Kayvon Haghighi, DDS, MD,* Manolis G. Manolakakis, DMD, † and Connor Balog, BS ††

Purpose: The aim of this study was to determine the feasibility of direct transcortical stabilization of fracture dislocations of the mandibular condyle (FDMCs) using narrow-diameter non-threaded Kirschner wire (K-wire).

Materials and Methods: This retrospective review reports on the treatment outcomes for 12 patients (15 fractures) with FDMCs treated with open reduction using transcortical 0.027-inch K-wire stabilization. Postoperative parameters of relevance included infection, facial nerve function, hardware removal, mandibular range of motion, and radiographic determination of fracture union.

Results: Three patients had bilateral FDMCs and 9 had unilateral FDMCs (age range at time of injury, 14 to 72 yr; mean age, 32 yr). Postoperative follow-up ranged from 6 weeks to 2 years. Four patients required removal of K-wire hardware for different reasons. K-wires were removed because of infection in 1 patient. Another patient required removal because of migration of the pin into the joint space. One pin was removed electively and another was removed for nonspecific postoperative symptoms that resolved after pin removal. Persistent facial nerve deficit was observed in 1 patient.

Conclusion: Open reduction with transcortical K-wire stabilization can achieve satisfactory outcomes for the treatment of FDMC. Further investigation is needed in determining the efficacy of this fixation technique in the management of FDMC.

© 2017 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1.e1-1.e7, 2017

Fractures of the peri-condylar region of the mandibular ramus are a unique surgical challenge. Fracture dislocation of the mandibular condyle (FDMC) extending into the joint capsule can add to the degree of complexity. Treatment modalities for this type of fracture vary and can be a topic of controversy. The objective for the open reduction technique is anatomic reconstruction of the temporomandibular joint (TMJ) complex, re-establishing the vertical height of the ramus, and early mobilization with return of physiologic function of the TMJ. Surgical approaches, fixation techniques, and hardware choices can vary.

For decades, the closed reduction technique has set the standard for the treatment of FDMCs.^1-3 Subsequent analysis of clinical outcomes has favored open treatment with reservation and select indications.^4-6

Thoma⁷ first advocated for the open technique and fixation of FDMCs. Subsequently, Walker⁸ investigated surgically created FDMC and its effect on growth in young Macaca rhesus monkeys by comparing bone remodeling in anatomically reduced, fixated condyles with condyles that were not reduced. With innovations in surgical technique and imaging technology, classification schemes have further subdivided fractures of the head of the condyle that compromise the anatomic and functional integrity of the TMJ.^9-12

Although titanium screws and plate fixation are the most commonly used modalities for fixation, use of Kirschner pins has been described for fixation of condylar fractures.^13-17 This has been limited to larger-diameter pins (range, 1.5 to 3 mm) being used predominantly in pin-in-groove techniques.⁶ In the authors’ search of the literature, direct, transcortical, positional stabilization of FDMCs using 0.6-mm nonthreaded Kirschner wire (K-wire) has not previously been reported. This technique is particularly effective in managing capsular fractures with dislocation of the condylar head, where smaller proximal segments can be fragile under compression with threaded screws.

The purpose of this article is to report on the results of a retrospective review for the feasibility of using narrow-diameter K-wire fixation as a means of stabilization in the management of FDMCs treated with open reduction.

Materials and Methods

This study reports on the results of an internal quality assurance audit, which reviewed 12 consecutive cases from June 2007 through June of 2013, of open reduction of FDMCs using narrow-diameter K-wire fixation. Patients’ charts were retrieved by cross referencing procedure codes and review of operative reports. Personal health information was protected by assigning sequential numbers to each case selected for this study. The corresponding author was solely involved in the collection of data.

Excluded from this study were concomitant maxillary and other midfacial fractures and late repairs performed as a result of complication of previous treatment. Data collection protocols were formulated with approval from the investigational review board of Meridian Health (Neptune, NJ).

Surgical access was through a standard preauricular approach to the TMJ. This was followed by identification of the joint capsule with location of the distal stump of the mandibular ramus. With profound neuromuscular blockade and downward traction at the mandibular angle, the medially displaced condylar head was identified. Lateral distraction of the condylar head was performed using a modification of a previously described technique1⁸ of engaging the dislocated segment with a 0.027- inch non-threaded K-wire. The condylar head fragments were positioned in correct anatomic relation to the distal segment and the meniscus while maintaining lateral traction and without stripping of the lateral pterygoid muscle. Non-threaded K-wires 0.027 inch in diameter were introduced through the lateral cortex of the ramus, engaging the medial cortex of the proximal fragment (transcortical) and fixating the fractured segment to the ramus. The number of wires varied from 1 to 3 depending on the geometric configuration of the fracture. Dental segment reduction and occlusion were confirmed intraoperatively. Patients were placed on a liquid diet for 2 weeks postoperatively. After 2 weeks, they were encouraged to perform passive range of motion and then advanced to a soft diet for an additional 4 weeks.

Results

Twelve patients, 3 with bilateral FDMCs and 9 with unilateral FDMCs, were treated with open reduction and internal stabilization using transcortical narrowdiameter non-threaded K-wires (Table 1). Ages ranged from 14 to 72 at the time of injury (mean age, 32 yr).  Postoperative follow-up ranged from 6 weeks to 2 years. Two patients had other concomitant fractures of the mandible. Four patients required removal of hardware. K-wire was removed because of infection in 1 patient. Another patient required removal because of migration of the pin into the joint space. One pin was removed electively and another was removed for nonspecific postoperative symptoms. Pins were removed after 6 weeks of healing, which is the time used to determine fracture union. Pin removal did not affect fracture union. All patients with removed hardware showed improvement with resolution of symptoms. Persistent facial nerve deficit was observed in 1 patient. This was limited to ipsilateral paresis of the frontalis muscle. No relevant dental malocclusions were observed or reported. In all patients, postoperative interincisal opening was restored to a physiologic baseline (recorded at the last follow-up interval). Postoperative computed tomographic scans depicted a malunion of fracture segments in 1 patient. All other fractures showed radiographic signs of optimal reduction with uncomplicated healing of fractures.

Discussion

The mandibular condyles represent the terminal portions of the mandibular ramus with physical, anatomic, and geometric considerations that are differentiated from other areas of the mandible.^19,20 Of particular concern in fracture fixation is the paucity of cortical bone in the condylar head. The advantage of using non-threaded fixation pins compared with standard threaded screw fixation is that it can provide transcortical stability without the additional strain of screw threads or predrilled holes that further compromise the fractured segment. In addition, a narrowdiameter K-wire is advantageous in that multiple pins can be used (preventing rotational displacement of the fracture segment), and the narrow-diameter K-wires can be introduced transcutaneously, allowing for optimal angulation. Furthermore, there is greater latitude in the working length of the K-wire compared with limitations in the length of narrow-diameter titanium screws.

Although classification schemes might have limited prognostic relevance, they can provide guidance in management and approach to treatment. The preferred usage of the descriptive ‘‘FDMC’’ terminology for referencing this type of condylar fracture is for 2 reasons: 1) it places emphasis on the dislocated condyle and 2) it signifies a displaced fracture that is inclusive of the TMJ. More advanced classification schemes have been formulated21 that can guide approaches to reduction and the choice for fracture stabilization. For example, the composition of cortical bone in the condylar neck region favors the use of plate-and-screw fixation in fractures of the condylar neck and condylar base (Spiessl II to IV). Conversely, for fractures involving the head of the condyle (Spiessl and Neff VIA to C), transcortical positional stabilization (with pins or screws) is the desirable method of fixation.

Reduction of the dislocated joint associated with a condylar head fracture is an important part of the repair and can be properly accomplished through open access to the joint. The preauricular access is ideal for open reduction of the dislocated condylar head. This approach facilitates direct visualization, reduction of the dislocated joint segment within the fossa, and stabilization of the fractured segment to the distal ramus segment. It also allows for direct examination of the meniscus and associated ligaments. Alternatively, condylar base and neck fractures can be approached through retromandibular approaches. In some instances, it might be necessary to combine approaches for optimal access. All the fractures in this series were classified as Neff A to C (Figs 1-3) fractures of the condylar head. These fracture types are most amenable to transcortical pin fixation through a preauricular approach.

The FDMC also is unique in that the proximal segment is acted on directly by the superior head of the lateral pterygoid muscle, which pulls the relatively small terminal segment of the mandible in the direction of the infratemporal fossa. Maintaining this muscle attachment despite its disruptive action is important in preserving condylar function and blood supply to the segment. Complete neuromuscular paralysis is critical in achieving reduction. This facilitates inferior distraction of the ramus, allowing access to the medially displaced segment, and negates the force of the lateral pterygoid in achieving lateral manipulation of the condylar segment for proper anatomic reduction.

Access to this area can be further complicated by variations of anatomy in the location of the internal maxillary artery, facial nerve, and proximity to the skull base. The post-traumatic preauricular approach to the TMJ can be further complicated by interstitial edema, hemorrhage, and displaced anatomic landmarks usually used to identify the joint capsule.

The traditional concerns4 for the open treatment of condylar fractures were observed in the present study population. Mechanical complications of reduction were overcome by intraoperative maneuvers. Nevertheless, 1 patient had postoperative malunion (lost to follow-up), which can be attributed to early function in an otherwise inadequately fixated segment (single pin). In the authors’ cumulative experience with the preauricular approach to the TMJ, facial nerve deficit is a rare and permanent complication. Deficits in facial nerve function are generally transient and limited to the frontal branch. Facial scarring with this approach is of minimal consequence.

Whether adequate clinical results for FDMC treatment can be achieved with closed reduction is questionable. Based on the authors’ observations, open treatment of these injuries can reconstruct normal anatomic form and physiologic function with minimal risk. The best possible outcome for closed reduction of FDMC is the formation of a quasi-functional pseudojoint. However, the choice of treatment must be made on an individual basis in consideration of other comorbid variables associated with the management of the injured patient.

“”In the management of any wound, restoration of function with the least harm to the patient should be the primary focus, and this is also true with fractured mandibular condyles.”1 In the management of FDMC, the use of narrow-diameter K-wire for transcortical stabilization is a feasible treatment option. Further investigation in a larger population including controls will be required in the determination of the efficacy of this treatment modality.

*Private Practice, Oral and Maxillofacial Surgery, Red Bank, NJ; Attending, Oral and Maxillofacial Surgeon, Jersey Shore University Medical Center, Neptune, NJ.

†Program Director, Facial Cosmetic Surgery Fellowship, Robert Wood Johnson-Barnabas/Monmouth Medical Center, Long Branch, NJ.

††Dental Student (Class of 2019), Medical University of South Carolina School of Dentistry, Charlotte, SC.

Conflict of Interest Disclosures: None of the authors have any relevant financial relationship(s) with a commercial interest.

Address correspondence and reprint requests to Dr Haghighi: 276 Broad Street, Red Bank, NJ 07701; e-mail: drhaghighi@njfacialsurgery.com

Received October 23 2016

Accepted January 30 2017

© 2017 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons

0278-2391/17/30123-4

http://dx.doi.org/10.1016/j.joms.2017.01.038

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