Surgical treatment of the fractured and dislocated condylar process of the mandible

doi:10.1016/S1010-5182(05)80132-5

Journal of Cranio-Maxillofacial Surgery

Volume 23, Issue 6, December 1995, Pages 369-376

https://doi.org/10.1016/S1010-5182(05)80132-5 Get rights and content

Summary

Most fractures of the mandible can be managed conservatively. This report is a retrospective evaluation of the clinical and radiological results in 17 patients with 21 dislocated fractures submitted to open reduction and fixation, employing steel wires and maxillomandibular fixation. Follow-up ranged from 7 to 55 months, (mean 29.5). Functional assessment showed good opening movements (mean 41.9 mm). There were no cases of ankylosis, pain, or paralysis of the facial nerve. Radiological assessment was normal when the lateral pterygoid muscle was maintained adherent to the fractured proximal segment. Radiological signs of bone resorption occurred when the fractured segment was detached from the lateral pterygoid muscle. In our opinion, dislocated condylar process fractures can be managed surgically and with steel wire ligatures and maxillomandibular fixation. Whenever possible, the lateral pterygoid muscle should be inserted into the fractured proximal segment, i.e. as an osteomuscular flap.

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Cited by (43)

Evaluating the efficacy of disc repositioning in the management of high condylar fracture — A prospective clinical trial
2022, Journal of Cranio-Maxillofacial Surgery
The aim of the study was to assess the role of disc repositioning in treating high condylar fractures.
Patients who reported to the Department of Oral and Maxillofacial surgery with high condylar fractures were recruited for this study, and randomized into two groups. The study group underwent ‘disc repositioning during ORIF’, while ‘ORIF without disc repositioning’ was performed for the control group.
Patients were assessed for pain, mouth opening, clicking, and mandibular deviation (Helkimo clinical dysfunction Index), preoperatively and postoperatively (immediate and at 3 months). The position of the disc was assessed by MRI preoperatively and at 3 months postoperatively.
24 patients were included in the study, and divided equally into test (N = 12) and control (N = 12) groups. Descriptive statistics were used to find the means and standard deviations of the parameters, and inferential statistics to assess p-values, using an independent-sample t-test. At 3 months after surgery, 10 patients in the test group demonstrated absence of pain (mean 0.1 ± 0.3), while only one patient was pain free in the control group (mean 5.2 ± 2.3). There was a significant improvement in mouth opening in the study group (mean 37.4 ± 3.4) in comparison with the control group (mean 22.5 ± 9.5). The study group demonstrated favourable surgical outcomes for all parameters (p < 0.0001), aside from clicking.
Within the limitations of the study, disc repositioning in high condylar fractures appeared to demonstrate a positive effect on TMJ function, and hence should be considered in appropriate indications.
Will Closed Treatment Provide Better Mandibular Motion Than Open Reduction and Internal Fixation in Cases of Unilateral Displaced Subcondylar Fracture? A Systematic Review and Meta-Analysis
2020, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Of the 54 studies, 43 were excluded after the full-text article screening. Of the 43 excluded studies, 21 were excluded because of the study design,4,10-12,15,17,28,31-34,36,38,40,43,45,46,50,54,59,60 20 were excluded because their topic was irrelevant,13,14,18-27,29,37,39,41,44,47,61,62 and 2 were excluded because the studies had not been reported in English.35,42 Of the 11 included studies, 5 were RCTs,30,49,52,53,58 3 were NRCTs,51,55,56 and 3 were observational studies.16,48,57
The aim of the present systematic review was to determine whether closed treatment (CLT) with intermaxillary fixation (IMF) is superior or equivalent to open reduction and internal fixation (ORIF) in the management of unilateral displaced subcondylar fractures regarding the range of mandibular motion.
To address our question, we conducted a systematic review and meta-analysis of the reported data after a comprehensive manual and electronic database search of studies reported up to 2017 in the English language that had compared CLT and ORIF of mandibular condyle fractures in adults. The following outcomes were recorded: maximum interincisal opening (MIO), protrusive movement (PM), lateral excursion toward the fractured side (LEFS), and lateral excursion toward the nonfractured side (LENFS).
The search resulted in 8 studies, 4 of which were included in the meta-analysis. The MIO and PM showed no statistically significant differences, with an effect size of −0.823 (P = .112) and −0.633 (P = .079), respectively. However, the LEFS and LENFS were superior after CLT, with an effect size of −0.710 (P = .031) and −0.682 (P = .017), respectively.
The findings from the present review suggest that both ORIF and CLT can provide comparable MIO and PM in subjects with unilateral displaced subcondylar fractures. However, CLT was superior to ORIF for both LEFS and LENFS.
Changes of disc status in adult patients with condylar head fracture who did or did not undergo disc anchoring operation
2018, Journal of Cranio-Maxillofacial Surgery
Views on treatment procedures for condylar head fractures (CHFs) are far from reaching a consensus. The aim of this study was to evaluate the changes in disc status for anteromedial disc displacement with anchorage (AMDDwA) and without anchorage (AMDDwoA — just suturing to the adjacent TMJ soft tissue) in adult CHFs, to get a better understanding of this very complex process and to show that rigid disc anchorage is an essential technique for the treatment of CHF during the open reduction and internal fixation (ORIF).
144 temporomandibular joints (TMJ) in 95 patients were included in this retrospective study, and were divided into an AMDDwA group (50 TMJs in 38 patients) and an AMDDwoA group (94 TMJs in 57 patients) based on the different surgical procedures. The joints were quantitatively and qualitatively assessed for disc length and disc morphology preoperatively and at follow-up visits. Other variables, such as disc position, joint effusion, retrodiscal tear and lateral capsular tear, were also evaluated. Paired t-tests, Wilcoxon signed rank tests, independent t-tests and χ² tests were used to assess intragroup and intergroup differences.
The results showed that discs became shorter, moved further forward and distorted more seriously in the AMDDwoA group. In contrast, discs became longer, maintained a normal disc–condyle relationship in the AMDDwA group. Joint effusion, retrodiscal tear, and lateral capsular tear healed well in both groups.
Taking these findings together suggests that the rigid disc anchorage is an alternative technique for the treatment of CHF.
Does the surgical approach for treating mandibular condylar fractures affect the rate of seventh cranial nerve injuries? A systematic review and meta-analysis based on a new classification for surgical approaches
2018, Journal of Cranio-Maxillofacial Surgery
The purpose of this study was to determine the rate of facial nerve injury (FNI) when performing (ORIF) of mandibular condylar fractures by different surgical approaches.
A systematic review and meta-analysis were performed that included several databases with specific keywords, a reference search, and a manual search for suitable articles. The inclusion criteria were all clinical trials, with the aim of assessing the rate of facial nerve injuries when (ORIF) of mandibular condylar fractures was performed using different surgical approaches. The main outcome variable was transient facial nerve injury (TFNI) and permanent facial nerve injury (PFNI) according to the fracture levels, namely: condylar head fractures (CHFs), condylar neck fractures (CNFs), and condylar base fractures (CBFs). For studies where there was no delineation between CNFs and CBFs, the fractures were defined as CNFs/CBFs. The dependent variables were the surgical approaches.
A total of 3873 patients enrolled in 96 studies were included in this analysis. TFNI rates reported in the literature were as follows: A) For the transoral approach: a) for strictly intraoral 0.72% (1.3 in CNFs and 0% for CBFs); b) for the transbuccal trocar instrumentation 2.7% (4.2% in CNFs and 0% for CBFs); and c) for endoscopically assisted ORIF 4.2% (5% in CNFs, and 4% in CBFs). B) For low submandibular approach 15.3% (26.1% for CNFs, 11.8% for CBFs, and 13.7% for CNFs/CBFs). C) For the high submandibular/angular subparotid approach with masseter transection 0% in CBFs. D) For the high submandibular/angular transmassetric anteroparotid approach 0% (CNFs and CBFs). E) For the transparotid retromandibular approach a) with nerve facial preparation 14.4% (23.9% in CNFs, 11.8% in CBFs and 13.7% for CNFs/CBFs); b) without facial nerve preparation 19% (24.3% for CNFs and 10.5% for CBFs). F) For retromandibular transmassetric anteroparotid approach 3.4% in CNFs/CBFs. G) For retromandibular transmassetric anteroparotid approach with preauricular extension 2.3% for CNFs/CBFs. H) For preauricular approach a) deep subfascial dissection plane 0% in CHFs b) for subfascial approach using traditional preauricular incision 10% (8.5% in CHFs and 11.5% in CNFs). I) For retroauricular approach 3% for CHFs. PFNI rates reported in the literature were as follows: A) for low submandibular approach 2.2%, B) for retromandibular transparotid approach 1.4%; C) for preauricular approach 0.33%; D) for high submandibular approach 0.3%; E) for deep retroparotid approach 1.5%.
According to published data for CHFs, a retroauricular approach or deep subfascial preauricular approach was the safest to protect the facial nerve. For CNFs, a transmassetric anteroparotid approach with retromandibular and preauricular extension was the safest approach to decrease risk of FNI. For CBFs, high submandibular incisions with either transmassetric anteroparotid approach with retromandibular or transmassetric subparotid approach, followed by intraoral (with or without endoscopic/transbuccal trocar) were the safest approaches with respect to decreased risk of FNI.
Delayed open reduction and single screw internal fixation as a treatment option in cases of failed non-surgical treatment of bilateral condylar head fractures with fragmentation
2016, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
No matter how, the LPM should never be stripped from the fragment in any process of the operation. The importance of preservation of the LPM is that it is essential to provide sufficient vascular supply to the condyle to avoid the ischemic necrosis and resorption (Iizuka et al., 1991; Pereira et al., 1995; Kermer et al., 1998; Vesnaver, 2008; Chen et al., 2010). It is also related to the movement mechanism of the condyle (Sasaki et al., 2002; Chen et al., 2010).
To share our experience in the open reduction and single screw internal fixation of delayed bilateral condylar head fractures with fragmentation and evaluate its feasibility and outcomes.
The study involved 6 males and 1 female. All patients had multiple injuries at different body sites and failed non-surgical treatment of bilateral condylar head fractures. The mean period between the injury and the operation was 5.7 (4–8) weeks. According to the preoperative computer-aided design, and the clinical manifestations, the fracture fragments were reduced and fixed with a single screw. A helical CT scan was requested postoperatively to check the reduction of the fragments and the location of the screws. Mean follow-up duration was 9.7 (8–14) months.
The malocclusion was corrected after operation. The intraoperative passive mouth opening was 3.93 ± 0.19 cm. The mouth opening was 3.43 ± 0.35 cm in 3 months follow-up, and more than 3 transverse fingers at the last follow up. No one had a progressive limitation of the mouth opening in 8–14 months of follow up.
The strategy of open reduction and single screw internal fixation of bilateral condylar head fracture with fragmentation of mandible is feasible and effective. It is a treatment option in the rare delayed cases of failed non-surgical treatment.
Nonsurgical management of condylar fractures in children: A 15-year clinical retrospective study
2016, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Fractures of the mandibular condylar region especially have been reported to account for as much as 72%–80% of all mandibular fractures in children and adolescents (Thorén et al., 1992), with boys more commonly affected than girls (Zerfowski and Bremerich, 1998; Wu et al., 2012). As most condylar fractures are not caused by direct trauma but indirectly from a blow to a different mandibular site, the mandibular condyle is the most overlooked and least diagnosed trauma site in the head and neck region (Pereira et al., 1995; Chrcanovic, 2012). Undiagnosed and consequently not treated condylar fractures in childhood may become apparent later on, as they may create serious problems such as growth disturbances and asymmetry at multiple facial levels, temporomandibular joint disorders (dysfunction mainly and ankylosis), malocclusion, chronic dislocation, and pain on both the injured and the noninjured side (Zachariades et al., 1990; Lee et al., 1993).
To present the 15 years of experience after closed treatment of condylar fractures in children, by evaluating the short- and long-term results and propose treatment modalities.
Data were retrieved for all young patients with condylar fractures who were treated from 2000 to 2014. Gender, age of patient, date of injury, type of fracture, treatment provided, and follow-up were registered.
A total of 84 patients (mean age: 8.9 years) with 106 condylar fracture sites were included in the study. In 80 cases (95.2%), treatment was nonsurgical, with or without intermaxillary fixation, followed by kinesiotherapy. An intraocclusal block was additionally placed in 19 cases. Open reduction was selected in 4 cases. All condylar fractures healed without functional or esthetic complications, with the exception of 2 patients (2/80, 2.5%). Therefore, in late follow-up, no subjective symptoms were recorded, and a functional well-contoured condylar process was observed in all X-rays. Slight asymptomatic mandibular deviation was recorded in wide mouth opening in 29.1% of the patients.
Conservative treatment of condylar fractures is the treatment of choice in children. However, the child's age, adequacy of function of the mandible, degree of displacement or dislocation of the condylar fragment, and need for active kinesiotherapy should be considered in all cases.

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Surgical treatment of the fractured and dislocated condylar process of the mandible

Summary

Br. J. Oral and Maxillofac. Surg.

Clin. Radiol.

Oral Surg. Oral Med. Oral Pathol.

Int. J. Maxillofac. Surg.

J. Oral Maxillofac. Surg.

J. Craniomaxillofac. Surg.

J. Maxillofac. Surg.

Int. J. Oral Surg.

Int. J. Oral Surg.

Int. J. Oral Surg.