Recovery of mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures

Comparative Evaluation of Open Reduction with Internal Fixation Against Closed Reduction Methods for Condylar Fracture Management: A Systematic Review and Meta- analysis

Background

Mandibular fractures are frequent in facial trauma. Management of mandibular condylar fractures (MCF) remains an ongoing matter of controversy in maxillofacial injury. A number of techniques, from closed reduction (CR) to open reduction and internal fixation (ORIF), can be effectively used to manage these fractures. The best treatment strategy, that is, closed reduction or open reduction with internal fixation, remains controversial.

Aim

The aim of this study is to systematically review the existing scientific literature to determine whether open reduction with internal fixation or closed reduction is a better treatment alternative for the patients with condylar fractures through a meta-analysis.

Methods

A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Electronic databases like PubMed, google scholar and Ebsco Host were searched from 2000 to December 2021 for studies reporting management of condylar fractures through open reduction with internal fixation against closed reduction and reporting the outcome in terms of mean and standard deviation (SD). Quality assessment of included case control and cohort studies was performed using Newcastle-Ottawa Scale, and randomized studies were evaluated using Cochrane risk-of-bias (ROB)-2 tool through its domains. The risk of bias summary graph and risk of bias summary applicability concern was plotted using RevMan software version 5.3. The standardized mean difference (SDM) was used as summary statistic measure with random effect model and p value <0.05 as statistically significant.

Results

Seventeen studies fulfilled the eligibility criteria and were included in qualitative synthesis, of which only nine studies were suitable for meta-analysis. The pooled estimate through the Standardized Mean Difference (SMD) of 0.80, 0.36 and 0.42 for maximum inter incisal opening, laterotrusion and protrusion favours CR compared to ORIF for condylar fracture management. Also, most results of heterogeneity tests were poor and most of the funnel plots showed asymmetry, indicating the presence of possible publication bias.

Conclusion

The results of our meta-analysis suggest that CR provides superior outcomes in terms of maximum inter incisal opening, laterotrusion and protrusion compared to ORIF in condylar fractures management. It is necessary to conduct more prospective randomized studies and properly control confounding factors to achieve effective results and gradually unify clinical guidelines.

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Retraction force necessary to expose the mandibular neck in Risdon and high cervical anteroparotid transmasseteric approaches: an anatomic comparative study

PURPOSE

The purpose of this anatomic study was to compare the retraction force necessary to expose the mandibular neck in the Risdon and the high cervical anteroparotid transmasseteric (HAT) approaches.

METHODS

An anatomic study was performed on 18 formalin-embalmed cadavers. We performed a Risdon approach on the left side, and an HAT approach on the right side in all the cases. The subjects were placed in a normative frame and the force necessary to maintain a satisfactory exposure of the condyle was measured with a system of cables, pulleys, and mechanical dynamometer. The statistical comparison between the two sides was carried out using the Wilcoxon signed-rank test for paired series.

RESULTS

In all the cases, the region of interest was exposed as in the operating room. In the Risdon approach, the mean force was 32 Newtons (4-47). In the HAT approach, the mean force was 19 Newtons (4-33). The difference was statistically significant (p < 0.001). The age, gender, and duration of conservation had no influence on the retraction force.

CONCLUSION

In the HAT approach, the retraction of the soft tissues was significantly lower than in the Risdon approach. This study gave an additional explanation to the remarkable safety of the HAT approach. Our results were in favor of the generalization of this technique.

Physiotherapy Maneuver Is Critical to Recover Mouth Opening After Pediatric Trauma

PURPOSE

A restricted mouth opening (MO) is predominantly a complication of maxillofacial trauma in pediatric patients and develops in 4 to 26.2% of cases. The purpose of the present study was to quantitatively investigate the influence of patient demographic data, fracture characteristics, and regular vigorous physiotherapy, with either voluntary or forcible MO exercises, on the recovery of a post-traumatic restricted MO in pediatric patients.

PATIENTS AND METHODS

A prospective cohort study was performed of pediatric patients with maxillofacial injuries who had been referred to Al-Zahraa and El-Fayoum Hospitals from 2013 to 2015. The predictive variables were patient demographic data, fracture characteristics, and regular vigorous physiotherapy. The patients were treated with a closed technique. The MO measurements were the clinical outcome variables and were recorded at the first week and then monthly for 12 months. Regular vigorous physiotherapy was performed until the patients had returned to their preoperative MO. The data were tabulated and statistically analyzed.

RESULTS

Eighty-six patients were enrolled in the present study. Males predominated. Falls were the most common cause of fracture. Condylar fractures had the greatest incidence. A restricted MO occurred in 81 patients. The results showed no interaction between MO recovery and age, gender, etiology, or fracture site. After physiotherapy, the patients had returned to their preoperative MO at the fourth month, with the measurements fixed at normal values at the sixth month. The recovery rate was nonlinear, with faster improvement in the months closest to the injury.

CONCLUSION

Physiotherapy is more critical in the recovery of the MO and prevention of bony ankylosis than patient data or fracture characteristics in pediatric trauma. We highly advocate the performance of voluntary mouth exercises, even in the absence of fracture. Forcible MO exercises are mandatory to recover a restricted MO. These exercises should be performed under close supervision of the patient's surgeon with the parents motivated to cooperate for at least 6 months.

Use of a modified high submandibular approach to treat condylar base fractures: Experience with 44 consecutive cases treated in a single institution

PURPOSE

The aim of this article is to present our experience treating fractures of the condylar base with a modification of the high submandibular approach (HSA).

MATERIALS AND METHODS

Between June 2012 and April 2015, 44 fractures of the condylar base were treated in the Department of Oral and Maxillofacial Surgery of the Medical Hospital of Graz using the modified HSA.

RESULTS

We did not observe any damage (even transient) to the facial nerve or any complication related to violation of the parotid capsule (such as a salivary fistula, Frey syndrome, or a sialocele).

CONCLUSIONS

This approach provides good access to the condylar base, ensuring easier internal fixation, excellent protection of the facial nerve and parotid gland, and good cosmetic results.

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.

Functional evaluation in orthodontic surgical treatment: long-term stability and predictability

Background

The introduction of electromyographic and kinesiographic technology in orthodontics allows to obtain objective data regarding the functional aspects of the mandibular movements and the masticatory muscular activity. It is then important to be able to correlate the data obtained by instrumental activity with the clinical ones. The aim of this study consists to analyse the post ortodontic surgical stability through instrumental evaluation of the masticatory muscles and mandibular movements.

Method

30 patients undergo electromyographic and kinesiographic evaluations through all the surgical orthodontic iter and were than followed during other 4 years. JMP software was used to analyze and correlate the electromyographic and knesioographic data during treatment and during the follow up.

Results

A linear correlations between some functional objective values collected from the examinations at the beginning and during therapy and the follow up one has been demonstrated.

Conclusion

It is important to submit patients in surgical ortodontic treatment to instrumental analysis which can evidence how masticatory function and mandibular movements are performed. It is also important to highlight some functional values also from the beginning of the treatment because an alteration of such values can be related to a better or worse postsurgical rehabilitation.

Evaluation of Retro Mandibular Approach to Open Reduction and Internal Fixation of Condylar Fractures: A Cross-sectional Study

PURPOSE

The present study was carried out to evaluate the usefulness of mini retromandibular approach on accessibility, scarring and stability in open reduction and internal fixation of sub condylar fractures.

MATERIALS AND METHODS

Fifteen patients underwent open reduction and rigid fixation of middle and low subcondylar fractures, with mini-retro mandibular approach.

RESULTS

No signs of infection were observed in any patient postoperatively. Surgical scar was imperceptible and esthetically acceptable in all the cases. Out of 15 patients, only one patient had discrepancy in occlusion and after 2 months satisfactory centric occlusion was achieved. Salivary fistula (parotid fistula) was observed in 3 cases within 1 week postoperatively, which was treated spontaneously with the use of hypertonic saline. Transient facial nerve weakness was observed in 2 patients, in one patient it resolved in 4 weeks postoperatively and in second patient 3 months postoperatively. Mouth opening increased in all the patients with time. Average mouth opening at 1 week interval was 19.6 mm, at 2 months interval 28.2 mm, and after 6 months 38.33 mm suggesting that mouth opening gradually increased with time. At the end of 2 months postoperatively none of the patients had any restriction in lateral movements. At 2 months postoperatively 4 patients had deviation but none of the patients had any deviation 6 months postoperatively.

CONCLUSION

It is evident from the results of our study that open reduction and internal fixation using mini-retromandibular approach is good treatment option in management of mandibular condylar fractures.

Evaluation of mechanical resistance after fixation of mandibular condylar fracture with single and double miniplates: a comparative in vitro study

OBJECTIVES

To evaluate the efficacy of two plating system in comparison with single plating systemTo study the biomechanical behaviour of single and two plating system when compression load is applied.

MATERIALS AND METHODS

Twenty hemimandibles were divided into two groups A and B of ten each. A subcondylar fracture was created. Group A was stabilized by single adaptation plating technique and group B by double adaptation plating technique and both the groups were tested for stability by using universal testing machine.

RESULTS

Higher mean displacement was observed in Group A compared to Group B, but the difference in mean displacement between the two groups was not statistically significant (p > 0.05). Higher mean load was recorded in group B compared to group A and the difference in mean load between them was found to be statistically significant (p < 0.001).

CONCLUSION

The present study demonstrated that double adaptation plating technique had greater resistance to compression load than single adaptation plating technique and it shows more favorable biomechanical behavior.

Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study

Surgical management of mandibular condyle fractures is still controversial. Although it provides better outcome than closed treatment questions still remain about the surgical approach and the osteosynthesis devices to be used. Between 2005 and 2010, we managed 168 mandibular condyle fractures with open treatment. Two surgical approaches were used in this study, a pre-auricular and a high submandibular approach (one or the other or as a combined approach). Internal fixation was performed using TCP(®) plates (Medartis, Basel, Switzerland) or with two lag screws (15 and 17 mm). Delta plates were used in 15 cases (8.9%). We report the epidemiology of these fractures and the outcomes of the surgical treatment. We assessed the complications related to the surgical procedure and those related to the osteosynthesis material. The facial nerve related complication rate was very low and the osteosynthesis materials used proved to be strong enough to realize a stable fixation. The two approaches used in this study appeared to be safe with good aesthetic results. Most of the surgical procedure failures occurred in high subcondylar fractures especially when bilateral.

Evaluation of clinical use of indigenously developed delta plate in management of subcondylar fracture

Condylar fractures account for 25-35% of mandibular fractures and deserve a special consideration apart from rest of the mandible due to their anatomical differences and healing potential. Previous clinical and biomechanical studies have recommended using two miniplates for fixation of condyle fractures. Two miniplates require a certain size of the proximal condyle fragment and thus are applicable mainly in cases involving low fractures. The present study evaluates the clinical use of indigenously developed titanium delta-shaped miniplate in open reduction and internal fixation of subcondylar fracture.

Treatment of low subcondylar fractures--a 5-year retrospective study

The aim of the present study was to retrospectively review the treatment outcome of low subcondylar temporomandibular joint fractures. The retrospective analysis was performed on all patients treated for low subcondylar fractures (below the sigmoid notch) between 2006 and 2011. Patients were divided into two groups: the closed reduction group (maxillomandibular fixation, MMF) and the open reduction group (anteroparotid transmasseteric (APTM) approach). Out of 129 condylar fractures, a total of 37 patients met the inclusion criterion of a fracture below the sigmoid notch (low subcondylar). Ten patients (seven males and three females) were treated using the APTM approach, and 27 patients were treated conservatively by MMF. In the open reduction group, two patients (20%) had limited mouth opening that resolved following physiotherapy; the closed reduction group had a similar percentage (18.5%) of mouth opening limitation (below 35 mm). No facial nerve damage was noted. Adult patients suffering from low subcondylar fractures can be treated by open reduction and internal fixation using the APTM approach, which was found to be a safe and reproducible procedure with no facial nerve damage; however this is a surgical procedure with a shallow learning curve.

Transoral open reduction with rigid internal fixation for subcondylar fractures of the mandible using a small angulated screwdriver system: is endoscopic assistance necessary?

PURPOSE

Although endoscopically assisted transoral open reduction and internal fixation of condylar mandible fractures is currently a popular technique, the need for it and its benefits remains unclear. This prospective study evaluated the efficacy and safety of open reduction and rigid internal fixation of subcondylar fractures of the mandible using a new small angulated screwdriver system without endoscopic assistance.

PATIENTS AND METHODS

Fifteen patients with 15 linear subcondylar fractures were treated using this intraoral approach from June 2007 through March 2010 at the Division of Oral and Maxillofacial Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan. The anatomic reduction of the displaced condylar segments and rigid fixation with 2 2.0-mm locking miniplates were performed using a small angulated screwdriver system, with an average follow-up of 13 months (range, 6 to 30 months).

RESULTS

Correct anatomic reduction of the condylar segments at centric occlusion followed by immediate functional recovery was achieved in all patients. Mean operating time was 50 minutes (range, 35 to 70 minutes) when performed by the consultant surgeon and the residents. In addition, all patients had good temporomandibular joint articular function, with no harmful clinical symptoms or deviation.

CONCLUSIONS

The surgical treatment of linear subcondylar fractures of the mandible can be achieved with an intraoral approach alone, using a small angulated screwdriver system, without endoscopic assistance, offering reliable clinical results and safe and minimally invasive surgery.

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.

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

PURPOSE

The present study was conducted to provide an overall perspective on the diagnosis of condylar fractures, to analyze the technique and results of different treatment methods used, and to evolve a protocol for the selection of an appropriate treatment modality for an individual case.

PATIENTS AND METHODS

A total of 28 patients with a condylar fracture were selected and were classified with the help of orthopantomogram and reverse Towne view radiographs. Of the 28 patients, 22 had unilateral fractures of the mandibular condyle process and 6 had bilateral fractures. They were treated with no invasive treatment, closed reduction with maxillomandibular fixation, or open reduction with internal semirigid fixation.

RESULTS

No significant difference was observed in the occlusion, maintenance of fixation of anatomically reduced fractured bony segments, trismus index, movements of the mandible (ie, opening, protrusion, and lateral excursions), or masticatory efficiency. The only significant difference was the subjective discomfort of the surgically treated patients in terms of pain on movement and mastication, swelling, neurologic deficit, and parotid fistula formation.

CONCLUSION

Patients with a condylar fracture with no displacement, dislocation, or derangement of occlusion seem best treated with medication only for symptomatic relief without any invasive treatment. Patients with derangement of occlusion or displacement of fractured fragments, especially in unilateral cases, seem best treated with closed reduction and maxillomandibular fixation, with medication for symptomatic relief and postoperative physiotherapy. Patients with deranged occlusion, displaced bony fractured fragments, and a dislocated condylar process out of the glenoid fossa, especially bilateral cases, seem best treated with open reduction with internal semirigid fixation.

Three-dimensional mandibular motion after closed and open reduction of unilateral mandibular condylar process fractures

OBJECTIVE

To detect the changes in 3D mandibular motion after two types of condylar fracture therapies.

MATERIALS AND METHODS

Using a 3D motion analyzer, free mandibular border movements were recorded in 21 patients successfully treated for unilateral fractures of the mandibular condylar process (nine patients: open reduction, rigid internal fixation, and functional treatment; 12 patients: closed reduction and functional treatment; follow-up: 6-66 months), and in 25 control subjects.

RESULTS

No differences were found among the groups at maximum mouth opening (MO), protrusion and in lateral excursions. During opening, the patients had a larger maximal deviation to the fractured side than the controls (controls 2.3 mm, open treatment 3.9 mm, closed treatment 4.2 mm; Kruskal-Wallis test, p=0.014; closed treatment vs. controls, p=0.004), with a larger coronal plane angle (controls 2.4°, open treatment 3.6°, closed treatment 4.4°; p=0.016; closed treatment vs. controls, p=0.013). In the closed treatment patients, a longer follow-up was related to increased maximum MO (p=0.04), sagittal plane angle (p=0.03), and reduced lateral mandibular deviation during MO (p=0.03).

CONCLUSION

Mandibular condylar fractures can recover good function; some kinematic variables of mandibular motion were more similar to the norm in the open treatment patients than in closed treatment patients.

Interventions for the treatment of fractures of the mandibular condyle

BACKGROUND

Fractures of the condylar process account for between 25% and 35% of all mandibular fractures. Treatment options for fractures of the condyles consist of either the closed method or by open reduction with fixation. Complications may be associated with either treatment option; for the closed approach these can include malocclusion, particularly open bites, reduced posterior facial height and facial asymmetry in addition to chronic pain and reduced mobility. A cutaneous scar and temporary paralysis of the facial nerve are not infrequent complications associated with the open approach. There is a lack of consensus currently surrounding the indications for either surgical or non-surgical treatment of fractures of the mandibular condyle.

OBJECTIVES

To evaluate the effectiveness of interventions that can be used in the treatment of fractures of the mandibular condyle.

SEARCH STRATEGY

The databases searched were: the Cochrane Oral Health Group's Trials Register (to 12th March 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (from 1950 to 12th March 2010), and EMBASE (from 1980 to 12th March 2010). The reference lists of all trials identified were cross checked for additional trials. Authors were contacted by electronic mail to ask for details of additional published and unpublished trials. There were no language restrictions and several articles were translated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which included adults, over 18 years of age, with unilateral or bilateral fractures of the mandibular condyles. Any form of open or closed method of reduction and fixation was considered.

DATA COLLECTION AND ANALYSIS

Review authors screened trials for inclusion. Extracted data were to be synthesised using the fixed-effect model but if substantial clinical diversity was identified between the studies we planned to use the random-effects model with studies grouped by action and we would explore the heterogeneity between the included studies. Mean differences were to be calculated for continuous outcomes and risk ratios for dichotomous outcomes together with their 95% confidence intervals.

MAIN RESULTS

No high quality evidence matching the inclusion criteria was identified.

AUTHORS' CONCLUSIONS

No high quality evidence is available in relation to this review question and no conclusions could be reached about the effectiveness or otherwise of the two interventions considered in this review. A need for further well designed randomised controlled trials exists. The trialists should account for all losses to follow-up and assess patient related outcomes. They should also report the direct and indirect costs associated with the interventions.

Transmasseter approach to condylar fractures by mini-retromandibular access

PURPOSE

The published data are full of evidence that surgical treatment of condylar fractures, performed through an intraoral or extraoral approach, leads to better results than nonoperative treatment. Intraoral surgery can be technically demanding, and an extraoral approach presents risks of facial nerve injuries and visible scarring. The mini-retromandibular approach we have described allows the treatment of condylar fractures at any level in a simplified and rapid manner while reducing the risk of complications common to the other techniques.

PATIENTS AND METHODS

A total of 33 patients with 38 condylar fractures were treated with a 20-mm mini-retromandibular approach. The mean operative time was 33 minutes (range 17 to 56). One patient in the present study was only 14 years old at surgery, which was performed 25 days after the associated trauma.

RESULTS

Correct anatomic reduction and occlusion were achieved in all cases. Additionally, all patients showed normal articular function. Infection of the surgical site occurred in the first 2 surgical cases. In another patient, an additional operation was necessary to fix an erroneously reduced fracture, which had occurred because of insufficient surgical access (15 mm). No facial nerve injury was observed, and all surgical scars were barely visible.

CONCLUSIONS

We suggest that the mini-retromandibular approach outlined in the present study should be the technique of choice for condylar fracture management, because it allows for easy, fast reduction and synthesis while minimizing the risk of facial nerve injury and visible scars.

Prospective closed treatment of nondisplaced and nondislocated condylar neck and head fractures versus open reposition internal fixation of displaced and dislocated fractures

OBJECTIVE

assessment of open reduction internal fixation in displaced or dislocated fractures of the condylar neck and head assessed versus closed treatment of nondisplaced, nondislocated fractures.

MATERIALS AND METHODS

One hundred and twenty patients suffering from 158 fractures; classes II to V according to Spiessl and Schroll, e.g., displaced and dislocated fractures were operated on; classes I and VI nondisplaced, nondislocated fractures were treated conservatively. At 1year, facial symmetry, pain, facial nerve function, and scarring were assessed clinically; reossification and fragment angulation were assessed from radiographs; vertical position, incisal maximum movements, and condyle translation were judged by millimeters.

RESULTS AND DISCUSSION

Clinical courses were uncomplicated in classes I to IV and did reach horizontal and vertical fragment reposition with minor remodeling in follow-up. Single cases evinced persistent pain, dysocclusion, facial nerve palsy, and plate fractures. Results were less successful in classes V and VI: although open reposition internal fixation showed good repositioning in class V, marked vertical bone remodeling occurred; single cases suffered from pain, dysocclusion, and plate fracture. Class VI cases had the worst translation, likewise marked condyle remodeling, and frequent dysocclusion.

CONCLUSION

Classes V and VI remain challenging to treat, while the other classes can be treated reliably with this study's rationale. Condyle remodeling in classes V and VI, translation in class VI may benefit prospectively from even more careful mobilization, improved osteofixation as minimalized operation trauma.

Endoscopic management of facial fractures

PURPOSE OF REVIEW

Endoscopic applications in otolaryngology continue to expand, most recently in the area of maxillofacial trauma. Endoscopic management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures has been described. This paper reviews the current literature including new techniques, indications, and outcomes in endoscopic management of facial fractures.

RECENT FINDINGS

Very few large studies of endoscopic fracture repair exist. The current literature, however, suggests that, when compared with an open approach, smaller endoscopic incisions result in reduced patient morbidity with similar outcomes. Dedicated endoscopic instrumentation and novel surgical approaches continue to be developed.

SUMMARY

Endoscopic repair of facial fractures is a new and evolving technique that offers the potential for reduced patient morbidity and operating time, as well as quicker patient recovery. Current applications include the management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures. It should be emphasized that endoscopy augments, rather than replaces, the 'time tested' principles of adequate skeletal exposure, accurate fracture reduction, and appropriate internal fixation.

The biophysics of mandibular fractures: an evolution toward understanding

BACKGROUND

Predicting outcomes based on a variety of fixation techniques remains problematic in the treatment of mandible fractures. There is inherent difficulty in comparing the hundreds of published articles on the subject because of the large number of variables, including injury patterns, assessment techniques, treatment approach, device selection and application, and definition of outcome.

METHODS

The authors review the behavior of the human mandible. Behavior of the intact mandible, multiple fracture scenarios, and small and large (single and multiple) plating applications are reviewed.

RESULTS

Several misconceptions in the literature are clarified. Factors that will resolve the dichotomy between clinical results and current biomechanical theories are presented such that a more logical biomechanical model may be used to approach fixation of the mandibular fracture being treated.

CONCLUSIONS

Current mandibular biomechanics theory must be expanded to reflect the complex nature of the system and to more accurately describe conditions that exist in the physical world. Otherwise, further analysis in advancements in outcome and treatment will be relegated to chance.

Closed reduction, open reduction, and endoscopic assistance: current thoughts on the management of mandibular condyle fractures

The management of fractures of the mandibular condyle continues to be controversial. This is in part attributable to a misinterpretation of the literature from decades prior, a lack of uniformity of classification of the various anatomical components of the mandibular condyle, and a perceived potential to cause harm through the open approach based in part on the surgeon's lack of a critical examination of the literature. This review explores the key historical articles that deal with the management of mandibular condyle fractures, and those modern-day contributions that represent the state of the art. The authors' intention was to provide the reader with an objective summary of the management of this form of injury, to place its management into a modern-day perspective, and perhaps to minimize the perception of controversy.