下颌升支后缘小切口穿腮腺入路治疗髁突中低位骨折

Surgical treatment of condylar fractures with mini-retromandibular and transparotid approach

目的探讨下颌骨后缘小切口穿腮腺入路在髁突中低位骨折切开复位内固定术中的应用效果。方法回顾分析2016年1月至2019年1月,于南京市口腔医院采用下颌骨升支后缘小切口穿腮腺入路行骨折复位的28例下颌骨髁突骨折患者的临床资料。其中男18例,女10例,平均年龄42.5岁;左侧髁突骨折11例,右侧13例,双侧4例。术中于下颌骨后缘,切开皮肤、皮下组织,切口长度为2~3 cm,平行于面神经走行钝性分离,直接穿过腮腺及咬肌,不必刻意解剖面神经,暴露骨折线后,直视下以2块4孔钛板复位固定骨折断端。于术后3 d及3~6个月期间进行临床及影像学检查、评估,内容包括:术后血肿、术后感染、神经损伤、涎瘘、最大张口度、张口型、咬合关系、瘢痕情况等。结果28例患者骨折断端均复位良好,无神经损伤,涎瘘等并发症,仅有1例患者术后发生感染,3个月后进行二次手术取出钛板。所有患者出院时张口度为1.5~3.8 cm,平均3.1 cm,较手术前(0.5~2.0 cm,平均1.2 cm)均有明显改善。1例患者开口时颏部稍偏向患侧,术后配合颌间弹性牵引3~5 d,咬合关系恢复良好。其余患者张口口形均基本正常。随访6~36个月,所有患者术后瘢痕均不明显,患者对手术效果表示满意。所有患者于术后3~6个月拍摄术后CT及三维重建,均显示骨折复位良好。结论下颌升支后缘小切口穿腮腺入路对于治疗髁突中低位骨折效果良好、方法简单、高效、快捷,不需要解剖面神经,不仅能够减少手术时间,降低损伤面神经的可能性,而且术后瘢痕也较隐蔽。

Objective To investigate the effect of mini-retromandibular and transparotid approach in open reduction and internal fixation of middle or low condylar fractures.Methods A total of 28 condylar fracture cases which were treated with mini-retromandibular approach from January 2016 to January 2019 in Nanjing Stomatological Hospital were included in this study.These cases included 18 males and 10 females with ameanage of 42.5 years.There were 11 cases of left condyle fractures,13 cases of right condyle fractures and 4 of bilateral condyle fractures.During the operations,incisions of 2-3 cm long were made on the skin and subcutaneous tissue along the posterior margin of the mandible.Then we performed blunt dissections parallel to the facial nerves,directly passing through the parotid gland and masseter muscles,without the facial nerve injuried.After exposing the fracture line,the fracture ends were fixed and restored with two 4-hole titanium miniplates under direct vision.The medical reviews were performed on the third day and 3-6 months after operation by imaging examination and clinical examination.The contents included:postoperative hematoma,postoperative infection,nerve injury,salivary fistula,maximum mouth opening degree,mouth opening type,occlusal relationship,scar condition,etc.Results All of the 28 patients had good restoration of fracture ends without nerve injury,salivary fistula or other complications.Only one patient suffered with postoperative infection.After 3 months,titanium miniplate was removed by second operation.The mouth opening of patients ranged 1.5-3.8 cm,with an average of 3.1 cm,which was significantly improved compared to the pre-operation(0.5-2.0 cm,average 1.2 cm).One patient’s chin was slightly deviated to the affected side at the time of opening,and the occlusal relationship was recovered well with intermaxillary elastic traction for 3-5 days.The mouth opening type of other patients was nearly normal.Followed up for 6-36 months,all of the patients had no obvious scars after operation.The patients were satisfied with the operation effect.All patients took postoperative CT and 3D reconstruction 3 to 6 months after operation,which showed that the fracture reduction was good.Conclusions Mini-retromandibular and transparotid approach is effective,simple,efficient and fast in the treatment of condylar middle or low fracture,without facial nerve dissection.It can not only reduce the operation time and the possibility of facial nerve injury,but also make postoperative scar relatively inconspicuous.