Analysis of Different Treatment Protocols for Fractures of Condylar Process of Mandible

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J Oral Maxillofac Surg70:83-91, 2012

Analysis of Different TreatmentProtocols for Fractures of Condylar

Process of MandibleMonika Gupta, MDS,* Nageshwar Iyer, MDS,†

Debdutta Das, MDS,‡ and Jagannath Nagaraj, MDS§

Purpose: The present study was conducted to provide an overall perspective on the diagnosis ofcondylar fractures, to analyze the technique and results of different treatment methods used, and toevolve a protocol for the selection of an appropriate treatment modality for an individual case.

Patients and Methods: A total of 28 patients with a condylar fracture were selected and wereclassified with the help of orthopantomogram and reverse Towne view radiographs. Of the 28 patients,22 had unilateral fractures of the mandibular condyle process and 6 had bilateral fractures. They weretreated with no invasive treatment, closed reduction with maxillomandibular fixation, or open reductionwith internal semirigid fixation.

Results: No significant difference was observed in the occlusion, maintenance of fixation of anatom-ically reduced fractured bony segments, trismus index, movements of the mandible (ie, opening,protrusion, and lateral excursions), or masticatory efficiency. The only significant difference was thesubjective discomfort of the surgically treated patients in terms of pain on movement and mastication,swelling, neurologic deficit, and parotid fistula formation.

Conclusion: Patients with a condylar fracture with no displacement, dislocation, or derangement ofocclusion seem best treated with medication only for symptomatic relief without any invasive treatment.Patients with derangement of occlusion or displacement of fractured fragments, especially in unilateralcases, seem best treated with closed reduction and maxillomandibular fixation, with medication forsymptomatic relief and postoperative physiotherapy. Patients with deranged occlusion, displaced bonyfractured fragments, and a dislocated condylar process out of the glenoid fossa, especially bilateral cases,seem best treated with open reduction with internal semirigid fixation.© 2012 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 70:83-91, 2012
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he topic of condylar injury has generated more dis-ussion and controversy than any other in the field ofaxillofacial trauma. The condylar process fracture

eads to a break in the continuity of the mandible and,ence, to malocclusion, internal derangements of theemporomandibular joint (TMJ), restricted mandibu-ar movements, ankylosis, and disturbed mandibularrowth (when occurring in children), hamperingunction and cosmesis.1 This has forced surgeons tottempt to treat such cases using a variety of treat-ent protocols ranging from no invasive treatment, a

elatively conservative approach with maxilloman-

Received from Department of Oral and Maxillofacial Surgery, M. M.

College of Dental Sciences and Research, Mullana, Ambala, Hary-

ana, India.

*Senior Lecturer.

†Professor.

‡Professor and Head of Department.

§Associate Professor. d

83

ibular fixation, to open surgical treatment. Numer-us surveys and experimental studies have shownonclusively that the conservative method of treatinghese fractures is apparently complication free androvides very satisfactory end results. However, seri-us late complications have been reported, includingMJ ankylosis, avascular necrosis of the condylar pro-ess, inhibition of mandibular growth, and occlusalisturbances.2 For these reasons, surgical treatment is

favored by many surgeons.2 The intended aim of sur-ical treatment of the condylar process fracture is toestore the pre-existing anatomic relationships and

Address correspondence and reprints to Dr Gupta: Depart-

ment of Oral and Maxillofacial Surgery, M. M. College of Dental

Sciences and Research, House No. 879, Sector 8, Panchkula, Hary-

ana 134109, India; e-mail: [email protected]

© 2012 American Association of Oral and Maxillofacial Surgeons

278-2391/12/7001-0$36.00/0

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84 TREATMENT PROTOCOLS FOR CONDYLAR PROCESS FRACTURES

acceptable function by stable fixation.3 Zide andent4 described the classic absolute and relative indi-ations for surgical reduction in 1983. These wereodified by Zide5 in 1989.The intended aim of the present study was to com-

are the outcome of different treatment modalities forracture of the mandibular condyle, with the follow-ng objectives:

● To study the syndrome associated with fracturesof the condylar process of the mandible

● To determine the clinical and radiologic criteriaused to evaluate and select a treatment modality

● To study the efficacy of management for eachtreatment modality and catalog their complica-tions

● To devise a protocol for selection of the mosteffective modality for management of a specificcase

Patients and Methods

The study protocol structure was reviewed andapproved by the institutional research, reviewboard, and institutional ethics committee. A total of28 patients were selected. Of these 28 patients, 22had unilateral fractures and 6 had bilateral fractures(Table 1).

As listed in Table 2, 8 patients with normal occlu-sion underwent no invasive treatment (group I) andwere merely treated with a soft diet and mouth open-ing and lateral excursion exercises. The remainingpatients with deranged occlusion were included ingroups II and III. The 10 patients in group II requiredopen reduction and semirigid internal fixation with2-mm stainless steel plates and screws using preauric-ular and/or retromandibular approaches, as deemednecessary. In group III, 10 patients underwent closedreduction and maxillomandibular fixation (MMF) us-ing different wiring techniques (arch bar wiring,

Table 1. DISTRIBUTION OF DIAGNOSED FRACTURES O

Sr. No. Fracture Group I (No Treatment)

1 Unilateral 7 (87.5)2 Bilateral 1 (12.5)

Total 8 (100)

Abbreviations: Sr. No., serial number; ORIF, open reductimaxillomandibular fixation.

Data presented as number of patients, with percentagesStatistical analysis (�2 test): calculated value of �2 3.22%;

P � .05, not significant.

Gupta et al. Treatment Protocols for Condylar Process Fractures

transalveolar screws, or eyelet wiring).

The following parameters were recorded on a pre-designed form and compared:

● Clinical diagnostic parameters and diagnostic im-aging

● Post-treatment stability of occlusion assessedclinically at regular intervals

● Post-treatment stability of fixation (ie, mainte-nance of reduced fracture position) evaluatedwith orthopantomogram radiograph at regularintervals

The quality of postoperative healing was also eval-ated. Pain was assessed using a visual analog scaleith a scale score of 0 to 10. Swelling was measuredsing a silk thread to measure the surface distance in

DYLAR PROCESS OF MANDIBLE

Group II (ORIF) Group III (MMF) Overall

9 (90) 6 (60) 22 (78.6)1 (10) 4 (40) 6 (21.4)

10 (100) 10 (100) 28 (100)

th internal semirigid fixation; MMF, closed reduction and

entheses.el table value of �2 at df � 4, 5.991; P � .1948; inference,

Maxillofac Surg 2012.

Table 2. AGE, GENDER, AND TREATMENTGROUP DISTRIBUTION

TreatmentGroup Patients

Age Range(yr)

Mean Age(yr)

(No treatment)Male 7 (87.5) 2–45 21.4Female 1 (12.5) 45 45Total 8 (100) 2–45 24.3

I (ORIF)Male 10 (100) 14–45 29Female 0 (0) — —Total 10 (100) 14–45 26.8

II (MMF)Male 8 (80) 19–65 33.3Female 2 (20) 15–30 22.5Total 10 (100) 15–65 28.2verallMale 25 (89.2) 2–65 28.2Female 3 (10.8) 15–45 30Total 28 (100) 2–65 28.4

bbreviations as in Table 1.Data presented as number of patients, with percentages

n parentheses.

Gupta et al. Treatment Protocols for Condylar Process Fractures.

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J Oral Maxillofac Surg 2012.

GUPTA ET AL 85

millimeters from inferior end of the tragus to thelowermost point of ala nasi (both right side and leftside). This was then transferred to a scale. The neu-rologic evaluation included the observation of sen-sory deficits in the form of paresthesia with the helpof cotton wool, pinprick, and an assessment of thepatient’s objective feedback. To observe any motordeficits, the individual function of the facial muscleswas evaluated.

Finally, the incidence of complications was ob-served clinically by recording the trismus index, asmeasured using a scale. The patients were asked toopen their mouth to the maximum (ie, the interin-cisal distance in millimeters). This was determinedat the first examination after the injury and then atregular intervals and compared. The maximum pro-trusion was measured using a scale by asking thepatients to protrude their mandible to the maxi-mum. This was recorded as the horizontal distancein millimeters from the incisal edge of the upperincisors to the incisal edge of lower incisors, whenthe mandible was in its maximal protruded posi-tion. The maximal lateral excursion (right and leftsides) was observed when the patients were askedto move their mandible laterally to the maximum tothe right and left sides. The distance was measuredhorizontally with a scale in millimeters from the

Table 3. MAINTENANCE OF REDUCED FRACTURE POSIT

Sr. No. Group Immediately Postopera

1 I (No treatment) 8 (100)2 II (ORIF) 10 (100)3 III (MMF) 10 (100)

Abbreviations as in Table 1.Data presented as numbers of patients, with percentagesStatistical analysis (�2 test): calculated value of �2, 0.442;

P � .05, not significant.


Table 4. PASSIVE PAIN (VISUAL ANALOG SCALE, 0–10

Sr. No. Group PreoperativelyImme

Postop

1 I (No treatment) 3.1 � 1.4 2.3 �2 II (ORIF) 6.3 � 2.9 5.1 �3 III (MMF) 6.3 � 2.8 0 �

Abbreviations as in Table 1.Data presented as mean � standard deviation.Statistical analysis (analysis of variance): calculated value

inference, highly significant.

Gupta et al. Treatment Protocols for Condylar Process Fractures. J Oral

mesioincisal angle of the upper central incisor tothe mesioincisal angle of the lower central incisoron both sides.

The quality of post-treatment function (masticatoryefficiency) was evaluated by asking the patients toscore, on a scale of 0 to 3, their chewing ability,where 0 indicates an inability to chew; 1, the ability tochew soft food; 2, the ability to chew medium hardfood; and 3, the ability to chew hard food.

All patients of all 3 groups underwent preoperative,immediately postoperative, and 1-, 4-, 8-, and 12-weekpostoperative examinations.

Results

The results of the study were as follows. Occlusionwas maintained in all patients except for 1 patient ingroup III. The fractured bony segments were main-tained in their reduced position in all patients, exceptfor in 2 patients in group III (Table 3).

The amount of passive pain was greatest in groupIII for 1 week and remained for up to 4 weeks ingroup II. In contrast, passive pain had disappearedimmediately in group I (Table 4). The pain withmovement was greatest for the surgically treatedpatients in group II. The patients in group III hadsome pain on movement after the release of IMF for

Postoperative Follow-Up (wk)

1 4 8 12

8 (100) 8 (100) 8 (100) 8 (100)10 (100) 10 (100) 10 (100) 10 (100)10 (100) 8 (80) 8 (80) 8 (80)

rentheses.el table value of �2 at df � 4, 15.507; P � .999; inference,


e


1 4 8 12

1.1 � 0.6 0 � 0 0 � 0 0 � 02.4 � 1.2 0.6 � 0.5 0 � 0 0 � 0

0 � 0 0.1 � 0.3 0.7 � 0.7 0.1 � 0.3

9.589; 1% level table value of “F” at df � 2, 5.39; P � .01;

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up to 12 weeks. In contrast, pain on movementremained for only 1 week in patients in group I(Table 5). Pain on mastication remained greatest forup to 4 weeks in group II (surgery group). Pain waspresent in group III after release of IMF at 12weeks. Pain on mastication was found for up to 4weeks in group I (Table 6).

Swelling was greatest in the surgically treated pa-tients and lowest in group I patients (Table 7). Theincidence of neurologic deficit was marginally in-creased (by 1 patient) in the surgically treated pa-tients (Table 8). The trismus index had recovered bestin group I and took the longest time to recover ingroup III (Table 9). All movements of the mandible(opening, protrusion, and lateral excursions) had re-covered the best in the group I patients; however, ittook the longest time to recover in the group IIIpatients (Tables 10, 11).

At the end of 12 weeks, the patients who hadundergone no invasive treatment (group I) had thegreatest masticatory efficiency, followed very closelyby those treated surgically (group II). The patientswho had undergone closed reduction and intermax-illary fixation took a longer period to recover in termsof masticatory efficiency (Table 12).

Table 5. PAIN ON MOVEMENT (VISUAL ANALOG SCAL


Postop



nference, significant.


Table 6. PAIN ON MASTICATION (VISUAL ANALOG SC


Postop

1 I (No treatment) 4.7 � 2.3 3.8 �2 II (ORIF) 7.9 � 2 7.1 �3 III (MMF) 6.4 � 3.8 0 �


nference, highly significant.


Discussion

For decades, the treatment of condylar fracture hasbeen the subject of debate. Patient age was notablynot a criterion for selection of the treatment modality(Table 2). The unilateral and bilateral fractures of thecondylar process occurred in an approximate ratio of4:1 (Table 1). The chin was the most common site ofinjury of the face in all 3 groups. Overall, parasym-physis fractures were the most commonly associatedwith fractures of the condylar process (Table 13). Theinability to chew was the most common chief com-plaint, reported by 26 patients, followed by pain in 23patients, and swelling in 9 patients. The most com-mon mode of injury was a road traffic accident(53.6%). Other causes included a fall in 28.6% andassault in 10.7%; 1 patient was injured by a kick froma horse, and 1 was hit by a block of wood. TMJmovements, tenderness, and sounds did not influencethe selection of the treatment modality (Table 14).We noted that occlusion was maintained adequatelyin all the patients, except for 1 patient who hadundergone closed reduction and MMF. Hlawitschka etal2 found postoperative occlusal disturbances in onehird of the cases of a closed functionally treatedatient group. No occlusal disturbance was observed

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GUPTA ET AL 87

in those treated with open reduction with internalsemirigid fixation (ORIF). The fixation of bony frag-ments as seen radiographically was maintained in allpatients in groups I and II but was not maintainedfrom the 4-week assessment onward in 2 patients ingroup III (Table 3). These differences, however, werenot statistically significant (P � .05). The stability offixation was compromised, probably owing to loos-ening of the IMF screws, in 1 patient. In another, witha bilateral condylar neck and symphysis fracture, fix-ation was not maintained, probably owing to neuro-muscular imbalance, causing displacement of the frac-ture fragments.

Passive pain (Table 4) was greatest in group IIpreoperatively owing to the severity of the inflamma-tion caused by the trauma. However, the pain de-creased first in group I, probably because of the loweramount of inflammation caused by less severe trauma.In group III, pain required the longest time to re-cover, probably because of muscle spasms resultingfrom MMF. These results were highly statistically sig-nificant (P � .01).

Preoperative pain on movement (Table 5) wasgreater in groups II and III, probably owing to thedisplaced fracture fragments that moved during jawmovements more than in group I. However, the painhad decreased after treatment the fastest in group I,

Table 7. LINEAR MEASUREMENT OF SWELLING

Sr. No. GroupPreoperatively

(mm)Immediately

Postoperative (

1 I (No treatment) 111.8 � 15.2 109.8 � 15.2 II (ORIF) 125.4 � 9.5 135 � 10.3 III (MMF) 121.4 � 7.5 117.9 � 6.8

Abbreviations as in Table 1.Data presented as mean � standard deviation calculated

only.Swelling over affected site measured as surface distance in

nasi.Statistical analysis (analysis of variance): calculated value

inference, highly significant.


Table 8. INCIDENCE OF NEUROLOGIC DEFICIT

Sr. No. Group Preoperatively P

1 I (No treatment) 0 (0)2 II (ORIF) 1 (10)3 III (MMF) 1 (1)

Abbreviations as in Table 1.Data presented as number of patients, with percentages


probably owing to early resolution of inflammationand the faster healing of uncomplicated and less se-vere trauma. Group III required the longest time torecover, probably owing to muscle spasms resultingfrom MMF. After releasing the MMF, the patients ex-perienced pain during opening and closing of thejaws because of muscle spasms. These results werefound to be statistically significant (P � .05).

Preoperative pain on mastication (Table 6) wasgreatest in group II, probably owing to the move-ments of displaced fracture fragments, but decreasedmore quickly in groups I and II (by the end of 4weeks). This occurred because of the lack of displace-ment of fractured fragments in group I and properanatomic reduction in group II. The question of painin group III (closed reduction) during mastication inthe MMF period did not arise. The patients in groupIII, however, reported pain on mastication after re-lease of MMF, probably from muscle spasms. In groupIII, it is presumed that a new neuromuscular andocclusal balance is created and a compensatory mech-anism results in proper physiologic balance, leadingto pain and discomfort in the post-MMF phase forvarying periods owing to compromise in the perfectanatomic reduction of the bone fragments, as statedby Ellis6 in 1998. The pain lasted up to the 12th weekof follow-up, much beyond that for patients in the

Postoperative Follow-Up (mm)

1 wk 4 wk 8 wk 12 wk

108.1 � 15.2 106.2 � 14.1 105.9 � 13.9 105.9 � 13.9124.8 � 7.1 121.9 � 7.2 121.5 � 7.4 121.5 � 7.4

116 � 6.3 114.9 � 6.2 114.6 � 6.3 114.6 � 6.3

measurements made over fractured condylar process sites

eters from inferior end of tragus to lowermost point of ala

43.40; 1% level table value of “F” at df � 2, 5.39; P � .01;


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other groups. These results were highly statisticallysignificant (P � .01). No studies reviewed to date hadassessed pain with the method used in the presentstudy.

Preoperative and postoperative swelling (Table 7)was greatest in group II (ORIF). Preoperative swellingprobably resulted from the greater displacement ofthe fractured fragments and postoperative swellingoccurred because of surgical trauma. The swellinghad reduced uniformly in all groups by the fourthweek in our study. These results were highly statisti-cally significant (P � .01).

Preoperatively, 1 patient in group II (Table 8) had aneurologic deficit. An additional patient in group IIreported transient facial paralysis immediately aftersurgery that had resulted from excessive retraction.Both patients in group II had recovered completely by12 weeks.

Table 9. TRISMUS INDEX—MAXIMAL MOUTH OPENIN

Sr. No. GroupPreoperative

(mm)Immed

Postoperat

1 I (No treatment) 23.3 (4) 24.4 (2 II (ORIF) 22.1 (7.8) 15.6 (3 III (MMF) 20.9 (7.4) 0 (4 III* 22 0

Abbreviations as in Table 1.Data presented as number of patients, with percentagesStatistical analysis (analysis of variance) for all groups (I, II

of “F” at df � 2; P � .05; inference, significant.Statistical analysis (analysis of variance) for groups I and

level table value of “F” at df � 2, 5.39; P � .01; inference,Statistical analysis (analysis of variance) for all groups (I, I

4; 5% level table value of “F” at df � 2, 3.32; P � .05; infe*Readings of 1 patient, aged 15 years in group III (closed

excluded from group III calculations.


Table 10. MAXIMAL PROTRUSION

Sr. No. GroupPreoperatively

(mm)Imm

Postope

1 I (No treatment) 1.4 (1.1) 1.2 II (ORIF) 1.6 (2.0) 0.3 III (MMF) 1.5 (2.9)4 III* 0

bbreviations as in Table 1.Data presented as number of patients, with percentagesStatistical analysis (analysis of variance) for all groups (I, I

0.58; 1% level table value of “F” at df � 2, 5.39; P � .01;*Readings of 1 patient, aged 15 years in group III (closed



Hlawitschka et al2 reported that immediately afterurgery, 1 patient experienced a temporary weaknessf the temporal branch of facial nerve. Manisali et al7

noted postoperative facial nerve weakness involvingthe marginal mandibular nerve in 30% of their pa-tients, of whom 33% had complete recovery of facialnerve weakness within 1 month and the remainingwithin 3 months.

The mean value for preoperative interincisal open-ing (Table 9) was 23.3, 22.1, and 20.9 mm in groupsI, II, and III, respectively. These differences werestatistically significant (P � .05). This probably showsthat patients with fracture of condylar process withless initial trismus can be considered favorably forconservative treatment. Because patients in group IIIwere kept in MMF for 4 weeks, a comparison of thetrismus index at 4 weeks was possible only betweengroups I and II. At 4 weeks postoperatively, the group

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31.4 (6.3) 38.5 (7.5) 38.5 (7.5) 39.1 (5.8)21.3 (5.5) 29.5 (9) 34.7 (8.2) 37.5 (6.1)

0 (0) 0 (0) 29.9 (7.7) 34.6 (7)0 35 36 36

entheses.eoperatively: calculated value of “F,” 4; 5% level table value

weeks postoperatively): calculated value of “F,” 12.8; 1%significant.

at 8 and 12 weeks postoperatively: calculated value of “F,”significant.

tion) for whom MMF was removed at 4 weeks; these were


ly(mm)



2.3 (1.3) 3.1 (1.6) 3.1 (1.6) 3.1 (1.6)1.8 (1.5) 2.9 (2.2) 3.4 (2.1) 3.5 (2.1)

0 (0) 0 (0) 1.7 (1.4) 2.4 (2.2)0 0 1 1

entheses.at 8 and 12 weeks postoperatively: calculated value of “F,”nce, highly significant.tion) for whom MMF was removed at 4 weeks; these were

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GUPTA ET AL 89

I patients had improved more than the group II pa-tients. This difference was highly statistically signifi-cant (P � .01).

A comparison among all 3 groups was possible onlyat 8 and 12 weeks postoperatively. Again, during thisperiod, group I patients had recovered the most andgroup III patients the least. These differences werealso statistically significant (P � .05). In group II, 20%of the patients had a reduced mouth opening of lessthan 35 mm when reviewed after 12 weeks, probablyowing to scar development at the surgical site. Ingroup III, 20% of the patients had reduced mouthopening, attributable to muscle spasms.

According to Rowe and Williams,8 an interincisalouth opening of 35 mm is considered as satisfactoryostoperative mouth opening. Joos et al9 noted after

a period of 12 months that the average mouth open-ing was 41 mm in the nonsurgical group and 45 mmin the surgical group. Hlawitschka et al2 found the

Table 11. MAXIMAL LATERAL EXCURSION

Sr. No. Side GroupPreoperative

(mm)Immed

Postopera

1 Left I 2.9 � 1.4 2.9 �2 Left II 3.3 � 3.6 2.2 �3 Left III 2.8 � 4.2 0 �4 Left III* 0 01 Right I 2.4 � 1.2 2.4 �2 Right II 5.0 � 3.4 1.1 �3 Right III 2.8 � 4.0 0 �4 Right III* 1 0

Abbreviations as in Table 1.Data presented as mean � standard deviation.Statistical analysis (analysis of variance) for all groups (I, I

28.9; 1% level table value of “F” at df � 2, 5.39; P � .01; i*Readings of 1 patient, aged 15 years in group III (closed



Table 12. MASTICATORY EFFICIENCY

Sr. No. Group PreoperativeImmed

Postope


Abbreviations as in Table 1.Data presented as mean � standard deviation.Masticatory efficiency score: 0, unable to chew; 1, able t

chew hard food.Statistical analysis (analysis of variance) for all groups (I, I

19.7; 1% level table value of “F” at df � 2, 5.39; P � .01; i


ostoperative mouth opening was not less than 30m in both groups.The mean preoperative maximal protrusion (Ta-

le 10) was greatest in group II and least in group. Postoperatively, group II patients had recoveredhe most and those in group III the least. Theseifferences were highly statistically significant (P �

01).Joos et al9 noted that an average of 2 mm greater

rotrusive movement occurred in the nonsurgicalroup than in the surgical group, with an overallestricted protrusive excursion after 12 months inoth groups. Hlawitschka et al2 found postoperative

restriction of protrusion in the closed, functionallytreated group.

The mean preoperative maximum lateral excursion(Table 11) was greatest in group II and least in groupI. In terms of lateral excursions, the group I patientsrecovered the best and the group III patients the least.

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7.1 � 3.4 9.1 � 4.3 9.1 � 4.2 9.1 � 4.24.9 � 2.6 6.0 � 2.6 6.6 � 1.8 6.7 � 1.7

0 � 0 0 � 0 5.7 � 2.8 6.5 � 3.10 6 6 10

5.9 � 2.7 8.9 � 4.2 9 � 4.2 9 � 4.25.4 � 3.0 6.0 � 2.7 6.8 � 1.8 6.8 � 1.8

0 � 0 0 � 0 6.6 � 3.4 6.9 � 3.50 7 10 10

at 8 and 12 weeks postoperatively: calculated value of “F,”ce, highly significant.tion) for whom MMF was removed at 4 weeks; these were



1 4 8 12

1.9 � 0.4 2.1 � 0.4 3 � 0 3 � 01.2 � 0.4 1.9 � 0.3 2.9 � 0.3 2.9 � 0.3

0 � 0 0.1 � 0.3 1.9 � 0.9 2.6 � 1.0

soft food; 2, able to chew medium hard food; 3, able to

at 8 and 12 weeks postoperatively: calculated value of “F,”ce, highly significant.

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These differences were highly statistically significant(P � .01).

Joos et al9 noted the range of lateral excursionncreased more rapidly in the nonsurgical than in theurgical group; however, the final results did nothow any differences between the 2 groups or sides.

The mean preoperative masticatory efficiencycore (Table 12) was 1.1 in group I but only 0.1 inroups II and III. The postoperative recovery in mas-icatory efficiency was fastest and greatest in group I.roup II patients recovered next, and group III pa-

ients took the longest time and also had recoveredhe least. These differences were highly statisticallyignificant (P � .01). No studies reviewed to datessessed patients’ postoperative recovery in mastica-ory efficiency.

A parotid fistula occurred in 1 patient in group II.his was later successfully closed surgically.Ellis et al10 reported 3 instances of drainage through

the incision site, representing salivary fistulas (parotidsecretions) in 2.3% of the cases. All were treated withocclusive pressure dressings and antisialogogue agents

Table 13. DISTRIBUTION OF ASSOCIATED FRACTURES

Sr. No. Associated Fracture Group I (No Treatm

1 Symphysis 3 (37.5)2 Parasymphysis 1 (12.5)3 Mid-face 0 (0)4 Dentoalveolar 0 (0)5 Total 4 (50)

Abbreviations as in Table 1.Data presented as number of patients, with percentages


Table 14. GROUP WISE PREOPERATIVE TEMPOROMAN

Sr. No. TMJ Assessment Group 1

1 No movement 0 (0)2 Reduced movement 9 (56.3)3 Normal movement 7 (43.8)4 Tenderness 9 (56.3)5 Sounds 2 (12.5)

bbreviations: Sr. No., serial number TMJ, temporomandibData presented as number of sites, with percentages in pStatistical analysis (�2 test) for TMJ movements: calculat� .6952; inference, P � .05, not significant.Statistical analysis (�2 test) for TMJ tenderness: calculated

6879; inference, P � .05, not significant.Statistical analysis (�2 test) for TMJ sounds: calculated valu

nference, P � .05, not significant.


and none persisted for longer than 3 weeks.

Previously, conservative management of condylarfractures was favored. Current published data suggestthat condylar fractures should almost always betreated using ORIF. However, ORIF has its associatedsurgical morbidity, warranting reconsideration. Theresults of our study have shown that the end resultachieved by all 3 treatment modalities selected usingbroad-based principles was reasonably satisfactory.Also, the morbidity associated with surgery added tothe morbidity associated with the primary trauma.This suggests that a balance is needed between treat-ment efficacy and overall patient comfort. This formsthe basis for selecting the appropriate treatmentmethod. Patients with condylar fractures without dis-placement, dislocation, or derangement of occlusionseem best treated with medication only for symptomaticrelief without any invasive treatment. However, pa-tients with slight derangement of occlusion andmild to moderate displacement, especially in unilat-eral cases, seem best treated by closed reductionand MMF with medication for symptomatic reliefand postoperative physiotherapy. Finally, patients

Group II (ORIF) Group III (MMF) Overall

2 (20) 0 (0) 5 (17.9)5 (50) 11 (110) 17 (60.7)2 (20) 0 (0) 2 (7.1)0 (0) 1 (10) 1 (3.6)9 (90) 12 (120) 25 (89.3)

entheses.


AR JOINT ASSESSMENT

Group II Group III Overall

2 (10) 5 (25) 7 (12.5)11 (55) 9 (45) 29 (51.8)7 (35) 6 (30) 20 (35.7)

13 (65) 14 (70) 36 (64.3)2 (10) 4 (20) 8 (14.3)

eses.e of �2 0.73; 5% level table value of �2 at df � 4, 5.991;

of �2 0.73; 5% level table value of �2 at df � 4, 5.991; P �

0.93; 5% level table value of �2 at df � 4, 5.991; P � .5767;


ent)

in par

DIBUL

ular.arenth

ed valu

value

e of �2

with grossly displaced, dislocated fractures, espe-

1

GUPTA ET AL 91

cially those with bilateral fractures, seem best treatedwith ORIF.

References1. Jindal G, Sharma CB, Sharma P, et al: Management of man-

dibular condylar fractures—A pragmatic approach. J Maxil-lofac Oral Surg 4:21, 2005

2. Hlawitschka M, Loukota R, Eckelt U, et al: Functional and radiologicalresults of open and closed treatment of intracapsular condylar frac-tures of the mandible. J Oral Maxillofac Surg 34:597, 2005

3. Throckmorton GS, Eills E III: Recovery of mandibular motion
after closed and open treatment of unilateral mandibular con-dylar process fractures. Int J Oral Maxillofac Surg 29:421, 2000
4. Zide MF, Kent JN: Indications for open reduction of mandibularcondylar fractures. J Oral Maxillofac Surg 41:89, 1983

5. Zide MF: Open reduction of mandibular condyle fractures.Indications and technique. Clin Plast Surg 16:69, 1989

6. Ellis E III: Complications of mandibular condyle fractures. IntJ Oral Maxillofac Surg 27:255, 1998

7. Manisali M, Amin M, Aghabeigi B, et al: Retromandibular ap-proach to the mandible condyle: A clinical and cadaveric study.Int J Oral Maxillofacial Surg 32:253, 2003

8. Rowe NL, Williams JL: Maxillofacial Injuries. Vol. 1. Edinburgh,United Kingdom, Churchill Livingstone, 1985, pp 337–363

9. Joos U, Kleinheizn J: Therapy of condylar neck fractures. IntJ Oral Maxillofac Surg 27:247, 1998

0. Ellis E III, McFadden D, Simon P, et al: Surgical complications
with open treatment of mandibular condylar process fractures.J Oral Maxillofac Surg 58:950, 2000

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Analysis of Different Treatment Protocols for Fractures of Condylar Process of Mandible