Condylar fractures: surgical management

Absorbance or organization into ankylosis: a microarray analysis of haemarthrosis in a sheep model of temporomandibular joint trauma

Background

Traumatic haemarthrosis was hypothesized to be the etiology of temporomandibular (TMJ) ankylosis. Here, taking haematoma absorbance as a control, we aimed to reveal the molecular mechanisms involved in haematoma organizing into ankylosis using transcriptome microarray profiles.

Material/methods

Disk removal was performed to building haematoma absorbance (HA) in one side of TMJ, while removal of disk and articular fibrous layers was performed to induced TMJ ankylosis through haematoma organization (HO) in the contralateral side in a sheep model. Haematoma tissues harvested at days 1, 4 and 7 postoperatively were examined by histology, and analyzed by Affymetrix OviGene-1_0-ST microarrays. The DAVID were recruited to perform the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis for the different expression genes (DEGs). The DEGs were also typed into protein–protein interaction (PPI) networks to get the interaction data. Six significant genes screened from PPI analysis, were confirmed by real-time PCR.

Results

We found 268, 223 and 17 DEGs at least twofold at days 1, 4 and 7, respectively. At day 1, genes promoting collagen ossification (POSTN, BGN, LUM, SPARC), cell proliferation (TGF-β), and osteogenic differentiation of mesenchymal stem cells (BMP-2) were up-regulated in the HO side. At day 4, several genes involved in angiogenesis (KDR, FIT1, TEK) shower higher expression in the HO side. While HA was characterized by a continuous immune and inflammatory reaction.

Conclusions

Our results provide a comprehensive understanding of the role of haematoma in the onset and progress of TMJ ankylosis. The study will contribute to explaining why few injured TMJs ankylose and most do not from the molecular level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-02033-w.

The Role of a Deep Neuromuscular Block in the Treatment of Mandibular Subcondylar Fractures

ABSTRACT

Mandibular fractures are the third most frequents maxillo-facial fractures. Most frequent site is the subcondylar region. Different approaches to reach subcondylar region, have been described. In the study was evaluated the advantages of neuromuscular block during endoscopic surgery for subcondylar fractures. Twenty-five patients affected by subcondylar fractures were enrolled in this study and divided in 2 groups; group A: patients who received an intraoperative booster of curare during surgical procedure and group B patients who underwent surgery treated without the intraoperative booster of curare. All patients were treated successfully by endoscope-assisted transoral approach. The analysis of time required for surgery showed a reduction in group A comparing to group B. The mean time for surgery for the patients in group B with displacement between 0° and 45° was 170 minutes, and for 45° to 90° was 230 minutes. In group A, the mean time was 117.5 minutes for patients with condylar displacement between 0° and 45°, and 147.5 minutes for the other group. In conclusion, deep neuromuscular block seems to improve the surgical conditions in patients undergoing subcondylar endoscopic assisted surgery, further study needs to assess this surgical technique in order to better define this surgical protocol.

A comparative study of intraoral versus retromandibular approach in the management of subcondylar fracture

Background

The purpose of this study was to compare the outcomes and effectiveness between intraoral approach and retromandibular approach for treatment of subcondylar fracture of mandible.

Methods

Between March 2011 and October 2013, 24 patients with subcondylar fractures of the mandible were treated by a single surgeon with an intraoral approach using an angulated screwdriver (n = 14) or by another surgeon using a retromandibular approach (n = 10). The interincisal distance was measured 1 week (T0), 6 weeks (T1), 3 months (T2), and 6 months (T3) postoperatively. We also compare the average operation time and the cost of operation between the two groups.

Results

At 6 months postoperatively, all 24 patients achieved satisfactory ranges of temporomandibular joint movement, with an interincisal distance > 40 mm without deviation and with stable centric occlusion. The intraoral group had the median interincisal distance of 14 mm at T0, 38 mm at T1, 42.5 mm at T2, and 43 mm at T3, while the retromandibular group had that of 15, 29, 35, and 42.5 mm respectively. There was no statistically significant difference between the intraoral and the retromandibular group at T0 and T4. However, significant differences were noted T1 and T2 (p < 0.01). The differences of average operation time between the intraoral (81 min) and retromandibular group (45 min) were statistically significant (p < 0.01). The cost of an operation was 369.96 ± 8.14 (United States dollar [USD]) in intraoral group and was 345.48 ± 0.0 (USD) in retromandibular group. The differences between the two groups were statistically significant (p < 0.01).

Conclusion

In open reduction of a subcondylar fracture of the mandible, a intraoral approach using an angulated screwdriver is superior to the retromandibular approach in terms of interincisal distance, although the operation time is longer.

Removal of the articular fibrous layers with discectomy leads to temporomandibular joint ankylosis

OBJECTIVE

The aim of this study was to investigate whether direct damage of the articular fibrous layers without condylar fracture, combined with discectomy, was enough to induce temporomandibular joint (TMJ) ankylosis.

STUDY DESIGN

Bilateral TMJ surgery was performed in 8 growing sheep. Disk removal (DR) was performed in the lateral two-thirds on the control side, and disk and articular fibrous layers removal (DFLR) was performed in the lateral two-thirds on the experimental side. Four animals were sacrificed for each side at 1 and 3 months postoperatively.

RESULTS

Fibrous ankylosis was achieved on the DFLR side in 2 of 4 sheep and fibro-osseous ankylosis in the other 2 sheep at 1 month after surgery. Fibro-osseous ankylosis developed on the DFLR side in 4 sheep at 3 months postoperatively. On the DR side, pathologic characteristics of TMJ osteoarthritis could be seen; however, no evidence of ankylosis was observed. The scores of TMJ ankylosis for the DR side were significantly lower than those for the DFLR side at different time points (P < .05).

CONCLUSIONS

This study demonstrated that removal of articular fibrous layers combined with discectomy can lead to traumatic TMJ ankylosis.

Anatomical and Functional Recovery of Intracapsular Fractures of the Mandibular Condyle: Analysis of 124 Cases after Closed Treatment

Purpose:

The purpose of this study is to evaluate the influence of intracapsular fracture lines of the mandibular condyle on the anatomical and functional recovery after non-surgical closed treatment.

Methods:

Clinical and radiological follow-up of 124 patients with intracapsular fractures of the mandibular condyle was performed after closed treatment between 2005 and 2012. The intracapsular fractures were classified into three categories: type A (medial condylar pole fracture), type B (lateral condylar pole fracture with loss of vertical height) and type M (multiple fragments or comminuted fracture).

Results:

By radiological finding, fracture types B and M lost up to 24% vertical height of the mandibular condyle compared to the height on the opposite side. In Type M, moderate to severe dysfunction was observed in 33% of the cases. Bilateral fractures were significantly associated with the risk of temporomandibular joint (TMJ) dysfunction in fracture types A and B. Bilateral fracture and TMJ dysfunction were not statistically significantly associated in type M fractures.

Conclusion:

Most of the mandibular intracapsular condylar fractures recovered acceptably after conservative non-surgical treatment with functional rehabilitation, even with some anatomical shortening of the condylar height. The poor functional recovery encountered in type M fractures, especially in cases with additional fracture sites and bilateral fractures, points up the limitation of closed treatment in such cases.

Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis

Traumatic temporomandibular joint (TMJ) ankylosis can be classified into fibrous, fibro-osseous and bony ankylosis. It is still a huge challenge for oral and maxillofacial surgeons due to the technical difficulty and high incidence of recurrence. The poor outcome of disease may be partially attributed to the limited understanding of its pathogenesis. The purpose of this article was to comprehensively review the literature and summarise results from both human and animal studies related to the genesis of TMJ ankylosis.

Setbacks of bio-resorbable plates and screws in the management of condylar fractures: our experience

PURPOSE

Fractures of the condyle can be managed by open or by closed reduction. This study was designed to mention the complications of the bio-resorbable material we had experienced while using them in the management of condylar fractures.

METHODS

Fifteen (11 men and four women) patients with subcondylar fractures were included in the study. Resorbable poly-l-lactide plates and screws were used for the fracture fixation. Patients were followed up clinically and radiographically for a period of 2 years.

RESULTS

Seven patients had a satisfactory reduction following the placement of bio-resorbable plates. Three patients had developed a swelling in the pre-auricular region, extending till the angle. Two patients had a screw breakage whereby leading to malunion and three other patients had bone resorption, at the fractured site that was appreciated radiographically.

CONCLUSION

Inspite of the advantages of these materials, certain complications has been experienced in our study with regard to the resorption and degradation of the material which has been mentioned and explained in our article.

Open versus closed treatment of unilateral subcondylar and condylar neck fractures: a prospective, randomized clinical study

PURPOSE

The purpose of the present study was to compare closed treatment with open reduction and internal fixation for displaced unilateral subcondylar and condylar neck fractures.

MATERIALS AND METHODS

A total of 32 patients with displaced unilateral condylar fractures were included in the present study. Of the 32 patients, 27 were men and 5 were women. The patients were divided into 2 groups. The group I patients were treated with closed treatment and rigid maxillomandibular fixation, and group II patients were treated with open reduction and internal fixation. The patients were assessed for maximal interincisal opening, protrusive movements, lateral excursion movements on the fractured and nonfractured sides, anatomic reduction of the condyle on radiography, pain in the temporomandibular joint, and malocclusion. Parameters such as the maximal interincisal opening, protrusive movements, and lateral excursion movements on the fractured and nonfractured sides between the 2 groups were compared statistically using an independent t test. Parameters such as anatomic reduction of the condyle, pain in the temporomandibular joint, and malocclusion between the 2 groups were compared statistically using the chi(2) test.

RESULTS

No significant difference was found between the 2 groups in the maximal interincisal opening, protrusion, lateral excursion movement, malocclusion, and temporomandibular joint pain; however, a statistically significant difference was seen in the anatomic reduction of the condyle.

CONCLUSIONS

The results of the present study have shown that no significant clinical difference exists between patients undergoing closed treatment and rigid maxillomandibular fixation or open reduction and internal fixation. However, a radiographically better anatomic reduction of the condylar process was seen in the patients treated with open reduction and 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.

A New 3-Dimensional Plate for Transoral Endoscopic-Assisted Osteosynthesis of Condylar Neck Fractures

PURPOSE

Transoral surgical treatment of condylar neck fractures minimizes the risk of damaging the facial nerve. But fracture reduction and plate osteosynthesis remain challenging, especially when using 2 plates, although endoscopic assistance has proven helpful. To further improve and simplify osteosynthesis at the condylar neck, a new delta-shaped osteosynthesis plate that mimics the function of 2 plates has been developed. The present clinical follow-up study was conducted to evaluate this new plate.

PATIENTS AND METHODS

A total of 16 patients with 19 condylar neck fractures (3 Spiessl I, 13 Spiessl II, 1 Spiessl III, 2 Spiessl IV) and 3 bilateral fractures were treated through an endoscopic-assisted transoral approach. After reduction, the plate was applied, with the screws inserted either transcutaneously or with angulated instruments.

RESULTS

The operation time ranged between 55 and 120 minutes. More than 6 months after the operation, functional parameters returned to normal, with an average mouth opening of 41 mm, protrusion of 5 mm, and laterotrusion of 6 mm. Radiographic controls showed good fracture alignment in 15 of 19 cases immediately after the operation, and in 14 of 19 cases 6 months after the operation. No plate fracture or bending was observed. In 3 patients, loose screws were found on plate removal.

CONCLUSIONS

The clinical data and the engineering and biomechanical background suggest that the new delta-shaped plate can be regarded as 2 miniplates. The new plate is suitable for treatment of condylar neck fractures, particularly when used in an endoscopic-assisted transoral approach.

Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals

INTRODUCTION

The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) or intracapsular, undisplaced, deviated, displaced or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and the dental occlusion, and the surgeon's experience.

PURPOSE

This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment.

MATERIAL AND METHODS

The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted.

RESULTS

Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively.

CONCLUSIONS

Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with 'medical problems' where intermaxillary fixation is not recommended.

Transorale operative Therapie von Kiefergelenkfrakturen mit einer 3D-Platte

AIM

The transoral approach minimizes the risk of damaging the facial nerve. However, stable osteosynthesis with two miniplates at the proximal fragment is often not possible. To achieve a stable fixation also of condylar neck fractures a new delta-shaped plate was developed, which meets the biomechanical demands of this region. This plate was tested in a clinical study.

PATIENTS AND METHODS

In total 11 patients suffering from 13 condyle fractures (Spiessl I: n=2, Spiessl II: n=10, Spiessl III: n=1, 3 bilateral fractures) were treated via a transoral approach and assessed clinically as well as radiologically in the follow-up period. Functional parameters and fracture alignment were assessed.

RESULTS

After 6 months postoperative function had returned to normal with a mouth opening of 42 mm and pro- and laterotrusion of more than 5 mm. Postoperative radiographic controls showed a good fracture alignment in 7 of 8 patients respectively in 6 of 8 cases after 6 months. In 12 of 13 fractures directly postoperative and in 10 of 13 fractures 6 months postoperative, respectively, Towne's view radiographs showed an anatomical correct position. No plate fracture and no bending of plates were observed. Loosening of screws was found in 2 patients during plate removal.

CONCLUSION

The newly developed three-dimensional plate was easy to handle, and a sufficiently stable osteosynthesis of condyle fractures was possible. This plate can be recommended for surgical fracture treatment via a transoral approach omitting extraoral scars and damage to the facial nerve.

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.

Cross-sectional and functional imaging of the temporomandibular joint: radiology, pathology, and basic biomechanics of the jaw

The temporomandibular joint (TMJ) is a common site of complaint. Clicking sounds and pain are indicators of a frequent condition called internal derangement, most often affecting females. As a general term, internal derangement describes a structural abnormality within an articulation. The internal derangement of the TMJ is a specific term defined as an abnormal positional and functional relationship between the disk and articulating surfaces. Imaging of the joint is an important element in the diagnostic work-up. Trauma and inflammatory arthritis account for most of the other TMJ problems. A thorough understanding of joint anatomy and normal function is a prerequisite for perceiving abnormalities and making the correct diagnosis. The authors elucidate joint anatomy, correlating cadaveric specimen and anatomic slices with conventional and cross-sectional imaging studies. TMJ biomechanics are illustrated with schematics and animations, and an overview of imaging strategies and techniques is presented. Common abnormalities are described and illustrated, and a brief discussion of therapeutic options is included.

Frontiers in maxillofacial endoscopic surgery

The use of endoscopically assisted techniques allows limited incisions for the open reduction of condylar process fractures. Intraoperative control after fracture reduction in areas of limited exposure and visibility is possible. In addition, the risk of facial nerve damage and extensive visible scars can be reduced by using minimally invasive endoscopic techniques. Although the use of endoscopically associated techniques in maxillofacial surgery offers many options and advantages, indications for open treatment of maxillofacial trauma have not changed. The repair of severely dislocated and comminuted fractures of the facial skeleton and major reconstruction of craniomaxillofacial structures still require extended exposure with traditional intraoral and extraoral approaches.

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.

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.

Transoral miniplate osteosynthesis of condylar neck fractures

OBJECTIVE

In a retrospective study, we reviewed a series of 55 consecutive patients with 57 fractures of the condylar neck that were treated with transoral miniplate osteosynthesis.

STUDY DESIGN

Forty-one patients were included in a clinical follow-up study; the median length of study was 26.5 months (minimum, 7 months; maximum, 79 months). In a radiographic study, the positions of the condyle before open reduction, after open reduction, and more than 6 months postoperatively were evaluated in 3 radiographic planes. A statistical analysis was performed to determine factors that lead to secondary instability of the reduced condyle and to correlate the actual position of the condyle with clinical parameters collected in follow-up examinations.

RESULTS

At the time of the follow-up examination, the median measurement of the mandibular openings was 48.3 +/- 8.0 mm (minimum, 32 mm; maximum, 66 mm). A deviation of 2 mm to the operated side when opening was observed in 7 patients. The median range of laterotrusion was 10.0 mm to the fracture side and 9. 0 mm to the opposite side. In 7 patients, radiographic follow-up more than 6 months postoperatively revealed a medial tilt of the proximal fragment of 15 to 40 degrees despite a good immediate postoperative position of the condyle. This may be attributed to bone resorption in the fracture gap, together with a bending instability observed when titanium miniplates with a thickness of 0. 9 mm were used. The position of the condyle at the follow-up examination did not correlate with clinical parameters.

CONCLUSIONS

Transoral approach miniplate osteosynthesis of dislocated condylar neck fractures is indicated when visible scars in the head and neck region, which are encountered with other fixation techniques, must be avoided.

The value of coronal computer tomograms in fractures of the mandibular condylar process

OBJECTIVE

A prospective investigation designed to compare the diagnostic accuracy of conventional panoramic and posteroanterior mandibular radiographs with that of coronal computed tomography scans in cases of fracture of the mandibular condylar process was conducted.

STUDY DESIGN

In all, 182 patients with a total of 249 fractures (some unilateral and some bilateral) of the mandibular condyle received conventional radiographs and coronal computed tomography scans as diagnostic procedures. The ability of these procedures to detect and correctly classify these fractures was determined, and their importance for therapeutic decision-making is described.

RESULTS

All clinically identified fractures were detected by means of both conventional and computed tomography imaging. However, only computed tomography scanning could correctly classify high condylar neck fractures.

CONCLUSIONS

Especially in cases of high condylar neck fracture, coronal computed tomography scans were more useful than conventional radiographs in the determination of type of condylar fracture so that a correct treatment decision could be made.

Fractures of the condylar process: surgical versus nonsurgical treatment

PURPOSE

The purpose of this study was to compare outcomes from surgical and nonsurgical treatment of condylar process fractures.

PATIENTS AND METHODS

Two hundred thirty-four patients with fractures of the mandibular condylar process were treated by open or closed methods. In the follow-up study, 150 patients with a mean follow-up time of 2.5 years were analyzed using radiologic and objective and subjective clinical examinations.

RESULTS

No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve disorders were observed when the surgically and nonsurgically treated patients were compared. The only significant difference was in subjective discomfort. Surgically treated patients showed significantly more weather sensitivity and pain on maximum mouth opening.

CONCLUSION

Because of its disadvantages, open surgery is only indicated in patients with severely dislocated condylar process fractures.

Endoscope-assisted fixation of mandibular condylar process fractures

PURPOSE

Reduction and plate osteosynthesis of condylar fractures often require a wide extraoral approach with the risk of aesthetic impairment and possible facial nerve palsy. To avoid complications, the purpose of this pilot study was to use an endoscopic device for the treatment of condylar fractures also allowing for endoscopically assisted plate application.

PATIENTS AND METHODS

Seven condylar fractures were operated under endoscopic control. In three patients, a newly developed device for endoscopically controlled plate application was clinically tested. The new device and the application technique is described in detail.

RESULTS

In two of three cases using this approach, fracture healing was achieved with the condyle in the anatomically correct position. In the third case the plate had to be removed early because of insufficient screw fixation.

CONCLUSION

This technique may be helpful to further minimize surgical trauma in head and neck fracture treatment. The newly developed plate application device may also be used to approach other regions of the skull eg, the skull base, the zygoma, or the orbit.

The influence of the spring activator on the mobility of the lower jaw in traumatically injured patients

For functional rehabilitation and improvement of mandibular mobility, 14 patients with dislocated collum or collum fracture dislocations were treated with a spring activator after surgical-conservative treatment. With an interincisal distance of < 12 mm, therapy was started with a loop spring. The average age of the patients was 26.6 years. Eight patients showed additional traumatic injuries, 2 patients were seriously polytraumatically injured. The clinical investigations referring to the maximum mouth opening and maximal interincisal distance resulted in a good to very good functional rehabilitation in all cases. The average maximal interincisal distance of 31.7 mm at the beginning of the spring activator therapy could be increased to 47.3 mm. The largest increase of the maximal interincisal distance was observed after 4 weeks of therapy. The type of reaction, however, differed interindividually. Three patients showed a spontaneous improvement of the interincisal distance within the first 2 to 3 weeks of removal of intermaxillary fixation, whereas 7 patients showed no improvement or only slightly improved values until insertion of the spring activator. An enlargement of the interincisal distance could be achieved in almost every patient within a relatively short period of time despite a drastically reduced mouth opening. Consequently, because of its mode of action in the form of a neuromuscular influence, the spring activator is especially suitable for the functional rehabilitation of patients with fractures of the condylar process.

Endoscopic subcondylar fracture repair: functional, aesthetic, and radiographic outcomes

An endoscopic method of mandibular subcondylar fracture repair has been described recently. To determine the effectiveness of this new technique, we longitudinally studied functional, aesthetic, and radiographic parameters following endoscopic repair of 22 subcondylar fractures in 20 patients. Restoration of mandibular function was achieved without postoperative maxillomandibular fixation. Premorbid occlusion was restored. Clinical jaw motion was found to progressively increase with a mean interincisal jaw opening of 43 mm achieved after the eighth postoperative week. Patients were pleased with the aesthetic restoration of their chin projection,jaw line, and the symmetric midline movement of the chin point onjaw opening. Anatomic fracture reduction with rigid plate fixation was confirmed on early postsurgical radiographs. Late radiographs showed fracture union without remodeling of the condylar head. Endoscopic subcondylar fracture repair was efficacious at functional, aesthetic, and radiographic restoration of the mandible.

Surgical reduction and fixation of intracapsular condylar fractures. A follow up study

Controversies still exist about the preferred treatment of condylar head and neck fractures. Newly developed access techniques in combination with new methods to fix the fragments, lead to satisfactory results. This study deals with a refinement of surgical treatment of intracapsular 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.

Internal fixation of severely displaced mandibular condylar neck fracture with the aid of ramus osteotomy. A revised technique

A technique is described whereby the mandibular condyle can be located, replaced and fixed in case of a severely displaced fracture with exarticulation of the condylar head.

Surgical management of mandibular malposition after malunited condylar fractures in adults

Fourteen patients who had occlusal disturbance and mandibular malposition following malunited condylar fractures are presented, to demonstrate the variety of surgical corrective procedures used. In order to achieve an anatomically correct mandibular position, a subcondylar osteotomy was performed in 2 patients, and in 11 patients a uni- or bilateral sagittal split osteotomy was carried out. In 1 patient, a Le Fort I osteotomy was the method of choice. In all patients, it was possible to correct the occlusal and mandibular imbalance, as well as to facilitate normal mandibular movement.