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Minimally invasive open reduction of a displaced condylar fracture in a child
British Journal of Oral and Maxillofacial Surgery (2005) 43, 258—260
CASE REPORT
Minimally invasive open reduction of a displaced condylar fracture in a child Ralf Schoen ∗, Nils-Claudius Gellrich, Rainer Schmelzeisen Department of Oral and Maxillofacial Surgery, Universit¨ atsklinik und Poliklinik f¨ ur Mund-, Kiefer- und Gesichtschirurgie, University Clinic Freiburg, i. Br., Hugstetter Str. 55, D 79106 Freiburg, Germany Accepted 17 November 2004 Available online 3 March 2005 KEYWORDS Condylar fracture; Towne radiographs
Summary We treated successfully a severely displaced condylar fracture in a child 9 years of age by endoscopically assisted open operation. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Fractures of the mandibular condyle are common and account for about half of all mandibular fractures in children.1,2 Because of the regenerative power of the mandibular condyle it is accepted that injuries in young children require different treatment from those sustained in late adolescence.2—4 In severely dislocated condylar and subcondylar fractures anatomical restoration is not always achieved and may result in long-term impairment of the function of the temporomandibular joint associated with abnormally shaped condylar heads, reduced height of the mandibular ramus, and growth anomalies with facial asymmetry.3—7 Superior functional results after surgical treatment of severely * Corresponding author. Tel.: +49 761 270 4940; fax: +49 761 270 4800. E-mail address: [email protected] (R. Schoen).
displaced and dislocated condylar fractures are reported in adolescent and adult patients.6,8 However, surgical or conservative treatment remains controversial as complications such as injury of the facial nerve and visible scars may complicate extraoral approaches.5,6,8,9 The risk of damage to the facial nerve is minimal and scars are not visible when a transoral endoscopically assisted technique of open reduction of condylar fractures is used.9
Case report A 9-year-old boy sustained a right subcondylar fracture that was displaced medially by 90◦ as a result of a bicycle accident. He had malocclusion with an open bite deformity on the left side as a result of shortening of the right mandibular ramus. The type of fracture, degree of displacement, and the result of reduction were recorded preoperatively
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.11.005
Minimally invasive open reduction of a displaced condylar fracture in a child
259
Result
Figure 1 (a) Computed tomogram shows a 90◦ medially dislocated right condylar fracture in this child. (b) Endoscopic view after transoral reduction and insertion of a miniplate.
and postoperatively by Towne and panoramic radiographs, and a computed tomogram was taken at the referral clinic before he was admitted (Figs. 1a and 2a). During the operation the fracture was inspected by a 30◦ angled 4 mm diameter endoscope and a Xenon light source (Karl Storz, Tuttlingen, Germany). The fracture was reduced and stabilised transorally using a miniplate and an angulated drill and screw driver8 (Stryker, Leibinger, M¨ uhlheim a.d.Ruhr, Germany) (Figs. 1b and 2b). The function of the temporomandibular joint was measured by maximal incisal opening, deviation on mouth opening, degree of lateral excursion, and the presence of clicking of the temporomandibular joint, and pain 4 weeks, 6 months, and 2 years after operation. The technique of the endoscopically assisted transoral treatment of condylar fractures has been described previously.8,9
Standard postoperative radiographs verified the anatomical reduction (Fig. 2b). Six months later when the plate was removed (Fig. 2c) the bone was found to be healed. Normal occlusion and painfree function of the temporomandibular joint, without deviation or limitation of mouth opening were achieved 4 weeks, 6 months and 2 years postoperatively.
Discussion Non-operative treatment is thought to be correct for fractures of the mandibular condyle in children because of the high potential for regeneration of the growing condylar process.2,3,10,11 It is, however, suspected that fractures of the mandibular condyle may be involved in 5—10% of all severe problems of mandibular deficiency or asymmetry as a result of dysplastic growth after injury.1,4,7,10 The incidence of impaired growth is related not only to the age of the patient, but also to the degree of displacement of the condylar fracture.4,10 Dysplastic growth following condylar fractures was reported in 22% of patients who had grossly displaced condylar fractures.4 Superior functional results without damage to the facial nerve or visible scars have been reported in adults after minimally invasive transoral open treatment of displaced condylar fractures.8,9 One miniplate with four screws or two miniplates would be better for osteosynthesis of condylar fractures if that is technically possible.9
Figure 2 Towne radiographs preoperatively (a), postoperatively (b), and after elective removal of the miniplate (c) show the anatomical reduction and uneventful healing.
260
References 1. Myall RWT. Condylar injuries in children: what is different about them? In: Worthington P, Evans JR, editors. Controversies in oral and maxillofacial surgery, vol. 17. Philadelphia: WB Saunders; 1994. p. 191—200. 2. Rowe NL. Fractures of the jaws of children. J Oral Surg 1969;27:497—507. 3. Kaban LB, Mulliken JB, Murray JE. Facial fractures in children: an analysis of 122 fractures in 109 patients. Plast Reconstr Surg 1977;59:15—20. 4. Lund K. Mandibular growth and remodeling processes after condylar fracture. A longitudinal roentgencephalometric study. Acta Odontol Scand 1974;32(Suppl):3—11. 5. Dahlstrom L, Kahnberg K-E, Lindahl L. Fifteen years followup on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18—23.
R. Schoen et al. 6. Ellis III E, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. Int J Oral Maxillofac Surg 2000;58:260—8. 7. Proffit WR, Vig KWL, Turvey TA. Early fracture of the mandibular condyles: frequently an unsuspected cause of growth disturbance. Am J Orthod 1980;78:1—24. 8. Sch¨ on R, Schramm A, Gellrich N-C, Schmelzeisen R. Follow up of condylar fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg 2003;61:49—54. 9. Sch¨ on R, Gutwald R, Schramm A, Gellrich N-C, Schmelzeisen R. Endoscopic assisted treatment of condylar fractures: extraoral versus intraoral approach. Int J Oral Maxillofac Surg 2002;31:237—43. 10. Lindahl L, Hollender L. Condylar fractures of the mandible II. A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 1977;6:12—21.
CASE REPORT
Minimally invasive open reduction of a displaced condylar fracture in a child Ralf Schoen ∗, Nils-Claudius Gellrich, Rainer Schmelzeisen Department of Oral and Maxillofacial Surgery, Universit¨ atsklinik und Poliklinik f¨ ur Mund-, Kiefer- und Gesichtschirurgie, University Clinic Freiburg, i. Br., Hugstetter Str. 55, D 79106 Freiburg, Germany Accepted 17 November 2004 Available online 3 March 2005 KEYWORDS Condylar fracture; Towne radiographs
Summary We treated successfully a severely displaced condylar fracture in a child 9 years of age by endoscopically assisted open operation. © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Fractures of the mandibular condyle are common and account for about half of all mandibular fractures in children.1,2 Because of the regenerative power of the mandibular condyle it is accepted that injuries in young children require different treatment from those sustained in late adolescence.2—4 In severely dislocated condylar and subcondylar fractures anatomical restoration is not always achieved and may result in long-term impairment of the function of the temporomandibular joint associated with abnormally shaped condylar heads, reduced height of the mandibular ramus, and growth anomalies with facial asymmetry.3—7 Superior functional results after surgical treatment of severely * Corresponding author. Tel.: +49 761 270 4940; fax: +49 761 270 4800. E-mail address: [email protected] (R. Schoen).
displaced and dislocated condylar fractures are reported in adolescent and adult patients.6,8 However, surgical or conservative treatment remains controversial as complications such as injury of the facial nerve and visible scars may complicate extraoral approaches.5,6,8,9 The risk of damage to the facial nerve is minimal and scars are not visible when a transoral endoscopically assisted technique of open reduction of condylar fractures is used.9
Case report A 9-year-old boy sustained a right subcondylar fracture that was displaced medially by 90◦ as a result of a bicycle accident. He had malocclusion with an open bite deformity on the left side as a result of shortening of the right mandibular ramus. The type of fracture, degree of displacement, and the result of reduction were recorded preoperatively
0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2004.11.005
Minimally invasive open reduction of a displaced condylar fracture in a child
259
Result
Figure 1 (a) Computed tomogram shows a 90◦ medially dislocated right condylar fracture in this child. (b) Endoscopic view after transoral reduction and insertion of a miniplate.
and postoperatively by Towne and panoramic radiographs, and a computed tomogram was taken at the referral clinic before he was admitted (Figs. 1a and 2a). During the operation the fracture was inspected by a 30◦ angled 4 mm diameter endoscope and a Xenon light source (Karl Storz, Tuttlingen, Germany). The fracture was reduced and stabilised transorally using a miniplate and an angulated drill and screw driver8 (Stryker, Leibinger, M¨ uhlheim a.d.Ruhr, Germany) (Figs. 1b and 2b). The function of the temporomandibular joint was measured by maximal incisal opening, deviation on mouth opening, degree of lateral excursion, and the presence of clicking of the temporomandibular joint, and pain 4 weeks, 6 months, and 2 years after operation. The technique of the endoscopically assisted transoral treatment of condylar fractures has been described previously.8,9
Standard postoperative radiographs verified the anatomical reduction (Fig. 2b). Six months later when the plate was removed (Fig. 2c) the bone was found to be healed. Normal occlusion and painfree function of the temporomandibular joint, without deviation or limitation of mouth opening were achieved 4 weeks, 6 months and 2 years postoperatively.
Discussion Non-operative treatment is thought to be correct for fractures of the mandibular condyle in children because of the high potential for regeneration of the growing condylar process.2,3,10,11 It is, however, suspected that fractures of the mandibular condyle may be involved in 5—10% of all severe problems of mandibular deficiency or asymmetry as a result of dysplastic growth after injury.1,4,7,10 The incidence of impaired growth is related not only to the age of the patient, but also to the degree of displacement of the condylar fracture.4,10 Dysplastic growth following condylar fractures was reported in 22% of patients who had grossly displaced condylar fractures.4 Superior functional results without damage to the facial nerve or visible scars have been reported in adults after minimally invasive transoral open treatment of displaced condylar fractures.8,9 One miniplate with four screws or two miniplates would be better for osteosynthesis of condylar fractures if that is technically possible.9
Figure 2 Towne radiographs preoperatively (a), postoperatively (b), and after elective removal of the miniplate (c) show the anatomical reduction and uneventful healing.
260
References 1. Myall RWT. Condylar injuries in children: what is different about them? In: Worthington P, Evans JR, editors. Controversies in oral and maxillofacial surgery, vol. 17. Philadelphia: WB Saunders; 1994. p. 191—200. 2. Rowe NL. Fractures of the jaws of children. J Oral Surg 1969;27:497—507. 3. Kaban LB, Mulliken JB, Murray JE. Facial fractures in children: an analysis of 122 fractures in 109 patients. Plast Reconstr Surg 1977;59:15—20. 4. Lund K. Mandibular growth and remodeling processes after condylar fracture. A longitudinal roentgencephalometric study. Acta Odontol Scand 1974;32(Suppl):3—11. 5. Dahlstrom L, Kahnberg K-E, Lindahl L. Fifteen years followup on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18—23.
R. Schoen et al. 6. Ellis III E, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. Int J Oral Maxillofac Surg 2000;58:260—8. 7. Proffit WR, Vig KWL, Turvey TA. Early fracture of the mandibular condyles: frequently an unsuspected cause of growth disturbance. Am J Orthod 1980;78:1—24. 8. Sch¨ on R, Schramm A, Gellrich N-C, Schmelzeisen R. Follow up of condylar fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg 2003;61:49—54. 9. Sch¨ on R, Gutwald R, Schramm A, Gellrich N-C, Schmelzeisen R. Endoscopic assisted treatment of condylar fractures: extraoral versus intraoral approach. Int J Oral Maxillofac Surg 2002;31:237—43. 10. Lindahl L, Hollender L. Condylar fractures of the mandible II. A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 1977;6:12—21.