Open reduction of subcondylar fractures. A study of functional rehabilitation

Comparison of approaches for the rigid fixation of sub-condylar fractures

AIM

The objective of this study was to compare the rate of complications encountered on using different incisions to access the fracture site for the open reduction and internal fixation of isolated subcondylar fractures. The parameters evaluated are: the occurrence of salivary fistula, infection, and injuries to the seventh facial nerve. An assessment of the surgical scar was also undertaken.

MATERIALS AND METHODS

20 patients who met the previous criteria and were willing to participate in the study were placed (five each) into the pre-auricular, submandibular, retromandibular transparotid or retromandibular transmassetric group based on the incision scar they selected after a description of the operation and being explained about the possible complications.

RESULTS AND CONCLUSION

Comparison of the complications could not ascertain the superiority of any approach over the other since the outcomes were not statistically significant. However, judging by operator and assistants' subjective assessment, the retromandibular approaches seem to provide a more direct visual field and an almost straight line access for the fixation of the fracture. The transmassetric approach seems to be a safer approach since the nerves encountered can be visualized and avoided.

Management of mandibular sub condylar and condylar fractures using retromandibular approach and assessment of associated surgical complications

PURPOSE

To evaluate surgical complications associated with open reduction and internal fixation of condylar fractures using retromandibular approach in terms of intraoperative and postoperative complications.

METHOD

Ten patients with displaced unilateral/bilateral condylar fractures were selected for the study. Intraoperative complications were evaluated in the form of haemorrhage due to damage to retromandibular vein and damage to marginal mandibular branch of facial nerve. Postoperative complications like presence of infection, signs of Frey's syndrome, parotid fistula formation, facial nerve palsy, and discrepancy in occlusion and functions of temporomandibular joint were evaluated at intervals of 24 h, one week, six weeks and three months postoperative. Radiographically, the approximation of fracture fragments, plate fracture and screw loosening on orthopantomograph and Reverse Towne's view were evaluated at intervals of 24 h, six weeks and three months postoperatively.

RESULTS

None of the patients suffered from any major complication intra and post operatively.

CONCLUSION

Open reduction and internal fixation should be given due consideration in the management of displaced mandibular condylar fractures and is associated with minimal morbidity using retromandibular approach.

Reappraisal of the surgical strategy in treatment of mandibular condylar fractures

BACKGROUND

Over the past few decades, there has been a trend toward open reduction and internal fixation of mandibular condylar fractures. However, not all patients have fared well following the open surgical approach. A number of clinical parameters have been observed to be related to suboptimal treatment results on a long-term basis. A comprehensive investigation of the role of those risk factors is a worthwhile pursuit.

METHODS

A total of 23 surgically treated patients were enrolled in the study during an 11-year period. A retrospective chart review was conducted to collect clinical and radiographic information both before and after surgery. Statistical analyses were used to determine the relationship of presurgical clinical variables to the postsurgical complications.

RESULTS

Fractures of the condylar neck and head were associated with a high incidence of postoperative morbidity; all cases (seven of seven) suffered from some form of image or clinical disorder. In contrast, the subcondylar fracture fared well following surgery, with maintenance of function, cosmesis, and skeletal integrity in the majority (14 of 16) over long-term follow-up (p < 0.000). Comminution and obliquity of the fracture line were also correlated with the occurrence of postoperative morbidities.

CONCLUSIONS

Results of the present study suggest that patients with subcondylar fracture fare better with open reduction in comparison with those suffering condylar neck or head fractures. Delayed-onset deformation tends to occur in patients with a short proximal segment, comminuted head, and obliquity of the fracture line. A renewed algorithm is thus provided to address the high condylar fracture problems.

Application of modified retromandibular approach indirectly from the anterior edge of the parotid gland in the surgical treatment of condylar fracture

PURPOSE

To introduce a new surgical approach for open reduction and internal fixation of condylar fracture.

PATIENTS AND METHODS

In this study, 36 patients with condylar fractures (51 sides) and those of the mandibular ramus and coronoid process were treated using a modified retromandibular approach indirectly from the anterior edge of the parotid gland. The degree and type of mouth opening, occlusal relationship, facial nerve function, and other complications in the patients were assessed and evaluated.

RESULTS

During the follow-up conducted over 12 to 24 months, x-ray examinations revealed good fracture healing. The occlusal relationship and degree and type of mouth opening improved significantly over those before operation. During the final follow-up at 24 months, no case of ankylosis and/or salivary fistula was observed. Major complications at 1 week postoperation included temporary injury to the facial nerve branches in 4 cases; this condition improved after 1 to 3 months.

CONCLUSIONS

Open reduction and internal fixation of condylar fracture by using the modified retromandibular approach indirectly from the anterior edge of the parotid gland has many advantages. Compared with the traditional surgical incision, this method is simple and short, and the completely exposed operative field facilitates reduction and fixation. Compared with transparotid approaches, it substantially reduces the risk to the facial nerve. At the same time, this method is not only suitable for the surgical treatment of condylar fractures but also for those of the mandibular ramus and coronoid process.

Endoscopic management of facial fractures

PURPOSE OF REVIEW

Endoscopic applications in otolaryngology continue to expand, most recently in the area of maxillofacial trauma. Endoscopic management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures has been described. This paper reviews the current literature including new techniques, indications, and outcomes in endoscopic management of facial fractures.

RECENT FINDINGS

Very few large studies of endoscopic fracture repair exist. The current literature, however, suggests that, when compared with an open approach, smaller endoscopic incisions result in reduced patient morbidity with similar outcomes. Dedicated endoscopic instrumentation and novel surgical approaches continue to be developed.

SUMMARY

Endoscopic repair of facial fractures is a new and evolving technique that offers the potential for reduced patient morbidity and operating time, as well as quicker patient recovery. Current applications include the management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures. It should be emphasized that endoscopy augments, rather than replaces, the 'time tested' principles of adequate skeletal exposure, accurate fracture reduction, and appropriate internal fixation.

Preliminary functional results of endoscope-assisted transoral treatment of displaced bilateral condylar mandible fractures

Temporomandibular joint (TMJ) function was evaluated following endoscope-assisted transoral open reduction and miniplate fixation of displaced bilateral condylar mandibular fractures. The transoral treatment of bilateral condylar fractures was performed in 13 patients from May 2000 to December 2004. Eleven of the 13 patients had additional mandibular fractures. Out of 26 fractures of the condylar process, 11 were located at the condylar neck and 15 were subcondylar. One, 6 and 12 months after surgery TMJ function was evaluated. Anatomic reduction was achieved using an endoscope-assisted transoral approach even when the condylar fragment was displaced medially and in fractures with comminution. Good TMJ function was noted 6 and 12 months after surgery. Mouth opening was measured to be more than 40 mm without deviation. Postoperative range of motion with a satisfying lateral excursion was found. Early rehabilitation and pre-injury TMJ function was achieved following minimally invasive anatomic fracture reduction.

Long-Term Outcomes After Treatment of Condylar Fracture by Intraoral Access: A Functional and Radiologic Assessment

PURPOSE

The aim of the present study was to investigate radiographic and functional long-term results after condylar fractures have been reduced by an exclusively intraoral surgical approach.

PATIENTS AND METHODS

A total of 25 (21 male, 4 female) consecutive patients with 30 condylar process fractures were retrospectively investigated. Clinical follow-up was performed in 19 patients (16 male, 3 female) with a total of 24 fractures. Median postoperative follow-up time was 19.7 months. Surgical indications followed specific parameters of fracture localization, dislocation, and ramus shortening. All patients were examined in accordance with the Research Diagnostic Criteria for Temporomandibular Dysfunction (RDC/TMD) and the Helkimo Index. Orthopantomograms (OPGs) were analyzed with use of the condylar morphologic scale (CMS), and mandibular ramus position and height were measured.

RESULTS

Fractures were classified as condylar neck (n = 2) and basis fractures (n = 28), according to criteria of the Strasbourg Osteosynthesis Research Group (SORG). Mean age of patients was 33 years (standard deviation [SD], 13 yr). RDC/TMD measurements at follow-up showed a mean mouth opening of 48 mm (SD, 9), mandibular laterotrusion right of 11 mm (SD, 3.8), laterotrusion left of 10 mm (SD, 4.5), and protrusion with a mean of 5.83 mm (SD, 3). No joint clicking, weakness of the facial nerve, or joint or muscular pain was observed. Statistical analysis of the CMS showed significantly better postoperative ramus height (P < .05).

CONCLUSION

Reduction achieved by this technique allows reconstruction of anatomic ramus height in combination with excellent functional results.

Traitement chirurgical des fractures du condyle mandibulaire de l'adulte en France en 2005

INTRODUCTION

The authors had for aim to present the latest trends in the surgical management of mandibular condylar fractures in France, in 2005.

MATERIAL AND METHODS

One hundred maxillofacial surgeons were questioned on the surgical management of condylar fractures and indications. Results were presented at the 41st Congress of Stomatology and Maxillofacial surgery.

RESULTS

The overall reply rate was 70%. Condylar fractures are generally managed in teaching hospitals. Open reduction and fixation was deemed appropriate in low subcondylar fractures in 76% of the cases, in 10% for diacapitular fractures. Therapeutic details and indications were a matter of huge variability.

DISCUSSION

This survey highlighted the absence of any consensus as far as condylar fractures are concerned. It seems that the higher the fractures are, the lesser they are approached.

Open reduction and rigid internal fixation of mandibular condylar fractures by an intraoral approach: a long-term follow-up study of 15 patients

PURPOSE

To evaluate the long-term results obtained with open reduction and rigid internal fixation of mandibular condylar fractures by an intraoral approach.

PATIENTS AND METHODS

Fifteen patients with 24 mandibular condylar fractures were retrospectively examined with an average follow-up of 23 months (range, 6-63 months). Clinical and radiographic examination was conducted according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), including an evaluation of maximum voluntary bite force measurements and facial nerve function. Statistical analysis was performed on maximum voluntary bite force measurements and maximum pressure pain threshold.

RESULTS

Two patients fulfilled the criteria for a RDC/TMD diagnosis. Myofacial pain (group I) and bilateral arthralgia (group III), combined with a moderate nonspecific physical symptom score, was diagnosed in 1 patient and 1 patient received a diagnosis of disc displacement with reduction (group II). Satisfying radiographic fracture healing was seen in 12 joints. However, miniplate fracture occurred in 3 patients and severe bone resorption of the condylar head was seen in one patient. Minor adjustment of the postoperative occlusion was necessary in 6 patients. No significant difference between maximum voluntary isometric bite force measurements or maximum pressure pain threshold was found between the fracture side and the opposite side in unilateral cases or between the operated and nonoperated side in bilateral cases. None of the patients showed facial nerve injury or visible facial scars.

CONCLUSION

Within the limitations of a retrospective study, the present study emphasized that optimal management of dislocated bilateral condylar injuries combined with other fractures of the facial skeleton constitute a challenging issue in maxillofacial trauma. Moreover, open reduction and rigid internal fixation of mandibular condylar fractures by an intraoral approach is a technically demanding surgical procedure associated with a high risk of postoperative complications in these injuries.

Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy

Traditional treatment of subcondylar fractures with maxillomandibular fixation often results in a malreduction and significant functional and aesthetic sequelae, including facial asymmetry, decreased jaw opening, and potential for late derangements of the temporomandibular joint. When used selectively, based on preoperative CT scans, the endoscopic technique will reliably restore condylar anatomy in nearly 95% of patients, thus obviating the consequences of malunion. Furthermore, unlike traditional open techniques no significant facial scarring or permanent facial nerve palsies have resulted. Thus, the authors strongly advocate endoscopic repair of adult condylar neck and subcondylar fractures that demonstrate displacement or dislocation and have adequate proximal bone stock to accept miniplate fixation.

Condylar Motion After Open and Closed Treatment of Mandibular Condylar Fractures

PURPOSE

A comparative study was performed to evaluate the function of the temporomandibular system after open and closed treatment of condylar fractures.

MATERIALS AND METHODS

A total of 37 temporomandibular joints were examined that had undergone either open treatment (n = 24) or closed treatment with maxillomandibular fixation (n = 13) for condylar fracture. The joints were investigated clinically and on the basis of radiographs. In addition, the movements of the condyles of the temporomandibular system were recorded in 3 dimensions with a computed electronic jaw tracking system (stereognathograph).

RESULTS

The clinical investigation revealed no severe functional abnormality in either of the 2 groups. The mean of the recorded condyle paths was, however, consistently lower in the temporomandibular joints with closed treatment than in those with open treatment, although the difference was only significant for movements without tooth contact (Mann-Whitney U test, P < .05).

CONCLUSIONS

In summary, open as well as closed treatment gave clinically acceptable functional results. However, condylar mobility was markedly greater after open treatment than after closed treatment.

Five-Year Experience with the Transoral Endoscopically Assisted Treatment of Displaced Condylar Mandible Fractures

BACKGROUND

From April of 1998 to May of 2003, the minimally invasive transoral approach for endoscopically assisted reduction and osteosynthesis of 62 displaced condylar mandible fractures was performed in 58 patients.

METHODS

By means of limited transoral incision, the endoscopically assisted reduction and fixation of condylar fractures was performed using 30- and 45-degree angled endoscopes. Twenty-five fractures were condylar and 37 were subcondylar. The condylar neck of the proximal fragment was displaced medially in 17 fractures and laterally in 45 fractures. Four patients presented bilateral condylar mandible fractures. Using angled endoscopes, good visibility of the fracture site was obtained, which allowed for precise anatomical reduction in all patients. An angulated drill and screwdriver facilitated miniplate fixation by means of the transoral approach. The mean operating time was measured in the last 30 consecutive cases: 1 hour 5 minutes.

RESULTS

Postoperatively, all patients showed quick recovery to preinjury occlusion. Normal temporomandibular joint function was noted 6 months after surgery in all patients.

CONCLUSIONS

The transoral endoscopically assisted treatment using an angulated drill and screwdriver is the method of choice for surgical management of displaced condylar fractures, even in fractures with medial override. Facial nerve injury and visible scars are avoided by using the transoral approach.

Der transparotideale Zugang zur operativen Versorgung von Collumfrakturen

AIM

Different surgical approaches for the open treatment of mandibular condylar fractures are described in the literature. We evaluated the morbidity of the transparotidean approach in a prospective study over 5 1/2 years.

PATIENTS AND METHODS

A total of 48 patients with 52 condylar neck fractures class II and IV according to the Spiessl and Schroll classification were treated by a transparotidean approach. Rigid internal fixation was performed by means of miniplate fixation. After surgery, no mandibulomaxillary fixation was performed. The occurrence of surgical and functional complications was documented both during hospitalization and 1, 3, 6 and >9 months after surgery.

RESULTS

In none of our patients were major problems in wound healing such as infection of the fracture site observed. At the beginning of the study, in four cases a fistula of the parotid gland was seen within the initial days after surgery; after careful wound closure of the parotid capsula in the following operations, no further complications involving fistulas were observed. Signs of temporary palsy of the facial nerve caused by the hooks occurred in ten (19.6%) of all patients but was completely reversible within the first 6 months after the procedure. One patient suffered temporarily from a minimal malocclusion and two patients from symptoms of the temporomandibular joint 6 months postoperatively. In three patients we observed miniplate fractures without consecutive dysfunction of the TMJ or malocclusion.

CONCLUSION

Open reduction and rigid internal fixation of condylar neck fractures by transparotidean approach is a recommendable procedure in class II and IV fractures. With the advantages of minimal tissue alteration and rare complications on the one hand and sufficient exposure of the fracture site on the other hand, this technique has been established as a standard procedure in treating condylar neck fractures by open reduction.

Treatment of mandibular condylar process fractures: Biological considerations

The topic of condylar injury in adults has generated more discussion and controversy than any other in the field of maxillofacial trauma. It is an important subject because such injuries are common and complications of trauma to the temporomandibular joint (TMJ) are far-reaching in their effects. Why are there so many different methods to treat this injury? How can seemingly disparate treatment options all produce satisfactory outcomes in the majority of patients? The reason lies with the biological adaptations that occur within the masticatory system that are poorly understood, not readily quantifiable, and variable from one person to the next. This discussion presents our current understanding of the adaptations that must occur to provide the patient with a satisfactory outcome. The adaptations for patients treated open are different than for those treated closed. However, it is when these adaptations fail to occur that unsatisfactory outcomes occur, regardless of how they were treated.

Retromandibular approach to the mandibular condyle: a clinical and cadaveric study

This prospective study was carried out to assess the morbidity of the retromandibular approach in the management of condylar fractures. Twenty consecutive patients underwent open reduction and internal fixation of their condylar fractures using this technique. Branches of the facial nerve were encountered in six cases (30%). Temporary weakness of the facial nerve occurred in six patients (30%), but this resolved in all cases within 3 months and there were no cases of permanent nerve injury. Two patients had a temporary deficit of the great auricular nerve and one patient developed a sialocoele that resolved with aspiration. A cadaveric study using 30 facial halves (15 fresh cadavers) was also conducted. Branches of the facial nerve were encountered in 12 dissections (40%). The literature regarding facial nerve morbidity in relation to the management of condylar fractures is reviewed.

Follow-up of condylar fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment

PURPOSE

The results of endoscopic-assisted transoral approach for open reduction and miniplate fixation of condylar mandible fractures were evaluated 18 months after surgery.

PATIENTS AND METHODS

The transoral endoscopic-assisted treatment of condylar fractures was performed in 8 consecutive patients from April 1998 to December 1999 at the University Hospital Freiburg. Four of 8 condylar fractures were dislocated, and 6 of the 8 patients had additional mandibular fractures.

RESULTS

Anatomic reduction was achieved in all patients without facial nerve damage. There were no signs of bony resorption and good temporomandibular joint function 18 months after surgery. In 4 patients, the transoral management of condylar fractures was facilitated by angulated drills and screw drivers. Transbuccal stab incisions were not needed in these 4 patients. In all 8 patients, visible scars were avoided.

CONCLUSIONS

The endoscopic-assisted transoral approach proved to be a reliable surgical method for condylar fractures when dislocation with lateral override was present.

Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs intraoral approach

By using an endoscopy assisted extraoral and transoral approach for open reduction of condylar mandible fractures with limited incisions, the risk of facial nerve damage and extensive visible scars can be reduced. The endoscopy-assisted treatment of 17 consecutive patients with fractures of the condyle was performed from April 1998 to December 1999. Of the 17 patients, 13 presented with additional mandibular fractures. Nine of the 17 patients were treated by a submandibular approach and eight by a transoral approach. Adequate anatomic reduction was achieved by the submandibular and transoral approach using an endoscopy-assisted technique. The transoral approach proved to be a reliable surgical approach for fractures of the mandibular condyle, even when dislocation with lateral override was present. In four patients, angulated drills and screwdrivers facilitated the transoral treatment of condylar fractures. Transbuccal stab incisions and the use of trochars were not needed in these four patients. The extraoral approach was indicated for severely dislocated fractures such as fractures with medial override or comminution.

A biomechanical evaluation of mandibular condyle fracture plating techniques

OBJECTIVES

The purpose of this investigation was to evaluate the biomechanical behavior of various rigid internal fixation techniques for mandibular condylar process fractures.

MATERIALS AND METHODS

Synthetic mandible replicas (Synbone, Landquart, Switzerland) were used to evaluate a control, and four monocortical mandibular condyle plating techniques. Each group was subjected to linear loading in lateral to medial, medial to lateral and posterior to anterior directions by an Instron 1331 (Instron, Canton, MA) servohydraulic mechanical testing unit. Yield load, yield displacement, and stiffness were measured. In addition, each group was subjected to torsional loading using an Instron 8521 (Instron). Yield torque, yield rotation, and stiffness were measured. Five samples were tested for each group and method of loading (n = 100). Means and standard deviations were derived and compared for statistical significance using a 1-way analysis variance (P <.05). Third-order polynomial best-fit curves were also created for each group to further evaluate and compare the mechanical behavior.

RESULTS

Statistically significant differences were noted between fixation groups for the different mechanical measures evaluated under the different conditions of linear loading. Statistically significant differences were noted between groups for yield rotation during torsional loading. Although different in magnitude, similar patterns of mechanical behavior were observed in the third-order polynomial best-fit curves for lateral to medial loading, medial to lateral loading and torsional loading. For posterior to anterior loading, different patterns of mechanical behavior were noted between the experimental groups, but similar behavior was noted between the control and mini dynamic compression plate

CONCLUSIONS

While differences were noted between each of the fixation systems in their abilities to resist loads under the conditions tested, the mini dynamic compression plate provided the most favorable mechanical behavior. Based on the presumed clinical parameters, we can suggest that none of the systems evaluated were ideal for the treatment of mandibular condyle fractures, but that the mini dynamic compression plate is the closest to an effective means for reconstruction.

A comparison of open and closed treatment of condylar fractures: a change in philosophy

A comparison between two samples of patients with condylar fractures is reported: the first treated non-surgically and the second with open reduction and rigid internal fixation. The functional results for both groups were similar. However, open reduction gave better occlusal results, anatomic restoration and faster recovery rates than non-surgical techniques.

Fractures of the mandibular condyle. Part 2: results of treatment of 348 patients

This study was designed to record the results of conservative treatment of condylar fractures and to find out if there were any variables that were predictive of complications. Data were analysed in our computer department. During the period 1984-1996, all patients who presented with a fracture of the mandibular condyle and who attended for control examination one year after treatment were recorded at the end of treatment and one year later. The ability to open the mouth, deviation and occlusion were recorded. After one year 45 of the 348 patients (13%) had minor physical complaints such as reduced ability to open the mouth, deviation, or dysfunction. Ten of them (3%) had pain in the joint or muscles or both. Eight patients (2%) had malocclusion, which in seven could be related to dislocation of the condylar head out of the fossa. Five of the eight patients had had bilateral fractures. We conclude that conservative treatment of condylar fractures is non-traumatic, safe, and reliable and in only a few cases may cause disturbances of function and malocclusion. The risk associated with the latter is greatest with bilateral fractures and dislocation of the condylar head from the fossa.

Surgical complications with open treatment of mandibular condylar process fractures

PURPOSE

This study assessed the surgical complications after open treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

A total of 178 patients with unilateral fractures of the mandibular condylar process, 85 treated closed and 93 treated open, were included in this study. A tabulation of surgical findings and intraoperative and postoperative complications was prospectively performed. Standardized animating facial photographs were obtained at several postsurgical intervals and were examined and scored by a prosthodontist and an orthodontist for signs of facial nerve palsy and the quality of the surgical scar. Standard statistical methods were used to assess differences between open and closed treatment groups.

RESULTS

There were very few intraoperative or postoperative complications. At the 6-week point, 17.2% of patients treated open had some weakness of their facial nerve. This had resolved by 6 months. The scars were judged either wide or hypertrophic in 7.5% of cases.

CONCLUSIONS

Based on this study, surgical complications of open treatment of condylar process fractures that lead to permanent dysfunction or deformity are uncommon.

Facial symmetry after closed and open treatment of fractures of the mandibular condylar process

PURPOSE

This study compares vertical measures of mandibular and facial morphology after open or closed treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

One hundred forty-six patients (121 male, 25 female), 81 treated by closed and 65 by open methods, were included in this study. Towne's and panoramic radiographs, taken at several intervals, were used to quantify the displacement of the condylar process fractures. Posteroanterior cephalograms taken at 6 weeks, 6 months, 1 year, and 2 to 3 years after treatment were used to assess posterior facial height and bigonial and occlusal plane angles. Additionally, panoramic radiographs were used to assess ramus height at the same periods. Standard statistical methods were used to assess differences between groups.

RESULTS

Patients whose condylar process fractures were treated by closed methods had significantly shorter posterior facial and ramus heights on the side of injury, and more tilting of the occlusal and bigonial planes toward the fractured side, than patients whose fractures were treated by open methods. Most of the asymmetry in patients treated by closed methods was present by 6 weeks after injury.

CONCLUSIONS

Patients treated by closed methods develop asymmetries characterized by shortening of the face on the side of injury. It is likely that loss of posterior facial height on the side of fracture in these patients is an adaptation that helps reestablish a new temporomandibular articulation.

Occlusal results after open or closed treatment of fractures of the mandibular condylar process

PURPOSE

This study compared the occlusal relationships after open or closed treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

A total of 137 patients with unilateral fractures of the mandibular condylar process (neck or subcondylar), 77 treated closed and 65 treated open, were included in this study. Standardized occlusal photographs obtained at several postsurgical time intervals were examined and scored by a surgeon and an orthodontist. Standard statistical methods were used to assess differences between groups.

RESULTS

Patients treated by closed techniques had a significantly greater percentage of malocclusion compared with patients treated by open reduction, in spite of the fact that the initial displacement of the fractures was greater in patients treated by open reduction.

CONCLUSIONS

Based on this study, more consistent occlusal results can be expected when fractures of the mandibular condylar process are treated by open reduction.

Further displacement of condylar process fractures after closed treatment

PURPOSE

This study examined the changes in the position of the fractured condylar process immediately before and immediately after application of arch bars and at 6 weeks after surgery in a group of patients who underwent closed treatment.

PATIENTS AND METHODS

Sixty-five patients over the age of 16 years underwent closed treatment of unilateral mandibular condylar process fractures. Coronal and sagittal displacement of the condylar process was examined using Towne's and panoramic radiographs before treatment, immediately after placement of arch bars, and at 6 weeks. The change in position of the condylar process from one time to the next was analyzed statistically.

RESULTS

There was a statistically significant difference (mean, -5.5 degrees) in the coronal position of the condylar processes from immediately after injury to immediately after placement of arch bars. There was great variability, with some segments becoming more medially displaced and some more laterally displaced. In contrast, mean change in the sagittal position of the condylar process was not statistically significant, although some became more anteriorly and others became more posteriorly displaced. Similarly, from immediately after placement of arch bars to 6 weeks, there was great variability in position of the condylar process, but the overall change was not statistically significant.

CONCLUSIONS

The results of this study showed that position of the condylar process is not static in patients treated for condylar process fractures by closed means. These results suggest that care must be taken in basing treatment decisions on the degree of displacement or dislocation of the condylar process in presurgical radiographs.

Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures

PURPOSE

This study compared mandibular and condylar mobility after open or closed treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

One hundred thirty-six patients (111 male, 25 female), 74 treated by closed and 62 by open methods, were included in this study. They underwent testing of mandibular and condyle mobility at 6 weeks, 6 months, and 1, 2, and 3 years postsurgery. A jaw-tracking device was used to assess mandibular motion. Radiographs that were traced and digitized were used to assess condylar displacement and condylar mobility. Standard statistical methods were used to assess differences between groups.

RESULTS

Patients treated by open reduction had significantly greater initial displacement of their condylar processes than did the group treated closed. Immediately after treatment and uprighting of the condyles in the open treatment group, patients treated closed had significantly more displacement. At 6 weeks, patients treated closed had some measures of mandibular mobility that were significantly greater than those in patients treated by open reduction. However, after the 6-week period there were minimal differences in mandibular mobility between groups. At 6 weeks, patients treated by open reduction had significantly greater vertical mobility of the condyle than patients treated closed despite less mouth opening. After the 6-week period, patients treated by open reduction continued to have greater condylar mobility on the fractured side than did patients treated by closed methods. No measures of postsurgical displacement correlated with mobility measures in patients treated by open reduction. However, several measures of mandibular displacement correlated with measures of mobility in patients treated closed, indicating that the more displaced the condylar process, the more limited the mobility of the mandible.

CONCLUSIONS

Based on this study, patients treated for fractures of the mandibular condylar process by open reduction had somewhat greater condylar mobility than patients treated closed, even though the former group had more severely displaced fractures before surgery. Therefore, open reduction may produce functional benefits to patients with severely displaced condylar process fractures.

Endoscopically assisted mandibular subcondylar fracture repair

The endoscope has been widely used in aesthetic surgery in recent years, but rarely has it been used in cases of facial trauma. From July of 1996 to December of 1996, the endoscope was used successfully to assist in the repair of mandibular subcondylar fractures in eight patients (five men and three women). Their ages ranged from 15 to 60 years with an average age of 31 years. Six of the patients had other associated mandibular fractures including angular, parasymphyseal, and contralateral subcondylar fractures. A 4.0-mm, 30-degree telescope was introduced to visualize the fracture site by means of an intraoral incision over the ascending ramus. A miniplate was used to stabilize the fracture site with the help of a percutaneous trocar. Intermaxillary fixation was applied for 3 to 6 days. Functionally, all patients returned to normal range of motion within 8 weeks. A slight deviation to the trauma site was noted on maximal opening in three patients, but this condition returned to normal 3 months after surgery. There was no facial palsy or lip numbness. The benefits of the endoscopic approach include not only the provision of better visualization and precise anatomic alignment of bony segments but also the avoidance of large facial scars and facial nerve injuries.

Open reduction without fixation of dislocated condylar process fractures: long-term clinical and radiologic analysis

PURPOSE

This study evaluates the long-term results of open reduction without fixation for displaced fractures of the condylar process.

PATIENTS AND METHODS

Clinical and radiologic examinations were performed on 27 patients with 29 operated joints an average of 6.7 years postoperatively. The postoperative result was evaluated on the basis of occlusal and joint function, as well as radiographic assessment of condylar changes.

RESULTS

Clinically, satisfactory results were achieved. Radiologically, despite correct intraoperative alignment of the fractured segments, a slight medial deviation of the condylar process was found on the posteroanterior radiograph. However, in only two cases was a 20-degree deviation observed. On final follow-up, 48% of the cases had a normal condylar configuration radiologically, and in the remaining cases, normal function was established even though there were condylar changes. Fully exposed and devascularized condylar processes generally showed more severe changes than those in which partial vascularization was maintained.

CONCLUSION

The surgical management described enables a satisfactory outcome to be achieved with dislocated condylar process fractures.

A multicentre audit of unilateral fractures of the mandibular condyle

OBJECTIVE

To audit a series of isolated unilateral fractures of the mandibular condyle treated in a number of units in the United Kingdom.

DESIGN

Prospective confidential multicentre audit with review by a single external examiner between July 1993 and January 1994.

SETTING

Nine Maxillofacial units. Pro-formas were alphanumerically coded. Units are referred to by code letter.

SUBJECTS

142 patients with fractures of the mandibular condyle.

MAIN OUTCOME MEASURES

Pain, crepitus, interincisal opening, mandibular deviation on movement, occlusion and posteroanterior and lateral radiographic analysis by a single examiner.

RESULTS

Of the 142 patients, 135 over the age of 12 years had unilateral condylar fractures. Seventy-three attended appointments at both 6 and 12 weeks. Forty-one had identifiable symptoms attributable to the injury at 12 weeks, and most of these had fracture displacements or dislocations which had not been openly reduced. There was a 50-85% positive correlation between radiographic findings of the first clinician and the external auditor. Open reduction and internal fixation was uncommon.

CONCLUSIONS

Follow-up studies of trauma patients are difficult because of poor attendance. Fractures of the mandibular condyle should be treated by specialists in the management of facial fractures. Accurate clinical and radiographic diagnosis is more difficult than commonly supposed. Fracture displacements and dislocations have a suboptimal outcome in nearly 30% of cases. More should be spent to improve care of these patients. A consensus on objective indicators of satisfactory outcome is needed to establish a 'gold standard' and close the audit loop.