Closed treatment of unilateral mandibular condyle fractures in adults: a systematic review

Which is the fastest and safest approach? A comparison of time and complications of transparotid and anteroparotid retromandibular approach in management of mandibular subcondylar fractures: A prospective randomized controlled trial

INTRODUCTION

Mandibular condylar fractures are among the most common facial fractures and its incidence has been rising since the past few decades. Although various approaches for management of mandibular condylar fractures have been described in literature there is a gap in the published literature when it comes to comparison of these approaches. There have only been a handful of studies which have compared use of Retromandibular Transparotid against Retromandibular anteroparotid approach in management of mandibular condylar fractures with conflicting results. The aim of this study was to aid in decision making regarding the choice of approach between the Retromandibular Transparotid and Anteroparotid Transmasseteric approach based on the ease of surgical access and incidence of complications.

MATERIALS AND METHODS

A total of 24 patients were registered in the study under two treatment groups, Transparotid (Group A) and Anteroparotid (Group B). Data collection was done by a single blinded observer for measurement of exposure time, facial nerve weakness, facial oedema, presence of a sialocele, presence of a parotid fistula (and presence of various complications).

RESULTS

The average time required for exposure of fracture site in group A was 11 min ± 2.73 min and in group B was 9 min ±1.91 min. Facial nerve injury (Grade III House Brackmann scale) was noted in one patient in group A. There was no significant difference in quality of reduction, occlusion and mandibular mobility.

CONCLUSION

The results of this study indicate that the rate of complications and time required to access the fracture site was comparable in both the approaches. It can be said that both the anteroparotid and transparotid approaches are reasonably safe and convenient in management of mandibular condylar fractures.

Condyle head fracture management: A systematic review of outcomes

The management of Condylar Head fractures (CHFs) has historically been with closed treatments(CTR); however, contemporary studies suggest that Open Reduction and Internal Fixation(ORIF) may produce better clinical and radiographic results. Our primary aim was to review the literature on the clinical and radiological outcomes of open and closed management of CHFs. A systematic literature search was undertaken using EMBASE, MEDLINE and PubMed, using PRISMA guidelines, for all studies relating to outcomes following CHF. The inclusion criteria include 1) studies focused on CHF in adult patients that included at least 20 cases 2) published in English language. ROBINS-1 tool was used for risk assessment. Data extracted was analysed and compared using the relative risks. A total of 29 studies reporting on 1550 ORIF and 798 CTR were included. ORIF resulted in significantly less trismus (RR 9.5), chin deviation (RR 7.3), malocclusion (RR 6.5), TMJ clicking (RR 4.3) and pain(RR 12.6) than CTR. Due to the substantial heterogeneity of studies, firm conclusions are difficult but there does appear to be objective benefits in outcomes following ORIF than CTR. Satisfactory results may however be achieved with CTR. Further large studies using standardised outcome measurements will be required to help elucidate exactly which CHF are best served by ORIF.

Management of Pediatric Mandibular Condyle Fractures: A Literature Review

This narrative review evaluates the literature on the management of mandibular condyle fractures in growing patients. It aims to illustrate some fundamental biological principles and to offer a series of considerations applicable to clinical practice. The discussion is based on 116 papers published in PubMed and two relevant textbooks. Condylar fractures may be overlooked, especially in pre-scholar children, where compliance is usually reduced. However, these injuries can have disabling sequelae such as ankyloses, facial deformities, malocclusion, and chronic pain in some patients if not diagnosed and managed correctly. Due to their significance, mandibular condyle fractures in children are a subject of considerable clinical interest. As of today, there is consensus about their treatment. Four management options are available: expectative (analgesia, soft food and follow-up), functional protocols (guiding elastics, orthodontic appliances and exercises), maxillomandibular fixation (MMF), and open reduction and internal fixation (ORIF). Nondisplaced and minimally displaced fractures should be treated expectantly; severely displaced non-comminuted fractures can be safely operated on if the expertise is available, even in patients with deciduous dentition. Moderately displaced fractures can be managed with functional protocols or operatively, depending on the background and know-how of the specialist. Functional protocols can achieve good outcomes, especially in patients with deciduous dentition. MMF should be foregone in children due to its many drawbacks.

Three-Dimensional Analysis of Bone Remodeling After Closed Treatment for Mandibular Condylar Head Fracture

Closed treatment of mandibular condylar fractures has been used for its indications based on the fracture site, fracture status, and patient age. Posttreatment mandibular condyle size is associated with mandibular function; however, a few studies have reported bone remodeling patterns and volume changes in the condyle and glenoid fossa after mandibular condylar head fractures (CHFs). Therefore, volumetric changes in the mandibular condyle and glenoid fossa were analyzed in the present study, and bone remodeling patterns were evaluated after mandibular CHFs. The present study included 16 condyles from 12 patients who received closed treatment for CHF. After reconstruction of a 3-dimensional skull model, including the mandible, using computed tomography data taken immediately after injury and 6 months after treatment, volume changes in the mandibular condyle and glenoid fossa were analyzed. The condylar volume increased by 0.32±0.66 cm3 during the 6-month healing period without statistical significance (P=0.093). Regarding the glenoid fossa, the fossa showed a statistically significant volume increase of 0.41±0.59 cm3 (P=0.021), and 12 glenoid fossae (75%) showed downward bone apposition; however, no change or only mild bone resorption was observed in 4 glenoid fossae (25%). The results of this study indicated that the volume changes in the mandibular condyle after closed treatment of a mandibular CHF are not significant, and the glenoid fossa adapts to the displaced mandibular condyle through downward growth accompanied by volume increase.

Can dynamic elastic therapy be established as the standard protocol of closed reduction for moderately displaced extracapsular condylar fractures?

OBJECTIVE

This study was conducted with the aim to establish standard technique of closed reduction (CR) and compare functional outcomes in patients of moderately displaced unilateral extracapsular condylar fractures.

MATERIAL AND METHODS

This study is a retrospective randomized controlled trial, conducted at a tertiary care hospital setting from August, 2013 to November, 2018. Patients of unilateral extracapsular condylar fractures with ramus shortening < 7mm and deviation < 35° were divided in two groups by drawing lots and were treated by dynamic elastic therapy and maxillomandibular fixation (MMF). Mean and standard deviation were calculated for quantitative variables, and one way analysis of variance (ANOVA) and Pearson's Chi-square test were used to determine significance of outcomes between two modalities of CR. P value < 0.05 was taken as significant.

RESULTS

The numbers of patients treated by dynamic elastic therapy and MMF were 76 (38 in each group). Out of which 48 (63.15%) were male and 28 (36.84%) were female. The ratio of male to female was 1.7:1. The mean ± standard deviation (SD) of age was 32 ± 9.57 years. In patients treated by dynamic elastic therapy, the mean ± SD (at 6-month follow-up) of loss of ramus height (LRH), maximum incisal opening (MIO) and opening deviation were 4.6mm ± 1.08mm, 40.4mm ± 1.57mm and 1.1mm ± 0.87mm respectively. Whereas, LRH, MIO and opening deviation were 4.6mm ± 0.85mm, 40.4mm ± 2.37mm and 0.8mm ± 0.63mm respectively by MMF therapy. One-way ANOVA was statistically insignificant (P value > 0.05) for above mentioned outcomes. Pre-traumatic occlusion was achieved in 89.47% of patients by MMF and in 86.84% patients by dynamic elastic therapy. Pearson's Chi-square test was statistically insignificant (p value < 0.05) for occlusion.

CONCLUSION

Parallel results were obtained for both modalities; thus, the technique as dynamic elastic therapy, which promotes early mobilization and functional rehabilitation, can be favored as standard technique of closed reduction for moderately displaced extracapsular condylar fractures. This technique eases patients' stress associated with MMF and prevents ankylosis.

Changes in load distribution after unilateral condylar fracture: A finite element model study

OBJECTIVE

Premature dental contact on the fractured side and a contralateral open bite are signs of a unilaterally fractured condyle of the temporomandibular joint (TMJ). The lateral pterygoid muscle pulls the condyle inwards, causing angulation of the fractured part and shortening of the ramus. This imbalance after fracture might change the load in both TMJs and consequently induce remodeling. The present study aimed to calculate this change in load. It is hypothesized to decrease on the fractured side and increase on the non-fractured side.

DESIGN

For these calculations, a finite element model (FEM) was used. In the FEM, shortening of the ramus varied from 2 mm to 16 mm; angulation, from 6.25° to 50°.

RESULTS

After fracture, load on the non-fractured side increased, but only at maximal mouth opening (MMO). Simultaneously, load on the fractured side decreased, at both timepoints, i.e., MMO and closed mouth. When comparing all simulations at those time points, i.e., from 2 mm and 6.25° to 16 mm and 50°, the load in the fractured condyle declines steadily. However, for both timepoints, a threshold stands out around 6 mm shortening and 18.75° angulation: visualization of the fractured condyle showed, apart from load on the condylar head, a second point of load more medial in the TMJ which was most evident in the 6 mm - 18.75° simulation.

CONCLUSIONS

These findings could implicate that the balance between both TMJs is more difficult to restore after a fracture with more than 6 mm shortening and more than 18.75° angulation.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials

PURPOSE

Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.

RESULTS

The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).

CONCLUSIONS

This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Analysis of Mandibular Muscle Variations Following Condylar Fractures: A Systematic Review

This review analyzes muscle activity following mandibular condylar fracture (CF), with a focus on understanding the changes in masticatory muscles and temporomandibular joint (TMJ) functioning.

MATERIALS AND METHODS

The review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A search was performed on online databases using the keywords "masticatory muscles" AND ("mandibular fracture" OR "condylar fracture"). The eligibility criteria included clinical trials involving human intervention and focusing on muscle activity following a condylar fracture.

RESULTS

A total of 13 relevant studies were reviewed. Various studies evaluated muscle activity using clinical evaluation, bite force measurement, electromyography (EMG), magnetic sensors and radiological examinations to assess the impact of mandibular fractures on masticatory muscles.

CONCLUSIONS

Mandibular condylar fractures can lead to significant changes in muscle activity, affecting mastication and TMJ functioning. EMG and computed tomography (CT) imaging play crucial roles in assessing muscle changes and adaptations following fractures, providing valuable information for treatment planning and post-fracture management. Further research is required to explore long-term outcomes and functional performance after oral motor rehabilitation in patients with facial fractures. Standardized classifications and treatment approaches may help improve the comparability of future studies in this field.

Healthcare costs of different treatment options for condylar fractures

Objective

As treatment options for condylar fractures have comparable outcomes, getting insight into associated costs is a first step towards implementing value-based healthcare (VBH). Therefore, we described the actual costs of the different treatment options (surgical, conservative, and expectative treatment) for condylar fractures. We expected surgical treatment to be the most expensive treatment.

Study design

This is a cost-of-illness study, based on estimates from the literature. Firstly, care pathways of all treatment options were described. Secondly, the costs per step were calculated based on the literature and Dutch guidelines for economic evaluations in health care.

Results

The direct treatment costs of surgical treatment (€3721 to €4040) are three to five times higher than conservative treatment (€730 to €1332). When lost productivity costs during the recovery period are included, costs of surgical treatment remain 1.5 times higher (€9511 to €9830 for surgical treatment and €6224 to €6826 for conservative treatment). The costs of expectative treatment (€5436) are lower than both other treatments.

Conclusion

The costs for surgical treatment are considerably higher than those for conservative or expectative treatment, mainly related to direct treatment cost. Future research should focus on the patients' perspective, to support implementation of VBH in treating condylar fractures.

Load distribution after unilateral condylar fracture with shortening of the ramus: a finite element model study

OBJECTIVES

After a fracture of the condyle, the fractured ramus is often shortened, which causes premature dental contact on the fractured side and a contralateral open bite. The imbalance could change the load in the temporomandibular joints (TMJs). This change could lead to remodelling of the TMJs to compensate for the imbalance in the masticatory system. The load in the non-fractured condyle is expected to increase, and the load in the fractured condyle to decrease.

MATERIALS AND METHODS

These changes cannot be measured in a clinical situation. Therefore a finite element model (FEM) of the masticatory system was used. In the FEM a fractured right condyle with shortening of the ramus was induced, which varied from 2 to 16 mm.

RESULTS

Results show that, with a larger shortening of the ramus, the load in the fractured condyle decreases and the load in the non-fractured condyle increases. In the fractured condyle during closed mouth a major descent in load, hence a cut-off point, was visible between a shortening of 6 mm and 8 mm.

CONCLUSIONS

In conclusion, the change of load could be associated with remodelling on both condyles due to shortening of the ramus.

CLINICAL RELEVANCE

The cut-off point implies that shortening over 6 mm could present more difficulty for the body to compensate.

Open versus closed treatment for extracapsular fracture of the mandibular condyle

Objectives

Selection of treatment methods for mandibular condylar fractures remains controversial. In this study, we investigated treatment methods for condylar fractures to determine the indications for open or closed reduction.

Patients and Methods

Patients >12 years of age treated for mandibular condylar fractures with a follow-up period of ≥3 months were included in this study. The medical records of enrolled patients were reviewed for sex, age, fracture site, treatment method (open or closed reconstruction), postoperative intermaxillary fixation period, operation time, and complications. Radiological analysis of fracture fragment displacement and changes in ramal height difference was performed using computed tomography and panoramic radiography.

Results

A total of 198 patients was investigated, 48.0% (n=95) of whom underwent closed reduction and 52.0% (n=103) underwent open reduction. There was no significant correlation between reduction method and patient sex, age, or follow-up period. No statistically significant difference between the incidence of complications and treatment method was observed. None of the patients underwent open reduction of condylar head fracture. Binary logistic regression analysis showed that open reduction was significantly more frequent in patients with subcondylar fracture compared to in those with a fracture in the condylar head area. There was no statistically significant correlation between the groups and fracture fragment displacement. However, there was a significant difference between the treatment groups in amount of change in ramal height difference between the fractured and the non-fractured sides during treatment.

Conclusion

No significant clinical differences were found between the open and closed reduction methods in patients with mandibular condylar fractures. According to fracture site, closed reduction was preferred for condyle head fractures. There was no significant relationship between fracture fragment displacement and treatment method.

Long-term Complications of Isolated and Combined Condylar Fractures: A Retrospective Study

Study Design

Fractures of the mandibular condyle are a common injury in maxillofacial trauma. Both conservative treatment (i.e., analgesic therapy and soft diet) and intermaxillary fixation (IMF) or open reduction internal fixation (ORIF) have satisfactory and functional outcomes, though severe late-onset complications have been reported.

Objective

We compared the long-term complications of patients with condylar fractures treated conservatively, with IMF, or with combined ORIF and IMF.

Methods

We retrospectively analyzed all patients diagnosed with unilateral or bilateral condylar fracture, isolated or combined with a fracture of the mandibular body, admitted to the Department of Maxillofacial Surgery at UZ Leuven between January 2013 and January 2020. We collected data on age, gender, side of condylar fracture, presence of associated fracture of the mandibular body, referrals, initial treatment, long-term complications and secondary treatment. Long-term complications were defined as sequelae still present 6 weeks after initial treatment.

Results

Among 192 patients, 68.8% had unilateral and 31.2% bilateral condylar fractures; an associated fracture of the mandibular body was seen in 45.8%, 31% received conservative treatment, 51% IMF only, and 18% combined ORIF and IMF. Forty-eight percent of all patients suffered from 1 or more long-term complications, most frequently malocclusion (24%), reduced mouth opening (15.1%), nerve disturbances (13.5%), pain (8.9%), and facial asymmetry (2.6%). Surgery as a secondary treatment was necessary in 25% of all cases.

Conclusions

The presence of bilateral condylar fractures or associated fracture of the mandibular body is a risk factor for developing long-term complications. Most patients with long-term complications were initially treated with combined ORIF and IMF, but long-term complications after initial conservative or IMF treatment were treated with secondary surgery.

Evaluation and Prediction of Healing Morphology After Closed Reduction for Unilateral Mandibular Condyle Fractures: A Retrospective Study

Although closed reduction is common for condylar fractures, bone fragments may heal improperly. This study aimed to investigate the healing morphology of unilateral condylar fractures. We retrospectively investigated 70 patients with unilateral condylar fractures. Clinico-statistical analyses were performed on the whole-condylar fracture, closed reduction, and observation/functional therapy groups. Among these patients, 52 patients aged older than 16 years underwent closed reduction. The extent of maximum mouth opening, the incidence of malocclusion, and the relationship between healing morphology and Arbeitsgemeinschaft für Osteosynthesefragen classification or trismus were analyzed in the closed reduction group. There were significant differences in age (P=0.008) and sex (P=0.025) between the closed reduction and observation/functional therapy groups. However, there were no significant differences in trauma etiologies and concomitant fractures between the 2 groups. The average maximum mouth opening extent for unilateral fractures after closed reduction was 42.6±6.1 mm. Only 1 case (2.1%) of post-treatment malocclusion was observed. In all the MacLennan classification of deviation or more, regardless of the classification, upper fractures (head and upper neck) tended to heal through a spherical (P<0.001) morphology, whereas lower fractures (lower neck and subcondylar) tended to heal through an L-shaped and lateral fusion (P<0.001). There was no significant difference in the incidence of trismus between the healing morphology of unchanged type and others (P=0.690). Our results elucidated the etiology, dysfunction, and healing morphology classification of unilateral mandibular condyle fractures treated with closed reduction.

Temporomandibular joint prosthesis as treatment option for mandibular condyle fractures: a systematic review and meta-analysis

The aim of this study was to perform a systematic review of the literature on the temporomandibular joint (TMJ) prosthesis as a treatment option after mandibular condyle fracture. Three databases were searched (PubMed, Embase, Cochrane Library) and 2670 unique papers were identified. A total of 337 studies were included (121 case reports, 89 case series, and 127 cohort/clinical studies). In total 14,396 patients and 21,560 prostheses were described. Of the 127 cohort or clinical studies, 100 (79%) reported inclusion criteria, 54 (43%) reported exclusion criteria, and 96 (76%) reported the inclusion period. The base population from which patients were recruited was reported in 57 studies (45%). The reason for TMJ prosthesis implantation was reported for 4177 patients (29.0%). A history of condylar fracture was present in 83 patients (2.0%); a history of mandibular trauma was present in 580 patients (13.9%). The meta-analysis showed a pooled prevalence of condylar fracture of 1.6% (95% confidence interval 0.9-2.4%) and a pooled prevalence of trauma or condylar fracture of 11.3% (95% confidence interval 7.1-16.0%). Heterogeneity was highly significant (P < 0.001). The TMJ prosthesis appears to be reserved for patients with persistent pain, bony or fibrous ankylosis, or osteomyelitis after primary closed or open treatment of fractures of the mandibular condyle.

Comparative Evaluation of Modified Tragus Edge Approach and Retromandibular Approach to Mid- or Low-Level Mandibular Condylar Fractures

Objectives

To compare and evaluate the modified tragus edge approach (MTEA) with retromandibular approach for surgical access to mid-level or low-level mandibular condylar fractures.

Materials and Methods

This study comprised of 22 patients with mid-level or low-level condylar fracture. Patients with clinical and radiological evidence of mid-level or low-level condylar fracture are included only in this study. Patients were randomly divided into two groups: group A includes 11 patients, in which modified tragus edge approach was used, and group B includes 11 patients treated with retromandibular approach. Patients were evaluated clinically after first week, second week, fourth week, third month, and sixth month radiographically.

Results

The mean age of the study subjects in group A was 32.45 ± 8.98 years, while in group B, the mean age was 26.91 ± 5.79 years. Post-operatively, no significant difference was seen in relation to pain, occlusal relationship, mouth opening, and deviation of jaw during opening and closing movements. In terms of post-operative complication, only significant difference found between two groups is post-operative scar visibility, which is higher in retromandibular incision group as compared to MTEA.

Conclusion

Thus, we can conclude that MTEA provides ease of operation as a good exposure of mandibular mid- or low-level condylar fracture as retromandibular approach but with less visibility of post-operative scar as compared to retromandibular approach.

Mandibular Condylar Fractures

Mandibular condyle fractures can result in short-term and long-term morbidity. As a weak area of the mandible, the condyle is vulnerable to injury by a direct impact or an indirect force. Current treatment recommendations aim to better match the severity of the fracture with the choice of closed or open approach. Long-term follow-up of patients provides the best opportunity to monitor the degree of functional restoration after treatment. There is a growing consensus regarding the use of standardized fracture classification methods and outcomes measures that will allow better assessment of treatment results and strengthen the quality of outcomes research.

Unilateral Condylar Fracture with Review of Treatment Modalities in 30 Cases - An Evaluative Study

Introduction:

The treatment of subcondylar mandible fractures is a topic of debate and can be variable even though these fractures are commonly seen. The present study aimed at evaluation of various treatment modalities for unilateral condylar fracture in adults.

Materials and Methods:

Thirty patients with unilateral condylar fractures between the age of 18 and 60 years were evaluated. Treatment protocol included closed reduction for 15 patients and open reduction for 15 patients.

Results:

Assessment was done functionally for maximum interincisal mouth opening, deviation on maximum interincisal mouth opening, occlusion and facial nerve function, and radiologically for ramus height shortening. In general, there were no statistically significant differences between closed and open methods.

Discussion:

Both the treatment options for condylar fractures of the mandible yielded acceptable results. Closed treatment appears to be a safe and appropriate modality for most unilateral condylar fractures. Although the open group, in general, showed similar outcomes, this treatment should be reserved for limited indications. The present study has confirmed that both treatment options can yield acceptable results. On clinical examination, there was no significant difference in mouth opening measures, the incidence of occlusal disturbances or in the degree of pain perception.

Identification of malocclusion risk factors after closed treatment of condylar fractures using a novel three-dimensional computed tomography approach

The condyle is the most common site of mandibular fracture. In the present study, an attempt was made to utilize three-dimensional computed tomography (3D-CT) images to evaluate mandibular condyle fractures and identify prognostic indicators of malocclusion after closed treatment. Accurate morphometric measurements were performed using 3D-CT images obtained before trauma, after trauma, and after healing. Morphometry revealed significant differences in loss of ramus height (LRH) and lateral movement length in patients with malocclusion, and significant LRH differences in patients with other maxillomandibular fractures after healing, or in those with dislocation-displacement. The present method of 3D-CT image analysis appears useful for evaluation of condylar fractures.

Algorithm for Management of Mandibular Condylar Base Fractures

Supplemental Digital Content is available in the text.

Background:

Increasing evidence suggests that open reduction and internal fixation of condylar base fractures in adults results in improved outcomes in regard to interincisal opening, jaw movement, pain, and malocclusion. However, most of the condylar fractures are managed by maxillomandibular fixation alone due to the need for specialized training and equipment. Our aim was to present an algorithm for condylar base fractures to simplify surgical management.

Methods:

A retrospective review was performed of patients (n = 22) with condylar base fractures treated from 2016 to 2020. Patients who presented with operative fractures that require open treatment underwent 1 of 2 different techniques depending on the fracture type: a preauricular approach with a transoral approach if the condyle was dislocated (n = 2) or a transoral only approach (n = 20) in nondislocated cases. Operative time, occlusion, range of motion, and postoperative complications were assessed.

Results:

Condylar base fractures were combined with other mandibular fractures in 16 of 22 patients. Patients with condylar dislocation were managed with a preauricular approach with a secondary transoral incision (n = 2, median 147 minutes). Those without dislocation were treated with a transoral approach (n = 20, median 159 minutes). Most patients were restored to their preoperative occlusion without long-term complications.

Conclusions:

We present a simplified algorithm for treating condylar base fractures. Our case series suggests that reduction in operative time and clinical success can be achieved with open reduction and internal fixation using a transoral approach alone or in combination with a preauricular approach for dislocated fractures.

Assessment of biomechanical properties of specially-designed miniplate patterns in a mandibular subcondylar fracture model with finite element analysis and a servohydraulic testing unit

The aim of our study was to compare the biomechanical stability of three different systems used to fix mandibular condylar fractures on synthetic polyurethane mandibles using a servohydraulic testing unit and finite element analysis (FEA). We measured the resistance to displacement loads causing 1.75 and 3.5mm displacements of the fragments, and the maximum resistance values before failure of the fixation system in 30 condylar necks of 15 polyurethane mandible models. The three subgroups investigated were arranged as a triangular plate (n=10), a quadrangular plate (n=10), and a straight miniplate (n=10). The most successful fixation pattern was achieved with two straight four-hole miniplates. However, the triangular plate can easily be applied as a second option by an endoscopic approach. The rectangular plates showed no success in mandibular condylar fractures.

Will Closed Treatment Provide Better Mandibular Motion Than Open Reduction and Internal Fixation in Cases of Unilateral Displaced Subcondylar Fracture? A Systematic Review and Meta-Analysis

PURPOSE

The aim of the present systematic review was to determine whether closed treatment (CLT) with intermaxillary fixation (IMF) is superior or equivalent to open reduction and internal fixation (ORIF) in the management of unilateral displaced subcondylar fractures regarding the range of mandibular motion.

MATERIALS AND METHODS

To address our question, we conducted a systematic review and meta-analysis of the reported data after a comprehensive manual and electronic database search of studies reported up to 2017 in the English language that had compared CLT and ORIF of mandibular condyle fractures in adults. The following outcomes were recorded: maximum interincisal opening (MIO), protrusive movement (PM), lateral excursion toward the fractured side (LEFS), and lateral excursion toward the nonfractured side (LENFS).

RESULTS

The search resulted in 8 studies, 4 of which were included in the meta-analysis. The MIO and PM showed no statistically significant differences, with an effect size of -0.823 (P = .112) and -0.633 (P = .079), respectively. However, the LEFS and LENFS were superior after CLT, with an effect size of -0.710 (P = .031) and -0.682 (P = .017), respectively.

CONCLUSIONS

The findings from the present review suggest that both ORIF and CLT can provide comparable MIO and PM in subjects with unilateral displaced subcondylar fractures. However, CLT was superior to ORIF for both LEFS and LENFS.

Condylar Fractures: An Argument for Conservative Treatment

Introduction

The treatment of mandibular condyle fractures remains a controversial topic in maxillofacial surgery. No uniform treatment protocol is currently available.

Purpose

We performed a retrospective monocentric cohort study of patients with condylar fractures and their treatment, including long-term follow-up by telephone, followed by a short review of the literature.

Patients and Methods

The available data on condylar fractures presenting at Leuven University Hospitals between January 1, 2009, and December 31, 2015, were analyzed. Cause, age, sex, fracture level, degree of displacement, associated facial fractures, malocclusion, type of treatment, and complications were noted. Follow-up by telephone was performed after an average 261 weeks for the conservative group.

Results

A total of 109 condylar fractures were observed with a male/female ratio of 1.14:1. Most fractures were subcondylar, unilateral, displaced, caused by road traffic accidents, and treated conservatively.

Discussion

In children and intracapsular fractures, conservative management remains the first choice. Maxillomandibular fixation should be used sparingly in children and for as short a time as possible. Some patients indicated for surgery can still have acceptable results if treated conservatively.

A modified approach from the edge of the tragus in the surgical treatment of mandibular condyle fractures

Introduction We present our experiences using a modified surgical approach from the edge of the tragus for mandibular condyle fractures, to reduce the risk of postoperative complications and visible scars. Materials and methods Thirty-two patients presenting with mandibular condyle fractures were treated through a modified approach on the edge of the tragus. The age of the patients ranged from 6 to 62 years. All mandibular condyle fractures were fixed. The patients were asked to start open-mouth training one week postoperatively, undergoing a cone-beam computed tomography examination and clinical follow-up. Postoperative complications were evaluated after surgery. Results Mouth opening was normal (average 39.5 mm) in all the patients during the operation and the occlusion improved significantly compared with preoperatively. No cases of damaged facial nerves were observed during the final follow-up at six months and postoperative scars were less noticeable. Conclusions The modified surgical approach from the edge of the tragus for mandibular condyle fractures provides a good view of the operative field, reduces the risk of facial nerve damage and produces a less noticeable postoperative scar.

Clinical outcomes in the treatment of unilateral condylar fractures: a cross-sectional study

The treatment of mandibular condyle fractures has been the subject of considerable discussion, especially whether open or closed treatment should be used. There is a need for practical,evidence-based guidelines, and both objective and subjective parameters should be measured. To date, fewstudies have considered clinically relevant subjective parameters. This study was performed to evaluate the outcomes of the treatment of condylar fractures using the Mandibular Function Impairment Questionnaire (MFIQ) and the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and to compare the outcomes of open and the closed treatment. Patients with condylar fractures and at least 1year of follow-up were examined. These patients completed the MFIQ and other questionnaires, and were examined according to the DC/TMD. Seventy-four of 171 eligible patients participated in this study. The mean MFIQ score was 10.70 (standard error 2.9) in the open group and 4.96 (standard error 1.3) in the closed group (P=0.023), an outcome in favour of the closed treatment group. Examination according to the DC/TMD did not reveal a significant prevalence of TMD complaints. Closed treatment appears to be a safe and appropriate modality for most unilateral condylar fractures. Although the open group in general showed similar outcomes, this treatment should be reserved for limited indications.