukund
Department of Plastic and Reconstructive Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.
Indian J Plast Surg. 2024 Jun 12;57(Suppl 1):S16-S23. doi: 10.1055/s-0044-1787659. eCollection 2024 Dec.
Fractures of the condylar region of the mandible, although fairly common, also generate the most debate regarding management-both closed and open treatment options have been recommended and shown to yield good results. We present our experience with a minimal access retromandibular approach to fractures of the vertical mandible. This is a retrospective study of all patients who underwent open reduction and internal fixation for fractures of the vertical mandible (condyle, subcondylar region, ramus) using a retromandibular approach at a tertiary care hospital in a metropolitan city in India between January 2022 and July 2023. All fractures were approached using a standard technique through a retromandibular incision and a transparotid route. The proximal segment was mobilized, reduced, and fixed to the ramus with two 2-mm miniplates-one along the posterior border and the other along the sigmoid notch border. Postoperative guiding elastics were placed for 2 weeks without any rigid maxillomandibular fixation. Patients were followed at weekly intervals for 1 month followed by monthly visits for 6 months. At each visit, mouth opening, occlusion, and facial nerve function were assessed. Scar quality was assessed by both examiner and patient using the Patient and Observer Scar Assessment Scale (POSAS) scoring system. A total of 25 subcondylar fractures in 20 patients were fixed using the retromandibular approach. Nineteen were male and 1 was female. The etiology of trauma was road accident (8), fall from train (2), fall from height (5) and assault (5). Fifteen patients had unilateral fractures while 5 had bilateral fractures. All patients had concomitant fractures of the mandibular arch which were also fixed. The interval between trauma and surgery ranged from 5 to 28 days. All patients had premature molar contact on the side of fracture with anterior open bite. Mouth opening ranged from 1.5 to 2.5 cm. All the fractures could be fixed using the retromandibular approach. None of the patients developed any facial nerve dysfunction or salivary leak. The occlusion was restored to pretrauma status in all patients and was stable at 6 months' follow-up. Mouth opening ranged from 3.5 to 4 cm. The POSAS observer score ranged from 09 to 19 with a mean score of 12.7. The POSAS patient score ranged from 17 to 28 with a mean score of 20.3 revealing that all patients were extremely happy with the scar. The minimal access retromandibular approach to the vertical mandible is a versatile technique enabling accurate reduction and fixation of fractures of the vertical segment of the mandible with good long-term functional and cosmetic results.
下颌骨髁突区骨折虽然相当常见，但在治疗方面也引发了最多的争论——闭合和开放治疗方案都有人推荐并已证明能产生良好效果。我们介绍我们采用微创下颌后入路治疗下颌骨垂直部骨折的经验。
这是一项回顾性研究，研究对象为2022年1月至2023年7月期间在印度一座大城市的三级护理医院接受下颌后入路切开复位内固定治疗下颌骨垂直部（髁突、髁突下区域、升支）骨折的所有患者。所有骨折均通过下颌后切口和透明腮腺入路采用标准技术进行处理。将近端骨折段游离、复位，并用两块2毫米微型钢板固定于升支——一块沿后缘，另一块沿乙状切迹缘。术后放置引导性弹力牵引2周，不进行任何坚固的颌间固定。患者每周随访1个月，之后每月随访6个月。每次随访时，评估开口度、咬合关系及面神经功能。由检查者和患者使用患者及观察者瘢痕评估量表（POSAS）评分系统评估瘢痕质量。
共有20例患者的25处髁突下骨折采用下颌后入路进行固定。男性19例，女性1例。创伤原因包括道路交通事故（8例）、从火车上跌落（2例）、高处坠落（5例）和袭击（5例）。15例患者为单侧骨折，5例为双侧骨折。所有患者均伴有下颌牙弓骨折，也进行了固定。受伤至手术的间隔时间为5至28天。所有患者骨折侧均有磨牙早接触伴前牙开 。开口度为1.5至2.5厘米。所有骨折均能通过下颌后入路进行固定。所有患者均未出现面神经功能障碍或涎瘘。所有患者的咬合关系均恢复至伤前状态，且在6个月随访时保持稳定。开口度为3.5至4厘米。POSAS观察者评分范围为9至19分，平均分为12.7分。POSAS患者评分范围为17至28分，平均分为20.3分，表明所有患者对瘢痕都非常满意。
下颌骨垂直部的微创下颌后入路是一种通用技术，能够准确复位和固定下颌骨垂直段骨折，长期功能和美容效果良好。
