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Open versus closed reduction of adult mandibular condyle fractures: an alternative interpretation of the evidence
CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART TWO J Oral Maxillofac Surg 61:1333-1339, 2003
Open Versus Closed Reduction of Adult Mandibular Condyle Fractures: An Alternative Interpretation of the Evidence Leon A. Assael, DMD* In their scholarly, evidence-based paper on the treatment of adult condylar fractures, Brandt and Haug offer information from previous historically important studies regarding outcome of treatment.1 Their review is intended to support their contention that “under similar indications and conditions, ORIF is the preferred approach” for the treatment of these injuries.1 In addition to this conclusion, the authors offer recommendations on the current optimal means of surgical access and internal fixation. The purpose of this report was to review the same studies, offer an alternative interpretation of the evidence, and further develop an understanding of the complicated mixture of factors affecting the outcome of condylar fracture treatment. The authors of the 2 papers were in the same department at the time of this writing. Thus, the debate over the proper treatment of fractures as those injuries in our patients is of continuous practical interest. Reading the same papers with an eye toward supporting a differing conclusion is an exercise the reader might find useful in his or her own thought processes regarding the best treatment plan for a given fracture.
Complications of Closed Reduction A recurring theme of Brandt and Haug1 is the demonstration of a high rate of complication and treatment failure after closed reduction. What better reason is there to offer patients open reduction than a supportable contention that closed reduction results in an unacceptable incidence of complications with *Professor, Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR. Address correspondence and reprint requests to Dr Assael: Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, 611 SW Campus Dr, SD-522, Portland, OR 97239; e-mail: [email protected] © 2003 American Association of Oral and Maxillofacial Surgeons
0278-2391/03/6111-0016$30.00/0 doi:10.1016/S0278-2391(03)00736-5
real clinical significance? Offered here is an assessment that includes evidence from a nonconcurrent control group, namely patients who have not sustained condylar fractures. These patients offer useful information on a realistic baseline of temporomandibular joint function in adults. Hence, the studies of functional derangements in closed reduction patients are compared with the studies of normal subjects. MacLennan’s2 series of 180 cases included 67 available for direct examination. Radiographic deformity is interpreted as a complication in 61% of cases and as clinical deformity in 6% of cases. These post-treatment findings are in no way complications of treatment. Patients interpret outcome based on the absence of pain, good function, and good appearance, not on the assessment of a healed fracture on a radiograph. A patient-centered approach to surgical outcome might offer a different perspective on what is a complication. As an illustration of this, the 6% incidence of clinical deformity in MacLennan’s study was puzzling, because condylar fracture patients who complained of a post-traumatic deformity are rare and are likely due to unusual sequelae such as avascular necrosis of the condylar head. MacLennan indicates that his definition of clinical deformity is “the injured side is characteristically flatter on palpation, with the condylar head less prominent.” Hence this incidence of deformity was detected by the clinician and not necessarily perceived by the patient. The facial projection of the lateral pole of the condyle is not normally considered an aesthetic reference point. Nearly all patients are aware of the visible deformity of a facial scar but not of decreased prominence of the lateral pole of the condyle. Temporalis or masseteric atrophy may highlight the position of the condyle, but these events are usually the result of open reduction. Patients perceive scars above all else. As the common aphorism states, “There is no scar, like no scar.” A more difficult to evaluate complication in MacLennan’s series is the 24% incidence of deviation noted in his series of examined patients.2 Because the
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detection of deviation depends on the criteria used to define it, comparison with a control group would be helpful in understanding the extent to which condylar fracture treatment played a role in the incidence of deviation. Serendipitously, MacLennan had such a group. Forty-nine patients with tuberculosis were examined who had no known temporomandibular disorder. Twenty-nine of 49 (58%) showed what MacLennan referred to as “textbook deviation.” As for the 2 patients with chronic pain, 1 had panfacial injuries and the other had legal action pending. Careful inspection of MacLennan’s paper, a much-cited series supporting nonsurgical management of condylar fractures, indeed does much to continue to support the view that the surgeon can expect a low incidence of true complications with that treatment strategy. Recently, Ellis and Throckmorton3 evaluated facial symmetry after closed and open reduction of condylar fractures. Using Towne’s and panoramic radiographs, but not clinical examination, posterior facial height was measured from an orbital reference point to gonion. In the 2 years of the study, the mean shortening of ramus height in the closed reduction group was only between 2 and 5 mm. Ramus height remained stable in the open reduction group. If one also accounts for radiographic magnification, it is clear that the changes were not clinically significant and that most of the patients undergoing closed reduction were well served by that method of treatment. Indeed Ellis and Throckmorton noted that the minimal loss of ramus height was a favorable adaptation permitting a new temporomandibular articulation (a neoarthrosis). Blevins and Gores4 reported on 90 condyle fracture patients who answered a questionnaire and 45 patients who appeared for examination an average of 5.8 years postinjury. Although Brandt and Haug concentrate on the spectrum of outcome as measured by the clinician over the treatment period in all 140 patients, it is more useful to concentrate on the 90 patients who were available for long-term follow-up and could offer their own, patient-centered views of the results of their conservative therapy.1 Many of these 90 patients also had additional facial fractures. This very long-term follow-up study is of special significance because both the patient perception and objective information are available. Although the mean interincisal opening was 34 mm, only 15% of patient reported inability to open and close normally and only 11% reported any jaw pain. Only 13% reported any difficulty in chewing. Objective interincisal opening was diminished, but only 13% of the patients reported diminished jaw movement.4 Of critical importance in interpreting this information is that the incidence of these problems does not differ from baseline epidemiologic studies of tem-
poromandibular disorders in nonpatient normal adult populations.5 Pain, deviation, other jaw excursion problems, and joint noise are common findings in all adults. For example, Pullinger et al6 reported on the temporomandibular findings in dental students of whom 29% had joint noise and 14% had pain. Because individuals who have never had a condyle fracture report such a high incidence of ostensibly abnormal temporomandibular joint findings, a suitable control group of uninjured patients to assess the outcome of condylar fracture treatment is necessary before any conclusions regarding the efficacy of treatment can be made. Regarding the condyle fracture populations in case series without control groups, Blevins and Gores4 found that 37 of 49 patients examined did not have a single clinical finding that showed they had a condylar process fracture; there was no deviation, deformity, or pain in these 37 patients. Certainly, had 49 patients received open reduction, all 49 would show physical findings related to treatment. Silvennoinen et al7 attempted to define those cases of condylar fracture at risk for post-treatment problems. Brandt and Haug1 contend that this report is another indication that closed reduction of condylar fractures is not a good technique because malocclusion was noted in 13% of patients and other complications of treatment were noted. However, the Silvennoinen group, on the contrary, was attempting to identify those patients who could properly be treated without open reduction surgical intervention.7 They appear to have successfully supported their conclusion that “problematic condylar fractures can often be identified preoperatively.”7 The patients whom they concluded could benefit from open reduction were a small subset of those with significant reduction of ramus height. A functional reduction of ramus height can be detected clinically through significant ipsilateral molar occlusal interference, through the inability to obtain maximum intercuspation, and through the radiographic finding of significant superior displacement of gonion. It is the subset of condylar fracture patients who have significantly functionally shortened ramus heights that likely benefit most from open reduction. Silvennoinen et al showed this on pretreatment examination, when 54% of their condylar fracture patients were able to bring their teeth into normal occlusion and these patients were treated successfully without surgery and without intermaxillary fixation. Only 9% of their patients with condylar fractures showed severe derangements in occlusion and excursions at the time of pretreatment examination. Nearly all of the patients with postoperative problems come from the group of patients whose injuries showed severe functional derangements before treatment.
LEON A. ASSAEL
The legitimate message of the Silvennoinen et al article is that there is a small (perhaps 10%) subset of condylar fracture patients with severe preoperative functional derangements, which can be identified before treatment, who will benefit from open reduction. Their investigation does not support blanket surgical treatment for the nearly 9 of 10 patients who recovered uneventfully with nonsurgical therapy. Although surgeons attempt to provide objective criteria to assess surgical outcome, patients are more inclined to value self-assessment as the sine quo non of the results of treatment. Although this consumerdriven approach to health care is now a standard assessment tool, the Chalmers J. Lyons Club were prescient in their 1947 study that used patient selfassessment as essential to their review of 120 patients.8 They found that none of the patients reported pain from their condylar fractures on postoperative assessment. Of 7 functional disturbances reported by patients, only 4 were found to be significant on physical evaluation.
Classification of Condylar Fractures as a Guide to Treatment Selection The primary issue is not whether closed reduction of adult mandibular condyle fractures can be done safely and with minimal subsequent morbidity. It is certain that open reduction has advanced considerably with experience and technology to permit improved minimally invasive techniques that result in undisturbed healing in most cases. For example, Troulis and Kaban9 recently showed effective open reduction with endoscopically assisted minimal invasive surgical technique. As these techniques become less morbid and more cost effective, it is certain that the indications for open reduction can and should grow. If, for example, the risk of nerve VII injury, postoperative infection, and avascular necrosis of the condylar head can be brought to nearly zero, the costbenefit ratio can favor open reduction for cases in which the clinical gain is real but modest in impact. For the present time the central question remains, “What are the current indications for selecting from the range of treatment available for these injuries?” While Brandt and Haug wisely look at classification systems for condylar fracture assessment that might offer insight into which fractures might be treated best with open reduction, a usable classification system must be responsive to the contemporary treatment options available to the surgeon. The various condylar fracture classifications of Brophy,10 Thoma,11 Rowe and Killey,12 and Dingman and Natvig13 relied on anatomic findings, usually found on radiography, not the functional assessment of the patient. While Zide and Kent14 first outlined the indi-
1335 cations for open reduction of mandibular condyle fractures, they did so in an era before stable fixation (followed by immediate function) of these fractures could be obtained. Open reduction of mandibular condyle fractures became available as a reasonable treatment choice only with the advent of miniplate fixation. Prior attempts with wire fixation commonly resulted in the loss of position of the condylar segment. Thus, a contemporary attempt to assess those fractures that would be best treated with open reduction should rely on only those case series with patients treated with stable internal fixation. It is of little value to know what the anatomic findings of a fracture are without the ability to provide meaningful comparison of treatment outcomes. Hence, these anatomic classifications are of little contemporary clinical value. Contemporary surgeons are developing indications for surgery based on emerging technology. Complications of surgery remain a central issue in treatment method selection. Preauricular, postauricular, retromandibular, transoral, and Risdon incisions all place both cranial nerve V and VII at only small risk for injury.15 Although marginal branch of cranial nerve VII is the most common injury, temporal ramus and zygomatic branch deficits also occur. Ellis et al16 reported 17.2% of open reduction patients with temporary facial nerve weakness and 7.5% with hypertrophic scars, when surgery was performed via a retromandibular approach. Hyde et al17 reported a 12% incidence of temporary facial nerve injury and none had malocclusion or pain. Devlin et al18 reported that of 40 patients undergoing open reduction via a retromandibular approach, 3 had persistent facial nerve weakness, 2 had poor reduction, and 1 had a hypertrophic scar. However, Schon et al19 reported no scars, no nerve VII derangements, and no functional disturbances 18 months after open reduction and plate fixation via endoscopic technique. It is worth noting that even with such exceptional outcomes, the cases selected by Schon et al included patients with dislocated fracture and those with additional facial fractures for whom the benefit of open reduction seemed clear. It is clear that emerging technology and the growth in surgical experience have expanded the indications of open reduction of condylar fractures.20 The increased frequency of open reduction has occurred without a further understanding of the benefits of such treatment. Assessment of the variables that influence the outcome of condylar fracture treatment illustrates the futility of seeking any incontrovertible answers regarding the global optimal management of condylar fractures. A careful assessment of these factors leaves the certain conclusion that a va-
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riety of reasonable choices remain for the treatment of a given fracture.
Assessment of Variables Affecting Condylar Fracture Treatment Selection and Outcome To consider the components of contemporary, meaningful condylar fracture treatment decisions, consideration of the each of the variables that affect outcome in condylar fractures is necessary. These important variables are so complex and intertwined as to make a usable classification (with specific evidence-based treatment recommendations for each subtype) unachievable. Each of these variables has been reported by various authors and surgeons as meaningful in predicting condylar fracture outcome. Hence, it is left to the clinician to evaluate each of these variables and make an individual decision regarding the best treatment for a given patient with a condylar fracture. The weight to be given to any of these variables in making a clinical decision regarding the need for surgery must remain an empirical art. These variables are as follows: 1. Patient age: Growing patients are known to have altered outcomes when compared to adults after condylar fracture. Lindahl and Hollender,21,22 in a series of articles, showed that children up to age 11 underwent considerable more adaptation and remodeling than teenagers or adults. Understanding the effect of treatment in elderly patients has remained empirical. 2. Patient gender: Females may sustain more functional derangement after condylar fractures, and this effect may not be altered by the mode of treatment. Idiopathic condylar resorption, disc displacement with symptoms, and arthralgia are all more common in females. 3. Systemic diseases: Osteoporosis, osteopetrosis, diabetes mellitus, other endocrine disorders, renal failure, alcoholism, drug and tobacco use, and other systemic conditions too numerous to mention are know to affect fracture treatment outcome. Risk of ankylosis after treatment may also be increased with an assortment of genetic and disease acquired influences. The presence of a particular systemic disease might mitigate toward or away from treatment with open reduction. 4. Patient compliance: Since Walker23 described the techniques for functional rehabilitation after condylar fracture, the issue of patient compliance to obtain favorable treatment outcome has been well known. Poor patient
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compliance after condylar fracture treatment is well known and documented. For example, Mitchell24 reported that only 73 of 142 patients with condylar fractures returned for both their 6- and 12-week post-treatment visits. While closed reduction patients require functional exercises to support the retention of functional occlusion and mandibular movement, surgical patients must also be compliant regarding diet and function. Risk of infection: The risk of infection after open treatment is small but always greater than with closed reduction.25 Delayed surgery, compromised host, extended hospitalization, and patients with multiple injuries are some of the factors known to increase the risk of infection. Risk of nerve injury: The risk of facial and trigeminal nerve injury may not be the same in all cases. Prolonged traction on the operative site, experience of the surgeon, postinjury edema, and other factors causing difficult wound access such as obesity might increase the risk of nerve injury. Risk for scarring: Patients have varied risk for scarring based on race, age, and gender. Haug and Assael26 reported that the most significant difference between the surgical and nonsurgical patient on postoperative self-assessment by the patient was the perception of scarring. Risk for chronic pain: Investigations into chronic pain indicate that risk factors exist for those patients who might be at higher risk for chronic pain. An emerging trend in the comparison of open and closed reduction patients is the contention that fewer open reduction patients present with chronic pain in the injured condyle. In one of the best long-term studies, Umstadt et al27 used the Helkimo index to determine that the open reduction group showed superior pain-free activity of the injured site at an average of nearly 4 years after treatment. The incidence of chronic pain was small in both groups, however. Comminution: Comminution of the condylar head or neck can make the achievement of stable internal fixation problematic and might increase the risk of ankylosis after surgical management. Assessment of condylar fractures with computed tomography has improved the preoperative assessment of comminution. The risk of fixation failure in such cases might also increase the risk of infection.28 Hemarthrosis: Hemarthrosis is probably a universal finding in condylar fractures, but it can achieve clinical significance in selected cases where the condyle is inferiorly displaced
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by the accumulation of blood or where the clot organizes and results in fibroankylosis. Piper and Chuong29 were the first to report arthroscopic intervention for lavage in association with open reduction, but this has not become routine in subsequent large case series. Disc injury: Open reduction does not address the function of the disc or other articulating ligaments of the joint. In separate reports, both Choi et al30 and Neff et al31 found that about 20% of open reduction patients have functional displacement of the disc on postoperative MRI. The clinical importance of these findings in open reduction patients compared with closed reduction patients remains to be completely explored. Osteoarthrosis and bone resorption: External auditory canal or penetrating wound, compound fracture, systemic predilection, and loss of perfusion to the proximal segment are known to cause late arthritides. Iizuka et al32 reported the universal finding of osteoarthrosis in all joints treated with open reduction in 13 cases at 18 months after treatment. The problem was of clinical significance in only 1 patient, however. Associated mandible fractures: Associated mandible fractures, particularly those of the symphysis, may cause flaring malposition of the distal segment when treated closed. Open reduction of both fractures is often needed to obtain functional anatomic position. Associated midface fractures: Restoration of the dimensions of the face in panfacial fractures requires the correction of posterior facial height and projection. Open reduction of condyle fractures is indicated in such cases.33 Associated cranial base fracture: Displacement of the condyle into the middle cranial fossa is considered a good indication for open reduction in patients whose overall status permits surgical treatment.34 Edentulism, partial or full: Although status of the dentition is known to be an essential component of condyle fracture outcome, little has been done to comparatively assess outcomes based on the status of the dentition. Empirically it is known that the posterior dentition plays a role in maintenance of ramus height, so that patients without “posterior occlusal stops” lose greater ramus height. Balancing side interferences during excursion away from the side of fracture may result in greater occlusal trauma when there is a partial loss of dentition. Dentofacial classification: Angle Class II pa-
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tients, especially those with a high mandibular plane angle, are more prone to open bite and further retrognathia after closed treatment. Other dental function and occlusion considerations: The depth of occlusal contacts in maximum intercuspation, and working/balancing occlusal contacts are known to play a role in the functional dental outcome of treatment. The ability to achieve maximum intercuspation during the postinjury examination is more often a result of the status of the dentition than the anatomic exigencies of the fracture. For example, a patient with a very flat occlusal plane will easily show an open bite and occlusal interferences during function. These may be very difficult to manage with closed reduction, whereas imprecise open reduction might create similar problems. Findings on lateral excursion and protrusion and interincisal opening in the postinjury evaluation might offer clues as to the best methods of treatment and rehabilitation Location of condylar fracture (low, medium, high) and displacement of proximal (condylar) segment: Very low fractures in patients with good dentition are known to often nicely self-reduce after closed reduction, whereas fractures of the condylar neck often cause loss of vertical dimension with anterior, medial, and inferior displacement of the condylar head. Clenching and bruxism: The presence of clenching and bruxism will have a profound impact on treatment outcome regardless of method selected. In the open reduction patient, the risk of fixation failure is increased. The wear on the occlusal surfaces of teeth makes maintenance of the occlusion problematic when closed reduction is selected. Functionally shortened ramus: A functionally shortened ramus differs from anatomic shortening. The anatomically shortened ramus is measurable on radiograph or clinically indicated a decreased distance from condyle to gonion. Because of the slope of the articular eminence as well as the functional adaptability of the associated structures, many such patients do not exhibit functional derangements in mastication or occlusion, such as a functionally shortened ramus. Patients with functional derangements due to a shortened ramus have an important indication for open reduction. Findings of ipsilateral persistent occlusal prematurity, inability to achieve maximum intercuspation, and inability to achieve contralateral
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occlusal working side contacts are some findings indicating a functionally shortened ramus. Patient expectations: The patient’s assessment of the benefits, risks, and alternatives of proposed therapy might differ from the surgeon’s perspective. Informing the patient to the best extent that circumstances allow will have a better chance of producing an outcome that will meet the patient’s desires. Ability of the surgeon: Experienced surgeons who undergo objective training and evaluation are more able to successfully perform open treatment of fractures.35,36 Where more than 1 treatment will result in a good outcome in general, it is wise to consider what has worked best in a particular patient care setting. Technology of the health care environment: Emerging technology will continue to alter the landscape of clinical decision making for condylar fractures. Minimally invasive surgery, navigation, and tissue engineering will affect the indications for surgery in the future. Institutional resources: Trauma care is a highly specialized and resource intense endeavor that depends on the ability of the health care environment to provide preoperative evaluation and intraoperative and postoperative care. The continued ability to effectively provide these demanding services has come into question in many centers.37 Willing payer: The emergence of managed care has affected the use of procedures as disparate as coronary artery bypass graft surgery and cholecystectomy. Justification for treatment of condylar fractures is dependent on the evidence amassed to support the proposed therapy.
A Reasoned Decision A careful assessment of the literature and the experiences of surgeons indicates that both open reduction and closed treatment of condyle fractures of the mandible have a deserved role in the treatment of these patients. Acceptable outcomes that permit full, pain-free function, with good aesthetics, have been amply shown with both techniques. Malocclusion, masticatory functional deficits, and internal derangement are pointed to as problems with one or the other treatment, yet they occur in both surgical and nonsurgical patients. The relative incidence of these complications remains a subject for continued investigation. However, there are several complications that remain reserved for those patients treated surgically. Although the incidence of each of these complications is small, in the aggregate they constitute a
considerable burden for the patients who undergo open reduction and internal fixation of condylar fractures. Those problems must be balanced against the advantages that can only be obtained with surgical treatment. Assessment of factors peculiar to the individual case must be made to determine the mode of therapy most likely to produce a favorable outcome. The mixture and relative role of each of these factors are evaluated individually by each surgeon for each patient. Hence, treatment selection for mandible condyle fractures remains an evidence-based art.
References 1. Brandt MT, Haug RH: Open versus closed reduction of adult mandibular condyle fractures: A review of the literature regarding the evolution of current thoughts on management. J Oral Maxillofac Surg 61:1324, 2003 2. MacLennan W: Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 5:122, 1952 3. Ellis E, Throckmorton G: Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 58:719, 2000 4. Blevins C, Gores R: Fractures of the mandibular condyloid process: Results of conservative treatment in 140 patients. J Oral Surg 19:28, 1961 5. Burakoff R: Epidemiology, in Kaplan A, Assael L (eds): Temporomandibular Disorders, Diagnosis and Treatment. Philadelphia, PA, Saunders, 1991, pp 95-103 6. Pullinger A, Seligman D, Solberg K: Temporomandibular disorders, Part 1: Functional status, dentomorphic features and sex differences in a nonpatient population. J Prosthet Dent 55:228, 1985 7. Silvennoinen U, Iizuka T, Oikarinen K, et al: Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. J Oral Maxillofac Surg 52:793, 1994 8. Goodsell J: Fractures involving the mandibular condyle: A posttreatment survey of 120 cases. J Oral Surg 5:45, 1947 9. Troulis MJ, Kaban LB: Endoscopic approach to the ramus/ condyle unit: Clinical applications. J Oral Maxillofac Surg 59: 503, 2001 10. Brophy TW: Oral Surgery: A Treatise on the Diseases, Injuries and Malformations of the Mouth and Associated Parts. Philadelphia, PA, B Blakiston’s Sons and Co, 1915, p 406 11. Thoma K: Oral Pathology: A Histological Roentgenological and Clinical Study of the Diseases of the Teeth, Jaws, and Mouth. St Louis, MO, CV Mosby, 1941, p 787 12. Rowe N, Killey H: Fractures of the Facial Skeleton (ed 2). Edinburgh, UK, E & S Livingstone Ltd, 1968, p 143 13. Dingman R, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, p 177 14. Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 15. Raveh J, Ladrach K, Vuillemin T, et al: Indication for open reduction of the dislocated, fracture condylar process, in Worthington P, Evans J (eds): Controversies in Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 1994, pp 173-190 16. Ellis E, McFadden D, Simon P, et al: Surgical complication with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 58:950, 2001 17. Hyde N, Manisali M, Aghabeigi B, et al: The role of open reduction and internal fixation in unilateral fractures of the mandibular condyle: A prospective study. Br J Oral Maxillofac Surg 40:19, 2002 18. Devlin MF, Hislop WS, Carton AT: Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: Surgical morbidity and informed consent. Br J Oral Maxillofac Surg 40:23, 2002
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LEON A. ASSAEL 19. Schon R, Schramm A, Gellrich NC, et al: Follow-up of condylar fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg 61:49, 2003 20. De Riu G, Gamba U, Anghinoni M, et al: A comparison of open and closed treatment of condylar fractures: A change in philosophy. Int J Oral Maxillofac Surg 30:384, 2000 21. 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 6:12, 1977 22. Lindahl L, Hollender L: Condyle fracture of the mandible: A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:153, 1977 23. Walker R: The consultant. J Oral Surg 24:367, 1966 24. Mitchell D: A multicentre audit of unilateral fractures of the mandibular condyle. Br J Oral Maxillofac Surg 35:230, 1997 25. Kent J, Neary J, Silvia C, et al: Open reduction of mandibular condyle fractures. Oral Maxillofac Clin North Am 2:69, 1990 26. Haug R, Assael L: Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 59: 370, 2001 27. Umstadt HE, Ellers M, Muller HH, et al: Functional reconstruction of the TM joint in cases of severely displaced fractures and fracture dislocation. J Craniomaxillofac Surg 28:97, 2000 28. Sugiura T, Yamamoto K, Murakami K, et al: A comparative evaluation of osteosynthesis with lag screws, miniplates, or
29. 30. 31.
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Kirschner wires for mandibular condylar process fractures. J Oral Maxillofac Surg 59:1161, 2001 Piper M, Chuong R: Open reduction of condylar fractions of the mandible in conjunction with repair of discal injury: A preliminary report. J Oral Maxillofac Surg 46:257, 1988 Choi BH, Yi CK, Yoo JH: MRI examination of the TMJ after surgical treatment of condylar fractures. Int J Oral Maxillofac Surg 30:296, 2001 Neff A, Kolk A, Horch HH: Position and mobility of the articular disk after surgical management of diacapitular and high condylar dislocation fractures of the temporomandibular joint. Mund Kiefer Gesichtschir 4:111, 2000 Iizuka T, Lindqvist C, Hallikainen D, et al: Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures. A clinical and radiologic study of thirteen patients. Oral Surg Oral Med Oral Pathol 72:400, 1991 Assael L: Considerations in rigid internal fixation of midface trauma. Oral Maxillofac Surg Clin North Am 2:103, 1990 Zide M, Kent J: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 Assael L: Evaluation of rigid internal fixation of mandible fractures performed in the teaching laboratory. J Oral Maxillofac Surg 51:1315, 1993 Assael L: Assisting the deficient resident in oral and maxillofacial surgery. J Oral Maxillofac Surg 45:1058, 1987 Assael L: A devotion to trauma. J Oral Maxillofac Surg 61:415, 2003
Open Versus Closed Reduction of Adult Mandibular Condyle Fractures: An Alternative Interpretation of the Evidence Leon A. Assael, DMD* In their scholarly, evidence-based paper on the treatment of adult condylar fractures, Brandt and Haug offer information from previous historically important studies regarding outcome of treatment.1 Their review is intended to support their contention that “under similar indications and conditions, ORIF is the preferred approach” for the treatment of these injuries.1 In addition to this conclusion, the authors offer recommendations on the current optimal means of surgical access and internal fixation. The purpose of this report was to review the same studies, offer an alternative interpretation of the evidence, and further develop an understanding of the complicated mixture of factors affecting the outcome of condylar fracture treatment. The authors of the 2 papers were in the same department at the time of this writing. Thus, the debate over the proper treatment of fractures as those injuries in our patients is of continuous practical interest. Reading the same papers with an eye toward supporting a differing conclusion is an exercise the reader might find useful in his or her own thought processes regarding the best treatment plan for a given fracture.
Complications of Closed Reduction A recurring theme of Brandt and Haug1 is the demonstration of a high rate of complication and treatment failure after closed reduction. What better reason is there to offer patients open reduction than a supportable contention that closed reduction results in an unacceptable incidence of complications with *Professor, Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, OR. Address correspondence and reprint requests to Dr Assael: Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, 611 SW Campus Dr, SD-522, Portland, OR 97239; e-mail: [email protected] © 2003 American Association of Oral and Maxillofacial Surgeons
0278-2391/03/6111-0016$30.00/0 doi:10.1016/S0278-2391(03)00736-5
real clinical significance? Offered here is an assessment that includes evidence from a nonconcurrent control group, namely patients who have not sustained condylar fractures. These patients offer useful information on a realistic baseline of temporomandibular joint function in adults. Hence, the studies of functional derangements in closed reduction patients are compared with the studies of normal subjects. MacLennan’s2 series of 180 cases included 67 available for direct examination. Radiographic deformity is interpreted as a complication in 61% of cases and as clinical deformity in 6% of cases. These post-treatment findings are in no way complications of treatment. Patients interpret outcome based on the absence of pain, good function, and good appearance, not on the assessment of a healed fracture on a radiograph. A patient-centered approach to surgical outcome might offer a different perspective on what is a complication. As an illustration of this, the 6% incidence of clinical deformity in MacLennan’s study was puzzling, because condylar fracture patients who complained of a post-traumatic deformity are rare and are likely due to unusual sequelae such as avascular necrosis of the condylar head. MacLennan indicates that his definition of clinical deformity is “the injured side is characteristically flatter on palpation, with the condylar head less prominent.” Hence this incidence of deformity was detected by the clinician and not necessarily perceived by the patient. The facial projection of the lateral pole of the condyle is not normally considered an aesthetic reference point. Nearly all patients are aware of the visible deformity of a facial scar but not of decreased prominence of the lateral pole of the condyle. Temporalis or masseteric atrophy may highlight the position of the condyle, but these events are usually the result of open reduction. Patients perceive scars above all else. As the common aphorism states, “There is no scar, like no scar.” A more difficult to evaluate complication in MacLennan’s series is the 24% incidence of deviation noted in his series of examined patients.2 Because the
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detection of deviation depends on the criteria used to define it, comparison with a control group would be helpful in understanding the extent to which condylar fracture treatment played a role in the incidence of deviation. Serendipitously, MacLennan had such a group. Forty-nine patients with tuberculosis were examined who had no known temporomandibular disorder. Twenty-nine of 49 (58%) showed what MacLennan referred to as “textbook deviation.” As for the 2 patients with chronic pain, 1 had panfacial injuries and the other had legal action pending. Careful inspection of MacLennan’s paper, a much-cited series supporting nonsurgical management of condylar fractures, indeed does much to continue to support the view that the surgeon can expect a low incidence of true complications with that treatment strategy. Recently, Ellis and Throckmorton3 evaluated facial symmetry after closed and open reduction of condylar fractures. Using Towne’s and panoramic radiographs, but not clinical examination, posterior facial height was measured from an orbital reference point to gonion. In the 2 years of the study, the mean shortening of ramus height in the closed reduction group was only between 2 and 5 mm. Ramus height remained stable in the open reduction group. If one also accounts for radiographic magnification, it is clear that the changes were not clinically significant and that most of the patients undergoing closed reduction were well served by that method of treatment. Indeed Ellis and Throckmorton noted that the minimal loss of ramus height was a favorable adaptation permitting a new temporomandibular articulation (a neoarthrosis). Blevins and Gores4 reported on 90 condyle fracture patients who answered a questionnaire and 45 patients who appeared for examination an average of 5.8 years postinjury. Although Brandt and Haug concentrate on the spectrum of outcome as measured by the clinician over the treatment period in all 140 patients, it is more useful to concentrate on the 90 patients who were available for long-term follow-up and could offer their own, patient-centered views of the results of their conservative therapy.1 Many of these 90 patients also had additional facial fractures. This very long-term follow-up study is of special significance because both the patient perception and objective information are available. Although the mean interincisal opening was 34 mm, only 15% of patient reported inability to open and close normally and only 11% reported any jaw pain. Only 13% reported any difficulty in chewing. Objective interincisal opening was diminished, but only 13% of the patients reported diminished jaw movement.4 Of critical importance in interpreting this information is that the incidence of these problems does not differ from baseline epidemiologic studies of tem-
poromandibular disorders in nonpatient normal adult populations.5 Pain, deviation, other jaw excursion problems, and joint noise are common findings in all adults. For example, Pullinger et al6 reported on the temporomandibular findings in dental students of whom 29% had joint noise and 14% had pain. Because individuals who have never had a condyle fracture report such a high incidence of ostensibly abnormal temporomandibular joint findings, a suitable control group of uninjured patients to assess the outcome of condylar fracture treatment is necessary before any conclusions regarding the efficacy of treatment can be made. Regarding the condyle fracture populations in case series without control groups, Blevins and Gores4 found that 37 of 49 patients examined did not have a single clinical finding that showed they had a condylar process fracture; there was no deviation, deformity, or pain in these 37 patients. Certainly, had 49 patients received open reduction, all 49 would show physical findings related to treatment. Silvennoinen et al7 attempted to define those cases of condylar fracture at risk for post-treatment problems. Brandt and Haug1 contend that this report is another indication that closed reduction of condylar fractures is not a good technique because malocclusion was noted in 13% of patients and other complications of treatment were noted. However, the Silvennoinen group, on the contrary, was attempting to identify those patients who could properly be treated without open reduction surgical intervention.7 They appear to have successfully supported their conclusion that “problematic condylar fractures can often be identified preoperatively.”7 The patients whom they concluded could benefit from open reduction were a small subset of those with significant reduction of ramus height. A functional reduction of ramus height can be detected clinically through significant ipsilateral molar occlusal interference, through the inability to obtain maximum intercuspation, and through the radiographic finding of significant superior displacement of gonion. It is the subset of condylar fracture patients who have significantly functionally shortened ramus heights that likely benefit most from open reduction. Silvennoinen et al showed this on pretreatment examination, when 54% of their condylar fracture patients were able to bring their teeth into normal occlusion and these patients were treated successfully without surgery and without intermaxillary fixation. Only 9% of their patients with condylar fractures showed severe derangements in occlusion and excursions at the time of pretreatment examination. Nearly all of the patients with postoperative problems come from the group of patients whose injuries showed severe functional derangements before treatment.
LEON A. ASSAEL
The legitimate message of the Silvennoinen et al article is that there is a small (perhaps 10%) subset of condylar fracture patients with severe preoperative functional derangements, which can be identified before treatment, who will benefit from open reduction. Their investigation does not support blanket surgical treatment for the nearly 9 of 10 patients who recovered uneventfully with nonsurgical therapy. Although surgeons attempt to provide objective criteria to assess surgical outcome, patients are more inclined to value self-assessment as the sine quo non of the results of treatment. Although this consumerdriven approach to health care is now a standard assessment tool, the Chalmers J. Lyons Club were prescient in their 1947 study that used patient selfassessment as essential to their review of 120 patients.8 They found that none of the patients reported pain from their condylar fractures on postoperative assessment. Of 7 functional disturbances reported by patients, only 4 were found to be significant on physical evaluation.
Classification of Condylar Fractures as a Guide to Treatment Selection The primary issue is not whether closed reduction of adult mandibular condyle fractures can be done safely and with minimal subsequent morbidity. It is certain that open reduction has advanced considerably with experience and technology to permit improved minimally invasive techniques that result in undisturbed healing in most cases. For example, Troulis and Kaban9 recently showed effective open reduction with endoscopically assisted minimal invasive surgical technique. As these techniques become less morbid and more cost effective, it is certain that the indications for open reduction can and should grow. If, for example, the risk of nerve VII injury, postoperative infection, and avascular necrosis of the condylar head can be brought to nearly zero, the costbenefit ratio can favor open reduction for cases in which the clinical gain is real but modest in impact. For the present time the central question remains, “What are the current indications for selecting from the range of treatment available for these injuries?” While Brandt and Haug wisely look at classification systems for condylar fracture assessment that might offer insight into which fractures might be treated best with open reduction, a usable classification system must be responsive to the contemporary treatment options available to the surgeon. The various condylar fracture classifications of Brophy,10 Thoma,11 Rowe and Killey,12 and Dingman and Natvig13 relied on anatomic findings, usually found on radiography, not the functional assessment of the patient. While Zide and Kent14 first outlined the indi-
1335 cations for open reduction of mandibular condyle fractures, they did so in an era before stable fixation (followed by immediate function) of these fractures could be obtained. Open reduction of mandibular condyle fractures became available as a reasonable treatment choice only with the advent of miniplate fixation. Prior attempts with wire fixation commonly resulted in the loss of position of the condylar segment. Thus, a contemporary attempt to assess those fractures that would be best treated with open reduction should rely on only those case series with patients treated with stable internal fixation. It is of little value to know what the anatomic findings of a fracture are without the ability to provide meaningful comparison of treatment outcomes. Hence, these anatomic classifications are of little contemporary clinical value. Contemporary surgeons are developing indications for surgery based on emerging technology. Complications of surgery remain a central issue in treatment method selection. Preauricular, postauricular, retromandibular, transoral, and Risdon incisions all place both cranial nerve V and VII at only small risk for injury.15 Although marginal branch of cranial nerve VII is the most common injury, temporal ramus and zygomatic branch deficits also occur. Ellis et al16 reported 17.2% of open reduction patients with temporary facial nerve weakness and 7.5% with hypertrophic scars, when surgery was performed via a retromandibular approach. Hyde et al17 reported a 12% incidence of temporary facial nerve injury and none had malocclusion or pain. Devlin et al18 reported that of 40 patients undergoing open reduction via a retromandibular approach, 3 had persistent facial nerve weakness, 2 had poor reduction, and 1 had a hypertrophic scar. However, Schon et al19 reported no scars, no nerve VII derangements, and no functional disturbances 18 months after open reduction and plate fixation via endoscopic technique. It is worth noting that even with such exceptional outcomes, the cases selected by Schon et al included patients with dislocated fracture and those with additional facial fractures for whom the benefit of open reduction seemed clear. It is clear that emerging technology and the growth in surgical experience have expanded the indications of open reduction of condylar fractures.20 The increased frequency of open reduction has occurred without a further understanding of the benefits of such treatment. Assessment of the variables that influence the outcome of condylar fracture treatment illustrates the futility of seeking any incontrovertible answers regarding the global optimal management of condylar fractures. A careful assessment of these factors leaves the certain conclusion that a va-
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riety of reasonable choices remain for the treatment of a given fracture.
Assessment of Variables Affecting Condylar Fracture Treatment Selection and Outcome To consider the components of contemporary, meaningful condylar fracture treatment decisions, consideration of the each of the variables that affect outcome in condylar fractures is necessary. These important variables are so complex and intertwined as to make a usable classification (with specific evidence-based treatment recommendations for each subtype) unachievable. Each of these variables has been reported by various authors and surgeons as meaningful in predicting condylar fracture outcome. Hence, it is left to the clinician to evaluate each of these variables and make an individual decision regarding the best treatment for a given patient with a condylar fracture. The weight to be given to any of these variables in making a clinical decision regarding the need for surgery must remain an empirical art. These variables are as follows: 1. Patient age: Growing patients are known to have altered outcomes when compared to adults after condylar fracture. Lindahl and Hollender,21,22 in a series of articles, showed that children up to age 11 underwent considerable more adaptation and remodeling than teenagers or adults. Understanding the effect of treatment in elderly patients has remained empirical. 2. Patient gender: Females may sustain more functional derangement after condylar fractures, and this effect may not be altered by the mode of treatment. Idiopathic condylar resorption, disc displacement with symptoms, and arthralgia are all more common in females. 3. Systemic diseases: Osteoporosis, osteopetrosis, diabetes mellitus, other endocrine disorders, renal failure, alcoholism, drug and tobacco use, and other systemic conditions too numerous to mention are know to affect fracture treatment outcome. Risk of ankylosis after treatment may also be increased with an assortment of genetic and disease acquired influences. The presence of a particular systemic disease might mitigate toward or away from treatment with open reduction. 4. Patient compliance: Since Walker23 described the techniques for functional rehabilitation after condylar fracture, the issue of patient compliance to obtain favorable treatment outcome has been well known. Poor patient
5.
6.
7.
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compliance after condylar fracture treatment is well known and documented. For example, Mitchell24 reported that only 73 of 142 patients with condylar fractures returned for both their 6- and 12-week post-treatment visits. While closed reduction patients require functional exercises to support the retention of functional occlusion and mandibular movement, surgical patients must also be compliant regarding diet and function. Risk of infection: The risk of infection after open treatment is small but always greater than with closed reduction.25 Delayed surgery, compromised host, extended hospitalization, and patients with multiple injuries are some of the factors known to increase the risk of infection. Risk of nerve injury: The risk of facial and trigeminal nerve injury may not be the same in all cases. Prolonged traction on the operative site, experience of the surgeon, postinjury edema, and other factors causing difficult wound access such as obesity might increase the risk of nerve injury. Risk for scarring: Patients have varied risk for scarring based on race, age, and gender. Haug and Assael26 reported that the most significant difference between the surgical and nonsurgical patient on postoperative self-assessment by the patient was the perception of scarring. Risk for chronic pain: Investigations into chronic pain indicate that risk factors exist for those patients who might be at higher risk for chronic pain. An emerging trend in the comparison of open and closed reduction patients is the contention that fewer open reduction patients present with chronic pain in the injured condyle. In one of the best long-term studies, Umstadt et al27 used the Helkimo index to determine that the open reduction group showed superior pain-free activity of the injured site at an average of nearly 4 years after treatment. The incidence of chronic pain was small in both groups, however. Comminution: Comminution of the condylar head or neck can make the achievement of stable internal fixation problematic and might increase the risk of ankylosis after surgical management. Assessment of condylar fractures with computed tomography has improved the preoperative assessment of comminution. The risk of fixation failure in such cases might also increase the risk of infection.28 Hemarthrosis: Hemarthrosis is probably a universal finding in condylar fractures, but it can achieve clinical significance in selected cases where the condyle is inferiorly displaced
1337
LEON A. ASSAEL
11.
12.
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14.
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by the accumulation of blood or where the clot organizes and results in fibroankylosis. Piper and Chuong29 were the first to report arthroscopic intervention for lavage in association with open reduction, but this has not become routine in subsequent large case series. Disc injury: Open reduction does not address the function of the disc or other articulating ligaments of the joint. In separate reports, both Choi et al30 and Neff et al31 found that about 20% of open reduction patients have functional displacement of the disc on postoperative MRI. The clinical importance of these findings in open reduction patients compared with closed reduction patients remains to be completely explored. Osteoarthrosis and bone resorption: External auditory canal or penetrating wound, compound fracture, systemic predilection, and loss of perfusion to the proximal segment are known to cause late arthritides. Iizuka et al32 reported the universal finding of osteoarthrosis in all joints treated with open reduction in 13 cases at 18 months after treatment. The problem was of clinical significance in only 1 patient, however. Associated mandible fractures: Associated mandible fractures, particularly those of the symphysis, may cause flaring malposition of the distal segment when treated closed. Open reduction of both fractures is often needed to obtain functional anatomic position. Associated midface fractures: Restoration of the dimensions of the face in panfacial fractures requires the correction of posterior facial height and projection. Open reduction of condyle fractures is indicated in such cases.33 Associated cranial base fracture: Displacement of the condyle into the middle cranial fossa is considered a good indication for open reduction in patients whose overall status permits surgical treatment.34 Edentulism, partial or full: Although status of the dentition is known to be an essential component of condyle fracture outcome, little has been done to comparatively assess outcomes based on the status of the dentition. Empirically it is known that the posterior dentition plays a role in maintenance of ramus height, so that patients without “posterior occlusal stops” lose greater ramus height. Balancing side interferences during excursion away from the side of fracture may result in greater occlusal trauma when there is a partial loss of dentition. Dentofacial classification: Angle Class II pa-
18.
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tients, especially those with a high mandibular plane angle, are more prone to open bite and further retrognathia after closed treatment. Other dental function and occlusion considerations: The depth of occlusal contacts in maximum intercuspation, and working/balancing occlusal contacts are known to play a role in the functional dental outcome of treatment. The ability to achieve maximum intercuspation during the postinjury examination is more often a result of the status of the dentition than the anatomic exigencies of the fracture. For example, a patient with a very flat occlusal plane will easily show an open bite and occlusal interferences during function. These may be very difficult to manage with closed reduction, whereas imprecise open reduction might create similar problems. Findings on lateral excursion and protrusion and interincisal opening in the postinjury evaluation might offer clues as to the best methods of treatment and rehabilitation Location of condylar fracture (low, medium, high) and displacement of proximal (condylar) segment: Very low fractures in patients with good dentition are known to often nicely self-reduce after closed reduction, whereas fractures of the condylar neck often cause loss of vertical dimension with anterior, medial, and inferior displacement of the condylar head. Clenching and bruxism: The presence of clenching and bruxism will have a profound impact on treatment outcome regardless of method selected. In the open reduction patient, the risk of fixation failure is increased. The wear on the occlusal surfaces of teeth makes maintenance of the occlusion problematic when closed reduction is selected. Functionally shortened ramus: A functionally shortened ramus differs from anatomic shortening. The anatomically shortened ramus is measurable on radiograph or clinically indicated a decreased distance from condyle to gonion. Because of the slope of the articular eminence as well as the functional adaptability of the associated structures, many such patients do not exhibit functional derangements in mastication or occlusion, such as a functionally shortened ramus. Patients with functional derangements due to a shortened ramus have an important indication for open reduction. Findings of ipsilateral persistent occlusal prematurity, inability to achieve maximum intercuspation, and inability to achieve contralateral
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OPEN VS CLOSED REDUCTION OF ADULT CONDYLE FRACTURES
occlusal working side contacts are some findings indicating a functionally shortened ramus. Patient expectations: The patient’s assessment of the benefits, risks, and alternatives of proposed therapy might differ from the surgeon’s perspective. Informing the patient to the best extent that circumstances allow will have a better chance of producing an outcome that will meet the patient’s desires. Ability of the surgeon: Experienced surgeons who undergo objective training and evaluation are more able to successfully perform open treatment of fractures.35,36 Where more than 1 treatment will result in a good outcome in general, it is wise to consider what has worked best in a particular patient care setting. Technology of the health care environment: Emerging technology will continue to alter the landscape of clinical decision making for condylar fractures. Minimally invasive surgery, navigation, and tissue engineering will affect the indications for surgery in the future. Institutional resources: Trauma care is a highly specialized and resource intense endeavor that depends on the ability of the health care environment to provide preoperative evaluation and intraoperative and postoperative care. The continued ability to effectively provide these demanding services has come into question in many centers.37 Willing payer: The emergence of managed care has affected the use of procedures as disparate as coronary artery bypass graft surgery and cholecystectomy. Justification for treatment of condylar fractures is dependent on the evidence amassed to support the proposed therapy.
A Reasoned Decision A careful assessment of the literature and the experiences of surgeons indicates that both open reduction and closed treatment of condyle fractures of the mandible have a deserved role in the treatment of these patients. Acceptable outcomes that permit full, pain-free function, with good aesthetics, have been amply shown with both techniques. Malocclusion, masticatory functional deficits, and internal derangement are pointed to as problems with one or the other treatment, yet they occur in both surgical and nonsurgical patients. The relative incidence of these complications remains a subject for continued investigation. However, there are several complications that remain reserved for those patients treated surgically. Although the incidence of each of these complications is small, in the aggregate they constitute a
considerable burden for the patients who undergo open reduction and internal fixation of condylar fractures. Those problems must be balanced against the advantages that can only be obtained with surgical treatment. Assessment of factors peculiar to the individual case must be made to determine the mode of therapy most likely to produce a favorable outcome. The mixture and relative role of each of these factors are evaluated individually by each surgeon for each patient. Hence, treatment selection for mandible condyle fractures remains an evidence-based art.
References 1. Brandt MT, Haug RH: Open versus closed reduction of adult mandibular condyle fractures: A review of the literature regarding the evolution of current thoughts on management. J Oral Maxillofac Surg 61:1324, 2003 2. MacLennan W: Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 5:122, 1952 3. Ellis E, Throckmorton G: Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 58:719, 2000 4. Blevins C, Gores R: Fractures of the mandibular condyloid process: Results of conservative treatment in 140 patients. J Oral Surg 19:28, 1961 5. Burakoff R: Epidemiology, in Kaplan A, Assael L (eds): Temporomandibular Disorders, Diagnosis and Treatment. Philadelphia, PA, Saunders, 1991, pp 95-103 6. Pullinger A, Seligman D, Solberg K: Temporomandibular disorders, Part 1: Functional status, dentomorphic features and sex differences in a nonpatient population. J Prosthet Dent 55:228, 1985 7. Silvennoinen U, Iizuka T, Oikarinen K, et al: Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. J Oral Maxillofac Surg 52:793, 1994 8. Goodsell J: Fractures involving the mandibular condyle: A posttreatment survey of 120 cases. J Oral Surg 5:45, 1947 9. Troulis MJ, Kaban LB: Endoscopic approach to the ramus/ condyle unit: Clinical applications. J Oral Maxillofac Surg 59: 503, 2001 10. Brophy TW: Oral Surgery: A Treatise on the Diseases, Injuries and Malformations of the Mouth and Associated Parts. Philadelphia, PA, B Blakiston’s Sons and Co, 1915, p 406 11. Thoma K: Oral Pathology: A Histological Roentgenological and Clinical Study of the Diseases of the Teeth, Jaws, and Mouth. St Louis, MO, CV Mosby, 1941, p 787 12. Rowe N, Killey H: Fractures of the Facial Skeleton (ed 2). Edinburgh, UK, E & S Livingstone Ltd, 1968, p 143 13. Dingman R, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, p 177 14. Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 15. Raveh J, Ladrach K, Vuillemin T, et al: Indication for open reduction of the dislocated, fracture condylar process, in Worthington P, Evans J (eds): Controversies in Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 1994, pp 173-190 16. Ellis E, McFadden D, Simon P, et al: Surgical complication with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 58:950, 2001 17. Hyde N, Manisali M, Aghabeigi B, et al: The role of open reduction and internal fixation in unilateral fractures of the mandibular condyle: A prospective study. Br J Oral Maxillofac Surg 40:19, 2002 18. Devlin MF, Hislop WS, Carton AT: Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: Surgical morbidity and informed consent. Br J Oral Maxillofac Surg 40:23, 2002
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LEON A. ASSAEL 19. Schon R, Schramm A, Gellrich NC, et al: Follow-up of condylar fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg 61:49, 2003 20. De Riu G, Gamba U, Anghinoni M, et al: A comparison of open and closed treatment of condylar fractures: A change in philosophy. Int J Oral Maxillofac Surg 30:384, 2000 21. 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 6:12, 1977 22. Lindahl L, Hollender L: Condyle fracture of the mandible: A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:153, 1977 23. Walker R: The consultant. J Oral Surg 24:367, 1966 24. Mitchell D: A multicentre audit of unilateral fractures of the mandibular condyle. Br J Oral Maxillofac Surg 35:230, 1997 25. Kent J, Neary J, Silvia C, et al: Open reduction of mandibular condyle fractures. Oral Maxillofac Clin North Am 2:69, 1990 26. Haug R, Assael L: Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 59: 370, 2001 27. Umstadt HE, Ellers M, Muller HH, et al: Functional reconstruction of the TM joint in cases of severely displaced fractures and fracture dislocation. J Craniomaxillofac Surg 28:97, 2000 28. Sugiura T, Yamamoto K, Murakami K, et al: A comparative evaluation of osteosynthesis with lag screws, miniplates, or
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Kirschner wires for mandibular condylar process fractures. J Oral Maxillofac Surg 59:1161, 2001 Piper M, Chuong R: Open reduction of condylar fractions of the mandible in conjunction with repair of discal injury: A preliminary report. J Oral Maxillofac Surg 46:257, 1988 Choi BH, Yi CK, Yoo JH: MRI examination of the TMJ after surgical treatment of condylar fractures. Int J Oral Maxillofac Surg 30:296, 2001 Neff A, Kolk A, Horch HH: Position and mobility of the articular disk after surgical management of diacapitular and high condylar dislocation fractures of the temporomandibular joint. Mund Kiefer Gesichtschir 4:111, 2000 Iizuka T, Lindqvist C, Hallikainen D, et al: Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures. A clinical and radiologic study of thirteen patients. Oral Surg Oral Med Oral Pathol 72:400, 1991 Assael L: Considerations in rigid internal fixation of midface trauma. Oral Maxillofac Surg Clin North Am 2:103, 1990 Zide M, Kent J: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 Assael L: Evaluation of rigid internal fixation of mandible fractures performed in the teaching laboratory. J Oral Maxillofac Surg 51:1315, 1993 Assael L: Assisting the deficient resident in oral and maxillofacial surgery. J Oral Maxillofac Surg 45:1058, 1987 Assael L: A devotion to trauma. J Oral Maxillofac Surg 61:415, 2003