Analysis of different treatment protocols for fractures of condylar process of mandible

Condylar position changes and prognosis in patients with unilateral mandibular condylar fracture treated non-surgically

BACKGROUND

Non-surgical method is a treatment option for mandibular condylar fracture; however, it is questionable whether bone fragments are adequately reduced and remodeled. The purpose of this study was to identify three-dimensional positional changes in the mandibular condyles in patients treated non-surgically, analyze factors influencing the extent of positional changes, and evaluate clinical prognosis.

METHODS

This retrospective study included 31 patients with unilateral mandibular condylar fractures treated non-surgically at the Ajou University Dental Hospital between 2005 and 2023. Computed tomography was performed at the time of the fracture (T 0) and > 6 months after non-surgical treatment (T 1). The extent of recovery of the highest point of the condyle head was measured in three-dimensional x-, y-, and z-axes. At the last follow-up > 6 months after remodeling (T 1), the prognosis was evaluated by clinical examination of mouth opening limitation, malocclusion, deviation on opening, temporomandibular joint disorder (TMD), and facial asymmetry.

RESULTS

Position differences were statistically significant between T0 and T1 (paired Student's t-test, P < 0.05), and between the x-, y-, and z-axes (Welch's ANOVA, P < 0.05). The degree of positional recovery in the superior and lateral directions showed a statistically significant negative correlation with age (Pearson's correlation analysis, P < 0.05). The average amount of recovery between two age groups of over and under 19 years old was statistically significant (independent t-test, P < 0.05). Complications included TMD (6.4%), malocclusion (3.2%) and facial asymmetry (3.2%).

CONCLUSION

After non-surgical treatment, the condyle head of the fractured mandible recovered significantly laterally and superiorly in under 19-year-olds. The functional prognosis was favorable in all age groups. Non-surgical treatment can be an applicable treatment option for patients with mandibular condylar fractures.

A Comparative Analysis of Surgical and Conservative Management in Intra-Articular Condylar Fractures: A Retrospective Study

Background: Mandibular condylar fractures are among the most common fractures of the facial skeleton, and their surgical management remains a topic of considerable debate in maxillofacial trauma surgery. Numerous studies in the literature internationally have explored optimal treatment approaches, with a growing preference for open reduction and internal fixation (ORIF). While conservative treatment has traditionally been the standard for intra-articular fractures, recent research suggests that ORIF may also be appropriate for selected cases of these fractures. Methods: This study presents a 14-year review (2009–2023) of the authors’ experience in the surgical management of intra-articular condylar fractures. Data were collected on surgical techniques, early and late complications, clinical and radiological outcomes, and comparisons with conservative treatment. Results: The analysis included evaluations of both short-term and long-term outcomes following ORIF, identifying specific scenarios where ORIF demonstrated advantages over conservative management. Clinical and radiographic assessments provided valuable insights into patient recovery and functional outcomes, while complication rates were documented for both treatment methods. Conclusions: Findings indicate that ORIF can be a beneficial treatment option for intra-articular condylar fractures in select patient groups, offering improved outcomes in cases where conservative treatment may be insufficient. However, conservative management remains a valid approach when surgical risks exceed potential benefits. This study adds to the ongoing discussion, supporting a tailored approach that considers individual patient factors when choosing between ORIF and conservative treatment.

Postoperative Complications following Open Reduction and Rigid Internal Fixation of Mandibular Condylar Fracture Using the High Perimandibular Approach

The high perimandibular approach is a feasible surgical technique for treating mandibular condylar fractures with open reduction and internal fixation, followed by fewer complications. Temporary trismus is the only postoperative complication that may occur. This study evaluated postoperative complications following open reduction and rigid internal fixation (OR-IF) of mandibular condylar fractures using the high perimandibular approach. Twenty consecutive patients undergoing OR-IF were included in this study. They included 11 male and 9 female patients, of an average age of 58.5 years, all of whom responded to a follow-up call at least 12 months after the surgery. All patients were evaluated for range of mouth opening, postoperative complications, and radiological findings. A statistical analysis of the relationship between range of mouth opening and related clinical parameters at 6 months postoperative evaluation was conducted. The fracture of the condylar neck was associated with a limited range of mouth opening and longer operation time. However, longer operation time was not associated with a limited range of mouth opening. The high perimandibular approach with OR-IF in mandibular condylar fractures is a feasible and safe technique; however, prolonged surgery and mandibular condylar neck fractures could affect the postoperative range of mouth opening.

Treatment of pediatric bilateral condylar fractures: A comprehensive analysis

Pediatric bilateral condylar fractures (PBCF) is a rare clinical pathology, where the management is carried out with both conservative and surgical approaches. The purpose of this study was to analyze and compare these two treatment approaches and their associated long term complications in PBCF. An extensive literature review- through the search of online databases- was conducted to survey, collect, analyze and compare the reported outcomes of different treatment modalities for PBCF. The number of studies presenting PBCF case reports was 16, while the number of such retrospective studies included here was 19. Analyses of these studies revealed that the conservative treatment is preferred in PBCF patients younger than 12 years of age. Moreover, a composite approach where the open reduction and internal fixation (ORIF) is carried out for one side while the intermaxillary fixation (IMF) for the contralateral side is frequently reported for the management of PBCF cases; this approach appears effective in improving daily functioning of temporomandibular joint and reducing long term complications. Performing ORIF for one side while IMF for the contralateral side seems the most common treatment approach in PBCF. This study may help in rapid decision making for treatment selection of PBCF patients while minimizing the risk for late complications.

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.

Open Reduction and Internal Fixation Versus Closed Reduction and Maxillomandibular Fixation of Condylar Fractures of the Mandible: A Prospective Study

Background

The choice of surgical versus nonsurgical treatment for fractures of the condylar process has its own limitations and remains a controversial issue. Improved knowledge of anatomy, technique, and technology combined with adequate experience with careful planning of surgical technique can avoid all the possible complications.

Aim

To compare open reduction and internal fixation with closed reduction and maxillomandibular fixation in the management of condylar fractures.

Materials and method

A prospective study was carried out among 22 patients who had minimally displaced or displaced condylar fractures. The patients were divided into two groups of 11 each: group A patients treated with open reduction and rigid internal fixation and group B patients treated with closed reduction and maxillomandibular fixation. Follow-up examinations were performed at one week, one month, three months, and six months postoperatively.

Results

Preauricular pain was significantly decreased (p < 0.001) in both groups postoperatively but more significantly decreased in the open reduction group. There was a significant improvement in the mouth opening at every follow-up to a maximum mean of 37.36 mm in group A and a mean of 33.64 mm in group B. Significantly more improvement in protrusive and lateral movements and reduced deviation on mouth opening at every follow up was observed in the open reduction group.

Conclusion

Both the treatment options for condylar fractures of the mandible yielded acceptable results with significant clinical differences in terms of occlusion, mouth opening, functional movements, and pain among patients with open reduction.

Bilateral mandibular condyle fractures: Should we open both?

Bilateral condylar fractures are common but are frequently undertreated. In most of the cases, only one side is surgically addressed and the other side is managed conservatively. Bilateral condylar fractures lead to loss of ramal height bilaterally, accentuated anterior open bite, disruption of articular surfaces, and disc and muscle attachments. In a mandibular bilateral condylar fracture, even though open reduction and internal fixation (ORIF) is done on one side, a patient still needs Inter Maxillary Fixation (IMF) for 2–4 weeks postoperatively to correct occlusion and deviation. The possibility of doing ORIF on the other is never explored. Here, we present two cases of bilateral condylar fracture treated both sides by ORIF. The article discusses the advantages and new approach to consider treating both sides.

Does Open Reduction and Internal Fixation Provide a Quality-of-Life Benefit Over Traditional Closed Reduction of Mandibular Condyle Fractures?

PURPOSE

This study sought to estimate patient-reported outcomes and compare quality-of-life (QOL) measures between patients electing for either open reduction internal fixation (ORIF) or closed reduction with intermaxillary fixation (CRIMF).

PATIENTS AND METHODS

This was a retrospective cohort study of patients with unilateral condyle fractures who had undergone either ORIF or CRIMF at the New York University Tisch Hospital and Bellevue Hospital Center. The primary study predictor was treatment choice (ORIF or CRIMF). Other study predictors were patient age, gender, and the presence of any other coexisting facial fractures. The 9 study outcomes were derived from an 11-item postoperative QOL questionnaire evaluating self-reported perceptions of pain and function. Univariate comparisons and multivariate regression models were calculated.

RESULTS

A total of 38 patients (21 CRIMF and 17 ORIF) comprised the study sample. All patients were eligible for either ORIF or CRIMF, and the choice of treatment was decided through shared decision making after a comprehensive discussion of risks and benefits. With respect to pain outcomes, patients who underwent ORIF reported lower overall pain scores at 2 weeks (P < .01) and 2 months (P = .01), less mastication pain at 3 months (P = .01), and a lower rate of persistent headaches after 6 weeks (P = .04). With respect to functional outcomes, patients who underwent ORIF reported better range of motion at 3 months (P = .01), less treatment-related weight loss (P = .01), and more ease when performing physical (P < .01) and work-related (P < .01) activities. In the multivariate regression models, ORIF was independently associated with decreased pain at 2 weeks (P < .01) and decreased difficulty in obtaining nutrition (P < .01), performing physical activities (P = .02), and performing work-related activities (P < .01).

CONCLUSIONS

Patients who underwent ORIF appeared to experience subjective favorable pain and functional QOL outcomes. Given the clinical controversy, the choice of treatment should synthesize patient-reported outcomes and be approached through shared decision making.

The Effects of Frontal Trauma on 4 Interforaminal Dental Implants: A 3-Dimensional Finite Element Analysis Comparing Splinted and Unsplinted Implant Configurations

PURPOSE

With increased implant-prosthodontic rehabilitation for mandibular edentulism together with the increased life expectancy and activity of the elderly population, a greater number of implant patients may be at risk of facial trauma. The aim of this 3-dimensional (3D) finite element analysis (FEA) was to evaluate the biomechanical effects of the edentulous mandible (EM) with and without implants exposed to frontal facial trauma including assessment of the fracture risk of different mandibular areas.

MATERIALS AND METHODS

By use of a 3D FEA, our experimental study design comprised 3 different models (model A, EM; model B, EM with 4 unsplinted interforaminal implants; and model C, EM with 4 splinted interforaminal implants) exposed to application of symphyseal frontal trauma of 2 MPa. In 3 defined regions of interest (ROIs) (ROI 1, symphyseal area; ROI 2, mental foraminal area; and ROI 3, condylar neck), the effective stress was measured at predefined sites in the superficial cortical mandibular area. The stress values of all ROIs evaluated were compared within each model (intramodel) as well as between the 3 models (intermodel).

RESULTS

For all models evaluated, a frontal traumatic load generated the highest stress levels in the condylar neck. However, for both models with implants (models B and C), the stress values were reduced significantly (P < .01) in the condylar neck region (ROI 3) but increased significantly (P < .001) in the mental foraminal area (ROI 2) compared with the EM model without implants. For the symphyseal area (ROI 1) evaluated, the unsplinted 4-implant model (model B) presented significantly (P < .001) higher stress values than the splinted implant model (model C) when frontal forces were applied.

CONCLUSIONS

Regardless of splinting or lack of splinting of 4 interforaminal implants, force absorption or transmission may shift the predominant risk factor from the condylar neck to the corpus or foramen mandibulae. However, splinting of 4 interforaminal implants may be beneficial in reducing the risk of bone fracture by providing protection for anterior risk situations.

Open reduction and internal fixation of mandibular condylar fractures: A national inpatient sample analysis, 2005-2014

The purpose of this study was to compare outcomes of open reduction and internal fixation (ORIF) versus closed reduction (CR) for mandibular condylar fractures.Patients included in the National Inpatient Sample (NIS) database (2005-2014) who were admitted to the hospital for unilateral mandibular condylar fracture were included in the analysis. Patient characteristics and clinical outcomes were compared between those who received ORIF and those receiving CR. Logistic regression analysis was performed to estimate odds ratios (ORs) for each aspect of the main observed events.NIS data of 12,303 patients who underwent ORIF and 4310 patients who underwent CR were analyzed. Compared to CR, ORIF had an increased risk of longer hospital stay (adjusted OR [aOR] = 1.78, 95% confidence intervals [CIs] = 1.51-2.09), higher total medical cost (aOR = 2.57, 95% CI = 2.17-3.05), and hematoma development (aOR = 10.66, 95% CI = 1.43-75.59), but had a lower risk of having wound complications (aOR = 0.86, 95% CI = 0.79-0.93).Patients with mandibular condylar fractures who receive ORIF have greater risk of having an extended hospital stay, higher total medical costs, and hematoma development but lower risk of experiencing wound complications compared to those who receive CR.

Unilateral mandibular condylar process fractures: a retrospective clinical comparison of open versus closed treatment

PURPOSE

To retrospectively compare the clinical outcomes of closed treatment (closed reduction and intermaxillary fixation) with open treatment (open reduction and internal fixation with miniplates and screws) of unilateral mandibular condylar process fractures.

METHODS

Adult patients with unilateral condylar fractures treated from January 2011 to July 2013 in the Oral and Maxillofacial Surgery Service at the Base Hospital of the Federal District, Brazil, were invited to participate. Those who agreed to participate were scheduled for clinical evaluation, which consisted of a subjective questionnaire (completed by the examiner) and an objective physical examination of the temporomandibular joints and mandibular range of motion. The following variables were analyzed: mouth opening; lateral excursions of the mandible; presence of clicking; mandibular function impairment (speech, chewing); and occlusion.

RESULTS

Seventeen patients (15 men and 2 women) attended the scheduled appointment: 9 had received open treatment (surgical) and 8 had received closed treatment (nonsurgical). Patients were evaluated at 6-30 months postoperatively. Only maximum mouth opening (p = 0.044) and maximum lateral excursion to the unaffected side (p = 0.030) showed a significant difference between the closed and open treatment groups.

CONCLUSIONS

Our findings are consistent with those reported in the literature as both methods (closed and open treatment) produced satisfactory outcomes. The only between-group difference was the amount of maximum mouth opening and lateral excursion to the unaffected side. Further randomized studies with a larger number of patients with condylar process fractures are needed to verify the results obtained with each treatment.

Mandible Fractures

Mandible fractures account for a significant portion of maxillofacial injuries and the evaluation, diagnosis, and management of these fractures remain challenging despite improved imaging technology and fixation techniques. Understanding appropriate surgical management can prevent complications such as malocclusion, pain, and revision procedures. Depending on the type and location of the fractures, various open and closed surgical reduction techniques can be utilized. In this article, the authors review the diagnostic evaluation, treatment options, and common complications of mandible fractures. Special considerations are described for pediatric and atrophic mandibles.

Mandibular Subcondylar Fractures: A Review on Treatment Strategies

Condylar injuries are often subjected to discussion and controversy in maxillofacial surgery as they constitute many of the facial fractures. The condylar area has a great clinical value due to its important components. Vital components in this area are susceptible to functional disability due to either the fracture itself or the subsequent surgical intervention. Each of the strategies for the management of these fractures has its advantages and disadvantages. As there are controversies around management of condylar fractures, different treatment modalities are suggested in literature, so this paper reviews different treatment strategies of the following types of fractures in adults: 1-Closed reduction with maxillomandibular fixation, 2-Open reduction with internal fixation, 3-Endoscopic-assisted reduction with internal fixation. In conclusion, we declare that the endoscopic surgery is certainly a good replacement for approaches through the skin, for subcondylar fractures, but still more randomized clinical trials are needed to be carried out on this issue.

Contrast analysis of open reduction and internal fixation and non-surgical treatment of condylar fracture: a meta-analysis

BACKGROUND

To take surgical treatment or non-surgical treatment on condylar fracture, clinicians are faced with a difficult choice. Traditional treatment on condylar fracture advocated non-surgical treatment, including intermaxillary traction and intermaxillary fixation, which relies mainly on condylar rebuilt. In recent years, with the development of rigid internal fixation, open reduction and internal fixation technique has been well applied in the treatment of condylar fracture and has obtained an optimistic therapeutic effect. More and more of patients with condylar fracture are advised to undergo surgical treatment. However, surgical treatment sometimes causes some discomforts and complications to patients. Is surgery treatment inevitable for condylar fracture? We, in this study, adopted a meta-analysis to compare the efficacy of open reduction and fixation surgical treatment with that of the non-surgical treatment on condylar fracture to give a reference to clinic.

METHODS

Computer retrieval of PubMed, Cochrane Library, and EMbase was used to identify literatures that reported the efficacy of open reduction and fixation surgical treatment compared with that of the non-surgical treatment on condylar fracture. Retrieval time began from the establishment of database to January 2012. Two reviewers assessed the quality of each trial and extracted data independently. RevMan 5.0 software was used for statistical analysis.

RESULTS

Thirteen literatures including 859 patients were included. A total of 409 patients underwent surgical treatment and 450 patients underwent non-surgical treatment. The results of the meta-analysis showed that the indicator of maximal mouth opening of the surgical treatment group was higher than that in the non-surgical treatment group (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.21-0.50; P < 0.00001). After 1 year of follow-up, the malocclusion incidence in the surgical group was less than that in the non-surgical treatment group (OR, 0.29; 95% CI, 0.13-0.66; P = 0.003). The incidence of temporomandibular joint pain has no significant statistical difference in the 2 groups (OR, 0.76; 95% CI, 0.25-2.29; P = 0.63). No significant statistical difference in the indicators of facial symmetry (OR, 1.27; 95% CI, 0.34-4.79; P = 0.73) and mandibular activity status (OR, 0.94; 95% CI, 0.43-2.07; P = 0.88) has been found in the 2 groups.

CONCLUSIONS

Surgical treatment has significant advantages in improving the maximal mouth opening as well as the occlusional relationship and has no significant statistical difference in the occurrence of joint pain after treatment, facial symmetry, and mandibular activity status in the 2 groups. Surgical treatment is suggested for patients older than 16 years with low position of condylar fracture, severe displacement, dislocation, and malocclusion. Joint pain, mandibular activity, facial symmetry after treatment, and jaw development impact should not be used as the influencing factors for treatment methods selection.

Comparison between two techniques for the treatment of mandibular subcondylar fractures: closed treatment technique and transoral endoscopic-assisted open reduction

PURPOSE

The endoscopic-assisted technique for the treatment of subcondylar fractures has been used successfully and its acceptance develops as more surgeons gain experience. We present the short term results of this technique in a randomized prospective clinical trial.

METHODS AND MATERIALS

A total of 40 patients with mandibular subcondylar fracture were included in our study in two groups randomly. Patients of first group were treated by closed treatment technique and patients of second group by transoral endoscopic-assisted open reduction. All patients were followed for minimum of 12 weeks and occlusion, Mandibular Anterior Opening (MAO), mandibular deviation, and posterior ramal height were assessed.

RESULTS

In the endoscopic group the MAO was significantly greater and mandibular deviation was lesser at 2nd and 4th week of follow up. Posterior ramal height showed significant increase in the endoscopic group rather than closed treatment group.

CONCLUSION

The transoral endoscopic-assisted technique is a reliable and successful technique to address subcondylar fractures. The patients who were treated by this technique showed better results in the fields of mandibular function and patient satisfaction and comfort, although it is time consuming and needs expensive instruments.

Effect of surgical repair of the joint capsule in mandibular condyle fractures in adult rats

PURPOSE

The aim of the present study was to assess histologic changes in the temporomandibular joint (TMJ) of adult rats subjected to unilateral fracture of the mandibular condyle and soft tissue injury.

MATERIALS AND METHODS

The animals were divided into 2 groups: one had surgical treatment for soft tissue repair and the other had no soft tissue treatment. All histologic evaluations were performed according to the presence or absence of synovitis, vascularity, presence or absence of joint inflammation, and presence or absence of the articular disc. The contralateral TMJs also were evaluated.

RESULTS

The results showed few histologic changes in the synovial membrane and joint disc for the 2 groups and in the synovial membrane and disc of the contralateral side, where indirect trauma occurred in the unoperated joint.

CONCLUSION

This study showed that treating or not treating soft tissues does not change the treatment results of condyle fracture or interfere with TMJ pathosis.

Long-term results and complications after treatment of bilateral fractures of the mandibular condyle

The purpose of this study was to investigate the long-term results of conservative treatment of bilateral condylar fractures and to study the influence of possible functional impairment on intensity of pain and associated disability. We studied 71 patients (mean (SD) age 33 (14) years) with conservatively treated bilateral condylar fractures. Traffic crashes (n=42, 59%) and falls (n=20, 28%) were the main cause of the fractures. Forty-one patients (58%) were re-examined after about 90 months (mean 86, range 3-193). Five of the 41 (12%) had developed malocclusion, but did not experience any pain in the temporomandibular joint according to the Research Diagnostic Criteria for Temporomandibular Disorders. There was a significant negative relation between the presence of pain and the duration of follow up (p=0.02). Increasing age was significantly related to reduction in the intensity of pain (p=0.03). Of the remaining 30 patients who were not followed up, 2 had had bilateral sagittal split osteotomy and 1 a Le Fort I osteotomy. One patient had had orthodontic correction for a malocclusion. Including the five malocclusion patients, at least 9 of the total of 71 (13%) developed a malocclusion after conservative treatment. Functional impairment had no influence on the intensity of pain or pain-related disability in the patients with malocclusion after conservatively treated bilateral condylar fractures. This report may therefore be of value in the debate about whether open or closed treatment is better for bilateral mandibular condylar fractures.

Closed reduction of mandibular condyle fractures using C-arm fluoroscopy: a technical note

We describe a C-arm technique for mandibular condylar fractures in an anatomic study using a model skull and show its feasibility in a clinical case. The C-arm allowed posterior-anterior visualization of the condylar process. The X-ray axis was canted ∼15 degrees cranially to the Frankfort horizontal line. The skull's sagittal plane was rotated ∼15 degrees ipsilaterally to the X-ray axis. This technique facilitates clear visualization of the condylar neck with easy, flexible, and timely adjustments. In selected cases, this method would convert the clinical settings of the condylar fracture pattern to that which would not be amenable to an open approach, making possible minimally invasive surgical procedures.