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Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible
Int. J. Oral Maxillofac. Surg. 2005; 34: 597–604 doi:10.1016/j.ijom.2005.02.004, available online at http://www.sciencedirect.com
Leading Clinical Paper Trauma
Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible
M. Hlawitschka, R. Loukota, U. Eckelt Klinik und Poliklinik fu¨r Mund-, Kiefer- und Gesichtschirurgie der Medizinischen Fakulta¨t, ‘‘Carl Gustav Carus’’ der Technischen Universita¨t Dresden, D-01307 Dresden, Germany
M. Hlawitschka, R. Loukota, U. Eckelt: Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible. Int. J. Oral Maxillofac. Surg. 2005; 34: 597–604. # 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. 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.
0901-5027/060597+08 $30.00/0
Accepted for publication 2 February 2005
# 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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Fractures of the mandibular condyle are frequently treated using closed functional techniques. Although in many cases good initial clinical results are achieved, serious late complications have been reported such as ankylosis, condylar necrosis, inhibition of mandiblar growth and occlusal disturbances5,19. Differentiated evaluation using modern diagnostic methods such as computed tomography (CT), magnetic resonance imaging (MRI) and electronic axiography have demonstrated that clinical outcome depends upon the intracapsular fracture line and comminution. Patients display significantly poorer clinical, radiological and axiographical results if the fracture line runs through the lateral condylar pole and the displacement of the proximal fragment has resulted in a shortening of the mandibular ramus, when compared to those patients whose fracture line runs through the medial condylar pole and in whom the vertical dimension of the mandibular ramus has remained intact17,18. For this reason some authors advocate ORIF in adults demonstrating shortening of the mandibular ramus and have obtained good radiological and clinical results22,17,18. The aim of this study is to compare ORIF of unsupported types of diacapitular condyle fractures and conventional closed functional techniques. Material and methods
The distribution of the condylar fractures and their treatment is depicted in Table 1. Thirteen male patients and 1 female patient (mean age: 30 years, range: 15.1–73.6) with 19 intracapsular condylar
Table 1. Patients with mandibular fractures treated using open techniques—distribution after classification according to SPIESSL & SCHROLL (1972) as well as, NEFF & co-workers (1999) and their treatment Number
Type I Type II Type III Type IV Type V Type VI Subtype A Subtype B
Treatment
Patients Mandibular fractures
n = 14 n = 24
Closed
Fracture without displacement Low fracture with displacement High fracture with displacement Low fracture with dislocation High fracture with dislocation Intracapsular fracture (diacapitular) Without mandibular ramus height reduction With mandibular ramus height reduction
1 3 – 1 –
– – – – –
1 3 – 1 –
4 15
4 –
– 15
fractures have been treated in the Dresden Clinic since 1998. Fifteen condylar fractures were treated by ORIF; all were displaced, intracapsular shortened condylar fractures and were classified as Type B, NEFF et al.17 The joint was accessed via the modified auricular approach, RASSE et al.21 The fractures were fixed using a titanium compression screw in 10 cases (Fig. 1), in 4 cases with a titanium micromesh and in 1 case with an absorbable polylactide screw. All patients were placed into intermaxillary fixation (IMF) until after the postoperative radiological check the next day and then mobilised. The four contralateral, vertically unshortened condylar fractures (Fracture Type A) were treated using the closed functional method. In these cases a 10day period of immobilisation was implemented followed by a functional mobilisation schedule for 3 weeks. All concomitant fractures of the mandible were treated according to standard principles of functionally stable osteosynthesis, including five contralateral sub-
Open
capitular mandibular fractures which were treated using compression screw osteosynthesis1. Closed functionally treated patient group
For comparison the retrospective followup results of 29 adult patients with 34 condylar head fractures treated since 1995 using closed functional methods were used. The average age of the 25 male and 4 female patients was 28 years (range: 13.7–76.9 years). These intracapsular fractures were also the displaced, shortened Type B fractures. The fracture line through the condyle was determined by conventional radiographs on two levels (Orthopantogram, P.A. skull film and CT). Concomitant mandible fractures were also surgically treated including five dislocated and two displaced subcapitular condylar fractures. Two undisplaced condylar neck fractures were treated using the closed method. The intracapsular fractures were immobilised with rigid IMF for 10 days followed by 6–
Fig. 1. Coronal CTs depicting the results of repositioning following a one-sided intracapsular fracture of the mandibular condyle with a primary reduction of the mandibular ramus (a) preoperative and (b) postoperative after 3 months, fixation of the fracture fragment with a compression screw made of titanium.
Open and closed treatment of intracapsular condylar fractures
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Fig. 2. Distances and angles in (a) OPG, (b) PA-radiograph according to Clementschitsch (1963) and (c) the Submentovertex-radiograph.
8 weeks of functional treatment. The patients were instructed to eat soft foods for 3 weeks and intensively performed mouth-opening exercises. In eight cases, a functional orthodontic activator from Andresen-Ha¨ upl was prescribed for a mean of 8 weeks. The ORIF group was examined after a mean of 11 months and the closed functionally treated group after a mean of 20 months. Clinical examinations involved the inspection, palpation and auscultation of the TMJ. Lateral deviation of more than 2 mm on mouth opening, the length of the maximum interincisal opening, protrusion and laterotrusion and occlusal disturbances were recorded. The clinical findings were summarized by applying the
dysfunction index according to HELK11 , i.e., mandibular mobility, TMJ function, masticatory muscle pain, TMJ pain and pain precipitated by movement. Changes in the condyle’s form and position were assessed by an orthopantogram, P.A. skull film and submento-vertex view (Fig. 2). Condylar paths, in relation to the hinge axis, were electronically recorded using the CADIAX-System (Computer Aided Axis-Recording) and were analysed according to SLAVICEK24.
IMO
Results
Post-treatment there were few subjective complaints of minor dysfunction in either group. The results of the Helkimo-dys-
function11 (the evaluation of the five different criteria) and the numerical classification of the Helkimo index are presented in Table 2. In the closed functionally treated patient group a rate >30% of moderate and serious dysfunction was observed. In particular lateral deviation during mouth opening exceeding 2 mm, crepitation, restriction of protrusion and medial movement and, in one third of the cases, occlusal disturbances were observed. In the ORIF group however, no occlusal disturbances were noted. In comparison to the closed functionally treated patients, lower values of mandibular mobility (Fig. 3) were measured. This particularly applied to medial movement and mouth opening. No cases of mouth opening less
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Table 2. Clinical dysfunction index according to HELKIMO (1974)—degree of dysfunction and occlusal disturbances in open and closed treated patients with intracapsular mandibular condyle fractures Treatment Dysfunction index Dysfunction
D D D D
0 symptom-free I slight II moderate III severe
Open (n = 14)
Closed (n = 29)
1 10 3 –
1 19 8 1
–
10
Occlusal disturbances
according to GSELLMANN et al.8 and from the clinic’s own control group. After open treatment the reduced range of movement was mainly the result of a reduction in rotation, whereas after closed functional treatment a reduction in translation movement of the condyle was apparent. Non-physiological excursions of the fractured condyle were present in both groups but were less common after open treatment when compared to closed functional treatment (Table 3). In both groups nonphysiological excursions were also frequently registered on the unfractured TMJ. Radiological findings
Fig. 3. Clinical findings of mandibular mobility in open (n = 14) and closed functionally (n = 24) treated adult patients with intracapsular fractures of the mandible.
than 30 mm were recorded. The ORIF group displayed no problem with wound healing and all were satisfied with the cosmesis of the result. Immediately after the operation one patient experienced a temporary weakness of the temporal branch of the facial nerve. No local problems secondary to the osteosynthesis material were recorded.
Functional diagnostic findings
Axiographic evaluation of condylar excursions following open and closed functional treatment of condylar fractures revealed moderate to serious limitations in all directions of excursion compared to the non-fractured contralateral side; data gathered from healthy test patients
In all ORIF cases significant improvement in the position of the major fragments was achieved. In three cases additional bony fragments on the dorsal-lateral pole of the condyle were apparent. These were reduced but not fixed on two occasions. The remaining bony fragment was removed. Subsequent movement of these reduced fragments was not observed. The results after ORIF of the condyles are shown in Table 4. The largest postoperative condylar displacements were medially, with an average of 1.5 mm seen in a Clementschitsch (reverse Towne’s) radiographs. In preoperative radiographs the height of the mandibular ramus was reduced on average 5.7 mm due to vertical fragment displacement. This resulted in a reduction of the mandibular ramus height of 8% compared to the opposite side. After reduction of the fractured fragment, the immediate postoperative radiograph demonstrated an average reduction to 1.1 mm displacement, corresponding to 1.4% on the normal side. This distance remained unchanged throughout radiolo-
Table 3. Axiographic findings in open and closed functionally treated patients with intracapsular fractures of the mandibular condyle compared to the non-fractured contralateral side Patient group Open treatment Non-fractured contralateral side (n = 4)
Closed functional treatment
Fractured mandibular condyle (n = 15)
Non-fractured contralateral side (n = 12)
Fractured mandibular condyle (n = 34)
Rotational angle translations excursion
Gamma S
100% 100%
14% 5%
100% 100%
6% 25%
Limitation of mandibular movement
Opening Medial movement Protrusion
100% 100%
32% 26%
100% 100%
31% 26%
100%
29%
100%
21%
Condylar excursion
Regular Irregular
1 3
9 6
8 4
8 26
Open and closed treatment of intracapsular condylar fractures Table 4. Radiological results of the fragment repositioning of intracapsular fractures treated using open techniques (n = 15) Fragment displacement Preoperative
Displacement-position Posterior ! anterior Lateral ! medial Superior ! inferior
X-ray OPG Clementschitsch OPG
Postoperative
Range Range (min–max) (min–max) Mean Mean (mm) (mm) (mm) SD (mm) SD 7.5 6.7 5.7
3.4 1.6 2.0
4–15 4–10 3–10
0.7 1.5 1.1
2 0.9 1.4
0–3 0–4 0–4
SD: standard deviation.
601
dylar angle (Fig. 2) was 68.68 compared to 67.88 in the unfractured contra-lateral side. In comparison the group of closed functionally treated diacapitular mandibular, condylar fractures displayed the largest condylar angle of an average 80.6%. In the closed functionally treated group, the mean reduction in condylar height of 5.8 mm corresponded to a height reduction of 8.2% when compared to the normal side (Fig. 4). After closed functional treatment, considerable malalignment (notably in the anterior–posterior direction), distinctive changes in condylar form (flattening of the articular condylar surface) and resorption of the fractured condyle were frequently seen (Table 5). A re-modelling process was observed in only one third of the cases. Characteristic condylar deformations were the so-called bifid condyle and loose bodies in the joint (Fig. 5). Discussion
Fig. 4. Percentage height reduction of the mandibular ramus in OPG following open and closed treatment of intracapsular fractures opposite the contralateral side of the mandible.
gical follow-up (Fig. 4). In most cases an optimal fragment reduction and 100% mandibular ramus length were achieved. One case showed an incomplete reduction of the condyle, with an anterior–inferior malalignment of 3 or 4 mm in the sagittal plane, however this was an improvement in the fragment position compared to the
preoperative position. In this case signs of condylar deformation in the form of a partial fracture on the joint surface was apparent in the radiological examination. In five cases minor resorption was observed (Table 5). After operative treatment of diacapitular TMJ fractures the mean middle con-
Table 5. Morphological description of the condyle following intracapsular fractures and in relation to fossa articularis after open and closed functional treatment Treatment Radiological criteria
Graduation
Open (n = 15)
Closed (n = 34)
Condylar location in relation to fossa articularis
Normal Anterior Inferior Anterior–inferior Posterior–inferior Dislocated
13 1 – 1 – –
13 1 5 10 1 4
Condylar shape
Regular Irregular
12 3
15 19
Degree of resorption
None Up to 1/3 the condyle length Up to 2/3 the condyle length More than 2/3 the condyle length
10 5 – –
8 7 14 5
Bony changes in the TMJ area
None Exophytes Bifid condyle Isolated bony fragment Callus formation Combination of the above
9 – – – 6 –
16 4 11 2 – 1
The management of subcapitular mandibular fractures by open reduction and internal fixation in adult patients is increasing2,4,25,16,12; reservations exist toward open anatomical reduction of fractured condylar heads. Recovery of mastication, on the basis of adaptive processes on the TMJ, is achieved in most cases of closed functional treatment, although complete remodelling of the fractured condyle is not achieved with closed functional treatment after 10 years of age9,10. However, closed treatment avoids potential complications, such as facial nerve damage and loss of osteosynthesis material. However, extensive condylar deformation, height reduction of the mandibular ramus, disc displacement, dysfunctional complaints (such as limitation of mandibular mobility, crepitation, lateral deviation during mouth opening) and occlusal disturbances have also been described2. NEFF et al.18 describe ‘‘irreversible displacement of the entire discoligamentous unit’’ after fracture and with this explains the unfavourable functional results of this fracture group after closed functional treatment. Since the 1990s, the technical aspects of ORIF of intracapsular fractures have improved following the development of special instruments, miniature osteosynthesis systems and new materials. RASSE20, KERMER et al.14 and NEFF et al.17,18 report good radiological and clinical results from patients exclusively treated for intracapsular fractures using open techniques. This cohort study presents patients with the same intracapsular fracture type trea-
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Fig. 5. Coronal CT with isolated intra-articular bony fragment 8 months after closed functional treatment of a intracapsular mandibular condyle fracture.
ted consistently with either an open or closed functional technique and evaluated with the same examination method. The indication for selecting open treatment of the intracapsular fractures was based upon the age and fracture type. Only adult patients with displaced, intracapsular mandibular fractures, with a loss of vertical height of the mandibular ramus were treated surgically. Even with sufficient closed functional treatment of comminuted fractures of the mandible head, this patient group displayed the worst radiological, clinical and axiographic results2. The repositioning and fixation of comminuted fractures is classified as technically complicated. KERMER et al.14 describe that only intracapsular fractures with a single fragment can be repaired with the screw osteosynthesis. In all but one of the postoperative patients, optimal repositioning of the fractured part of the condyle and the functionally stable fixation of the fragment using a compression screw or a micromesh was successful. No re-displacement of the fragment was observed as described by RASSE20 for two joints after pin fixation. In a third of the cases minor callus formation on the caudal, medial and anterior parts of the condyle was observed, being a sign of secondary bone healing. The intraoperative control of this area of the fixed fragment is most difficult. In our cases there was no evidence of necrosis following operative repositioning. NEFF et al.17 report two complete resorptions of the condyle following compression screw osteosynthesis and over six
resorptions following Kirschner wire osteosynthesis. An aseptic condylar necrosis is more likely to be the result of the trauma, with an almost complete resorption of the condylar process following closed functional treatment being observed in 7% of the cases. On the other hand, KERMER et al.14 point out the necessity of gentle open repositioning of the small fragment due to the attachment of the lateral pterygoid muscle. In most cases they achieved the original mandibular ramus length following ORIF, from a preoperative 12.7% shortening of the mandibular ramus. In two cases a shortening to 98% of the original was seen, due to resorption. In our series, the reduction of the mandibular ramus following ORIF was 1.3% compared to 8.2% in the patient group following closed functional treatment. The reduction of the postoperative condylar process length was primarily determined by the results of repositioning and the remodelling process. General traumatology guidelines on expedient fractures treatment, gentle bony repositioning and atraumatic preparation are especially applicable to TMJ surgery. In a third of our operative cases only minor resorption in the form of a discrete flattening of the articular condylar surface was noted. Serious condylar deformation or loose intra-articular bony fragments were not seen in the ORIF group in contrast to the closed functional treatment group. According to the dysfunction index, clinical findings in the operated patients were slightly better, compared to those patients treated by closed functional meth-
ods. However, the absence of crepitus, lateral deviation, occlusal disturbances and ramus height disparity in patients after ORIF showed significantly better results. Occlusal disturbances were mainly responsible for the postraumatic dysfunctional complaints following TMJ fractures5,6,23 and according to the patient, aside from joint crepitation, these were a major source of discomfort. With regard to the movement of the fractured condyle and mandible, no differences could be seen between the ORIF group and the closed treatment group. Half of the patients axiographically examined by NEFF et al.17 with an intracapsular fracture which showed a shortening of the mandibular ramus also displayed a high level of movement limitation of over 50% of the excursion path. KERMER et al.14 found longer movement paths in the intracapsular fractures after open treatment. Their results were significantly lower than the condylar path lengths on the opposite side. However, differences in the length of the follow-up examinations limit direct comparison. After the injury, with the increased space of time between the follow-up examinations, an increase in the condylar path lengths can be expected through changes due to the capacity for adaptation and compensation. In their postoperative patients, with subcapitular condylar fractures, JOOS & KLEINHEINZ13 recorded a vertical increase in the condylar movement paths of 29% and horizontal increase of 17%. Limitations of movement of the condyle are related to adhesions in the articular cavity, postoperative scarring in the capsular ligament system and disc dislocation. NEFF et al.18 recommend the release of intra-articular adhesions, which may be combined with removal of the osteosynthesis material, for cases of significant limited mouth opening after ORIF. One interesting aspect of the axiographical examination is the restriction in the condyle’s rotational movement components following open fragment reduction; whereas in the closed functionally treated patients a more significant limitation of the translation movement is apparent. The rotary movement, which takes place mainly between the disc and the condyle in the lower compartment of the joint, is restricted due to postoperative scarring. These results also prove that translation limitation in the closed treatment group is mainly the result of the functional loss of the lateral pterygoid muscle. This muscle displaces the proximal fragment inferiorly and antero-medially, contracts and loses its function. Early operative reduction of
Open and closed treatment of intracapsular condylar fractures the musclebound fragment creates favourable conditions for restoring these functions. Apart from understanding the pathogenesis of movement limitations after fracture treatment, this aspect also has therapeutic ramifications for the functional outcome for intracapsular fractures. In most cases, as most of the clinical and axiographical findings demonstrate, sufficient mouth opening due to a compensatory rotary movement of the condyle after closed treatment is achieved15. The functional deficit lies in the translatory movement components with limitation of protrusion and lateral excursion movement. Physical therapy should therefore support mandibular mobility. After open treatment, the anatomical requirements for the restoration of the function of lateral pterygoid muscle are achieved. Physiotherapy should be focused on rotational movement components and mouth opening exercises in the immediate postoperative phase. After serious trauma, intracapsular fractures are always surrounded by soft tissue, derived from the joint capsule and ligaments. Displacement and/or disruption of the articular disc disrupts the quality and interaction of the parts of the joint. In 75% of our cases following closed treatment, the axiographic condylar path recordings mirror these functional disruptions. This is confirmed in several MRI studies3,18. After the surgical reduction of the condylar process following subcapitular fractures the disc also returns to the articular fossa, which MRI and axiographic examinations confirm7,2,13. As persistent disc displacement cannot be assessed when submandibular or intraoral access is used, we suggest auricular access of intracapsular fractures. The medial capsular injury cannot be treated. Less non-physiological condylar paths were seen following open treatment of intracapsular fractures in comparison to the patient group after closed functional treatment. However, axiographically a suspicion exists that in 40% of the group treated surgically, despite good osseous reduction, destruction of the disc ligament system led to an irregular movement process; in two cases there was a persistent disc displacement. Using MRI, NEFF et al.18 found in their surgically treated intracapsular fractures with simultaneous soft tissue reconstruction, 73% of the discs on the fractured side lay in an anatomical position. Incidence of temporary facial nerve dysfunction following open reduction varies between 5 and 11%. The frequency of permanent damage is noted by NEFF et al.
to be 4.2%. The risk of nerve damage is reduced by using a nerve stimulator, meticulous haemostasis and cautious retraction. RASSE20 reports no permanent facial nerve injury during 118 TMJ operations. An advantage of the modified auricular approach21 is that the access is based on the anatomical boundary of blood vessels and nerves and the scars are acceptable. None of our patients complained of the aesthetics of the access incision. In future, the use of resorbable slender osteosynthesis material is desirable. To date there is no data regarding long-term damage caused by titanium osteosynthesis material left in the TMJ. Open reduction and internal fixation of selected intracapsular fractures improves prognosis by anatomical bone and soft tissue recovery when combined with physical therapy. In order to emphasize the functional aspect of condyle and juxta-articular surgery following TMJ trauma, the term ‘‘open functional treatment’’ should be used.
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Kiefergelenksbahnla¨ ngen dreier Subpopulationen mittels elektronischer Axiographie. Z Stomatol 1993: 90: 111–118. Gundlach K, Lammers E, Schwipper E. Growth of the mandibular condyle: histological findings in rodents relevant to the treatment of fractures of the condyle. In: Ho¨rting-Hansen E, ed: Oral and Maxillofacial Surgery. Chicago: Quintessence Publishing Co. 1985: 200. Gundlach K, Schwipper E, Fuhrmann A. Die Regenerationsfa¨ higkeit des Processus condylaris mandibulae. Dtsch zahna¨ rztl Z 1991: 46: 36–38. Helkimo M. Studies on function and dysfunction of the masticatory system. Index for anamnestic and clinical dysfunction and occlusal state. Sven Tandlak Tidskr 1974: 67: 101–121. Hidding J, Wolf R, Pingel D. Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J Craniomaxillofac Surg 1992: 20: 345– 347. Joos U, Kleinheinz J. Therapy of condylar neck fractures. Int J Oral Maxillofac Surg 1998: 27: 247–254. Kermer CH, Undt G, Rasse M. Surgical reduction and fixation of intracapsular condylar fractures. A follow up study. Int J Oral Maxillofac Surg 1998: 27: 191–194. Kolk A, Bernhard O, Meyer G. Posttherapeutic evaluation with MRI, electronic axiographic and clinical examination in articular process fractures. J Dent Res 1997: 76: 471–473. Konstantinovic VS, Dimitrijevic B. Surgical versus conservative treatment of unilateral condylar process fractures clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 1992: 50: 349–352. Neff A, Kolk A, Deppe H, Horch HH. Neue Aspekte zur Indikation der operativen Versorgung intraartikula¨ rer und hoher Kiefergelenkluxationsfrakturen. Mund Kiefer Gesichtschir 1999: 3: 24– 29. Neff A, Kolk A, Horch HH. Position und Beweglichkeit des Discus articularis nach operativer Versorgung diakapitula¨ rer und hoher Kiefergelenkluxationsfrakturen. Mund Kiefer Gesichtschir 2000: 4: 111–117. Newman L. A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles. Br J Oral Maxillofac Surg 1998: 36: 176–179. Rasse M. Diakapitula¨ re Frakturen der Mandibula. Eine neue Operationsmethode und erste Ergebnisse. Z Stomatol 1993: 90/8: 413–428. Rasse M, Fialka V, Paternostro T. Modifikationen des Zugangs zum Kiefergelenk und Ramus mandibulae. Acta Chir Aust 1993: 1: 49–54. Rasse M, Schober C, Piehslinger E, Scholz R, Hollmann K. Intra- und
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extrakapsula¨ re Kondylusfrakturen im Wachstumsalter. Dtsch Zahna¨ rztl Zeitung 1991: 46: 49–51. 23. Seeger P, Becker R, Palmen E, Ferger P, Jeep I. Nachuntersuchungen unilateraler Kollumfrakturen unter Beru¨ cksichtigung der funktionellen Gebißanalyse. Fortschr Kiefer Gesichtschir 1980: 25: 98–101. 24. Slavicek R. Clinical and instrumental functional analysis for diagnosis and
treatment planning. Part 7: computeraided axiography. J Clin Orthod 1988: 22: 776–787. 25. Worsaae N, Thorn J. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures. J Oral Maxillofac Surg 1994: 52: 353–361. Address: U. Eckelt Klinik und Poliklinik fu¨r Mund-
Kiefer- und Gesichtschirurgie der Medizinischen Fakulta¨t ‘‘Carl Gustav Carus’’ der Technischen Universita¨t Dresden Fetscherstrasse 74 D-01307 Dresden Germany Tel: +49 351 458 3382 Fax: +49 351 458 5348. E-mail: [email protected]
Leading Clinical Paper Trauma
Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible
M. Hlawitschka, R. Loukota, U. Eckelt Klinik und Poliklinik fu¨r Mund-, Kiefer- und Gesichtschirurgie der Medizinischen Fakulta¨t, ‘‘Carl Gustav Carus’’ der Technischen Universita¨t Dresden, D-01307 Dresden, Germany
M. Hlawitschka, R. Loukota, U. Eckelt: Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible. Int. J. Oral Maxillofac. Surg. 2005; 34: 597–604. # 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. 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.
0901-5027/060597+08 $30.00/0
Accepted for publication 2 February 2005
# 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
598
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Fractures of the mandibular condyle are frequently treated using closed functional techniques. Although in many cases good initial clinical results are achieved, serious late complications have been reported such as ankylosis, condylar necrosis, inhibition of mandiblar growth and occlusal disturbances5,19. Differentiated evaluation using modern diagnostic methods such as computed tomography (CT), magnetic resonance imaging (MRI) and electronic axiography have demonstrated that clinical outcome depends upon the intracapsular fracture line and comminution. Patients display significantly poorer clinical, radiological and axiographical results if the fracture line runs through the lateral condylar pole and the displacement of the proximal fragment has resulted in a shortening of the mandibular ramus, when compared to those patients whose fracture line runs through the medial condylar pole and in whom the vertical dimension of the mandibular ramus has remained intact17,18. For this reason some authors advocate ORIF in adults demonstrating shortening of the mandibular ramus and have obtained good radiological and clinical results22,17,18. The aim of this study is to compare ORIF of unsupported types of diacapitular condyle fractures and conventional closed functional techniques. Material and methods
The distribution of the condylar fractures and their treatment is depicted in Table 1. Thirteen male patients and 1 female patient (mean age: 30 years, range: 15.1–73.6) with 19 intracapsular condylar
Table 1. Patients with mandibular fractures treated using open techniques—distribution after classification according to SPIESSL & SCHROLL (1972) as well as, NEFF & co-workers (1999) and their treatment Number
Type I Type II Type III Type IV Type V Type VI Subtype A Subtype B
Treatment
Patients Mandibular fractures
n = 14 n = 24
Closed
Fracture without displacement Low fracture with displacement High fracture with displacement Low fracture with dislocation High fracture with dislocation Intracapsular fracture (diacapitular) Without mandibular ramus height reduction With mandibular ramus height reduction
1 3 – 1 –
– – – – –
1 3 – 1 –
4 15
4 –
– 15
fractures have been treated in the Dresden Clinic since 1998. Fifteen condylar fractures were treated by ORIF; all were displaced, intracapsular shortened condylar fractures and were classified as Type B, NEFF et al.17 The joint was accessed via the modified auricular approach, RASSE et al.21 The fractures were fixed using a titanium compression screw in 10 cases (Fig. 1), in 4 cases with a titanium micromesh and in 1 case with an absorbable polylactide screw. All patients were placed into intermaxillary fixation (IMF) until after the postoperative radiological check the next day and then mobilised. The four contralateral, vertically unshortened condylar fractures (Fracture Type A) were treated using the closed functional method. In these cases a 10day period of immobilisation was implemented followed by a functional mobilisation schedule for 3 weeks. All concomitant fractures of the mandible were treated according to standard principles of functionally stable osteosynthesis, including five contralateral sub-
Open
capitular mandibular fractures which were treated using compression screw osteosynthesis1. Closed functionally treated patient group
For comparison the retrospective followup results of 29 adult patients with 34 condylar head fractures treated since 1995 using closed functional methods were used. The average age of the 25 male and 4 female patients was 28 years (range: 13.7–76.9 years). These intracapsular fractures were also the displaced, shortened Type B fractures. The fracture line through the condyle was determined by conventional radiographs on two levels (Orthopantogram, P.A. skull film and CT). Concomitant mandible fractures were also surgically treated including five dislocated and two displaced subcapitular condylar fractures. Two undisplaced condylar neck fractures were treated using the closed method. The intracapsular fractures were immobilised with rigid IMF for 10 days followed by 6–
Fig. 1. Coronal CTs depicting the results of repositioning following a one-sided intracapsular fracture of the mandibular condyle with a primary reduction of the mandibular ramus (a) preoperative and (b) postoperative after 3 months, fixation of the fracture fragment with a compression screw made of titanium.
Open and closed treatment of intracapsular condylar fractures
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Fig. 2. Distances and angles in (a) OPG, (b) PA-radiograph according to Clementschitsch (1963) and (c) the Submentovertex-radiograph.
8 weeks of functional treatment. The patients were instructed to eat soft foods for 3 weeks and intensively performed mouth-opening exercises. In eight cases, a functional orthodontic activator from Andresen-Ha¨ upl was prescribed for a mean of 8 weeks. The ORIF group was examined after a mean of 11 months and the closed functionally treated group after a mean of 20 months. Clinical examinations involved the inspection, palpation and auscultation of the TMJ. Lateral deviation of more than 2 mm on mouth opening, the length of the maximum interincisal opening, protrusion and laterotrusion and occlusal disturbances were recorded. The clinical findings were summarized by applying the
dysfunction index according to HELK11 , i.e., mandibular mobility, TMJ function, masticatory muscle pain, TMJ pain and pain precipitated by movement. Changes in the condyle’s form and position were assessed by an orthopantogram, P.A. skull film and submento-vertex view (Fig. 2). Condylar paths, in relation to the hinge axis, were electronically recorded using the CADIAX-System (Computer Aided Axis-Recording) and were analysed according to SLAVICEK24.
IMO
Results
Post-treatment there were few subjective complaints of minor dysfunction in either group. The results of the Helkimo-dys-
function11 (the evaluation of the five different criteria) and the numerical classification of the Helkimo index are presented in Table 2. In the closed functionally treated patient group a rate >30% of moderate and serious dysfunction was observed. In particular lateral deviation during mouth opening exceeding 2 mm, crepitation, restriction of protrusion and medial movement and, in one third of the cases, occlusal disturbances were observed. In the ORIF group however, no occlusal disturbances were noted. In comparison to the closed functionally treated patients, lower values of mandibular mobility (Fig. 3) were measured. This particularly applied to medial movement and mouth opening. No cases of mouth opening less
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Table 2. Clinical dysfunction index according to HELKIMO (1974)—degree of dysfunction and occlusal disturbances in open and closed treated patients with intracapsular mandibular condyle fractures Treatment Dysfunction index Dysfunction
D D D D
0 symptom-free I slight II moderate III severe
Open (n = 14)
Closed (n = 29)
1 10 3 –
1 19 8 1
–
10
Occlusal disturbances
according to GSELLMANN et al.8 and from the clinic’s own control group. After open treatment the reduced range of movement was mainly the result of a reduction in rotation, whereas after closed functional treatment a reduction in translation movement of the condyle was apparent. Non-physiological excursions of the fractured condyle were present in both groups but were less common after open treatment when compared to closed functional treatment (Table 3). In both groups nonphysiological excursions were also frequently registered on the unfractured TMJ. Radiological findings
Fig. 3. Clinical findings of mandibular mobility in open (n = 14) and closed functionally (n = 24) treated adult patients with intracapsular fractures of the mandible.
than 30 mm were recorded. The ORIF group displayed no problem with wound healing and all were satisfied with the cosmesis of the result. Immediately after the operation one patient experienced a temporary weakness of the temporal branch of the facial nerve. No local problems secondary to the osteosynthesis material were recorded.
Functional diagnostic findings
Axiographic evaluation of condylar excursions following open and closed functional treatment of condylar fractures revealed moderate to serious limitations in all directions of excursion compared to the non-fractured contralateral side; data gathered from healthy test patients
In all ORIF cases significant improvement in the position of the major fragments was achieved. In three cases additional bony fragments on the dorsal-lateral pole of the condyle were apparent. These were reduced but not fixed on two occasions. The remaining bony fragment was removed. Subsequent movement of these reduced fragments was not observed. The results after ORIF of the condyles are shown in Table 4. The largest postoperative condylar displacements were medially, with an average of 1.5 mm seen in a Clementschitsch (reverse Towne’s) radiographs. In preoperative radiographs the height of the mandibular ramus was reduced on average 5.7 mm due to vertical fragment displacement. This resulted in a reduction of the mandibular ramus height of 8% compared to the opposite side. After reduction of the fractured fragment, the immediate postoperative radiograph demonstrated an average reduction to 1.1 mm displacement, corresponding to 1.4% on the normal side. This distance remained unchanged throughout radiolo-
Table 3. Axiographic findings in open and closed functionally treated patients with intracapsular fractures of the mandibular condyle compared to the non-fractured contralateral side Patient group Open treatment Non-fractured contralateral side (n = 4)
Closed functional treatment
Fractured mandibular condyle (n = 15)
Non-fractured contralateral side (n = 12)
Fractured mandibular condyle (n = 34)
Rotational angle translations excursion
Gamma S
100% 100%
14% 5%
100% 100%
6% 25%
Limitation of mandibular movement
Opening Medial movement Protrusion
100% 100%
32% 26%
100% 100%
31% 26%
100%
29%
100%
21%
Condylar excursion
Regular Irregular
1 3
9 6
8 4
8 26
Open and closed treatment of intracapsular condylar fractures Table 4. Radiological results of the fragment repositioning of intracapsular fractures treated using open techniques (n = 15) Fragment displacement Preoperative
Displacement-position Posterior ! anterior Lateral ! medial Superior ! inferior
X-ray OPG Clementschitsch OPG
Postoperative
Range Range (min–max) (min–max) Mean Mean (mm) (mm) (mm) SD (mm) SD 7.5 6.7 5.7
3.4 1.6 2.0
4–15 4–10 3–10
0.7 1.5 1.1
2 0.9 1.4
0–3 0–4 0–4
SD: standard deviation.
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dylar angle (Fig. 2) was 68.68 compared to 67.88 in the unfractured contra-lateral side. In comparison the group of closed functionally treated diacapitular mandibular, condylar fractures displayed the largest condylar angle of an average 80.6%. In the closed functionally treated group, the mean reduction in condylar height of 5.8 mm corresponded to a height reduction of 8.2% when compared to the normal side (Fig. 4). After closed functional treatment, considerable malalignment (notably in the anterior–posterior direction), distinctive changes in condylar form (flattening of the articular condylar surface) and resorption of the fractured condyle were frequently seen (Table 5). A re-modelling process was observed in only one third of the cases. Characteristic condylar deformations were the so-called bifid condyle and loose bodies in the joint (Fig. 5). Discussion
Fig. 4. Percentage height reduction of the mandibular ramus in OPG following open and closed treatment of intracapsular fractures opposite the contralateral side of the mandible.
gical follow-up (Fig. 4). In most cases an optimal fragment reduction and 100% mandibular ramus length were achieved. One case showed an incomplete reduction of the condyle, with an anterior–inferior malalignment of 3 or 4 mm in the sagittal plane, however this was an improvement in the fragment position compared to the
preoperative position. In this case signs of condylar deformation in the form of a partial fracture on the joint surface was apparent in the radiological examination. In five cases minor resorption was observed (Table 5). After operative treatment of diacapitular TMJ fractures the mean middle con-
Table 5. Morphological description of the condyle following intracapsular fractures and in relation to fossa articularis after open and closed functional treatment Treatment Radiological criteria
Graduation
Open (n = 15)
Closed (n = 34)
Condylar location in relation to fossa articularis
Normal Anterior Inferior Anterior–inferior Posterior–inferior Dislocated
13 1 – 1 – –
13 1 5 10 1 4
Condylar shape
Regular Irregular
12 3
15 19
Degree of resorption
None Up to 1/3 the condyle length Up to 2/3 the condyle length More than 2/3 the condyle length
10 5 – –
8 7 14 5
Bony changes in the TMJ area
None Exophytes Bifid condyle Isolated bony fragment Callus formation Combination of the above
9 – – – 6 –
16 4 11 2 – 1
The management of subcapitular mandibular fractures by open reduction and internal fixation in adult patients is increasing2,4,25,16,12; reservations exist toward open anatomical reduction of fractured condylar heads. Recovery of mastication, on the basis of adaptive processes on the TMJ, is achieved in most cases of closed functional treatment, although complete remodelling of the fractured condyle is not achieved with closed functional treatment after 10 years of age9,10. However, closed treatment avoids potential complications, such as facial nerve damage and loss of osteosynthesis material. However, extensive condylar deformation, height reduction of the mandibular ramus, disc displacement, dysfunctional complaints (such as limitation of mandibular mobility, crepitation, lateral deviation during mouth opening) and occlusal disturbances have also been described2. NEFF et al.18 describe ‘‘irreversible displacement of the entire discoligamentous unit’’ after fracture and with this explains the unfavourable functional results of this fracture group after closed functional treatment. Since the 1990s, the technical aspects of ORIF of intracapsular fractures have improved following the development of special instruments, miniature osteosynthesis systems and new materials. RASSE20, KERMER et al.14 and NEFF et al.17,18 report good radiological and clinical results from patients exclusively treated for intracapsular fractures using open techniques. This cohort study presents patients with the same intracapsular fracture type trea-
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Fig. 5. Coronal CT with isolated intra-articular bony fragment 8 months after closed functional treatment of a intracapsular mandibular condyle fracture.
ted consistently with either an open or closed functional technique and evaluated with the same examination method. The indication for selecting open treatment of the intracapsular fractures was based upon the age and fracture type. Only adult patients with displaced, intracapsular mandibular fractures, with a loss of vertical height of the mandibular ramus were treated surgically. Even with sufficient closed functional treatment of comminuted fractures of the mandible head, this patient group displayed the worst radiological, clinical and axiographic results2. The repositioning and fixation of comminuted fractures is classified as technically complicated. KERMER et al.14 describe that only intracapsular fractures with a single fragment can be repaired with the screw osteosynthesis. In all but one of the postoperative patients, optimal repositioning of the fractured part of the condyle and the functionally stable fixation of the fragment using a compression screw or a micromesh was successful. No re-displacement of the fragment was observed as described by RASSE20 for two joints after pin fixation. In a third of the cases minor callus formation on the caudal, medial and anterior parts of the condyle was observed, being a sign of secondary bone healing. The intraoperative control of this area of the fixed fragment is most difficult. In our cases there was no evidence of necrosis following operative repositioning. NEFF et al.17 report two complete resorptions of the condyle following compression screw osteosynthesis and over six
resorptions following Kirschner wire osteosynthesis. An aseptic condylar necrosis is more likely to be the result of the trauma, with an almost complete resorption of the condylar process following closed functional treatment being observed in 7% of the cases. On the other hand, KERMER et al.14 point out the necessity of gentle open repositioning of the small fragment due to the attachment of the lateral pterygoid muscle. In most cases they achieved the original mandibular ramus length following ORIF, from a preoperative 12.7% shortening of the mandibular ramus. In two cases a shortening to 98% of the original was seen, due to resorption. In our series, the reduction of the mandibular ramus following ORIF was 1.3% compared to 8.2% in the patient group following closed functional treatment. The reduction of the postoperative condylar process length was primarily determined by the results of repositioning and the remodelling process. General traumatology guidelines on expedient fractures treatment, gentle bony repositioning and atraumatic preparation are especially applicable to TMJ surgery. In a third of our operative cases only minor resorption in the form of a discrete flattening of the articular condylar surface was noted. Serious condylar deformation or loose intra-articular bony fragments were not seen in the ORIF group in contrast to the closed functional treatment group. According to the dysfunction index, clinical findings in the operated patients were slightly better, compared to those patients treated by closed functional meth-
ods. However, the absence of crepitus, lateral deviation, occlusal disturbances and ramus height disparity in patients after ORIF showed significantly better results. Occlusal disturbances were mainly responsible for the postraumatic dysfunctional complaints following TMJ fractures5,6,23 and according to the patient, aside from joint crepitation, these were a major source of discomfort. With regard to the movement of the fractured condyle and mandible, no differences could be seen between the ORIF group and the closed treatment group. Half of the patients axiographically examined by NEFF et al.17 with an intracapsular fracture which showed a shortening of the mandibular ramus also displayed a high level of movement limitation of over 50% of the excursion path. KERMER et al.14 found longer movement paths in the intracapsular fractures after open treatment. Their results were significantly lower than the condylar path lengths on the opposite side. However, differences in the length of the follow-up examinations limit direct comparison. After the injury, with the increased space of time between the follow-up examinations, an increase in the condylar path lengths can be expected through changes due to the capacity for adaptation and compensation. In their postoperative patients, with subcapitular condylar fractures, JOOS & KLEINHEINZ13 recorded a vertical increase in the condylar movement paths of 29% and horizontal increase of 17%. Limitations of movement of the condyle are related to adhesions in the articular cavity, postoperative scarring in the capsular ligament system and disc dislocation. NEFF et al.18 recommend the release of intra-articular adhesions, which may be combined with removal of the osteosynthesis material, for cases of significant limited mouth opening after ORIF. One interesting aspect of the axiographical examination is the restriction in the condyle’s rotational movement components following open fragment reduction; whereas in the closed functionally treated patients a more significant limitation of the translation movement is apparent. The rotary movement, which takes place mainly between the disc and the condyle in the lower compartment of the joint, is restricted due to postoperative scarring. These results also prove that translation limitation in the closed treatment group is mainly the result of the functional loss of the lateral pterygoid muscle. This muscle displaces the proximal fragment inferiorly and antero-medially, contracts and loses its function. Early operative reduction of
Open and closed treatment of intracapsular condylar fractures the musclebound fragment creates favourable conditions for restoring these functions. Apart from understanding the pathogenesis of movement limitations after fracture treatment, this aspect also has therapeutic ramifications for the functional outcome for intracapsular fractures. In most cases, as most of the clinical and axiographical findings demonstrate, sufficient mouth opening due to a compensatory rotary movement of the condyle after closed treatment is achieved15. The functional deficit lies in the translatory movement components with limitation of protrusion and lateral excursion movement. Physical therapy should therefore support mandibular mobility. After open treatment, the anatomical requirements for the restoration of the function of lateral pterygoid muscle are achieved. Physiotherapy should be focused on rotational movement components and mouth opening exercises in the immediate postoperative phase. After serious trauma, intracapsular fractures are always surrounded by soft tissue, derived from the joint capsule and ligaments. Displacement and/or disruption of the articular disc disrupts the quality and interaction of the parts of the joint. In 75% of our cases following closed treatment, the axiographic condylar path recordings mirror these functional disruptions. This is confirmed in several MRI studies3,18. After the surgical reduction of the condylar process following subcapitular fractures the disc also returns to the articular fossa, which MRI and axiographic examinations confirm7,2,13. As persistent disc displacement cannot be assessed when submandibular or intraoral access is used, we suggest auricular access of intracapsular fractures. The medial capsular injury cannot be treated. Less non-physiological condylar paths were seen following open treatment of intracapsular fractures in comparison to the patient group after closed functional treatment. However, axiographically a suspicion exists that in 40% of the group treated surgically, despite good osseous reduction, destruction of the disc ligament system led to an irregular movement process; in two cases there was a persistent disc displacement. Using MRI, NEFF et al.18 found in their surgically treated intracapsular fractures with simultaneous soft tissue reconstruction, 73% of the discs on the fractured side lay in an anatomical position. Incidence of temporary facial nerve dysfunction following open reduction varies between 5 and 11%. The frequency of permanent damage is noted by NEFF et al.
to be 4.2%. The risk of nerve damage is reduced by using a nerve stimulator, meticulous haemostasis and cautious retraction. RASSE20 reports no permanent facial nerve injury during 118 TMJ operations. An advantage of the modified auricular approach21 is that the access is based on the anatomical boundary of blood vessels and nerves and the scars are acceptable. None of our patients complained of the aesthetics of the access incision. In future, the use of resorbable slender osteosynthesis material is desirable. To date there is no data regarding long-term damage caused by titanium osteosynthesis material left in the TMJ. Open reduction and internal fixation of selected intracapsular fractures improves prognosis by anatomical bone and soft tissue recovery when combined with physical therapy. In order to emphasize the functional aspect of condyle and juxta-articular surgery following TMJ trauma, the term ‘‘open functional treatment’’ should be used.
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treatment planning. Part 7: computeraided axiography. J Clin Orthod 1988: 22: 776–787. 25. Worsaae N, Thorn J. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures. J Oral Maxillofac Surg 1994: 52: 353–361. Address: U. Eckelt Klinik und Poliklinik fu¨r Mund-
Kiefer- und Gesichtschirurgie der Medizinischen Fakulta¨t ‘‘Carl Gustav Carus’’ der Technischen Universita¨t Dresden Fetscherstrasse 74 D-01307 Dresden Germany Tel: +49 351 458 3382 Fax: +49 351 458 5348. E-mail: [email protected]