This action might not be possible to undo. Are you sure you want to continue?
001, available online at http://www.sciencedirect.com
Clinical paper Trauma
Unilateral mandibular condylar fractures: a 31-year follow-up of non-surgical treatment
J. Andersson, F. Hallmer, L. Eriksson: Unilateral mandibular condylar fractures: a 31-year follow-up of non-surgical treatment. Int. J. Oral Maxillofac. Surg. 2007; 36: 310–314. # 2006 International Association of Oral and Maxillofacial surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. At the University Hospital of Malmo, Sweden, standardized trauma charts ¨ were used for registration of all jaw fractures from 1972 to 1976. During the year 2005 the aim was to interview all patients treated non-surgically for unilateral mandibular condylar fractures during this period. In total, 49 patients with unilateral condylar fractures were treated non-surgically in 1972–1976. Of these, 23 patients were available for follow-up, 17 were dead, 7 were not found and 2 did not answer letters or phone calls. The follow-up was a telephone interview according to a standardized questionnaire concerning occurrence of pain and headache, function of the jaw and joint sounds. Information from original records, radiographic reports and the standardized trauma charts revealed fracture site, type of fracture and intermaxillary ﬁxation if any. Eighty-seven percent of the patients reported no pain from the jaws, 83% had no problems chewing and 91% reported no impact of the fracture on daily activities. Neck and shoulder symptoms were reported by 39% and back pain by 30%. The 31-year results of non-surgical treatment of unilateral nondislocated and minor dislocated condylar fractures seem favourable concerning function, occurrence of pain and impact on daily life.
J. Andersson1,4,a, F. Hallmer2,4,a, L. Eriksson3,4
¨ National Dental Service, Sondrum, Getinge, ¨ Sweden; 2National Dental Service, Orebro, 3 Sweden; Department of Oral and Maxillofacial Surgery, University Hospital ¨, MAS, Malmo Sweden; 4Department of Oral Surgery and Oral Medicine, Faculty of ¨, ¨, Odontology, University of Malmo Malmo Sweden
Key words: condylar fractures; non-surgical treatment; long-term results. Accepted for publication 8 November 2006 Available online 18 January 2007
Condylar fractures account for between 25% and 35% of all mandibular fractures. Concerning condylar fractures in children there is a consensus of opinion for a nonsurgical approach4,5,10,11. In adults it is still a highly debated theme, and MALKIN et al.12 already in 1964 stated that: ‘Concerning the treatment of condylar fractures, it seems that the battle will rage forever between the extremists who urge nonoperative treatment in practically every case and the other extremists who advocate open reduction in almost every
0901-5027/040310 + 05 $30.00/0
case.’ According to ELLIS & THROCKMOR5 TON the topic of mandibular condylar fractures has generated more discussion and controversy than any other in the ﬁeld of trauma. At the University Hospital of Malmo, ¨ Sweden, standardized trauma forms were used for registration of all jaw fractures between 1972 and 1976. This hospital was the only location for treatment of jaw fractures in Malmo at that time. The ¨ aim of this study was to interview all patients treated non-surgically for unilat-
eral mandibular condylar fractures during this period, giving a follow-up of 31 years as a mean.
Patients and methods
In total, 49 patients, 37 men and 12 women (mean age 32.4 years, SD = 19.5, median age 27 years, range 5–83), with unilateral condylar fractures were
These authors contributed equally to the present work.
# 2006 International Association of Oral and Maxillofacial surgeons. Published by Elsevier Ltd. All rights reserved.
Condylar fractures: a 31-year follow up
treated non-surgically during 1972–1976. The patients had no other jaw fractures diagnosed clinically or radiologically. When treatment of the fractures was ﬁnished, data from the records were collected on all patients by the same person, according to a standardized form. In 2005 a followup was performed based on these forms. From the register of national registration numbers at the national registration authority current addresses were found. Fourteen men and three women (mean age 49.8 years, SD = 20.6, median age 49.0 years, range 16–83) were dead at the time of the follow up, and four men and three women (mean age 32.1 years, standard deviation SD = 8.1, median age 34 years, range 18– 42) could not be found in the national register. Two men did not answer letters or phone calls. Thus a total of 23 patients, 17 men and 6 women (mean age at follow-up 50.4 years, SD = 8.9, median age 49 years, range 37–75), were available for a 31-year follow-up (range 29–33). At the time of the fracture 15 of the patients were between 17 and 44 years old and 8 patients between 5 and 15 years (infant group). In the infant group four patients had fractures on the left side and four on the right side. None or only minor dislocation of the fractured condyle was seen in two of these patients at the time of injury. In three patients the condyles were severely tilted medially and anteriorly. Information on the occurrence of dislocation was not available for three patients. In the adult group seven patients had fractures on the left side and eight on the right side. None or only minor dislocation of the fractured condyle was seen in 10 of these 15 patients at the time of the injury. One of these fractures was classiﬁed as intracapsular. In three patients the condyles were severely tilted medially and anteriorly. Information on any dislocation could not be gained for two patients. In the infant group none of the patients had intermaxillary ﬁxation. In the adult group (15 patients) 4 patients were intermaxillary ﬁxated, 3 of whom had dislocated condyles, for 2–6 weeks with elastics, while 9 patients only were recommended a soft diet for 2 weeks. Information on two patients was not available. At the time of the last consultation, according to the records, 17 patients had an occlusion identical to the pretrauma occlusion. One patient had a minor bite opening in the cuspid and premolar region on the contralateral side to the fracture. This patient reported at the long-term follow-up moderate problems with chewing. Information on occlusion at the last consultation was missing for ﬁve patients. The reason for the missing information on some parameters is that most of the records and forms were stored on CD, and scanning had in some cases resulted in parts of the text not being readable. The 23 patients available at follow-up were informed by letter that they would be contacted by telephone in a couple of weeks to hear if they were willing to participate in a telephone interview concerning the current status of their earlier fractured jaw. A standardized questionnaire was used to record occurrence of pain, headache, problems in functioning of the jaw, joint sounds and disturbed sleep because of joint pain according to Table 1. A 10-grade visual analogue scale (VAS) was used for evaluation of intensity of pain (no pain – intolerable pain), ability to chew (no problem – very severe problems) and impact on daily life (not at all – very great impact). The patients were asked if they had all their teeth, partial loss of teeth or total loss of teeth, and if they had a removable prosthesis. There was no question on any disturbance in occlusion, as the patient’s evaluation was thought to be too uncertain, especially as major prosthetic reconstructions might have been done during the 30 years since the fracture. Joint and muscle disease, neck and shoulder problems, back pain and migraine were recorded, as well as occurrence of further jaw fractures after the initial fracture. Regular use of pain medication, muscle relaxants and tranquilizers was recorded. Information from the original records, radiographic reports and the standardized
summary revealed fracture site, appearance of the fracture and any intermaxillary ﬁxation. The fractures were classiﬁed as intracapsular or fracture of the condylar neck. Fractures without dislocation or with only minor dislocation, according to the radiographic report, were classiﬁed as non-dislocated. The others were classiﬁed as dislocated. Panoramic radiographs and postero-anterior projections were used on all patients at the initial examination. The examinations were done at the Department of Oral Radiology, Dental School, Malmo, ¨ Sweden. Owing to the long interval between the initial examination and the follow-up no radiographs were available, as they were discarded after 10 years according to ofﬁcial regulations.
At the time of follow-up, 18 patients had all their teeth, 4 patients were partially edentulous and 1 patient had upper and lower full dentures. None of the patients had suffered any further jaw fractures. History of pain, headache, function of the jaw, joint sounds and disturbed sleep because of joint pain is shown in Table 1. As some of the data concerning pain, disturbed ability to chew and impact on daily activities seemed to be contradictory, those who had made positive indications received a second phone call. Twenty out of 23 patients reported no pain from the jaws and/or face. Three out of 23 patients reported pain, one daily and two more sporadically. The patient with daily pain, estimated as VAS 1, would according to the second phone call rather classify the pain as spasm and fatigue. The sensation was the same also on movement of the lower jaw. This patient was in the infant group at the time of fracture and had no dislocation of the condyle. The second patient estimated the pain as VAS 4 when she was opening her mouth maximally, for example when yawning. This patient was in the adult group at the time of fracture and had only minor dislocation of the condyle. The third patient estimated his
Table 1. History according to telephone interview 31 years after non-surgical treatment of unilateral condylar fractures (n = 23) Never Pain in the face and jaws Headache Pain on jaw movements Restricted opening Feeling of fatigue in the jaws Clicking Crepitation Locking Disturbed sleep because of joint pain 20 15 21 22 15 15 22 22 23 1–2 times a month 1 5 1 3 4 1 1 Once a week 1 1 1 1 Several times a week 2 1 1 3 4 Daily 1
Andersson et al.
The national registration numbers used for all Swedes nowadays were not in use in hospital records 30 years ago. In spite of this, current addresses, and also information on those patients who had died, were acquired by the aid of the national registration and taxation authorities. On seven of the initial 49 patients it was not possible to get any information, as they might have moved abroad or changed identity. A comparison of the 23 patients found with the data of the missing patients did not indicate any major differences concerning type of fracture, age at the time of trauma and treatment. These results may be looked upon as representative of all the patients in spite of the major loss (53%) at follow-up. According to this 31-year follow-up of non-surgically treated unilateral mandibular condylar fractures, the results seem to be acceptable. Eighty-seven percent reported no pain from the jaws, 83% had no problems when chewing and 91% had no problems maintaining their daily activities, when those who were children and those who were adults at the time of fracture were looked upon as one group. From earlier studies it is well known that fractures in children usually have a good prognosis2,7,10,19. The fact that in the present study 35% of the patients were children at the time of fracture might have had a positive inﬂuence on the results. Concerning the age of the patients it seemed reasonable to classify patients 15 years or younger as children. Only one out of eight patients who were children at the time of the fracture reported minor pain on movement of the jaw 31 years later. This patient had a non-dislocated fracture. None of the other patients in this group experienced any problems with pain, chewing or impact on daily activities, in spite of the fact that at least three of them had initially displaced condyles. When those who were adult at the time of the fracture were looked upon as one group, 20% (3/15 patients) reported minor to moderate problems (VAS 1–4) and 7% (1/15 patients) more severe problems (VAS 5–10), with either pain on movement of the lower jaw, problems chewing or impact on daily life. One of the patients in the ﬁrst group had a dislocated fracture and the patient in the second group had an intracapsular fracture, while the other two patients had non-dislocated fractures. The number of dislocated condyles or intracapsular fractures was small, which is why the impact of ﬁndings on pain and function in this group should be interpreted with caution. SANTLER et al.14 reported that dislocation often led to a reduction in mouth opening and higher incidence of subjective discomfort during heavy chewing. High-grade dislocation or luxation has been reported to cause frequent pathological changes in function19 as well as altered occlusion or ability to bite only unilaterally16. Frequent consumption of pain medication, muscle relaxants and tranquilizers for other reasons than jaw problems might also have an inﬂuence on the results. As only two patients reported such medication, it should not have a major impact on the ﬁndings. In spite of more than 30% of the patients reporting neck and shoulder symptoms and/or back pain, referred pain does not seem to have a major effect on the results, as the majority of the patients reported that they had no pain in the face and jaws. Thirty-ﬁve percent of the patients experienced headache and 13% reported migraine, most often sporadically. As the prevalence of tension headache has been reported to be 86% among women and 63% among men, while the corresponding ﬁgures for migraine are 15% and 6%, respectively, headache does not appear to be a consequence of condylar fracture6. Thirty-nine percent of the patients reported clicking or crepitation daily or sporadically from the temporomandibular joints. This is in accordance with observations on the prevalence of awareness of undeﬁned TMJ sounds in the population, estimated to be 6–48%1, and thus fractured condyles did not seem to have a major inﬂuence on the occurrence of joint sounds. The treatment philosophy for the patients in this study was to mobilize the jaw early and use rubber bands for ﬁxation, if the occlusion was not spontaneously normalized, within the ﬁrst 3 days after the fracture (ﬁve patients). This is principally in agreement with treatment regimes used at other centers4,7,22. Concerning fractures in children, THOREN et al.20 concluded that conservative treatment of dislocated condylar process fractures results in satisfactory long-term outcome of jaw function despite a high frequency of radiologically noted aberrations. Similar observations were made by CHOI et al.2. There seem to be different opinions concerning such long-term radiological ﬁndings in children, as LINDAHL & HOLLENDER11 found that children until they were teenagers had a good capacity to completely return to normal skeletal relations. They concluded that remodelling processes of the condylar process in a clinical sense may be looked upon as restitutional in children, and adjusting and functional in adults.
pain as VAS 2 once or twice a month, and related to a feeling of numbness in a scar on the lip following the trauma. This patient had an intracapsular fracture and was adult at the time of fracture. Nineteen patients out of 23 reported that they had no problems chewing. One patient marked VAS 1 on the ability to chew. She was in the adult group at the time of trauma with minor dislocation of the condyle. Two patients marked VAS 4. One of them was the same patient as mentioned above, who reported pain as VAS 4 on maximal opening. During the second phone call the patient revealed that the problem with chewing was that the bite did not ﬁt correctly. The other patient with VAS 4 was also in the adult group at the time of trauma and had a dislocated condyle. The problem in chewing was a feeling of fatigue in the cheeks. Similar fatigue was also reported by the patient with the intracapsular fracture mentioned above, who estimated the problems with chewing as VAS 6. No impact on daily activities was reported by 21/23 patients. One patient in the adult group with a dislocated condyle at time of fracture reported VAS 3 concerning impact on daily activities. This patient was the same one who experienced fatigue on chewing, estimated as VAS 4. The second patient with impact on daily activities was the one with the intracapsular fracture, who also reported fatigue on chewing estimated as VAS 6. History of joint and muscle disease, neck and shoulder symptoms, back pain and migraine is shown in Table 2. Pain medication was used regularly by two patients, one of whom reported joint and muscle disease. This patient also used muscle relaxants and a tranquilizer regularly. The patient was the same one who reported pain at maximal opening of the mouth and a non-ﬁtting bite on chewing. The other patient taking pain medication regularly because of neck and shoulder problems was the one with the intracapsular condylar fracture.
A disadvantage of long-term follow-ups is the difﬁculty of ﬁnding all the patients.
Table 2. History according to telephone interview 31 years after non-surgical treatment of unilateral condylar fractures (n = 23) Yes Joint and muscle disease Neck and shoulder symptoms Back pain Migraine 1 9 7 3 No 22 14 16 20
Condylar fractures: a 31-year follow up
Recently, KONDOH et al.8 reported that intra-articular irrigation and corticosteroid injection into a fractured joint is a more effective and faster acting method than conventional closed reduction with intermaxillary ﬁxation for functional recovery and control of clinical symptoms of patients with unilateral fresh condylar fractures. This method may have an initial beneﬁcial effect, but the present study indicates that irrigation and steroids are not necessary to achieve acceptable long-term results. In a follow-up of 348 patients with condylar fractures MARKER et al.13 concluded that conservative treatment of condylar fractures is non-traumatic, safe and reliable, and in only a few cases may cause disturbance of function and malocclusion. The indications for surgical treatment are still under debate. According to a study by THROCKMORTON & ELLIS21 in general patients with unilateral fractures of the condylar process had maximum excursions that returned to normal values within 3 years of fracture regardless of treatment, but patients treated surgically exhibited a faster rate of improvement in maximum interincisal opening than patients treated closed. Patients treated open also exhibited a faster rate of improvement in maximum excursion toward the fracture side than patients treated closed. Based upon the same study, patients with unilateral fractures of the condylar process who were treated closed and not put into maxillomandibular ﬁxation but instructed in physical therapy could be expected to achieve normal maximum excursions within 3 years of the end of treatment. According to STIESCH-SCHOLZ et al.18 open as well as closed treatment gave clinically acceptable functional results, although they found that condylar mobility was markedly greater after open treatment than after closed treatment. Using radiographic examinations KON9 STANTINOVIC & DIMITRIJEVIC found statistically better position of surgically reduced condylar fractures but according to clinical parameters, no statistical differences between surgically and conservatively treated fractures were found. Similar results have been reported by SANTLER et al.14 who did not ﬁnd any signiﬁcant differences in mobility, joint problems, occlusion, muscle pain or nerve disorders when surgically and non-surgically treated patients were compared. They concluded that, because of its disadvantages, open surgery is only indicated in patients with severely dislocated condylar process fractures. A more aggressive treatment philosophy is supported by WORSAAE & THORN23, who found that malocclusion, mandibular asymmetry, impaired masticatory function, and pain located to the affected joint or masticatory muscles were seen signiﬁcantly more frequently in patients treated with closed reduction compared to those treated surgically. Neither the degree of dislocation of the proximal fragment, concomitant mandibular fractures, nor the absence of posterior occlusal support seemed to inﬂuence the results. SILVENNOINEN et al.15,16 stressed the importance of observing the ramus height in patients with persistent malocclusion. The height was signiﬁcantly reduced in patients with persistent malocclusion irrespective of degree or direction of the angulations between the fragments. They concluded that condylar fractures with the potential for future problems can often be identiﬁed preoperatively by means of simple radiographic measurements, and those cases with reduced height should probably be treated surgically. A similar treatment philosophy has been proposed by SMETS et al.17, that only in selected patients with shortening of the ascending ramus of 8 mm or more and/or considerable displacement of the condylar fragment should surgical repositioning and rigid internal ﬁxation be considered. Although the topic of mandibular condylar fractures is still controversial, for non-dislocated or only minor dislocated condylar fractures several studies seem to support non-surgical treatment. DAHL3 ¨ STROM et al. in a prospective 15-year follow-up concluded that condylar fractures without dislocation showed minimal signs of dysfunction that were independent of age. This is in accordance with the present observations, which show results to be favourable up to 31 years after the fracture.
1. Carlsson GE. Epidemiological studies of signs and symptoms of temporomandibular joint-pain-dysfunction. A literature review. Aust Prosthodont Soc Bull 1984: 14: 7–12. 2. Choi J, Oh N, Kim IK. A follow-up study of condyle fracture in children. Int J Oral Maxillofac Surg 2005: 34: 851–858. ¨ 3. Dahlstrom L, Kahnberg KE, Lindahl L. 15 years follow-up on condylar fractures. Int J Oral Maxillofac Surg 1989: 18: 18–23. 4. Ellis III E. Condylar process fractures of the mandible. Facial Plast Surg 2000: 16: 193–205. 5. Ellis III E, Throckmorton GS. Treatment of mandibular condylar process
fractures: Biological considerations. J Oral Maxillofac Surg 2005: 63: 115–134. ¨ Hindfelt B, Kahn R, Traff P. Huvudvark. The Drug Book. Stockholm: The ¨ National Corporation of Swedish Pharmacies 2001/2002: pp. 716–726 [Headache (in Swedish)]. Hovinga J, Boering G, Stegenga B. Long-term results of nonsurgical management of condylar fractures in children. Int J Oral Maxillofac Surg 1999: 28: 429–440. Kondoh T, Hamada Y, Kamei K, Kobayakawa M, Horie A, Iino M, Kobayashi K, Seto K. Comparative study of intra-articular irrigation and corticosteroid injection versus closed reduction with intermaxillary ﬁxation for the management of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004: 98: 651–656. Konstantinovic VS, Dimitrijevic B. Surgical versus conservative treatment of unilateral condylar process fractures: clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 1992: 50: 352–353. Lindahl L. Condylar fractures of the mandible. IV. Function of the masticatory system. Int J Oral Surg 1977: 6: 195–203. Lindahl L, Hollender L. Condylar fractures of the mandible. II. A radiographic study of remodelling processes in the temporomandibular joint. Int J Oral Surg 1977: 6: 153–165. Malkin M, Kresberg H, Mandel L. Submandibular approach for open reduction of condylar fractures. Oral Surg Oral Med Oral Pathol 1964: 17: 152–157. Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 2: results of treatment of 348 patients. Br J Oral Maxillofac Surg 2000: 38: 422–426. Santler G, Karcher H, Ruda C, Kole E. Fractures of the condylar process: surgical versus nonsurgical treatment. J Oral Maxillofac Surg 1999: 57: 392–397. Silvennoinen U, Iizuka T, Oikarinen K, Lindqvist C. Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. J Oral Maxillofac Surg 1994: 52: 793–799. Silvennoinen U, Raustia AM, Lindquist C, Oikarinen K. Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. A prospective one-year study. Int J Oral Maxillofac Surg 1998: 27: 280–285. Smets LM, Van Damme PA, Stoelinga PJ. Non-surgical treatment of condylar fractures in adults: a retrospective analysis. J Craniomaxillofac Surg 2003: 31: 162–167. Stiesch-Scholz M, Schmidt S, Eckardt A. Condylar motion after open and closed treatment of mandibular condylar fractures. J Oral Maxillofac Surg 2005: 63: 1304–1309. Stoll P, Waechter R, Schlotthauer U, Tuerp J. Late results of 15 years and longer after mandibular condyle
Andersson et al.
condylar process fractures. Int J Oral Maxillofac Surg 2000: 29: 421–427. 22. Walker RV. Condylar fractures: nonsurgical management. J Oral Maxillofac Surg 1994: 52: 1185–1188. 23. Worsaae N, Thorn JJ. Surgical versus non-surgical treatment of unilateral dislocated low subcondylar fractures: a clinical study of 52 cases. J Oral Maxillofac Surg 1994: 52: 353– 360. Address: Lars Eriksson Department of Oral and Maxillofacial Surgery ¨ Malmo University Hospital SE 205 02 ¨ Malmo Sweden Tel: +46 40 33 31 09 Fax: +46 40 33 62 05 E-mail: email@example.com
fractures. Fortschr Kiefer Gesichtschir 1996: 41: 127–130. 20. Thoren H, Hallikainen D, Iizuka T, Lindquist C. Condylar process fractures in children: a follow-up study of fractures with total dislocation of the condyle from the glenoid fossa. J Oral Maxillofac Surg 2001: 59: 768–773. 21. Throckmorton GS, Ellis 3rd E. Recovery of mandibular motion after closed and open treatment of unilateral mandibular
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.