CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART TWO
J Oral Maxillofac Surg
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 treat-
ment of adult condylar fractures, Brandt and Haug
offer information from previous historically important
studies regarding outcome of treatment.1 Their re-
view is intended to support their contention that
“under similar indications and conditions, ORIF is the
preferred approach” for the treatment of these inju-
ries.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 in-
terest. 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 dem-
onstration of a high rate of complication and treat-
ment failure after closed reduction. What better rea-
son 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, Ore-
gon Health & Science University, Portland, OR.
Address correspondence and reprint requests to Dr Assael: De-
partment of Oral and Maxillofacial Surgery, Oregon Health & Sci-
ence University, 611 SW Campus Dr, SD-522, Portland, OR 97239;
e-mail: assaell@ohsu.edu
© 2003 American Association of Oral and Maxillofacial Surgeons
0278-2391/03/6111-0016$30.00/0
doi:10.1016/S0278-2391(03)00736-5
1333
61:1333-1339, 2003
real clinical significance? Offered here is an assess-
ment that includes evidence from a nonconcurrent
control group, namely patients who have not sus-
tained condylar fractures. These patients offer useful
information on a realistic baseline of temporomandib-
ular 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 avail-
able for direct examination. Radiographic deformity is
interpreted as a complication in 61% of cases and as
clinical deformity in 6% of cases. These post-treat-
ment findings are in no way complications of treat-
ment. Patients interpret outcome based on the ab-
sence of pain, good function, and good appearance,
not on the assessment of a healed fracture on a radio-
graph.
A patient-centered approach to surgical outcome
might offer a different perspective on what is a com-
plication. As an illustration of this, the 6% incidence
of clinical deformity in MacLennan’s study was puz-
zling, because condylar fracture patients who com-
plained of a post-traumatic deformity are rare and are
likely due to unusual sequelae such as avascular ne-
crosis of the condylar head. MacLennan indicates that
his definition of clinical deformity is “the injured side
is characteristically flatter on palpation, with the con-
dylar head less prominent.” Hence this incidence of
deformity was detected by the clinician and not nec-
essarily perceived by the patient.
The facial projection of the lateral pole of the con-
dyle 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 prom-
inence 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 Mac-
Lennan’s series is the 24% incidence of deviation
noted in his series of examined patients.2 Because the
1334 OPEN VS CLOSED REDUCTION OF ADULT CONDYLE FRACTURES
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 condy-
lar fracture treatment played a role in the incidence of
deviation. Serendipitously, MacLennan had such a
group. Forty-nine patients with tuberculosis were ex-
amined who had no known temporomandibular dis-
order. Twenty-nine of 49 (58%) showed what Ma-
cLennan referred to as “textbook deviation.” As for
the 2 patients with chronic pain, 1 had panfacial
injuries and the other had legal action pending. Care-
ful inspection of MacLennan’s paper, a much-cited
series supporting nonsurgical management of condy-
lar fractures, indeed does much to continue to sup-
port 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 go-
nion. 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 ac-
counts 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 pa-
tients who appeared for examination an average of
5.8 years postinjury. Although Brandt and Haug con-
centrate 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 sig-
nificance 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% re-
ported any difficulty in chewing. Objective interin-
cisal opening was diminished, but only 13% of the
patients reported diminished jaw movement.4
Of critical importance in interpreting this informa-
tion 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 condy-
lar process fracture; there was no deviation, defor-
mity, 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 prob-
lems. Brandt and Haug1 contend that this report is
another indication that closed reduction of condylar
fractures is not a good technique because malocclu-
sion was noted in 13% of patients and other compli-
cations of treatment were noted. However, the Silven-
noinen 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 conclu-
sion 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 ipsilat-
eral molar occlusal interference, through the inability
to obtain maximum intercuspation, and through the
radiographic finding of significant superior displace-
ment 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 ex-
amination, when 54% of their condylar fracture pa-
tients were able to bring their teeth into normal oc-
clusion 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 excur-
sions 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 arti-
cle is that there is a small (perhaps 10%) subset of
condylar fracture patients with severe preoperative
functional derangements, which can be identified be-
fore treatment, who will benefit from open reduction.
Their investigation does not support blanket surgical
treatment for the nearly 9 of 10 patients who recov-
ered 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 consumer-
driven approach to health care is now a standard
assessment tool, the Chalmers J. Lyons Club were
prescient in their 1947 study that used patient self-
assessment as essential to their review of 120 pa-
tients.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 phys-
ical 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 consider-
ably with experience and technology to permit im-
proved minimally invasive techniques that result in
undisturbed healing in most cases. For example, Trou-
lis and Kaban9 recently showed effective open reduc-
tion 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, postop-
erative infection, and avascular necrosis of the condy-
lar head can be brought to nearly zero, the cost-
benefit 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 sys-
tem must be responsive to the contemporary treat-
ment options available to the surgeon.
The various condylar fracture classifications of Bro-
phy,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 seg-
ment. Thus, a contemporary attempt to assess those
fractures that would be best treated with open reduc-
tion should rely on only those case series with pa-
tients treated with stable internal fixation. It is of little
value to know what the anatomic findings of a frac-
ture are without the ability to provide meaningful
comparison of treatment outcomes. Hence, these an-
atomic classifications are of little contemporary clini-
cal value.
Contemporary surgeons are developing indications
for surgery based on emerging technology. Complica-
tions of surgery remain a central issue in treatment
method selection. Preauricular, postauricular, retro-
mandibular, 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 re-
ported 17.2% of open reduction patients with tempo-
rary facial nerve weakness and 7.5% with hypertro-
phic 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 re-
ported that of 40 patients undergoing open reduction
via a retromandibular approach, 3 had persistent fa-
cial 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 func-
tional disturbances 18 months after open reduction
and plate fixation via endoscopic technique. It is
worth noting that even with such exceptional out-
comes, the cases selected by Schon et al included
patients with dislocated fracture and those with addi-
tional facial fractures for whom the benefit of open
reduction seemed clear. It is clear that emerging tech-
nology and the growth in surgical experience have
expanded the indications of open reduction of con-
dylar fractures.20
The increased frequency of open reduction has
occurred without a further understanding of the ben-
efits of such treatment. Assessment of the variables
that influence the outcome of condylar fracture treat-
ment illustrates the futility of seeking any incontro-
vertible answers regarding the global optimal manage-
ment of condylar fractures. A careful assessment of
these factors leaves the certain conclusion that a va-
1336 OPEN VS CLOSED REDUCTION OF ADULT CONDYLE FRACTURES
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 evi-
dence-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 re-
garding 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 Hol-
lender,21,22 in a series of articles, showed that
children up to age 11 underwent considerable
more adaptation and remodeling than teenag-
ers or adults. Understanding the effect of treat-
ment in elderly patients has remained empiri-
cal.
2. Patient gender: Females may sustain more
functional derangement after condylar frac-
tures, and this effect may not be altered by the
mode of treatment. Idiopathic condylar resorp-
tion, disc displacement with symptoms, and
arthralgia are all more common in females.
3. Systemic diseases: Osteoporosis, osteopetro-
sis, diabetes mellitus, other endocrine disor-
ders, renal failure, alcoholism, drug and to-
bacco use, and other systemic conditions too
numerous to mention are know to affect frac-
ture treatment outcome. Risk of ankylosis after
treatment may also be increased with an assort-
ment of genetic and disease acquired influ-
ences. The presence of a particular systemic
disease might mitigate toward or away from
treatment with open reduction.
4. Patient compliance: Since Walker23 de-
scribed the techniques for functional rehabili-
tation after condylar fracture, the issue of pa-
tient compliance to obtain favorable treatment
outcome has been well known. Poor patient
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 ex-
ercises to support the retention of functional
occlusion and mandibular movement, surgical
patients must also be compliant regarding diet
and function.
5. Risk of infection: The risk of infection after
open treatment is small but always greater than
with closed reduction.25 Delayed surgery, com-
promised host, extended hospitalization, and
patients with multiple injuries are some of the
factors known to increase the risk of infection.
6. 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.
7. 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 nonsurgi-
cal patient on postoperative self-assessment by
the patient was the perception of scarring.
8. 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 com-
parison of open and closed reduction patients
is the contention that fewer open reduction
patients present with chronic pain in the in-
jured 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 in-
jured site at an average of nearly 4 years after
treatment. The incidence of chronic pain was
small in both groups, however.
9. 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 man-
agement. 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
10. 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
LEON A. ASSAEL
by the accumulation of blood or where the clot
organizes and results in fibroankylosis. Piper
and Chuong29 were the first to report arthro-
scopic intervention for lavage in association
with open reduction, but this has not become
routine in subsequent large case series.
11. 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.
12. Osteoarthrosis and bone resorption: Exter-
nal auditory canal or penetrating wound, com-
pound 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 prob-
lem was of clinical significance in only 1 pa-
tient, however.
13. 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.
14. Associated midface fractures: Restoration of
the dimensions of the face in panfacial frac-
tures requires the correction of posterior facial
height and projection. Open reduction of con-
dyle fractures is indicated in such cases.33
15. Associated cranial base fracture: Displace-
ment of the condyle into the middle cranial
fossa is considered a good indication for open
reduction in patients whose overall status per-
mits surgical treatment.34
16. 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 out-
comes based on the status of the dentition.
Empirically it is known that the posterior den-
tition plays a role in maintenance of ramus
height, so that patients without “posterior oc-
clusal stops” lose greater ramus height. Balanc-
ing side interferences during excursion away
from the side of fracture may result in greater
occlusal trauma when there is a partial loss of
dentition.
17. Dentofacial classification: Angle Class II pa-
1337
tients, especially those with a high mandibular
plane angle, are more prone to open bite and
further retrognathia after closed treatment.
18. Other dental function and occlusion con-
siderations: The depth of occlusal contacts in
maximum intercuspation, and working/balanc-
ing 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 of-
ten 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 occlu-
sal interferences during function. These may
be very difficult to manage with closed reduc-
tion, whereas imprecise open reduction might
create similar problems. Findings on lateral ex-
cursion and protrusion and interincisal open-
ing in the postinjury evaluation might offer
clues as to the best methods of treatment and
rehabilitation
19. Location of condylar fracture (low, me-
dium, high) and displacement of proximal
(condylar) segment: Very low fractures in
patients with good dentition are known to of-
ten 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 con-
dylar head.
20. 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 pa-
tient, the risk of fixation failure is increased.
The wear on the occlusal surfaces of teeth
makes maintenance of the occlusion problem-
atic when closed reduction is selected.
21. Functionally shortened ramus: A function-
ally shortened ramus differs from anatomic
shortening. The anatomically shortened ramus
is measurable on radiograph or clinically indi-
cated 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 pa-
tients do not exhibit functional derangements
in mastication or occlusion, such as a function-
ally shortened ramus. Patients with functional
derangements due to a shortened ramus have
an important indication for open reduction.
Findings of ipsilateral persistent occlusal pre-
maturity, inability to achieve maximum inter-
cuspation, and inability to achieve contralateral
1338 OPEN VS CLOSED REDUCTION OF ADULT CONDYLE FRACTURES
occlusal working side contacts are some find-
ings indicating a functionally shortened ramus.
22. Patient expectations: The patient’s assess-
ment of the benefits, risks, and alternatives of
proposed therapy might differ from the sur-
geon’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.
23. Ability of the surgeon: Experienced sur-
geons who undergo objective training and eval-
uation 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.
24. Technology of the health care environ-
ment: Emerging technology will continue to
alter the landscape of clinical decision making
for condylar fractures. Minimally invasive sur-
gery, navigation, and tissue engineering will
affect the indications for surgery in the future.
25. Institutional resources: Trauma care is a
highly specialized and resource intense en-
deavor that depends on the ability of the health
care environment to provide preoperative eval-
uation and intraoperative and postoperative
care. The continued ability to effectively pro-
vide these demanding services has come into
question in many centers.37
26. Willing payer: The emergence of managed
care has affected the use of procedures as dis-
parate as coronary artery bypass graft surgery
and cholecystectomy. Justification for treat-
ment 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 expe-
riences of surgeons indicates that both open reduc-
tion 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 derange-
ment 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 inves-
tigation. However, there are several complications
that remain reserved for those patients treated surgi-
cally. Although the incidence of each of these com-
plications is small, in the aggregate they constitute a
considerable burden for the patients who undergo
open reduction and internal fixation of condylar frac-
tures. 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 mix-
ture and relative role of each of these factors are
evaluated individually by each surgeon for each pa-
tient. Hence, treatment selection for mandible con-
dyle fractures remains an evidence-based art.
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