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Indications for open reduction and closed reduction treatment
Symposia observe order in patterns which before appeared to be dominated by randomness and not accessible to any geometric analysis. In fact, self-similarity is the key platform for a new geometry—the fractal geometry conceived by Benoit Mandelbrot—which allows us to analyze the geometry of nature and find laws which provides us with tools to simulate natural pattern formation processes such as the vascular growth in an organ. As an application of the strands of chaos theory and self-organization the lecture will present breakthrough research and results dedicated to the detection, evaluation and exclusion of risks in tumor surgery. Particular attention
will be given to brain, lung and liver lesions. Finally, applications of these new tools for living-donor-livertransplantation will be discussed. References Gleick J: Chaos: Making a New Science. Penguin Books, 1988 Peitgen H-O, Ju ¨ rgens H, Saupe D: Chaos and Fractals, New Frontiers of Science (ed 2). New York, NY, Springer, 2004 Peitgen H-O, et al: Computer-assisted planning and decision-making in living-donor liver transplantation, in Tanaka K, et al (eds): LivingDonor Liver Transplantation—Surgical Techniques and Innovations. Barcelona, Spain, Prous Science 2003
SYMPOSIUM ON MANAGEMENT OF SUBCONDYLAR FRACTURES: HISTORICAL PERSPECTIVES AND NEW HORIZONS Presented on Friday, October 1, 2004, 12:30 pm—2:30 pm Moderator: Joseph P. McCain, DMD, Miami, FL
History of Sub-Condylar Fractures Edward Ellis III, DDS, MS, Dallas, TX For most of history, condylar process fractures were either not treated because the diagnosis was not made, or were managed minimally using external bandages to immobilize the mandible. The beginning of the 20th century is when articles on the management of condylar fractures became common in the literature. Surprisingly, open treatment was mentioned often, perhaps because closed treatment was common and not worthy of publication, which at that time was usually case reports. All methods that one might dream up were applied to condylar fractures, including: 1. Open reduction via a medial approach to the ramus 2. Condylectomy to prevent hypomobility 3. Varying periods of MMF from none to 6 weeks 4. Closed manipulation under general anesthesia This talk will center on historical progress in the treatment of condylar fractures, and arguments such as the need for a period of MMF. References Zemsky JL: New conservative treatment versus surgical operation for displaced fractures of the neck of the mandibular condyle. Dent Cosmos 68:43, 1926 Chalmers J: Lyons Club: Fractures of the mandibular condyle: A post-treatment survey of 120 cases. J Oral Surg 5:45, 1947 MacLennan DW: Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 5:122, 1952
Indications for Open Reduction and Closed Reduction Treatment Edward Ellis III, DDS, MS, Dallas, TX The treatment of condylar fractures is still a highly debated theme. With the advent of stable internal fixa12
tion devices, open treatment has become more popular. However, there is still no universal agreement on the indications for open or closed treatment. These seem to vary with every surgeon who treats such injuries. This talk will focus on factors that may be taken into account when one decides how a given condyle fracture is to be treated. The basis of the talk, however, will be that the majority of condylar fractures can be treated satisfactorily by closed techniques. The question is, Which fractures might have better outcomes when treated open? Absolute Indications for Open Treatment 1. Displacement of condyle into the middle cranial fossa (with or without fracture) 2. Lateral extracapsular displacement of condyle (with or without fracture) 3. Impossibility of obtaining proper occlusion by closed techniques 4. Condylar fractures associated with comminuted fractures at or above the LF 1 level Relative Indications for Open Treatment All other condylar fractures may be treated closed or open. The decision to choose one method over another will vary depending upon the experience and philosophy of the surgeon, the expected outcomes from either treatment, and the factors discussed below. I therefore will not list any relative indications because what is a relative indication in my opinion may not be in another’s. I. Loss of Ramus Height. Fractures that are displaced will lead to decreases in the height of the ramus. In most cases this loss of ramus height is acceptable and will be manifest by a small cant in the occlusal plane (if the fracture is unilateral). However, if few posterior teeth are present, control of ramus height by functional (nonAAOMS • 2004
Symposia surgical) therapy will be difficult and large losses of ramus height may occur. II. Skeletal Maturation of Patient. Skeletally immature individuals possess the unique ability to regenerate the entire condylar process after fracture/dislocation. They also function more symmetrically after non-surgical treatment. On the other hand, skeletally mature individuals have a more limited capacity for condyle regeneration/restitution. Further, most studies indicate more functional disturbances to the masticatory system in later years in such individuals than in those injured when skeletally immature. III. Feasibility of Open Reduction and Internal Fixation. High-level fractures pose a problem in that they do not have adequate bulk to perform stable osteosynthesis. In such cases, one may select non-surgical treatment. Other factors that relate to the choice between surgical and non-surgical treatment are the general health of the patient, the pre-traumatic occlusal relationship, and the desire to avoid intermaxillary fixation/traction. IV. Associated Fractures. When bilateral condylar fractures are present, especially those that are displaced, treatment using closed techniques is extremely difficult, even when a full complement of teeth is present. Treatment will be prolonged and many adaptations, including anterior dental extrusion, will occur out of necessity to maintain the pre-trauma occlusal relationship. Open treatment of at least one fracture seems to improve the occlusal outcomes. V. State of the Dentition. Closed techniques all rely on using the dentition to position the mandible while the new articulation is established. Patients who have an incomplete dentition present a challenge for closed treatment of the condylar fracture, and might necessitate the fabrication of splints to maintain the posterior vertical dimension. Open treatment may be more efficient and may produce improved outcomes in such cases. References Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 Konstantinovic VS, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures: Clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 50:349, 1992 Ellis E: Condylar process fractures of the mandible. Fac Plast Surg 16:193, 2000
Extraoral Approach Maria J. Troulis, DDS, MSc, Boston, MA (no abstract provided)
AAOMS • 2004
Intraoral Approach Ralf Scho ¨ n, MD, DMD, Freiburg, Germany The transoral approach for reduction of condylar mandible fractures has been described to minimize the risk of facial nerve injury without visible scars. From April 1998 to May 2004 the minimally invasive transoral approach for the endoscopic assisted reduction and osteosynthesis of 73 displaced condylar mandible fractures was performed in 66 patients. Via limited intraoral incision the endoscopic assisted reduction and fixation of condylar fractures was performed using 30 and 45 degree angled endoscopes (Karl Storz, Tuttlingen, Germany). Thirty-two fractures were condylar and 41 were subcondylar fractures; the condylar neck of the proximal fragment was displaced medially in 21 fractures and laterally in 52 fractures. Seven patients presented bilateral condylar mandible fractures. Using angled endoscopes good visibility of the fracture side was obtained and allowed for precise anatomic reduction in all patients. Angulated drill and screw driver (Stryker Howmedica, Leibinger, Mu ¨ hlheim a.d., Ruhr, Germany) facilitated the miniplate fixation (Synthes, Paoli, PA, USA) by transoral approach. The mean operating time measured in the last 40 consecutive cases was 1 hour 5 minutes. Postoperatively all patients showed quick recovery, and preinjury occlusion. Normal temporomandibular joint function was noted six months after surgery in all patients. The transoral endoscopic assisted treatment using angulated drill and screw driver is the method of choice for the surgical management of displaced condylar fractures even in fractures with medial override. Facial nerve injury and visible scars are avoided using the transoral approach.
References Scho ¨ n R, Gutwald R, Schramm A, et al: Endoscopic assisted treatment of condylar fractures. Extraoral versus intraoral approach. Scho ¨ n R, Schramm A, Gellrich N-C, et al: Follow up 18 months after transoral endoscopic assisted treatment of condylar fractures. J Oral Maxillofac Surg 61:49, 2003 Scho ¨ n R, Gellrich NC, Schmelzeisen R: Frontiers in maxillofacial endoscopic surgery. Atlas Oral Maxillofac Surg Clin North Am 11: 209, 2003
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will be given to brain, lung and liver lesions. Finally, applications of these new tools for living-donor-livertransplantation will be discussed. References Gleick J: Chaos: Making a New Science. Penguin Books, 1988 Peitgen H-O, Ju ¨ rgens H, Saupe D: Chaos and Fractals, New Frontiers of Science (ed 2). New York, NY, Springer, 2004 Peitgen H-O, et al: Computer-assisted planning and decision-making in living-donor liver transplantation, in Tanaka K, et al (eds): LivingDonor Liver Transplantation—Surgical Techniques and Innovations. Barcelona, Spain, Prous Science 2003
SYMPOSIUM ON MANAGEMENT OF SUBCONDYLAR FRACTURES: HISTORICAL PERSPECTIVES AND NEW HORIZONS Presented on Friday, October 1, 2004, 12:30 pm—2:30 pm Moderator: Joseph P. McCain, DMD, Miami, FL
History of Sub-Condylar Fractures Edward Ellis III, DDS, MS, Dallas, TX For most of history, condylar process fractures were either not treated because the diagnosis was not made, or were managed minimally using external bandages to immobilize the mandible. The beginning of the 20th century is when articles on the management of condylar fractures became common in the literature. Surprisingly, open treatment was mentioned often, perhaps because closed treatment was common and not worthy of publication, which at that time was usually case reports. All methods that one might dream up were applied to condylar fractures, including: 1. Open reduction via a medial approach to the ramus 2. Condylectomy to prevent hypomobility 3. Varying periods of MMF from none to 6 weeks 4. Closed manipulation under general anesthesia This talk will center on historical progress in the treatment of condylar fractures, and arguments such as the need for a period of MMF. References Zemsky JL: New conservative treatment versus surgical operation for displaced fractures of the neck of the mandibular condyle. Dent Cosmos 68:43, 1926 Chalmers J: Lyons Club: Fractures of the mandibular condyle: A post-treatment survey of 120 cases. J Oral Surg 5:45, 1947 MacLennan DW: Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 5:122, 1952
Indications for Open Reduction and Closed Reduction Treatment Edward Ellis III, DDS, MS, Dallas, TX The treatment of condylar fractures is still a highly debated theme. With the advent of stable internal fixa12
tion devices, open treatment has become more popular. However, there is still no universal agreement on the indications for open or closed treatment. These seem to vary with every surgeon who treats such injuries. This talk will focus on factors that may be taken into account when one decides how a given condyle fracture is to be treated. The basis of the talk, however, will be that the majority of condylar fractures can be treated satisfactorily by closed techniques. The question is, Which fractures might have better outcomes when treated open? Absolute Indications for Open Treatment 1. Displacement of condyle into the middle cranial fossa (with or without fracture) 2. Lateral extracapsular displacement of condyle (with or without fracture) 3. Impossibility of obtaining proper occlusion by closed techniques 4. Condylar fractures associated with comminuted fractures at or above the LF 1 level Relative Indications for Open Treatment All other condylar fractures may be treated closed or open. The decision to choose one method over another will vary depending upon the experience and philosophy of the surgeon, the expected outcomes from either treatment, and the factors discussed below. I therefore will not list any relative indications because what is a relative indication in my opinion may not be in another’s. I. Loss of Ramus Height. Fractures that are displaced will lead to decreases in the height of the ramus. In most cases this loss of ramus height is acceptable and will be manifest by a small cant in the occlusal plane (if the fracture is unilateral). However, if few posterior teeth are present, control of ramus height by functional (nonAAOMS • 2004
Symposia surgical) therapy will be difficult and large losses of ramus height may occur. II. Skeletal Maturation of Patient. Skeletally immature individuals possess the unique ability to regenerate the entire condylar process after fracture/dislocation. They also function more symmetrically after non-surgical treatment. On the other hand, skeletally mature individuals have a more limited capacity for condyle regeneration/restitution. Further, most studies indicate more functional disturbances to the masticatory system in later years in such individuals than in those injured when skeletally immature. III. Feasibility of Open Reduction and Internal Fixation. High-level fractures pose a problem in that they do not have adequate bulk to perform stable osteosynthesis. In such cases, one may select non-surgical treatment. Other factors that relate to the choice between surgical and non-surgical treatment are the general health of the patient, the pre-traumatic occlusal relationship, and the desire to avoid intermaxillary fixation/traction. IV. Associated Fractures. When bilateral condylar fractures are present, especially those that are displaced, treatment using closed techniques is extremely difficult, even when a full complement of teeth is present. Treatment will be prolonged and many adaptations, including anterior dental extrusion, will occur out of necessity to maintain the pre-trauma occlusal relationship. Open treatment of at least one fracture seems to improve the occlusal outcomes. V. State of the Dentition. Closed techniques all rely on using the dentition to position the mandible while the new articulation is established. Patients who have an incomplete dentition present a challenge for closed treatment of the condylar fracture, and might necessitate the fabrication of splints to maintain the posterior vertical dimension. Open treatment may be more efficient and may produce improved outcomes in such cases. References Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 Konstantinovic VS, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures: Clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 50:349, 1992 Ellis E: Condylar process fractures of the mandible. Fac Plast Surg 16:193, 2000
Extraoral Approach Maria J. Troulis, DDS, MSc, Boston, MA (no abstract provided)
AAOMS • 2004
Intraoral Approach Ralf Scho ¨ n, MD, DMD, Freiburg, Germany The transoral approach for reduction of condylar mandible fractures has been described to minimize the risk of facial nerve injury without visible scars. From April 1998 to May 2004 the minimally invasive transoral approach for the endoscopic assisted reduction and osteosynthesis of 73 displaced condylar mandible fractures was performed in 66 patients. Via limited intraoral incision the endoscopic assisted reduction and fixation of condylar fractures was performed using 30 and 45 degree angled endoscopes (Karl Storz, Tuttlingen, Germany). Thirty-two fractures were condylar and 41 were subcondylar fractures; the condylar neck of the proximal fragment was displaced medially in 21 fractures and laterally in 52 fractures. Seven patients presented bilateral condylar mandible fractures. Using angled endoscopes good visibility of the fracture side was obtained and allowed for precise anatomic reduction in all patients. Angulated drill and screw driver (Stryker Howmedica, Leibinger, Mu ¨ hlheim a.d., Ruhr, Germany) facilitated the miniplate fixation (Synthes, Paoli, PA, USA) by transoral approach. The mean operating time measured in the last 40 consecutive cases was 1 hour 5 minutes. Postoperatively all patients showed quick recovery, and preinjury occlusion. Normal temporomandibular joint function was noted six months after surgery in all patients. The transoral endoscopic assisted treatment using angulated drill and screw driver is the method of choice for the surgical management of displaced condylar fractures even in fractures with medial override. Facial nerve injury and visible scars are avoided using the transoral approach.
References Scho ¨ n R, Gutwald R, Schramm A, et al: Endoscopic assisted treatment of condylar fractures. Extraoral versus intraoral approach. Scho ¨ n R, Schramm A, Gellrich N-C, et al: Follow up 18 months after transoral endoscopic assisted treatment of condylar fractures. J Oral Maxillofac Surg 61:49, 2003 Scho ¨ n R, Gellrich NC, Schmelzeisen R: Frontiers in maxillofacial endoscopic surgery. Atlas Oral Maxillofac Surg Clin North Am 11: 209, 2003
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