Jeong et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:26 DOI 10.1186/s40902-015-0028-y

CASE REPORT Open Access

Simultaneous surgery for subcondylarfracture and prominent angle of the mandibleChang-Hwa Jeong, Jae-Young Ryu* , Woo-Yul Lee and Hyeon-Min Kim

Abstract

We experienced a patient of subcondylar fracture who had a squared contour of the lower face with prominentangle of the mandible and masseter hypertrophy. Our patient was increasingly seeking esthetic improvement ofthe lower third of the face. But she did not want multi-stage operations. Thus, we decided and performed a one-stagemandibular angle ostectomy with fracture management. We have a stable and esthetic result simultaneously despitefractures of the fixation plates during follow-up period, so report a case.

Keywords: Mandibular condyle; Mandibular osteotomy; Botulinum toxin

BackgroundA prominent mandibular angle with a square face sym-bolizes masculinity in a viewpoint of Korean people [1].Factors contributing to the contour of the lower face in-clude the shape of the mandible and the bulkiness of themasseter muscles. Available treatments include fromcombined muscle and bone resection to injections ofbotulinum toxin on the masseter muscle. So ostectomyof the mandibular angle or botulinum toxin injection isperformed in the many Korean people depending on apatient’s esthetic demands.Ostectomy of the mandibular angle or management of

subcondylar fracture can be performed through anintraoral approach. But intraoral approach offers limitedvisual field and difficulty during operation. The purposeof this article is to report a case wherein a simultaneoussurgery for subcondylar fracture and prominent man-dibular angle was performed intraorally.

Case presentationA 38-year-old woman, victim of a family violence, came toour department with a subcondylar fracture on the rightside of mandible (Fig. 1). She presented malocclusion withswelling and tenderness on the right cheek and preauriculararea and was planned for surgery under general anesthesia.By the way, she complained of bilateral prominent

* Correspondence: face@gilhospital.comDepartment of Oral & Maxillofacial Surgery, Gachon University Gil MedicalCenter, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon 405-760,Republic of Korea

© 2015 Jeong et al. Open Access This article iInternational License (http://creativecommons.oreproduction in any medium, provided you givthe Creative Commons license, and indicate if

mandibular angles and wanted angle ostectomy simultan-eously. She also had the bilateral masseter hypertrophy. Sowe decided and proceeded with simultaneous surgery offracture management and angle ostectomy.The patient was operated under general anesthesia

with nasotracheal intubation. Intermaxillary fixation(IMF) was installed using eight IMF screws during oper-ation. Lidocaine with 1:100,000 epinephrine was infil-trated in the posterior vestibule and retromolar area ofboth lower sides. First, the fractured subcondyle was re-duced transorally via a vestibular approach. After that,two 2.0-mm system plates and screws (Synthes Inc.,West Chester, PA, USA) were used for fixation with thehelp of a trocar. The first plate was usually installed inthe posterior border of the ramus. However, in this case,we placed the first plate in the anterior portion of the es-timated ostectomy line, because the posterior border ofthe ramus would be resected to some extent. Then, thesecond plate was installed more anteriorly than the firstplate. Two miniplates were positioned at the thickestpart of subcondylar area in a surgeon’s preference. Then,the IMF was removed and the mouth was opened andthe occlusion and mandibular movement were checked.After that, usual angle ostectomy of both sides was pro-gressed using bur, oscillating and reciprocating saw in acondition of IMF to stabilize the mandible. In the imme-diate postoperative period, we recognized damage of thefixation plate. The damaged trace of the fixation platewas observed at postoperative radiograph (Fig. 2). It wasassumed that the reciprocating saw was invaded to

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Fig. 1 Preoperative: panoramic radiograph (above) and 3D-CT, frontal and right lateral view, (below) showing the fractured right subcondyle andprominent angle of mandible

Jeong et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:26 Page 2 of 4

posterior plate. The patient was kept 5 days in IMF withelastics to keep the proper occlusion. After releasing theIMF, exercise was started with guiding elastics for 2 weeks.After that, only opening exercise was performed by herselffor another 1 week. Then, she had a normal range ofmouth opening. She had no difficulty or pain in mouthopening at the first month after the operation. But platefractures were confirmed in a panoramic radiograph atthat period. After that, we planned the closed observationwithout any intervention. Though more dislocated frag-ments of fractured plates were observed at the thirdmonth of postoperative period, there were no clinicalsymptoms. But the muscular strength of both massetersgradually increased, so botulinum toxin type A (BOTOX,Allergan Inc., Irvine, CA, USA) was applied at 3 monthsafter the operation. Two 25-unit injections were appliedon each masseter area of the face. Despite the fracture ofplates, there was no clinical problem until 8 months afterthe operation and the result satisfied her esthetic demand(Fig. 3). This study was approved by the regional EthicalReview Board of the Gachon University Gil MedicalCenter (Certificate No.: GAIRB2015-66).

DiscussionBecause there is enough bone stock to stabilize a fixationplate, subcondylar fractures may be amenable to rigid

fixation. Though there are different approaches for thefixation of mandibular subcondylar fractures, that areacan be typically well visualized using instrument such asBauer retractors, followed by anatomic reduction transo-rally [2]. In this case, fractured fragment displaced lat-erally and patient did not want to make operation scarsin her face. Mandibular angle ostectomy can be also per-formed transorally [3]. So we chose intraoral approach.The intraoral approach for mandibular surgery offersmany advantages that minimize the risks of visible scarsand facial nerve injury. But the limitation of that ap-proach is a narrow surgical field, which makes it difficultto view the operative site directly. So there is possibilityof surgical and esthetic complications. In this case, weexperienced the fractures of fixation plates.Osteosynthesis of subcondylar fractures with two

straight plates has been shown to be a suitable methodthat withstands the functional loading transmitted tothat area [4, 5]. In this case, we also used two 2.0-mmsystem plates and screws. Because the estimated area ofangle ostectomy was overlapped with reduction and fix-ation area, posterior object among two plates waslocated more anteriorly than the usual position. Ana-tomical reduction is the most important thing in theoperation of fracture management. So, reduction andfixation were progressed before angle ostectomy. After

Fig. 2 Immediate postoperative: panoramic radiograph (above) and 3D-CBCT, frontal and right lateral view, (below) showing the damage ofposterior plate

Jeong et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:26 Page 3 of 4

fixation, usual ostectomy of mandibular angle was per-formed under the plate fixation and IMF state to makethe mandible stable. Because that situation is moresimilar and stable condition in shape than in displacedstate, the operator could be more familiar for angleostectomy. But, it was assumed that fixation plate wasdamaged by the reciprocating saw during angle ostect-omy. Distortion of plate shape could be observed on

Fig. 3 Postoperative 8-month 3D-CBCT, frontal and right lateral view, show

immediate postoperative radiograph. Even though theoperator paid particular attention to ostectomy, platedamage occurred on the account of limited operationfield of vision. Immediately after the operation, therewas no clinical problem such as malocclusion despitethe damage of a plate. After that, individual protocolsuch as postoperative IMF (for 5 days) and elastic train-ing (for additional 2 weeks) was carried out.

ing no distinct displacement of condylar fragment

Jeong et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:26 Page 4 of 4

The fractures of two fixation plates were observed inpanoramic radiograph at the first postoperative month.Posteriorly positioned plate was already broken duringthe ostectomy as confirmed from the immediate postop-erative radiograph. Moreover, it is presumed that vibra-tion of sawing for ostectomy could be an additionalreason for weakening of plates. Though fixation plateswere damaged, proximal fragment of fracture site wasnot displaced. There were also good occlusion and re-covery of mouth opening, so we planned the closed ob-servation without any intervention, because non-surgicaland conservative management can be recommendedwhen there is no displacement of subcondylar fractures[6, 7]. Limited mouth opening and relatively soft dietwere instructed to patient for one more month. Despitethe fracture of plates, there was no more displacementof subcondylar fragment or clinical problem until8 months after the operation. Though there was no clin-ical problem in this case, stable fixation of fracture siteis important. So if simultaneous treatment is necessarysuch as this patient, we suggest that reduction and fix-ation first then, do the ostectomy after the removal ofthe existing fixation plate. So after finishing the ostect-omy, fixation plate will be repositioned to the originalfixation site, like when using reconstruction plate forsegmental mandibulectomy. This method will help inminimizing plate and screw weakening.Over time, muscular strength of both masseters grad-

ually increased, so injection of botulinum toxin type Awas considered. Yan et al. measured the maximal biteforce, maximal opening of the mouth, and maximal pro-trusion before and after curved osteotomy of the man-dibular angle to evaluate the effect of mandibularresection on oral physiological function [8]. They foundthat function was partially restricted during the earlypostoperative stage but was recovered by 3 months post-operatively. So, botulinum toxin was applied at 3 monthsafter the operation in our patient for the reduction ofmasseter muscular power and making a more slenderface. Intramuscular injection with botulinum toxin leadsto the reduction of the thickness of the masseter, with-out serious side effects [9].

ConclusionsWe experienced a case wherein simultaneous surgery forsubcondylar fracture and prominent mandibular anglewas performed intraorally, and fracture of fixation plateshappened after the operation. Despite of a limited surgi-cal approach and fracture of fixation plates during andafter the operation, there was no clinical problem anddisplacement of fractured fragment until the postopera-tive 8 months. The patient was also satisfied in the es-thetic aspect. We operated fracture management and

angle ostectomy simultaneously; then, we had a satisfac-tory result with the postoperative proper management.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available for re-view by the Editor-in-Chief of this journal.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsCHJ drafted the manuscript. JYR was the operator of this case and conceivedof the study. WYL collected the data of the patient. HMK participated in thedesign and coordination of this study. All authors read and approved thefinal manuscript.

Received: 8 June 2015 Accepted: 24 August 2015

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