Fractures of the mandibular condyle

The Case of the Irretrievable Mandibular Condyle: My Experience with Utilization of an Extraoral Vertical Ramus Osteotomy in Managing Severely Medially Displaced or Dislocated Mandibular Condyle Fractures

Medially displaced condylar head fractures pose a challenge for oral and maxillofacial surgeons. Accessing, retrieving, and reducing a displaced fracture is seemingly impossible at times. Consideration of the risks must also be taken, including significant bleeding during exposure, injury to the facial nerve, and ability to fixate an unstable segment. Performing an extraoral vertical ramus osteotomy to safely access the condylar head fracture will provide a safer and more meaningful approach to managing severely medially displaced or dislocated mandibular condyle fractures in cases when the condyle is irretrievable.

Does magnitude of deformity correlate with functional outcome following closed reduction in unilateral condylar fracture?

Introduction: Condyle fracture can be treated surgically (ORIF) or conservatively (CTR). When treated by CTR, the fracture might not heal in a morphologically ideal shape. The severity of the deformity and its effects on the functional outcome is not known. This study would investigate the anatomical outcome of CTR and its effect on the functional outcome. Methods: Using a cross-sectional study design, we enrolled patients identified from our trauma census that meets the pre-determined inclusion criteria. Patient underwent assessment which involves clinical and radiographic evaluation. Clinical examination was done by using Helkimo Index. Radiographic evaluation by using cone beam computed tomography (CBCT) scan were traced and digitized, and the position and morphology of the fractured mandibular condyle was measured and compared with those of the contralateral non-fractured condyle in the axial, coronal and sagittal planes. Radiographic data was then compared with data from clinical examination. Results: 25 patients with unilateral condyle fracture and met the inclusion criteria were identified. Eight patients were successfully recalled and included in the study. Assessment was done on average of 40 months post-treatment. Clinical assessment with Helkimo Index showed that 63% had at least mild temporomandibular symptoms or dysfunction. CBCT examinations revealed that most patients had morphologically deformed healed condyle. No pattern can be seen in the magnitude of deformity with functional outcome. Conclusions: Following CTR, condyle fracture would heal in a morphologically deformed shape. Satisfactory functional outcome is still attainable despite this. The magnitude of the deformity does not appear to influence the functional outcome.

Unilateral Subcondylar and Condylar Neck Fractures: Randomized Clinical Study

Aims and Objectives:

The aim of the present study was to compare closed treatment with open reduction internal fixation (ORIF) for subcondylar and condylar neck fractures.

Materials and Methods:

This randomized prospective study was conducted on thirty patients who visited the Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar, with condylar fractures. All fractures were displaced; either angulated between 10° and 45° and the ascending ramus was shortened by >2 mm to <15 mm. Patients were divided into two groups after satisfying the inclusion and exclusion criteria – Group I (closed treatment) and Group II (open reduction) (15 implants in each group). In Group I, patients were treated by mandibulo-maxillary fixation using arch bar and elastics for 4 weeks, and in Group II, patients were treated by ORIF using two 1.5-mm miniplates. Follow-up was done at 1 month, 3 months, and 6 months. Our postoperative evaluation included five parameters – maximal interincisal opening, protrusion, lateral excursion on fractured and nonfractured sides, anatomical reduction, and pain and malocclusion. Nonparametric data were compared for statistical significance with Chi square test and parametric data with an independent sample's t-test (P < 0.05).

Results:

Correct anatomical position of the fragments was achieved significantly more accurately in the operative group in contrast to the closed treatment group. Regarding mouth opening/lateral excursion on fractured and nonfractured sides/protrusion, significant (P < 0.05) differences were observed between both groups (open 39.73/7.50/8.17/7.87 mm vs. closed 36.87/6.07/7.23/7.13 mm). Pain also revealed significant (P = 0.025) difference with less pain in the operative treatment group.

Conclusion:

Both treatment options for condylar fractures of the mandible yielded acceptable results. However, operative treatment was superior in all objective and subjective functional parameters except occlusion.

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.

Remodeling of Displaced Condylar Fractures with Functional Treatment: High-Quality Radiographic Documentation in Three-Patient Series

Treatment of condylar fractures is variable and controversial. Treatment options for management of condylar fractures include surgical and nonsurgical methods, and if a nonsurgical method is as effective as a surgical method, the former is preferred. Although plain film radiographs and functional outcomes attained through nonsurgical treatment are well established in literature, evidence of the remodeling process through detailed, high-quality imaging is lacking. The purpose of this case series is to describe and illustrate two adults and one pediatric patient with significantly displaced condylar fractures treated nonsurgically with excellent clinical results. It is unique for such patients to have pre- and posttreatment computed tomography scans with high-quality three-dimensional reconstruction as in the case of two adults and to have 3.5-year posttrauma radiographs and 14.5-year follow-up as in the case of the pediatric patient. As such, this report is useful in visually presenting three examples of repositioning and reformation of the temporomandibular joint structures in displaced condylar fractures in a postmenarche 14-year-old female patient, a 21-year-old male patient, and an 18-month-old male patient.

Functional outcomes of preauricular underparotid retrograde approach for mandibular condyle fractures

Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. Various approaches have been previously mentioned for the access to the mandibular condyle. The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures. This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Functional outcomes with this method were addressed in light of the results obtained in this clinical series. We suggest this method in the management of condylar fractures.

Increased levels of interleukin-6 in synovial lavage fluid from patients with mandibular condyle fractures: correlation with magnetic resonance evidence of joint effusion

PURPOSE

The aim of the present study was to investigate the relation between magnetic resonance (MR) evidence of joint effusion and concentrations of proinflammatory cytokines, including interleukin (IL)-1β and IL-6, in washed-out synovial fluid samples obtained from patients with mandibular condyle fractures.

PATIENTS AND METHODS

Twenty-five joints in 23 patients with mandibular condyle fractures were examined. Computed tomography was used to determine the position of the fracture and MR examination was performed in all cases. Twenty-five joints underwent temporomandibular joint (TMJ) irrigation before surgical treatment for the fractures. The detection rates and concentrations of the tested cytokines were determined, and their relations to evidence of joint effusion and positions of the condylar fractures were analyzed.

RESULTS

Six TMJ fractures were found in the head, 10 in the upper neck, 4 in the lower neck, and 5 in the subcondyle. MR evidence of joint effusion was observed in 17 of 25 TMJs (68.0%). The detection rate and concentration of IL-6 were significantly higher in patients with MR evidence of joint effusion and those with high condylar fractures. Moreover, there was a correlation between joint effusion grade and IL-6 concentration.

CONCLUSIONS

The present findings showed a correlation between MR evidence of joint effusion and concentration of IL-6 in washed-out synovial fluid samples collected from patients with mandibular condyle fractures. These results may provide support for arthrocentesis as a reasonable treatment modality for high condylar fractures.

Evaluation of prevalence in the treatment of mandible condyle fractures

OBJECTIVE

To study the treatment of fractures of the mandibular condyle and discuss conservative versus surgical therapy.

METHODS

We examined the medical records of 892 bucofacial traumas, from which we selected only those who had: reports of condylar fractures, isolated or associated with other facial bones, identification data, dental care history and treatment applied for the condylar fracture. Data were analyzed using descriptive statistics, and the conservative and surgical therapies were compared.

RESULTS

Condyle fractures were present in 124 cases. Males represented 72.0% of the sample, the age group most affected being the one between 21 and 30 years. Conservative treatment was used in 61.0% of patients.

CONCLUSION

Surgical treatment was predominantly used in patients over ten years old, victims of traffic accidents and falls, followed by assaults, firearms and sporting accidents.

Endoscope-assisted transoral reduction and internal fixation versus closed treatment of mandibular condylar process fractures--a prospective double-center study

PURPOSE

The aim of this international AO-study was to compare the functional outcome after open versus closed treatment of mandibular condylar neck fractures.

PATIENTS AND METHODS

A prospective comparative study with two follow-ups (FU) at 8-12 weeks and 1 year was undertaken in two clinics, which exclusively privileged either surgical or conservative treatment due to different therapeutic agendas. Patients from clinic 1 (ENDO group) received endoscope-assisted transoral open reduction and internal fixation, whereas patients from clinic 2 (CONS group) were treated conservatively without surgery. Patients with unilateral condylar neck fractures showing one or more of the following conditions were included: displacement of the condyle with an inclination >30° and/or severe functional impairment such as malocclusion or open bite, with or without dislocation of the condylar fragment; severe pain upon palpation or movement, and/or vertical shortening of the ascending ramus. High or intracapsular condylar neck fractures were excluded.

RESULTS

75 patients (44 CONS and 31 ENDO patients) with condylar neck fractures were included in this study. The Asymmetric Helkimo Dysfunction Score (A-HDS) was slightly lower in the CONS group than in the ENDO group at the 8-12-week FU, corresponding to better function on the short-term. At the 1-year FU, however, there were slightly better values in the ENDO group. For the Clinical Dysfunction Index (Di) and the Anamnestic Dysfunction Index (Ai), CONS patients had a better outcome than ENDO patients at the 8-12 week FU, ie, a higher proportion of ENDO patients had severe symptoms due to the operative trauma. Yet these symptoms improved by one year, finishing with a significant higher proportion of symptom-free patients in the ENDO group. In addition, these patients had better values for the Index for Occlusion and Articulation Disturbance (Oi) at both FU examinations, ie, the proportion of patients without any occlusal disturbances was significantly higher in the ENDO group. On average, the duration of postoperative maxillo-mandibular fixation (MMF) was 3 times longer for the CONS group than for the ENDO group (33 vs. 11 days).

CONCLUSION

Both treatment options may yield acceptable results for displaced condylar neck fractures. Especially in patients with severe malocclusion directly after trauma, however, endoscope-assisted transoral open reduction and fixation seems to be the appropriate treatment for prevention of occlusal disturbances during FU.

Outcomes of open versus closed treatment of mandibular subcondylar fractures: a prospective randomized study

PURPOSE

To compare open reduction and internal fixation with closed treatment and maxillomandibular fixation for the management of subcondylar fractures of the mandible.

PATIENTS AND METHODS

Forty patients with subcondylar fractures of the mandible were evaluated. All fractures were displaced; either angulated between 10 degrees and 35 degrees or the ascending ramus was shortened by more than 2 mm. Clinical and radiographic evaluation was performed 6 months after the trauma. Clinical parameters included mouth opening, protrusion, laterotrusion, deviation on mouth opening, and occlusion. Radiographic parameters included level of the fracture, deviation of the fragment, and shortening of the ascending ramus. Subjective parameters included pain according to a visual analog scale. Nonparametric data were compared for statistical significance with a chi(2) analysis and parametric data with an independent samples t test (P < .05).

RESULTS

Correct anatomical position of the fragments was achieved significantly more accurately in the operative group in contrast to the closed treatment group. Regarding mouth opening/lateral excursion/protrusion, significant (P = .00) differences were observed between both groups (open 39.6/12.5/5.9 mm vs closed 33.5/9.8/4.1 mm). The visual analog scoring revealed significant (P = .00) difference with less pain in the operative treatment group (1.1 open vs 5.2 closed). No statistically significant difference was found between the 2 groups for occlusion (P = .86).

CONCLUSION

Both treatment options for condylar fractures of the mandible yielded acceptable results. However, operative treatment was superior in all objective and subjective functional parameters except occlusion.

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.

Biomechanical evaluation of different types of rigid internal fixation techniques for subcondylar fractures

PURPOSE

The aim of this study was to evaluate the biomechanical stability of various internal fixation systems for subcondylar fractures.

MATERIALS AND METHODS

Eighteen identical synthetic mandibles were used. Left condylar processes were cut to mimic perpendicular subcondylar fracture and right sides were mimicked oblique subcondylar fracture. The fixation systems used included single 4-hole mini adaptation plate, double fixation with the same plates, single 4-hole mini dynamic compression plate (DCP), Eckelt lag screw system, Wurzburg lag screw plate system and double 4-hole biodegradable miniplates made of poly L-lactide (PLLA). In oblique fractures, one of the screws fixing plates was used bicortically through bone fragments. The loading vector simulated physiologic forces to the condyle on biting with servohydraulic testing machine until failure was reached. Load-displacement curve, maximum load for failure, and stiffness were measured.

RESULTS

In perpendicular fracture, double adaptation plate showed the highest level of tolerance load followed by Eckelt lag and double PLLA plate. In stiffness, double adaptation plate and Eckelt lag screw showed higher level of stiffness, whereas double PLLA was almost at the same level of single DCP. In oblique fracture, double adaptation plate showed the highest strength.

CONCLUSIONS

In this laboratory setting, double adaptation plates fixation proved to have superior biomechanical stability in both fracture conditions. Eckelt lag screw showed good stability in the perpendicular fracture, however, it was weak in the oblique fracture.

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.

Open versus closed treatment of fractures of the mandibular condylar process-a prospective randomized multi-centre study

AIM

The aim of this international prospective randomized multi-centre study was to compare operative and conservative treatment of displaced condylar fractures of the mandible.

METHODS AND PATIENTS

Out of a total of 88 randomized patients from 7 centres, 66 patients with 79 fractures of the mandibular condylar process completed the study and were evaluated. All fractures were displaced, being either angulated between 10 degrees and 45 degrees or the ascending ramus was shortened by more than 2mm. The follow-up examinations 6 weeks and 6 months following treatment included evaluation of radiographic measurements, clinical, functional and subjective parameters including visual analogue scale for pain and the Mandibular Function Impairment Questionnaire index for dysfunction.

RESULTS

Correct anatomical position of the fragments was achieved significantly more often in the operative group in contrast to the closed treatment group. Regarding mouth opening/lateral excursion/protrusion, significant (p=0.01) differences were observed between both groups (open 47/16/7mm versus closed 41/13/5mm). The visual analogue scoring revealed significant (p=0.03) differences with less pain in the operative treatment group (2.9 open versus 13.5 closed). The Mandibular Function Impairment Questionnaire index recorded a significant (p=0.001) difference with less pain and discomfort in the open treatment group (10.5 versus 2.4 points).

CONCLUSION

Both treatment options for condylar fractures of the mandible yielded acceptable results. However, operative treatment, irrespective of the method of internal fixation used, was superior in all objective and subjective functional parameters.

The periauricular transparotid approach for open reduction and internal fixation of condylar fractures

INTRODUCTION

Treatment of fractures of the mandibular condyle fractures varies among centres as there still is no general consensus. The aim of this paper was to determine the safety and efficiency of surgical treatment using a transparotid approach for direct plating.

PATIENTS AND METHODS

A prospective clinical study was conducted on 34 patients with 36 fractures of the condyle. All 36 fractures were displaced, and 14 (39%) of them were fracture dislocations. The fractures were treated surgically with a transparotid facelift or retromandibular approach using miniplates and screws for fixation. Patients were carefully followed up and were asked to answer a survey paper 2-39 months postoperatively.

RESULTS

Occlusion practically identical to the pretraumatic condition was achieved in 31 out of 33 dentate patients (94%). Postoperative interincisal distance was 30-61 mm (mean 44 mm), 4 patients (12%) had postoperative deflection to the side of injury during mouth opening. Facial symmetry was achieved in all of the patients. Eight out of 36 cases (22%) had a transient weakness of certain ipsilateral facial muscle groups, lasting for 4-8 weeks. In one of these patients, a mild weakness of the upper lip and lower eyelid persisted after 13 months. There were 5 cases of miniplate fractures (14%), all of them in patients in whom 1.7 or thinner miniplates were used. There were 5 cases of salivary fistulae (14%), all of them in patients where the parotid capsule was not closed in a watertight fashion. According to the postoperative survey completed by 32 patients, 30 of them (94%) were very satisfied with the outcome of treatment.

CONCLUSION

If conducted properly, the transparotid facelift approach offers a safe and effective approach for direct fixation of condylar fractures.

Comparative study of intra-articular irrigation and corticosteroid injection versus closed reduction with intermaxillary fixation for the management of mandibular condyle fractures

OBJECTIVE

To evaluate the clinical outcome of a modified conservative treatment protocol involving intra-articular irrigation and corticosteroid injection into the superior joint compartment (SJC) of patients with fresh mandibular condyle fractures. Study design A total of 26 consecutive unilateral fresh condylar fractures in 26 patients were divided into the intra-articular irrigation (IR) group (14 patients, 14 joints) and the conventional conservative treatment (CC) group (12 patients, 12 joints). In the IR group, the SJCs of the fractured joints were irrigated with saline solution and injected dexamethazone sodium, followed by conventional rehabilitation. In the CC group, patients were treated by closed reduction with intermaxillary fixation (IMF) for 2 weeks, followed by conventional rehabilitation. Clinical outcome at 1 month, 3 months, 6 months, and 1 year after injury was determined by clinical examination of jaw motion, joint pain, and occlusal changes. The posttreatment results were compared with the pretreatment baseline data. Between-group differences in clinical parameters were analyzed.

RESULTS

There were significant between-group differences in the range of mandibular motion at 1 month and 3 months after injury (1 month, P=.0022; 3 months, P=.0022). In the IR group, joint pain was well relieved from the early stage of treatment. Occlusal changes were found in 1 patient in the IR group and 4 patients in the CC group at 1 year after injury.

CONCLUSIONS

The modified treatment protocol involving intra-articular irrigation and corticosteroid injection into the SJC is a more effective and quick-acting modality than conventional closed reduction with IMF for functional recovery and control of clinical symptoms of patients with unilateral fresh condylar fractures.

Mandibular condyle fractures: determinants of treatment and outcome

PURPOSE

The objective of this study was to analyze the principal variables that determine the choice of the method of treatment and the outcome in condylar fractures.

MATERIALS AND METHODS

We conducted a retrospective analysis of 104 mandibular condyle fractures to analyze and determine the relation between the principal clinical variables and the postoperative results. All patients underwent a clinic-radiologic investigation focusing on fracture remodeling, evolution, dental occlusion, and symmetry of the mandible. We analyzed the influence of the preoperative clinical variables (level of fracture, treatment, postoperative physical therapy, displacement and dislocation, comminution, loss of ramus height, patient age, gender, etiology, occlusion, status of dentition, and presence of facial and mandibular fractures) over the postoperative results and outcome.

RESULTS

The principal factors that determined the treatment decision were the level of the fracture and the degree of displacement. The level of the fracture influenced the degree of preoperative coronal and sagittal displacement (neck fractures had greater medial and anterior displacement than head and subcondylar fractures) and the treatment applied. The functional improvement obtained by open methods was greater than that obtained by closed treatment. Open treatment increased the incidence of postoperative condylar deformities and mandibular asymmetry.

CONCLUSION

The variables that influenced the method of treatment and predicted the prognosis are the level of fracture, degree and direction of displacement of the fractured segments, age, medical status of the patient, concomitant injuries, and status of dentition.

Endoscopic mandibular condyle fracture repair

Treatment of mandibular condyle fractures remains a controversial issue. Arguments center on the relative merits of open versus closed treatment. In the past decisions were largely based on philosophy, anecdotal experience, and retrospective case series with short follow-up. Well-designed studies have now begun to appear in the literature and suggest improved results after open, anatomic reduction and fixation. Many surgeons are still hesitant about liberally applying the open approach due to the resultant facial scarring and the risk of facial nerve injury. Developments in endoscopic technology have recently been applied to facial fracture repair. The endoscopic approach to mandibular condyle fracture repair reduces the risk of facial nerve injury, and dramatically reduces facial scarring, compared with standard open approaches. We feel that the reduced morbidity of the endoscopic approach may allow the benefits of anatomic reduction and rigid fixation to be offered to a larger proportion of patients with mandibular condyle fractures. Technical and technological advances are expected to aid in the dispersal of these techniques in the future.

Non-surgical treatment of condylar fractures in adults: a retrospective analysis

PURPOSE

The aim of the study was to investigate the results of non-surgical treatment of condylar fractures in a group of 60 patients with 71 condylar fractures, in order to establish a protocol to select patients for surgical treatment of condylar fractures.

MATERIAL

Out of a group of 91 patients treated in a non-surgical fashion, 60 patients with a total of 71 condylar fractures responded to the request for follow-up.

METHODS

Retrospective study, including clinical analysis of occlusion, asymmetry at rest and during mouth opening, maximum interincisal distance, signs of TMJ-dysfunction and analysis of radiographic data, i.e. shortening of the ascending ramus as measured on sequential orthopantomograms.

RESULTS

There were five patients (8%) with an unacceptable malocclusion of which one also had considerably limited mouth opening. Fifty-five patients (92%) had none or only minor signs of TMJ-dysfunction not requiring further treatment.

CONCLUSION

Only in selected patients with shortening of the ascending ramus of 8mm or more and/or considerable displacement of the condylar fragment, surgical repositioning and rigid internal fixation should be considered.

Functional results of unilateral mandibular condylar process fractures after open and closed treatment

BACKGROUND

This retrospective study compared the functional results of unilateral mandibular condylar process fractures treated either by open reduction or by closed treatment.

METHODS

Sixty-six patients with unilateral mandibular condylar process fractures were reviewed. Thirty-six patients received open reduction, and the other 30 underwent closed treatment (intermaxillary fixation only). Each group was further divided into condylar and subcondylar subgroups according to fracture level. The functional outcome was evaluated by posttreatment occlusion status, maximal mouth opening, facial symmetry, chin deviation, and temporomandibular joint symptoms.

RESULTS

Patients undergoing closed treatment exhibited more condylar motility than those treated by open reduction. Patients in the condylar subgroup with open reduction presented less chin deviation (21.43%) compared with those with closed treatment (56.25%; p = 0.072). Although a greater severity of subcondylar fractures existed in patients treated with open reduction, patients treated with open reduction or closed treatment did not reveal a significantly functional difference.

CONCLUSION

The present study revealed that patients with condylar neck or head fractures gained more benefits from open reduction in terms of chin deviation and temporomandibular joint pain. For subcondylar fractures, open reduction provides satisfactory functional results in patients with severely displaced fractures.

The role of open reduction and internal fixation in unilateral fractures of the mandibular condyle: a prospective study

The purpose of this report is to present our experience in the management of unilateral condylar fractures between 1995 and 1998. This prospective study was carried out at a Regional Maxillofacial Unit and Teaching Hospital in the UK, and included 54 patients, of whom 32 attended for review. In all, 42 men and 12 women (age range 17-40 years) entered the study: 28 patients had unilateral fractures of the mandibular condyle alone; the remainder also had another mandibular fracture, invariably at the parasymphysis. Thirty-five of the patients (65%) had allegedly been assaulted. This is at variance with a recent study published by the British Association of Oral and Maxillofacial Surgeons, which showed that only 24% of facial injuries were the result of inter-personal violence. Open reduction and internal fixation of the mandibular condyle seems to carry low morbidity and may be of considerable functional benefit to the patient.

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.

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.

[Electromyography studies for objective assessment of loss of function of the lateral pterygoid muscles after dislocation fractures of the mandibular processes]

The aim of treatment for luxation fractures of the mandibular articular processes is not only complete anatomical restitution but also restoration of the mobility. In a retrospective study on 242 patients after operative and conservative treatment, it was possible to demonstrate that there are no correlations between fragment position and functional result. Functional restitution was observed after conservative treatment in 65% of cases and after operative treatment in 57%. In order to establish the causes for dysfunction of the lateral pterygoid muscle an electromyographical technique was developed to dissipate the action potentials of the muscle. Another retrospective study, performed in 23 patients with dysfunction of the mandible revealed loss of activity of the lateral pterygoid muscle after fracture treatment, independent of the treatment method, in 11.5% of cases (two patients). Without any connection to the treatment method, the remaining results permit to conclude that there are preoperative neurological defects. Therefore the pre- and posttherapeutic functions of muscles and nerves were investigated in a prospective study on 18 patients. Before the treatment 16.6% of the patients (n = 3) showed defects of the lateral pterygoid nerve with a resulting loss of muscle function. According to the findings, residual dysfunction of the lateral pterygoid muscle is determined by the extend of the traumatic nerve injury, independent of the treatment method. In the case of axonal defects of the pterygoid nerve, there can be no expectation of a restitutio ad integrum after the operative fragment position.

Open reduction of subcondylar fractures. A study of functional rehabilitation

Open reduction of dislocated subcondylar fractures was carried out in 19 adult patients between 1990 and 1992. A comparison of the results between two groups of patients was made 1 year after trauma. The reference group consisted of patients with the same type of fracture but treated with only intermaxillary fixation (IMF) and moderate jaw exercises after release of IMF. Dysfunction of the masticatory system was noticed in only a few cases of either group. Open reduction with plate osteosynthesis made it possible to avoid IMF in 12 of 19 patients. The results in the two groups did not differ significantly from a functional point of view. There are, however, specific indications for open reduction based on the degree of dislocation and concomitant subjective symptoms.

Open reduction and internal fixation of condylar fractures via an extended bicoronal approach with a masseteric myotomy

Although condylar fractures of the mandible may be treated by closed reduction and appropriate physiotherapy, open reduction and internal fixation is indicated in specific circumstances. We report 25 cases of a previously unreported method of exposure of condylar fractures using an extended bicoronal approach combined with myotomy of the masseter muscle. Acceptable reduction and fixation was achieved in all cases with an early return to function. The incidence of complications was low, with three mild temporary facial palsies which had resolved by the sixth postoperative week and one haematoma beneath the bicoronal scalp flap. A cosmetically acceptable scar was produced in all cases. The excellent surgical exposure and protection of the facial nerve, combined with cosmetically acceptable scars, commend the use of this technique.