A comparison of open and closed treatment of condylar fractures: a change in philosophy

Giacomo De Riu, Ugo Gamba, Marilena Anghinoni, Enrico Sesenna Maxillofacial Surgery Department, Parma, Italy Int. J. Oral Maxillofac. Surg. 2001; 30: 384389

AIM OF THE STUDY

In this study, the results that we obtained in a homogenous sample of surgically treated condylar fractures with those for a group of patients with similar fractures treated with functional therapy at our centre several years ago.

Materials and methods

4 years 64 mandibular condylar fractures treated in 49 patients, aged 1369 (15 were bilateral). 20 open reduction and rigid fixation with plates and screws. non-surgical group 19 patients

Materials and methods

Functional treatment consisted of: (1) individual occlusion restoration with MMF for 57 days; (2) achievement of lateral protrusion on the contralateral side with horizontal light training elastics and nocturnal vertical traction to maintai the midline for 4060 days2; and (3) a lateral propulsion splint for a further 4050 days, in cases with less favourable progress (approximately 60%). During therapy, clinical checks were performed twice in the first 2 weeks and on a weekly basis subsequently.

 Surgical access :submandibular or preauricular approach, variant of the retromandibular approach. It consists of making a cutaneous incision on the surface of the mandibular angle and over the masseter muscle between the buccal and marginal rami of the facial nerve MMF was performed for 35 days followed by light functional therapy for periods varying from 12 months (weekly controls).

 Pre-treatment X-rays of fractured condyles were selected to obtain two groups of patients with similar kinds of fractures; only neck and lower condylar fractures with or without dislocation were included in the study Comparison of the two groups was based on pre- and post-treatment Xrays and clinical data.

Results
No significant differences were observed between the surgical and non-surgical groups for protrusive, lateral protrusive, or opening movements. Both groups showed similar signs of mandibular recovery and absence of muscular and joint pain. On radiographic analysis, surgical patients showed TMJ morphology similar to that on the contralateral unaffected side. Neither differences in the height of the rami nor alterations of the glenoid fossa were recorded, compared to the frequent rami asymmetry observed in nonsurgical patients.

Open versus closed treatment of fractures of the mandibular condylar processa prospective randomized multi-centre study.
Journal of Cranio-Maxillofacial Surgery (2006) 34, 306314 Uwe ECKELT

AIM:This study was an international prospective randomized multi-centre study was to compare operative and conservative treatment of displaced condylar fractures of the mandible.

MATERIAL AND METHORD

66 patients with 79 fractures of the mandibular condylar process. fractures were displaced, being either angulated between 10 and 45 or the ascending ramus was shortened by more than 2 mm. The follow-up examinations 6 weeks and 6 months following treatment included evaluation of radiographic measurements, clinical, functional and subjective parameters including visual analogue scale for pain.

Results
Correct anatomical position of the fragments was achieved signicantly more often in the operative group in contrast to the closed treatment group. Regarding mouth opening/lateral excursion/protrusion, signicant differences were observed between both groups (open 47/16/7 mm versus closed 41/13/5 mm).

 The visual analogue scoring revealed signicant differences with less pain in the operative treatment group (2.9 open versus 13.5 closed). After 6 months, in the closed treatment group 7 out of 30 (23%) patients reported occlusal disturbances. In the operatively treated group, 3 out of 36 (9%) patients reported occlusal disturbances.

 In 20 of 30 (66%) patients in the closed treatment group, terminal lateral shifts were observed. The average deection from the midline was 3.1 mm (range 17 mm) in this group. Operatively treated patients, a deection was observed in 7 cases (19%) with an average of 2.6 mm (range 17 mm) deviation.

Fractures of the Condylar process: Surgical Versus Nonsurgical treatment

Gert Santler Hans Kiircher , f Christof Ruda and Ernst KGle

J Oral Maxillofac Surg 1999; 57:392-397,

The purpose of this study was to compare outcomes from surgical and nonsurgical treatment of condylar process fractures.

 From 1987 to 1995, 292 fractures of the condylar process were treated in 234 patients. The ages ranged from 5 to 90 years (mean, 25; standard deviation [SD], 13.8). In 82 cases, the left, in 94 the right, and in 58 cases both sides were affected. There were 37 fractures of the condyle and 255 of the condylar neck (69 high, 125 medium, 61 low) Of those patients treated nonsurgically, 161 (195 joints) were treated with MMF and 11 (19 joints) without it. Sixty-two patients (70 joints) were treated surgically.

 The clinical examination included measurement of maximal interincisal distance, protrusion and laterotrusion, a Krough-Poulsen-test to analyse joint problems, assessment of the occlusion, palpation of the masticatory muscles, neurologic evaluation of the 5th and 7th cranial nerves, and a questionnaire related to subjective discomfort.

 Both surgical and nonsurgical treatment showed satisfactory results. Only four patients(3%) had an interincisal distance of less than 35 mm, which was equally distributed in both groups. The mean mouth opening was 45.5 mm (surgical) and 47mm (nonsurgical). maximum mouth opening, protrusion, laterotrusion to and from the fractured side, as well as the difference between laterotrusion to and from the fractured side and deviation during mouth opening, were similar in both groups.

 Pain, muscle tension, and hypertrophy of the muscles were similarly distributed, as were joint problems such as pain, clicking, and crepitation on the fractured and the nonfractured side. The incidence of hypesthesia, paresthesia, and anesthesia of the mental nerve and the incidence of frontal and marginal facial nerve palsy were not significantly increased in the operated group. Also, occlusal disturbances showed no significant differences.

 Displacement of the ramus, deviation or dislocation of the condylar process, and absence of fragment contact all significantly influenced the results in the nonsurgical group. Displacement led to a reduced protrusion, laterotrusion to the non fractured side, and a greater difference between laterotrusion to and from the fractured side. Higher degrees of deviation led to more muscular pain, tooth grinding, and subjective discomfort.

 Lack of bony contact was correlated significantly with reduced mouth opening, laterotrusion to the non fractured side, a higher incidence of asymmetry during laughing and lip pursing, as well as weatherrelated discomfort. Dislocation also led to a reduction in mouth opening, a higher incidence of asymmetrical laughing and lip pursing, tooth grinding, and subjective discomfort during weather changes and heavy chewing.

Bite Forces After Open or Closed Treatment of Mandibular Condylar Process Fractures Edward Ellis III and Gaylord S. Throckmorton J Oral Maxillofac Surg 59:389-395, 2001

Purpose: This study compared maximum voluntary bite forces in patients who received either open or closed treatment for fractures of the mandibular condylar process.

Patients and Methods: One hundred fty-ve patients (127 male, 28 female) with unilateral fractures of the mandibular condylar process (91 treated closed and 64 treated open) were included in this study. Maximum voluntary bite forces were measured at 6 weeks, 6 months, and 1, 2, and 3 years after fracture.

 At each trial, unilateral maximum voluntary bite force was measured at 4 different tooth positions bilaterally using a standard transducer. Electromyography (EMG) of the masseter muscles was also recorded during the bite force measurements, and ratios of the working/balancing side EMG were calculated.

 This analysis found no signicant difference between treatment groups, and a reanalysis including condylar head fractures did not produce any signicant differences between treatment groups. No signicant differences were observed between maximum ipsilateral and contralateral bite forces for either group at any bite position at any time period.

 Ipsilateral and contralateral maximum bite forces were strongly correlated (range of r 5 0.638 to 0.934). Maximum bite forces did not differ signicantly among the fracture levels of the head, neck, or subcondylar regions. The presence of additional mandibular and/or maxillary fractures did not signicantly affect maximum bite forces.

 No correlations were observed between maximum bite forces and the amount of displacement of the condylar process. Maximum bite forces showed signicant differences with respect to tooth position, sex, and side of condylar process fracture.

 In both groups, molar bite forces were signicantly greater than premolar bite forces (P , .001), premolar bite forces were significantly greater than canine bite forces (P , .001), and canine bite forces were signicantly greater than incisor bite forces (P , .001) at all time intervals. Male bite forces were signicantly greater than female bite forces at all tooth positions in both treatment groups

Occlusal Results After Open or Closed Treatment of Fractures of the Mandibular Condylar Process Edward Ellis III,Patricia Simon and Gaylord S. Thockmorton J Oral Moxillofoc Surg 58; 260-268.2000
Aim: compared the occlusal relationships after open or closed treatment for fractures of the mandibular condylar process. Patients and Methods: A total of 137 patients with unilateral fractures of the mandibular condylar process (neck or subcondylar), 77 treated closed and 65 treated open, were included in this study. Standardized occlusal photographs obtained at several postsurgical time intervals were examined and scored by a surgeon and an orthodontist. Standard statistical methods were used to assess differences between groups.

Procedure
Standardized photographs of the patients occlusion were obtained at 6 weeks, 6 months, and 1,2, and 3 years after treatment. One surgeon (E.E.) and one orthodontist (P.S.) independently examined each set of photographs and rated the occlusion as good (normal for the patient), poor (abnormal for the patient), or undecided (could not decide from photographs). No attempt was made to quantify the malocclusion, if present.

TREATMENT GROUPS

Patients were placed into the open or closed treatment group based on the method of treatment they selected.

MEASUREMENTS OF CONDYLAR PROCESS DISPLACEMENT

If the condylar head was nondisplaced in either image, it was rated as having no displacement. If the head was grossly in the fossa and there was less than 20 of condylar process tilting, the score was minimal displacement. If the head was at the tip of, or anterior to the eminence in the panoramic image, and medially tilted more than 20" in the Townes view, it was rated as maximum displacement.

EVALUATION OF OCCLUSION
One surgeon (E.E.) and one orthodontist (P.S.) independently examined each set of photographs and rated the occlusion as good (normal for the patient), poor (abnormal for the patient), or undecided (could not decide from photographs). No attempt was made to quantify the malocclusion, ifpresent.

Results
Observer 1 (P.S.) scored 240 occlusions as normal, 67 as poor, and 8 as unable to determine. Observer 2 (E.E.) scored 274 occlusions as normal, 41 as poor, and none as unable to determine. The occlusions scored as unable to determine were then eliminated, yielding a total of 307 occlusions in 135 patients for observer 1, and 315 occlusions in 137 patients for observer 2.

OCCLUSION AT SEQUENTIAL PERIODS

Both observers scored a significantly higher percentage of poor occlusions at the Gweek and 2- and 3-year periods for the closed treatment group. Observer 1 found a significantly higher percentage of poor occlusions in the closed treatment group at the lyear period. Neither observer found significant differences in the percentage of poor occlusions between open and closed treatment groups at 6 months. No poor occlusions were found by either observer for the open treatment group at 1, 2, or 3 years

Fracture location
Those treated by the closed technique showed a significantly greater percentage of poor occlusions than the open treatment group for fractures involving both the subcondylar and neck regions closed treatment group, those with neck fractures showed a greater percentage of poor occlusions than those with subcondylar fractures. Within the open treatment group, no significant difference was found in the percentage of poor occlusions between fractures of the subcondylar and neck regions.