Authors of section

Authors

Nicolas Homsi, Paulo Rodrigues, Gregorio Sánchez Aniceto, Beat Hammer, Scott Bartlett

Executive Editors

Edward Ellis III, Eduardo Rodriguez

General Editor

Daniel Buchbinder

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Debridement and internal fixation

1. Introduction

Non-union of the condylar process may be diagnosed by:

  • Development of malocclusion with or without facial asymmetry
  • TMJ pain and functional limitation
Nonunion of the condyle treated with MMF - Revision surgery - Debridement and internal fixation

2. Approach

Upper condylar fractures

For the condylar head and the superior part of the condylar neck, the preauricular approach may be selected.

For superior condylar neck and head fractures, a transoral approach with endoscopic assistance may be selected. However this requires formal training of the surgical team and specialized equipment.

Malreduction of the condyle - Revision surgery - Open reduction and internal fixation

Lower condylar fractures

For the lower part of the condylar neck, the retromandibular approach or...

Malreduction of the condyle - Revision surgery - Open reduction and internal fixation

...the submandibular approach may be selected.

Nonunion of the condyle treated with MMF - Revision surgery - Debridement and internal fixation

3. Debridement

Removal of failed plates and screws (if present)

Nonunion may have occurred due to a wrong choice of or improper insertion of plates and screws. The osteosynthesis material is removed before debridement.

Nonunion of the condyle treated with MMF - Revision surgery - Debridement and internal fixation

Debridement of fibrous tissues

Fibrous tissues tend to form around the unstable fracture site as a consequence of persistent mobility.

If the fibrous tissue will not allow for proper fragment realignment, debridement will be necessary.

Nonunion of the condyle treated with MMF - Revision surgery - Debridement and internal fixation

Debridement of necrotic bone

Poorly vascularized fragments are removed to ensure the presence of healthy bone (normally bleeding bone) in the fracture line.

The debridement is performed using rongeurs, saws, or burs.

Nonunion of the condyle treated with MMF - Revision surgery - Debridement and internal fixation

4. Fixation

The condylar segment is functionally repositioned in the glenoid and internal fixation is performed as described in the trauma section. A more rigid plating system should be used compared to a primary repair procedure since the bone contact is less favorable.

Nonunion of the condyle treated with MMF - Revision surgery - Debridement and internal fixation

5. Aftercare following revision ORIF of the condylar process and head

If MMF screws are used intraoperatively, they are usually removed at the conclusion of surgery. Arch bars may be maintained postoperatively for functional therapy.

Postoperative x-rays are taken within the first days after surgery.

It is imperative that the occlusal relationship and mandibular function be assessed early and on a regular basis. The patient is evaluated at 1 week to verify the occlusion and to assure adequate performance of functional rehabilitation exercises.

If a malocclusion is detected, the surgeon must ascertain its etiology (using the appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics will be beneficial. The lightest elastics possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to incorrect bone alignment (mal reduction) or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery. A slight malocclusion can be corrected by orthodontics or dental adjustments with the help of a dentist.

The frequency of follow-up will largely be based on the findings of the 1 week appointment. Typically, if the patient is doing well at 1 week, they will not be seen for 2 more weeks. The necessity and frequency of future appointments will be based upon the findings from this appointment.

Postoperatively, patients will have to follow three basic instructions:

1. Diet:
The patient can consume liquids and semiliquids for the first couple of weeks and then advanced to more solid foods as tolerated and recommended by the surgeon.

2. Oral hygiene
Patients with extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure than normal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® or similar device is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence. The assistance of a dental hygienist may be helpful.

3. Physiotherapy
Patients are instructed in physical therapy maneuvers to restore mandibular excursions. This includes maximum jaw opening, right and left lateral excursions, and protrusive excursions of the mandible, as well as assistance from a physiotherapist if required. They should perform these exercises several times a day.