28 June 2023: Articles
Unusual or unexpected effect of treatmentTadashi Kawai1ABE*, Shinsuke Kawamata1BC, Shuu Suzuki1B, Yuudai Ishikawa1B, Yuunosuke Ikeda1B, Erika Yasuge1B, Shintaro Kogi1BD, Atsushi Ogawa1CD, Mitsuru Izumisawa2C, Hiroyuki Yamada1ACE
Am J Case Rep 2023; 24:e940681
BACKGROUND: Open reduction and internal fixation of condyle fractures are sometimes difficult for the upper region. This report presents a case of condyle fracture at the upper neck region treated with a custom-made titanium mesh and a titanium miniplate, which makes it easy to reposition the fragment and keep it in place.
CASE REPORT: A 20-year-old man was injured during a soccer match and was referred to our hospital with the symptom of trismus and deviation of the mandible to the left with an opened mouth. Fracture of the right condyle neck region was diagnosed; open reduction and internal fixation was planned under general anesthesia. A custom-made titanium mesh was prepared to make it easy to reposition the fragment and keep it in place because the reduction and fixation were expected to be difficult. The fracture region was exposed using the modified Risdon-Strasbourg approach. The segments were gripped with custom-made titanium mesh, and the condyle head was reduced easily. The segments were fixed with titanium mesh, a miniplate, and screws. Nine months after the operation, the mouth opening was good at 40 mm, there was no deviation of the mandible, and there was no breakage on the titanium mesh or plate.
CONCLUSIONS: This report presents a case of condyle fracture at the upper neck region reduced and fixed with a custom-made titanium mesh and a titanium miniplate, which make it easy to reposition the fragment and keep it in place.
Keywords: Mandibular Condyle, Open Fracture Reduction, surgical fixation devices
Condyle fractures are the second most common in the cranio-facial region  and usually occur as an indirect fracture with mandible injuries . Condyle fractures are treated with open reduction and internal fixation (ORIF), or conservative treatment . The treatment is selected according to the symptom, fracture region, fragment deviation, or the general condition of the patient . Both treatments can equally restore malocclusion and trismus . Conservative treatment takes a few months for the hard callus formation and there are restrictions on diet and activities . In contrast, ORIF can obtain stable fixation, improve activities, and restore the anatomical form .
Titanium mesh or miniplates serve as excellent fixation material in ORIF and are used frequently in oral and maxillofacial surgery [7,8]. ORIF of condyle fractures is sometimes difficult to perform for the upper condyle region. At the condylar head region, although fixation with miniplates is difficult due to the small size of the fragment, lag screws may be used for fixation . The condylar neck region needs 2 miniplates or 1 three-dimensional (3D) plate for fixation [10,11]. If there is no deviation of bone fragments, it will be easy to fix with these materials. However, if the bone fragment is pulled strongly by muscles and deviates mesially and downward , it may be difficult to reposition the bone fragment and keep it in place until fixation. Therefore, a device that easily repositions the fragment and serves as a reinforcement for fixation is desired. Recently, 3D virtual planning and customized 3D printing has been introduced, showing promising results in dentistry  and maxillofacial surgery . This report presents a case of condyle fracture at the upper neck region treated with custom-made titanium mesh and titanium miniplate, which make it easy to reposition the fragment and keep it in place.
A 20-year-old man with no medical history was injured during a soccer match when an opposing player’s head hit his right mandible. The patient visited a dental clinic due to occlusal deviation and pain 3 days later. A condyle fracture was suspected, and the patient was referred to our hospital 7 days after the injury. At the visit, the occlusal deviation was not observed; however, the midline of the mandible was slightly displaced to the left with an opened mouth (Figure 1A, 1B). The mouth opening, defined as between the edge of the upper and lower incisor edge, was 30 mm. Dental panoramic tomography (Veraviewepocs 2D, MORITA Corp., Tokyo, Japan) and dental cone-beam computed tomography (CBCT: KaVo OP 3D Vision V17, KaVo Dental Systems Japan G.K., Tokyo, Japan) revealed a condyle neck fracture and deviation of the condyle head forward, inward, and downward (Figure 2A, 2B). Since the patient wanted to return to normal and be able to play soccer in a shorter period, ORIF was planned under general anesthesia. It was predicted that fixation and complete reduction using 2 mini-plates would be difficult because the fracture line was superior to the condyle and the condyle head deviated medially and inferiorly. A virtual surgical plan was prepared with computer software (Volume Extractor®, i-Plants Systems, Iwate; Geomagic Freeform®, 3D Systems, Rock Hill, SC) based on the preoperative CBCT data. The condyle head was repositioned as an image, and a 3D model was constructed using a 3D printer (Straumann® CARES®P20+, Straumann, Basel Switzerland). A custom-made titanium mesh was prepared by adjusting the form surrounding the condylar neck on the 3D model using a pre-form mesh sheet (Universal mesh, Stryker Japan, Tokyo, Japan) to make it easy to reposition the condyle head and to serve as a reinforcement for fixation (Figure 3A–3C). Preoperative preparation was completed, and surgery was performed on the 6th hospital day. The fracture region was exposed using the modified Risdon-Strasbourg approach. The ramus was retracted downward to reveal the condyle head. The segments were gripped with custom-made titanium mesh, and the condyle head was easily reduced. A titanium miniplate was placed close to the posterior margin with 4 screws (MINI PLATING MODUL Plates/Screws, Stryker Japan, Tokyo, Japan), and the titanium mesh was fixed with 3 screws (Figure 4A–4C). After irrigation, the operative site, the muscle, subcutaneous tissue, and skin were sutured using VICRYL® plus (Johnson & Johnson K.K., Tokyo, Japan) and ETHILON® (Johnson & Johnson K.K., Tokyo, Japan).
The operation took 114 mins, and blood loss was 13 mL. After surgery, since there was no movement disorder of the forehead or eyelids, facial nerve damage was not detected. Intermaxillary fixation was performed for 4 days to stabilize the surgical site, and functional rehabilitation was started. Deviation of the mandible when opening the mouth was not observed, and there was no malocclusion. The mouth opening was 30 mm, there was no pain, and there was no problem with eating. The patient was discharged from the hospital on the 9th postoperative day. Nine months after the operation, although there was slight absorption on the condylar head surface, the mouth opening was good at 40 mm, there was no deviation of the mandible, and X-rays showed there was no breakage of the titanium mesh or miniplate (Figure 5A–5C).
In condyle fractures, the treatment is performed with ORIF or conservative treatment . These treatments are reported to show similar results on occlusal and functional features . Conservative treatment requires a period of time until the fracture site is stabilized, and there are some restrictions on daily activities. In addition, the deformity of the condyle may remain . It has been reported that ORIF should be considered if there is a deformity and a height loss of the ramus, and it can improve activities and functionally stable fixation . This patient was injured while playing soccer and wanted to play again as soon as possible. Therefore, ORIF was chosen to eliminate restrictions on daily life, such as being able to exercise as early as possible.
Various techniques for ORIF of superior condyle fracture have been reported. Lag screws use has been reported for condylar head fracture with minimally invasive surgical access . In addition, cone-beam computed tomography use in a hybrid operating room has been reported to evaluate the reduction achieved in an insufficient operative field . Preoperative virtual evaluation using a 3D image or model enables analysis of the fracture site from different aspects, and the prediction of fixed positions, such as those of miniplates . Additionally, virtual planning allows the clinician to choose the screw diameter and length, thus reducing the risk of failure . In this case, a 3D model of the condyle after reduction was prepared. Reduction and fixation with 2 or more miniplates are recommended; however, in this case, the fracture site was located upward, so it was expected that this would be difficult. In addition, there was also a deviation of the condyle forward, inward, and downward, and it was thought that it would be difficult to restore it and keep it in that position. A miniplate could be used in the posterior region where fixation is most effective . Therefore, this case was attempted to increase the strength of fixation with a custom-made titanium mesh to compensate for the fixing strength. It was easy to make according to the shape of the model, and it became possible to hold the condyle fragment and mandible fragment in 3 dimensions and keep the condyle in place. Another study reported the use of resorbable 3D mesh for condyle fracture . However, the reduction and retention of the fragment were easy and fixed with the resorbable 3D mesh. In this case, the resorbable mesh would be too weak to reduce and fix the condyle fragment. However, if the fracture site was higher, it would have been difficult to fix the titanium mesh with screws using the method described in this report.
There are some reports of post-ORIF complications. Risk of infection near the geomatic titanium materials due to smoking and advanced periodontitis has been reported . This patient, in addition to being young, was not a smoker and did not have periodontal disease; therefore, there is no immediate risk of infection. However, since periodontitis may develop or progress with age, it will be necessary to pay attention to this patient’s oral care in the future. In addition, if the patient re-injures the mandible, the miniplate may affect biomechanical behavior and cause complex fractures . As the patient is young and has been involved in sports such as soccer, there is a possibility of re-injury. It is necessary to explain this possibility to such patients and have the patient be careful in daily life.
This case report confirms the possibility that a custom-made titanium mesh could contribute to the repositioning and maintenance of bone fragments in the treatment of condyle fractures at the upper region. However, it is necessary to consider its stability via further follow-up observations.
In this case report, a condyle fracture at the upper neck region was reduced and fixed with a custom-made titanium mesh and a titanium miniplate, considering the convenience of surgical operation and the patient’s daily life. The method described made it easy to reposition the fragment and keep it in place. However, it is necessary to pay attention to infection with titanium materials from periodontal disease and re-fracture due to biomechanical behavior at re-injury.
FiguresFigure 1.. Intraoral findings. (A) No deviation in occlusion. (B) Picture at the opening of the mouth. The midline of the mandible was slightly displaced to the left (arrow). Dotted line: midline of the mandible. Figure 2.. X-rays at the first visit. (A) Dental panoramic tomography. (B) Dental cone-beam computed tomography. 3D surface rendering. The condyle neck fracture and deviation of the condyle head forward, inward, and downward, were confirmed. Arrows indicate the deviated condyle head. Figure 3.. Pictures of 3D model and preparing the custom-made titanium mesh and miniplate. (A) Repositioning the condyle. Red line indicates fracture region. (B) Adjusting the titanium mesh. (C) A miniplate was added to posterior margin of ramus. Figure 4.. Pictures during operation. (A) The fracture region is exposed. (B) The condyle fragment is repositioned and gripped by a custom-made titanium mesh with a mandible fragment. (C) A miniplate is placed closer to the posterior margin and 7 screws are used for fixation. Figure 5.. Pictures 9 months after the operation. (A) Picture the opening of the mouth showing that there is no deviation. (B) Dental panoramic tomography. (C) Dental cone-beam computed tomography. 3D surface rendering. Although there is slight absorption on the condylar surface, the condyle is repositioned and stable.
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