Clinical and radiological evaluation following surgical treatment of condylar neck fractures with lag screws

Analysis of Mandibular Muscle Variations Following Condylar Fractures: A Systematic Review

This review analyzes muscle activity following mandibular condylar fracture (CF), with a focus on understanding the changes in masticatory muscles and temporomandibular joint (TMJ) functioning.

MATERIALS AND METHODS

The review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A search was performed on online databases using the keywords "masticatory muscles" AND ("mandibular fracture" OR "condylar fracture"). The eligibility criteria included clinical trials involving human intervention and focusing on muscle activity following a condylar fracture.

RESULTS

A total of 13 relevant studies were reviewed. Various studies evaluated muscle activity using clinical evaluation, bite force measurement, electromyography (EMG), magnetic sensors and radiological examinations to assess the impact of mandibular fractures on masticatory muscles.

CONCLUSIONS

Mandibular condylar fractures can lead to significant changes in muscle activity, affecting mastication and TMJ functioning. EMG and computed tomography (CT) imaging play crucial roles in assessing muscle changes and adaptations following fractures, providing valuable information for treatment planning and post-fracture management. Further research is required to explore long-term outcomes and functional performance after oral motor rehabilitation in patients with facial fractures. Standardized classifications and treatment approaches may help improve the comparability of future studies in this field.

Prevalence of surgical site infections after open reduction and internal fixation for mandibular fractures: a systematic review and meta-analysis

Our study aims to estimate the prevalence of surgical site infections (SSI) following open reduction and internal fixation (ORIF) for mandibular fractures and to determine the effect of potential moderators on it. A systematic literature search (Medline and Scopus databases) was conducted independently by two reviewers. The pooled prevalence with 95% confidence intervals was estimated. Quality assessment as well as outlier and influential analysis were performed. Additionally, subgroup and meta-regression analysis were conducted in order the effect of categorical and continuous variables on the estimated prevalence to be investigated. In total, seventy-five eligible studies (comprising a sum of 5825 participants) were included in this meta-analysis. The overall prevalence of SSI following ORIF for mandibular fractures was estimated as high as 4.2% (95% CI 3.0-5.6%) with significant heterogeneity between studies. One study was identified to be critically influential. In the subgroup analysis, the prevalence was 4.2% (95% CI 2.2-6.6%) among studies conducted in Europe, 4.3% (95% CI 3.1-5.6%) among studies conducted in Asia and higher among those conducted in America (7.3%) (95% CI 4.7-10.3%). It is important for healthcare professionals to be aware of the etiology of these infections, despite the relatively low rate of SSI in these procedures. However, further, well-designed prospective and retrospective studies need to be conducted in order this issue to be fully clarified.

Modified high-submandibular appraoch for open reduction and internal fixation of condylar fracture: case series report

OBJECTIVES

Recently a modified high-submandibular approach (HSMA) has been introduced for treatment of condylar fracture. This approach involves an incision line close to the mandibular angle and transmasseteric transection, leading to a low incidence of facial palsy and allowing good visualization of the condyle area, especially the condylar neck and subcondyle positions. This study reports several cases managed with this modified HSMA technique for treating condylar fractures.

MATERIALS AND METHODS

Six cases of condylar fractures treated with modified HSMA technique were reviewed.

RESULTS

Three unilateral subcondylar fracture, 1 bilateral subcondylar fracture, 1 unilateral condylar neck fracture, 1 unlateral simultaneous condylar neck and subcondylar fracture cases were reviewed. All the cases were successfully treated without any major complication.

CONCLUSION

Reduction, fixation, and osteosynthesis of condylar fractures via the modified HSMA technique enabled effective and stable treatment outcomes. Therefore, the described approach can be used especially for subcondylar and condylar neck fractures with minimal complications.

Cortical lag screw fixation for the management of mandibular injuries

Objectives

Here, we present cases of mandibular fracture that were managed with the cortical lag screw fixation technique (CLSFT) in order to critically evaluate technique indications and limitations of application at various fracture sites.

Materials and Methods

This was a retrospective cohort study. The study sample was composed of patients suffering from mandibular fractures that were treated by the CLSFT. The outcome variables were fracture type, duration of surgery, number of screws, and pattern of application. Other study categories included patient demographics and causes of injury. Chi-square tests were used to assess descriptive and inferential statistical differences, and the P-value was set at 0.05.

Results

Thirty-three patients were included in the study sample, with a mean age of 30.9±11.5 years and a male predominance of 81.8%. The technique was applied more frequently in the anterior mandibular region (51.5%) than in other sites. Double CLSFT screws were required at the symphysis and parasymphysis, while single screws were used for body and angle regions. No intraoperative and postoperative variables were significantly different except for surgical duration, which was significantly different between the sites studied (P=0.035).

Conclusion

We found that CLSFT is a rapid, cost-effective technique for the fixation of mandibular fractures yielding good treatment results and very limited complications. However, this technique is sensitive and requires surgical expertise to be applied to mandibular fractures that have specialized characteristics.

Comparison of Titanium and Bioresorbable Plates in "A" Shape Plate Properties-Finite Element Analysis

(1) Background: The main disadvantage of rigid fracture fixation is remain material after healing period. Implementation of resorbable plates prevents issues resulting from left plates. The aim of this study is to compare the usage of bioresorbable and titanium “A” shape condyle plate in condylar fractures. (2) Methods: Thickness of 1.0 mm, height of 31 mm, and width of 19 mm polylactic acid (PLLA) and titanium “A” shape plate with 2.0 mm-wide connecting bar and 9 holes were tested with finite element analysis in high right condylar neck fracture. (3) Results: On bone surface the highest stress is on the anterior bridge around first hole (approx. 100 MPa). The highest stress on screws is located in the first screw around plate in the anterior bridge and is greater in titanium (150 MPa) than PLLA (114 MPa). (4) Conclusion: Pressure on bone in PLLA osteosynthesis is two times higher than in titanium fixation. On small areas where pressure on bone is too high it causes local bone degradation around the fracture and may delay the healing process or make it impossible. Fixation by PLLA is such flexible that bone edges slide and twist what may lead to degradation of callus.

Use of Transgingival Lag Screw Osteosynthesis in the Management of Alveolar Process Fracture

The purpose of this study is to check the efficacy of transgingival lag screw osteosynthesis in alveolar process fractures of maxilla and mandible. A single-arm nonrandomized observational study was performed for the treatment of alveolar process fractures of maxilla and mandible. In this study, 20 mixed age group patients with alveolar process fracture were included. All the patients were treated by a 2.0-mm transgingival screw fixation under local or general anesthesia. All the patients were evaluated for fracture stability, anatomical reduction, bone loss and bone resorption of alveolar process, tooth loss, and wound infection at 3 months of follow-up. A simple descriptive statistical analysis was done to evaluate the parameters and it was shown that the treatment of alveolar process fracture with two or three lag screws provides adequate fracture stability and anatomical reduction with no signs of bone loss and tooth loss, and wound infections were noted post lag screw fixation. The study concludes that transgingival lag screw fixation is a suitable alternative for alveolar process fractures in all the age groups and two to three lag screws are generally sufficient to fix fractured alveolar process either under local anesthesia or general anesthesia.

Ultrasound-aided resorbable osteosynthesis of fractures of the mandibular condylar base: an experimental study in sheep

We evaluated the osteosynthesis of condylar fractures using resorbable mini plates and ultrasound-aided insertion of pins clinically and histologically. Stability was greater than that with resorbable screws because of the fusion of pin and plate. Long term evaluation showed complete resorption of the polymeric osteosynthesis material.

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.

Long-term clinical and radiological outcomes for the surgical treatment of mandibular condylar fractures

PURPOSE

This retrospective study evaluated the long-term results and complications of open reduction and internal fixation of displaced and dislocated fractures of the condylar process.

PATIENTS AND METHODS

Two hundred four patients were treated via various surgical approaches between 1991 and 2005. Fifty patients with a total of 57 treated condylar fractures who underwent complete clinical and radiological documentation were included in this study. Follow-up clinical and radiological evaluations were carried out after an average period of 88 months.

RESULTS

We found that 12% of our patients reported temporary weakness of the facial nerve and 4% had mild permanent facial nerve palsy. Clinical and radiological assessment showed satisfactory recovery of facial symmetry. Excellent recovery of function was observed, and very few patients complained of temporomandibular joint-related symptoms. Severe condylar remodeling was observed in 8% of the patients, 47% showed slight or moderate remodeling, and 45% showed no remodeling. A statistically significant association was observed between the presence of condylar remodeling and poor mouth opening at the follow-up examination.

CONCLUSIONS

Surgical treatment of condylar fractures, in association with postoperative functional therapy, promotes the recovery of function, occlusion, and facial symmetry with few complications. However, some difficulties remain related to the surgeon, the patient, and the objective complexity of this pathology.

Clinical experience with osteosynthesis of subcondylar fractures of the mandible using TCP plates

AIM

To evaluate the clinical and radiological results obtained with a new kind of osteosynthesis device (Modus TCP) plates, Medartis, Basel, Switzerland), especially designed for low subcondylar fracture (LSCF) and high subcondylar fracture (HSCF) of the mandible in association with the high submandibular approach (HSMA).

METHOD

A prospective clinical and radiological study was carried out over a 41-month period. All adult patients suffering from a displaced LSCF or HSCF who consented to the surgical treatment were included in the study. All fractures were operated on using an HSMA and were stabilised using a 4- or 9-hole TCP((R)) plate. No intermaxillary fixation was used and a soft diet was started on the 1st postoperative day. Clinical examinations and control X-rays were carried out on the 10th postoperative day, in the 1st, the 3rd and, at least, in the 6th postoperative months.

MATERIAL

Sixty-four patients (12 females, 52 males - mean age: 28.3) with a total of 75 fractures (54 LSCF, 21 HSCF) were included in the study. Mean postoperative follow-up was 14 months.

RESULTS

In the 6th postoperative month, all fractures were consolidated in 79% of the cases in an anatomical position. A secondary displacement of the fracture occurred in 6.6% of the cases. Plate fracture was not observed. Dental occlusion remained unchanged in 94% of the patients. The mandibular movements (mouth opening, protrusion, lateral movements on the unfractured and fractured side) had normal mean values (49.5, 10.4, 12.8, 12.1mm, respectively). These movements were symmetrical in 95% of the patients. No patient complained about articular pain or noise. No facial nerve palsy was noticed, not even a transiently one. All patients but one found the scars acceptable.

CONCLUSION

TCP plates, in association with HSMA, were found to be an efficient osteosynthesis device for stabilising subcondylar fractures.

Study on treatment of condylar process fractures of the mandible

Treatment of mandibular condylar process fractures may be conservative or surgical. Both treatment approaches aim to reconstruct the articulating joint surfaces in a physiological position to the discoligamentary structures. The study comprised 1812 patients of Wuerzburg University who presented with a fracture of the mandibular condylar process between 1981 and 2001. Besides conservative management options, surgical interventions using mini-plate osteosynthesis and the Wuerzburg lag screw plate were studied for post-treatment changes. Statistical analysis revealed that surgical osteosynthesis is superior to merely conservative therapy in terms of post-treatment dysgnathic severity. Hence, surgical osteosynthesis is advocated especially in patients with high condylar fractures or dislocated fractures in order to ideally achieve 'restitutio ad integrum'.

A New 3-Dimensional Plate for Transoral Endoscopic-Assisted Osteosynthesis of Condylar Neck Fractures

PURPOSE

Transoral surgical treatment of condylar neck fractures minimizes the risk of damaging the facial nerve. But fracture reduction and plate osteosynthesis remain challenging, especially when using 2 plates, although endoscopic assistance has proven helpful. To further improve and simplify osteosynthesis at the condylar neck, a new delta-shaped osteosynthesis plate that mimics the function of 2 plates has been developed. The present clinical follow-up study was conducted to evaluate this new plate.

PATIENTS AND METHODS

A total of 16 patients with 19 condylar neck fractures (3 Spiessl I, 13 Spiessl II, 1 Spiessl III, 2 Spiessl IV) and 3 bilateral fractures were treated through an endoscopic-assisted transoral approach. After reduction, the plate was applied, with the screws inserted either transcutaneously or with angulated instruments.

RESULTS

The operation time ranged between 55 and 120 minutes. More than 6 months after the operation, functional parameters returned to normal, with an average mouth opening of 41 mm, protrusion of 5 mm, and laterotrusion of 6 mm. Radiographic controls showed good fracture alignment in 15 of 19 cases immediately after the operation, and in 14 of 19 cases 6 months after the operation. No plate fracture or bending was observed. In 3 patients, loose screws were found on plate removal.

CONCLUSIONS

The clinical data and the engineering and biomechanical background suggest that the new delta-shaped plate can be regarded as 2 miniplates. The new plate is suitable for treatment of condylar neck fractures, particularly when used in an endoscopic-assisted transoral approach.

Development and biomechanical testing of a new osteosynthesis plate (TCP®) designed to stabilize mandibular condyle fractures

INTRODUCTION

In this paper, the different steps of development and experimental validation of a new type of three-dimensional (3-D) trapezoidal osteosynthesis plate (Modus TCP 2.0, Medartis, Basel, Switzerland) is described. These plates have been designed to stabilize sub-condylar and condylar neck fractures of the mandible.

MATERIAL AND METHODS

In order to apply the principles of functionally stable osteosynthesis to the mandibular condyle, i.e. to put the plate as close as possible to the tensile strain lines occurring during function, two new 4- and 9-hole 3-D trapezoidal plates were designed. Tests were conducted on fresh human mandibles before and after osteosynthesis of a standardised unilateral sub-condylar 'fracture', and a static biting exercise between the ipsilateral first molars was reproduced on a test bench. The resulting condylar fragment displacement in the sagittal plane was measured and the alterations of the condylar tensile strain lines induced by the osteosynthesis were investigated by using photoelastic strain tests.

RESULTS

None of the plates broke. No macroscopic condylar displacement was noted when assessing the quality of the primary stabilization. Strain analysis showed the ability of these 3-D plates to transmit physiological strains across the fracture line and the absence of potentially damaging strains around the plate.

DISCUSSION

These results were accredited to the 3-D and trapezoidal features of the plates.

CONCLUSION

The Modus TCP plates experimentally fulfil the principles of functionally stable osteosynthesis in the condylar region and are able to resist physiological strains.

Biomechanical comparison of plating techniques for fractures of the mandibular condyle

We compared the biomechanical behaviour of various rigid internal fixation techniques for treatment of fractures of the mandibular condylar process. Fifteen sheep hemimandibles were used to evaluate three bicortical plating techniques. A custom-made 3-point biomechanical test model was used for the samples. Each group was tested with compression forces by an Instron Lloyd LRX machine. The resistance to forces (N) that caused displacements of 1.75 and 3.50mm were compared using the Instron software programme and displacement graphics. There were no significant differences among the three groups for displacements of 1.75 and 3.50mm. Our study showed that the titanium miniadaptation plates, minicompression plates, and the absorbable miniplates did not differ significantly in their biomechanical behaviour.

Computed tomography imaging findings of simultaneous bifid mandibular condyle and temporomandibular joint ankylosis: case report

Bifid mandibular condyle is an uncommon entity described in the literature as having a controversial etiology. Despite the absence of clinical symptomatology, the radiologist must be aware and should have some knowledge of this abnormality, as well its implications regarding functional and morphological changes. TMJ ankylosis is a disabling disease with involvement of the mandibular condyle, articular fossa and base of the skull. The association of bifid condyle with temporomandibular joint ankylosis is rare and must be carefully evaluated. The purpose of this paper is to report a case of simultaneous bifid mandibular condyle and temporomandibular joint ankylosis and to describe its computed tomography imaging findings.

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.

Transorale operative Therapie von Kiefergelenkfrakturen mit einer 3D-Platte

AIM

The transoral approach minimizes the risk of damaging the facial nerve. However, stable osteosynthesis with two miniplates at the proximal fragment is often not possible. To achieve a stable fixation also of condylar neck fractures a new delta-shaped plate was developed, which meets the biomechanical demands of this region. This plate was tested in a clinical study.

PATIENTS AND METHODS

In total 11 patients suffering from 13 condyle fractures (Spiessl I: n=2, Spiessl II: n=10, Spiessl III: n=1, 3 bilateral fractures) were treated via a transoral approach and assessed clinically as well as radiologically in the follow-up period. Functional parameters and fracture alignment were assessed.

RESULTS

After 6 months postoperative function had returned to normal with a mouth opening of 42 mm and pro- and laterotrusion of more than 5 mm. Postoperative radiographic controls showed a good fracture alignment in 7 of 8 patients respectively in 6 of 8 cases after 6 months. In 12 of 13 fractures directly postoperative and in 10 of 13 fractures 6 months postoperative, respectively, Towne's view radiographs showed an anatomical correct position. No plate fracture and no bending of plates were observed. Loosening of screws was found in 2 patients during plate removal.

CONCLUSION

The newly developed three-dimensional plate was easy to handle, and a sufficiently stable osteosynthesis of condyle fractures was possible. This plate can be recommended for surgical fracture treatment via a transoral approach omitting extraoral scars and damage to the facial nerve.

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.

Minimally Invasive Fracture Treatment With Cannulated Lag Screws in Intracapsular Fractures of the Condyle

PURPOSE

We examined the use of cannulated lag screw osteosynthesis for the treatment of fractures of the mandibular condylar head in providing a high-quality durable fixation, while at the same time reducing the trauma necessary for an open approach to the fracture site.

PATIENTS AND METHODS

A preauricular approach was used for exposure, reduction, and osteosynthesis in 5 cases of type B condylar fractures. A cannulated screw system was used that allowed optimum placement of the self-cutting cannulated lag screw following insertion of a guiding wire and using clinical control to ensure its correct position. The joints were submitted to functional exercises immediately following surgery and postoperative radiologic, axiographic, and clinical follow-ups were performed.

RESULTS

Radiologic follow-up revealed correct reduction and fixation in all 5 cases. Axiographic and clinical follow-up showed an initial limitation, but normal mobility of the condyles was achieved within 3 months postoperatively, with a maximum mouth opening of 41.2 +/- 9.4 mm after 6 months. There were no occlusal disturbances, no trismus, no lateral deviations of the mandible, and no nerve lesions. Intraoperatively, the method applied shortened the time necessary for and simplified the procedure of reduction and osteosynthesis.

CONCLUSION

By using a cannulated lag screw, it was shown that the major factor in the extent of the trauma relating to surgical access was the reduction of the fracture fragments. The method ensured stable fixation of the fracture with a minimum of osteosynthesis material, while reducing the operative time. In combination with intraoperative imaging techniques it can also successfully be applied to other fractures in maxillofacial surgery.

Experimental evaluation of three osteosynthesis devices used for stabilizing condylar fractures of the mandible

INTRODUCTION

The purpose of the study is to evaluate experimentally the quality of the primary stability achieved in treating low subcondylar fractures by means of three different osteosynthesis devices.

MATERIAL AND METHODS

The devices, a standard four-hole plate, an axial lag screw and a three-dimensional rectangular plate were tested on fresh isolated human mandibles. Testing was done on a test bench by reproducing static biting exercises between the first molars on the side of the fracture. The quality of the osteosynthesis was assessed by measuring the macroscopic amount of fragment displacement and on the device's ability to diffuse the mechanical strain within the fractured area by photoelastic stress analysis.

RESULTS

The straight plates provided the worst restoration. This was explained by the unfavourable position of the plate along compression lines. The axial lag screws allowed average stability. This was due to the difficulty of intra-medullary positioning of the screw, and by the compression of the fracture line. Rectangular plates allowed good stability associated with rather good restitution of the strains. These good results were assigned to the shape of the plate, one of its arms approximating the tensile strain lines.

CONCLUSION

Positioning and shape of the osteosynthesis device are of prime importance for condylar fracture stabilization. None of the three tested devices was optimal but the three-dimensional plate was the best. There is a need to develop the geometry of new plates.

Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy

Traditional treatment of subcondylar fractures with maxillomandibular fixation often results in a malreduction and significant functional and aesthetic sequelae, including facial asymmetry, decreased jaw opening, and potential for late derangements of the temporomandibular joint. When used selectively, based on preoperative CT scans, the endoscopic technique will reliably restore condylar anatomy in nearly 95% of patients, thus obviating the consequences of malunion. Furthermore, unlike traditional open techniques no significant facial scarring or permanent facial nerve palsies have resulted. Thus, the authors strongly advocate endoscopic repair of adult condylar neck and subcondylar fractures that demonstrate displacement or dislocation and have adequate proximal bone stock to accept miniplate fixation.

Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible

The study was performed to evaluate and compare the results of open and closed treatments of diacapitular fractures of the mandible. Following open reduction and internal fixation (ORIF) 14 patients with 15 displaced condylar fractures, which had caused a shortening of the mandibular ramus, were examined clinically (Helkimo index), radiologically (Orthopantomogram, Clementschitsch [reversed Towne's] view, Submentovertex view) and axiographically (CARDIAX). These findings were compared to a group of 29 patients with 34 similar condylar fractures which had been treated using closed techniques. Following ORIF patients showed better radiological results with regard to the mandibular ramus height, resorption and pathological changes to the condyle, compared to the patient group after closed functional treatment. In both groups some signs of dysfunction persisted, although there were slightly better results in the ORIF group. In 30% of the closed treatment group, lateral deviation during mouth opening, crepitus and occlusal disturbances were noted. No cases of occlusal disturbance were observed in the ORIF group. The axiographic examinations revealed a significant limitation of movement of the fractured condyle in both groups. However, after open treatment, the temporomandibular joint displayed significantly less irregularities in the condylar paths. In cases of complex reconstruction of the mandibular condyle, ORIF appears to improve the function of fractured condyles, when combined with a postoperative therapeutic exercise regime.

Function Impairment and Pain After Closed Treatment of Fractures of the Mandibular Condyle

BACKGROUND

To determine the prognosis of fractures of the mandibular condyle after closed treatment.

METHODS

Patients (n = 144) with a fracture of the mandibular condyle, all treated closed, were included in the study. Fracture types and position of the fracture parts were determined on radiographs. Follow-up was after 12 months in which the average pain, experienced during the last week (visual analog scale, 100 mm), and mandibular functioning were assessed (mandibular function impairment questionnaire (MFIQ)).

RESULTS

Data of 116 (81%) patients, 41 women (35%) and 75 men (65%), were available for analysis. Condylar neck fractures were most common (52%). Bilateral fractures were present in 28% of the patients. Pain (visual analog scale score >0) was found in 9% of the patients. Impaired mandibular function was found in 40% (MFIQ >0) and 24% (MFIQ > or =4) of the patients. The most important risk factor for pain was being a woman. The most important risk factors for function impairment were > or =25 years of age and gross displacement of the fracture parts.

CONCLUSION

The overall prognosis of mandibular function and pain after closed treatment of condylar fractures is good. The most important risk factor for pain persisting for 1 year after closed treatment of a condylar fracture is being a woman. The most important risk factors for function impairment are an age of > or =25 years and gross displacement of the fracture parts.

Lag screw osteosynthesis of fractures of the mandibular condyle: potential benefit of preoperative planning using multiplanar CT reconstruction

OBJECTIVE

The purpose of the study was to develop a method of multiplanar CT reconstruction in fractures of the mandibular condyle in order to evaluate the feasibility of lag screw osteosynthesis.

STUDY DESIGN

Angulated axial and sagittal images of the mandibular ramus were calculated using collected CT data. In 183 mandibular rami the optimal position of the screw axis was determined retrospectively. The thickness of the covering bone as well as the degree of screw exposure were measured.

RESULTS

Application of the method led to medial (28.4% of cases) or lateral (3.8% of cases) correction of the usual screw axis. In 1.6% of cases an extraosseous position of screws could not be avoided by this correction.

CONCLUSIONS

Evaluation of the feasibility of lag screw osteosynthesis by this method is possible. Medial or lateral change of the axis ensures the optimal intraosseous screw position. Intraosseous screw placement is almost always possible.

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.

A comparative evaluation of osteosynthesis with lag screws, miniplates, or Kirschner wires for mandibular condylar process fractures

PURPOSE

This study compared the clinical and radiologic outcomes of open treatment of mandibular condylar process fractures using lag screws, miniplates, or Kirschner wires.

PATIENTS AND METHODS

Open reduction and internal fixation was performed for severely displaced or dislocated mandibular condylar process fractures in 23 patients (26 fractures) using Eckelt lag screws, in 10 patients (10 fractures) using Kirschner wires, and in 21 patients (22 fractures) using miniplates. Clinical and radiologic evaluations were made 6 months postoperatively and at final follow-up (mean, 18.4 months; range, 7 to 106 months). Radiologic evaluation included accuracy of reduction of the fractured condylar processes and changes in ramus height.

RESULTS

Most fractured condylar processes (approximately 90%) were repositioned precisely in all groups. A shortening of the ramus of more than 5 mm was observed significantly more frequently (P <.05) in the miniplate group than in the lag screw group at 6 months. The condyles were severely resorbed in 2 or 3 patients in each group. All of these patients were associated with malunion, and partial bone resorption of the condyles was seen during the first 6 months. The relation between reduction or screw position and bone healing in patients treated with lag screws indicated that correct reduction and screw insertion allowed normal bone healing. The patients in all groups showed satisfactory clinical results. No significant intergroup differences were noted in maximum mouth opening and laterotrusion. However, deviation during mouth opening was significantly greater (P <.05) in cases treated with miniplates than with lag screws.

CONCLUSION

Lag screw osteosynthesis may be more advantageous for restoration of ramus height than miniplates or Kirschner wires.