Endoscopic Treatment of Facial Fractures

Endoscopic Treatment of Facial FracturesReid Mueller, M.D.1

ABSTRACT

The application of endoscopic surgical techniques to the treatment of craniomax-illofacial fractures not only has decreased the morbidity associated with the surgicalapproaches but has significantly altered the treatment philosophy for many types of fracture.Frontal sinus fractures, orbital floor fractures, zygomatic arch fractures, and subcondylarmandible fractures are the most notable examples where endoscopic techniques have foundacceptance.

KEYWORDS: Face, fracture, orbital floor, blowout, frontal sinus, zygomatic arch,

subcondylar, mandible, endoscope, endoscopic

The treatment of facial fractures has undergoneseveral revolutions over the last century. The advent ofridged internal fixation has given us the tools to performmore accurate repairs of facial fractures while at the sametime reducing much of the morbidity. Modern recon-structive surgery has focused on accurate, reliable resto-ration of the facial bony framework; however, the softtissue sequelae of many surgical approaches persist as alasting reminder of the original injury. The most notableexamples of this are temporal wasting and scalp alopeciaassociated with the bicoronal approach, ectropian asso-ciated with lower lid incisions, and facial nerve injuryand scar associated with approaches to subcondylarfractures. Over the last 10 years, innovative surgeonshave applied alternative endoscopic approaches to facialfracture repair in an effort to achieve results equal totraditional open approaches but with reduced morbidityfrom the surgical approach.

HISTORY OF ENDOSCOPYEndoscopy literally means to look inside (Origin: <Gk,comb. form of endon withinþ skopıa, watching), typi-cally referring to looking inside the body for a medicalpurpose with an endoscope. Modern endoscopes consist

of a ridged or flexible tube with a light delivery systemusually composed of fiber optics to route light from anexternal source to the area of interest. There is a systemof lenses in ridged endoscopes that transmit the image toan eyepiece or video camera for the surgeon. Mostflexible endoscopes rely on a coherent optical fibersystem to transmit the image. Many endoscopes willalso have channels for irrigation, suction, or the intro-duction of surgical instruments.

The first descriptions of endoscopy were by Hip-pocrates (460–375 BCE) who used rectal speculums thatare little different than those used today. The Romansalso had a variety of speculums used to peer into orificesand body cavities with nothing more than availablelight.1 For over a century, various simple tubes wereused, but the lack of good illumination hampered theiruse.

Phillip Bozzini (1773–1809), an obstetrician, iscredited with the first major endoscopic advancement toimprove illumination. His invention consisted of a lightguide (Lichtleiter) that would reflect candlelight via amirror down a funnel-shaped tube.2 The faculty inVienna ridiculed him for his ‘‘undue curiosity’’; however,his ideas lived on. Others improved on the basic designwith brighter lights and better mirrors and lens systems.

1Division of Plastic Surgery, Oregon Health Sciences University,Portland, Oregon.

Address for correspondence and reprint requests: Reid Mueller,M.D., Associate Professor, Division of Plastic Surgery, Oregon HealthSciences University, 3303 SW Bond Avenue, CH5P, Portland, OR97239.

Aesthetic Reconstruction of Head and Neck Defects; Guest Editors,Manoj T. Abraham, M.D., F.A.C.S., Keith E. Blackwell, M.D.

Facial Plast Surg 2008;24:78–91. Copyright # 2008 by ThiemeMedical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,USA. Tel: +1(212) 584-4662.DOI 10.1055/s-2008-1037452. ISSN 0736-6825.

78

Rather than shining light down a tube, MaximilianNitze (1848–1906) placed a light source on the end ofthe endoscope saying ‘‘to light up the room one mustcarry the lamp inside.’’3 He accomplished this by placinga glowing platinum wire on the end of the endoscope.A number of internal burns resulted. In further develop-ments, the glowing wire was replaced with a small lightbulb and lenses were placed into the tube to magnifyingthe image. Despite these improvements, the light andimage quality was poor.

To address the limitations of the Nitze opticalsystem Harold Hopkins (1918–1995) developed the rodlens system4 that replaced the air spaces between lenseswith solid glass rods cemented between the lenses. Thissignificantly increased light transmission and allowed forwider field of view, better color rendition, and smallercaliber endoscopes. This basic system is the basis forrigid endoscopes today.

Modern flexible endoscopes are not based on therod lens but on fiber optics. In 1930, Lamm, a Germanurologist, showed that a bundle of thin glass fibers wouldtransmit light despite flexure.5 The idea floundered untilthe 1950s, when Hopkins used fiber optics in a flexiblegastroscope to transmit light in and image out. Fibersthat are not aligned in an orderly manner (incoherent)can be used to transmit light into the body; fibers that arearranged identically on both ends (coherent) will trans-mit a useful image out.

Endoscopic techniques have revolutionized manyareas of surgery and have been applied to both aestheticand reconstructive procedures in head, neck, and cranio-maxillofacial surgery. The first applications in craniomax-illofacial surgery were for aesthetic procedures such asbrow-lifting,6–8 procerus resection,8 and forehead recon-touring.9,10 In short order, endoscopy was applied tomany different areas of the head and neck in craniomax-illofacial surgery, including cranial synostosis,11–19 resec-tion of forehead and scalp soft tissue and bony tumors,20–

25 treatment of frontal sinus fractures,26–35 decompres-sion for Graves opthamalopathy,36–41 treatment of orbitalwall fractures,42–71 distraction osteogenesis,72–76 andtreatment of zygoma fractures44,47,48,77–83 and subcon-dylar fractures.84–90

FRONTAL SINUSThe logical extension of an endoscopic brow-lift ap-proach was to apply the same techniques and tools to thetreatment of a variety of forehead pathologies, includinglipomas,21,22,24,25 benign bony tumors,91 frontozygo-matic dermoid cysts,23 and osteomas22 as well as endo-scopic reduction and internal fixation of anterior tablefractures.

It is important to remember that an isolated outertable frontal sinus fracture is a cosmetic defect. Often thescar, alopecia, and temporal wasting associated with a

bicoronal approach are more problematic than theunderlying contour defect from the fracture. The endo-scopic approach addresses this problem for isolated outertable fractures but has no application for those fractureswith significant posterior table displacement or naso-frontal duct disruption. There are two basic endoscopictreatment options: endoscopic reduction and miniplatefixation or camouflage of the contour defect.

The first reported use of an endoscope for treat-ment of a frontal sinus fracture was in 1996.26 Since then,a number of authors have reported on the reduction andminiplate fixation of isolated outer table fractures usingan endoscopic approach.28–30,32,33,92 The basic techniqueinvolves two or three small incisions placed behind thehairline in much the same way as one would approach anendoscopic brow-lift. A subperiosteal dissection exposesthe depressed anterior table fragments (Fig. 1).

The most challenging aspect of this technique isthe elevation of the depressed fragments. In the author’shands, the most reliable method to elevate the depressedsegments is to use a threaded fragment manipulator(Fig. 2)—basically a long self-drilling, self-tapping 2.0screw (Synthes, Paoli, PA) that is inserted through asmall stab incision and screwed into the depressed frag-ment or fragments. A rocking and pulling motion is thenused to reduce the fracture (Fig. 3). Often a surprisingamount of force is required to pull the fragment intoreduction in part because the original compressive forcesthat were generated during collapse of the anterior tableare re-created when elevating the fragment (Fig. 4).After the segments have been reduced, miniplates are

Figure 1 An endoscopic view of an isolated anterior table

frontal sinus fracture. The depressed segment is visible; a

green arrow points toward the supraorbital vessels and

nerve.

ENDOSCOPIC TREATMENT OF FACIAL FRACTURES/MUELLER 79

used to secure the fragments (Fig. 5). If more than onefragment has been elevated, it is useful to apply a longplate starting on stable bone and then proceed sequen-tially across the fragments (stable bone ! fragment !fragment! stable bone). Self-drilling screws and screw-driver are introduced via small stab incisions; alterna-tively, a right angle screwdriver may be used. Severelycomminuted fractures are not amenable to this techniquedue to the difficulty of reducing and holding multiplesmall fragments simultaneously.

The technical difficulties achieving endoscopicreduction and fixation of comminuted frontal sinusfractures have spawned recommendations for camou-flage rather than reduction and fixation. These camou-flage procedures are best done after the wound hashealed and the frontal sinus is no longer in continuitywith the subperiosteal space. After a few months ofhealing, a subperiosteal endoscopic dissection is usedto expose the fracture. The defect is then camouflagedwith hydroxyapatite cement,29 porous polyethylene cus-tom implants, or 0.85-mm porous polyethylene sheets35

inserted endoscopically.If hydroxyapatite cement is used, it is injected

through a small tube into the defect and contoured toappropriate shape (Fig. 6). Some have found that placing athin plastic membrane over the cement as it is hardening

Figure 2 The threaded fragment manipulator is introduced

and secured to the depressed anterior table fragment prior to

reduction.

Figure 3 The threaded fragment manipulator has pulled

the fragment into reduction. A plate is being secured with

self-drilling screw.

Figure 4 As the threaded fragment manipulator is pulled

outward (blue arrow), the depressed anterior wall segments

of the frontal sinus go through a compression (red arrow)

before achieving reduction. The force required can be con-

siderable.

80 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

makes it easier to contour the cement without fragmen-tation.

Porous polyethylene implants may be insertedendoscopically to camouflage the defect. Experimentalwork in cadavers has shown that if the defect is not toolarge, using a porous (0.85 mm) polyethylene sheetsecured with several screws is just as effective as a customimplant in resorting forehead contour.35 In addition, thesheet is readily available, inexpensive, and easy to insertthrough a small incision.

ORBITEndoscopy has been used for orbital decompression inGraves disease,36–41 transantral diagnosis of orbital frac-

tures,68,71 and assistance in locating the posterior edge inopen orbital floor repair.66 Endoscopic approaches forrepair of orbital fractures include transnasal approachwith balloon catheter stabilization,46 transconjunctivalmedial approach for medial blowout fractures,42,43,55,59

transnasal approach for medial blowout fractures,54,60,65

and transantral repair of orbital floor fractures withbone,63,70 titanium mesh,64 and porous polyethylenesheets49,50,56,64,69; endoscopic approaches can also beused for balloon stabilization52,58 and placement ofresorbable plates.61

The most accepted endoscopic approach is thetransantral approach via an upper sulcus incision andmaxillary antrostomy. Most authors agree that the bestcandidates for this procedure are those with trapdoorfractures or blowout fractures located between theinfraorbital nerve and the medial wall of the orbit.Large orbit fractures require careful restoration of orbitshape and volume that is simply not possible with thistechnique.

The approach involves an upper buccal sulcusincision and subperiosteal dissection to expose the maxillaand inferior orbital nerve. A maxillary antrostomy meas-uring about 2� 1 cm is made just below the nerve andabove the canine tooth root. A small cutout on theinferior aspect of the antrostomy forms a stable restingspot for the endoscope (Fig. 7). The endoscope is insertedinto the sinus and directed up toward the orbital floor(Fig. 8). Oxymetolazine-soaked pledgets will decreasebleeding and improve visualization. A Freerer-typeelevator is used to strip the mucosa from the margins ofthe defect and free the orbital contents from the fracturemargins. Loose, unstable bone should be removed. Oncethe entire defect is visualized and stable bone is identified,the implant can be cut to size. In the author’s opinion, thebest material for repair of the defect is 0.85-mm-thickporous polyethylene. It is possible to use titanium mesh,

Figure 5 The frontal sinus fracture is reduced then fixed

with a miniplate.

Figure 6 Hydroxyapatite cement is placed into an anterior

table fracture and contoured. The cement was introduced

through a separate stab incision; however, it may also be

applied via the other access incisions.

Figure 7 A 2� 1-cm antrostomy is made below the inferior

alveolar nerve, avoiding the canine tooth root and pyriform

aperture. A notch is cut in the inferior aspect to accommo-

date the endoscope.


bone, or bioresporbable sheets; however, the flexibility ofthe polyethylene sheets makes the placement of theimplant much easier.

The implant is cut just slightly large than thedefect. This is often a trial and error process to get the

size just right. The implant is placed into the defect inmuch the same way an acoustic ceiling tile is placed bysliding one edge into the defect, sliding the implant toone side to allow the opposite side to lift over the edge,and then sliding the implant back to the middle (Fig. 9).

Figure 8 The endoscope is inserted into the maxillary sinus to view the roof of the sinus and the floor of the orbit. A porous

polyethylene sheet is inserted from the sinus to repair the orbital floor.

Figure 9 An orbital blowout fracture is repaired via a transantral approach. (A) The blowout fracture with orbital fat bulging into

the maxillary sinus. (B) The sinus after limited mucosal stripping from the periphery of the fracture, removal of loose bone, and

insertion of a piece of porous polyethylene. (C) The prosthetic material partially inserted into the defect. (D) The implant is fully in

place and the defect repaired. Note the limited mucosal stripping. The asterisk shows the location of the maxillary sinus ostia.


One must pay particular attention to the infraorbitalnerve and make sure the implant is not impinging uponit. A forced duction test is done to make sure there is noentrapment of orbital contents.

ZYGOMAEndoscopic approaches for zygomatic arch fractureshave received the least acceptance from the craniomax-illofacial community and will only be mentioned briefly.Kobayashi et al first described the endoscopic approachfor a fractured zygoma and reported success but difficultywith the fixation.77 Lee and colleagues advocated re-moving the comminuted segment of zygoma and attach-ing a miniplate ex vivo with subsequent reinsertion andfixation proximally and distally.47,48,78 Subsequently,other authors found that 25% of patients who had exvivo plating had resorption of the arch on long-termfollow-up.81 The author has had some success withprecontouring a plate and lagging the fractured archsegments up to the plate, thereby reducing the risk ofabsorption of the comminuted segment. The techniqueinvolves an incision superior to the ear and endoscopicdissection on top of the deep temporal fascia down to thearch. At this point, a precontoured plate may be intro-duced and the fractured arch segments lagged up to theplate. This can be accomplished with a right anglescrewdriver or a small stab incision for screw application.There are several reports of transient frontal nervepalsy with endoscopic zygomatic arch approaches.80

SUBCONDYLAR MANDIBLE FRACTURESFew aspects of mandible fracture management generatemore controversy than the management of condylarprocess fractures. Traditionally, the majority of thesefractures have been managed with closed techniques.Proponents of closed treatment point to a large body ofliterature that suggests that most patients do well after aperiod of maxillomandibular fixation (MMF) followedby physiotherapy and training elastics. Although accept-able outcomes have usually been achieved with closedtreatment, clinicians advocating open reduction arguethat the failure of MMF to restore anatomy leads tocondylar deformity, mandibular dysfunction, and facialasymmetry. Open approaches have been reserved forcertain specific circumstances,93,94 which many regardas too restrictive given modern techniques. Eager forbetter and more predictable outcomes, some have turnedto open reduction with ridged fixation, and recent workreveals comparable if not superior results with the openapproach.95–107

Proponents of endoscopic-assisted approaches tocondylar process fractures have strived to accomplishequivalent anatomic reduction and ridged fixation seenwith traditional open approaches while eliminating

much of the morbidity that concerns critics of opentreatment. When applied to favorable fractures, endo-scopic-assisted treatment combines the best of open andclosed treatments. In the final analysis, it seems clear thatwe should not ask ourselves ‘‘Should condylar processfractures be treated open or closed?’’ but rather ‘‘What isthe best treatment for this particular fracture?’’ basingour decision on the patient’s age, fracture geometry, andour patient’s informed preference.

In 1997, Honda et al reported on the use ofan endoscope to improve visualization for resection ofthe mandibular angle in cases of masseteric hypertro-phy.108 The following year, Lee and colleagues pio-neered the use of endoscopy to assist in the reductionand fixation of subcondylar fractures.84,109 Over thelast decade, a number of authors have used puretransoral, transoral with cheek trochar, or submandib-ular incisions for endoscopic reduction and internalfixation.85,86,88–90,110–117 In addition to fracture treat-ment, orthognathic applications for condylectomy,costochondral graft reconstruction, and mandibularvertical ramus osteotomy have been successfully per-formed.74,87,118 In addition, foreign bodies have alsobeen successfully removed from the condylar process119

and temporomandibular joint.120

Open approaches to condylar neck fractures havenot found broader application outside the traditionalindications set forth by Zide and Kent94 in 1983 becauseof technical demands of the open approach, external scar,fear of facial nerve injury, and the belief that a closedapproach was adequate. Most surgeons accept, on anintellectual level, that fracture reduction and rigid fix-ation with restoration of anatomy is a laudable goal if itcan be achieved without undue morbidity. For mostsurgeons, the risk and demands of an external approachhave not warranted its use for routine condylar neckfractures. The endoscopic approach described here hasthe potential to reduce morbidity by limiting scar,reducing the risk to the facial nerve, and eliminatingthe need for MMF, all the while embracing the acceptedadvantages of anatomic reduction and rigid fixation. Thereduced morbidity associated with endoscopic reductionmay well expand the indications for reduction and rigidfixation in the future.

Patients with condylar process fractures are se-lected for endoscopic-assisted reduction and fixationbased on age, location of fracture, degree of comminution,direction of proximal fragment displacement, dislocationof condylar head, concomitant medical or surgical illness,and—importantly—patient choice. Contraindications arelisted in Table 1. The guidelines put forth by Zide andKent in 198394 for open treatment of condylar fracturesform a starting point for surgical decision making; how-ever, their relative indications should be broadened in thecontext of current surgical technique and decreased mor-bidity when using an endoscopic approach.


AGEThere is a consensus of opinion that most fractures inchildren are best treated with MMF. This belief is notentirely founded on solid science, and some endoscopicenthusiasts have successfully used endoscopy to assist infracture reduction for severely displaced fractures with orwithout ridged fixation. Endoscopy can be used inselected cases if conditions would otherwise favor tradi-tional open approach.

LOCATION OF FRACTUREFractures within the joint capsule and those of thecondylar neck are not amenable to endoscopic repairbecause the proximal fragment will not afford sufficient

room to accommodate at least two screws of a 2.0 plate.Most subcondylar fractures will have enough length onthe proximal fragment distal to the joint capsule toaccommodate two or three screws (Fig. 10).

DEGREE OF COMMINUTIONHigh-energy comminuted fractures are a relative contra-indication for endoscopic repair and should not beattempted by the inexperienced endoscopic surgeon.During reduction, the anterior and posterior border ofthe fracture line is used as an anatomic landmark toassess accurate reduction. Comminuted fractures willoften have fracture fragments that involve the borderand thereby obscure the landmarks. Microcomminutionwill obscure the interdigitation of small irregularitiesalong the fracture line, which ordinarily assist in precisereduction. Unfortunately, the visual limitations of en-doscopy make reliable assessment of reduction decep-tively challenging in the face of comminution.

DIRECTION OF PROXIMAL FRAGMENTDISPLACEMENTFractures with lateral displacement of the proximalfragment are the most favorable for endoscopic repair.The proximal fragment is much easier to control whenabutting the lateral surface of the distal fragment, andreduction is achieved with medially directed pressure viaa cheek trochar. When the proximal fragment is located

Table 1 Contraindications for Endoscopic Reductionand Ridged Fixation of Mandibular Condyle Fractures

Absolute Relative

Intercondylar fractures Child <12 y old

Condylar neck fractures

without sufficient room

for two fixation screws

Comminuted fracture

Any patient with medical

illness or other serious

injury who may be harmed

by a longer surgical procedure

or extended general anesthesia

Medial override of the

proximal fragment

When a simpler

method is equally

effective

Figure 10 Three broad groups of condylar fractures are: intracapsular, involving the condylar head proximal to the insertion of

the joint capsule; neck just distal to the joint capsule at the thin and slightly constricted portion of the bone; and subcondylar,

which typically extends from the lowest point of the sigmoid notch obliquely toward the posterior border of the ascending

ramus. Those fracture within the shaded area may be approached with endoscopic assistance.


medially, it is difficult to control and is partially hiddenbehind the distal fragment (Fig. 11). The mechanicsrequired for control and reduction of these fracturesrequire some experience with the technique and shouldbe reserved for those with some endoscopic experience.

DISLOCATED CONDYLAR HEADFractures associated with nondislocated condylar headsare the most favorable for endoscopic repair. A dis-placed condylar head without true dislocation canusually be relocated easily into anatomic position;however, those fractures with dislocation of the con-dylar head are more challenging.

CONCOMITANT MEDICAL OR SURGICALILLNESSAny patient with medical illness or other serious injurythat may be harmed by a longer surgical procedure orextended general anesthetic should not undergo endo-scopic repair. Patients with even mild coagulopathiespresent difficulties from persistent bleeding that mayobscure the limited visual field.

PATIENT PREFERENCEWhen no absolute of relative contraindication exists forendoscopic repair, every patient has the right to choosetheir treatment after a discussion as to the risks, benefits,and alternatives. They need to understand that the dataregarding open versus closed treatment of condylarfractures are imperfect, but that in general functionaloutcomes are at least as good if not better with openapproaches. They should clearly understand the risks oftraditional open approaches including significant scar

(especially in dark-skinned individuals) and facial nerveinjury. They should also understand that endoscopy canoffer reduced morbidity and good outcomes but that nolong-term data are yet available.

SURGICAL TECHNIQUEThe operation begins with the application of arch barsand treatment of other associated mandible fractures.Precise reduction and fixation of the other fractures willrestore the dental arch and make reduction of thecondylar segment more straightforward. After the otherfractures have been addressed, MMF is released andreplaced with elastic MMF. Elastic MMF should betight enough to maintaining proper occlusal relation-ships but not so tight as to prevent distraction of thefracture when downward traction is applied to the angleof the mandible.

The intraoral incision site and the lateral aspect ofthe mandible and condylar region are injected with a1:200,000 epinephrine solution 10 minutes prior tomaking the incision. The surgeon stands on the ipsi-lateral side, and the assistant stands on the contralateralside (Fig. 12). The endoscope video monitor is located atthe head of the bed slightly toward the contralateralshoulder. A 2-cm intraoral incision along the anteriorborder of the ascending ramus is carried down toperiosteum with electrocautery (Fig. 13). The approachis much like that used for transoral vertical ramusosteotomy. A subperiosteal dissection is used to elevatethe masseteric attachments and liberate the pterygomas-seteric sling from the posterior and inferior ramus. Widesubperiosteal dissection allows for increased mobility ofthe soft tissue envelope and improved visualization byvirtue of a larger optical cavity. It is very important thatthe dissection be strictly subperiosteal to avoid bleeding

Figure 11 A three-dimensional and coronal computed tomography scans of a patient with bilateral subcondylar fractures. The

green arrow points to the right fracture, which has a medial override of the condylar fragment. The arrow also depicts the

direction of visualization and surgical approach highlighting the inherent difficulties in controlling the condylar fragment with

medial override. To simplify the approach to these fractures, the medial override fragment should be converted to a lateral

override by distracting the fracture and displacing the fragment laterally.


that will quickly obscure the endoscopic view. Hypo-tensive anesthesia will help to minimize bleeding; how-ever, if bleeding should occur from the retromandibularvein, it is best to pack a gauze into the wound, applyexternal pressure, and wait 5 to 10 minutes—the bleed-ing will usually stop.

A 4-mm 30-degree endoscope fitted with anendoscopic brow sheath (Stortz, Carver City, CA) isinserted into the optical cavity. With the endoscope inone hand and a periosteal elevator in the other, thesubperiosteal dissection is carried proximally. Theassistant may hold the endoscope while the surgeonuses the periosteal elevator and suction to continue thedissection proximally to reveal the condylar fragment.A common mistake is to inadvertently dissect under(or medial) to the proximal fragment. This occursbecause of a failure to appreciate the degree of lateraloverride and coronal plane angulation of the proximalfragment. Once the proximal fragment is identified,the subperiosteal dissection continues on the lateralsurface up to the joint capsule, or a sufficient distanceto place the fixation hardware. Once the fracture isexposed, a cheek trochar is passed through the cheekdirectly opposite the fracture at the posterior border ofthe mandible.

Appreciation of the position of the condylarfragment will shed light on maneuvers needed to reducethe fracture. Typically, the proximal fragment issituated with a lateral override and in a flexed posture.

At this point in the operation, pharmacological musclerelaxation will assist in the reduction by paralyzingthe lateral pterygoid and masseter muscles. The initialmaneuver to reduce the fracture should be distractionof the mandibular angle downward and medialpressure on the condyle with the cheek (Fig. 14). Thedownward traction on the angle can then be released.Frequently, interfragmentary friction will hold thefracture in reduction without pressure from the cheektrochar.

Fractures are stabilized with standard five- or six-hole 2.0 craniofacial zygoma dynamic compression plates(Synthes, Paoli, PA). This particular plate is thin andmalleable enough that in situ self-contouring is possible,yet it is strong enough that plate failures are rare. Theplate is affixed with at least two 6-mm screws on eitherside of the fracture. The plate is temporarily mounted ona plate delivery device with a hinge mechanism thatallows for precise positioning of the plate (Fig. 15).Others have simply delivered the plate into the woundon a long clamp or dangling from a suture. The plateshould be positioned with at least two holes on eitherside of the fracture along the posterior border of themandible.

Figure 12 Arrangement of the surgeon, assistant, and

endoscopic video monitor in relation to a fracture.

Figure 13 Endoscopic view of the initial incision and the

subsequent dissection of the optical cavity in a subperiosteal

plane to reveal the proximal condylar fragment. Note the

angulation of the proximal fragment.


Before completing fixation, a check of the reduc-tion should be done. The anterior and posterior borderof the fracture should be inspected for anatomic align-ment. In noncomminuted fractures, this is usuallystraightforward; however, a fracture with even slightcomminution will be difficult to assess. If reduction isnot acceptable, then one screw may be removed and thefragments repositioned. Once reduction has been con-firmed, the remaining screws are placed via the cheektrochar. If possible, a second plate should be placed.

Careful inspection of the anterior and posteriorborder of the fracture will confirm proper reduction(Fig. 16). Any comminution will make assessment ofthe reduction more difficult. If the condyle was dislo-cated preoperatively and there is any uncertainty aboutthe reduction, a cross-table intraoperative lateral ceph-alogram should be obtained. The elastic MMF isreleased and the fixation is inspected while openingand closing the mouth to confirm stable fixation.MMF is not needed postoperatively. The intraoral in-cision is closed with absorbable suture.

Lee et al84 published their initial series of 22fractures in 20 patients and reported 43-mm interincisaljaw opening after 8 weeks, with restoration of premorbidocclusion and radiographic evidence of anatomic reduc-tion in 21 of 22 fractures. Patients were pleased with theaesthetic restoration of their chin projection, jaw line,and the symmetric midline movement of the chin pointon jaw opening. Late radiographs showed stable fixation,good bone healing, and no condylar resorption. Otherreports have shown encouraging results with minimalmorbidity85,87,110,112,121,122; however, good prospectivedata are not yet available.

The author has collected data on 80 fractures in72 patients: 78 of 80 fractures had anatomic reduction,and two high-energy severely comminuted fractureswhere inadequately reduced and required a second endo-scopic procedure for reduction. Interincisal opening hasaveraged 42 mm after 8 weeks. The operative time has

Figure 14 The maneuvers needed for reduction are shown. (A) Initial configuration; (B) distraction of the fracture by a

downward pull on the mandibular angle and rotation of the proximal fragment out of a flexed posture; (C) final reduction after

release of downward pull on the angle. Often the fracture will be stable in this configuration by virtue of interfragmentary friction.

Figure 15 Plate delivery device. A five- or six-hole 2.0 plate

is attached with a locking screw to this delivery device, which

is hinged to allow for positioning of the plate. After the plate is

affixed to the mandible, the plate is released from the device

with a quarter turn of the locking screw.


been decreasing as experience is gained. The averageoperative time for simple noncomminuted fractures withlateral override is about 70 minutes. There was one lateplate fracture without functional detriment to the pa-tient. One transient frontal branch palsy was observed.All patients have been pleased with the cosmetic out-come.

CONCLUSIONThe application of endoscopic techniques in cranio-maxillofacial surgery has been substantially slowercompared with other specialties. It is hoped thatcontinued technical refinements in techniques, equip-ment, and case selection will allow the endoscopicapproach to give our patients the best possible treat-ment for their fractures. Many ingenious surgicalapproaches and procedures have been identified whereendoscopic assistance significantly facilitates a givenprocedure or decreases morbidity. In many cases, theendoscope is not only an aid; it significantly alters thetreatment philosophy. The future of endoscopic cra-niomaxillofacial surgery is bright. We await goodrandomized trials to confirm our gut feeling that wecan provide equivalent care with reduced morbidityand improved patient satisfaction with the aid of anendoscope.

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Figure 16 Before and after coronal computed tomography

scans of a patient with bilateral subcondylar fractures. The

right panels show the left fracture after reduction and after

fixation.


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Endoscopic Treatment of Facial Fractures

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