Prospective evaluation of a pragmatic Prospective evaluation of a pragmatic treatment rationale:treatment rationale:

ORIF ORIF of displaced and dislocated condyle of displaced and dislocated condyle andand condylar condylar head fractures and head fractures and closed closed

reduction reduction of non-displaced,of non-displaced,non-dislocated fracturesnon-dislocated fractures

Part I: condyle and subcondylarPart I: condyle and subcondylarfracturesfractures.. C. A. Landes, R. Lipphardt C. A. Landes, R. Lipphardt

Moderator: Dr. Shireen Fatima Presented by: Dr. Shahid Khan

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INTRODUCTION:• Traditionally, Condylar fractures were treated by

closed reduction (CR) with varying degrees of mandibulo-maxillary fixation(MMF) or guided occlusion.

• Survey of the IAOMS surgeons published in 1998 shows the increasing popularity of ORIF: in general,57% of surgeons prefer ORIF compared to 40% in favor of closed reduction.

Non-dislocated, non-displaced condyle fractures, incomplete fracture lines, unchanged occlusion, normal vertical mouth opening were reported to heal

without any immobilization.

,but were treated with soft diet and vertical mouth opening exercises.

Displaced, dislocated and 3-week-old fractures had better outcomes with ORIF.

Conservative treatment is generally recommended in children up to 12 years due to high local restitution capacity.

However, increasing dysfunction Index proportional with age and incomplete remodeling in dislocated fractures in children are reported. Therefore, recent reports favor ORIF even in patients under 12 years of age.

PURPOSE:• To evaluate outcomes of closed reduction (CR) in

nondisplaced, non-dislocated condyle and subcondylar fractures.

& open reduction and internal fixation (ORIF) of displaced & dislocated condyle fractures.

• Pt’s with malocclusion, locking, or a displaced or dislocated condyle were operated on.

• Non-displaced fractures with normal occlusion and moderate joint tenderness were treated with CR. The results were evaluated separately.

MATERIALS AND METHODS:Inclusion criteria:• Unilateral or bilateral condyle fractures, located at

the sigmoid notch or subcondylar region. Exclusion criteria:• Pt’s with a H/O TMJ dysfunction and insufficient

dentition to reproduce occlusal relationships & severe pre-traumatic dysgnathia.

The mean age in the operated group was 36 (9–79) yrs.& in non-operated group 30yrs (15–60)yrs.

• 45pt’s with 51 fractures [6(13%) with bilateral fractures].

11 pt’s (25%) CR. 34 pt’s (75%) ORIF(includes all bilateral fracture)were enrolled in a 1-year follow up that 20 pt’s with 25 fractures completed.

Diagnostic imaging: This was performed with mandibular tomograms and Towne views.

Fracture classification was performed radiologically to separate condyle/subcondylar from high condylar/condylar head fractures.

Class-I: Non-displaced condylar/subcodylar fractures.

Class-II: Displaced condylar/subcodylar fractures. Class-III: Displaced High condylar/condylar head

fractures. Class-IV: Dislocated condylar/subcondylar

fractures. Class-V: Dislocated High condylar/condylar head

fractures. Class-VI: Non-displaced High condylar/codylar head

fractures.

OPERATIVE TECHNIQUE:• The condyle fractures at the lower condylar neck, at

or below the sigmoid notch, were operated by the Retromandibular approach.

• Osteosynthesis being performed with 2mm 4-hole miniplates and 7mm screws of 1.2mm diameter.

In 10% of cases, a single plate adapted to the dorsal rim & a second plate was adapted to the lateral cortex.

All patients were operated on using this standard technique.

CLOSED REDUCTION:• With 2 weeks of intermaxillary guided occlusion by

2 maxillomandibular 1.5 mm diameter rubber bands. These bands were suspended over 14 mm 2.4 mm

set-screws, inserted between the canine and first premolar root in all four quadrants .

Pt’s younger than 12 yrs received guided occlusion by a removable orthodontic appliance for 3 months to avoid tooth buds trauma by set-screw insertion.

When a permanent tooth subluxation was present, arch bars were placed, followed by identical rubber band-guided occlusion for 2 weeks.

In the 3rd week -vertical opening exercises -contralateral excursion exercises were started.

In the 4th week -pt’s were trained to keep their mandible in the

midline during vertical opening and protrusion. -Physiotherapy. -Set-screws were removed if the occlusion remained

stable.

FOLLOW UP: at 1, 6 & 12 months. Maximum interincisal distance on vertical opening, Protrusion & laterotrusion were performed using an

orthodontic slide gauge. Local inflammation, scarring, pain, facial nerve function, occlusion, static and functional asymmetry were evaluated.

RESULTS: 45 patients with 51 condyle, condylar neck or subcondylar

fractures were enrolled, three pt’s with four fractures were excluded, and 20 patients with 25 fractures completed 12months’ follow up.

For Class I -translation / incisal movement was 12.1/46 mm in vertical

mouth opening, -9/8 mm in protrusion. -8/9 mm for mediotrusion / laterotrusion.

Complications-1 pt. with contralateral open bite and internal derangement for 3 months that was leveled by condylar remodeling and physiotherapy.

For Class II -mean vertical opening translation was 10 mm. -protrusion 6.5 mm. -Mediotrusion 8.6 mm. There was slightly less initial translation increase after the

first 5 postoperative weeks compared to patients treated by CR.

The 1-year follow up incisal movements on vertical opening were 44 mm,7 mm protrusion & 9 mm laterotrusion.

Complications: -1 Pt. with plate fracture after 2 days postoperatively &

required a re-operation. -1 pt. with wound infection requiring metal removal. -1 pt. with transient nerve paresis. -2 pt’s with transient malocclusions. -1pt. developed asymmetric vertical opening due to improper

physiotherapy.

For Class IV -mean vertical opening translation was 7.9 mm.

-protrusion 6.5 mm. -mediotrusion 7 mm. The incisal vertical opening movement was 43 mm.

protrusion 5 mm and laterotrusion 7 mm after 1yr follow up.

Complications:-1 pt. with malocclusion at 6 months, which was resolved by

remodeling & prosthetic restoration, -1pt. with wound infection that resolved with antibiotics.-1pt. with nerve paresis, which subsided after 6 months.

DISCUSSION: Despite nearly 100 publications in the last 50 yrs,

several authors have based their approach on practical methods adapted to the circumstances & collected opinions rather than on theory.

our prospective study included the following framework:

An agreed quantification of the deformity: this was the assignment of cases into Class I, II & IV and Class III, V & VI.

An unacceptable function: this was predefined as malocclusion, joint pain & locking movement.

Timing of intervention: this was the same day for CR, and for ORIF the following day when traumatic swelling had subsided.

An agreed operative method: this was with a guided occlusion for 2 weeks as CR & a standardized submandibular or retromandibular approach with miniplate osteosynthesis.

Subsidiary protocol for postoperative management: this included physiotherapy & soft diet (used by 90% of IA-OMS panel) & follow up at 1–3, 4–6 and 6–12 months.

Quantification of outcome: this was by measurement of millimeters of translation (the most sensitive parameter of joint function), incisal movement, asymmetry, scarring, pain, swelling and infection.

From our results• Class I fractures have an uncomplicated prognosis

when treated conservatively ,Occlusal correction is performed by prolonged MMF.

• Operated Class II cases have a good prognosis with ORIF. Class IV fractures also recuperate to full incisal movement.

Malocclusion is treated as stated above and occurs in 10% of class I,9.3% of Class II & IV cases.

Facial nerve palsy of the marginal mandibular branch was seen in 6.3% of ORIF cases, but all resolved after 6 months.

Only one (3%) hypertrophic scar was found in this study & treated by CO2 laser.

The results of this study indicate successful management of Classes I,II and IV fractures with a practical approach .

OTHER RELATED STUDIES:

CONDYLAR FRACTURES- OPEN VS CLOSED REDUCTION: A REVIEW OF 39 CASES:

S.M. BALAJI [JOMS 2003]

• To compare the mandibular & facial morphology after open & closed T/t of condylar fractures,39 pt’s 9 treated by closed and 30 by open methods.

• CR develop asymmetries like shortening of face on the side of injury.

• ORIF provides faster & better recovery rates, with reduced resultant deformities, malocclusion & TMJ derangements.

OPEN Vs CLOSED TREATMENT OF FRACTURES OF THE MANDIBULAR CONDYLAR PROCESS-

A Prospective Randomized Multicenter Study: ECKELT & SCHNEIDER[Journal of Cranio-Maxillofacial Surgery

2006]

To compare operative and conservative treatment of displaced condylar fracture of mandible 66 patients with 79 fractures were evaluated.

Both treatment options for condylar fractures of the mandible provides acceptable result ,

However ORIF, irrespective of the method of internal fixation used, was superior in all objective and subjective functional parameters.

FRACTURES OF THE CONDYLAR PROCESS: SURGICAL VS NONSURGICAL TREATMENT

SANTLER, KIIRCHER [JOMS 1999]

To compare outcomes from surgical and nonsurgical T/t of condylar fractures,234 pt’s with fractures of the condylar process were treated by open or closed methods.

150 patients with a mean follow-up time of 2.5 years were analyzed.

Open surgery is only indicated in pt’s with severely dislocated condylar process fractures.

OPEN TREATMENT OF CONDYLAR PROCESS FRACTURES:ASSESMENT OF ADEQUACY OF

REPOSITIONING AND MAINTAINANCE OF STABILITYEdward ellis [JOMS-2000]

To determine how fractured condyle were reduced and the stability of the internal fixation in a group of pt’s who’s fractures were treated by open reduction.

61 patients treated by ORIF for unilateral condylar fractures were studied.

This study showed that it is possible to anatomically reduce the fractured condylar process, but changes in position of the condylar fragment may then result from a loss of fixation.

CONCLUSION: Major risk in displaced and

dislocated cases can safely be avoided through ORIF, with acceptable complication rates. Bilateral fractures can be treated with the identical approach of ORIF on the displaced and dislocated side, and CR on the non-displaced sides for comparable results.

This Treatment Rationale Conforms To The General Rule Of Traumatology: ORIF For Dislocated Fractures And Conservative Treatment For Non-dislocated Fractures & Gave Successful

Results.

THANK YOU…