Analysis of Patterns and Treatment

Strategies for Mandibular condyle

Fractures: Review of 175 Condyle

Fractures

with Review of Literature

Reddy NV, Reddy PB, Rajan R, Ganti S, Jhawar DK, Potturi A,  Pradeep. Analysis of Patterns and Treatment Strategies for Mandibular condyle Fractures: Review of 175 Condyle Fractures with Review of Literature. J Maxillofac Oral Surg. 2013Sep;12(3):315-20.

Dr. N. V. Reddy , Dr. P. B. Reddy, Dr. R. Rajan , Dr. S. Ganati, Dr. D. K. Jhawar, Dr. A. Pottsri, Dr. Pradeep. Department of Oral & Maxillofacial Surgery, SVS Institute of Medical & Dental

Sciences, Mehaboobnagar, Hyderabad, India.

Key words

• Age distribution of fractures,

• Dental occlusion, Mandibular condyle fractures,

• Temporomandibular joint, Treatment algorithm

Inclusions

1. Abstract

2. Introduction

3. Patients and methods

4. Results

5. Discussion

6. Cross references

7. References

Abstract• A study was conducted to evaluate incidence, patterns and epidemiology of

mandibular condylar fractures (MCF) to propose a treatment strategy for

managing MCF and analyze the factors which influence the outcome.

• 175 MCFs were evaluated over a four year period and their pattern was

recorded in terms of displacement, level of fracture, age of incidence and

dental occlusion.

• They observed that among the 2718 facial bone fractures, MCF incidence

was the third most common, mostly unilateral, associated with midline

symphysis or contralateral parasymphysis fractures.

• Most of the MCF was seen in the age group of above 16 years, at

subcondylar level.

•  Majority of MCF due to inter personal violence were undisplaced and

during road traffic accident were displaced. 

• Most of the fractures required open reduction and rigid fixation and most

of MCF managed with closed reduction were in the age group of below

16 years.

• They observed that absolute indication for open reduction of MCF is

inability to achieve satisfactory occlusion by closed method and absolute

contraindication for open reduction is condylar head fracture irrespective

of the age of the patient.

Introduction

• In the entire spectrum of maxillofacial trauma no other topic has created so much of debate and controversies than that of mandibular condyle fractures {MCF} both among children and adult population.

• Though it is a small non weight bearing joint, the significance of its nominal functioning has been best demonstrated in the statement by Ellis III and Gaylord [1]

• Complications of trauma to the temporomandibular joint (TMJ) are far-reaching in their effects and not always immediately apparent.

• Disturbance of occlusal function, deviation of the mandible, internal derangements of the TMJ, and ankylosis of the joint with resultant inability to move the jaw are all sequel of this injury.

Ellis III E, Gaylord S (2005) Throckmorton: treatment of mandibular condylar process fractures: biological considerations. J Oral Maxillofac Surg 63:115–134.

• Thus proper assessment and choosing appropriate treatment strategy is of paramount importance.

• Injuries to the condylar cartilage as well as gross condylar head dislocation in children can reduce the capacity for complete remodeling and often result in mandibular deviation, but a {genetic} guidance system exists to rebuild the condylar process in children sustaining fractures [2]

• In children between the ages of 3 and 11 the dislocated fractured condylar segment tends to be resorbed after successful therapy. [3]

• Teenagers show condylar remodeling which is neither complete nor predictable and in adults it remodels only functionally. [2]

Lindahl L, Hollender L (1977) Condylar fractures of the mandible II. Radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:157–165

Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89–98 

• The ability of condyle to remodel and regenerate is more impaired and unpredictable in adults and thus there is a greater need for open reduction in post pubertal patients. [4]

• An analysis of the frequency of fractures at different anatomic sites of the mandible revealed that the mandibular condyle sustains a fracture in 10 to 40% cases.[5,6]

• Fridrich et al.[7] in their study of 1067 patients found condylar fracture to be the second most common form of fracture after mandibular angle fractures.

Takenoshita Y, Oka M, Tashiro H (1989) Surgical treatment of the mandibular condylar neck. J Cranio-Maxillofac Surg 17:119–124 

Brasileiro BF, Passeri LA (2006) Epidemiological analysis of maxillofacial fractures in Brazil: a five-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:28

Bataineh A (1998) Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86:31 

Fridrich KL, Pena-Velasca G, Olson RAJ (1992) Changing trends with mandibular fractures: a review of 1067 cases. J Oral Maxillofac Surg 50:586–589 

• The ranging controversies from open (ORIF) against closed or functional treatment of condylar fracture {CMMF} are guided by three main factors:

1. The age of fracture incidence,

2. Pattern of deviation of fracture

3. level of fracture

• This article not only adds to the existing literature on various patterns of MCF and its distribution but also presents the treatment protocol in choosing appropriate treatment, based on the above 3 factors in comparison to the existing literature.

Patients and methods

• A1l the recorded data related to trauma between May 2006 to April 2010 (4years duration) was retrieved and analyzed retrospectively from the medical records wing of their unit which is located in a southern state of India.

• Information was collected from the clinical and surgical notes of each of the patients in a standardized and systematic pattern to evaluate the epidemiological factors of general- facial and condylar trauma in a generalized population where road traffic accidents are highly rampant in the form of high speed motor vehicle collisions.

• The data collected included incidence of MCF with respect to generalized facial trauma, age, gender, diagnosis, location, pattern, level of condylar fractures, dislocation of the fracture, status of dentition and occlusion, methods and duration between trauma and the treatment.

• The exclusion criteria was, if any of the above mentioned information are missing from the case notes of the patients.

• The patients were divided into growing and non-growing groups based on their age and the time of presentation to understand the effect of choice of treatment and its outcome.

• The diagnosis was made in all the cases with the aid of orthopantomogram and multi detector CT scan (MDCT).

• The fractures were classified as condylar head, condylar neck (intracapsular) or subcondylar (extracapsular) . [8]

Silvennoinen U, Iizuka T, Lindqvist C, Oikarinen K (1992) Different patterns of condylar fractures: an analysis of 382 patients in a 3 year period. J Oral Maxillofac Surg 50:1032–1037 

• The degree of condylar displacement was categorized according to MacLennan in to four classes:

I. no displacement

II. deviation at the fracture line

III. displacement (condylar fragment are not in contact with the distal fragment

IV. dislocation (condyle dislocated from the glenoid fossa)

• Treatment of condylar fractures were divided into –

A. Non surgical treatment (arch bars/ elastics/ physiotherapy )

B. Surgical treatment (ORIF)

• Other associated fractures were classified based upon their location as symphysis, parasymphysis, body, angle, dentoalveolar, midface, isolated condylar fractures.

• The condylar fractures were grouped as unilateral / bilateral fractures.

Results

• A total of 15,345 trauma patients were received at the casualty wing of SVS Medical College & Hospital were evaluated between May 2006 to May 2010.

• 2718 individuals suffered maxillofacial trauma in isolation or in combination with other body injuries.

• Of the 2718 facial trauma, 674(24.79%) were fractures of mandible.• Of all mandibular fractures – parasymphysis (32.78%) , condyle (18.39%)

8

Results….

Results….

• Male : female = 1.5:1

• Majority of MCF were found in the subjects above 16 yrs of age(74.19%)

which was taken as delineating factor between the pediatric & adult

population in deciding their treatment algorithm.

Results….

Results…. 16 pts had minimal displacement

4 pts had lateral displacement

2 pts had medial displacement

• Most of the bilateral condylar fractures were associated with symphyseal

fracture (67%).

• Most of the unilateral condylar fractures were associated with

parasymphyseal fracture (43.8%).

• This data corroborates the fact when the impact is on midline of the

mandible, the force is transmitted equally to the bilateral condyles,

fracturing both of them.

• When the patients turn their head to one side as a protective mechanism at

the time of impact it results in the energy being transferred to opposite

condyle resulting in unilateral fracture.

Discussion• Epidemiologic surveys will vary with geographic region, population

density, socioeconomic status, regional government policies, era in time and type of facility in which the study was conducted. Comparison of surveys requires consideration of these factors.[10]

• This retrospective study which analyzed 15345 trauma patients over a period of 4 years reiterates the fact that maxillofacial injuries are frequent, with 17% incidence & thus stresses on importance of having a maxillofacial surgeon as part of the trauma team.

• This is in agreement with 15% incidence of facial fractures in a sample of 1088 in study conducted at Liverpool, UK. [11]

•Haug RH, Prather J, Indresano AT (1990) An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 48:926–932.

•Down KE, Boot DA, Gorman DF (1995) Maxillofacial and associated injuries in severely traumatized patients: implications of a regional survey. Int J Oral Maxillofac Surg 24:409–412 

• 24 % incidence of mandibular fractures among 2718 facial fractures establishes the fact that mandible is one of the most frequently injures bones stated by other authors in their reports. [12,13]

• In this study MCF (18%) is next only to angle fracture in frequency as in a study conducted by Marker et al.[14 ]

• Condyle comprises of 41% of all mandibular fractures. In contrast Ellis et al [12] found only 29% incidence of condyle fracture in sample of 2137 mandibular fractures.

• Marker et al attributed this to the larger no. of young & unemployed people with more propensities for interpersonal violence & increased edentulism in their study population. In this study, the pattern of displacement or dislocation of condylar fracture is also dictated by the status of dentition & position of the mandible at the time of impact.

•Ellis E 3rd, Moos KF, El-Attar A (1985) Ten years of mandibular fractures: an analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol 59:120–129 •Fasola AO, Nyako EA, Obiechina AE, Arotiba JT (2003) Trends in the characteristics of maxillofacial fractures in Nigeria. J Oral Maxillofac Surg 61:1140–1143 

Marker P, Nielsen A, Lehmann Bastian H (2000) Fractures of the mandibular condyle. Part 1: patterns of distribution of types and causes of fractures in 348 patients. Br J Oral Maxillofac Surg 38:417–421 

• It was noted that significantly displaced condylar fracture were noted in RTA & no/minimal displaced fractures resulting from IPV. This similar to observations made by Silvennoinen et al, where they noticed 26 % of condylar dislocation due to RTA & only 8% from IPV.

• Author hypothesize that the status of lateral pterygoid muscle contraction at the time of impact & kinematics condylar movement plays an important role in the dislocation of MCF. Lateral pterygoid muscle is one of the chief depressors of the mandible & causes translation of the condylar head anteriorly in the glenoid fossa .

• At the time of impact to the mandible when the subject is in the process of opening the mouth as in yelling out / shouting. The lateral pterygoid muscle is in the process of continued contraction. If a fracture condyle occurs at this situation below the level of muscle insertion, the muscle fibers snap like in stretched elastic fibers & thus result in severely dislocated proximal fragment.

• This situation is akin to what happens in high speed collisions where the subject tends to open the mouth wide in shock.

• In IPV, subjects generally tend to keep their mandible tightly closed with teeth in firm occlusion like clenching. This act will keep the condyle firmly seated at the centre of glenoid fossa & thus results in laterally deviated fracture or a compression type of fracture with minimal displacement.

• In the kinematics of mandibular movements, rotation of condyle head is followed by translation. If the impact on mandible occurs when the mouth is partially opened, which is when the head is still in rotation, the degree of displacement is much less than when the mouth is wide opened, (>15mm) as the condyle shifts to translatory motion.

• This is because of continuity of movements of condyle in its anterior direction even after the fracture due to inertia which is coupled with lateral pterygoid pull.

• Another significant finding was association of bilateral condylar fractures with symphysis fractures & unilateral fractures with opposite parasymphysis fractures.

• Lindhal & Hollender (1977) [2] have also found that concomitant fractures of the mandibular body are more frequent in bilateral than in unilateral condylar fractures.

• Zachariades [15] recorded 52% , 19% & 11% of symphysis, parasymphysis, body & angle fractures respectively as other associated fractures.

• They concluded that condylar fractures result from an indirect force applied to the mandible, associated with at least one other mandibular fracture, mostly symphyseal or parasymphyseal. This suggests that condylar fractures may be the result of transmission of force which is not fully absorbed in the majority of cases in the area of its primary application, i.e. the mantle region.[15]

•Lindahl L, Hollender L (1977) Condylar fractures of the mandible II. Radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:157–165

•Zachariades N, Mezitis M, Mourouzis C, Papadakis D, Spanou A (2006) Fractures of the mandibular condyle: a review of 466 cases. Literature review, reflections on treatment and proposals. J CranioMaxillofac Surg 34:421–432 

• There is no other single concept in the entire spectrum of maxillofacial trauma which has created so much furore as that of MCF treatment.[16-19]

• Lindahl & Hollender [2] had stressed on the importance of age & growth on the treatment outcome of MCF.

• In author’s view age plays a very significant role in the choice of treatment & this forms the baseline for their treatment algorithm.

•Konstantinovic V, Dimitrijevic B (1992) Surgical versus conservative treatment of unilateral condylar process fractures: clinical and radiological evaluation of 80 patients. J Oral Maxillofacial Surg 50:349 CrossRef

•Raveh J, Vuillemin T, Ladrach K (1989) Open reduction of the dislocated, fractured condylar process: indications and surgical procedures. J Oral Maxillofacial Surg 47:120 CrossRef

•Haug RH, Assael LA (2001) Outcome of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofacial Surg 59:370CrossRef

•Hidding J, Wolf R, Pingel D (1999) Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J Craniomaxillofac Surg 20:345 CrossRef

•Lidahl L, Hollender L (1977) Condylar fractures of the mandible II. Radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 6:157–165

• Assael[20] in his review paper of 2033 patients , proposed 26 variables influencing MCF treatment selection & outcome, starting from age to institutional resources & willing prayers. This data though elaboratory covers all the aspects of MCF, treatment is to laborious & impractical to apply in every situations.

• Zide & Kent’s [3] landmark publication of 1983 on absolute & relative indication has undergone considerable modifications with time by various authors & also same authors.[21,22]

•Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89–98 

•Zide MF (1989) Open reduction of mandibular condyle fractures. Clin Plast Surg 16:69

•Kent JN, Neary JP, Silvia C (1990) Open reduction of mandibular condyle fractures. Oral Maxillofac Clin North Am 2:69

• Haug & Assael [18] in 2001 made an attempt refining the absolute & relative indications & contraindications.

• In this paper treatment protocol agrees with some of the aspects of their proposals like absolute contraindication for ORIF would be condyle head fractures in respective of the age & absolute indication would be inability to achieve desirable occlusion for condylar neck & subcondylar level fractures with CMMF.

• Authors believe that the indications / contraindications , method of proposals are highly subjective & does not draw any definitive conclusion on treatment choice.

• The protocol suggested by the authors is highly objective & self derivative when they come across a MCF, more or less it works like a mathematical formula & it is based on the radiographic findings except for status of occlusion & age of the patients.

Haug RH, Assael LA (2001) Outcome of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofacial Surg 59:370

• In case of bicoldylar fractures the algorithm was applied to both condyles separately & if at least 1 condyle comes into open reduction category, it needs to be treated accordingly.

• Retromandibular approach [23, 24] gives an advantage of shorter working distance from the skin, greater access to the posterior border of mandible, sigmoid notch & thus subcondylar fractures.[25]

•Koberg WG, Momma W (1978) Treatment of fractures of the mandibular process by functional stable osteosynthesis using miniaturized dynamic compression plates. Int J Oral Surg 7:256–262 CrossRef

•Manisali M, Amin M, Aghabeigi B, Newman L (2003) Retromandibular approach to the mandibular condyle and cadaveric study. Int J Oral Maxillofacial Surg 32:253–256 CrossRef

•Narayanan V, Kannan R, Sreekumar K (2009) Retromandibular approach for reduction and fixation of mandibular condyle fractures: a clinical experience. Int J Oral Maxillofacial Surg 38:835–839 CrossRef

• 50% of MCF in this study were subcondylar & they used retromandibular approach in 61.2% of these cases. The greatest advantage with this approach apart from the mentioned above was greater accessibility to the fracture site & convenience in fixing a miniplate in low lying condylar fractures.

• The greatest disadvantage with this approach is difficulty in locating the medially dislocated condylar head in which case preauricular approach would be the better option. Also 2 patients presented with postoperative sialocele which was managed conservatively with pressure dressing.

• Preauricular approach was used in 21[26.9%] cases & the major disadvantage was in accessing distal mandibular portion while fixing the plate. This could be achieved by slightly lengthening the incision or retraction but both at the risk of facial nerve.

• Apart from these indications & contraindications for each approach they didn't find any other significant morbidity related to facial nerve in any of the approaches when the surgical dissection planes were well maintained & respected.

• With its rapidly growing economy, India is an epitome of changing disease patterns of developing nation to developed nation & thus serves as the best feeding ground for researchers to analyze & test various disease patterns & treatment concepts.

• The author’s treatment protocol for condylar fractures resulted in a logical choice of treatment in varying patterns of fracture with fewer complications & satisfactory outcome.

• Yet it needs to be analyzed further as this is partly a retrospective study & the nature of a retrospective study inherently results in flaws.

• These problems were manifested by the gaps in information & incomplete records.

• Furthermore, all data rely on the accuracy of the original examination & documentation. Items may have been excluded in initial examination or not recorded in the medical chart.

Cross references

Classifications

Clinical classification by MacLennan (1952)

a, no displacement;

b, deviation at fracture line;

c, fracture displacement (overlapping between segments)

d, severe/complete dislocation/luxation (extracapsular)

Classification of fractures accordingto Spiessl & Schroll 1972

type 1: fractures without displacement

type 2: low fractures with displacement

type 3: high fractures with displacement

type 4: low fractures with dislocation

type 5: high fractures with dislocation

type 6: intracapsular fractures

Lindahl 1977 proposed a quite complex classification based on fracture level, deviation / displacement, and position of the condylar head in relation to the fossa:

1, Fracture level:

a, condylar head

b, condylar neck

c, subcondylar/condylar base

2, relationship of condylar fragment of mandible

a, undisplaced fissural fracture

b, deviation without overlap

c, displacemant with medial overlapping of condylar fragment;

d, displacemant with lateral overlapping of condylar fragment;

e, anterior / posterior overlapping;

f, displacement with no contact between segments

3, Relation between condylar head and fossa:

a, no dislocation;

b, displacement(slight / moderate );

c, severe/complete dislocation/luxation

horizontal

vertical

impacted/compression fracture

• In 1997, Krenkel proposed the following classification based on objective measurement criteria.

1. High condylar neck fracture: fracture located within the upper quarter or upper third of the mandibular condyle.

2. Intermediate condylar neck fracture: fracture located within the upper third or upper half of the mandibular condyle.

3. Low condylar neck fracture: fracture located in the lower half of the mandibular condyle.

• Ellis et al. classified condylar fractures as follows:

1. Condylar head fracture: an intracapsular fracture located at the border between the condylar head and neck

2. Condylar neck fracture: fracture located below the condylar head but on or above the lowest point of the sigmoid notch

3. Condylar base fracture: fracture in which the fracture line is located below the lowest point of the sigmoid notch

They also differentiated between• No detectable dislocation on X-rays and correct position

of the condylar head• Slight dislocation in which most of the condylar head

remains within the articular fossa and the degree of angulation/bending of the condylar process is < 20°

• Severe/maximum dislocation: the condylar head is

positioned on the articular tubercle or more anteriorly,

and the degree of angulation/bending is > 20°

Treatment options

Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89–98 

Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. Jul 2012; 39(4): 301–308.

Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. Jul 2012; 39(4): 301–308.

• W. D. Maclennan in an excellently documented publication in which he treated 1250 condylar fractures has concluded the following points: -

(a) Prolonged immobilization in intracapsular fracture is likely to create complications.

(b) In vast majority of condylar fractures, the wound is a closed one and if conservative methods of treatment can offer satisfactory functional results with a minimum of complications there would be little justification for surgically exposing the area, which has potential hazards.

(c) Acrylic splints and circumferential wires to a plaster of paris head splint with bite slightly open can support a bilateral condyle fracture.

(d) Open reduction to be carried in grossly displaced fracture condyle in older patients to maintain vertical height.

(e) Condylectomy should be considered if closed reduction results in limited movement or painful TMJ movements.

W. D. Maclennan (1969) : Fractures of the mandibular condylar process British Journal of oral surgery Pg 31 – 39

• N. L. Rowe on studying fractures of jaws in children has described following modalities of immobilization: -

(a) 0-2 yrs. - No immobilization with gunning splint with thick lining of guttapercha.

(b) 2-4yrs. - As there are well-formed roots, arch bars, loops, cap splints should be given.

(c) 5-8yrs. - as resorbing roots are present cap splints to be given stabilized by circumferential wires.

(d) 9-11yrs. - arch bars splints can be given as permanent teeth are developing.

N. L. Rowe (1969):Fractures of the jaws in childrenJournal of oral surgery:Vol 27: 497 – 507

• (a) The new mandibular joint retractor device, the length of which is 21 cm. (b) The top of the tip is 1mm thickness and 3mm width, the triangular projected portion is made 6mm proximal from the top of the tip to catch fracture ends of the bone.

• This new retractor was fabricated to pull down the condylar process and obtain a better field of view during surgery.

• It is possible to produce a high-grade opening force at the tips of the retractor, which is achieved with the specially made wrench system.

• In using this retractor, the fracture stumps are more clearly exposed and easily repaired with surgery.

Akira Sugamata, Naoki Yoshizawa, and Yoshio Jimbo. Open Reduction of Subcondylar Fractures Using a New Retractor. Volume 2011, Article ID 421245, 5 pages

• Because the X-ray axis was parallel to the FH line, and the image of the mandibular condyle was masked by the zygoma, the axis was canted about 15 degrees cranially to the FH line.

• The skull’s sagittal plane was rotated about 15 degrees ipsilaterally to the X-ray axis, free of the mastoid bone’s image.

• These positions allowed for posterior-anterior visualization of the condylar process, suitable for displaying the condylar neck and mediolateral malpositioning of the condylar process.

• In the clinical case using fluoroscopy, the operator manipulated the mandible to reduce the fractured condyle, followed by assessment of the bone alignment and its relapse during simulated jaw movements.

• A definitive plan for repairing these fractures by either surgical or nonsurgical treatment was based on reduction status mentioned above and confirming improved occlusal stability.

Imai T, Michizawa M, Yamamoto N, Kai T. Closed reduction of mandibular condyle fractures using C-arm fluoroscopy: a technical note. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Jan;115(1):e4-9.

• Because the X-ray axis was parallel to the FH line, and the image of the mandibular condyle was masked by the zygoma, the axis was canted about 15 degrees cranially to the FH line.

• The skull’s sagittal plane was rotated about 15 degrees ipsilaterally to the X-ray axis, free of the mastoid bone’s image.

• These positions allowed for posterior-anterior visualization of the condylar process, suitable for displaying the condylar neck and mediolateral malpositioning of the condylar process.

• In the clinical case using fluoroscopy, the operator manipulated the mandible to reduce the fractured condyle, followed by assessment of the bone alignment and its relapse during simulated jaw movements.

• A definitive plan for repairing these fractures by either surgical or nonsurgical treatment was based on reduction status mentioned above and confirming improved occlusal stability.

Imai T, Michizawa M, Yamamoto N, Kai T. Closed reduction of mandibular condyle fractures using C-arm fluoroscopy: a technical note. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Jan;115(1):e4-9.

Nonsurgical treatment

1. Immediate intermaxillary fixation (IMF) using minihooks according to ~30 (spinomental immobilization), nonrigid fixation using interocclusal elastics for 10 days was applied.

2. Use of an acrylic splint on the upper jaw with hypomochlion at the fracture side for distraction of the fragments.

3. Intensive functional treatment for 6 months immediately after release of MME

EVALUATION OF HEIGHT OF HYPOMOCHLION

4. Amount of anterior open bite is recorded (X)

5. 2 mm is added (normal overbite value)

Ulrich Joos, Johannes Kleinheinz. Therapy of condylar neck fractures. International Journal of Oral and Maxillofacial Surgery, Volume 27, Issue 4, August 1998, Pages 247-254

Ulrich Joos, Johannes Kleinheinz. Therapy of condylar neck fractures. International Journal of Oral and Maxillofacial Surgery, Volume 27, Issue 4, August 1998, Pages 247-254

The following formula was applied for calculation of the loss of height:

y=h - h', cos a = h'/ hh'=h x cos a

y=h - h x cos a=h x (1-cos a)

Illustration of mathematical model for evaluation of loss of ramus height according to angle of dislocation, y=loss of height, h=distance fracture line - articular surface of the condyle (=fracture height), h'=loss of height after fracture, a=angle of dislocation.

Radiographic evaluation of height of hypomochlion

• For the reduction of facial bone fracture, the authors suggest that after reducing other elements according to centric occlusion condyle (CO) with normal functions should be identified, followed by performing the condyle fracture reduction.

• After facial bone surgery related to occlusion, disorders of functional movement that might occur later should be checked.

• This is done by checking the disorder of mandibular functional movement after reduction according to CO. when mouth opening is performed by holding the mandible with hands, translation movement occurs after appropriate rotation movement.

• At that point, if condyle head movement is palpitated at the preauricular area, mandibular movement at the sagittal plane is considered good. No deflection of mandibular movement should occur at this point.

Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. Jul 2012; 39(4): 301–308.

Final check point after open reduction

• Next, guidance teeth are identified from anterior and lateral movement after

checking the attrition status of the occlusion surface. If the guidance teeth

found during mandibular movement by maintaining the contact of the

maxillary and mandibular teeth by holding the mandible with hands, and the

guidance teeth during movement are identical, and if no premature contact

occur in other teeth, functional movement is expected to be normal.

Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. Jul 2012; 39(4): 301–308.

Final check point after open reduction

Conclusion • Injuries of the condyle deserve special consideration apart from the rest of

the mandible due to its anatomical differences and healing potential.

• Proverbially speaking in Shakespeare’s words ‘TO OPEN OR NOT TO OPEN IS THE QUESTION’.

• The most important question is what the difference in results between open and closed reduction (i.e. 5 mm loss in post. Facial height) means to the patient.

• Is this difference seen extraorally and does it motivate the patient to have an open reduction performed? May be patients are more concerned about major facial scars than having a perfect post surgical radiographic appearance.

Renato Valiati, Danilo Ibrahim, Marcelo Emir Requia Abreu, Claiton Heitz, Rogério Belle De Oliveira, Rogério Miranda Pagnoncelli, Daniela Nascimento SILVA. The treatment of condylar fractures: to open or not to open? A critical review of this controversy. Int. J. Med. Sci. 2008, 5.

Conclusion Finally, rather than judging the appropriateness of surgical or non-surgical

method the efficacy of any method in restoring the function with least harm is the main concern.

Certain criteria should be met before judging the line of treatment given:

• free movement of jaw in all excursions

• pain free movement with normal interincisal distance

• restoration of occlusion to preinjury state

• stable temperomandibular joint

• acceptable facial symmetry

If the above criteria are met then, it does not matter which mode of therapy is employed.

Walker. Condylar fractures, Non Surgical management Jour. Of Oral & Maxillofac. Surg. (1994). Vol 52, 1185.

References 1. Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral

Maxillofac Surg 41:89–98 

2. Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg. Jul 2012; 39(4): 301–308.

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