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OP-Journal 2012; 28(2): 194-210
DOI: 10.1055/s-0031-1298507
Georg Thieme Verlag KG Stuttgart · New York

„Open book“-Frakturen des Mandibularbogens: Bilaterale Gelenkfortsatzfrakturen in Kombination mit Paramedian-/Medianfrakturen des Unterkiefers. Operative Behandlungsstrategien

Sebastian Schiel
,
Wenko Smolka
,
Christoph Leiggener
,
Gabriele Kaeppler
,
Carl-Peter Cornelius
Further Information

Publication History

Publication Date:
03 December 2012 (online)

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Zusammenfassung

In Analogie zu einem aufgeschlagenen Buch weit lateralwärts dislozierte Unterkieferhälften nach einem Gesichtsschädeltrauma sind Folge eines typischen Frakturmusters: die Symphysen-/Parasymphysen- bzw. Kinnregion ist aufgesprengt, gleichzeitig sind beide Kiefergelenkfortsätze nach Brüchen auf dem Niveau von Basis, Kollum oder Walze disloziert und/oder aus der Gelenkgrube luxiert. Aus derartigen Dreifachfrakturen resultieren massive Okklusionsstörungen (Kreuzbiss, frontal offener Biss), die nach Konsolidierung in Fehlstellung kaum funktionell kompensiert werden können. Daneben kann es zu einer ästhetisch ungünstigen Breitenzunahme des Untergesichts in Kombination mit einer Abnahme der hinteren Gesichtshöhe kommen. Aktuelle Konzepte tendieren daher zu einer operativen Versorgung sämtlicher Frakturzonen mit anatomisch korrekter Reposition und rigider Fixierung der Fragmente. Dieses aggressive Prozedere konnte sich erst auf der Grundlage von Fortschritten in der Behandlung von Kiefergelenkfortsatzfrakturen entwickeln, wo ein Paradigmenwechsel von der geschlossenen Behandlung zur Osteosynthese über offene transfaziale oder transorale Zugänge stattgefunden hat. Die Biomechanik, die klinische und bildgebende Diagnostik und die operative Gesamtstrategie der „Open book“-Frakturen des Unterkiefers werden hier dargestellt. Die Differenzialindikation der operativen Zugänge, ebenso wie Entscheidungskriterien, wo (Gelenkfortsatzbereich oder Unterkiefermitte?) in der OP-Behandlungssequenz mit der Fixierung begonnen werden sollte sowie die Auslegung und Dimensionierung von Osteosynthesematerial finden dabei ausführliche Berücksichtigung.

“Open Book” Fractures of the Mandible: Bilateral Condylar Process Fractures Combined with Paramedial/Medial Fractures of the Lower Jaw. Strategies for Surgical Treatment

Lateral displacement of the mandibular body divisions analogous to an open book after trauma to the facial skeleton are the result of a typical fracture pattern: a disjunction of the symphyseal/parasymphyseal region goes along with bilateral condylar process fractures at the level of either the base of the process, the neck or the condylar head. The condylar process fragments are commonly displaced and/or dislocated from the glenoid fossa. Such triple mandibular fractures result in severe malocclusion (cross bite, frontal open bite) that can hardly be compensated for if the fractures consolidate in bony malalignment. Besides, the lower face may be widened and diminished in vertical height posteriorly in an aesthetically unpleasing manner. Present day concepts suggest open surgical treatment of all fracture sites with anatomic reduction and rigid fixation. This aggressive approach was only recently developed based on the advances in the treatment of condylar processes, where the paradigms have shifted from closed treatment to open reduction and osteosynthesis using a transfacial or a transoral access. The biomechanics, the clinical signs and symptoms, and imaging diagnostic work-up as well as the overall surgical strategy in the treatment of “open book” mandible fractures are presented in this article. The appropriate choice of the surgical access, the operative sequence at which site (condylar process or symphysis/parsymphysis) to start with the fixation of fragments as well as the type, number, location and dimensions of osteosynthesis material are thoroughly outlined.

 

  • Literatur

  • 1 Huelke DF. Mechanics in the production of mandibular fractures: a study with the “stresscoat” technique. I. Symphyseal impacts. J Dent Res 1964; 43: 437-446
    PubMedGoogle Scholar
  • 2 Huelke DF, Burdi AR, Eymen C. Mandibular fractures as related to site of trauma and state of dentition. J Dent Res 1961; 40: 1262-1266
    CrossrefPubMedGoogle Scholar
  • 3 Huelke DF, Burdi AR, Eymen CE. Association between mandibular fractures and site of trauma, dentition and age. J Oral Surg Anesth Hosp Dent 1962; 20: 478-481
    PubMedGoogle Scholar
  • 4 Huelke DF, Harger JH. Maxillofacial injuries: their nature and mechanisms of production. J Oral Surg 1969; 27: 451-460
    CrossrefPubMedGoogle Scholar
  • 5 Huelke DF, Patrick LM. Mechanics in the production of mandibular fractures: strain-gauge measurements of impacts to the chin. J Dent Res 1964; 43: 437-446
    PubMedGoogle Scholar
  • 6 Lindahl L. Condylar fractures of the mandible. I. Classification and relation to age, occlusion and concomitant injuries of teeth and teeth supporting structures and fractures of the mandibular body. Int J Oral Surg 1977; 6: 12-21
    CrossrefPubMedGoogle Scholar
  • 7 Rowe NL, Killey HC. Fractures of the facial Skeleton. 2nd. ed. Edinburgh: Churchill-Livingstone; 1968
    Google Scholar
  • 8 Cope MR, Lawlor MG. An unusual mandibular dislocation. Br J Oral Maxillofac Surg 1985; 23: 112-117
    CrossrefPubMedGoogle Scholar
  • 9 Petzel JR, Bulles G. Experimental studies of the fracture behaviour of the mandibular condylar process. J Maxillofac Surg 1981; 9: 211-215
    CrossrefPubMedGoogle Scholar
  • 10 Loukota RA, Neff A, Rasse M. Nomenclature/classification of fractures of the mandibular condylar head. Br J Oral Maxillofac Surg 2010; 48: 477-478
    CrossrefPubMedGoogle Scholar
  • 11 Rasse M. Neuere Entwicklungen der Therapie der Gelenkfortsatzbrüche der Mandibula. Mund Kiefer Gesichtschir 2000; 4: S69-S87
    CrossrefPubMedGoogle Scholar
  • 12 Neff A. Funktionsstabile Osteosynthese bei Frakturen der Kiefergelenkwalze: Ergebnisse experimenteller und klinischer Untersuchungen. Med. Habil. Schrift, Tech. Universität München 2002. Göttingen: Cuvillier; 2003
    Google Scholar
  • 13 Neff A, Kolk A, Deppe H et al. Neue Aspekte zur Indikation der operativen Versorgung intraartikulärer und hoher Kiefergelenkluxationsfrakturen. Mund Kiefer Gesichtschir 1999; 3: S24
    CrossrefPubMedGoogle Scholar
  • 14 Neff A, Kolk A, Hoch HH. Position und Beweglichkeit des Discus articularis nach operativer Versorgung intraartikulärer und hoher Kiefergelenkluxationsfrakturen. Mund Kiefer Gesichtschir 2000; 4: S111
    CrossrefPubMedGoogle Scholar
  • 15 Schneider M, Erasmus F, Gerlach KL et al. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg 2008; 66: 2537-2544
    CrossrefPubMedGoogle Scholar
  • 16 Singh V, Bhagol A, Dhingra R. A comparative clinical evaluation of the outcome of patients treated for bilateral fracture of the mandibular condyles. J Craniomaxillofac Surg 2011; August [Epub ahead of print]
    PubMedGoogle Scholar
  • 17 Ellis 3rd E, Tharanon W. Facial width problems associated with rigid fixation of mandibular fractures: case reports. J Oral Maxillofac Surg 1992; 50: 87-94
    CrossrefPubMedGoogle Scholar
  • 18 Gerbino G, Boffano P, Bosco GF. Symphyseal mandibular fractures associated with bicondylar fractures: a retrospective analysis. J Oral Maxillofac Surg 2009; 67: 1656-1660
    CrossrefPubMedGoogle Scholar
  • 19 Ellis 3rd E. Is lag screw fixation superior to plate fixation to treat fractures of the mandibular symphysis?. J Oral Maxillofac Surg 2012; 70: 875-882
    CrossrefPubMedGoogle Scholar
  • 20 Scolozzi P, Richter M. Treatment of severe mandibular fractures using AO reconstruction plates. J Oral Maxillofac Surg 2003; 61: 458
    CrossrefPubMedGoogle Scholar
  • 21 Neff A, Kolk A, Meschke F et al. Kleinfragmentschrauben vs. Plattenosteosynthese bei Gelenkwalzenfrakturen – Vergleich funktioneller Ergebnisse mit MRT und Achsiographie. Mund Kiefer Gesichtschir 2005; 9: S80
    CrossrefPubMedGoogle Scholar
  • 22 Eckelt U. Gelenkfortsatzfrakturen. Mund Kiefer Gesichtschir 2000; 4 (Suppl. 01) S110-S117
    CrossrefPubMedGoogle Scholar
  • 23 Ellis 3rd E, Zide MF. Retromandibular Approach. In: Ellis 3rd E, Zide MF, eds. Surgical Approaches to the facial Skeleton. Baltimore: Williams & Wilkins; 1995: 139
    Google Scholar
  • 24 Silverman S. A new operation for displaced fractures at the neck of the mandibular condyle. Dental Cosmos 1925; 67: 876-877
    PubMedGoogle Scholar
  • 25 Fritzemeier CU, Bechthold H. Unterkiefergelenkfortsatzfrakturen mit alleinigem Zugang von intraoral. Mund Kiefer Gesichtschirurgie 1993; 17: 66-70
    PubMedGoogle Scholar
  • 26 Schön R, Gutwald R, Schramm A et al. Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs. intraoral approach. Int J Oral Maxillofac Surg 2002; 31: 237-243
    CrossrefPubMedGoogle Scholar
  • 27 Schmelzeisen R, Cienfuegos-Monroy R, Schon R et al. Patient benefit from endoscopically assisted fixation of condylar neck fractures – a randomized controlled trial. J Oral Maxillofac Surg 2009; 67: 147-158
    CrossrefPubMedGoogle Scholar
  • 28 Schön R, Fakler O, Metzger MC et al. Preliminary functional results of endoscope-assisted transoral treatment of displaced bilateral condylar mandible fractures. Int J Oral Maxillofac Surg 2008; 37: 111-116
    CrossrefPubMedGoogle Scholar
  • 29 Hoffmann A, Mast G, Ehrenfeld M. Verwendung von IMF-Schrauben zur mandibulo-maxillären Fixation. OP-Journal 2003; 19: 70-75
    PubMedGoogle Scholar
  • 30 Arthur G, Berardo N. A simplified technique of maxillomandibular fixation. J Oral Maxillofac Surg 1989; 47: 1234
    CrossrefPubMedGoogle Scholar
  • 31 Tillmann B, Härle F, Schleicher A. Biomechanik des Unterkiefers. Dtsch Zahnärztl Z 1983; 38: 285-293
    PubMedGoogle Scholar
  • 32 Hammer B, Schier P, Prein J. Osteosynthesis of condylar neck fractures: a review of 30 patients. Br J Oral Maxillofac Surg 1997; 35: 288-291
    CrossrefPubMedGoogle Scholar
  • 33 Eckelt U. Zur funktionsstabilen Osteosynthese bei Unterkiefergelenkfortsatzfrakturen. Universität Dresden: Habilitationsschrift; 1984
    Google Scholar
  • 34 Krenkel C. Axial “anchor” screw (lag screw with biconcave washer) of “slanted-screw” plate for osteosynthesis of fractures of the mandibular condylar process. J Craniomaxillofac Surg 1992; 20: 348-353
    CrossrefPubMedGoogle Scholar
  • 35 Tiwana PS, Kushner GM, Alpert B. Lag screw fixation of anterior mandibular fractures: A retrospective analysis of intraoperative and postoperative complications. J Oral Maxillofac Surg 2007; 65: 1180
    CrossrefPubMedGoogle Scholar
  • 36 Champy M, Loddé JP, Schmitt R et al. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg 1978; 6: 14-21
    CrossrefPubMedGoogle Scholar
  • 37 Umstadt HE, Ellers M, Müller HH et al. Functional reconstruction of the TM joint in case of severely displaced fractures and fracture dislocation. J Caniomaxillofac Surg 2000; 28: 97-105
    PubMedGoogle Scholar
  • 38 Vogt A, Roser M, Weingart D. Transparotidean approach to surgical management of condylar neck fractures. A prospective study [Article in German]. Mund Kiefer Gesichtschir 2005; 9: 246-250
    CrossrefPubMedGoogle Scholar
  • 39 Biglioli F, Coletti G. Transmasseter approach to conylar fractures by miniretromandibular access. J Oral Maxillofac Surg 2009; 67: 2418-2424
    CrossrefPubMedGoogle Scholar
  • 40 Klatt J, Heiland M, Blessman M et al. Clinical indication for intraoperative 3D imaging during open reduction of fractures of the neck and head of the mandibular condyle. J Craniomaxillofac Surg 2011; 39: 244-248
    CrossrefPubMedGoogle Scholar