- Email: [email protected]
Fractures of the condylar process: Surgical versus nonsurgical treatment
J Oral Maxillofac 57:392-397,
Surg 1999
Fractures of the Condylar Surgical Versus Nonsurgical
Process: Treatment
Gert Santler MD, DDS, * Hans Kiircher MD, DDS, f Christof Ruda, MD, DDS,$ and Ernst KGle, MD, DDSJ Purpose: The purpose of this study was to compare outcomes of condylar process fractures.
from surgical and nonsurgical
treatment
Patients and Methods: Two hundred thirty-four patients with fractures of the mandibular condylar process were treated by open or closed methods. In the follow-up study, 150 patients with a mean follow-up time of 2.5 years were analyzed using radiologic and objective and subjective clinical examinations. Results: No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve disorders were observed when the surgically and nonsurgically treated patients were compared. The only significant difference was in subjective discomfort. Surgically treated patients showed significantly more weather sensitivity and pain on maximum mouth opening. Conclusion: Because of its disadvantages, dislocated condylar process fractures.
open surgery
The choice of surgical’ versus nonsurgical treatment* for fractures of the condylar process remains a controversial issue.sm5 Historically, nonsurgical treatment by means of maxillomandibular fixation (MMF) was standard practice, especially in children, who showed a high potential for adaptation and spontaneous regeneration.@ Another reason favoring nonsurgical treatment was the disadvantages of the open approach. Preauricular, submandibular, postauricular, retromandibular, intraoral, coronal, and combined approaches have been described. Because of the close anatomic relationship of the facial nerve and the temporal vessels, these approaches may damage these important structures. Also, extraoral approaches inevitably are associated with visible scars. The introduction of better materials for osteosynthesis, such as Kirschner wires,‘O wires,” miniplates,l* and lag screws,*3-15 have
Received
from
University
the Department
Clinic
‘Senior
for Dentistry,
Oral Maxillofacial
facial Surgery. THead, Department *Senior
Oral
Maxillofacial SResident, Address
and
of Oral and Maxillofacial Department
of Oral Maxillofacial Maxillofacial
Department
of Oral Maxillofacial and
reprint
of Oral
Surgery. requests
to Dr Santler:
Klinische Abteilung fur Mund-, Kiefer- und Gesichtschirurgie, UniversitNdinik ftir ZMK, Auenbruggerplatz 7, A-8036 Austria;
Surgery,
Surgery. correspondence
der Graz,
e-mail: [email protected]
6 1999 American Association of Oral and Maxillofacial 0278-2391/99/5704-0007$3.00/0
severely
From 1987 to 1995, 292 fractures of the condylar process were treated in 234 patients. The ages ranged from 5 to 90 years (mean, 25; standard deviation [SD], 13.8). In 82 cases, the left, in 94 the right, and in 58 cases both sides were affected. There were 37 fractures of the condyle and 255 of the condylar neck (69 high, 125 medium, 61 low) according to the classitication suggested by Krenkel. l5 Condylar and high condylar neck fractures correspond with condylar and condylar neck fractures according to Lindahl’G nomenclature, medium condylar fractures are similar to subcondylar fractures, and low condylar fractures extend from halfway up the ramus to the angle of the mandible. Of those patients treated nonsurgically, 161 (195 joints) were treated with MMF and 11 (19 joints) without it. Sixty-two patients (70 joints) were treated surgically. One hundred fifty patients were available for follow-up examination. The evaluation included panoramic and frontal radiographs,*O and a clinical ex-
of Oral Maxillo-
Department
with
Patients and Methods
Surgery.
Surgeon,
in patients
made open surgical treatment more advantageous. This advantage is based on exact fragment repositioning, the possibility of disc repair and, in the case of rigid fixation, MMF becomes superfluous. Several authors have compared results of surgical and nonsurgical treatment.lG18 Our clinic treated severely dislocated fractures only by means of MMF until 1990. Thus, it was possible to compare nonsurgical and surgical treatment in patients with similar dislocation patterns.
Gmz, Austria. Surgeon,
is only indicated
Surgeons
392
393
SANTLER ET AL
amination. The clinical examination included measurement of maximal interincisal distance, protrusion and laterotrusion, a Krough-Poulsen-test21 to analyse joint problems, assessmentof the occlusion, palpation of the masticatory muscles,neurologic evaluation of the 5th and 7th cranial nerves, and a questionnaire related to subjective discomfort. The dislocation patterns were assessedby measurement of the preoperative and postoperative radiographs, including maximum deviation and displacementls as well as assessment of dislocation and bony contact between the fragments. The data from the surgically treated patients were compared with data from the nonsurgically treated patients, and the intluence of the different dislocation patterns was analysed. For statistical analysis, the SPSS program with the chi-square test, the Mann-Whitney test, the Kruskal-Wallis test, and the Spearman correlation coefficient were used.
Results One hundred nfty patients (Table 1) with 189 fractures of the condyle and the condylar neck were available for follow-up examination. Traffic accidents were the main cause of the trauma (Fig 1). The age distribution showed a typical peak between 20 and 30 years (mean, 24; SD, 13.7; range, 6 to 72). In 82 cases, the left; in 94, the right; and in 58 cases, both sides were affected. There were 27 fractures of the condyle and 162 of the condylar neck (42 high, 83 medium, 37 low). In 57 fractures, there was no dislocation; 42 showed medium dislocation, and 90 had severe dislocation. In 72 patients, the condylar process fractures were combined with additional fractures of the mandible. Of those patients treated nonsurgically, 107 (132 joints) were treated with MMF, and six (10 joints) without it. Thirty-seven patients (43 joints) were treated surgically. Different surgical treatments were performed: miniplates (13 joints), anchor screws (10 joints), open reduction (nine joints), microplates (four joints), wire osteosynthesis (four joints), screws (two joints), and removal of the small fragment (one joint).
Treatment Surgical Nonsurgical Total
No. of Cases (%I
Sex (F/M) (Ratio)
(Z,
17/20 1:1.2 23/90 1:4 40/110 1:2.8
113 (75) 150 (100)
Mean Age (YO @weI $3)
No. of Condylar Process Fractures 43
Both surgical and nonsurgical treatment showed satisfactory results (Table 2, Fig 2). Only four patients (3%) had an interincisal distance of less than 35 mm, which was equally distributed in both groups. The mean mouth opening was 45.5 mm (surgical) and 47 mm (nonsurgical). Although preoperative dislocation patterns differed significantly (Table 2) comparison of surgically and nonsurgically treated patients showed no significant difference in jaw mobility (Fig 2): maximum mouth opening, protrusion, laterotrusion to and from the fractured side, as well as the difference between laterotrusion to and from the fractured side and deviation during mouth opening, were similar in both groups. Pain, muscle tension, and hypertrophy of the muscles were similarly distributed, as were joint problems such as pain, clicking, and crepitation on the fractured and the nonfractured side. The incidence of hypesthesia, paresthesia, and anesthesia of the mental nerve and the incidence of frontal and marginal facial nerve palsy were not significantly increased in the operated group. Also, occlusal disturbances showed no significant differences. Two subjective complaints were found to be significantly different between the groups: weather sensitivity and pain during maximum mouth opening were found more often in the surgically treated group (Table 2, Fig 2). This was also true for patients with severely dislocated fractures; however, this was not statistically significant. Nonsurgically treated patients with fractures healed in a dislocated position were significantly older than those with fractures healed in correct or at least improved position (Table 3). Increasing age was significantly associated with a reduction of mouth opening and protrusion. Of the operatively treated patients, older patients more often exhibited subjective complaints and a reduced laterotrusion to the nonfractured side. Displacement of the ramus, deviation or dislocation of the condylar process, and absence of fragment contact all significantly influenced the results in the
No. With Associated Mandibular Fractures
No. With Insufkient Posterior Occlusal Support
13
7
142
59
13
189
72
20
(4 Nonsurg)
Follow-Up (mo) Mean (Ewe> (6::)
(8%)
(Z3)
394
FRACTURES
Traffic accident 55%
Horse kick 3% accident 5% FIGURE
Fight 7% 1. Cause
accident 9% of the fractures
nonsurgical group. Displacement led to a reduced protrusion, laterotrusion to the nonfractured side, and a greater difference between laterotrusion to and from the fractured side. Higher degrees of deviation led to more muscular pain, tooth grinding, and subjective discomfort. Lack of bony contact was correlated significantly with reduced mouth opening, laterotrusion to the nonfractured side, a higher incidence of asymmetry during laughing and lip pursing, aswell as weather-related discomfort. Dislocation also led to a reduction in mouth opening, a higher incidence of asymmetrical laughing and lip pursing, tooth grinding, and subjective discomfort during weather changes and heavy chewing. In the operated patients, preoperatively dislocated condyles significantly led to weather sensitivity. It is obvious that patients with higher degrees of displacement, deviation, and dislocation lessoften end up with correct anatomic healing of the fractures.
Discussion Bellinger et al4 reported surgical therapy of condylar neck fractures in only two of 100 cases after complications had developed. The risk of wound infection in the preantibiotic era, the proximity of nerves and vessels, and the absence of sophisticated osteosynthesis materials were the reasonsfor nonsurgical treatment. With the introduction of better anesthestic techniques and the advent of antibiotics, open repositioning has increasingly been performed. The disadvantage of open repositioning,22 wire osteosynthesis,6and Kirschner wireslo lies in the lack of functional stability. Open repositioning and the use of MMF without osteosynthesis in casesin which the fragments remain stable after repositioning, has its advantages. Only a minimum of stripping of the fragments is necessary, and the already reduced blood supply remains undisturbed. Also, there is no need for osteosynthesis material and consequently no necessity for a second operation to remove it.
OF THE
CONDYLAR
PROCESS:
SURG
VS NONSURG
395
SANTLER ET AL
80% 60%
FIGURE 2. Comparison of operative and nonsurgical treatment with respect to preoperative dislocation and postoperative outcome.
20% 0% SN
SN
SN
SN
SN
SN
SN
Miniplates, l2 lagscrew osteosynthesis,1sa15,2s and pin fixation2* allow functional stability and early movement of the joint. Microplates, especially threedimensional microplates, although they do not provide functional stability, allow fixation with a minimum detachment of soft tissue. This is an advantage, especially in extremely high condylar process fractures in children. Exact anatomic repositioning of the fractured condylar process seems to be the most important objective in treatment. In our opinion, the method of fixation is of minor importance. The type of osteosynthesis depends not only on the location and direction of the fracture and the number of fragments but also on posterior occlusal support. These factors also influence the choice of the approach. In cases in which
Treatment Surgical NOllsurgical
As Condylar displacement
Surgical NOllsurgical
Anatomic Position Post OP
MOUtb Opening
Laterotrusion NOAXture Side
SN
SN
conventional radiographs do not allow precise diagnosis of the location and direction of the fracture and number of fragments, computed tomography (CT) scans are of great value. CT-based three-dimensional models facilitate the diagnosis of dislocation and identification of the number of fragments. In this study, preauricular or submandibular incisions were used and, in rare cases, a combination. Extensive approaches as proposed by Mizuno and Shikimori25 are not necessary for most cases. Removal of the condylar process and the ramus by vertical osteotomy and extracorporal osteosynthesis of the fracture26 allows precise repositioning but transforms condylar process and ramus into free grafts. This was unnecessary in all of our patients. Iizuka et a12’ have described severe resorption and
Discomfort
AsylllProtmsion
“;I
2% Laughing
g:E of the Lips
t%%comfort
Weather Sensitivity
2: Chewing
L$%% Opening
Grinding
P= ,005 P=
,004
P=
.05
P=.OO3
P < .OOl
P=.OO58
P= ,048
P=
P= .04
,069
Condylar
deviation Missing bony contact Condylar dislocation
NOTE.
Surgical Nonsurgical Surgical Nonsurgical Surgical Nonsurgical
Significance
P= .0006
P=
P=
,013 P= ,033
,046
P= .05
P < ,001
P < ,001
P= ,003
Pi
.OOl
P= .056 P= .0004 P= ,048
levels are presented
in case of significant
P < ,001 influence
in surgically
P < .OOl or nonsurgically
P = ,057
treated
P < ,001
patients.
P = .0013
396
FRACTURES OF THE CONDYLAR
osteoarthrosis in all 13 patients treated by the extracorporal method, although the functional result was satisfactory in all but one case. In accord with the findings of Lindahl and Hollender,28who described a great remodeling potential in growing children, a significantly better position of the condylar process was found in our study in children up to the age of 15 years. This could be explained by the fact that all of the nonsurgically treated fractures in our seriesdid not show preoperative dislocation. Yasuharu et all6 compared 16 surgical and 20 nonsurgically treated patients. Although the surgical cases showed greater preoperative dislocation, the resulting function and occlusion were satisfactory. Similar results were presented by Hidding et al29for 34 patients, also confirming our own results. Konstantinovic and Dimitrijevicl’ found no statistically relevant difference in clinical parameters of surgically and nonsurgically treated fractures in 80 patients. However, in the surgical group, the condyle showed a better position. Unfortunately, the authors did not describe the method of selection of patients in their article. Worsaae and Thorn’* have presented the only study with a randomized selection of patients. In surgically treated patients, they found complications such as malocclusion, mandibular asymmetry, impaired masticatory function, and pain in a significantly higher frequency than in nonsurgically treated patients. They used wire fixation and MMF in surgically treated patients. Eleven of 28 nonsurgically treated patients had complications, which appears not to be the best possible outcome compared with results in the literature.30 Suuronen et a131described degenerative joint diseasecaused by rigid fixation in an animal model. Ti.irp et als2 showed that patients after nonsurgical treatment still had reduced mobility compared with the control group even 19 years after treatment. It is mainly dislocation that negatively influences the outcome of treatment. However, because of a great adaptive capacity, even patients with severely dislocated condyles only rarely have unsatisfactory treatment results. In times when the medical care system is confronted with great financial problems, cost and hospitalization time become an increasing concern. The higher costs of surgical therapy, involving longer operation and hospitalization times, and expensive osteosynthesis materials, must be weighed against the advantage of early mobilization and integration into the working process. Basedon the results of this study, minimal invasive therapy for condylar process fractures has again become the method of choice in our department. In our
PROCESS: SURG VS NONSURG
opinion, there is no indication for surgical treatment if nonsurgical treatment leads to comparable results. Only patients with severely dislocated condyles, who are known to benefit from surgical intervention, may be candidates for open surgery.
References 1. Hall MB: Condylar fractures: Surgical management. J Oral Maxillofac Surg 521192, 1994 2. Walker RV: Condylar fractures: Nonsurgical management. J Oral Maxillofac Surg 52:1185,1994 for open reduction of mandibular 3. Zide MF, Kent JN: Indications condyle fractures. J Oral Maxillofac Surg 89:89, 1983 4. Bellinger DH, Henny FA, Peterson LW: Fracture of the mandibular condyle. J Oral Maxillofac Surg 1:48, 1943 5. Hayward JR, Scott RF: Fractures of the mandibular condyle. J Oral Maxillofac Surg 51:57, 1993 6. Hoopes JE, Wolfort FG, Jabaley ME: Operative treatment of fractures of the mandibular condyle ln children. Plast Reconstr Surg 46:357,1970 follow-up of 7. Leake D, Doykos J III, Habal MB, et al: Long-term fractures of the mandibular condyle in children. Plast Reconstr Surg 47:127, 1971 8. Gundlach KKH, Schwipper E, Fuhrmann A: Die Regenerationsftiigkeit des Processus condylarls mandibulae. Dtsch Zahnarztl 2 46:36, 1991 SE, Krlshnan V, Sindet-Pedersen S, et al: Pediatric 9. Norholt condylar fractures: A long-term follow-up study of 55 patients. J OralMaxillofac Surg 51:1302,1993 10. Timmel R: Die operative Behandhmg der Luxationsfraktur des Kleferkiipfchens. 2 Stomatol79:190, 1982 11. Peters RA, Caldwell JB, Olsen ThW: A technique for open reduction of subcondylar fractures. Oral Surg Oral Med Oral Path01 41:273, 1976 12. Koberg W, Momma W: Treatment of the articular process by functional stable osteosynthesis using miniaturized dynamic compression plates. Int J Oral Surg 7:256, 1978 condylar process 13. Petzel JR, Bulles G: Stability of the mandibular after functionally stable traction-screw-osteosynthesis (TSO) with a self-tapping screw-pin. J Maxillofac Surg 10:149, 1982 14. Eckelt U, Gerber S: Zugschraubenosteosynthese bei Unterkiefergelenkfortsatzfrakturen mit einem neuartigen Osteosynthesebesteck. Zahn Mund Kieferheilk 69:485, 1981 15. Krenkel Ch: Axial “anchor” screw (lag screw with biconcave washer) or “slanted screw” plate for osteosynthesis of fractures of the mandibular condylar process. J Craniomaxillofac Surg 201348, 1992 16. Yasuharu T, Ishibashi H, Oka M: Comparison of functional recovery after nonsurgical and surgical treatment of condylar fractures. J Oral Maxillofac Surg 48: 1191, 1990 17. Konstantinovic VS, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures. J Oral Maxlllofac Surg 50:349, 1992 18. Worsaae N, Thorn JJ: Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures. J Oral Maxillofat Surg 52:353, 1994 19. Lindahl L: Condylar fractures of the mandible. I. Classification and relation to age, occlusion and concomitant injuries of teeth and teeth-supporting structures and fractures of the mandibular body. Int J Oral Surg 6:153,1977 20. Clementschitsch F: Die Riintgendarstelhmg des Gesichtsschadels. Wien, Urban and Schwarzenberg, 1951 2 1. Krough-Paulsen WG: Zusammenh~ge zwischen Lokalisation von Abrasionsfacetten und Schmerzen in der Kaumuskulatur und der Bedeutung fiir Diagnostik und Behandlung. 2 Stomatol 64:402, 1967
RUDOLF
R.M.
BOS
Henny FA: A technique for open reduction of fractures of the mandibular condyle. J Oral Surg 9:233, 1951 23. Krenkel Ch: Biomechanics and Osteosynthesis of Condylar Neck Fractures of the Mandible. Chicago, IL, Quintessence, 22.
28.
29.
1994
RasseM: Diakapitulare Frakturen der Mandibula: Die operative Versorgung: Tierexperiment und Klinik. Habilitationsschrift Med Fakultat Universitat Wien, 1993 25. Mizuno A, Shikimori M: Adaptive and remodelling changes in the fractured mandibuku condyle after open reduction using the Kirschner pin. J Oral MaxiUofac Surg 48:1024, 1990 26. Ellis E, Reynolds ST, Park HS: A method to rigidly Iix high condylar fractures. Oral Surg Oral Med Oral Path01 68:369, 1989 27. Iizuka T, Lindqvist Ch, Hallikainen D, et al: Severe resorption and osteoarthrosis after miniplate fixation of high condylar fractures. Oral Surg Oral Med Oral Path01 72:400, 1991 24.
J Oral
Maxillofac
57:397-398,
30.
31.
32.
Lindahl L, Hollender L: Condylar fractures of the mandible. II. A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:153, 1977 Hidding J, Wolf R, Pingel D: Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J CranlomaxiIlofac Surg 20:345, 1992 Bradley P, James D, Noorman JE de B: Injuries of the condylar and coronoid processes, in Rowe NL, Williams JL: MaxiIlofacial Injuries. New York, NY, Churchill Livingston, 1994, p 405 Suuronen R, Vainionpaa S, Hietanen J, et al: The effect of osteotomy and osteosynthesis In the mandibular condyle: A radiologic and histologic study in sheep. Int J Oral Maxillofac Surg 23:174, 1994 Tiirp JC, StoII P, Schlotthauer U, et al: Computerized axiographic evaluation of condylar movements in cases with fractures of the condylar process: A follow-up over 19 years. J CraniomaxIIIofac Surg 24:46, 1996
Surg
1999
Discussion Fractures Surgical
of the Condylar Versus Nonsurgical
Process: Treatment
Rud0lfR.M. Bos, DDS, PhD Associate Professor, Department University Hospital Groningen, e-mail: [email protected]
of Oral and Maxillofacial Groningen, The Netherlands;
Surgery,
In their article, the authors try to answer the question of whether there is evidence to determine if, when, and how treatment for fractures involving the mandibular condylar process should be carried out. By comparing surgically and nonsurgically treated patients in a retrospective way, they conclude, based on radiologic, objective, and subjective criteria, that there is no significant difference between the two groups except for more weather sensitivity and more pain on maximum mouth opening in the surgically treated patients. Consequently, they conclude that open surgery is only indicated in patients with severely dislocated fractures of the condylar process. Whether open or closed management of fractures of the condylar process is the most appropriate approach is still a subject of debate. This debate has gained attention since new surgical techniques for open reduction and internal fixation of these fractures have become available. These open techniques aim for anatomic reduction of the fractured condylar process with restoration of the vertical dimension. Factors that dominate this discussion are the location of the fracture, whether it is bilateral or unilateral, the extent of dislocation of the fractured condylar process, whether there are other associated facial fractures, the age of the patient, the medical and dental condition of the patient, the absence of occlusal support, and a history of temporomandibular joint disease. Prospective, randomized, clinical trials comparing different treatment modalities are lacking except for the one by Worsaae and Thorn1 as mentioned in this article. A major
disadvantage of that study was that they used an unstable fixation method with wires that necessitated additional maxillomandibular fixation (MMF). The use of a stable internal fixation method, not necessitating MMF, could have influenced the outcome of the study. Prospective as well as retrospective outcome studies are mostly confined to one surgical technique and/or short follow-up, thus not answering the question if, when, and how treatment for fractures involving the condylar process should be carried out. It is questionable if a randomized clinical study comparing closed treatment and any kind of open reduction and internal fixation is possible and/or ethical. A prospective multicenter condylar process fracture audit seems easier and thus more desirable. It is not unusual that the authors focused on severely dislocated and/or displaced fractures, because this is the group of fractures that causes the most problems. However, there is not necessarily a relationship between the severity of the dislocation/displacement and the outcome of closed or open surgical treatment, as they have shown in their results. Therefore, the conclusion that patients with severely dislocated condyles are candidates for surgical intervention is premature; who should be operated and who should not is still unclear. Is it correct to compare the nonsurgical group with the surgical group when different surgical modalities were used in the surgical group without taking into account the influence of individual techniques on the outcome? Moreover the exact treatment in the nonsurgical group is not specified, as well as if it was the same in all patients. How long was the MMF and what kind of MMF was applied, what kind of instructions did the patient receive, and whether they underwent active and/or passive physiotherapy is also not addressed. These are all questions that should be answered before one can come to any reliable conclusions. Then the question still remains whether a retrospective study is able to give the right answers.
Surg 1999
Fractures of the Condylar Surgical Versus Nonsurgical
Process: Treatment
Gert Santler MD, DDS, * Hans Kiircher MD, DDS, f Christof Ruda, MD, DDS,$ and Ernst KGle, MD, DDSJ Purpose: The purpose of this study was to compare outcomes of condylar process fractures.
from surgical and nonsurgical
treatment
Patients and Methods: Two hundred thirty-four patients with fractures of the mandibular condylar process were treated by open or closed methods. In the follow-up study, 150 patients with a mean follow-up time of 2.5 years were analyzed using radiologic and objective and subjective clinical examinations. Results: No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve disorders were observed when the surgically and nonsurgically treated patients were compared. The only significant difference was in subjective discomfort. Surgically treated patients showed significantly more weather sensitivity and pain on maximum mouth opening. Conclusion: Because of its disadvantages, dislocated condylar process fractures.
open surgery
The choice of surgical’ versus nonsurgical treatment* for fractures of the condylar process remains a controversial issue.sm5 Historically, nonsurgical treatment by means of maxillomandibular fixation (MMF) was standard practice, especially in children, who showed a high potential for adaptation and spontaneous regeneration.@ Another reason favoring nonsurgical treatment was the disadvantages of the open approach. Preauricular, submandibular, postauricular, retromandibular, intraoral, coronal, and combined approaches have been described. Because of the close anatomic relationship of the facial nerve and the temporal vessels, these approaches may damage these important structures. Also, extraoral approaches inevitably are associated with visible scars. The introduction of better materials for osteosynthesis, such as Kirschner wires,‘O wires,” miniplates,l* and lag screws,*3-15 have
Received
from
University
the Department
Clinic
‘Senior
for Dentistry,
Oral Maxillofacial
facial Surgery. THead, Department *Senior
Oral
Maxillofacial SResident, Address
and
of Oral and Maxillofacial Department
of Oral Maxillofacial Maxillofacial
Department
of Oral Maxillofacial and
reprint
of Oral
Surgery. requests
to Dr Santler:
Klinische Abteilung fur Mund-, Kiefer- und Gesichtschirurgie, UniversitNdinik ftir ZMK, Auenbruggerplatz 7, A-8036 Austria;
Surgery,
Surgery. correspondence
der Graz,
e-mail: [email protected]
6 1999 American Association of Oral and Maxillofacial 0278-2391/99/5704-0007$3.00/0
severely
From 1987 to 1995, 292 fractures of the condylar process were treated in 234 patients. The ages ranged from 5 to 90 years (mean, 25; standard deviation [SD], 13.8). In 82 cases, the left, in 94 the right, and in 58 cases both sides were affected. There were 37 fractures of the condyle and 255 of the condylar neck (69 high, 125 medium, 61 low) according to the classitication suggested by Krenkel. l5 Condylar and high condylar neck fractures correspond with condylar and condylar neck fractures according to Lindahl’G nomenclature, medium condylar fractures are similar to subcondylar fractures, and low condylar fractures extend from halfway up the ramus to the angle of the mandible. Of those patients treated nonsurgically, 161 (195 joints) were treated with MMF and 11 (19 joints) without it. Sixty-two patients (70 joints) were treated surgically. One hundred fifty patients were available for follow-up examination. The evaluation included panoramic and frontal radiographs,*O and a clinical ex-
of Oral Maxillo-
Department
with
Patients and Methods
Surgery.
Surgeon,
in patients
made open surgical treatment more advantageous. This advantage is based on exact fragment repositioning, the possibility of disc repair and, in the case of rigid fixation, MMF becomes superfluous. Several authors have compared results of surgical and nonsurgical treatment.lG18 Our clinic treated severely dislocated fractures only by means of MMF until 1990. Thus, it was possible to compare nonsurgical and surgical treatment in patients with similar dislocation patterns.
Gmz, Austria. Surgeon,
is only indicated
Surgeons
392
393
SANTLER ET AL
amination. The clinical examination included measurement of maximal interincisal distance, protrusion and laterotrusion, a Krough-Poulsen-test21 to analyse joint problems, assessmentof the occlusion, palpation of the masticatory muscles,neurologic evaluation of the 5th and 7th cranial nerves, and a questionnaire related to subjective discomfort. The dislocation patterns were assessedby measurement of the preoperative and postoperative radiographs, including maximum deviation and displacementls as well as assessment of dislocation and bony contact between the fragments. The data from the surgically treated patients were compared with data from the nonsurgically treated patients, and the intluence of the different dislocation patterns was analysed. For statistical analysis, the SPSS program with the chi-square test, the Mann-Whitney test, the Kruskal-Wallis test, and the Spearman correlation coefficient were used.
Results One hundred nfty patients (Table 1) with 189 fractures of the condyle and the condylar neck were available for follow-up examination. Traffic accidents were the main cause of the trauma (Fig 1). The age distribution showed a typical peak between 20 and 30 years (mean, 24; SD, 13.7; range, 6 to 72). In 82 cases, the left; in 94, the right; and in 58 cases, both sides were affected. There were 27 fractures of the condyle and 162 of the condylar neck (42 high, 83 medium, 37 low). In 57 fractures, there was no dislocation; 42 showed medium dislocation, and 90 had severe dislocation. In 72 patients, the condylar process fractures were combined with additional fractures of the mandible. Of those patients treated nonsurgically, 107 (132 joints) were treated with MMF, and six (10 joints) without it. Thirty-seven patients (43 joints) were treated surgically. Different surgical treatments were performed: miniplates (13 joints), anchor screws (10 joints), open reduction (nine joints), microplates (four joints), wire osteosynthesis (four joints), screws (two joints), and removal of the small fragment (one joint).
Treatment Surgical Nonsurgical Total
No. of Cases (%I
Sex (F/M) (Ratio)
(Z,
17/20 1:1.2 23/90 1:4 40/110 1:2.8
113 (75) 150 (100)
Mean Age (YO @weI $3)
No. of Condylar Process Fractures 43
Both surgical and nonsurgical treatment showed satisfactory results (Table 2, Fig 2). Only four patients (3%) had an interincisal distance of less than 35 mm, which was equally distributed in both groups. The mean mouth opening was 45.5 mm (surgical) and 47 mm (nonsurgical). Although preoperative dislocation patterns differed significantly (Table 2) comparison of surgically and nonsurgically treated patients showed no significant difference in jaw mobility (Fig 2): maximum mouth opening, protrusion, laterotrusion to and from the fractured side, as well as the difference between laterotrusion to and from the fractured side and deviation during mouth opening, were similar in both groups. Pain, muscle tension, and hypertrophy of the muscles were similarly distributed, as were joint problems such as pain, clicking, and crepitation on the fractured and the nonfractured side. The incidence of hypesthesia, paresthesia, and anesthesia of the mental nerve and the incidence of frontal and marginal facial nerve palsy were not significantly increased in the operated group. Also, occlusal disturbances showed no significant differences. Two subjective complaints were found to be significantly different between the groups: weather sensitivity and pain during maximum mouth opening were found more often in the surgically treated group (Table 2, Fig 2). This was also true for patients with severely dislocated fractures; however, this was not statistically significant. Nonsurgically treated patients with fractures healed in a dislocated position were significantly older than those with fractures healed in correct or at least improved position (Table 3). Increasing age was significantly associated with a reduction of mouth opening and protrusion. Of the operatively treated patients, older patients more often exhibited subjective complaints and a reduced laterotrusion to the nonfractured side. Displacement of the ramus, deviation or dislocation of the condylar process, and absence of fragment contact all significantly influenced the results in the
No. With Associated Mandibular Fractures
No. With Insufkient Posterior Occlusal Support
13
7
142
59
13
189
72
20
(4 Nonsurg)
Follow-Up (mo) Mean (Ewe> (6::)
(8%)
(Z3)
394
FRACTURES
Traffic accident 55%
Horse kick 3% accident 5% FIGURE
Fight 7% 1. Cause
accident 9% of the fractures
nonsurgical group. Displacement led to a reduced protrusion, laterotrusion to the nonfractured side, and a greater difference between laterotrusion to and from the fractured side. Higher degrees of deviation led to more muscular pain, tooth grinding, and subjective discomfort. Lack of bony contact was correlated significantly with reduced mouth opening, laterotrusion to the nonfractured side, a higher incidence of asymmetry during laughing and lip pursing, aswell as weather-related discomfort. Dislocation also led to a reduction in mouth opening, a higher incidence of asymmetrical laughing and lip pursing, tooth grinding, and subjective discomfort during weather changes and heavy chewing. In the operated patients, preoperatively dislocated condyles significantly led to weather sensitivity. It is obvious that patients with higher degrees of displacement, deviation, and dislocation lessoften end up with correct anatomic healing of the fractures.
Discussion Bellinger et al4 reported surgical therapy of condylar neck fractures in only two of 100 cases after complications had developed. The risk of wound infection in the preantibiotic era, the proximity of nerves and vessels, and the absence of sophisticated osteosynthesis materials were the reasonsfor nonsurgical treatment. With the introduction of better anesthestic techniques and the advent of antibiotics, open repositioning has increasingly been performed. The disadvantage of open repositioning,22 wire osteosynthesis,6and Kirschner wireslo lies in the lack of functional stability. Open repositioning and the use of MMF without osteosynthesis in casesin which the fragments remain stable after repositioning, has its advantages. Only a minimum of stripping of the fragments is necessary, and the already reduced blood supply remains undisturbed. Also, there is no need for osteosynthesis material and consequently no necessity for a second operation to remove it.
OF THE
CONDYLAR
PROCESS:
SURG
VS NONSURG
395
SANTLER ET AL
80% 60%
FIGURE 2. Comparison of operative and nonsurgical treatment with respect to preoperative dislocation and postoperative outcome.
20% 0% SN
SN
SN
SN
SN
SN
SN
Miniplates, l2 lagscrew osteosynthesis,1sa15,2s and pin fixation2* allow functional stability and early movement of the joint. Microplates, especially threedimensional microplates, although they do not provide functional stability, allow fixation with a minimum detachment of soft tissue. This is an advantage, especially in extremely high condylar process fractures in children. Exact anatomic repositioning of the fractured condylar process seems to be the most important objective in treatment. In our opinion, the method of fixation is of minor importance. The type of osteosynthesis depends not only on the location and direction of the fracture and the number of fragments but also on posterior occlusal support. These factors also influence the choice of the approach. In cases in which
Treatment Surgical NOllsurgical
As Condylar displacement
Surgical NOllsurgical
Anatomic Position Post OP
MOUtb Opening
Laterotrusion NOAXture Side
SN
SN
conventional radiographs do not allow precise diagnosis of the location and direction of the fracture and number of fragments, computed tomography (CT) scans are of great value. CT-based three-dimensional models facilitate the diagnosis of dislocation and identification of the number of fragments. In this study, preauricular or submandibular incisions were used and, in rare cases, a combination. Extensive approaches as proposed by Mizuno and Shikimori25 are not necessary for most cases. Removal of the condylar process and the ramus by vertical osteotomy and extracorporal osteosynthesis of the fracture26 allows precise repositioning but transforms condylar process and ramus into free grafts. This was unnecessary in all of our patients. Iizuka et a12’ have described severe resorption and
Discomfort
AsylllProtmsion
“;I
2% Laughing
g:E of the Lips
t%%comfort
Weather Sensitivity
2: Chewing
L$%% Opening
Grinding
P= ,005 P=
,004
P=
.05
P=.OO3
P < .OOl
P=.OO58
P= ,048
P=
P= .04
,069
Condylar
deviation Missing bony contact Condylar dislocation
NOTE.
Surgical Nonsurgical Surgical Nonsurgical Surgical Nonsurgical
Significance
P= .0006
P=
P=
,013 P= ,033
,046
P= .05
P < ,001
P < ,001
P= ,003
Pi
.OOl
P= .056 P= .0004 P= ,048
levels are presented
in case of significant
P < ,001 influence
in surgically
P < .OOl or nonsurgically
P = ,057
treated
P < ,001
patients.
P = .0013
396
FRACTURES OF THE CONDYLAR
osteoarthrosis in all 13 patients treated by the extracorporal method, although the functional result was satisfactory in all but one case. In accord with the findings of Lindahl and Hollender,28who described a great remodeling potential in growing children, a significantly better position of the condylar process was found in our study in children up to the age of 15 years. This could be explained by the fact that all of the nonsurgically treated fractures in our seriesdid not show preoperative dislocation. Yasuharu et all6 compared 16 surgical and 20 nonsurgically treated patients. Although the surgical cases showed greater preoperative dislocation, the resulting function and occlusion were satisfactory. Similar results were presented by Hidding et al29for 34 patients, also confirming our own results. Konstantinovic and Dimitrijevicl’ found no statistically relevant difference in clinical parameters of surgically and nonsurgically treated fractures in 80 patients. However, in the surgical group, the condyle showed a better position. Unfortunately, the authors did not describe the method of selection of patients in their article. Worsaae and Thorn’* have presented the only study with a randomized selection of patients. In surgically treated patients, they found complications such as malocclusion, mandibular asymmetry, impaired masticatory function, and pain in a significantly higher frequency than in nonsurgically treated patients. They used wire fixation and MMF in surgically treated patients. Eleven of 28 nonsurgically treated patients had complications, which appears not to be the best possible outcome compared with results in the literature.30 Suuronen et a131described degenerative joint diseasecaused by rigid fixation in an animal model. Ti.irp et als2 showed that patients after nonsurgical treatment still had reduced mobility compared with the control group even 19 years after treatment. It is mainly dislocation that negatively influences the outcome of treatment. However, because of a great adaptive capacity, even patients with severely dislocated condyles only rarely have unsatisfactory treatment results. In times when the medical care system is confronted with great financial problems, cost and hospitalization time become an increasing concern. The higher costs of surgical therapy, involving longer operation and hospitalization times, and expensive osteosynthesis materials, must be weighed against the advantage of early mobilization and integration into the working process. Basedon the results of this study, minimal invasive therapy for condylar process fractures has again become the method of choice in our department. In our
PROCESS: SURG VS NONSURG
opinion, there is no indication for surgical treatment if nonsurgical treatment leads to comparable results. Only patients with severely dislocated condyles, who are known to benefit from surgical intervention, may be candidates for open surgery.
References 1. Hall MB: Condylar fractures: Surgical management. J Oral Maxillofac Surg 521192, 1994 2. Walker RV: Condylar fractures: Nonsurgical management. J Oral Maxillofac Surg 52:1185,1994 for open reduction of mandibular 3. Zide MF, Kent JN: Indications condyle fractures. J Oral Maxillofac Surg 89:89, 1983 4. Bellinger DH, Henny FA, Peterson LW: Fracture of the mandibular condyle. J Oral Maxillofac Surg 1:48, 1943 5. Hayward JR, Scott RF: Fractures of the mandibular condyle. J Oral Maxillofac Surg 51:57, 1993 6. Hoopes JE, Wolfort FG, Jabaley ME: Operative treatment of fractures of the mandibular condyle ln children. Plast Reconstr Surg 46:357,1970 follow-up of 7. Leake D, Doykos J III, Habal MB, et al: Long-term fractures of the mandibular condyle in children. Plast Reconstr Surg 47:127, 1971 8. Gundlach KKH, Schwipper E, Fuhrmann A: Die Regenerationsftiigkeit des Processus condylarls mandibulae. Dtsch Zahnarztl 2 46:36, 1991 SE, Krlshnan V, Sindet-Pedersen S, et al: Pediatric 9. Norholt condylar fractures: A long-term follow-up study of 55 patients. J OralMaxillofac Surg 51:1302,1993 10. Timmel R: Die operative Behandhmg der Luxationsfraktur des Kleferkiipfchens. 2 Stomatol79:190, 1982 11. Peters RA, Caldwell JB, Olsen ThW: A technique for open reduction of subcondylar fractures. Oral Surg Oral Med Oral Path01 41:273, 1976 12. Koberg W, Momma W: Treatment of the articular process by functional stable osteosynthesis using miniaturized dynamic compression plates. Int J Oral Surg 7:256, 1978 condylar process 13. Petzel JR, Bulles G: Stability of the mandibular after functionally stable traction-screw-osteosynthesis (TSO) with a self-tapping screw-pin. J Maxillofac Surg 10:149, 1982 14. Eckelt U, Gerber S: Zugschraubenosteosynthese bei Unterkiefergelenkfortsatzfrakturen mit einem neuartigen Osteosynthesebesteck. Zahn Mund Kieferheilk 69:485, 1981 15. Krenkel Ch: Axial “anchor” screw (lag screw with biconcave washer) or “slanted screw” plate for osteosynthesis of fractures of the mandibular condylar process. J Craniomaxillofac Surg 201348, 1992 16. Yasuharu T, Ishibashi H, Oka M: Comparison of functional recovery after nonsurgical and surgical treatment of condylar fractures. J Oral Maxillofac Surg 48: 1191, 1990 17. Konstantinovic VS, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures. J Oral Maxlllofac Surg 50:349, 1992 18. Worsaae N, Thorn JJ: Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures. J Oral Maxillofat Surg 52:353, 1994 19. Lindahl L: Condylar fractures of the mandible. I. Classification and relation to age, occlusion and concomitant injuries of teeth and teeth-supporting structures and fractures of the mandibular body. Int J Oral Surg 6:153,1977 20. Clementschitsch F: Die Riintgendarstelhmg des Gesichtsschadels. Wien, Urban and Schwarzenberg, 1951 2 1. Krough-Paulsen WG: Zusammenh~ge zwischen Lokalisation von Abrasionsfacetten und Schmerzen in der Kaumuskulatur und der Bedeutung fiir Diagnostik und Behandlung. 2 Stomatol 64:402, 1967
RUDOLF
R.M.
BOS
Henny FA: A technique for open reduction of fractures of the mandibular condyle. J Oral Surg 9:233, 1951 23. Krenkel Ch: Biomechanics and Osteosynthesis of Condylar Neck Fractures of the Mandible. Chicago, IL, Quintessence, 22.
28.
29.
1994
RasseM: Diakapitulare Frakturen der Mandibula: Die operative Versorgung: Tierexperiment und Klinik. Habilitationsschrift Med Fakultat Universitat Wien, 1993 25. Mizuno A, Shikimori M: Adaptive and remodelling changes in the fractured mandibuku condyle after open reduction using the Kirschner pin. J Oral MaxiUofac Surg 48:1024, 1990 26. Ellis E, Reynolds ST, Park HS: A method to rigidly Iix high condylar fractures. Oral Surg Oral Med Oral Path01 68:369, 1989 27. Iizuka T, Lindqvist Ch, Hallikainen D, et al: Severe resorption and osteoarthrosis after miniplate fixation of high condylar fractures. Oral Surg Oral Med Oral Path01 72:400, 1991 24.
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30.
31.
32.
Lindahl L, Hollender L: Condylar fractures of the mandible. II. A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:153, 1977 Hidding J, Wolf R, Pingel D: Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J CranlomaxiIlofac Surg 20:345, 1992 Bradley P, James D, Noorman JE de B: Injuries of the condylar and coronoid processes, in Rowe NL, Williams JL: MaxiIlofacial Injuries. New York, NY, Churchill Livingston, 1994, p 405 Suuronen R, Vainionpaa S, Hietanen J, et al: The effect of osteotomy and osteosynthesis In the mandibular condyle: A radiologic and histologic study in sheep. Int J Oral Maxillofac Surg 23:174, 1994 Tiirp JC, StoII P, Schlotthauer U, et al: Computerized axiographic evaluation of condylar movements in cases with fractures of the condylar process: A follow-up over 19 years. J CraniomaxIIIofac Surg 24:46, 1996
Surg
1999
Discussion Fractures Surgical
of the Condylar Versus Nonsurgical
Process: Treatment
Rud0lfR.M. Bos, DDS, PhD Associate Professor, Department University Hospital Groningen, e-mail: [email protected]
of Oral and Maxillofacial Groningen, The Netherlands;
Surgery,
In their article, the authors try to answer the question of whether there is evidence to determine if, when, and how treatment for fractures involving the mandibular condylar process should be carried out. By comparing surgically and nonsurgically treated patients in a retrospective way, they conclude, based on radiologic, objective, and subjective criteria, that there is no significant difference between the two groups except for more weather sensitivity and more pain on maximum mouth opening in the surgically treated patients. Consequently, they conclude that open surgery is only indicated in patients with severely dislocated fractures of the condylar process. Whether open or closed management of fractures of the condylar process is the most appropriate approach is still a subject of debate. This debate has gained attention since new surgical techniques for open reduction and internal fixation of these fractures have become available. These open techniques aim for anatomic reduction of the fractured condylar process with restoration of the vertical dimension. Factors that dominate this discussion are the location of the fracture, whether it is bilateral or unilateral, the extent of dislocation of the fractured condylar process, whether there are other associated facial fractures, the age of the patient, the medical and dental condition of the patient, the absence of occlusal support, and a history of temporomandibular joint disease. Prospective, randomized, clinical trials comparing different treatment modalities are lacking except for the one by Worsaae and Thorn1 as mentioned in this article. A major
disadvantage of that study was that they used an unstable fixation method with wires that necessitated additional maxillomandibular fixation (MMF). The use of a stable internal fixation method, not necessitating MMF, could have influenced the outcome of the study. Prospective as well as retrospective outcome studies are mostly confined to one surgical technique and/or short follow-up, thus not answering the question if, when, and how treatment for fractures involving the condylar process should be carried out. It is questionable if a randomized clinical study comparing closed treatment and any kind of open reduction and internal fixation is possible and/or ethical. A prospective multicenter condylar process fracture audit seems easier and thus more desirable. It is not unusual that the authors focused on severely dislocated and/or displaced fractures, because this is the group of fractures that causes the most problems. However, there is not necessarily a relationship between the severity of the dislocation/displacement and the outcome of closed or open surgical treatment, as they have shown in their results. Therefore, the conclusion that patients with severely dislocated condyles are candidates for surgical intervention is premature; who should be operated and who should not is still unclear. Is it correct to compare the nonsurgical group with the surgical group when different surgical modalities were used in the surgical group without taking into account the influence of individual techniques on the outcome? Moreover the exact treatment in the nonsurgical group is not specified, as well as if it was the same in all patients. How long was the MMF and what kind of MMF was applied, what kind of instructions did the patient receive, and whether they underwent active and/or passive physiotherapy is also not addressed. These are all questions that should be answered before one can come to any reliable conclusions. Then the question still remains whether a retrospective study is able to give the right answers.