CONTROVERSIES IN CONDILAR FRACTURES

7/30/2019 CONTROVERSIES IN CONDILAR FRACTURES

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Controversies inMandibular Condyle Fracture

RepairFrederick Mars Untalan MD

Baguio General Hospital & Medical Center


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Concerning the treatment ofcondylar

fractures, it seems that the battle will rage

forever between the extremists who urgenonoperative treatment in practically

every case and the other extremists who

advocateopen reduction in almost everycase.

Malkin et al..


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Objectives

To mention condyle fracture treatmentcontroversies (OPEN vs CLOSE Treatment)

To become aware of landmark studies withregards treatment of Condyle fracture

To discuss possible future directions to settlethese controversies


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Main treatments advocated for adults withcondylar process fractures

NONSURGICAL

1. a period ofmaxillomandibular fixation

(MMF) followed byfunctional therapy

2. functional therapy without aperiod of MMF

SURGICAL

3. open reduction with or

without internal fixation.


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Conflicting Terminology

closedreduction

(misnomer)

closed treatment

nonsurgicaltreatment


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CONDYLE fractures

Type A:

Intracapsular fracturesof the mandibular

condyle

Type C :

fractures through the lateralcondylar pole w/ loss of

vertical height of themandibular ramus

Type B:

fractures throughthe medial condylarpole

Type M :

multiple fragmentscomminutedfractures.


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Mandibular Condyle Fractures: Evaluation of the

Strasbourg Osteosynthesis Research Group Classification

Journal of Craniofacial Surgery: January 2009 - Volume 20 - Issue 1 - pp 24-28

Cenzi, Roberto MD; Burlini, Dante MD; Arduin, Laura MD; Zollino, Ilaria MD; Guidi, Riccardo DDS; Carinci,Francesco MD

Abstract

Condylar fractures (CFs) are about 30% of mandibular fractures. Condylar fractures are treated with severalprotocols, and unsatisfying outcome is achieved in some cases. A staging system for classifying CFs is of paramountimportance to plan therapy, to define prognosis, and to exchange information among trauma centers. TheStrasbourg Osteosynthesis Research Group proposed a classification system for CFs, but no report focusing to itseffectiveness is still available. Thus, we performed a retrospective study on a series of patients affected by CFs.

The Strasbourg Osteosynthesis Research Group classification defines 3 main types of CFs: diacapitular fracture(i.e., through the head of the condyle [DF]), fracture of the condylar neck, and fracture of the condylar base (CBF).A series of 66 patients (and 84 CFs) was evaluated, and age, sex, clinical diagnosis at admission, treatment, andoutcome were considered.

Fractures of the condylar base and DFs are the most (52.4%) and the least (4.8%) frequent fractures, respectively.Conversely, associated fractures of the facial skeleton are found in most cases of DFs (75%) and in few cases ofCBFs (20.5%). Surgery was performed in about 15% of all cases: no DF was operated, whereas fractures of thecondylar neck and CBFs have an open reduction and an internal rigid fixation in 57% and 43%, respectively.Postsurgical and late sequelae were 22.3% and 19%. Temporomandibular joint symptoms and malocclusion cover

about 80% and 90% of postsurgical and late sequelae. The new classification is a simple method to define CFs and can give some elements about the prognosis.

3 main types of CFs:1. diacapitular fracture (i.e., through the head of the condyle [DF])2. fracture of the condylar neck3. fracture of the condylar base (CBF).

simple method to define CFs and cangive some elements about the prognosis.

Fractures of the condylar base are the most (52.4%)DFs least (4.8%) frequent fractures

Temporomandibular joint symptoms and malocclusioncover about 80% and 90% of postsurgical and latesequelae.


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The treatment of condylar fractures: to open ornot to open? A critical review of this controversy

Renato VALIATI,1* Danilo IBRAHIM,1* Marcelo Emir Requia ABREU,1* Claiton HEITZ,2* Rogrio Belle de OLIVEIRA,2* Rogrio MirandaPAGNONCELLI,2* and Daniela Nascimento SILVA2*

The treatment of condylar process fractures has generated a great deal ofdiscussion and controversy in oral and maxillofacial trauma and there are manydifferent methods to treat this injury.

For each type of condylar fracture, the techniques must be chosen taking into

consideration the presence of teeth, fracture height, patient's adaptation,patient's masticatory system, disturbance of occlusal function, deviation of themandible, internal derangements of the temporomandibular Joint (TMJ) andankylosis of the joint with resultant inability to move the jaw, all of which aresequelae of this injury. Many surgeons seem to favor closed treatment withmaxillomandibular fixation (MMF), but in recent years, open treatment of condylarfractures with rigid internal fixation (RIF) has become more common.

The objective of this review was to evaluate the main variables that determine thechoice of method for treatment of condylar fractures: open or closed, pointing outtheir indications, contra-indications, advantages and disadvantages.

techniques must be chosen taking into consideration the presence ofteeth, fracture height, patient's adaptation, patient's masticatory system,

disturbance of occlusal function, deviation of the mandible, internalderangements of the temporomandibular Joint (TMJ) and ankylosis of the

joint with resultant inability to move the jaw

in recent years, open treatment of condylarfractures with rigid internal fixation (RIF) has

become more common


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Interventions for the treatment of

fractures of the mandibular condyleSharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R

Fractures of the condylar process of the mandible (lower jaw) arecommon.

Two treatment options are available: either closed treatment (withoutsurgery) or open reduction (involving surgery).

Complications are associated with both treatment modalities.

With a closed approach the complications include disturbances in the way theteeth meet, facial asymmetry, chronic pain and reduced mobility of the lowerjaw.

With an open approach the complications include a scar on the overlying skinand also the possibility of temporary paralysis of the nerve supplying some ofthe facial muscles involved in smiling and eye opening/closing.

Currently there is much controversy regarding the most appropriate

method for the management of fractured mandibular condyles. This review revealed that there is a lack of high quality evidence for the

effectiveness of either approach, and that there is a need for furtherresearch to help clinicians and patients to make informed choices oftreatment options.

closed approach the complications includedisturbances in the way the teeth meet, facial

asymmetry, chronic pain and reduced mobility of the

lower jaw.

open approach the complications include a scar onthe overlying skin and also the possibility of temporary

paralysis of the nerve supplying some of the facialmuscles involved in smiling and eye opening/closing.


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Fractures of the mandibular condyle.

Therapeutic controversies Acta Med Port. 1999 Apr-Jun;12(4-6):209-15. Martins JS, Frage ZB. Servio de Cirrgia Plstica e Reconstrutiva, Hospital Egas Moniz, Lisboa. Abstract

The condylar mandibular fractures are important because its incidence,possible complications and controversial treatment. The treatment of

condylar fractures has generated more controversy and discussion thanany other in the field of maxillofacial trauma. The main goal of treatmentis restoration of function and not anatomic restoration of parts. Despiteseveral clinical and anatomical studies still lack consensus regarding thebest method of treatment. This review article focus on the controversythat surrounds treatment of the condylar fractures, trying to supplyconsensus about questions like: Should condylar mandibular fractures be

managed via a closed or open technique? What is the best surgicalapproach? Surgical timing? What is the degree and duration of mandibularimmobilization? Is or not necessary to treat the ATM disc?

The main goal of treatment is restoration offunction and not anatomic restoration of

parts.

Despite several clinical and anatomical studies stilllack consensus regarding the best method of

treatment.


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The majority of surgeons seem to favornon surgical treatment of condylar fractures.

3 main factors.

1stnonsurgical tx

givessatisfactory

results in themajority of

cases.

2

nd

no large series of

patients reported

in the literaturewho have beenfollowed aftersurgical treatment( management of

condylar fractureshas historicallybeen w/nonsurgicalmeans)

3

rd

surgery of

condylarfractures isdifficult becauseof the Inherent

anatomical

hazards (ie, VIInerve)


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Is MMF Necessary/Desirable?

2 main treatments advocated when performingclosed treatment:

1) a periodof MMF

followed by

functional

therapy

2) functionaltherapy

without aperiod of

MMF.traditionand

experience


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MMF is instituted for 3 main reasons:

to make the patient more comfortable

to promote osseous union to help reduce the fractured fragment


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Unilateral mandibular condylar fractures:31-year follow-up of non-surgical treatment

1National Dental Service, Sndrum, Getinge, Sweden

2National Dental Service, rebro, Sweden

3Department of Oral and Maxillofacial Surgery, University Hospital MAS, Malm, Sweden

4Department of Oral Surgery and Oral Medicine, Faculty of Odontology, University of Malm, Malm, Sweden

Accepted 8 November 2006.

Available online 18 January 2007.

Abstract

At the University Hospital of Malm, 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 19721976.

Of these, 23 patients were available for follow-up, 17 were dead, 7 were not found and 2 did not answer letters orphone calls.

The follow-up was a telephone interview according to a standardized questionnaire concerning occurrence of painand 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 non-dislocated and minor dislocated condylar fracturesseem favourable concerning function, occurrence of pain and impact on daily life.

87% of patients reported no pain from the jaws83% no problems chewing91% reported no impact of the fracture on daily

activities.

Neck and shoulder symptoms were reported by39% and back pain by 30%.


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Botulinum toxin in closed treatment

of mandibular condylar fracture Ann Plast Surg. 2007 May;58(5):474-8. Canter HI, Kayikcioglu A, Aksu M, Mavili ME. Hacettepe University, Faculty

of Medicine, Department of Plastic and Reconstructive Surgery, Ankara, Turkey. [email protected]

Abstract

BACKGROUND: The topic of condylar injury in adults has generated more discussion and controversy than anyother in the field of maxillofacial trauma. The treatment of condylar fractures in adults is still a highly debatedtheme.

METHODS: Patients with unilateral subcondylar or condylar neck fractures of the mandibula without anysignificant angulation of the condylar head were managed with closed-treatment protocol. Closed treatment wasapplied through the injection of 100 units of botulinum toxin A, diluted to a concentration of 20 IU/mL, into the

muscles of mastication of the fractured side. Masseter and anterior fibers of temporalis muscles were reachedthrough percutaneous extraoral route and 30 IU of the toxin was injected to each muscle. Additional 40 IU of thetoxin was injected around the fractured bone fragments through transmucosal intraoral route to paralyze medialand lateral pterygoid muscles as much as possible. An asymmetric occlusal splint was applied formaxillomandibular fixation to restore the vertical height for 10 days. Functional therapy with intermaxillaryguiding elastics was advocated for 2 months.

RESULTS: There were no complications related to either toxin injections or splint application procedures. The toxinwas effective on all occasions. Fractured condylar process and ramus of the mandibula were in goodapproximation and remained in reduced positions. None of the patients had any occlusal disturbance, mandibularasymmetry, or joint dysfunction in the follow-up period.

CONCLUSIONS: We believe that modification of treatment options concerning the clinical situation of the patientsis the best method for condylar injury. The purpose of this study is to present and discuss the results achieved inclosed treatment of a selected group of patients with mandibular condylar fractures to whom botulinum toxin Awas injected to relieve the spasm of muscles of mastication, along with special splint application.

Closed treatment was applied through:

1. injection of100 units of botulinum toxin A, diluted to a concentration of20 IU/mL, into the muscles of mastication of the fractured side. Masseterand anterior fibers of temporalis muscles were reached throughpercutaneous extraoral route and 30 IU of the toxin was injected to eachmuscle.

2. Additional 40 IU of the toxin was injected around the fractured bonefragments through transmucosal intraoral route to paralyze medial andlateral pterygoid muscles as much as possible.

3. An asymmetric occlusal splint was applied for maxillomandibular fixationto restore the vertical height for 10 days.

4. Functional therapy with intermaxillary guiding elastics was advocated for

2 months.

to relieve the spasm of muscles of mastication,along with special splint application.


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OPEN TREATMENT

becoming more common, probably because ofthe introduction of plate and screw fixationdevices that allow stabilization of such

injuries.no definitive study performed that has shown

the superiority ofopen versus closedreduction

Unfortunately, the type of study needed toclarify this question may never be possible.


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Is Open Reduction and Internal Fixation of Condylar Process

Fracture Biologically Sound?

To determine whether or not open treatmentof condylar process fractures is biologicallysound:

1) the blood supply to the condyle, 2) whether or not the blood supply is essential to

open treatment.

availability of plate &

screw fixation systemsSAFE??


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condyle blood supply is mostly derivedfrom 3 sources

inferior alveolar artery

A branch of theinferior alveolar

artery coursesupward throughthe neck of thecondylar process,where itanastomoses

liberally withvessels from theattachedmusculature.

TMJ capsule

major componentto the condyle and

its articular surfaceis derived from theTMJ capsule, withits lush vascularplexus.

branches of the lateralpterygoid

a largecontribution of

blood supply frombranches of thelateral pterygoidmuscle through itsattachment at thepterygoid fovea.


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Indications for open reduction and rigid internal fixation of

mandibular condyle fractures(MITCHELL, 19971; HAUG and ASSAEL, 200119; BRANDT and HAUG, 200330)

Absolute Indications: Patient preference (when no absolute

or relative contraindications co-exist) When manipulation and closed

treatment cannot re-establish the

pretraumatic occlusion; mutliple facial fractures When stability of the occlusion is

limited Displacement into the middle cranial

fossa Lateral extracapsular deviation Open fracture with potential for fibrosis Invasion by foreign body.

Relative Indications: Edentulous jaws

Periodontal problems

Bilateral condylar fractures in an edentulous patientwithout a splint

Unilateral or bilateral condylar fractures where

splinting cannot be accomplished for medicalreasons or because physiotherapy is impossible

Bilateral condylar fractures with comminutedmidfacial fractures, prognathia or retrognathia;

Unilateral condylar fracture with unstable base;

Displaced condyle with edentulous or partiallyedentulous mandible with posterior bite collapse;

Noncompliance

Uncontrolled seizure disorders

Status asthmaticus Obtunded neurologic status with documentation of

predicted improvement

Psychologic compromise (e.g., mental retardation,organic mental syndrome, psychosis)

Substance abuse


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Contraindications to open reduction and rigid internalfixation of mandibular condyle fractures

(MITCHELL, 19971; HAUG and ASSAEL, 200119; BRANDT and HAUG, 200330).

Absolute Contraindications:

Condylar head fractures (at orabove the ligamentousattachmentsingle fragment,

comminuted, or medial pole) When medical illness or

systemic injury add undue riskto an extended generalanesthetic

Good occlusion Minimal pain Acceptable mandibular

movement.

Relative Contraindications:

When a simpler method isas effective

Condylar neck fractures (thethin, constricted regioninferior to the condylarhead)

Obtunded neurologic statuswhen there is nodocumented hope forimprovement


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Surgical versus conservative treatment of

unilateral condylar process fractures: Clinical

and radiographic evaluation of 80 patients Volume 50, Issue 4, Pages 349-352 (April 1992) Vitomir S. Konstantinovi, DDS, Branislav Dimitrijevi, DDD, PhD Abstract

Treatment results of26 surgically and 54 conservatively treated unilateralcondylar process fractures were investigated by standardized clinical

examination and by evaluation of computer-simulated graphicpresentations of posteroanterior (PA) radiographs of the mandible. The radiographic evaluation compared the relation of actual reduction of

the condylar process fractures with ideally reduced fractures produced onthe computer.

Using clinical parameters (maximal mouth opening, deviation, protrusion),

no statistical differences between surgically and conservatively treatedfractures were found. However, the radiographic examinations showed a statistically better

position of the surgically reduced condylar process fractures.

Using clinical parameters (maximal mouth opening,

deviation, protrusion), no statistical differences between

surgically and conservatively treated fractures were found.

However, the radiographic examinations showed a

statistically better position of the surgically reducedcondylar process fractures.


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Functional Results of Unilateral Mandibular

Condylar Process Fractures after Open and

Closed Treatment Journal of Trauma-Injury Infection & Critical Care: March 2002 - Volume 52 - Issue 3 - pp 498-503 Yang, Wen-Guei MD; Chen, Chien-Tzung MD; Tsay, Pei-Kwei PhD; Chen, Yu-Ray MD

Abstract

Background : This retrospective study compared the functional results of unilateral mandibularcondylar process fractures treated either by open reduction or by closed treatment.

Methods : Sixty-six patients with unilateral mandibular condylar process fractures were reviewed.Thirty-six patients received open reduction, and the other 30 underwent closed treatment

(intermaxillary fixation only). Each group was further divided into condylar and subcondylarsubgroups according to fracture level. The functional outcome was evaluated by posttreatmentocclusion status, maximal mouth opening, facial symmetry, chin deviation, and temporomandibularjoint symptoms.

Results : Patients undergoing closed treatment exhibited more condylar motility than those treatedby open reduction. Patients in the condylar subgroup with open reduction presented less chindeviation (21.43%) compared with those with closed treatment (56.25%;p = 0.072). Although agreater severity of subcondylar fractures existed in patients treated with open reduction, patientstreated with open reduction or closed treatment did not reveal a significantly functional difference.

Conclusion : The present study revealed that patients with condylar neck or head fractures gainedmore benefits from open reduction in terms of chin deviation and temporomandibular joint pain.For subcondylar fractures, open reduction provides satisfactory functional results in patients withseverely displaced fractures.

66 patients with unilateral mandibular condylar process fractures were reviewed.36 patients received open reduction30 underwent closed treatment MMF only

condylar subgroup with open reduction presented less chin deviation

(21.43%) compared with those with closed treatment (56.25%)

condylar neck or head fractures gained more benefits from open reductionin terms of chin deviation and temporomandibular joint pain.

For subcondylar fractures, open reduction provides satisfactory functional

results in patients with severely displaced fractures.


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Open Reduction and Internal Fixation Versus Closed Treatment and

Mandibulomaxillary Fixation of Fractures of the Mandibular CondylarProcess: A Randomized, Prospective, Multicenter Study With Special

Evaluation of Fracture Level

J Oral Maxillofac Surg. 2008 Dec ;66 (12):2537-2544 Matthias Schneider Francois Erasmus, Klaus Louis Gerlach, Eberhard Kuhlisch, Richard A Loukota, Michael Rasse,

Johannes Schubert, Hendrik Terheyden, Uwe Eckelt

Consultant, Department of Oral and Maxillofacial Surgery, Technical University of Dresden, Dresden, Germany.

PURPOSE: This randomized, clinical multicenter trial investigated the treatment outcomes of displaced condylarfractures, and whether radiographic fracture level was a prognostic factor in therapeutic decision-making betweenopen reduction and internal fixation (ORIF) versus closed reduction and mandibulomaxillary fixation (CRMMF).

PATIENTS AND METHODS: Sixty-six patients with 79 displaced fractures (deviation of 10 degrees to 45 degrees , orshortening of the ascending ramus >/=2 mm) of the condylar process of the mandible at 7 clinical centers wereenrolled. Patients were randomly allocated to CRMMF (n = 30 patients) or ORIF (n = 36 patients) treatment. Thefollowing parameters were measured 6 months after the trauma. Clinical parameters included mouth opening,protrusion, and laterotrusion. Radiographic parameters included level of the fracture, deviation of the fragment,and shortening of the ascending ramus. Subjective parameters included pain (according to a visual analoguescale), discomfort, and subjective functional impairment with a mandibular functional impairment questionnaire.

RESULTS: The difference in average mouth opening was 12 mm (P


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Intracapsular condylar fracture of the mandible: ourclassification and open treatment experience

J Oral Maxillofac Surg. 2009 Aug ;67 (8):1672-9 19615581 Cit:1 Dongmei He, Chi Yang, Minjie Chen, Bin Jiang, Baoli Wang

Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School ofMedicine, Shanghai Key Laboratory of Stomatology, Shanghai, China.

PURPOSE: We studied the classification of intracapsular condylar fracture (ICF) of the mandible based on coronalcomputed tomography (CT) scans and present our open treatment experience at the temporomandibular joint(TMJ) division of Shanghai's Ninth People's Hospital (Shanghai, China).

MATERIALS AND METHODS: From 1999 to 2008, 229 patients with 312 ICFs were treated in our division. Amongthem, 195 patients (269 joints) had CT scans for classification. We modified the classification of Neff et al, adding anew fracture type according to our experience: type A, fracture line through lateral third of condylar head withreduction of ramus height; type B, fracture line through middle third of condylar head; type C, fracture linethrough medial third of condylar head; and type M, comminuted fracture of condylar head. There was no ramusheight reduction in fracture types B and C. Our treatment protocol is open reduction for a fracture in which thesuperolaterally dislocated ramus stump is out of the glenoid fossa or any type of fracture with displaced ordislocated fragments that may cause TMJ dysfunction later.

RESULT: Among the 269 joints, 116 had type A fractures (43.1%), 81 had type B fractures (30.1%), 11 had type Cfractures (4.1%), and 58 had type M fractures (21.6%); 3 joints (1.1%) had fractures that were not displaced. Ofthe joints, 173 had open reduction-internal fixation; postoperative CT scans showed that 95.6% of these hadabsolute anatomic or nearly anatomic reduction. In all of them normal mouth opening and occlusion wererestored. No or little deviation was found during mouth opening. Complications were pain in the joint (n = 1),crepitations (n = 2), and facial nerve (temporal branch) paralysis (n = 1). Two patients had the plate removedbecause of these complications.

CONCLUSION: Our new classification based on CT scans can better guide clinical treatment. Open reduction for ICFcan restore the anatomic position for both the condyle and TMJ soft tissues with few complications, which canyield better functional and radiologic results.

treatment protocol is open reduction for a fracture in which the

superolaterally dislocated ramus stump is out of the glenoid fossa or any

type of fracture

type A: fracture line thru lateral third of condylar head w/ reduction of ramus height

type B: fracture line through middle third of condylar head

type C: fracture line through medial third of condylar head

type M: comminuted fracture of condylar head.

postoperative CT scans showed that 95.6% of these had absolute

anatomic or nearly anatomic reduction.

In all of them normal mouth opening and occlusion were

restored
http://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surghttp://lib.bioinfo.pl/pmid:19615581/pmid/cithttp://lib.bioinfo.pl/auth:He,Dhttp://lib.bioinfo.pl/auth:Yang,Chttp://lib.bioinfo.pl/auth:Chen,Mhttp://lib.bioinfo.pl/auth:Jiang,Bhttp://lib.bioinfo.pl/auth:Wang,Bhttp://lib.bioinfo.pl/auth:Wang,Bhttp://lib.bioinfo.pl/auth:Wang,Bhttp://lib.bioinfo.pl/auth:Wang,Bhttp://lib.bioinfo.pl/auth:Jiang,Bhttp://lib.bioinfo.pl/auth:Chen,Mhttp://lib.bioinfo.pl/auth:Chen,Mhttp://lib.bioinfo.pl/auth:Chen,Mhttp://lib.bioinfo.pl/auth:Yang,Chttp://lib.bioinfo.pl/auth:He,Dhttp://lib.bioinfo.pl/auth:He,Dhttp://lib.bioinfo.pl/auth:He,Dhttp://lib.bioinfo.pl/pmid:19615581/pmid/cithttp://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surghttp://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surghttp://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surghttp://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surghttp://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surghttp://lib.bioinfo.pl/pmid/journal/J%20Oral%20Maxillofac%20Surg


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Mini-retromandibular approach to

condylar fractures

Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-FacialSurgery. 01/08/2008; Authors: Federico Biglioli, Giacomo Colletti

INTRODUCTION: Among maxillofacial surgeons, a general agreement exists that the therapeutic strategy forintracapsular condylar fractures is conservative, while the treatment of extracapsular fractures of the mandibularcondyle is extremely controversial. The indications and choice of treatment are less than uniform, often relying onthe surgeon's personal experience and beliefs. The literature increasingly suggests that the surgical managementof these fractures is superior to conservative management in functional terms. Nonetheless, the indications forsurgically treating condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral routesto the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but

is demanding technically, especially for higher neck fractures. In our experience, a 2-cm-long retromandibularaccess allows straightforward management of condylar fractures, providing as a result a well concealed scar.

MATERIALS AND METHODS: From 2006 to 2007, 21 patients with 25 condylar fractures were treated surgicallyusing the mini-retromandibular access. The mean operating time was 32min (range 17-55min). No facial nerveinjuries were observed. The first two patients developed postoperative infections. One patient, in whom the firstintervention resulted in malreduction of the fracture because the access was insufficient (15mm incision),required a second operation to achieve correct reduction and rigid fixation of the condyle.

RESULTS: In all cases, good anatomical stump reduction was achieved. All the patients obtained good articularfunction, since the access was exclusively extra-articular.

CONCLUSIONS: Condylar fracture reduction, fixation and healing can be managed comfortably using a limited

retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are vieweddirectly.

fixation and healing can be managed comfortablyusing a limited retromandibular approach.

Moreover, the risk of facial nerve injury is limitedas the nerve fibres are viewed directly.


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Endoscopic-assisted repair of

subcondylar fractures Volume 96 Issue 4 Pages 387-391 (October 2003) Michael Miloro DMD, Md Abstract

Objective

To evaluate outcomes of a series of mandibular subcondylar fractures repaired with endoscopic reduction andfixation.

Study design

Six consecutive subcondylar fractures were treated endoscopically. Intermaxillary fixation was usedintraoperatively to aid in fracture reduction. A modified Risdon incision was used to gain access to the lateral

ramus, and a modified retractor and endoscope were used for retraction and visualization. Fracture fixation wasachieved with a 2-mm titanium plate and screws. Patients were evaluated clinically and radiographically for 6months and functional, radiographic, and esthetic parameters were assessed at each time period (1, 2, 4, 12, and24 weeks).

Results

All patients demonstrated a stable occlusion in the postoperative period and anatomic alignment of the condyleradiographically. By 1 month, maximum interincisal opening was 42.2 5.7 mm. There was no joint noise ortemporomandibular joint (TMJ) pain postoperatively. Radiographs at each follow-up visit indicated the ramusheight was maintained in most cases. There was minimal transient facial nerve paresis following surgery. Scarperception was considered acceptable by all patients. Operative times were acceptable as well.

Conclusion Endoscopic-assisted repair of subcondylar fractures is an additional tool for management of subcondylar fractures,

however there is a steep learning curve based on this study. The technique allows good visualization of thefracture site for reduction through an incision with an acceptable cosmetic result.

Endoscopic approacvhMMF was used intraoperatively to aid in fracture reduction.Modified Risdon incision

Endoscopic-assisted repair of subcondylar fractures is

an additional tool for management of subcondylar

fractures


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Endoscopically Assisted Mandibular

Subcondylar Fracture Repair Plastic & Reconstructive Surgery: January 1999 - Volume 103 - Issue 1 - pp 60-65 Chen, Chien-Tzung M.D.; Lai, Jui-Ping M.D.; Tung, Tung-Chain M.D.; Chen, Yu-Ray M.D.

Abstract

The endoscope has been widely used in aesthetic surgery in recent years, but rarely has it beenused in cases of facial trauma. From July of 1996 to December of 1996, the endoscope was usedsuccessfully to assist in the repair of mandibular subcondylar fractures in eight patients (five menand three women). Their ages ranged from 15 to 60 years with an average age of 31 years. Six ofthe patients had other associated mandibular fractures including angular, parasymphyseal, andcontralateral subcondylar fractures. A 4.0-mm, 30-degree telescope was introduced to visualize thefracture site by means of an intraoral incision over the ascending ramus. A miniplate was used tostabilize the fracture site with the help of a percutaneous trocar. Intermaxillary fixation was appliedfor 3 to 6 days. Functionally, all patients returned to normal range of motion within 8 weeks. Aslight deviation to the trauma site was noted on maximal opening in three patients, but thiscondition returned to normal 3 months after surgery. There was no facial palsy or lip numbness.The benefits of the endoscopic approach include not only the provision of better visualization andprecise anatomic alignment of bony segments but also the avoidance of large facial scars and facial

nerve injuries.

better visualization

precise anatomic alignment of bony segments the

avoidance of large facial scars and facial nerve injuries


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Open reduction and internal rigid fixation ofsubcondylar fractures via an intraoral approach

Oral Surgery, Oral Medicine, Oral PathologyVolume 71, Issue 3, March 1991, Pages 257-261

Joachim Lachner D.M.D., M.D.a, a, Jerald T. Clanton D.M.D., M.D.b, aand Peter D. Waite D.D.S., M.D., M.P.H., c, a

aDepartment of Oral and Maxillofacial Surgery, University of

Alabama at Birmingham Birmingham, Ala., USA Extraoral open reduction and rigid fixation of mandibular

subcondylar fractures is controversial among surgeons. An intraoralapproach with a percutaneous trocar and miniplates demonstratedsatisfactory reduction. This technique can be more easily performedthan a preauricular or submandibular incision, and risk of facial

nerve damage is diminished. Early function with proper verticaldimension was restored with minimal postoperative morbidity.

An intraoral approach with a percutaneous trocar and

miniplates demonstrated satisfactory reduction.

(a preauricular or submandibular incision)

Early function with proper vertical dimension was restored

with minimal postoperative morbidity.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=ahttp://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GHR-4KTDP7W-1&_user=10&_coverDate=03/31/1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1476123987&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c1d6551e50d9fd8d1044c4781593ee3f&searchtype=a


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Closed versus open reduction of mandibular

condylar fractures in adults: a meta-analysis

Journal of oral and maxillofacial surgery : official journal of the American Association of Oral andMaxillofacial Surgeons. 01/07/2008; 66(6):1087-92. Authors: Marcy L Nussbaum, Daniel M Laskin,Al M Best

PURPOSE: A review of the literature shows a difference of opinion regarding whether open orclosed reduction of condylar fractures produces the best results. It would be beneficial, therefore,to critically analyze past studies that have directly compared the 2 methods in an attempt toanswer this question.

MATERIALS AND METHODS: A Medline search for articles using the key words "mandibular condyle

fractures" and "mandibular condyle fracture surgery" was performed. Articles that compared openand closed reduction were selected for further evaluation. Additional articles were obtained fromreference lists in the Medline-selected articles. Of the 32 articles identified, 13 met the finalselection criteria. These contained data on at least one of the following: postoperative maximummouth opening, deviation on opening, lateral excursion, protrusion, asymmetry, and joint or musclepain.

RESULTS: Numerous problems were found with the information presented in the various articles.These included lack of patient randomization, failure to classify the type of condylar fracture,

variability within the surgical protocols, and inconsistencies in choice of variables and how theywere reported. However, the results from the meta-analyses were explored in a general sense. CONCLUSIONS: Because of the great variation in the manner in which the various study parameters

were reported, it was not possible to perform a reliable meta-analysis. There is a need for betterstandardization of data collection as well as randomization of the patients treated in future studiesto accurately compare the 2 methods.

Medline search"mandibular condyle fractures"

"mandibular condyle fracture surgery"

1. lack of patient randomization

2. failure to classify the type of condylar3. fracture variability within the surgical protocols,

4. inconsistencies in choice of variables and how

they were reported.

not possible to perform a reliable meta-analysis.There is a need for better standardization of data collection


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Closed reduction, open reduction, and endoscopic assistance:

current thoughts on the management of

mandibular condyle fractures

Plastic and reconstructive surgery. 01/01/2008; 120(7 Suppl 2):90S-102S. Authors: Richard H Haug, M Todd Brandt The management of fractures of the mandibular condyle continues to be

controversial. This is in part attributable to a misinterpretation of theliterature from decades prior, a lack of uniformity of classification of thevarious anatomical components of the mandibular condyle, and aperceived potential to cause harm through the open approach based inpart on the surgeon's lack of a critical examination of the literature. Thisreview explores the key historical articles that deal with the managementof mandibular condyle fractures, and those modern-day contributions thatrepresent the state of the art. The authors' intention was to provide thereader with an objective summary of the management of this form of

injury, to place its management into a modern-day perspective, andperhaps to minimize the perception of controversy.

1. a misinterpretation of the literature from decades prior2. a lack of uniformity of classification of the various

anatomical components of the mandibular condyle3. a perceived potential to cause harm through the open

approach based in part on the surgeon's lack of a criticalexamination of the literature.

The management of fractures of the mandibular

condyle continues to be controversial.


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Abstract Background

Fractures of the condylar process account for between 25% and 35% of all mandibular fractures. Treatment options for fractures of the condylesconsist of either the closed method or by open reduction with fixation. Complications may be associated with either treatment option; for the closedapproach these can include malocclusion, particularly open bites, reduced posterior facial height and facial asymmetry in addition to chronic pain andreduced mobility. A cutaneous scar and temporary paralysis of the facial nerve are not infrequent complications associated with the open approach.There is a lack of consensus currently surrounding the indications for either surgical or non-surgical treatment of fractures of the mandibular condyle.

Objectives

To evaluate the effectiveness of interventions that can be used in the treatment of fractures of the mandibular condyle. Search strategy

The databases searched were: the Cochrane Oral Health Group's Trials Register (to 12th March 2010), CENTRAL (The Cochrane Library2010, Issue 2),

MEDLINE (from 1950 to 12th March 2010), and EMBASE (from 1980 to 12th March 2010). The reference lists of all trials identified were crosschecked for additional trials. Authors were contacted by electronic mail to ask for details of additional published and unpublished trials. There wereno language restrictions and several articles were translated.

Selection criteria

Randomised controlled trials (RCTs) which included adults, over 18 years of age, with unilateral or bilateral fractures of the mandibular condyles. Anyform of open or closed method of reduction and fixation was considered.

Data collection and analysis

Review authors screened trials for inclusion. Extracted data were to be synthesised using the fixed-effect model but if substantial clinical diversitywas identified between the studies we planned to use the random-effects model with studies grouped by action and we would explore theheterogeneity between the included studies. Mean differences were to be calculated for continuous outcomes and risk ratios for dichotomousoutcomes together with their 95% confidence intervals.

Main results No high quality evidence matching the inclusion criteria was identified. Authors' conclusions

No high quality evidence is available in relation to this review question and no conclusions could be reached about the effectiveness or otherwise ofthe two interventions considered in this review. A need for further well designed randomised controlled trials exists. The trialists should account forall losses to follow-up and assess patient related outcomes. They should also report the direct and indirect costs associated with the interventions.

Interventions for the treatment of

fractures of the mandibular condyleSharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R

Cochrane Oral Health Group's Trials Register (to 12th March2010), CENTRAL (The Cochrane Library2010, Issue 2), MEDLINE(from 1950 to 12th March 2010), and EMBASE (from 1980 to12th March 2010).


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CONCLUSION

The final choice of treatment modality for eachindividual patient takes into account a number of

factors

position of the condyle

location of the fracture age of the fracture

character of the patient

age of the patient

presence or absence of

other associated injuries presence of other systemic

medical conditions

history of previous jointdisease,

cosmetic impact of thesurgery

desires of the patient.


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CONCLUSION

Perhaps the collective experience of the many surgeons who treatthese fractures can best be characterized as follows:

Intracapsular fractures arebest treated closed.

When open reduction isindicated, the proceduremust be performed well, appreciate patient's occlusal

relationships

must be supported by anappropriate physical therapyand follow-up regimen.

Most fractures in adults canbe treated closed.

Physical therapy that isgoal-directed and specific toeach patient is integral togood patient care and is the

primary factor influencingsuccessful outcomeswhether the patient istreated open or closed.


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Controversies inMandibular Condyle Fracture

RepairFrederick Mars Untalan MD

Baguio General Hospital & Medical Center


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Documents

CONTROVERSIES IN CONDILAR FRACTURES