Controversies in Mandibular Condyle Fracture Repair

Frederick Mars Untalan MD

Baguio General Hospital & Medical Center

Concerning the treatment of condylar fractures, it seems that the battle will rage forever between the extremists who urge nonoperative treatment in practically every case and the other extremists who advocate open reduction in almost every case.
Malkin et al..

Objectives
To mention condyle fracture treatment controversies (OPEN vs CLOSE Treatment) To become aware of landmark studies with regards treatment of Condyle fracture To discuss possible future directions to settle these controversies

Main treatments advocated for adults with condylar process fractures

NONSURGICAL
1. a period of maxillomandibular fixation (MMF) followed by functional therapy 2. functional therapy without a period of MMF

SURGICAL
3. open reduction with or without internal fixation.

Conflicting Terminology
closed

closed treatment nonsurgical treatment

reduction (misnomer)

CONDYLE fractures
Type A:

Intracapsular fractures of the mandibular condyle

Type C : fractures through the lateral condylar pole w/ loss of vertical height of the mandibular ramus

Type B: fractures through the medial condylar pole

Type M : multiple fragments comminuted fractures.

Mandibular Condyle Fractures: Evaluation of the Strasbourg Osteosynthesis Research Group Classification simple method to define CFs and can Journal of Craniofacial Surgery: January 2009 - Volume 20 - Issue 1 - pp 24-28 Cenzi, Roberto MD; Burlini, Dante MD; Arduin, Laura MD; Zollino, Ilaria MD; prognosis. give some elements about the Guidi, Riccardo DDS; Carinci, Francesco MD
Abstract Condylar fractures (CFs) 3 main types of CFs: are about 30% of mandibular fractures. Condylar fractures are treated with several protocols, and unsatisfying outcome is achieved in some cases. A staging system for classifying CFs is of paramount importance to plan therapy, define prognosis, and to head information among trauma centers. The 1. diacapitular fractureto(i.e., through theexchangeof the condyle [DF]) Strasbourg Osteosynthesis Research Group proposed a classification system for CFs, but no report focusing to its 2. fracture ofistheavailable. Thus,neck effectiveness still condylar we performed a retrospective study on a series of patients affected by CFs. The Strasbourg Osteosynthesis Research Group classification defines 3 main types of CFs: 3. fracture ofthe head of the condyle [DF]),(CBF). of the condylar neck, and fracture of diacapitular fracture (i.e., through the condylar base fracture the condylar base (CBF). A series of 66 patients (and 84 CFs) was evaluated, and age, sex, clinical diagnosis at admission, treatment, and outcome were considered. Fractures of the condylar base and DFs are the most (52.4%) and the least (4.8%) frequent fractures, respectively. Conversely, associated fractures of the facial skeleton are found in most cases of DFs (75%) and in few cases of CBFs (20.5%). Surgery was performed in about 15% of all cases: no DF was operated, whereas fractures of the condylar neck and CBFs have an open reduction and an internal rigid fixation in 57% and 43%, respectively. Postsurgical and late sequelae were 22.3% and 19%. Temporomandibular joint symptoms and malocclusion cover about 80% and 90% of postsurgical and late sequelae. The new classification is a simple method to define CFs and can give some elements about the prognosis.

Fractures of the condylar base are the most (52.4%) DFs least (4.8%) frequent fractures

Temporomandibular joint symptoms and malocclusion cover about 80% and 90% of postsurgical and late sequelae.

The treatment of condylar fractures: to open or not to open? A critical review of this controversy

techniques must be chosen taking into consideration the presence of teeth, fractureof condylar processadaptation, patient's masticatory of The treatment height, patient's fractures has generated a great deal system, discussion and controversy in oral and maxillofacial trauma and there are many disturbance of to treat this injury. different methods occlusal function, deviation of the mandible, internal derangements of the temporomandibular Jointmust beand ankylosis into For each type of condylar fracture, the techniques (TMJ) chosen taking of the consideration the presence of teeth, inabilityheight, patient's adaptation, joint with resultant fracture to move the jaw

Renato VALIATI,1* Danilo IBRAHIM,1* Marcelo Emir Requia ABREU,1* Claiton HEITZ,2* Rogrio Belle de OLIVEIRA,2* Rogrio Miranda PAGNONCELLI,2* and Daniela Nascimento SILVA2*

patient's masticatory system, disturbance of occlusal function, deviation of the mandible, internal derangements of the temporomandibular Joint (TMJ) and ankylosis of the joint with resultant inability to move the jaw, all of which are sequelaerecent years, surgeons treatment of condylar in of this injury. Many open seem to favor closed treatment with maxillomandibular fixation (MMF), but in recent years, open treatment of condylar fractures internal fixation (RIF) has become more (RIF) has fractures with rigid with rigid internal fixation common. The objective of this review was to evaluate the main variables that determine the choice of method forbecome more common or closed, pointing out treatment of condylar fractures: open their indications, contra-indications, advantages and disadvantages.

Interventions for the treatment of fractures of the mandibular condyle

Sharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R

Fractures of the condylar process of the mandible (lower jaw) are common. the complications include Two treatment options are available: either closed treatment (without surgery) disturbances in (involving surgery). meet, facial or open reduction the way the teeth Complications are associated with and reduced mobility of the asymmetry, chronic pain both treatment modalities.

closed approach

Currently there is much controversy regarding the most appropriate paralysis of the nerve supplying some of the facial method for the management of fractured mandibular condyles. This muscles involved in smiling and high quality evidence for the review revealed that there is a lack of eye opening/closing. effectiveness of either approach, and that there is a need for further research to help clinicians and patients to make informed choices of treatment options.

With a closed approach the complications include disturbances in the way the lower jaw. teeth meet, facial asymmetry, chronic pain and reduced mobility of the lower jaw. With an open approach the complications include a scar on the overlying skin the complications include a scar on and also the possibility of temporary paralysis of the nerve supplying some of the overlying involved in smiling and eye opening/closing. the facial musclesskin and also the possibility of temporary

open approach

Fractures of the mandibular condyle. Therapeutic controversies

Acta Med Port. 1999 Apr-Jun;12(4-6):209-15. Martins JS, Frage ZB. The main goal of treatment is restorationLisboa. Servio de Cirrgia Plstica e Reconstrutiva, Hospital Egas Moniz, of Abstract function and not anatomic restoration of The condylar mandibular fractures are important because its incidence, possible complications and controversial treatment. The treatment of parts. condylar fractures has generated more controversy and discussion than any other in the field of maxillofacial trauma. The main goal of treatment is restoration of function and not anatomic restoration of parts. Despite several clinical and anatomical consensus Despite several clinical studiesanatomical studies still and still lackfocus on theregarding the best method of treatment. This review article controversy that surrounds treatment of the condylar fractures,method of lack consensus regarding the best trying to supply be consensus about questions like: Should condylar mandibular fractures managed via a closed or open technique? What is the best surgical treatment. approach? Surgical timing? What is the degree and duration of mandibular immobilization? Is or not necessary to treat the ATM disc?

The majority of surgeons seem to favor non surgical treatment of condylar fractures.

3 main factors.
nonsurgical tx gives satisfactory results in the majority of cases.
no large series of patients reported in the literature who have been followed after surgical treatment ( management of condylar fractures has historically been w/nonsurgical means)

surgery of condylar fractures is difficult because of the Inherent anatomical hazards (ie, VII nerve)

1st

2nd

3rd

Is MMF Necessary/Desirable?
2 main treatments advocated when performing closed treatment: 1) a period of MMF followed by functional therapy 2) functional therapy without a period of MMF.

tradition and experience

MMF is instituted for 3 main reasons:

to make the patient more comfortable to promote osseous union to help reduce the fractured fragment

Unilateral mandibular condylar fractures: 31-year follow-up of non-surgical treatment

1National 2National

Dental Service, Sndrum, Getinge, Sweden Dental Service, rebro, Sweden 3Department of Oral and Maxillofacial Surgery, University Hospital MAS, Malm, Sweden 4Department of Oral Surgery and Oral Medicine, Faculty of Odontology, University of Malm, Malm, Sweden Accepted 8 November 2006. Available online 18 January 2007. Abstract At the University Hospital of Malm, Sweden, standardized trauma charts were used for registration of all jaw fractures from 1972 to 1976. During the year 2005 the aim was to interview all patients treated non-surgically for unilateral mandibular condylar fractures during this period. In total, 49 patients with unilateral condylar fractures were treated non-surgically in 19721976. Of these, 23 patients were available for follow-up, 17 were dead, 7 were not found and 2 did not answer letters or phone calls. The follow-up was a telephone interview according to a standardized questionnaire concerning occurrence of pain and headache, function of the jaw and joint sounds. Information from original records, radiographic reports and the standardized trauma charts revealed fracture site, type of fracture and intermaxillary fixation if any. Eighty-seven percent of the patients reported no pain from the jaws, 83% had no problems chewing and 91% reported no impact of the fracture on daily activities. Neck and shoulder symptoms were reported by 39% and back pain by 30%. The 31-year results of non-surgical treatment of unilateral non-dislocated and minor dislocated condylar fractures seem favourable concerning function, occurrence of pain and impact on daily life.

87% of patients reported no pain from the jaws 83% no problems chewing 91% reported no impact of the fracture on daily activities.
Neck and shoulder symptoms were reported by 39% and back pain by 30%.

1. injection of 100 units of botulinum toxin A, diluted to a concentration of Ann Plast Surg. 2007 May;58(5):474-8. Canter HI, Kayikcioglu A, Aksu M, Mavili ME. Hacettepe University, Faculty 20 IU/mL, into the muscles of mastication of the fractured side. Masseter of Medicine, Department of Plastic and Reconstructive Surgery, Ankara, Turkey. [email protected] Abstract and anterior fibers of temporalis muscles were reached through BACKGROUND: The topic of condylar injury in adults has generated more discussion and controversy than any other in the field of maxillofacial trauma. The treatment ofIU of the toxin adults is still a highly to each percutaneous extraoral route and 30 condylar fractures in was injected debated theme. METHODS: Patients with unilateral subcondylar or condylar neck fractures of the mandibula without any muscle. significant angulation of the condylar head were managed with closed-treatment protocol. Closed treatment was 2. applied through the injection of 100 units of botulinum toxin A, diluted to a concentration of 20 IU/mL, into the Additional 40 IU of the toxin was injected around the fractured bone muscles of mastication of the fractured side. Masseter and anterior fibers of temporalis muscles were reached fragments through transmucosal intraoral route each muscle. Additional 40 and through percutaneous extraoral route and 30 IU of the toxin was injected toto paralyze medial IU of the toxin was injected around the fractured bone fragments through transmucosal intraoral route to paralyze medial lateral pterygoid muscles as much asymmetric occlusal and lateral pterygoid muscles as much as possible. An as possible. splint was applied for 3. maxillomandibular fixation to restoremonths. was applied for maxillomandibular fixation An asymmetric occlusalthe vertical height for 10 days. Functional therapy with intermaxillary guiding elastics was advocated for 2 splint RESULTS: There were no complications relatedfor 10 days. to restore the vertical height to either toxin injections or splint application procedures. The toxin was effective on all occasions. Fractured condylar process and ramus of the mandibula were in good and 4. approximation jointremained inwith follow-up period. of the patients had any occlusal disturbance, mandibular Functional therapy reduced positions. None guiding elastics was advocated for intermaxillary asymmetry, or dysfunction in the 2 months. CONCLUSIONS: We believe that modification of treatment options concerning the clinical situation of the patients

Botulinum toxin in closed treatment Closed treatment was applied through: of mandibular condylar fracture

is the best method for condylar injury. The purpose of this study is to present and discuss the results achieved in closed treatment of a selected group of patients with mandibular condylar fractures to whom botulinum toxin A was injected to relieve the spasm of muscles of mastication, along with special splint application.

to relieve the spasm of muscles of mastication, along with special splint application.

OPEN TREATMENT
becoming more common, probably because of the introduction of plate and screw fixation devices that allow stabilization of such injuries. no definitive study performed that has shown the superiority of open versus closed reduction Unfortunately, the type of study needed to clarify this question may never be possible.

Is Open Reduction and Internal Fixation of Condylar Process Fracture Biologically Sound?

availability of plate & screw fixation systems

SAFE??

To determine whether or not open treatment of condylar process fractures is biologically sound:
1) the blood supply to the condyle, 2) whether or not the blood supply is essential to open treatment.

condyle blood supply is mostly derived from 3 sources

inferior alveolar artery

TMJ capsule
major component to the condyle and its articular surface is derived from the TMJ capsule, with its lush vascular plexus.

branches of the lateral pterygoid

A branch of the inferior alveolar artery courses upward through the neck of the condylar process, where it anastomoses liberally with vessels from the attached musculature.

a large contribution of blood supply from branches of the lateral pterygoid muscle through its attachment at the pterygoid fovea.

Indications for open reduction and rigid internal fixation of mandibular condyle fractures
(MITCHELL, 19971; HAUG and ASSAEL, 200119; BRANDT and HAUG, 200330)

Absolute Indications:
Patient preference (when no absolute or relative contraindications co-exist) When manipulation and closed treatment cannot re-establish the pretraumatic occlusion; mutliple facial fractures When stability of the occlusion is limited Displacement into the middle cranial fossa Lateral extracapsular deviation Open fracture with potential for fibrosis Invasion by foreign body.

Relative Indications:
Edentulous jaws Periodontal problems Bilateral condylar fractures in an edentulous patient without a splint Unilateral or bilateral condylar fractures where splinting cannot be accomplished for medical reasons or because physiotherapy is impossible Bilateral condylar fractures with comminuted midfacial fractures, prognathia or retrognathia; Unilateral condylar fracture with unstable base; Displaced condyle with edentulous or partially edentulous mandible with posterior bite collapse; Noncompliance Uncontrolled seizure disorders Status asthmaticus Obtunded neurologic status with documentation of predicted improvement Psychologic compromise (e.g., mental retardation, organic mental syndrome, psychosis) Substance abuse

Contraindications to open reduction and rigid internal fixation of mandibular condyle fractures
(MITCHELL, 19971; HAUG and ASSAEL, 200119; BRANDT and HAUG, 200330).

Absolute Contraindications:
Condylar head fractures (at or above the ligamentous attachmentsingle fragment, comminuted, or medial pole) When medical illness or systemic injury add undue risk to an extended general anesthetic Good occlusion Minimal pain Acceptable mandibular movement.

Relative Contraindications: When a simpler method is as effective Condylar neck fractures (the thin, constricted region inferior to the condylar head) Obtunded neurologic status when there is no documented hope for improvement

Surgical versus conservative treatment of unilateral condylar process fractures: Clinical and radiographic evaluation of 80 patients
Volume 50, Issue 4, Pages 349-352 (April 1992) Using clinical parameters (maximal mouth opening, Vitomir S. Konstantinovi, DDS, Branislav Dimitrijevi, DDD, PhD Abstract deviation, protrusion), no statistical differences between Treatment results of 26 surgically treated fractures treated unilateral surgically and conservatively and 54 conservativelywere found. condylar process fractures were investigated by standardized clinical examination and by evaluation of computer-simulated graphic presentations of posteroanterior (PA) radiographs of the mandible. The radiographic evaluation compared the relation of actual reduction of the condylar process fractures with ideally reduced fractures produced on the computer. However, the radiographicmouth opening, deviation, protrusion), examinations showed a Using clinical parameters (maximal no statistical better position of the surgically reduced statisticallydifferences between surgically and conservatively treated fractures were found. condylar process fractures. However, the radiographic examinations showed a statistically better position of the surgically reduced condylar process fractures.

Functional Results of Unilateral Mandibular Condylar Process Fractures after Open and Closed Treatment
Journal of Trauma-Injury Infection & Critical Care: March 2002 - Volume 52 - Issue 3 - pp 498-503 patients with MD; Chen, mandibular condylar process fractures were reviewed. 66 Yang, Wen-Guei unilateralChien-Tzung MD; Tsay, Pei-Kwei PhD; Chen, Yu-Ray MD patients 36 Abstract received open reduction 30 Background : This retrospective study compared the functional results of unilateral mandibular underwent closed treatment MMF only condylar process fractures treated either by open reduction or by closed treatment. Methods : Sixty-six patients with unilateral mandibular condylar process fractures were reviewed. Thirty-six subgroup with open reduction other 30 underwent closed treatment condylar patients received open reduction, and the presented less chin deviation (intermaxillary fixation only). Each group was further divided into condylar and subcondylar (21.43%) compared with thoseThe functional outcome was evaluated by posttreatment subgroups according to fracture level. with closed treatment (56.25%) occlusion status, maximal mouth opening, facial symmetry, chin deviation, and temporomandibular joint symptoms. condylar Patients undergoing closed treatment exhibited more condylar motility than those treated Results : neck or head fractures gained more benefits from open reduction by open reduction. Patients in the condylar subgroup with open reduction presented less chin deviationterms of chin deviation and closed treatment (56.25%;p joint pain. in (21.43%) compared with those with temporomandibular = 0.072). Although a greater severity of subcondylar fractures existed in patients treated with open reduction, patients For subcondylarreduction or closed treatment did not reveal a significantly functional difference. treated with open fractures, open reduction provides satisfactory functional Conclusion :results in patients with severely displaced neck or head fractures gained The present study revealed that patients with condylar fractures. more benefits from open reduction in terms of chin deviation and temporomandibular joint pain. For subcondylar fractures, open reduction provides satisfactory functional results in patients with severely displaced fractures.

Open Reduction and Internal Fixation Versus Closed Treatment and Mandibulomaxillary Fixation of Fractures of the Mandibular Condylar Process: A Randomized, Prospective, Multicenter Study With Special Evaluation of Fracture Level
J Oral Maxillofac average Dec in level (VAS from 0 to 100)wasafter CRMMF, and 1 The difference ;66 (12):2537-2544 The Surg. 2008 pain average mouth opening 25 12 mm (P </=.001) Matthias Schneider Francois Erasmus, Klaus Louis Gerlach, Eberhard Kuhlisch, Richard A Loukota, Michael Rasse, between both (P </=.001). after ORIF Johannes Schubert, Hendrik Terheyden, Uwe Eckelt treatment groups. Consultant, Department of Oral and Maxillofacial Surgery, Technical University of Dresden, Dresden, Germany. PURPOSE: This randomized, clinical multicenter trial investigated the treatment outcomes of displaced condylar fractures, and whether radiographic fracture level was a prognostic factor in therapeutic decision-making between In 53 unilateral fractures, better functional results were open reduction and internal fixation (ORIF) versus closed reduction and mandibulomaxillary fixation (CRMMF). observed for ORIF compared with CRMMF, irrespective of PATIENTS AND METHODS: Sixty-six patients with 79 displaced fractures (deviation of 10 degrees to 45 degrees , or shortening of the ascending ramus >/=2 mm) of the condylar process of the mandible at 7 clinical centers were fracture level (condylar base, = 30 patients) or ORIF (n = 36 patients) treatment. The enrolled. Patients were randomly allocated to CRMMF (nneck, or intracapsular head). following parameters were measured 6 months after the trauma. Clinical parameters included mouth opening, protrusion, and laterotrusion. Radiographic parameters included level of the fracture, deviation of the fragment, and shortening of the ascending ramus. Subjective parameters included pain (according to a visual analogue scale), discomfort,patients with bilateral condylarmandibular functional impairment questionnaire. In and subjective functional impairment with a fractures, ORIF was RESULTS: The difference in average mouth opening was 12 mm (P </=.001) between both treatment groups. The especially advantageous. average pain level (visual analogue scale from 0 to 100) was 25 after CRMMF, and 1 after ORIF (P </=.001). In 53 unilateral fractures, better functional results were observed for ORIF compared with CRMMF, irrespective of fracture level (condylar base, neck, or intracapsular head). Unexpectedly, the subjective discomfort level decreased with ascending level of the fracture. In patients with bilateral condylar fractures, ORIF was especially advantageous. CONCLUSION: Fractures with a deviation of 10 degrees to 45 degrees , or a shortening of the CONCLUSION: >/=2 mm, should be treated with ORIF, irrespective of level of the fracture. ascending ramus

Fractures with a deviation of 10 degrees to 45 degrees or a shortening of the ascending ramus >/=2 mm, should be treated with ORIF, irrespective of level of the fracture.

Intracapsular condylar fracture of the mandible: our classification and open treatment experience
J Oral Maxillofac Surg. 2009 Aug ;67 (8):1672-9 19615581 Cit:1 Dongmei He, Chi Yang, Minjie Chen, Bin Jiang, Baoli Wang treatment protocol is open reduction for a fracture in which the Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Keydislocated Stomatology, Shanghai, China. the glenoid fossa or any superolaterally Laboratory of ramus stump is out of PURPOSE: We studied the classification of intracapsular condylar fracture (ICF) of the mandible based on coronal type of fracture computed tomography (CT) scans and present our open treatment experience at the temporomandibular joint (TMJ) division of Shanghai's Ninth People's Hospital (Shanghai, China). MATERIALS AND METHODS: From 1999 to 2008, 229 patients with 312 ICFs were treated in our division. Among type A: them, 195 patients thrujoints) had CT scansof condylar head w/ reduction of ramus height a fracture line (269 lateral third for classification. We modified the classification of Neff et al, adding new fracture type according to our experience: type A, fracture line through lateral third of condylar head with type B: reduction of ramusthrough middle third of condylar head fracture line height; type B, fracture line through middle third of condylar head; type C, fracture line through medial third of condylar head; and type M, comminuted fracture of condylar head. There was no ramus type C: height reduction in through medial third of condylarisheadreduction for a fracture in which the fracture line fracture types B and C. Our treatment protocol open ramus stump is out of type M:superolaterally dislocated may causecondylarthe glenoid fossa or any type of fracture with displaced or comminuted fracture of TMJ dysfunction later. head. dislocated fragments that RESULT: Among the 269 joints, 116 had type A fractures (43.1%), 81 had type B fractures (30.1%), 11 had type C fractures (4.1%), and 58 had type M fractures (21.6%); 3 joints (1.1%) had fractures that were not displaced. Of the joints, 173 had open postoperative CT postoperative CT reduction-internal fixation;all of them normalscans showed that 95.6% of these had scans showed that 95.6% of theseopeningabsolute were absolute anatomic or nearly anatomic reduction. In mouth had and occlusion restored. No or little deviation was found during mouth opening. Complications were pain in the joint (n = 1), anatomic(nor2), and facial nerve (temporal branch) paralysis (n = 1). Two patients had the plate removed crepitations = nearly anatomic reduction. because of In all of these complications. mouthon CT scans can better guide clinical treatment. Open reduction for ICF them normal opening and occlusion were CONCLUSION: Our new classification based can restore both the restored the anatomic position for results. condyle and TMJ soft tissues with few complications, which can yield better functional and radiologic

Mini-retromandibular approach to condylar fractures

Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery. 01/08/2008; Authors: Federico Biglioli, Giacomo Colletti INTRODUCTION: Among maxillofacial surgeons, a general agreement exists that the therapeutic strategy for intracapsular condylar fractures is conservative, while the treatment of extracapsular fractures of the mandibular condyle is extremely controversial. The indications and choice of treatment are less than uniform, often relying on the surgeon's personal experience and beliefs. The literature increasingly suggests that the surgical management of these fractures is superior to conservative management in functional terms. Nonetheless, the indications for surgically treating condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but is demanding technically, especially for higher neck fractures. In our experience, a 2-cm-long retromandibular access allows straightforward management of condylar fractures, providing as a result a well concealed scar. MATERIALS AND METHODS: From 2006 to 2007, 21 patients with 25 condylar fractures were treated surgically using the mini-retromandibular access. The mean operating time was 32min (range 17-55min). No facial nerve injuries were observed. The first two patients developed postoperative infections. One patient, in whom the first intervention resulted in malreduction of the fracture because the access was insufficient (15mm incision), required a second operation to achieve correct reduction and rigid fixation of the condyle. RESULTS: In all cases, good anatomical stump reduction was achieved. All the patients obtained good articular function, since the access was exclusively extra-articular. CONCLUSIONS: Condylar fracture reduction, fixation and healing can be managed comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are viewed directly.

fixation and healing can be managed comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are viewed directly.

Endoscopic-assisted repair of subcondylar fractures

Endoscopic approacvh MMF was used intraoperatively to aid in fracture reduction. Modified Risdon incision

Volume 96 Issue 4 Pages 387-391 (October 2003) Michael Miloro DMD, Md Abstract Objective To evaluate outcomes of a series of mandibular subcondylar fractures repaired with endoscopic reduction and fixation. Study design Six consecutive subcondylar fractures were treated endoscopically. Intermaxillary fixation was used intraoperatively to aid in fracture reduction. A modified Risdon incision was used to gain access to the lateral ramus, and a modified retractor and endoscope were used for retraction and visualization. Fracture fixation was achieved with a 2-mm titanium plate and screws. Patients were evaluated clinically and radiographically for 6 months and functional, radiographic, and esthetic parameters were assessed at each time period (1, 2, 4, 12, and 24 weeks). Results All patients demonstrated a stable occlusion in the postoperative period and anatomic alignment of the condyle radiographically. By 1 month, maximum interincisal opening was 42.2 5.7 mm. There was no joint noise or temporomandibular joint (TMJ) pain postoperatively. Radiographs at each follow-up visit indicated the ramus height was maintained in most cases. There was minimal transient facial nerve paresis following surgery. Scar perception was considered acceptable by all patients. Operative times were acceptable as well. Conclusion Endoscopic-assisted repair of subcondylar fractures is an additional tool for management of subcondylar fractures, however there is a steep learning curve based on this study. The technique allows good visualization of the fracture site for reduction through an incision with an acceptable cosmetic result.

Endoscopic-assisted repair of subcondylar fractures is an additional tool for management of subcondylar fractures

Endoscopically Assisted Mandibular Subcondylar Fracture Repair

Plastic & Reconstructive Surgery: January 1999 - Volume 103 - Issue 1 - pp 60-65 Chen, Chien-Tzung M.D.; Lai, Jui-Ping M.D.; Tung, Tung-Chain M.D.; Chen, Yu-Ray M.D. Abstract The endoscope has been widely used in aesthetic surgery in recent years, but rarely has it been used in cases of facial trauma. From July of 1996 to December of 1996, the endoscope was used successfully to assist in the repair of mandibular subcondylar fractures in eight patients (five men and three women). Their ages ranged from 15 to 60 years with an average age of 31 years. Six of the patients had other associated mandibular fractures including angular, parasymphyseal, and contralateral subcondylar fractures. A 4.0-mm, 30-degree telescope was introduced to visualize the fracture site by means of an intraoral incision over the ascending ramus. A miniplate was used to stabilize the fracture site with the help of a percutaneous trocar. Intermaxillary fixation was applied for 3 to 6 days. Functionally, all patients returned to normal range of motion within 8 weeks. A slight deviation to the trauma site was noted on maximal opening in three patients, but this condition returned to normal 3 months after surgery. There was no facial palsy or lip numbness. The benefits of the endoscopic approach include not only the provision of better visualization and precise anatomic alignment of bony segments but also the avoidance of large facial scars and facial nerve injuries.

better visualization precise anatomic alignment of bony segments the avoidance of large facial scars and facial nerve injuries

Open reduction and internal rigid fixation of subcondylar fractures via an intraoral approach
Oral Surgery, Oral Medicine, Oral Pathology An 71, Issue approach with a percutaneous trocar and Volume intraoral3, March 1991, Pages 257-261 miniplates demonstrated satisfactory reduction. Joachim Lachner D.M.D., M.D.a, a, Jerald T. Clanton D.M.D., M.D.b, a and Peter D. Waite D.D.S., M.D., M.P.H., c, a (a preauricular or submandibular incision) aDepartment of Oral and Maxillofacial Surgery, University of Alabama at Birmingham Birmingham, Ala., USA Extraoral open reduction and rigid fixation of mandibular restored Early function with proper vertical dimension was subcondylar with minimal postoperative morbidity.An intraoral fractures is controversial among surgeons. approach with a percutaneous trocar and miniplates demonstrated satisfactory reduction. This technique can be more easily performed than a preauricular or submandibular incision, and risk of facial nerve damage is diminished. Early function with proper vertical dimension was restored with minimal postoperative morbidity.

Closed versus open reduction of mandibular condylar fractures in adults: a meta-analysis

Medline search Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 01/07/2008; "mandibular condyle fractures" 66(6):1087-92. Authors: Marcy L Nussbaum, Daniel M Laskin, Al M Best "mandibular condyle fracture surgery" PURPOSE: A review of the literature shows a difference of opinion regarding whether open or

1. lack of patient randomization 2. failure to classify the type of condylar 3. fracture variability within the surgical protocols, 4. inconsistencies in choice of variables and how they were reported.

not possible to perform a reliable meta-analysis. There is a need for better standardization of data collection

closed reduction of condylar fractures produces the best results. It would be beneficial, therefore, to critically analyze past studies that have directly compared the 2 methods in an attempt to answer this question. MATERIALS AND METHODS: A Medline search for articles using the key words "mandibular condyle fractures" and "mandibular condyle fracture surgery" was performed. Articles that compared open and closed reduction were selected for further evaluation. Additional articles were obtained from reference lists in the Medline-selected articles. Of the 32 articles identified, 13 met the final selection criteria. These contained data on at least one of the following: postoperative maximum mouth opening, deviation on opening, lateral excursion, protrusion, asymmetry, and joint or muscle pain. RESULTS: Numerous problems were found with the information presented in the various articles. These included lack of patient randomization, failure to classify the type of condylar fracture, variability within the surgical protocols, and inconsistencies in choice of variables and how they were reported. However, the results from the meta-analyses were explored in a general sense. CONCLUSIONS: Because of the great variation in the manner in which the various study parameters were reported, it was not possible to perform a reliable meta-analysis. There is a need for better standardization of data collection as well as randomization of the patients treated in future studies to accurately compare the 2 methods.

Closed reduction, open reduction, and endoscopic assistance: current thoughts on the management of mandibular condyle fractures
Plastic and reconstructive surgery. 01/01/2008; 120(7 Suppl 2):90S-102S. The management of fractures of the mandibular Authors: Richard H Haug, M Todd Brandt condyle continues to bethe mandibular condyle continues to be The management of fractures of controversial. 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 1. a misinterpretation of harmliterature fromcondyle, and a in perceived potential to cause the through the opendecades prior approach based part on the uniformity of classification of the the literature. This 2. a lack ofsurgeon's lack of a critical examination ofvarious review explores the key historical articles that deal with the management of anatomical components of the mandibular condyle mandibular condyle fractures, and those modern-day contributions that represent the state of the art. cause harm through the open 3. a perceived potential toThe authors' intention was to provide the reader with an objective summary of the management of this form of approach based in part on the surgeon's lack of a critical injury, to place its management into a modern-day perspective, and perhaps to minimize theperception of controversy. examination of the literature.

Interventions for the treatment of fractures of the mandibular condyle

Sharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R

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).

Abstract 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.

No high quality evidence is available

CONCLUSION
The final choice of treatment modality for each individual patient takes into account a number of factors
position of the condyle location of the fracture age of the fracture character of the patient age of the patient presence or absence of other associated injuries presence of other systemic medical conditions history of previous joint disease, cosmetic impact of the surgery desires of the patient.

CONCLUSION
Perhaps the collective experience of the many surgeons who treat these fractures can best be characterized as follows:

Intracapsular fractures are best treated closed. When open reduction is indicated, the procedure must be performed well,
appreciate patient's occlusal relationships must be supported by an appropriate physical therapy and follow-up regimen.

Most fractures in adults can be treated closed. Physical therapy that is goal-directed and specific to each patient is integral to good patient care and is the primary factor influencing successful outcomes whether the patient is treated open or closed.

Controversies in Mandibular Condyle Fracture Repair

Frederick Mars Untalan MD
Baguio General Hospital & Medical Center