Management and outcome of condylar fractures in children and adolescents: A review of the literature

Characteristics, Treatment, and Prognosis of Pediatric Symphyseal/Parasymphyseal-Condylar Fractures

BACKGROUND

Pediatric condylar fractures combined with symphyseal or parasymphyseal fractures are common but challenging to manage. The authors present fracture characteristics, propose a treatment algorithm, and evaluate the treatment prognosis of pediatric symphyseal/parasymphyseal-condylar fractures.

METHODS

A retrospective review was conducted on pediatric patients who underwent treatment for symphyseal/parasymphyseal-condylar fractures in a trauma center between January of 2006 and January of 2021. Demographic and fracture characteristics were recorded. Complications and functional evaluations, including maximum interincisal opening, Helkimo anamnestic index, and clinical dysfunction index, were assessed after at least 1 year of follow-up.

RESULTS

After screening, 104 participants met the inclusion criteria. Among them, 50.96% received open reduction and internal fixation for symphyseal/parasymphyseal fractures and closed treatment for condylar fractures, 45.19% were treated by liquid diet and functional exercise, and the remaining 3.85% with severe malocclusion were treated with the assistance of orthodontic appliances. During follow-up, the average maximum interincisal opening of the patients increased from 17 ± 6.29 mm to 41.64 ± 6.33 mm. No subjective symptoms were observed in 86.54% of the patients and 79.81% showed no or mild clinical symptoms. Except for 1 patient who developed temporomandibular joint ankylosis, no other severe complication was reported. Postfracture remodeling of the nonfractured condyle was noted in 3 cases.

CONCLUSIONS

Pediatric symphyseal/parasymphyseal-condylar fractures present unique biomechanical and anatomic challenges that require special consideration during management. In this study, satisfactory functional prognosis was achieved following implementation of the treatment algorithm.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical treatment of paediatric fractures of the mandibular condyle: a systematic review of the literature

This study aims to review surgical treatment in paediatric condylar fractures and describe different types of techniques performed, along with the results obtained from them. A retrospective review was conducted from records of paediatric patients (from one to 17 years old) who sustained fractures of the mandibular condyle and underwent surgical treatment from 2003 to 2023. The number of patients, age, location, and type of fracture, clinical and imaging examinations, treatment methods, intraoperative/postoperative complications, removal of osteosynthesis material, follow up and outcomes were recorded and analysed. A total of 68 patients with 79 fractures were identified. The most common fracture pattern was condylar neck fracture (61.1%). Of the 68 patients who underwent surgical treatment, one had a complication of minimal temporal paraesthesia and another patient had near-complete resorption of the condyle. A total of 55 patients (81%) reported normal dental occlusion, mouth opening (>35 mm), lateral excursions (7-8 mm), TMJ function, no pain, no deviation of the midline or the jaw, and no ankylosis. Thirteen patients (19%) developed an unsatisfactory result, nine patients (13%) had a jaw deviation on mouth opening, four patients (6%) had mandibular retrusion, and seven patients (10%) had signs of TMJ dysfunction. A total of 59 patients (87%) reported bone completely healed with no signs of bone abnormality; seven patients (10%) had shortening of the condylar neck and/or ramus. Surgical treatment can lead to good or excellent results for severely dislocated and displaced condylar fractures in children and can reduce the unsatisfactory results resulting from closed treatment.

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.

Endoscopic-Assisted Intraoral Approach for Osteosynthesis of Mandibular Subcondylar Fractures

The aim of this study is to follow-up and evaluate the treatment result of mandibular subcondylar (MSC) fractures by osteosynthesis via endoscopy-assisted intraoral approach.

Associations between condylar fractures and external auditory canal fracture: A 7-year retrospective study

The study aimed to investigate whether the incidence rate of external auditory canal (EAC) fracture varies among different clinical types of condylar fracture. A retrospective cohort study was conducted in single hospital of China. Eligible patients diagnosed with mandibular condylar fractures were retrospectively reviewed. Among all patients with condylar fractures (318 cases and 437 sides), 45 cases and 59 sides (59/437 sides, 13.5%) were found with EAC fracture, including 17(17/38, 44.7%) sides of sagittal fracture of condyle (Type I), 21(21/59, 35.6%) sides of intracapsular condylar fracture (Type II), 8 (8/306, 2.6%) sides of condylar neck fracture (Type III), and 6 (6/34, 17.7%) sides of condylar base fracture (Type IV). Type III condylar fracture had a significant lower rate of EAC fracture than all other three types (all p<0.001). Type I condylar fracture had a higher rate of EAC fracture compared to Type IV (p=0.014). The incidence rates of EAC fracture in combined Type I+Type II group (38/97, 39.2%) was significantly higher than Type III (8/306,2.6%, p<0.001) and Type IV (6/34,17.7%, p=0.002). A total of 35 sides (27 patients) with combined fractures were followed up for 6 months after treatment, among whom 11 sides (7 patients) were operated for both fractures simultaneously. Neither EAC stenosis nor hearing loss was observed. Meanwhile, for 24 non-operated ears from 20 patients, all EACs showed different degrees of stenosis. In conclusion, oral and maxillofacial surgeons should pay more attention to EAC fracture combined with condylar fracture, especially for patients diagnosed with condylar head fracture. Maxillofacial fractures should be accompanied by early treatment of EAC fractures, in order to prevent EAC stenosis, hearing loss, and other complications.

Radiographic evaluation in three dimensions of condylar fractures with closed treatment in children and adolescents

The study aimed at investigating a new three-dimensional classification of healing morphology in condylar fractures in children and adolescents after closed treatment, and establish its association with fracture type and clinical outcomes. The medical records of children and adolescents with condylar fracture were reviewed, retrospectively. The clinical outcomes were assessed by mandibular deviation during mouth opening, Helkimo anamnestic index (Ai), and Helkimo clinical dysfunction index (Di). The condylar healing morphology was evaluated through three-dimensional CT images after 1-2 years of follow-up. In total, 96 patients with 142 condylar fracture sites were included in the study. Condylar healing morphology was classified into three main patterns: unchanged (21.13%), spherical (62.68%), and irregular (16.19% - including the three subtypes triangular, L-shaped, and Y-shaped). There was a significant difference in the distribution of the three main healing patterns among various fracture types (p = 0.0227). Irregular patterns occurred more frequently in adolescents than in children. In unilateral fractures, no obvious association was found between condylar healing morphology and clinical outcomes, including mandibular deviation during mouth opening (p = 0.162), Ai (p = 0.0991) and Di (p = 0.25). Most patients healing in different condylar patterns reached a good clinical outcome after 1-2 years. Although the healing morphology of condylar fractures in children and adolescents remained abnormal, good clinical outcome was achieved over the 2-year follow-up. Therefore, closed treatment remains a good approach.

Classification and treatment strategies for condylar fractures in children

In this study, we aimed to describe a classification method (position and displacement (PD) classification) and the corresponding treatment strategies for condylar fractures in children, based on the anatomical position and displacement of the fractures. Moreover, we aimed to explore the effect of the treatment strategies for condylar fractures in children. Such fractures were classified into the following three types by PD classification: condylar head fracture (type A), mildly displaced condylar neck and base fracture (type B), and severely displaced condylar neck and base fracture (type C). According to this classification, we proposed the corresponding treatment strategy of closed treatment for types A and B fractures and open treatment for type C fractures. Eighty-four patients who had 123 condylar fractures (type A = 97, type B = 16, type C = 10) were included in this study. Type A fractures showed the restoration of normal function with favourable remodelling in the condyles. Types B and C fractures had good function and symmetry in the condylar angle and height of the condylar neck. The PD classification and corresponding treatment strategies may serve as a better option for the clinical treatment of condylar fractures in children.

Mandibular condylar fractures in children and adolescents: 5-Year retrospective cohort study

OBJECTIVE

This study aimed to evaluate and compare the demographic characteristics of mandibular condylar fractures between children and adolescents.

METHODS

The sample was composed of all children (less than 12 years) and adolescents (between 13 and 18 years old) who presented with mandibular condylar fractures within a 5-year period (January 2011 to April 2016). The age, gender, time of injury, mechanism of trauma, location and pattern of fracture, associated injuries and treatment methods were recorded and analysed. Data analysis included chi-square test and Fisher exact test. Differences at p less than 0.05 were considered significant.

RESULTS

A total of 111 children and 39 adolescent patients with condylar fractures were registered and compared. More children than adolescents were involved in falls from a height (p = 0.007), but nearly no relationship was observed between the trauma aetiology and type of condylar fracture in the two patient groups. Condylar head fractures occurred most frequently in the children and adolescents, especially in the children (p < 0.05). Condylar neck fractures were more frequently observed in the adolescent patients (p < 0.001) than in the children. Green-stick fractures occurred only in the child patients (p = 0.005). The patients who fractured other sites of the mandible tended to show a decreased frequency of dislocation (condylar head was out of the glenoid fossa) (p = 0.024). Symphysis/para-symphysis fractures were highly common in the children who sustained unilateral condylar fractures, compared to adolescents (p < 0.05). The patients with bilateral condylar fractures were more frequently associated with other mandibular fractures (children, p = 0.001; adolescents, p = 0.011), especially the fracture of the mandibular body or symphysis. The children who sustained extracapsular fractures were more prone to fractures of other mandibular sites (p = 0.009), especially fracture of the symphysis/para-symphysis (p = 0.014). Intracapsular fractures in children were treated non-surgically more frequently than surgically (p < 0.001). The extracapsular fractures (mild and serious fractures) in children were also treated non-surgically more frequently (p < 0.05).

CONCLUSIONS

The trauma mechanisms, incidence, pattern and treatment of condylar fractures in children substantially differ from those in adolescents. This study was conducted to enable the understanding of the differences in condylar fractures between children and adolescents. Accordingly, preventive measures and treatment plans in children or adolescents should be applied differently.

Early Orthopaedic Treatment of Hemifacial Microsomia

The aim of this paper is to report treatment effects of functional therapy in a growing patient affected by hemifacial microsomia (HM). According to Kaban's classification, the patient was classified as grade IIa as she presented all mandibular and temporomandibular joint components and a normal shaped, hypoplastic mandible. The therapeutic approach included the use of an asymmetrical functional activator (AFA) to stimulate the growth of the affected side and consequently to improve symmetry of the mandible and maxillary deficiency. Further effects were the lengthening of the mandibular ramus, restoration of occlusion, and expansion of soft tissues.

Conservative orthodontic fixed appliance management of pediatric mandibular bilateral condylar fracture

INTRODUCTION

Management of mandibular condylar fractures is difficult in children with their inherently dynamic and unstable deciduous and mixed dentitions. We present a variation of the conservative fixed orthodontic approach that was used as an adjunct to aid in the reduction of a bilateral condylar fracture in a pediatric patient.

METHODS

A boy, aged 10 years 9 months, came with clinical signs and symptoms of mandibular fracture after being involved in a motor vehicle accident. A computed tomography scan showed a vertical fracture on the left condylar head, a displaced fracture of the right condylar neck, and a mandibular symphysis fracture. The patient was treated with an orthodontic fixed appliance instead of an arch bar splint, followed by elastic traction to achieve a proper occlusion and condylar remodeling. Follow-up appointments were made 2 weeks and 1, 2, 20, 37, and 49 months after treatment.

RESULTS

Clinical recovery was observed 2 months after treatment. At the follow-up appointments at 20, 37, and 49 months, jaw function and occlusal relationship remained stable, and no ankylosis was observed. The computed tomography scans showed that the right condyle had remodeled, and the left condyle exhibited a slight curve in the head at 49 months posttreatment. The patient's satisfaction with these treatment results was high.

CONCLUSIONS

Conservative treatment of a mandibular fracture by fixed orthodontic means is a viable treatment option that is relatively straightforward and cost-effective and has a high level of patient acceptance and comfort.

The effect of extracapsular injuries on growth and development of the mandible condyle: an experimental study in growing dogs

OBJECTIVE

To investigate the effects of condylar extracapsular injuries on the development of the mandibular condyle and try to find a way to treat condylar hyperplasia by electively using such injuries to restrict the overdeveloped mandibular condyle.

STUDY DESIGN

Sixty 6-month-old beagle puppies were divided randomly into five groups: blank control; unilateral fracture to the condylar neck; unilateral fracture to the condylar neck treated with rigid internal fixation; unilateral periosteum injury; unilateral decortication of the condylar neck. Computed tomography, ^{99 m}Tc single-photon emission computed tomography, and tetracycline-calcein double-labeling were performed after surgery. The puppies were sacrificed 12 and 24 weeks after surgery. Morphologic analyses and examination of growth activity were done.

RESULTS

Unilateral fracture of the condylar neck without fixation caused local morphologic changes during the early postoperative period, but compensatory growth of the condyle altered such changes after healing. The other types of injury failed to inhibit the growth of the condyle and the mandible, whereas functional deviation of the chin was found after unilateral fracture of the condylar neck with or without fixation.

CONCLUSIONS

The four types of extracapsular injury described here failed to inhibit the growth of the mandibular condyle and could not be selected as alternatives to treat condylar hyperplasia.

Analysis of 126 hospitalized elder maxillofacial trauma victims in central China

Background

The aim of this study was to analyzed the characteristics and treatment of maxillofacial injuries in the elder patients with maxillofacial injuries in central China.

Material and Methods

We retrospectively analyzed the characteristics and treatment of maxillofacial injuries in the patients over the age of 60 to analyze the trends and clinical characteristics of maxillofacial trauma in elder patients from the First Affiliated Hospital of Zhengzhou University (from 2010 to 2013) in central China and to present recommendations on prevention and management.

Results

Of the 932 patients with maxillofacial injuries, 126 aged over 60 years old accounting for 13.52% of all the patients (male:female, 1.74:1; mean age, 67.08 years old). Approximately 52% of the patients were injured by falls. The most frequently observed type of injuries was soft tissue injuries (100%), followed by facial fractures (83.05%). Of the patients with soft tissue injuries, the abrasions accounted the most, followed by lacerations. The numbers of patients of midface fracture (60 patients) were almost similar to the number of lower face fractures (66 patients). Eighty two patients (65.08%%) demonstrated associated injuries, of which craniocerebral injuries were the most prevalent. One hundred and four patients (82.54%) had other systemic medical conditions, with cardiovascular diseases the most and followed by metabolic diseases and musculoskeletal conditions. Furthermore, the study indicated a relationship between maxillofacial fractures and musculoskeletal conditions. Only 13 patients (10.32%) sustained local infections, of whom had other medical conditions. Most of the facial injuries (85.71%) in older people were operated including debridement, fixing loose teeth, reduction, intermaxillary fixation and open reduction and internal fixation (ORIF).

Conclusions

Our analysis of the characteristics of maxillofacial injuries in the elder patents may help to promote clinical research to develop more effective treatment and possibly prevent such injuries.

Key words: Maxillofacial, trauma, elderly, characteristics, treatment.

Pediatric craniomaxillofacial trauma

Trauma is a leading cause of death in children. The pediatric facial skeleton goes through progressive development and major changes, including change in the size ratio of the cranium to the face; change in the ratio of facial soft tissue to bone, and pneumatization of the sinuses. The main goal of maxillofacial fracture repair is to reestablish normal or preinjury structure and function. Follow-up is typically recommended until children reach skeletal maturity as trauma may affect growth of the facial skeleton. Problems not obvious immediately after the injury may become an issue later, and secondary surgery might be needed to address such issues.

Open reduction and internal fixation of severely dislocated fractures of condylar neck and base using bioabsorbable miniplate in children: a 3-10 years follow-up study

OBJECTIVE

To evaluate the long-term clinical and radiologic outcomes of treating severely dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth sustained in childhood using bioabsorbable miniplate with open reduction and internal fixation (ORIF).

METHODS

Five children (age ranged from 3 to 11 years old averaged 8.2 years; 3 boys and 2 girls) with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth were treated with ORIF using 1 or 2 bioabsorbable miniplates (through preauricular approach and an oral vestibular approach). All patients have been followed-up clinically and radiographically for a mean of 5.6 years (range, 3-10 years).

RESULTS

All patients were cured satisfactorily with excellent occluding relation without restricted mandibular movement, facial asymmetry, retrognathism and ankylosis. 3-10 years follow-up study did not occur any mandibular development disorder.

CONCLUSION

The results suggested that ORIF using bioabsorbable miniplate was a reliable fixation technique for use in the treatment of severely dislocated fractures of the condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in children when the non-invasive or occlusal therapies were ineffective.