Long-term results of nonsurgical management of condylar fractures in children

Pediatric Mandible Fractures

The management of pediatric facial fractures requires several considerations by the treating surgeon. Pediatric facial fractures occur less commonly than in adults. Among fracture patterns in children, studies have repeatedly demonstrated that mandible fractures are the most common facial fracture particularly the condyle. Most fractures in children are amenable to nonsurgical or closed treatment; however, certain indications exist for open treatment. The literature describing epidemiology, treatment trends, and long-term outcomes are limited in comparison with adult populations. The purpose of the article is to review the etiology, workup, and management of mandible fractures in children.

Analysis of Pediatric Maxillofacial Fractures: A 10-year Retrospective Study

BACKGROUND

The aim of this study is to analyze patterns of maxillofacial fractures in children and adolescent in southeast of China,in a period of 10 years.

MATERIAL AND METHODS

In this retrospective study, the medical records of 162 hospitalized patients under 18 years old were analyzed in the Department of Oral and Maxillofacial Surgery, Stomatology Hospital of Wenzhou Medical University, China. Age, gender, etiology, site, and type of fracture, monthly distribution, weekly distribution, dental complications, and treatment were evaluated. The cases were divided into 3 age groups: group A: 0 to 6 years, group B: 7 to 12 years, and group C: 13 to 18 years.

RESULTS

Three hundred thirty-four maxillofacial fractures in 162 patients younger than 18 years were analyzed. The male to female ratio was 2.24:1 and mean age of these patients was 9.85 years old . Falls were the leading cause of maxillofacial fractures.The most frequent fracture site was mandible. Most patients with maxillofacial fractures were treated by open reduction. And it was done more in adolescents than in children.

CONCLUSIONS

Falls were the main reason for maxillofacial fracutres in childern, and traffic accidents was the leading cause in adolescent. Preventive measures should be applied to reduce occurrences of pediatric facial fractures .Children can not be left at home alone, and monitoring is very necessary when children play in the high place. The government can consider related e-bike driving skills training. Teenagers must pass the relevant electric vehicle test before they can drive. Make the law that the driver of e-bike must wear a safety helmet. Our study shows that open reduction was a good choice for pediatric facial fractures, but usually conservative treatment is a better choice for condylar fractures.

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.

Can malocclusion provide clinicians with information for differential diagnosis of temporomandibular joint diseases?: A review

The aim of this literature review was to summarize the clinical characteristics and symptoms of temporomandibular joint diseases, and to discuss the associations between temporomandibular joint diseases and categorization of malocclusion. Electronic literature searches were performed using the PubMed database. The authors established a differential diagnostic method for temporomandibular joint diseases related to malocclusion. A literature search using PubMed yielded 213 texts, of which based on exclusion criteria, 28 were included in this study. Malocclusions were categorized into 5 types. The authors suggested a diagnostic tree of temporomandibular joint diseases based on the types of malocclusion and 4 variables in clinical characteristics and symptoms. Clinicians treating malocclusions must attempt to clarify the cause of the occlusal condition. If caused by temporomandibular joint disease, it is important to make a proper differential diagnosis at first, and not to overlook the causative disease. Further clinical knowledge of associations between temporomandibular joint diseases and malocclusions should be accumulated, and the diagnostic tree should be improved based on new information.

Pediatric Facial Fractures in South Australia: Epidemiology, Clinical Characteristics, and Outcomes

INTRODUCTION

Facial fractures of children are relatively infrequent compared to adults. There are variations in facial fractures depending on the socioeconomic, cultural, and educational factors of the country and time. Our aim is to describe epidemiological trends of facial fractures in the pediatric population, understand differences amongst the age groups, and the impact this has on clinical outcomes and management in South Australia.

METHODS

A retrospective review was conducted from January 2012 to January 2017 at the Women and Children's Hosptial, Adelaide. All facial fractures of children, aged 16 years and below, that attended or were referred to the unit were included in this study.

RESULTS

A total of 265 pediatric patients presented with a facial fracture with a male predominance. Some 49.1% occurred from a sports-related injury with bicycle motocross as the single most common type of sport. The mandible was the common fracture type with 21.9% of the total cohort having an associated injury. There were significant differences between boys and girls for age, age groups, mechanism of injury, and type of sport (P < 0.05). Boys were 2.3 times more likely to have a sport-related facial fracture than girls. Early adolescence were 5.2 times more likely to have an orbitozygomatic fracture than children of early childhood (P < 0.05). Age, associated injuries, and sport-related facial fractures were independently associated with increased length of stay (P < 0.001).

CONCLUSIONS

There are differences amongst boys and girls and an understanding of these differences can aid the diagnosis and management in a growing child's face.

Extracapsular Condylar Fractures Treated Conservatively in Children: Mechanism of Bone Remodelling

OBJECTIVE

This study aims to reveal the reconstruction process in pediatric patients with extracapsular condylar fractures after conservative treatment. We clarify that the "upright" position (or "recontouring" or favorable prognosis) of condyles is not a result of the anatomical reduction of the deviated condylar processes but originates from the remodeling of the skeleton. We also explore the related mechanism.

METHODS

The sample consisted of 27 pediatric patients aged less than 12 years who presented with extracapsular condylar fractures and were treated conservatively within an 8-year period (June 2011-April 2019). Data on the age, gender, date of injury, mechanism of trauma, location and pattern of mandibular condylar fracture and associated injuries and treatment methods of the patients were obtained. The process of bone remodeling in condyles was also recorded and analyzed.

RESULTS

The 27 children in this study sustained 33 extracapsular condylar fractures over the 8-year period of record retrieval. Amongst these fractures, 8 (24.2%) and 25 (75.8%) were condylar neck and condylar base fractures, respectively. Deviation and green-stick fractures were the predominant types and accounted for over 3 quarters of the condylar neck and base fractures (28, 84.8%), followed by dislocation fracture (3, 9.1%), displacement fracture (1, 3.0%), and non-displaced fracture (1, 3.0%). The period of follow-up ranged from 2 days to 257 days (average, 58.78 days). Only 1 patient with bilateral extracapsular condylar fractures showed vertically reconstructed condyles, which indicates an upright position of the condylar processes. One patient showed less angulation after treatment than before treatment, 1 patient revealed greater angulation after treatment than before treatment and all other patients (20 patients) showed the same angulation pre- and post-treatment. Both patients with only extracapsular condylar fractures showed no obvious deviations in dentition and facial asymmetry after their injury and treatment. The shortest and longest times observed for bone remodeling were 33 and 256 days, respectively. Children whose condylar head remained completely or at least partly inside the glenoid fossa showed satisfactory remodeling results during follow-up. Computed tomography scan during follow-up generally showed bone regeneration in the lateral condyle articular surface and the medial portion of the ascending ramus and bone resorption in the displaced direction (ie, the medial condyle head became sharp). Condylar heads displaced completely outside of the glenoid fossa showed serious shortening of the ascending ramus, and no obvious bone remodeling was observed. Only 1 patient with bilateral extracapsular condylar fractures showed a normal contour (ie, a vertically reconstructed condyle reflecting the upright position of the condylar processes) after 8 months.

CONCLUSION

Stress stimulation originating from the glenoid fossa and ascending ramus of the mandible is a prerequisite for good condylar reconstruction. Conservative treatment could be carried out if the condylar head remains completely or at least partly inside the glenoid fossa. When the condylar head is dislocated completely outside the glenoid fossa, the glenoid-condylar relationship ceases to exist, joint function is lost and the height of the ascending ramus is significantly reduced. In this case, open reduction may be suitable.

Radiographic Assessment of Pediatric Condylar Fractures after Conservative Treatment with Functional Appliances-A Systematic Review

BACKGROUND

To evaluate the effectiveness of conservative treatment with functional appliances for condylar fractures in pediatric age.

METHODS

Four electronic databases (PubMed, EBSCO, Scopus, and Web of Science) were consulted with no restriction of publication status or year, up to 31 August 2020.

SELECTION CRITERIA

based on the PICOS criteria, the selection criteria were set for observational human studies, with at least 10 patients and six months of follow-up. The study population included pediatric patients (aged 5-16 years), with unilateral or bilateral condylar fracture, treated with functional appliances. Condylar remodeling and mandibular growth were analyzed through sequential radiographic examinations.

DATA COLLECTION AND ANALYSIS

Two independent reviewers carried out title-abstract screening, and a senior investigator was involved to solve any disagreement. The quality of the evidence was assessed through the Canada Institute of Health Economics (IHE) quality appraisal checklist, and the National Institutes of Health (NIH) quality assessment tool.

RESULTS

A total of 971 articles were retrieved from the electronic search; among them, three studies met the eligibility criteria. A moderate risk of bias was detected in all the studies, due to common limitations (absence of multicenter studies, prospective design, blindness of the investigators, patients' drop-out). At follow-up examinations (between 6 months and 4.9 years), the difference of condylar neck length between the "injured" and "healthy" side was approximately 2 mm, while the anteroposterior condylar width discrepancy was recorded up to 1 mm.

CONCLUSIONS

Short- and long-term data revealed that conservative treatment with functional appliances led to partial or full radiological recovery of the joint morphology, along with good to excellent functional results. Patients' age has a crucial role on the treatment choice, and the type of fracture (presence of condylar displacement, or dislocation) is also a major prognostic indicator of the radiologic outcome.

LIMITATION

To confirm the effectiveness of functional appliances, more prospective clinical long-term follow-up studies with homogeneous samples of condylar fractures are deemed necessary. Registration: The study protocol was registered on PROSPERO (CRD42020205650).

Surgical Treatment for Extracapsular Condylar Fractures of the Mandible

BACKGROUND

Condylar fractures are considered the most controversial mandibular fractures, regarding both the diagnosis and the treatment. With the increase in surgical indications for handling this type of fracture, it is important to discuss about the advantages and disadvantages of the several surgical approaches available. This article describes the surgical details and postoperative results of the mini-retromandibular transparotid approach for treating extracapsular condylar fractures of the mandible.

METHODS

In a 1-year period, 16 patients affected by extracapsular condylar fractures with surgical indication were treated with the mini-retromandibular transparotid approach. All the surgeries were executed by the same surgeon. Preoperative and postoperative details of each patient were analyzed.

RESULTS

In the postoperatory, only 2 patients had purulent drainage in the associated fractures area and only 1 patient had paresis of the buccal branch of the facial nerve. No scar issues concerning the surgical wound were observed and reintervention was not necessary in any of the patients.

CONCLUSION

The mini-retromandibular transparotid approach offers advantages and should be included as an option for the open treatment of extracapsular condylar fractures of the mandible.

Surgical Treatment of Posttraumatic Laterognathia: A Case Report and a Literature Review, Focused on the Effects of a Condylar Fracture on the Face

Facial asymmetry, following early childhood condylar trauma, is a common complaint among patients who seek surgical treatment. G.D.M., a 27-year-old male patient, sought professional help to correct his cosmetic flaw, caused by a condylar fracture when he was 8-years-old. After the proper orthodontic treatment, he underwent a double jaw orthognathic surgery and, 9 months later, a second one to correct the remaining asymmetry. Two years after this second procedure, the patient is still under surveillance and has no complaints.

Efficacy of the Retroparotid Trans-Masseteric Approach via Retromandibular Incision in ORIF of Subcondylar Fractures: Our Institution Experience

Background

Fractures of the mandible subcondyle have always presented a challenge to the maxillofacial surgeon, with a myriad of treatment options existing ranging from conservative management to open reduction and internal fixation (ORIF) to condylotomy. The complex anatomy of the region poses a challenge, with injury to the facial nerve branches being the primary concern.

Objective

This study evaluated the efficacy of a modified retromandibular approach, with retroparotid trans-masseteric dissection for ORIF of subcondylar fractures.

Methodology

Twenty-five patients with subcondylar fractures at varying levels were treated surgically by ORIF using this approach.

Results

All patients managed by this modified retromandibular approach had satisfactory results with restoration of vertical ramal height, satisfactory mouth opening, stable occlusion and no facial nerve damage post-op.

Conclusion

In our study, the modified retromandibular approach, with retroparotid trans-masseteric approach was effective in surgical management of subcondylar fractures by ORIF with minimal complications.

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.

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.

A Complex Facial Trauma Case with Multiple Mandibular Fractures and Dentoalveolar Injuries

The principles of management of mandibular fractures differ in children when compared to adults and depend on the specific age-related status of the growing mandible and the developing dentition. This paper presents a case report with a complex facial trauma affecting the mandibular body and condyle region and dentoalveolar complex. Clinical examination revealed soft tissue injuries, limited mouth opening, lateral deviation of the mandible, an avulsed incisor, a subluxated incisor, and a fractured crown. CBCT examination revealed a nondisplaced fracture and an oblique greenstick fracture of the mandibular body and unilateral fracture of the condyle. Closed reduction technique was chosen to manage fractures of the mandible. Favorable healing outcomes on multiple fractures of the mandible throughout the 6-year follow-up period proved the success of the conservative treatment. This case report is important since it presents a variety of pathological sequelae to trauma within one case.

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.

Closed reduction of displaced or dislocated mandibular condyle fractures in children using threaded Kirschner wire and external rubber traction

Most surgeons agree that closed treatment provides the best results for condylar fractures in children. Nevertheless, treatment of the paediatric mandibular condyle fracture that is severely displaced or dislocated is controversial. The purpose of this study was to investigate the long-term clinical and radiological outcomes following the treatment of displaced or dislocated condylar fractures in children using threaded Kirschner wire and external rubber traction. This procedure can strengthen the advantage of closed reduction and make up for the shortcomings of open reduction. From March 1, 2005 to December 25, 2011, 11 children aged between 4 and 12 years with displaced or dislocated mandibular condyle fractures were treated using threaded Kirschner wire and external rubber traction under portable C-arm fluoroscopy. All patients had unilateral displaced or dislocated condylar fractures. The follow-up period ranged from 24 to 42 months (mean 29.3 months). Normal occlusion and pain-free function of the temporomandibular joint, without deviation or limitation of jaw opening, was achieved in all patients. This closed reduction technique in displaced or dislocated condylar fractures in children offers a reliable solution in preventing the unfavourable sequelae of closed treatment and the open technique, such as altered morphology, functional disturbances, and facial nerve damage.

Long-term results of ORIF of condylar head fractures of the mandible: A prospective 5-year follow-up study of small-fragment positional-screw osteosynthesis (SFPSO)

BACKGROUND

Optimum treatment of condylar head fractures (CHF) remains subject to controversy. There are currently a variety of alternative techniques applied, data in literature are often inconsistent and especially systematic long-term data on results after treatment by open reduction and internal fixation (ORIF) have so far not been available. This study in hand is the first long-term prospective study of ORIF after CHF based on osteosynthesis with 1.7 mm small-fragment positional screws (SFPSO)via a retroauricular transmeatal approach (RA).

METHODS

The study made use of radiologic, anatomic and objective functional parameters (axiography and MRI) to assess vertical height, disk mobility, protrusive and translatory movement as well as potential physical complaints. Included were surgical long-term sequelae after RA, such as incidence of stenosis of the auditory canal, the facial nerve and resulting disturbance of facial skin sensitivity. Retroauricular scars were evaluated according to the Vancouver Scar Scale. Helkimo and RDC/TMD indices were applied for patient's self-assessment of quality of life aspects after ORIF via RA. The sample in the first follow-up trial (FFT) in the years 2003-2004 comprised 26 patients (36 CHF). 22 patients (31 CHF) were re-evaluated in a second follow-up trial (SFT) between 2006 and 2008. A reference collective (43 patients, 56 CHF) treated with ORIF from 1993 to 2000 mainly by mini- or microplates (MMP) served as a surgical control group.

RESULTS

Five years after ORIF all fractured condyles (FC) continued to show stable anatomic restoration of the pre-trauma vertical height. FC treated with SFPSO exhibited a significantly superior range of motion (p < 0.05) of disk and condyle during mouth opening and protrusion compared to a previous MMP reference collective. Also, no difference was found between condylar mobility of FC five years after surgery and non-fractured condyles (NFC). SFPSO had thus successfully achieved a sustainable, stable physiological restoration of protrusive mobility of the articular disk and condyle. Remarkably, these long-term results were even slightly better in SFT vs. FFT (p < 0.05). Except for sporadically occurring minor complaints, the patients' subjective overall long-term perception of the success of the treatment was equally positive to the surgeons' objective assessment.

CONCLUSIONS

This first long-term prospective follow-up study, based on objective assessment tools, demonstrates that in all cases the major goals of ORIF in CHF could be fully achieved. These goals are: restoration of vertical height viz. prevention of occlusal disorders, physiological function of disk and condyle as well as of the lateral pterygoid muscle. Accordingly, ORIF of CHF e.g. with SFPSO and via the RA secures both a long-term functionally and anatomically stable result and as best as possible pain-free result for the patient, a central prerequisite of optimum perceived HRQoL. The paper has been amended by an extensive review part that covers the current knowledge of the major surgical aspects regarding the treatment of condylar head fractures.

Anatomical and Functional Recovery of Intracapsular Fractures of the Mandibular Condyle: Analysis of 124 Cases after Closed Treatment

Purpose:

The purpose of this study is to evaluate the influence of intracapsular fracture lines of the mandibular condyle on the anatomical and functional recovery after non-surgical closed treatment.

Methods:

Clinical and radiological follow-up of 124 patients with intracapsular fractures of the mandibular condyle was performed after closed treatment between 2005 and 2012. The intracapsular fractures were classified into three categories: type A (medial condylar pole fracture), type B (lateral condylar pole fracture with loss of vertical height) and type M (multiple fragments or comminuted fracture).

Results:

By radiological finding, fracture types B and M lost up to 24% vertical height of the mandibular condyle compared to the height on the opposite side. In Type M, moderate to severe dysfunction was observed in 33% of the cases. Bilateral fractures were significantly associated with the risk of temporomandibular joint (TMJ) dysfunction in fracture types A and B. Bilateral fracture and TMJ dysfunction were not statistically significantly associated in type M fractures.

Conclusion:

Most of the mandibular intracapsular condylar fractures recovered acceptably after conservative non-surgical treatment with functional rehabilitation, even with some anatomical shortening of the condylar height. The poor functional recovery encountered in type M fractures, especially in cases with additional fracture sites and bilateral fractures, points up the limitation of closed treatment in such cases.

Pediatric Maxillofacial Trauma Outcomes Based on a Survey of 65 Patients: A Prospective Study of Etiology, Incidence and Methods of Treatment

BACKGROUND

The purpose of this study was to assess the etiology, incidence, and various methods of treatment of maxillofacial injuries in children presenting at our centre and to compare our findings with literature.

PATIENTS AND METHODS

We carried out prospective study of 65 pediatric maxillofacial trauma patients treated from January 2011 to October 2012 at our centre. Data was collected on age, gender, etiological factors, anatomic site and treatment methods. Follow-up was performed by recall survey.

RESULTS

Out of 65 patients 17 (26.15 %) presented with isolated soft tissue injuries and 48 (73.84 %) patients reported with 81 craniomaxillofacial fractures. Falls were most common mode of injury with 53 fractures (81.53 %). Treatment for fractures in our series comprised of periodic observation for non-displaced fractures (46.15 %), closed reduction (maxillomandibular fixation with IMF screws, acrylic cap splints) for minimally displaced fractures (15.38 %) and open reduction and internal fixation (ORIF) for grossly displaced fractures (12.30 %).

CONCLUSION

Paediatric maxillofacial trauma can be managed conservatively and surgical treatment by ORIF is required in a very small group of children with grossly displaced fractures as a result of high velocity injuries.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Conservative treatment of bilateral condylar fractures in children: case report and review of the literature

Two children (11 year old) with bilateral condylar fractures associated with symphysis fracture were conservatively treated. Both of them were followed up for about 1 year. A review of 21 cases of bilateral condylar fracture available in the literature revealed the younger the patient, the better the outcome of TMJ function or in radiographic remodeling. However, the longer the time elapsed, the higher the incidence of remodeling deformity and dysfunction. Thus, it must be better that a close follow-up of bilateral condylar fracture in children should be continued until the end of growth period.

Management of malocclusion and facial asymmetry secondary to fractures of the mandibular condyle process

INTRODUCTION

Most condylar process fractures can be managed conservatively with satisfactory outcome. However, unsuccessful treatment can result in malocclusion and facial asymmetry. We report our experience in surgical management of malunited condylar process fractures.

METHODS

This is a retrospective review of clinical records, photographs, imaging, and dental models of 12 consecutive patients who presented with malocclusion and facial asymmetry after nonoperative or failed treatment of condylar process fractures. Eight patients who presented relatively early (<6 months) after the initial trauma were treated with subcondylar osteotomy (SCO), whereas 4 patients who presented relatively late (>18 months) were treated with sagittal split osteotomy (SSO). These 2 groups were compared in terms of 3 parameters, namely, maximum mouth opening, aesthetic improvement, and patient satisfaction.

RESULTS

The 2 groups were statistically similar in all 3 parameters, with the SCO group trending toward higher scores in all 3 parameters. The mean increase in maximal mouth opening in the SCO group was 21 versus 2.5 mm in the SSO group.

CONCLUSIONS

Subcondylar osteotomy, performed at a relatively early time point, is at least as effective, if not more effective, than traditional SSO in the treatment of subcondylar malunions. Given this finding, a lower threshold should be adopted for the primary treatment of acute subcondylar fractures with open reduction and internal fixation, especially those with moderate displacement that may be at high risk for malunion.

Clinical and radiological outcomes after treatment of sagittal fracture of mandibular condyle (SFMC) by using occlusal splint in children

This study was designed to investigate the effects of occlusal splints in the treatment of sagittal fractures of the mandibular condyle in children. From January 1995 to December 2011, 37 sagittal fractures of the mandibular condyle in 30 patients aged 4-8 years old were included in this study. All the patients were treated with 1-2mm occlusal splints in the molar region. The mouths of the patients were kept slightly open by the occlusal splints for 3-6 months, and we reviewed the clinical and radiological remodelling of the affected condyles after treatment. Excellent (n=20) and good (n=10) clinical outcomes were achieved with full radiological remodelling seen in 19 and partial remodelling in 11. Treatment with occlusal splints is effective in delivering good results and function with minimal morbidity in children with sagittal fractures of the condyle, while permitting ongoing remodelling and growth in the short term.

Late reconstruction of condylar neck and head fractures

Condyle fractures are a common injury, but only a few of these injuries require immediate or late reconstruction. The complications that most frequently necessitate condylar reconstruction include proximal segment degeneration, malunion, and ankylosis. Costochondral grafts and total joint prostheses, both stock and custom, remain the most common methods of reconstruction. Reconstruction plates with condylar extensions should only be used temporarily as an unacceptable number cause serious complications. Distraction osteogenesis may have an occasional role in reconstructing the posttraumatic condyle.

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.

Severe open bite due to traumatic condylar fractures treated nonsurgically with implanted miniscrew anchorage

This case report illustrates the use of miniscrews to treat a patient with an open bite caused by mandibular condylar fractures. The patient was 36 years old when she visited our hospital with a chief complaint of difficulty with chewing. She had suffered condylar and maxillary bone fractures in a traffic accident 6 months before her visit. She had an anterior open bite and Angle Class II molar relationships. Her mandibular midline was deviated to the right relative to the maxilla. The cephalometric analysis showed a skeletal Class II relationship. Titanium miniscrews were implanted in the bilateral maxillary buccal areas. The maxillary dentition was retracted and intruded by using elastomeric chains and miniscrews. After this treatment, an Angle Class I molar relationship was achieved, her overjet and overbite became ideal, and a good facial appearance was obtained. The total active orthodontic treatment period was 33 months. Treating an open bite with molar intrusion often leads to counterclockwise rotation of the mandible; however, in this patient, the mandible was moved anteriorly and upward. We believe that this movement was caused by the patient's condylar fractures and the subsequent remodeling. Although there was some relapse, our results suggest that implant anchorage is useful for correcting anterior open bites originating from condylar fractures.

Open versus closed reduction: mandibular condylar fractures in children

PURPOSE

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of mandibular condylar fractures (MCFs) in children.

METHODS

An electronic search in PubMed was undertaken in May 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies published in English or German from the last 20 years (from 1992 onwards) reporting clinical series of MCFs in children and adolescents until the age of 18.

RESULTS

The search strategy initially identified 542 studies. The references from 1992 onwards totaled 339 articles. Twenty-seven studies were identified without repetition within the selection criteria. Additional hand-searching yielded two additional papers.

CONCLUSIONS

Pediatric MCFs require thoughtful consideration in management to avoid significant growth disturbance. Early treatment is indicated in order to improve the chances for favorable development. Long-term follow-up is required, in order to properly treat late complications that may appear. Coronal computed tomography is helpful in substantiating the correct final diagnosis. Many studies show that conservative treatment (CTR) has satisfactory long-term outcome of jaw function, occlusion, and facial esthetics, despite a high frequency of radiological aberrations. Surgery before puberty should be reserved for exceptional cases such as missile injuries, in cases with extensive dislocation and lack of contact between the fragments, in cases with multiple midfacial fractures, in which the mandible has to serve as a guide to reposition the midfacial bones, and in cases which the dislocation of the fractured stump creates a functional impediment that cannot be resolved by CTR. As the craniofacial skeleton becomes more adult-like in its form at about 12 years of age, the decreased remodeling capacity in the adolescents may occasionally result in abnormally shaped condylar heads or shortened ramus heights that may lead to persistent malocclusion. Thus, the indication of open reduction and internal fixation increases with age.

A retrospective study of using removable occlusal splint in the treatment of condylar fracture in children

BACKGROUND

Although the concept of conservative treatment for paediatric condylar fracture is well understood, there is still a lack of a recognized method for treating child patients with a condylar fracture. The purpose of this study was to investigate the effect of the removable occlusal splint in treating condylar fractures in children and adolescents.

MATERIALS AND METHODS

Forty children and adolescents with condylar fracture, aged 3-16, were included in this study. A removable occlusal splint with varying thickness was fabricated according to the age, developmental stage of the mandible, and degree of condylar dislocation. This was worn for 1-3 months, accompanied by functional exercises. Follow-up was carried out by clinical observation and panoramic X-ray.

RESULTS

Clinically satisfactory results with good occlusion were obtained in all the patients, along with unimpaired function and normal growth and development of the mandible. The panoramic image showed remodelling and reconstruction of the fractured condyles.

CONCLUSIONS

Our results confirm that conservative treatment has a satisfactory clinical outcome in treating condylar fracture in children. The removable occlusal splint is a promising approach for treating condylar fracture in children and adolescents.

Facial symmetry evaluation after experimentally displaced condylar process fracture in methotrexate treated rats

PURPOSE: To investigate the facial symmetry of high and low dose methotrexate (MTX) treated rats submitted to experimentally displaced mandibular condyle fracture through the recording of cephalometric measurements. METHODS: One hundred male Wistar rats underwent surgery using an experimental model of right condylar fracture. Animals were divided into four groups: A - saline solution (1mL/week); B - dexamethasone (DEX) (0,15mg/Kg); C - MTX low dose (3 mg/Kg/week); D - MTX high dose (30 mg/Kg). Animals were sacrificed at 1, 7, 15, 30 and 90 days postoperatively (n=5). Body weight was recorded. Specimens were submitted to axial radiographic incidence, and cephalometric mensurations were made using a computer system. Linear measurements of skull and mandible, as well as angular measurements of mandibular deviation were taken. Data were subjected to statistical analyses among the groups, periods of sacrifice and between the sides in each group (α=0.05). RESULTS: Animals regained body weight over time, except in group D. There was reduction in the mandibular length and also changes in the maxilla as well as progressive deviation in the mandible in relation to the skull basis in group D. CONCLUSION: Treatment with high dose methotrexate had deleterious effect on facial symmetry of rats submitted to experimentally displaced condylar process fracture.

Complications in pediatric facial fractures

Despite recent advances in the diagnosis, treatment, and prevention of pediatric facial fractures, little has been published on the complications of these fractures. The existing literature is highly variable regarding both the definition and the reporting of adverse events. Although the incidence of pediatric facial fractures is relative low, they are strongly associated with other serious injuries. Both the fractures and their treatment may have long-term consequence on growth and development of the immature face. This article is a selective review of the literature on facial fracture complications with special emphasis on the complications unique to pediatric patients. We also present our classification system to evaluate adverse outcomes associated with pediatric facial fractures. Prospective, long-term studies are needed to fully understand and appreciate the complexity of treating children with facial fractures and determining the true incidence, subsequent growth, and nature of their complications.

Management of paediatric mandibular condylar fractures with screw-based semi-rigid intermaxillary fixation

This study was designed to evaluate the feasibility and safety of screw-based semi-rigid intermaxillary fixation (IMF) combined with a specially designed occlusal splint in the conservative treatment of paediatric mandibular condylar fractures. Thirteen paediatric patients with 20 sides of condylar fractures treated with semi-rigid IMF were analyzed retrospectively. Semi-rigid IMF was achieved by inserting self-drilling IMF screws into the anterior alveolar bone of the maxilla and mandible suspended with elastic bands. An occlusal splint with a molar fulcrum was used for functional repositioning of the condylar fragment. After 4 weeks, the screws and occlusal splint were removed. During a mean period of 28.6 months' follow-up, the patients' maximal mouth opening increased to a mean of 37.69 mm. Clinical and radiological examinations revealed satisfactory results in facial symmetry and condylar remodelling. No clinical symptoms or radiographic evidence showed dental injuries associated with screw insertion. This study suggests that this method might be a safe, easy, and effective management of paediatric condylar fractures.