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Vol. 114 No. 5S November 2012

Management and outcome of condylar fractures in children andadolescents: A review of the literatureEmanuel Bruckmoser, MD, DMD,a and Gerhard Undt, MD, DMD, PhD,b Danube General Hospital, Vienna, andMedical University of Vienna, Vienna, Austria

Objective. The aim of this study was to provide a comprehensive review of all kinds of case reports and clinical studiesfocusing on management and outcome of mandibular condylar fractures (CFs) in children and adolescents.Study Design. A PubMed search of the international literature was done, completed by an additional hand search based onthe available references of the publications found.Results. In total, 73 articles were included in this review: 7 case reports and 2 retrospective clinical studies regarding surgicalmanagement, 1 publication with case reports, 1 prospective and 3 retrospective clinical studies comparing operative andconservative treatment, 20 publications with case reports, and 35 retrospective and 4 prospective clinical studies dealing withconservative management of CFs in children and adolescents.Conclusions. Despite frequently encountered radiologic abnormalities, conservative management of CFs in children usuallyyields satisfactory to excellent clinical results. However, in adolescents the outcome is often reported to be less favorable.Good prospective randomized multicenter studies would clarify from which age on patients could probably benefit from
operative treatment. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114(suppl 5):S86-S106)
According to Iida et al.,1 isolated mandibular fracturesrepresent the most common type of pediatric maxillo-facial fractures (56%), followed by alveolar fractures(32%) and midfacial fractures (11%). In a publicationdealing exclusively with mandibular fractures in chil-dren, Thorén et al.2 reported 72% of all fractures to belocated in the condylar region, with a significant cor-relation between age and fracture localization. Condy-lar fractures (CFs) were seen in about 3 out of 4 cases(76.0%) of mandibular fractures in children aged �5years, whereas the number of this type of fracturedecreased to 50% in patients aged 13-15 years. In mostcases (83.2%), only one condyle was concerned. Fur-thermore, Thorén et al.3 found the site of the condylarfracture to be age related, with a preponderance ofintracapsular fractures (58%) in patients �6 years old.In contrast, most of the older children sustained extra-capsular fractures, i.e., fractures of the condylar neck(78%) or in the subcondylar region (4%).

Regarding the classification of CFs, different con-cepts have been proposed, among others, by MacLen-nan,4 Lindahl,5 Spiessl and Schroll,6 Lund,7 Ellis etal.,8 and Neff et al.9 The classification by Loukota etal.10 intended to clarify some differences in grammar

aSpecialist Registrar, Department of Oral and Maxillofacial Surgery,Danube General Hospital.bAssociate Professor, University Hospital of Craniomaxillofacial andOral Surgery, Medical University of Vienna.Received for publication Mar 26, 2011; returned for revision Jul 25,2011; accepted for publication Aug 23, 2011.© 2012 Elsevier Inc. All rights reserved.2212-4403/$ - see front matter
doi:10.1016/j.oooo.2011.08.003
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across Europe and the USA. Misleading expressionsinclude “dislocated” (mainland Europe) being equiva-lent to “displaced” in Great Britain and the USA,whereas “dislocated” used by surgeons in Great Britain orthe US means “luxated” in the mainland Europe. Also, themisleading term “intracapsular” is discussed, becausemost of these fractures—though intracapsular in the con-dylar head region—extend to the medial aspect of thecondylar neck in an extracapsular position.

For diagnostic imaging, the panoramic radiographremains the basic diagnostic tool, usually combinedwith Clementschitsch11 or Towne radiographs. How-ever, computerized tomographic (CT) scans provideconsistently greater accuracy of diagnosis, sensitivity,and specificity and should therefore be considered forroutine investigation.12 The degree of dislocation androtation, as well as the multiplicity of fragments or apossible skull base involvement, can be reliably diag-nosed by spiral multislice CT.13

Myall et al.14 pointed out the importance of carefulexamination for disturbed dental occlusion, restrictedmouth opening, and pathologic signs in the preauricularregion (swelling, tenderness, crepitus, and lack ofmovement of the condylar head), because overlookedCFs can lead to persisting malocclusion, facial asym-metry, and in some instances ankylosis. In particular, achin laceration after rapid deceleration trauma shouldalert the examiner to the likelihood of the associatedbony injury. Possible complications of undiagnosedCFs in childhood include growth disturbances, as out-lined by Proffit et al.,15 who stated that previous CFsmay be involved in 5%-10% of all severe mandibular
deficiency and asymmetry. The incidence of CFs in

OOOO REVIEW ARTICLEVolume 114, Number 5S, Suppl 5 Bruckmoser and Undt S87

children is probably much higher than commonlythought, because three-fourths of these patients do notshow any growth deficits. Apart from these more com-monly encountered findings, rare complications, suchas traumatic dislocation of the mandibular condyle intothe middle cranial fossa16,17 or features resemblingPerthes disease,18 have also been described.

The purpose of the present review article is to give acomprehensive overview of the international literature,including case reports and clinical studies, focusing onmanagement and outcome of CFs in children and ado-lescents. To simplify matters, the terms child and chil-dren are used for any patient up to 20 years of age.Whenever necessary, a further graduation into children(usually patients �12 years old) and adolescents (teen-agers aged �12 years) is made.

MATERIALS AND METHODSTo identify publications dealing with CFs in children thefollowing Pubmed queries were created and merged. Re-garding fracture level, we searched for condylar, con-dyle(s), condyloid, diacapitular, condylar head(s), condy-lar neck(s), mandibular neck(s), mandibular process (es),collum, subcondylar, temporomandibular joint(s), or tem-poromandibular joint (TMJ)(s). To find publications ex-clusively dealing with children and adolescents, wesearched for pediatric(s), paediatric(s), child, children,childhood, infant(s), infancy, youth(s), adolescent(s), teen-ager(s), growing, or growth. Adding the key words frac-ture(s), fractured, trauma(tic), or injury as search headingsresulted in the following query: (condylar[title] ORcondyle*[title] OR condyloid[title] OR diacapitular[title]OR condylar head*[title] OR condylar neck*[title] ORmandibular neck*[title] OR mandibular process*[title]OR collum[title] OR subcondylar[title] OR temporoman-dibular joint*[title] OR tmj*[title]) AND (pediatric*[title]OR paediatric*[title] OR child[title] OR children[title] ORchildhood[title] OR infant*[title] OR infancy[title] ORyouth*[title] OR adolescent*[title] OR teenager*[title]OR growing[title] OR growth[title]) AND (fracture*[title]OR trauma*[title] OR injury[title] OR injuries[title]). Theasterisk was used as “wild card” to keep the query assimple and short as possible (e.g., fracture* would includethe terms fracture, fractures, and fractured). By applyingthese criteria, the corresponding Pubmed search yielded301 results. Several publications were excluded for thefollowing reasons: articles concerning CFs of other joints(e.g., elbow or knee), experimental (animal) or cadavericstudies, pure epidemiologic studies, publications includ-ing patients older than 20 years, papers concerning man-agement of sequelae of CFs, articles dealing solely withdiagnostic imaging of CFs, consensus papers, and reviewarticles without case presentations. Six articles were added
after performing a hand search based on the available
references of the publications identified. Finally, 73 arti-cles published in peer-reviewed journals were included inour review: 7 case reports and 2 retrospective clinicalstudies regarding surgical management, 1 publication withcase reports, 1 prospective and 3 retrospective clinicalstudies comparing operative and conservative treatment,20 publications with case reports, and 35 retrospective and4 prospective clinical studies dealing with conservativemanagement of CFs in children and adolescents.

All articles are listed in Tables I-III in chronologicorder by date of publication. The Results sections pro-vide complementary information and/or additional ex-planations whenever necessary. The inconsistent no-menclature of the various types and degrees of severityof CFs found in the literature was maintained, becausein some publications only the degree of severity of CFsis indicated (e.g., severely displaced or dislocated frac-tures), whereas in other articles only the fracture site isdescribed (e.g., head, neck, subcondylar).

RESULTSClinical studies and case reports on surgicalmanagement of CFs in children (Table I)In 1954, Becker19 reported the case of a unilateralcomminuted head fracture which was treated by con-dylectomy. The patient suffered very little from boththe operation and the missing condyle. His masticatorysystem was disturbed only very little.

In 1970, Hoopes et al.20 published 2 case reports, oneof which concerned a 2.5-year-old girl with a grosslydisplaced fracture of the left mandibular condyle. Oneyear after open reduction and internal fixation (ORIF)followed by interdental fixation, occlusion was normaland no pain, mandibular shift, or limitation of mandib-ular function was found. Although in this case reportno radiologic follow-up examination is mentioned, itcan be assumed that postoperative evaluation (includ-ing radiographs) was probably similar to the case ofanother patient described in the same article. Becausethe other patient (female, 8 years old) had sustained aCFs 2 years before consultation which led to growthdisturbance necessitating secondary TMJ surgery tocorrect facial asymmetry, she is not mentioned in TableI, because this review article focuses on primary surgi-cal interventions in recent CFs.

Lund21 reported a 5-year-old girl suffering from aright subcondylar fracture with the condylar fragmentdislocated nearly 180° medially. Open reduction andfixation by a Kirschner pin was performed. After sur-gery, the girl was put under rigid maxillomandibularfixation (MMF) for 4 weeks, which was altered to adecreasing elastic type and finally removed after an-other 3 weeks. Clinical and radiologic follow-up more
than 3 years later showed a normal condylar process, a

Table I. Surgical treatment

Author (y) Study designNo. of

patientsNo. of

fracturesAge atinjury Type of fracture Surgical procedure

Osteosynthesismaterials MMF

Follow-upperiod

Follow-upexaminations Outcome

Becker19 (1954) Case report 1 1 11 y Dislocated comminutedhead

Condylectomy None 4 wk 4 mo NA Satisfactory

Hoopes et al.20(1970) Case report 1 1 2 y NA Postauricular access Transosseous wire 3-4 wk 1 y Clinical examination,radiograph(s)

Excellent

Lund21 (1972) Case report 1 1 5 y Dislocated subcondylar Submandibularaccess

Kirschner pin 4 wk rigid �3 y Clinical examination,panoramicradiograph, pa andlateralcephalograms

Good

Hollmann et al.22 (1986) Case report 1 1 3 y Neck Wire extension to theretroauricularregion

None 3 wk 6 mo Clinical examination,conventionaltomography,coronal view

Good

Rodloff et al.23 (1991) Case report 1 1 9 y Dislocated low neck Submandibularapproach

None 1 wk 8 mo Clinical andradiologicexamination

Good

Sysoliatin et al.24 (1992) Retrospective study 35 39 3-17 y Subcondylar (16), neck(13), head (10)

ORIF (17),replantation (10),arthroplasty (12)

Kirschner wire(16), allograft/bone-pin (11)

1-2 wk 2-15 y Panoramic radiograph,cephalogram,sonography,electromyography

Good in 84.6%of cases

Bergsma25 (2001) Case report 1 1 5 y Dislocated Reposition viaintraoral access

None �2.5 wk 2 y Clinical examination,panoramicradiograph, Towneradiograph

Good

Schön et al.26 (2005) Case report 1 1 9 y Subcondylar Endoscopicallyassisted transoralaccess

1 miniplate NA 4 wk, 6 mo,and 2 y

Clinical examination,panoramicradiograph, Towneradiographs

Excellent

Deleyiannis et al.27

(2006)Retrospective study 6 8 2-14 y Neck (5), subcondylar

(3)Retromandibular (4

pts) or preauricular(2 pts) access;ORIF in situ (4CFs), removal ofcondyle as a freegraft (4 CFs)

Plates (1.0-2.0mm)

None 27-92 mo(mean67.6 mo)

Questionnaire, clinicalexamination,panoramicradiograph, PA andlateral cephalogram

Partiallynonsatisfactory

CF, Condylar fracture; MMF, maxillomandibular fixation; NA, data not available; ORIF, open reduction internal fixation; PA, posteroanterior; pt(s), patient(s).

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Table II. Surgical versus conservative treatment

Author (y) Study design No. of patientsNo. of

fractures Age at injury Type of fracture Surgical managementConservativemanagement

Follow-upperiod Follow-up examinations Outcome

Rasse et al.28 (1991) Retrospective study 37 (25 s, 12 c) 54 �16 y Intra- and extracapsular Preauricular access;wire extension tothe retroauricularregion or Kirschnerpin; MMF for 3wk

MMF for 4 wk,followed byfunctionaltreatment

NA(presumably�3-15 y)

Occlusal index, clinicalexamination,axiography, MPI,panoramicradiograph,Clementschitsch11

and submentovertexradiographs

Surgical outcomesimilar toconservativemanagementdespite poorerstarting point(severelydisplaced ordislocatedCFs)

Ziccardi et al.29

(1995)Review article with

5 casepresentations

5 (cases 1 and2: surgeryimmediatelyafter injury)

Case 1: 1;case 2: 2;case 3: 1;case 5: 2

Cases 1 and 2: 7 y;case 3: 9 y; case5: 3.5 y

Cases 1 and 2:subcondylar;cases 3 and 5:

intracapsular

Preauricular access;case 1: microplates;case 2: K-wires

Case 3: soft diet,physiotherapy;

case 5: rigid MMF(2 wk), guidingelastics (3 wk)

Case 1: 2 y;case 2: 15 mo;case 3: 2.5 y;case 5: 1 y

Clinical examination,panoramicradiograph, CT scan

Case 1: excellent;case 2: good;case 3: ankylosis;case 5: good

Cascone et al.30

(1999)Retrospective study 16 (6 s, 10 c) 19 �16 y (mean

9.81 y)Head (6), neck (10),

subcondylar (3)Reduction and

contention withexternal rigidfixation (3 pts) orcondylectomyfollowed byfunctional therapy(3 pts)

Liquid diet for15 d or MMFfor 7-15 d,followed byactivatortherapy andphysiotherapy

2-9 y Clinical examination,panoramicradiograph,cephalograms,radiographs inBretton projection,gnathography

Good surgicaloutcome(especially inpts treatedwith externalrigid fixation)

Landes et al.31 (2008) Prospective study 19 (10 s, 9 c) 20 s: 7-14 y (mean10.4 y); c: 5-14 y(mean 9.3 y)

s: classes II, IV, and V;c: classes I and VI

(classificationaccording to Spiessland Schroll6)

Preauricular orretromandibularaccess; microplatesor miniplates

MMF with guidingelastics orremovableorthodonticappliance,exercises,physiotherapy

1-5 y Clinical examination,TMJ sonography,panoramicradiograph, Towneview (in some pts)

Classes I, II, andIV: good;

class V and VI:not satisfactory

Hu et al.32 (2010) Retrospective study 25 (8 s, 17 c) 33 s: 8-13 y;c: 3-12 y

Head (10), neck (19),subcondylar (4)

Preauricular orretromandibularaccess; microplatesor miniplates

Craniomaxillaryelastic bandage,occlusal pads

1-6 y (mean3.5 y)

Clinical examination,panoramicradiograph, anteriorand lateralcephalograms, Towneview, 3D CT scan

Goodeffectivenessof bothsurgical andconservativemanagement

c, Conservative treatment; CT, computerized tomography; MPI, mandibular position indicator; s, surgical treatment; TMJ, temporomandibular joint; other abbreviations as in Table I.

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Table III. Conservative treatment

Author (year) Study design No. of patients No. of fractures Age at injury Type of fracture TreatmentFollow-up

periodFollow-up

examinations Outcome

Rakower et al.33 (1961) Case reports 3 3 3-12 y Displaced and dislocatedneck fractures

MMF (9 d to 4 wk) 5 mo to 2 y Clinical examination,radiographs

Very good

Kaplan and Mark34

(1962)Case report 1 2 18 mo Bilateral low condylar neck

fractures with 45°angulation

Observation, early restorationof jaw function (return tonursing bottle, etc.)

�2 y PA skull film, lateralprojections of themandible

Very satisfactory

Thomson et al.35 (1964) Retrospective study 23 NA Mean 6.7 y, 50% of pts�5 y

Condylar neck fractures withanteromedial subluxationor dislocation of thecondyle

No treatment, Barton bandage,MMF, or open reductionwiring condyle

Mean 4.5 y Clinical examination,radiographs(coronal view)

Excellent functionaloutcome,constanttendency toremodel inpractically allcases

MacLennan andSimpson36 (1965)

Case reports 6 7 2.5-7 y Displaced (2), dislocated (5) Lastonet bandage and soft dietfor 2 wk (4 pts), metal capsplints (1 pt), overlayGunning splint (1 pt)

2-5 y Clinical examination,radiographs(coronal view)

Very satisfactory(particularly in 3cases)

Brandt and Knak37

(1969)Retrospective study 19 NA for follow-up pts NA for follow-up pts NA for follow-up pts MMF for 2-3 wk with

subsequent functionalappliance therapy (in mostpts) or chin cup withmonoblock

2-15 y (mean7.5 y)

Clinical examination,radiograph(s)

Very satisfactoryfunctional andmorphologicoutcome

Gilhuus-Moe38 (1970) Retrospective study 62 81 3 age groups: 1-5 y (12pts), 6-11 y (21 pts),12-18 y (29 pts)

Head (2), neck (34),subcondylar (45),nondisplaced (10),displaced (22), dislocated(49)

Observation (12 pts), MMF for2-3 wk or up to 7 wk inpresence of concomitantfractures of the horizontalramus (50 pts)

1.3-12.6 y Clinical examination,radiographs

Favorable clinicaloutcome in 47pts, remodelingdependent on ageand dislocation

Leake et al.39 (1971) Retrospective study 20/13 25/17 2.5-12 y (mean slightlyless than 6 y)

Nondisplaced (9/6), slightlydisplaced (2/2), antero-medially displaced (4/2),moderately displaced(4/3), severely displaced(5/4), NA in 1 CF

Early motion withestablishment of normaleating habits

2 mo to 17 y Clinical examination,radiographs(coronal view)

Excellent

Hunter40 (1972) Case report 1 1 18 mo Nondisplaced neck Observation 1 wk Clinical examination Good

Holtgrave et al.41 (1975) Retrospective study 18 22 1-14 y Class I: 2;class II: 3;class III: 6;class IV: 4;class V: 4;class VI: 3 (classification

according to Spiessl andSchroll6)

Monoblock (2 pt), MMF viaelastics (4 pts), rigid MMFfor 1 wk with subsequentmonoblock therapy (1 pt),rigid MMF for 2 wk (6pts), rigid MMF for 2 wkwith subsequent monoblocktherapy (1 pt), rigid MMFfor 3 wk (3 pts), rigidMMF for 4 wk withsubsequent monoblocktherapy (1 pt)

NA (presumably�3-8 y)

Clinical examination,conventionaltomography in 2planes

Restitution mainlyin children�10 y

Campbell42 (1975) Case report 1 1 3 mo Anteriorly displaced Observation, physiotherapy 4 mo Radiograph Excellent

Brady43 (1978) Case report 1 1 11 y Subcondylar Jaw exercises, return to normaldiet as soon as possible

4 y Clinical examination,reverse Towneview

Very good

Balaban et al.44 (1979) Case reports 5 5 �12 y NA Initially liquid (then soft andregular) diet, mandibularexercises

�10 wk Clinical examination,radiographs

Good

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Table III. Continued


periodFollow-up


Knobloch45 (1980) Retrospective study 40 56 �14 y Intracapsular (14.3%),collum with (23.2%) orwithout (17.9%)displacement, dislocatedcollum (44.6%)

MMF using a wire-and-acrylicsplint, functional appliancetherapy (after MMF) insome pts; surgery in 1 pt

4-10 y Clinical examination,functional analysis,radiographs in 2planes

Good

Spence46 (1982) Case report 1 1 6 Medially displacedsubcondylar fracture

Soft diet for 1 mo �6 mo Clinical examination,panoramicradiograph

Excellent function,completecondylarremodeling

Spitzer and Zschiesche47

(1986)Retrospective study 28 34 2-18 y (mean 9 y) 23 fractures were dislocated Functional gnatho-orthopedic

treatment for 5.3 mo(mean)

Mean 3 y Clinical examination,radiographs

Restoration offunction (fully)and morphology(largely)

Williamson48 (1986) Case report 1 1 7 y Displaced subcondylar Ligated anterior repositioningsplint (�9 mo)

2 y 9 mo Panoramic andsubmentovertexradiographs

Normal condylarmorphology

Birchler-Argyros andChausse49 (1987)

Retrospective study 14 17 8-15 y Intracapsular (5),nondislocated collum (5),dislocated collum (7)

Rigid MMF (2-4 wk) and/orelastic MMF (2-5 wk) withsubsequent physiotherapy,physiotherapy alone insome intracapsular CFs

1-8 y (mean3.6 y)

Clinical examination,panoramic andClementschitsch11

radiographs in 10pts

Functionallyabsolutelyacceptable long-term results,favorableremodeling

Sahm and Witt50 (1989) Retrospective study 12 16 6-14 y (mean 9 y 5 mo) 6 low CFs (in 4 casesluxated), 10 high CFs

MMF for 2-3 wk, followed bya removable functionalorthopedic appliancetherapy (bionator)

NA (mean age atthe time ofCT scan 17 y6 mo)

CT scan (axial andcoronal views)

High degree ofremodeling inhigh CFs,unfavorableremodeling in all4 luxated lowCFs

Sahm et al.51 (1990) Case reports 5 5 7-13 y Dislocated low CFs Functional therapy in all pts,preceded by MMF for 2-4wk in 4 pts

2-17 y (mean8 y)

CT scan, MRI in 3pts

2 condylar parts,bifid condyle in1 pt

Sahm et al.52 (1990) Case reports 3 3 7-13 y Dislocated low CFs Functional therapy in all pts,preceded by MMF for 12 din 1 pt

9-22 mo CT scans (2-3 per pt) Small fragmentpartiallyresorbed, newbone formed onthe lateral aspect

Kahl and Gerlach53

(1990)Retrospective study 21 24 3-13 y Class III: 13; class IV: 5;

class V: 6 (classificationaccording to Spiessl andSchroll6)

3 treatment groups: functionalorthopedics for 9 mo (7pts), MMF for 2 wk withsubsequent functionalorthopedics for 9 mo (6pts), or MMF followed byexercises (8 pts)

Follow-up periodnot preciselyindicated (moor y aftertreatment)

Clinical examination,panoramicradiograph,mandible viewsemiaxial,axiography in 3pts

Good to excellentrestoration offunction in allpts, restoration ofanatomic form inonly 20%

Gundlach et al.54 (1991) Retrospective study 103 139 2-16 y Class I: 8;class II: 42;class III: 16;class IV: 31;class V: 34;class VI: 8 (classification


MMF for 10 d withsubsequent functionalexercises for 1 mo

�1 y Clinical examination,panoramicradiograph, PAskull view 19°

Better in youngerpts (�8-10 y),excellent innondislocatedCFs, lessfavorable indisplaced ordislocated CFs

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periodFollow-up


Gerlach et al.55 (1991) Retrospective study 34 37 4-13 y (mean 7 y) Class II: 9;class III: 16;class V: 7 (classification

according to Spiessl andSchroll6) remaining CFsnot exactly classified

Functional appliance therapyfor 9-12 mo (group 1, 17pts), MMF for 10-14 dwith subsequent functionalappliance therapy (group 2,9 pts), or functionalexercises (group 3, 8 pts)

12-48 mo (mean22.5 mo)

Clinical examination,panoramicradiograph, coronalview, axiographyin some pts

Good functionaloutcome,radiologicoutcome lessfavorable in somepts

Cornelius et al.56 (1991) Retrospective study 65 NA 2-12 y NA Rigid MMF for 12-14 d (28 din case of additionalmandibular fractures),followed by MMF viaelastics for 8-14 d, ifnecessary followed bymouth opening exercisesand functional appliancetherapy (activator)

2-15 y (mean7 y 3 mo)

Clinical examination,radiographs,axiography andsirognathographyin some pts

Restitutio adintegrum in 3 pts,less favorableoutcome in theremaining 62 pts

Mairgünther et al.57

(1991)Retrospective study 52 68 27 pts 5-15 y (mean

11.5 y), 25 pts 16-19y (mean 17.4 y)

Class I: 15;class II: 16;class III: 2;class IV: 17;class V: 16;class VI: 2 (classification


MMF with subsequent mouthopening exercises (40 pts),functional appliancetherapy (9 pts), MMF for�2 wk with subsequentfunctional appliancetherapy (3 pts)

Mean 6 y Clinical examination,sirognathography,radiographs

Satisfactory, bettertendency forrestitution in pts�15 y

Wiltfang et al.58 (1991) Retrospective study 42 54 1-14 y Class I: 5;class II: 16;class III: 13;class IV: 7;class V: 11;class VI: 2 (classification


Rigid MMF for 5-6 d,followed by functionaltherapy with elastics for4-5 wk

1-10 y Dysfunction indexaccording toHelkimo,59 clinicalexamination,plaster cast andphoto analysis,panoramic andClementschitsch11

radiographs, 45°lateralcephalograms

Good functional andanatomicremodeling, lesssatisfactoryoutcome indislocated CFsand older children

Spitzer et al.60 (1991) Retrospective study 48 NA 3-14 y NA Functional orthodonticappliance therapy for 18wk (mean)

Mean 3 y Clinical examination,panoramicradiograph, PAskull view withopen mouth, CTscan in 20 pts

Good TMJ function,often incompleteremodeling inolder pts andespecially in deepdislocated CFs

Schendel et al.61 (1991) Retrospective study 29 NA 2-16 y Low and high collumfractures with variousdegrees of displacement/dislocation

Functional appliance therapyfor 6-12 mo, in 15 ptspreceded by MMF

Mean 3.6 y Clinical examination,panoramicradiograph, PAskull view, MRI in14 pts

Overall good, betteroutcome withoutpreceding MMF

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periodFollow-up


Altmann andGundlach62 (1992)

Retrospective study 36 47 2-16 y Class I: 2;class II: 17;class III: 2;class IV: 15;class V: 9;class VI: 2 (classification


MMF for 10-14 d withsubsequent functionaltherapy for 4-6 wk, in somepts followed by functionalappliance therapy

�2 y (mean 61mo)

Clinical examination,panoramicradiograph, PAskull view 15°

Very good indisplaced CFs,less satisfactory indislocated CFs,better functionalresults in pts �8y, frequentlyincompleteremodeling indislocated CFs

Feifel et al.63 (1992) Retrospective study 28 37 2.3-14.2 y (mean 8.7 y) NA Orovestibular plates fixed tomaxilla and mandible forMMF (8-23 d), followed byfunctional treatment withpassive mouth openingexercises using theorovestibular plates withsprings (mean 7 mo)

Mean 15.1 y Clinical examination,electroniccomputer-assistedrecording system,panoramicradiograph, PAskull films in 15°eccentricprojection (Towne)

Good esthetic andfunctionaloutcome,condylarremodeling inabout half of thepts (the moredisplacement, theless remodeling)

Nørholt et al.64 (1993) Retrospective study 55 64 5-20 y (4 age groups:5-9 y, 10-14 y, 15-17 y, 18-20 y)

NA Observation (13 pts), elasticMMF (15 pts), rigid MMF(27 pts)

1-25 y (mean10.1 y)

Questionnaire,Helkimo59 index,panoramicradiograph, TMJview, frontal andlateralcephalogram

Good outcome, butincreasingdysfunctionindex valueswith increasingage, frequentradiologicabnormalities notcorrelated withseverity ofdysfunction

Kellenberger et al.65

(1994)Retrospective study 30 36 9 mo to 14 y (mean 6 y

9 mo)NA Rigid MMF for 5-7 d with

subsequent functionaltherapy by elastics

1 y 2 mo to 11 y9 mo (mean4 y 11 mo)


radiographs

Very goodfunctionaloutcome, verygood remodelingin 77%

Kahl-Nieke et al.66

(1994)Retrospective study 7 7 4-9 y Class I: 1;

class II: 2;class III: 1;class IV: 1;class V: 2 (classification


Functional orthopedic therapy(activator) for 9 mo

�5 y Clinical examination,spiral CT scans

Good to excellentfunctionaloutcome; CTscan: markedremodelingchanges withsignificantalterations ofcondylar andarticular surface

Kahl-Nieke andFischbach67 (1995)

Retrospective study 12 16 5-16 y (mean 10 y) Class I: 3;class III: 3;class IV: 5;class V: 5 (classification


Functional appliance therapy(activator) intended for 1 y

6 mo Clinical examination,spiral CT scansafter 6 mo ofactivator therapy

Good to very goodclinical outcome,5 hypoplastic, 5moderate, and 5severe deformedcondyles

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Kahl et al.68 (1995) Retrospective study 19 21 4-14 y Class I: 8;class II: 3;class III: 1;class IV: 2;class V: 7 (classification


Functional appliance therapy(9 mo)

3-9 y Spiral CT scan with2D and 3Dreconstructions

Very good clinicaloutcome, goodradiologicaloutcome in 11pts with 13 CFs

Kellenberger et al.69

(1996)Retrospective study 30 36 9 mo to 13 y (mean 6 y

9 mo)NA Rigid MMF for 5-7 d with

subsequent functionaltherapy via guiding elastics

1-11 y (mean4 y 11 mo)


radiographs

Good clinicaloutcome, goodcondylarremodeling in77%, shorteningof the ramus in70%-74%

Röthler et al.70 (1996) Prospective study 50 50 �10 y About two-thirds of all CFsclasses III and V(classification accordingto Spiessl and Schroll6)

Functional therapy (activator)for 4-6 mo

6 wk, 3 mo, 6mo, 12 mo,then once ayear until endof growth

Panoramic radiograph Very goodrestitution in pts�6 y, lessfavorable in pts�8 y withdislocated CFs

Kahl-Nieke andFischbach71 (1998)

Retrospective study(follow-upgroup)

19 (follow-up group),20 (treatment group)

19 (follow-up group),20 (treatment group)

9.0 � 3.3 y (follow-upgroup), 8.1 � 3.3 y(treatment group)

Follow-up group: class I: 6;class II: 3; class III: 2;class IV: 2; class V: 6;treatment group: class I:6; class II: 1; class III: 2;class IV: 3; class V: 8(classification accordingto Spiessl and Schroll6)

Follow-up group: functionalappliance therapy (activator�16 h per day) for 9 mo;treatment group: functionalappliance therapy (activator�16 h per day) for 6-8 mo

4.9 � 1.7 y(follow-upgroup)

Axial CT scan withsagittal andcoronal 2D and 3Dreconstructions

Relativemediolateraldecrease of 4.2%and PA increaseof 12.6% of thefracture sidecondyle,shortening ofcondylar neckand bonyovergrowth morefrequent indisplaced andlow CFs

Thorén et al.72 (1998) Retrospective study 37 45 3.1-15.1 y (mean 9.4 y) 9: intracapsular, 36:extracapsular (I: 4; II: 6;III: 2; IV: 24 [accordingto MacLennanclassification4])

Observation (22 pts) or rigid/elastic MMF (15 pts) for7-26 d (mean 17.2 d)

1-12 y (mean4.1 y)

Clinical examination,panoramicradiographs, lateralpanoramic images,Towne views

Subjectivesymptoms in 4pts (10.8%),objective signsof dysfunction in12 pts (37.8%),incompleteremodeling in 25CFs (56%),difference inramus height in15 pts (52% ofunilateral CFs)

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Strobl et al.73 (1999) Prospective study 55 55 2.5-9.75 y; 4 agegroups: 2-4 y (5 pts),5-6 y (42 pts), 7-8 y(5 pts), 9-10 y (3pts)

Class I: 6;class II: 7;class III: 23;class IV: 7;class V: 10;class VI: 2 (classification


Myofunctional appliancetherapy for 4-6 mo (�16 hper day)

6, 12, 24, 48, 72wk, then oncea year untilend ofgrowth

Clinical examination,panoramicradiographs

Satisfactory clinicaloutcome in allpts, no functionaldisturbance orasymmetry,better radiologicoutcome inyounger pts

Hovinga et al.74 (1999) Retrospective study 25 28 3-16 y (mean 8.7 y) Unilateral CFs: low (4),high (15), intracapsular(3); bilateral CFs: low(1), high (3),intracapsular (2)

Observation, home exercises(mirror), MMF for 2 wkfollowed by guidingelastics (5 pts), orthodontictreatment (4 pts)

5-24.5 y (mean15 y)

Clinical examination,panoramicradiographs,Towne view,frontal and lateralcephalograms incases of obviousdifference inramus height afterunilateral CFs

Good subjective andobjective clinicaloutcome, facialasymmetry in 4pts, obviousmalocclusion andfacial asymmetryrequiringorthognathicsurgery in 1 pt

Defabianis75 (2000) Case report 1 2 3 y Dislocated neck Liquid diet for 20-30 d,functional appliancetherapy

18 mo Clinical examination,radiographs

Very good

Thorén et al.76 (2001) Retrospective study 18 22 3.1-15.6 y (mean10.5 y)

CFs with total dislocation ofthe condyle from theglenoid fossa

Soft diet with immediatemobilization in 11 pts,MMF for 10-24 d (mean17 d) in 7 pts

4.8-16.4 y (mean8.6 y)

Questionnaire,Helkimo59 index,clinicalexamination,panoramicradiograph, lateralprojection of thecondyles, Towneview, PAcephalogram

Subjectivesymptoms in56%, objectivesigns of TMJdysfunction in72%, incompleteremodeling in76.5%,asymmetry of themandible in64.7%

Güven and Keskin77

(2001)Retrospective study 18 21 4-11 y (mean 7.7 y) Class I: 5;

class II: 9;class III: 3;class IV: 2;class V: 1;class VI: 1 (classification


MMF for 12-17 d via custom-made arch bars, followedby liquid diet for 15 d(without fixation) andfunctional treatment(passive mouth openingexercises)

3-6 y (mean4.7 y)

Clinical examination,panoramicradiograph, PAskull film, CT scanin some pts

Good function andgood remodelingof the condyle

Defabianis78 (2001) Case reports 3 Case 1: 2 Case 1: 3 y Case 1: bilaterally dislocatedneck

Liquid diet (20-30 d) andimmediate functionalappliance therapy

�8 mo Clinical examination,PA cephalometricprojection

Very good

Defabianis79 (2001) Retrospective study 46 NA 4-9 y Dislocated andnondislocated

Functional appliance therapyfor 2 y or physiotherapy fora few months

5 y Clinical examination,panoramicradiograph, lateraland PA projection,CT and MRI insome pts

Good outcome inthe functionallytreated group,variousalterations in thephysiotherapygroup

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Defabianis80 (2002) Case reports 2 2 6 y Medially dislocated Case 1: liquid diet (1 wk),stabilizing splint (removedafter 1 wk), functionalappliance therapy (�8 mo)

Case 1: 8 mo Case 1: clinicalexamination,panoramicradiograph, PAcephalometricprojection, TMJtomography, MRI

Case 1: good

Defabianis81 (2002) Case reports 2 3 3 y Case 1: bilateral dislocatedneck fracture, case 2:intra-articular

Case 1: liquid diet (20-30 d)and immediate functionalappliance therapy (18 mo);case 2: liquid diet only (20d)

Case 1: 3 y; case2: 1 y

Clinical examination,panoramicradiograph, PAcephalometricprojection, CTscan

Case 1: goodclinical andradiologicoutcome; case 2:nonsatisfactory

Defabianis82 (2003) Case report 1 2 3 y Bilateral dislocated Liquid diet, functionalappliance therapy for 18mo

1, 3, 6, 12 mo,then once ayear

Clinical examination,PA cephalometricprojection, CTscan after 2 y

Good

Defabianis83 (2003) Retrospective study 25 31 2-9 y Nondislocated (17 pts),dislocated (8 pts)

Physiotherapy with specifictreatment protocol (muscleexercises, control of postureand oral habits) for 16-24wk

5 y Clinical examination,panoramicradiograph,cephalograms,lateral TMJtomograms, CTscan, MRI

3 pts: normal TMJsand normal facialstructure; 22 pts:pathologicfindings

Defabianis84 (2004) Case reports 2 2 Case 2: 8 y Case 2: medially dislocated Case 2: soft diet withsubsequent functionalappliance therapy

Case 2: 3 y Clinical examination,radiographs, MRI

Case 2: very good

Choi et al.85 (2005) Retrospective study 11 14 3-15 y Low condyle neck (2), highcondyle neck (6),condyle head (3),intracapsular (3)

MMF for 2-10 d (6 pts) 1-6 y (mean:3.27 y)

Clinical examination,panoramicradiograph, frontaland lateralcephalogram, 3DCT

Satisfactoryrestitution of jawfunction despitehigh frequencyof radiologicallydetectedaberrations

Chatzistavrou andBasdra86 (2007)

Case reports 5 5 4.5-10 y Subcondylar (2), neck (1),remainder NA

Functional appliance therapy(activator for 9-12 mo)

Up to 2 y Clinical examination,panoramicradiograph

Good

Cucurullo et al.87 (2009) Case report 1 1 9.6 y Dislocated verticalintracapsular

Interarch elastics,physiotherapy, after 3 wkactivator for �24 mo

3.7 y Clinical examination,panoramicradiograph, CTscan

Very good

Medina88 (2009) Case report 1 2 7 y Severely displaced multiplesegment

Soft diet, followed byphysiotherapy and hybridfunctional appliancetherapy

6 y Clinical examination,panoramicradiograph, CTscan

Good clinicaloutcome,satisfactoryremodeling

Zhao et al.89 (2009) Prospective study 23 29 3-16 y Head (4 pts), high neck (14pts), low neck (5 pts)

Soft occlusal splint for 1-3 moaccompanied by functionalexercises

6 mo to 5 y Clinical examination,panoramicradiograph

Satisfactory clinicaloutcome, shortand flattenedremodeledcondyles

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well functioning TMJ with regular translation, and aharmonic growth of the facial complex.

Hollmann et al.22 reported the case of a 3-year-oldchild with a dislocated fracture of the left mandibularcondyle. Open reduction and stabilization by wire ex-tension to the retroauricular region was performed,succeeded by 3 weeks of MMF. Follow-up at 6 monthsafter surgery showed good clinical and radiologic re-sults without any postoperative complications.

A case of open reduction without internal fixation ina 9.5-year-old male patient who had suffered from adislocated low neck fracture was described by Rodloffet al.23 MMF was discontinued 7 days after the surgicalintervention, followed by functional mouth openingexercises. Both clinical and radiologic findings werevery satisfying 8 months after surgery.

Long-term results of 35 patients with 39 CFs werepublished by Sysoliatin et al.24 In 30 cases, a typicalanteromedial dislocation of the condyle was found. In 3cases the injury was so severe that the condyle wascompletely detached from muscle and capsule. Thesurgical intervention comprised reposition and osteo-synthesis in 17 patients. Replantation of the condylewas carried out in 10 children. Twelve patients under-went arthroplasty of the TMJ. MMF was applied for 1week after osteosynthesis and for 2 weeks after arthro-plasty and replantation. Good long-term anatomic,functional, and esthetic results were achieved in 17cases of reposition, 8 cases of replantation, and 8 casesof arthroplasty. In 3 cases, resorption of the condyleoccurred, involving 2 children with arthroplasty and 1child after replantation.

In a letter to the editor, Bergsma25 presented openreposition without internal fixation in a 5-year-old childsuffering from a 90° medially dislocated CFs and re-ported good outcome after 2 years.

Schön et al.26 successfully treated a severely dis-placed subcondylar fracture in a 9-year-old boy withthe use of an endoscopically assisted transoral ap-proach. The fracture was reduced and stabilized by aminiplate which was removed 6 months later. Fol-low-up investigations did not reveal any deviation orlimitation of mouth opening. TMJ function was painfree, and the child presented with normal occlusion.

In a retrospective study, Deleyiannis et al.27 pre-sented clinical and radiologic results of 6 children withdislocated CFs that were treated by ORIF either with orwithout removal of the condyle as a free graft. At thetime of the last follow-up, no patient had any limita-tions in interincisal opening, lateral excursions, or diet.On mouth opening, all patients showed deviation of thejaw to the dislocated side, but this was not bothersometo any of the patients. Objective and/or subjective signs
of TMJ dysfunction were present in 4 children. Radio-Ta L
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ORAL AND MAXILLOFACIAL SURGERY OOOOS98 Bruckmoser and Undt November 2012

logically, all children showed signs of remodeling andshortening of the mandibular ramus. A secondary cos-tochondral graft was required in 1 patient with near-complete condyle resorption.

Clinical studies and case reports on surgicalversus conservative management of CFs inchildren (Table II)In a retrospective study, Rasse et al.28 compared mor-phologic and functional results of 25 surgically and 12conservatively treated patients who had sustained CFsbetween 1975 and 1987. Because the study was pub-lished in 1991, it can be assumed that the follow-upperiod ranged from �3 years to �15 years. Because theindications for surgery were severely displaced or dis-located CFs, these patients had a poorer starting point.Nevertheless, clinical and radiologic results were equalin both groups. A moderate limitation of opening andmediotrusion on the fracture side, as well as a flatteningof the protrusion path, was found in both groups. Post-operative complications (facial nerve palsy, growth in-hibition, obvious scars) were not found in any of theoperated patients.

In a review article on the management of CFs inchildren with 5 case presentations, Ziccardi et al.29

reported an excellent outcome 2 years after surgery incase 1. The other surgically treated patient (case 2) alsocontinued to function well 15 months after the opera-tion. In case 3 (conservative therapy) an ankylosisdeveloped owing to poor compliance and had to beoperated on twice. A full-arch acrylic mandibular splintsecured with circumferential wiring was used in case 5.This patient showed normal mandibular developmentand good mouth opening and maintained a reproducibleocclusion 1 year after surgery. Case 4 concerned apatient who presented with ankylosis about 10 yearsafter sustaining a CFs and is therefore not discussed inthis review.

In a retrospective study, Cascone et al.30 directlycompared the results of 10 conservatively treated chil-dren with those of 6 patients who underwent eitheropen reduction with external rigid fixation (3 cases) orcondylectomy (3 cases). Taking into account the exist-ing literature on this topic as well as the authors’personal experience, a therapeutic protocol was estab-lished. According to this treatment algorithm, seriouslydislocated fractures associated with considerable limi-tation of TMJ function and all cases of bilaterallyfractured condyles should be treated surgically. A con-servative approach, including liquid diet for 15 days orintermaxillary blocking for 7-15 days, activator therapyfor 5 months, physiotherapy, and home exercises, isproposed for the remaining cases. In conclusion, the
authors recommend surgery in cases of dislocated frac-
tures leading to a functional impediment that cannot beresolved by conservative methods.

Landes et al.31 included 24 children in a prospectiveevaluation of closed treatment (CTR) of nondisplacedand nondislocated CFs versus ORIF of displaced anddislocated CFs. Class I and VI fractures were treatedconservatively, whereas ORIF was performed in classII, IV, and V fractures (class III fractures could not beincluded, because none presented). Nineteen patients(79%) with 20 CFss presented for the first follow-up.Good results were achieved in class I (CTR) as well asin class II and IV fractures (ORIF). Displaced anddislocated CFs treated with ORIF had fewer incidencesof occlusal imbalance, locking, and facial asymmetry.The outcomes were not satisfactory in class VI (CTR)and class V fractures (ORIF).

In a retrospective study, Hu et al.32 included 25children with 33 CFs who had been treated either byORIF (8 patients with 11 CFs) or conservatively (17patients with 22 CFs). After surgery, no MMF was usedin any patient. Conservative treatment included cranio-maxillary elastic bandage and occlusal pads. Good clin-ical and radiologic results were achieved in bothgroups, and the authors conclude that owing to the highremodeling capacity of the mandibular condyle inyoung children, conservative treatment should be firstselected in patients �7 years of age.

Clinical studies and case reports on conservativemanagement of CFs in children (Table III)In 1961, Rakower et al.33 published 3 case reports ofCFs with overall good outcome after MMF. In theyoungest patient (3-year-old boy) MMF for 9 days waspreceded by temporary treatment with a Barton-typebandage.

Kaplan and Mark34 reported on an 18-month-oldchild suffering from bilateral CFs and an associatedfracture of the symphysis menti (which was treated byopen reduction and fixation with a stainless steel wire).Radiologic results �2 years after the original traumawere very satisfying, with the condyles in excellentposition. Photographs did not reveal any abnormalitiesof facial development.

Thomson et al.35 successfully recalled 23 out of 52patients having suffered from unilateral (31 patients) orbilateral (21 patients) CFs during childhood. One childwas treated by open reduction and internal fixation ofthe condylar neck (wiring condyle). However, becauseno information is available about whether this patientwas among the 23 successfully recalled subjects, weclassified this retrospective study as conservative. In-formation on etiology, type of fracture, and treatmentmodality given in the article refers to the original pop-
ulation (52 patients), and no specific data focusing on


the 23 patients of the follow-up group is provided.Regarding treatment outcome in the 23 follow-upcases, retrusion (class II malocclusion) in 7 patients,loss of condylar bulk on the side of fracture in 10patients, swing to the fracture side on opening in 15patients, and an open bite in 1 patient were noticed.There was no case of gross maxillomandibular asym-metry, and all patients showed a full range of painlessmandibular movement.

MacLennan and Simpson36 reported treatment re-sults in 6 children with 7 CFs. In all of the patients, agood range of movement was achieved and no growthdisturbance was apparent. Deviation to the fracturedside was seen in 1 patient, and radiologically 3 patientsshowed straightening of the fractured condyle.

Although 1 patient suffering from CFs underwentORIF, the retrospective study by Brandt and Knak37 ismentioned in this section because no information isavailable about whether the corresponding patient wasamong the 19 patients who were successfully recalledfor follow-up. Data on age at injury and number andtype of CFs refer to all 44 children who had beentreated for their 57 CFs between 1955 and 1965 (age atinjury 0-16 years). Overall, very satisfactory functionaland morphologic results were found. In 47.3% a radio-logically detected arthropathy was present on the frac-tured side. One patient developed ankylosis leading tomicrogenia, and resorption of the condyle was found inanother patient.

In 1970, Gilhuus-Moe38 published clinical and ra-diologic results of 62 patients with 81 CFs. Whereas 11out of the 12 patients in age group 1 showed favorableclinical outcome, most of the unfavorable results (10patients) were found in adolescents, i.e., age group 3.Radiologic outcome was correlated with age and frac-ture displacement. Thus, most of the poorly remodeledcondyles were seen in adolescents after dislocated CFs.

In a follow-up study, Leake et al.39 evaluated theexperience in 20 children suffering from 25 condylarneck fractures who were treated between 1944 and1969. Thirteen of these patients with 17 CFs wereevaluated again in 1969 or 1970, giving a follow-upperiod of 2 months to 17 years. In all of the patients,condylar growth appeared to be normal. No deviationon mouth opening or residual pain was found, andocclusion was satisfactory.

Hunter40 presented the case of an 18-month-old boysuffering from midline fracture and left CFs. The latterwas not seen on skull and mandibular films but wasrevealed by a panoramic radiograph.

Holtgrave et al.41 reviewed the results of 18 childrenwho were conservatively treated between 1966 and1971. Because the article was published in 1975, it can
be assumed that the follow-up period ranged from �3
to 8 years. Two children with nondisplaced CFs (classI according to Spiessl and Schroll6) and normal occlu-sion had monoblock therapy only. Sixteen patientswere treated by MMF using a wire-and-acrylic splintwith or without subsequent monoblock therapy. Clini-cal and radiologic results showed restitution mainly inpatients �10 years old. Three children aged 11-14years at the time of injury showed deflection of 4-12mm to the formerly injured side. No ankylosis, pseu-doarthrosis, neoarthrosis, microgenia, facial asymme-try, occlusal disturbance, or restricted or painful mouthopening was reported.

Campbell42 reported a 3-month-old infant sufferingfrom unilateral CF. A radiograph taken 4 months afterinjury showed complete healing without evidence ofthe previously sustained CF.

Very good clinical and radiologic outcome with onlyminimal deviation of the lower jaw on mouth openingand minimal foreshortening of the ramus after func-tional therapy in an 11-year-old girl was described byBrady and Leake.43

In 1979, Balaban et al.44 reported successful man-agement of unilateral CFs in 5 children by applying aconservative approach without MMF.

Although the retrospective study by Knobloch45 in-cludes 1 child who underwent surgery for an open CFswith severe soft tissue damage, it is described in thissection because the remaining 39 children were treatedconservatively and no specific information on the out-come of that 1 patient is provided. According to theauthor, the clinical outcome confirms that operativetreatment of CFs in children is indicated in exceptionalcases only.

Postinjury condylar remodeling in a 6-year-old girlwas described by Spence,46 who found rapid and com-plete condylar regeneration. In addition, excellent func-tion without restricted mandibular movements or devi-ation was noticed.

Spitzer and Zschiesche47 successfully recalled 28patients with 34 CFs and found good clinical results,whereas radiologically 23 TMJs showed morphologicchanges, such as hypo- or hyperplastic condyles, de-formed condyles, medial angulation of the condylarfragment, or shortening of the condylar process. Theseirregularities especially occurred in older adolescents aswell as after severe luxation of the fractured condyle.

Williamson48 found radiologically normal condylarmorphology in a child after anterior repositioning splinttherapy. Articulator mountings showed correction ofretrognathism and closure of open bite.

Birchler-Argyros and Chausse49 found functionallyacceptable long-term results with favorable radiologicremodeling in 14 patients with 17 CFs. Best results
were achieved in children with intracapsular CFs,


whereas most pathologic findings were seen in patientswith dislocated collum fractures.

TMJ remodeling in 12 patients with 16 CFs wasinvestigated by Sahm and Witt50 in a CT study. Ac-cording to the authors, patients with luxated low CFsshowed the most interesting results because the remod-eled condyles consisted of 2 parts. The medial part wasinterpreted as remainder of the small fragment, whereasthe lateral part probably represented callus formation.

In a CT and magnetic resonance imaging (MRI)study, Sahm et al.51 presented morphologic character-istics of 5 dislocated low CFs 2-17 years after injury.Two parts of the condyle could be differentiated, withthe medial part representing the former small fragment.The lateral part was interpreted as compensatory bonyoutgrowth. In 1 patient a bifid condyle was seen.

In 1990, Sahm et al.52 presented a longitudinal studyregarding TMJ remodeling on the basis of several con-secutive CT scans in 3 patients (2-3 scans per patient).They found that during remodeling the small condylarfragment was partially resorbed, whereas new boneformation was seen on the lateral aspect. The remod-eling response was more vigorous in the 7-year-oldchild than in the 2 13-year-old adolescents (ages at thetime of injury).

A follow-up study of 21 patients with 24 CFs wascarried out by Kahl and Gerlach.53 Patients were treatedby either orthopedics, MMF with subsequent functionalorthopedics, or MMF with subsequent exercises. Clin-ical results were good to excellent in all cases regard-less of the type of fracture, although the radiologicoutcome was less favorable with restoration of ana-tomic form in 20% only. In conclusion, a functionaltreatment approach is recommended by the authors.

Another follow-up study, including 103 patientswith 139 CFs, was published by Gundlach et al.54 Acomplete restitution by conservative treatment wasachieved in all nondisplaced CFs, in most of the dis-placed CFs, and in �50% of the dislocated CFs. Chil-dren under the age of 8-10 years showed the bestoutcome. The authors stated that in children with dis-located CFs, surgical management should be consid-ered.

Gerlach et al.55 reported on 31 children with 34 CFswho were treated by different approaches (3 treatmentgroups). Regardless of the type of fracture, functionalresults were good and indicated advantages of func-tional appliance therapy. The radiologic outcome wasless favorable in some patients (deformed condyles,medial angulation of the condylar fragment, shorteningof the condylar process).

A retrospective study comprising 65 patients waspublished by Cornelius et al.56 According to the au-
thors, there were 46 unilateral and 9 bilateral CFs,
which is contradictory to the number of patients indi-cated. Regarding the outcome, only 3 patients showedrestitution indiscernible from normal. In the remaining62 patients radiographic irregularities of the ascendingramus or joint (50 patients) as well as varying degreesof subjective complaints and clinical dysfunction werefound.

Mairgünther et al.57 compared the outcome of dif-ferent treatment modalities in 2 age groups (5-15 and16-19 years). They did not find any difference betweenMMF and functional appliance therapy, except for theluxation fractures of the upper collum (better outcomewith functional appliance therapy). Only 3 patientswere treated by a combination of both MMF and func-tional appliance therapy and were not included in thestatistical analysis. The radiologic outcome was lessfavorable in collum luxation fractures. Interestingly,subjective complaints were encountered less frequentlythan objective clinical and radiologic findings wouldhave suggested.

Wiltfang et al.58 successfully recalled 42 patientswith 54 CFs and found good overall results. In 12%,moderate to severe growth abnormalities were ob-served. Dysfunction index values59 were less satisfac-tory in dislocated CFs and older children. Also, incom-plete anatomic remodeling occurred more frequently indislocated CFs and older children.

Spitzer et al.60 intended to recall 51 fully docu-mented patients with 60 CFs (class II: 10; III: 8; IV: 11;V: 29; and VI: 2; according to Spiessl and Schroll6). 48patients were available for follow-up. Neither the totalnumber of CFs in these patients nor the fracture clas-sification is provided in the publication. Although in-complete remodeling was often observed in older chil-dren and especially in deep dislocated CFs, TMJfunction was good in all of the patients.

Schendel et al.61 compared 2 treatment modalities in29 children: 15 of them received MMF with subsequentfunctional appliance therapy, and 14 children had func-tional appliance therapy only. Patients in the lattergroup on average were younger, had less severe frac-tures, and showed both better clinical and radiologicresults.

Altmann and Gundlach62 reported on 36 patientswith 47 CFs and found very good results in children �8years old. In older patients and especially in cases ofdislocated CFs, clinical and radiologic results were lesssatisfactory. Therefore, the authors recommend that inthese cases careful surgical reduction should be consid-ered more frequently.

Feifel et al.63 investigated the outcome of conserva-tively treated CFs in 28 patients by electronic comput-er-assisted recording of condylar movements. Esthetic
and functional results were good, although almost one-


half of the patients showed deformations of their frac-tured condyles. The rate of remodeling was dispropor-tionally related to the degree of displacement (the moredisplacement, the less remodeling).

Nørholt et al.64 successfully recalled 55 patients outof 139 subjects who sustained CFs in childhood. Con-servative treatment was shown to be highly effective,especially in the youngest patient groups. Frequentlyfound radiologic abnormalities could not be correlatedwith the severity of dysfunction. With increasing age atthe time of the trauma, dysfunction index values in-creased significantly, leading the authors to the conclu-sion that treatments other than conservative should beconsidered in older children.

A follow-up study of 30 patients with 36 CFs byKellenberger et al.65 revealed very good functionalresults in most of the cases. Mandibular mobility wasrestricted in 3 patients with bilateral CFs. Radiologi-cally, very good remodeling was seen in 77%. In 21%of unilateral CFs and in 33% of bilateral CFs, a persis-tent medial inclination of the condyle in the frontalplane was found.

A CT analysis of TMJ state in 7 children 5 years afterfunctional orthopedic treatment of unilateral CFs wasdone by Kahl-Nieke et al.66 The CT data were refor-matted to 2-dimensional (2D) images in differentplanes and to 3-dimensional (3D) reconstructions invarious projections, revealing alterations of size, shape,bony remodeling, and position of the condyle as well asadaptive changes of the temporal component of theTMJ. From a clinical point of view, good to excellentfunctional results were noticed.

A retrospective spiral CT analysis with 2D and 3Dreconstructions by Kahl-Nieke and Fischbach67 com-prised 12 children with 16 CFs. Clinically, all patientsexhibited restoration of normal TMJ function, whereasradiologically only 4 TMJs showed favorable remodel-ing. Radiologic findings in the remaining joints in-cluded hypoplastic or deformed condyles, resorption ofcondylar fragments, bony spurs, and neoarthrosis.

Kahl et al.68 also used spiral CT analysis to studyTMJ morphology after functional appliance therapy ofCFs and found restoration of normal function and fa-vorable remodeling in 11 (58%) of the 19 follow-uppatients. The remainder showed good function, al-though in 8 patients deformed condyles, asymmetry incondylar angle and length of the condylar neck, bonyspurs, neoarthrosis, or a bifid condyle were detected.

In a follow-up study, Kellenberger et al.69 investi-gated the clinical and radiological outcome in 30 pa-tients with 36 CFs. Overall clinical results were good inmost patients. Abnormalities found included 6 cases oftilted occlusion planes, 1 case of facial asymmetry, and
3 patients with restricted mandibular mobility. Radio-
logically, more than two-thirds of the patients showedgood condylar remodeling. A medial tilt of the condylarprocess was seen in fewer than one-third of the patients.A bifid condyle was found in 2 children.

First results of a prospective study which was startedin 1981 concerning the chronologic development ofmorphologic alterations in the orthopantomogram afterunilateral CFs were published by Röthler et al.70 in1996. Very good restitution could be obtained, espe-cially in children aged �6 years. In 8 patients withdislocated CFs aged �8 years, various morphologicalterations were seen (hypoplastic, deformed, or short-ened condylar process).

Kahl-Nieke and Fischbach71 investigated condylarrestoration after early CFs and activator therapy bymeans of spiral CT scans. An average 4.9 years afterthe 9 months of activator therapy, 19 patients could berecalled for follow-up (follow-up group). In addition,20 children during ongoing functional appliance ther-apy were examined 6-8 months after injury (treatmentgroup). Excessive bony overgrowth and shortening ofthe ramus were more often encountered in dislocatedand low CFs. Patients aged �10 years at the time ofinjury showed greater variation and greater differencesin mediolateral and anteroposterior condylar dimensionthan younger children.

Another study dealing with radiologic changes afterpediatric CFs was published by Thorén et al.72 Morethan one-half of the fractures were dislocated CFs(class IV according to MacLennan’s4 classification ofextracapsular CFs). Radiologically, incomplete remod-eling, including alteration in the configuration of thecondylar head and deformation of the condylar neckoccurred in 56% of the cases and was frequently (83%)related to fracture dislocation regardless of the agegroup. Also, a difference in ramus height was particu-larly frequent in dislocated fractures (80%) and wasseen in 52% of the whole study population.

A prospectively designed study including 55 childrenwho had suffered from unilateral CFs without associatedinjuries was done by Strobl et al.73 Long-term clinicalfollow-up showed satisfactory clinical results in all of thepatients without any functional disturbance or mandibularasymmetry. Radiologic results depended on the patients’age and were judged to be satisfactory in the 2–6-year-oldgroup. In contrast, incomplete condylar regeneration wasfound in the 7–10-year-old group, including condylar de-formities and reduction in condylar neck height.

Long-term results of conservative management ofpediatric CFs were reported by Hovinga et al.74 Overallpatient satisfaction, masticatory function, and radio-logic results were considered to be good. Intracapsularand low CFs gave rise to the largest number of facial
asymmetries. The authors conclude that conservative


treatment of condylar fractures in childhood is still themethod of choice and that surgery should be consideredonly in selected cases with extensive dislocation andlack of contact between fragments, multiple fractures ofthe midface, or dislocation of the condyle into themidcranial fossa.

Defabianis75 reported very good clinical results andgood radiologic outcome (with an almost normal con-dylar angulation) 18 months after conservative treat-ment of a unilateral CFs in a 3-year-old girl.

For a retrospective analysis, Thorén et al.76 success-fully recalled 18 patients with 22 dislocated CFs. Clin-ically, more than one-half of the patients had somesubjective symptoms and more than two-thirds showedobjective signs of TMJ dysfunction. Because thesesymptoms and signs were rather slight, treatment out-come was judged to be satisfactory by the authors.Radiologically detected mandibular asymmetry (differ-ence in ramus height of 4-11 mm and/or deviation ofsymphysis of 3°-8°) in 64.7% of the patients could notbe observed clinically. Because there was no correla-tion between clinical results and treatment method, themost conservative approach (soft diet and early mobi-lization) is recommended by these authors.

A retrospective analysis done by Güven and Kes-kin,77 including 18 patients with 21 CFs showed goodfunctional treatment results in most cases. A slightdeflection to the side of the fracture on wide mouthopening was seen in 4 patients. Remodeling of thecondylar head was judged to be good in 17 cases. Theremaining 4 condyles showed moderate remodeling.The authors conclude that conservative treatment asdescribed leads to satisfactory results, justifying surgi-cal interventions only in selected cases with interfer-ence during mandibular movements and/or severe dis-location of condyles.

Defabianis78 reported on 3 cases, 2 of which dealingwith management of sequelae of CFs and therefore notfurther discussed in the present review. Case 1 con-cerned a 3-year-old girl who showed very good clinicaland good radiologic outcome after functional appliancetherapy.

In a 5-year retrospective analysis, Defabianis79 pre-sented 46 patients having suffered from uni- or bilateralCFs during childhood. In children treated by functionalappliance therapy, both TMJs were normal, and they allshowed normal facial structure. In contrast, the phys-iotherapy group presented various types of alterations(inflammatory, mechanical, structural).

The clinical value of the occlusal plane orientationand correlation with facial development was discussedby Defabianis80 presenting 2 cases. In case 2, develop-ment of facial asymmetry 3 years after an overlooked
unilateral CFs is described and therefore not further
detailed in Table III. Case 1 concerned a young boywith a unilateral dislocated CFs treated by liquid diet,splint, and functional appliance therapy immediatelyfollowing the trauma. Clinical and radiologic resultsafter 8 months (when the boy was still in treatment)were good without facial asymmetry and no deviationof the chin. It is concluded that restoration of a plane ofocclusion orthogonally aligned to the forces of occlu-sion is essential for a proper facial development.

The importance of functional activation of musclesafter CFs was pointed out by Defabianis81 presenting 2cases. One patient (case 1) received functional appliancetherapy, which was refused in the other patient (case 2)who subsequently developed a facial asymmetry.

Treatment guidelines for CFs in children and adoles-cents were given by Defabianis82 and illustrated by acase presentation concerning a young girl who sufferedfrom bilateral dislocated CFs. Clinical and radiologicoutcomes were good, and functional appliance therapycould be discontinued after 18 months.

The impact of posttraumatic TMJ internal derange-ment on facial growth was studied by Defabianis83 in25 children with 31 CFs. Three patients showed normalTMJs and normal facial structure, whereas in the re-maining subjects various pathologic findings were no-ticed, such as mechanical TMJ dysfunction and skeletalabnormalities, including mandibular retrognathia andlower facial asymmetry.

A presentation of 2 cases was published by Defabi-anis,84 one of which concerning development of amarked facial asymmetry 18 months after CFs (andtherefore not discussed herein). In case 2, conservativemanagement of a unilateral CFs in a young boy isdescribed. Follow-up after 3 years revealed normalocclusion, facial symmetry, and an almost perfect res-toration of the condylar shape as shown in MRI.

A long-term clinical and radiologic evaluation wasreported by Choi et al.85 in a follow-up study of 11children with 14 CFs. Six children presenting excessivepain and/or persistent malocclusion had MMF for 2-10days. The conservative treatment approach in the re-maining 5 patients is not detailed in the publication.Recovery of TMJ function was judged to be excellent,and no pain or functional impairment was reported byany patient, although radiologically incomplete remod-eling was seen in 6 patients (54.5%) and asymmetry ofthe mandible in 3 patients (27.3%).

Successful healing and remodeling after activatortherapy in 5 children was described by Chatzistavrouand Basdra.86 Restoration of the fracture site and rees-tablishment of function without signs of dentofacialmaldevelopment were shown at clinical and radiologicfollow-up.

Cucurullo et al.87 reported very good clinical and


radiologic results in a 9.6-year-old girl with intracap-sular fracture of the right mandibular condyle followinga functional orthodontic protocol.

Medina88 reported good to excellent clinical resultsafter functional therapy using an elastic activator. Ra-diologically minor aberrations in condylar morphologywere seen.

Zhao et al.89 reported on 23 children with 29 CFs andfound normal mandibular growth and developmentwith good occlusion and unimpaired function in allpatients. Reconstruction of the fractured condyles,which were flattened and short, was seen in panoramicradiographs.

A 10-year follow-up study using telephone question-naires was carried out by Leuin et al.90 Forty-five out of83 patients with condylar or subcondylar fractures com-pleted the questionnaire. Fifteen patients (33.3%) indi-cated no symptoms of dysfunction, whereas mild andsevere symptoms were reported by 6 (13.3%) and 24(53.3%) patients, respectively. Interestingly an in-creased severity of TMJ dysfunction in females wasnoted.

Ben-Bassat et al.91 investigated morphologic occlu-sal features following CFs in 32 children with 43 CFs.Features of the study group were compared with thoseof a random control group comprising 705 schoolchil-dren. Malocclusion and lower midline deviation werefound to be more prevalent in the study group.

Good clinical long-term results and acceptable re-modeling in 42 children with 54 CFs were described byLekven et al.92 who found an increased risk for unfa-vorable clinical outcome in unilateral CFs. Overall clin-ical outcome was favorable in 74% of the patients.Radiologically complete remodeling was seen in 87%of all CFs, whereas moderate and poor remodeling wasfound in 9% and 4%, respectively.

DISCUSSIONBecause conservative management of CFs in childrenusually yields satisfactory to excellent clinical results,conservative treatment is the approach preferred by themajority of surgeons. Some authors93-101 have givenspecific recommendations for surgical management ofCFs in children and/or adolescents under certain cir-cumstances. Clinical studies and case reports regardingsurgical or surgical versus conservative managementare presented in Tables I and II and are discussedsubsequently.

Table I presents 7 case reports and 2 retrospectivestudies concerning surgical management of CFs in chil-dren. One case of a comminuted CFs19 was managed bycondylectomy. In 2 instances,23,25 only open reductionwithout osteosynthesis was performed. In the remain-
ing cases, various methods of fixation (transosseous
wire, Kirschner pin, wire extension, miniplate) wereapplied. The treatment outcomes of all patients de-scribed in the case reports were judged to be good oreven excellent by the authors.20-23,26 Regarding the 2retrospective studies,24,27 treatment results in some pa-tients were not satisfactory. In the patients described byDeleyiannis et al.,27 this could be due to the fact thatcomplete removal of the condylar head was performedin one-half of the fractures. This presumption is alsosupported by the finding that shortening of the mandib-ular ramus was least in the 2 patients who did notrequire removal of the condyle as a free graft. Severecomplications were reported by Deleyiannis et al.27 (1patient with near complete condyle resorption necessi-tating secondary costochondral grafting) as well as bySysoliatin et al.24 (resorption of the condyle in 3 cases).

Table II presents 1 review article with 5 case pre-sentations and 1 prospective and 3 retrospective studiesconcerning surgical versus conservative managementof CFs in children. Ziccardi et al.29 reported good (case2) to excellent (case 1) outcomes after surgery. Good(case 5) and nonsatisfactory (case 3) results were de-scribed after conservative treatment. Rasse et al.28

found similar results in both groups, although patientsin the surgical group had a poorer starting point (se-verely displaced or dislocated CFs). Cascone et al.30

reported good outcomes, especially in patients treatedwith external rigid fixation. Landes et al.31 found goodresults in class I (conservative) and II and IV (surgical)fractures, whereas the outcomes in classes V (surgical)and VI (conservative) were less satisfactory. Hu et al.32

reported good effectiveness in both treatment groupsand stated that conservative treatment should be firstselected in patients �7 years of age.

Clinical studies and case reports dealing with con-servative management of CFs in children and adoles-cents are presented in Table III and, similarly to thepapers in Tables I and II, are characterized by a greatheterogeneity in many aspects. Regarding the classifi-cation of CFs, different systems have been used. More-over, many authors did not provide sufficient informa-tion on fracture level and degree of displacement ordislocation. Also, follow-up periods greatly varied,ranging from �1 week to 25 years. Looking at theconservative treatment modalities listed in Table III, itcan be seen that in most cases the following options,alone or in various combinations, were chosen: liquidor soft diet for several weeks with close observation,functional exercises and/or physiotherapy, rigid and/orelastic MMF for several weeks, or functional appliancetherapy. Finally, a principal problem in assessing treat-ment results remains the lack of clearly defined criteriaand definitions of what is to be judged to be “satisfac-
tory” or “successful” outcome. All of these shortcom-


ings render it difficult to compare treatment outcomes,and one has to be prudent when trying to summarize oreven draw conclusions out of the existing literature.However, the following findings and statements arerepeatedly encountered in the articles presented in ourreview:

● Radiologic outcome after conservative treatment isoften found to be nonsatisfactory.

● The correlation between radiologic and clinical re-sults is often poor (good clinical outcome despitemorphologic alterations).

● In none of the reviewed publications comparingMMF to other conservative treatment methods hasMMF been reported to be superior or have any ben-efit with regard to treatment outcome.

● Clinical outcome after conservative treatment is usu-ally judged to be satisfactory to excellent. However,in adolescents (especially in cases with dislocatedCFs) the outcome is often reported to be lessfavorable.

Taking into consideration that conservative manage-ment of CFs has not changed markedly during the pastdecades while surgical techniques are continuouslyevolving, it might be concluded that only good pro-spective randomized multicenter studies would clarifyfrom which age on patients could probably benefit fromoperative treatment.

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Emanuel Bruckmoser, MD, DMDDepartment of Oral and Maxillofacial SurgeryDanube General HospitalLangobardenstrasse 122A-1220 ViennaAustria
[email protected]
mailto:[email protected]

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