villarreal, monje, junquera, mateo, morillo e gonzález (2004) mandibular condyle fractures -...

7/28/2019 Villarreal, Monje, Junquera, Mateo, Morillo e Gonzlez (2004) Mandibular Condyle Fractures - Determinants of Treatment and Outcome

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J Oral Maxillofac Surg62:155-163, 2004

Mandibular Condyle Fractures:Determinants of Treatment and Outcome

Pedro M. Villarreal, MD, PhD, FEBOMS,*

Florencio Monje, MD, PhD, FEBOMS, Luis M. Junquera, MD, DMD, PhD, FEBOMS, Jesus Mateo, MD, Antonio J. Morillo, MD, FEBOMS,

and Cristina Gonzalez, CNS

Purpose: The objective of this study was to analyze the principal variables that determine the choiceof the method of treatment and the outcome in condylar fractures.Materials and Methods: We conducted a retrospective analysis of 104 mandibular condyle fracturesto analyze and determine the relation between the principal clinical variables and the postoperativeresults. All patients underwent a clinic-radiologic investigation focusing on fracture remodeling, evolu-tion, dental occlusion, and symmetry of the mandible. We analyzed the inuence of the preoperativeclinical variables (level of fracture, treatment, postoperative physical therapy, displacement and disloca-tion, comminution, loss of ramus height, patient age, gender, etiology, occlusion, status of dentition, andpresence of facial and mandibular fractures) over the postoperative results and outcome.Results: The principal factors that determined the treatment decision were the level of the fracture andthe degree of displacement. The level of the fracture inuenced the degree of preoperative coronal andsagittal displacement (neck fractures had greater medial and anterior displacement than head andsubcondylar fractures) and the treatment applied. The functional improvement obtained by openmethods was greater than that obtained by closed treatment. Open treatment increased the incidence of postoperative condylar deformities and mandibular asymmetry.Conclusion: The variables that inuenced the method of treatment and predicted the prognosis are thelevel of fracture, degree and direction of displacement of the fractured segments, age, medical status of the patient, concomitant injuries, and status of dentition. 2004 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 62:155-163, 2004

Fractures of the mandibular condylar process arecommon injuries that account for 29% to 40% of

fractures of the facial bones 1 and represent 20% to62% of all mandibular fractures. 2

Condylar fractures probably represent the aspect of maxillofacial trauma that is most controversial with respect to classication, diagnosis, and therapeuticmanagement and that has generated the most numer-ous discussions and arguments in the literature. Evi-dence for it can be found in the various schemes usedto classify and subdivide these fractures. 3-5 A simple

classication based on the anatomic location of thefracture, condylar head, condylar neck, and subcon-dylar region, seems adequate, 6 although a combina-tion with the degree of displacement of the fracturedsegment enriches management decisions.

Mandibular condyle fractures are managed by 2methods of treatment, open and closed treatment, without a consensus about the proper management of this injury. 7 The advantages of both methods must becompared with the patient disability, morbidity, se-quelae, and risks involved, 8 because an ethically pro-spective randomized trial may not be possible. 6 As

*Staff, Department of Oral and Maxillofacial Surgery, Hospital deCabuenes, Gijon, Spain.

Staff, Department of Oral and Maxillofacial Surgery, HospitalInfanta Cristina, Badajoz, Spain.

Associate Professor, Department of Oral and Maxillofacial Sur-gery, Hospital Central de Asturias, Oviedo, Spain.



Clinical Nurse Specialist, Hospital Central de Asturias, Oviedo,Spain.

Address correspondence and reprint requests to Dr Villarreal:C/ Monte Auseva 12 4 B, 33012 Oviedo, Spain; e-mail:[email protected] 2004 American Association of Oral and Maxillofacial Surgeons0278-2391/04/6202-0006$30.00/0doi:10.1016/j.joms.2003.08.010

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always, however, the patient s best interest must havepriority over simple convenience for the surgeon.

The objective of this study was to analyze the in-uence of the principal clinical variables that deter-mine the choice of the method of treatment, the

prognosis, and the results in condylar fractures.

Materials and MethodsFrom March 1998 to April 2002, 104 condylar pro-

cess fractures were diagnosed and treated in 84 pa-tients in our department. Sixty-four patients had uni-lateral fractures (76.2%), and 20 patients had bilateralones (23.8%). Fifty-two fractures (50%) were on theleft and 52 were on the right. Thirty-seven (35.6%) were fractures of the head of the condyle, 28 (26.9%) were condylar neck fractures, and 39 (37.5%) weresubcondylar fractures. The fractures were classi edaccording to Yamaoka et al 3 and Spiessl 4 (Table 1). Allpatients underwent a clinic-radiologic investigationfocusing on fracture remodeling, outcome, dental oc-clusion, and symmetry of the mandible.

We examined the degree of coronal and sagittaldisplacement of the condylar process fractures, pre-operatively and after treatment (6 months), usingTowne projections, panoramic radiographs, and com-puted tomography scans according to Ellis et al. 9,10

Seventy-four patients (88.1%) with 92 condylar frac-tures (88.5%) had closed treatment, and 10 cases(11.9%) with 12 condylar fractures (11.5%) received

open treatment. In the group treated by closed meth-ods, 80 fractures (87.0%) were treated by intermaxil-lary xation (IMF) (64 patients, 86.5%), 2 fractures(2.2%) by functional treatment (2 patients, 2.7%) and10 fractures (10.9%) had no treatment rendered (8

patients, 10.8%). In the group treated by open meth-ods, 3 (25%) fractures were treated by open reduction with xation (2 patients, 20%), 1 fracture (10%) by open reduction without xation (1 patient, 10%), 3fractures (25%) by IMF plus open reduction with xation (3 patients, 30%), 4 fractures (33.3%) by IMFplus open reduction without xation (3 patients,30%), and 1 fracture (8.3%) by IMF plus resection of condylar fragment (1 patient, 10%).

We analyzed the in uence of the preoperative clin-ical variables (level of the condylar fracture, methodof treatment, time from initiating trauma to surgery,

length of surgical procedure, use of postoperativephysical therapy, magnitude and direction of displace-ment and dislocation, comminution, loss of preoper-ative ramus height, patient age, gender, etiology,preoperative occlusion, status of the preexisting den-tition, and presence of facial and mandibular frac-tures) over the postoperative results and outcome(Table 2).

The mean follow-up was 8.45 months (range, 0 to33 months). It was greater in the open group (14.60months; range, 3 to 31 months) than in the closedgroup (7.62 months; range, 1 to 33 months).

Table 1. CONDYLAR FRACTURES ACCORDING TO THE LEVEL OF FRACTURE AND YAMAOKA ET ALS ANDSPIESSLS CLASSIFICATIONS

Classication Type of Condylar Fractures Total (n)Classication Level (n)

Head Condyle Condylar Neck Subcondylar Region

Yamaoka et al 3 No displacement 20 9 3 8

(19.2%) (24.3%) (10.7%) (20.5%)Deviation and displacement 57 17 18 22(54.8%) (45.9%) (64.3%) (56.4%)

Dislocation 15 6 9(14.4%) (21.4%) (23.1%)

Sagittal splitting 12 11 1(11.5%) (29.7%) (3.6%)

Spiessl 4 Without angulation and dislocation 12 1 3 8(11.5%) (2.7%) (10.7%) (20.5%)

Basis of the condylar process with angulation 22 22(21.2%) (56.4%)

Condylar neck with angulation 19 19(18.3%) (67.9%)

Basis of the condylar process with dislocation 9 9(8.7%) (23.1%)

Condylar neck with dislocation 6 6(5.8%) (21.4%)Diacapitular or intra-articular 36 36

(34.6%) (97.3%)Total 104 37 28 39

(100.0%) (35.6%) (26.9%) (37.5%)

156 MANDIBULAR CONDYLE FRACTURES


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STATISTICAL ANALYSIS

The relationships between the different variables were analyzed by means of nonparametric statisticaltest (nonnormal variables) using SPSS 11.0 for Win-dows software (SPSS Inc, Chicago, IL). The 2 test wasused to analyze the relation between qualitative vari-ables (Fisher test when there were only 2 categoriesper variable). Wilcoxon W test was used to analyzethe relation between a qualitative variable (with 2categories) and a quantitative variable (Kruskal-Wallistest when the qualitative variable have more than 2categories). To analyze the relationship betweenquantitative variables, we used Spearman rank corre-lation coef cients. Differences were considered sig-nicant when P .05.

ResultsPREOPERATIVE EVALUATION

Age and Gender There were 65 men (77.4%) and 19 women

(22.6%), with an age range of 5 to 81 years (mean,26.77 16.28 years). Seven patients (8.3%) werechildren (3 to 11 years old), 32 patients (38.1%) wereteenagers (12 to 19 years old), and 45 patients (53.6%)

adults (20 years old or older). There was a statistical

signicant difference ( P .017) between the meanage of the patients treated by closed treatment(28.09 16.66 years old) and open treatment group(17 8.56 years old).

EtiologyThe most frequent cause was traf c accidents in 53

patients (63.1%). The remainder of the fractures oc-curred in the setting of casual accidents in 14 patients(16.7%), altercation in 8 patients (9.5%), sports acci-dents in 8 patients (9.5%), and fall in 1 patient (1.2%).Traf c accidents represented the most frequent causein all qualitative ranges of age. The second in fre-

quency was sports accidents in children and teenag-ers, and casual accidents in adults. By gender, themost frequent etiology was traf c accidents in both (43 cases, [66.2%] in men and 10 cases [52.6%] in women). The second most frequent cause was alter-cations in men and casual accidents in women.

Associated Facial and Mandibular FracturesSeventeen patients (20.2%) had associated facial

fractures: 6 patients (7.1%) had maxillary fractures, 7patients (8.3%) had zygomatic fractures, 3 (3.6%) hadfrontal fractures, 7 (8.3%) had comminuted midfacefractures, and 7 (8.3%) had nasal fractures. Forty-six

Table 2. STATISTICALLY SIGNIFICANT RELATIONSHIPS (P < .05) BETWEEN THE CLINICAL VARIABLES AND THEPRINCIPAL PREDICTOR FACTORS (LEVEL OF FRACTURE, TREATMENT APPLIED, DISPLACEMENT, AND DISLOCATION)THAT INFLUENCE THEM

Preoperative Clinical Variable Level Treatment Displacement Dislocation

Level of fracture Yes No NoPreoperative coronal and sagittal

displacement Yes (neck) Yes (open) NoDislocation No Yes (open) NoComminution of the condyle Yes (head) Yes (closed) No No

Intraoperative

Method of treatment (open and closed) Yes (head closed) No NoLength of surgical procedure No Yes (open) No Yes

Postoperative

Change in coronal and sagittal displacement with treatment Yes (open) No No No

Postoperative coronal and sagittaldisplacement No No No

Postoperative MMO Yes (head) No No No Asymmetrical MMO No No No YesPostoperative loss of ramus height Yes (head) No No NoChange in loss of ramus height with

treatment Yes (subcondylar) Yes (open) No NoCondylar deformities Yes (head and neck) Yes (open) No NoMandibular asymmetry No Yes (open) Yes YesComplications No Yes (open) Yes Yes

Abbreviations: Level, level of the fracture; treatment, method of treatment; MMO, maximum mouth opening. The level of fracture andmethod of treatment with the best results are given in parentheses.

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patients (54.8%) had associated mandibular fractures,11 (23.9%) had ipsilateral ones, 23 (50%) had con-tralateral fractures, and 12 (26.1%) had fractures inboth sides. Thirty- ve patients (76.1%) had symphys-eal fractures, 7 (15.2%) had body fractures, 9 (19.6%)had angle fractures, 2 (4.3%) had ramus fractures, and1 (2.2%) had dentoalveolar fracture.

Time From Initiating Trauma to SurgeryThe mean time from initiating trauma to surgery

was 4.36 days (range, 0 to 22 days). It was greater inthe open group (mean, 5.9 days; range, 0 to 15 days)than in the closed group (mean, 4.15 days; range, 0 to22 days) ( P .13).

Displacement There were 82 fractures (78.8%) with displace-

ment. The most frequent directions of displacement were the anteromedial (34 fractures, 32.7%) and me-

dial (15 fractures, 14.4%). Moreover, there were 9fractures (8.7%) with isolated anterior displacement,7 (6.7%) with posterior, 7 (6.7%) with lateral, 3 (2.8%) with posteromedial, 2 (1.9%) with inferior, 2 with anteroinferomedial, 1 (1.0%) with inferolateral, 1 with anterolateral, and 1 with posterolateral displace-ments.

There was a statistical signi cant relation betweenthe presence of displacement and the method of treatment ( P .048) but not with the level of fracture( P .176). All fractures without displacement and76.1% of the fractures with displacement were

treated by closed methods. Displacement was presentin 26 head fractures (70.3%), 25 condylar neck frac-tures (89.3%), and 31 subcondylar fractures (79.5%).

There were 56 fractures with preoperative coronaldisplacement. The range was between 95 (medial)and 35 (lateral), with a mean of 22.26 32.11 (medial). There were statistical signi cant relation-ships ( P .008) with the method of treatment (meanof 44 fractures treated by closed treatment, 13.65 ;12 fractures by open treatment, 53.83 ) and thelevel of the fracture ( P .040). Condylar neck frac-tures had a greater medial coronal displacement

( 41.23 29.3 ) than head ( 15.61 21.68 ) andsubcondylar ( 17.2 36.6 ) fractures.

There were 74 fractures with preoperative sagittaldisplacement. This was between 58 (posterior)and 90 (anterior), with a mean of 9.6 25.92 (anterior). There was a statistical signi cant relation-ship ( P .044) with the method of treatment (closedgroup, 6.95 ; open, 23.33 ) and the level of the frac-ture ( P .048). Condylar neck fractures had a greater anterior displacement (15.2 31.6 ) than head(7.81 22.93 ) and subcondylar (5.88 22.11 )fractures.

DislocationThere were 18 condylar fractures (17.3%) with dis-

location outside the glenoid fossa. Thirteen (72.2%) with anteromedial displacement, 3 (16.7%) with an-teroinferomedial, 1 (1.0%) with medial, and 1 (1.0%) with superolateral (temporal fossa) displacement. Themajority of the fractures treated by closed methods(84, 91.3%) had no dislocation, and 83.3% (10 frac-tures) of the ones treated by open methods had dis-location ( P .015).

Dislocation existed in 3 head fractures (8.1%), 6condylar neck fractures (21.4%), and 9 subcondylar fractures (23.1%) ( P .183).

Comminution of the CondyleThere were 16 fractures (15.4%) with comminution

of the condyle. Eleven head fractures (29.7%) werecomminuted. Only 2 of the neck (7.1%) and 3 of thesubcondylar (7.7%) fractures were comminuted ( P .011).

Loss of Preoperative Ramus Height Preoperatively, 77 fractures (74.03%) had loss of

ramus height, with a maximum of 15 mm and a meanof 5.4 3.12 mm. One patient with an anteromedialdislocated condylar neck fracture had an increase of ramus height (4 mm). There was no statistical relation with the level of the fracture (neck fractures, 5.463.55 mm; head fractures, 4.93 2.4 mm; subcondylar fractures, 5.85 3.12 mm).

Preoperative OcclusionThe preoperative occlusion was good in 17 patients

(20.2%), 29 patients (34.5%) had an anterior openbite, and 34 patients (40.5%) had a posterior openbite. Four patients (4.8%) were edentulous. There wasa statistical signi cant relationship with the presenceof displacement ( P .005). Only 9.8% of the fractures with displacement had a good preoperative occlu-sion, whereas 40.9% of the fractures without displace-ment had good occlusion.

Status of Preexisting DentitionThe status of preexisting dentition was good in 60

patients (71.4%), 13 patients (15.5%) were partialedentulous, 4 patients (4.8%) were edentulous, and 7patients (8.3%) had mixed dentition. There was nostatistical signi cant relationship with the treatmentapplied and the level of the fracture.

TREATMENT

Rigid IMF was applied in 71 patients (84.5%), with 87 fractures (83.7%). In 58 patients (81.69%), it wasobtained by Erich arch bars, in 8 patients (11.26%) by intraoral screws, in 3 patients (4.22%) by Ivy loops,and in 2 patients (2.81%) by brackets. The length of rigid IMF was between 7 and 40 days with a mean of 25.07 9.6 days. It was 25.22 9.64 days in the



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closed group and 23.71 3.71 days in the opengroup ( P .687).

Functional treatment with intermaxillary guidingelastics was applied in 13 patients (15.5%) (11 with closed and 2 with open treatment). The time of phys-iotherapy was between 7 and 21 days with a mean of 12.77 4.36 days (closed group, 12.36 4.65 days;open group, 15 0 days; P .513). Posterior biteblocks were used in 2 patients (2.4%).

The surgical approach was via a preauricular inci-sion in 11 fractures and a coronal incision in 1 patient.The type of xation was by miniplates and screws(2.0 mm) in 5 fractures (41.7%), and by wire in 1fracture (8.3%). In 5 fractures, the fragment was re-placed as a free graft, and in 1 case xation was notpossible. There was no correlation ( P .05) with theuse of rigid IMF, the use of functional treatment, andthe length of rigid IMF. Two miniplates were used in2 cases and 1 plate in 3 cases.

The mean length of the surgical procedure wasgreater in the open group (132.08 minutes; range, 90to 180 minutes) than in the closed group (71.8 min-utes; range, 15 to 200 minutes) with statistically sig-nicant differences ( P .0001).

There was a statistically signi cant relationship( P .024) between the method of treatment and thelevel of the fracture. All of the head fractures (37cases) were treated by closed methods, whereas only 82.1% (18 of 23 fractures) of the neck and 78.12% (7of 32 cases) subcondylar fractures were.

POSTOPERATIVE RESULTS

General OutcomeThe outcome was successful (normal occlusion,

pain-free joint, normal jaw opening, symmetry) in 76patients (90.5%) and not successful in 8 patients(9.5%). The percentage of patients with a successfuloutcome was identical in both groups of treatment(67 of 72 in the closed group and 9 of 10 in the opengroup). The unique variable with a statistically signif-icant relationship ( P .036) was the status of thepreexisting dentition. Fifty-six patients (93.3%) with good dentition, 4 (100%) who were edentulous, and 7(100%) with mixed dentition had a successful out-come. Otherwise, only 9 partially edentulous patients(62.9%) had a successful outcome.

Postoperative Displacement The postoperative coronal displacement was be-

tween 60 (medial) and 20 (lateral) with a mean of 6.07 15.06 . There was no statistically signi cant

relationship with the method of treatment ( P .703)(closed, 6.47 ; open, 4.58 ), and level of the frac-ture ( P .073) (head, 8.05 ; neck, 7.15 ; subcon-dylar, 4.08 ).

There were statistically signi cant differences ( P .0002) between the preoperative and postoperativecoronal displacement. The mean difference betweenthese was 42.06 (lateral displacement) with statisti-cally signi cant differences ( P .005) between theclosed treatment (mean, 7.18 ) and open treatment(mean, 49.25 ) groups. There was no statistically sig-nicant relationship with the level of the fracture( P .058).

The postoperative sagittal displacement was be-tween 58 (posterior) and 43 (anterior), with amean of 2.77 17.63 (anterior). There were nostatistically signi cant relationships with the level of the fracture ( P .246) (head, 4.77 ; neck, 3.52 ;subcondylar, 0.44 ), and treatment applied ( P .855)(closed, 2.61 ; open, 3.58 ).

There was a statistically signi cant difference ( P .001) between the preoperative and postoperativesagittal displacement. The mean difference between

these was 15.41 with no statistically signi cant dif-ferences ( P .104) between the closed ( 4.33 ) andopen treatment ( 19.75 ) groups. There was no sta-tistically signi cant relationship with the level of thefracture ( P .177).

Return to the Preinjury Occlusion After Treatment Eighty-one patients (96.4%) return to the preinjury

occlusion after treatment. Two patients (2.4%) re-mained with open bite occlusions (subcondylar frac-tures, one with dislocation and the other with devia-tion, both treated by closed treatment), and 1 patient(1.2%) had a posterior cross-bite (bilateral head frac-ture with parasymphyseal fracture and closed treat-ment). By treatment groups, 71 patients (95.9%)treated by closed treatment and all of the patients (10,100%) treated by open methods were able to return totheir preinjury occlusion ( P .810). There were nostatistically signi cant relationships ( P .05) with thelevel of fracture, presence of displacement, disloca-tion, comminution, and status of the preexisting den-tition.

Maximum Mouth Opening The 1-month postoperative maximum mouth open-

ing (MMO) was 22.90 12.82 mm (range, 0 to 40mm). It was greater in the open group (24.80 9.40mm) than in the closed group (22.65 13.25 mm)( P .938). It was greater in head fractures (29.747.09 mm) than in condylar neck (29.09 4.94 mm)and subcondylar (24.39 8.70 mm) fractures with statistically signi cant differences ( P .021). The6-month postoperative MMO was 40.69 4.36 mm(range, 20 to 50 mm). It was less in the open group(38.80 5.71 mm) than in the closed group (40.954.13 mm) ( P .230). It was greater in head fractures(41.19 3.81 mm) than in condylar neck (40.96



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3.55 mm) and subcondylar (40.03 4.97 mm) frac-tures ( P .942). There were no statistically signi -cant relationships ( P .05) between the MMO (1 and6 months) and the presence of displacement, disloca-tion, and comminution of the condyle.

Postoperative Loss of Ramus Height

Postoperatively, the mean loss of ramus height was4.25 3.22 mm (closed treatment, 4.24 mm; opentreatment, 4.27 mm; P .977). There was a signi -cant difference with the level of the fracture (head,5.19 mm; neck, 4.46 mm; subcondylar, 3.08 mm; P .018). There were no statistically signi cant correla-tions with the variables of age and gender.

The difference between the loss of preoperativeand postoperative ramus height was between 12and 13 mm with a mean of 1.15 3.48 mm (closedtreatment, 0.66 mm; open treatment, 4.09 mm; P .043). There were statistically signi cant differences

with the level of the fracture ( P .0002) (headfractures, mean 0.25 2.01 mm; subcondylar frac-tures, mean 2.76 4.82 mm; neck fractures, mean1 2.20 mm).

Asymmetrical Postoperative Maximum Mouth Opening Sixty-one patients (72.6%) had symmetrical postop-

erative MMO (59 of closed treatment, 79.7%; 2 of open treatment, 20%) ( P .0003). It was related tothe presence of dislocation ( P .0001) but not to thelevel of the fracture, presence of displacement, andcomminution of the condyle ( P .05).

Postoperative Condylar DeformitiesIn 50% of the condyles (52 fractures), there were

postoperative condylar deformities. In 35 fractures(33.7%), the result was a attening deformity; in 12(11.5%), there was condylar resorption; in 3 (2.9%), abid condyle; in 1 (1%), a medially rotated condyle;and in 1 (1%) case, an ankylosis. There was a statisti-cally signi cant relationship with the level of thefracture ( P .015). There was alteration in 62.2% of the head fractures (23), in 60.7% of the neck fractures(17), but in only 30.8% of the subcondylar fractures(12). Flattening was present in 45.9% of the headfractures (17) and in 46.4% of the neck fractures (13)but in only 12.8% of the subcondylar fractures (5).The percentage of condylar resorption was similar inthe 3 levels: 8.1% of head (3), 14.3% of neck (4), and12.8% of subcondylar (5) fractures. A bi d condyle was present in only 3 cases of head fractures (8.1%).The only case of a medially rotated condyle and theother case of ankylosis occurred in patients with sub-condylar fractures.

There was no alteration in 52.2% of the fracturestreated by closed methods (48) but in only 33.3% of the fractures treated by open methods (4) ( P .011).

Flattening was present in 34.8% of the closed frac-tures (32) and in 25% of open ones (3). Condylar resorption was present in 8.7% of the rst group (8)but in 33.3% of the second group (49). A bi d condyle was present in only 3 cases of closed treatment(3.3%); all of them were head fractures. The only caseof medially rotated condyle had been treated by openmethods, and the case of ankylosis had been treatedby closed methods. There was no statistically signi -cant relationship with the displacement of the frac-ture ( P .266) and comminution ( P .901).

Postoperative Facial and Mandibular SymmetryPostoperative facial symmetry was present in 81

patients (96.4%), without any statistically signi cantrelationship ( P .05).

Postoperative mandibular symmetry was present in79 patients (94%). There were statistically signi cantrelationships with the presence of displacement ( P

.049), dislocation ( P .035), and type of treatment( P .011). Although 97.3% of the patients treated by closed methods (72) had postoperative mandibular symmetry, only 70% of the patients treated by openmethods (7) had it.

DiscussionDecisions on management of mandibular condyle

fractures remains a major topic of oral and maxillofa-cial surgery practice. Some variables affect the deci-sion of closed versus open treatment (Table 2). This

includes the level of fracture, the degree and direc-tion of displacement of the fractured segments, theage and medical status of the patient, concomitantfacial fractures, and the presence and status of denti-tion. 7 Although areas of disagreement still exist, thereare many areas of agreement. 6 The majority of frac-tures of the mandibular condyle heal with function-ally acceptable results after closed treatment. 11 Thismethod is simpler and easier to perform and in mostinstances is as effective, if not more effective, as openreduction, with less potential morbidity. The mainreasons for open reduction and internal xation of condylar fractures are to permit primary healing of unreducible or unstable fractures, and to avoid IMF. 11 Absolute indications for open reduction are rare. Rel-ative indications primarily include adults with persis-tent malocclusion and condyles displaced out of thefossa. 8

The most common surgical approaches, usually used in combinations, are preauricular, retromandibu-lar, and a submandibular approach. The intraoral ap-proach has very limited use, only for very minimally displaced low fractures. 6,12 In our hands, a preauric-ular incision is the surgical approach of choice in themajority of condylar fractures, because it is the easier



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and more direct way to obtain an optimum surgicaleld.

Many types of xation have been used, including wire, lag screws, plates, and external xators. 7

Miniplates and screws are the gold standard hardwarein rigid internal xation of condylar fractures, provid-ing a more precise xation of fragments and goodstability for the fractured segments. 6,13 Replacementof the condyle as a free graft is an alternative inselected cases, 14 although internal xation withoutdisruption of the blood supply gave the most favor-able results. 15

If malocclusion with condylar fractures is to betreated closed, functional treatment with intermaxil-lary guiding elastics to control the occlusion seemspreferable to rigid IMF, because it may adversely af-fect future joint function. 6 The use and length of IMF,as well as the use and length of active jaw physiother-apy, are considered critical variables in patient man-agement. 14,16 Open reduction in our series did notimply a speci ed IMF treatment. Our results showedno statistically signi cant differences between pa-tients treated by closed or open methods, with re-spect to the use of rigid IMF, duration of rigid IMF,and functional treatment with intermaxillary guidingelastics. Perhaps, the principal reason is that there were 4 cases with replacement of the condyle with-out internal xation and 1 case of condylar resection,for which we thought that a period of rigid IMF wouldbe necessary.

The level of condylar fracture is one of the variablesthat strongly in uences the choice of a treatment.This is corroborated by our results with a statistically signicant relationship between the method of treat-ment and the level of the fracture. The degree of displacement is the second important variable when atreatment is being chosen. 3,4 The majority of condylar fractures present displacement independent of thelevel of the fracture. 3 Open treatment is justi ed only with displacement, although some unilateral or bilat-eral displaced fractures can be successfully treated by closed methods. The degree of displacement that jus-ties open treatment is controversial. 2

Our results con rm that the level of the fractureinuences the degree of preoperative coronal andsagittal displacement (condylar neck fractures had agreater medial and anterior displacement than didhead and subcondylar fractures) and thus the treat-ment rendered. This result is in accord with the sig-nicant correlation between the level of the fractureand the sagittal position of the condyle before treat-ment, obtained by Ellis et al. 9 Otherwise, no signi -cant correlations were found by these authors be-tween the coronal position of the condylar processand level of the fracture. Our results corroborate this

relationship, increasing the importance of the level of fracture in the displacement.

Both open and closed treatment are useful to im-prove the displacement of the condyle because there were statistically signi cant differences between thepreoperative and postoperative coronal and sagittaldisplacements. Ellis et al 9 showed that the position of the condylar process is not static in patients treatedfor condylar process fractures by closed means. Thecondylar processes became more medially tilted with application of the arch, and even the postoperativephysiotherapy could have contributed to further dis-placement. However, there was great variability, with some segments becoming more medially displacedand some more laterally displaced. These results sug-gest that care must be taken in basing treatmentdecisions on the degree of displacement or disloca-tion of the condylar process in presurgical radio-graphs. 9 In our study, the improvement obtained by

open treatment is greater than that obtained by closedmethods, with statistically signi cant differences, butthe truth is that the preoperative sagittal and coronaldisplacement in the rst group is comparatively greater and so required a greater amount of move-ment for reduction. There was no statistically signi -cant relationship between the level of the fractureand the change (preoperative to postoperative) insagittal or coronal displacement, in agreement with the results obtained by Ellis et al. 9,10 Finally, theseauthors obtained a signi cant correlation between thepostoperative sagittal position of the condylar process

and level of the fracture (but not with coronal posi-tion). 9 We did not nd any statistically signi cantrelationship between the postoperative coronal andsagittal displacement with the method of treatment or the level of the fracture, indicating that the postoper-ative results are less in uenced by these 2 variables.

The outcome was considered successful if thefollowing criteria were met: return to the preinjury occlusion, normal jaw opening, pain-free joint, sym-metry of the mandible, and absolutely minimal mor-bidity of surgery. 6,7 Traditional predictors of goodresults from closed treatment are in fact unreliable. 6Only the variable status of the preexisting dentition was correlated with the general outcome in thisstudy. Partially edentulous patients had the worst re-sults of all, compared with patients with good denti-tion, who were edentulous, and with mixed denti-tions.

The 1-month postoperative MMO was greater in theopen group and in general in head fractures. All headfractures were treated by closed methods, so thedifference between both methods of treatment insubcondylar and neck fractures is perhaps superior than the results re ect. Otherwise, the 6-month post-operative MMO was less in the open group (38.80



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mm) than in the closed group (40.95 mm) and similar in the 3 levels of fractures. Curiously, there were nostatistical signi cant correlations between the MMO(at 1 and 6 months) and the presence of displace-ment, dislocation, or comminution of the condyle, sothat few consequences are possible to obtain.

The majority of patients (72.6%) had symmetricalpostoperative MMO. The risk of developing asymmet-rical postoperative MMO is greater in the patientstreated by open methods (80%) than in the closedgroup (20.3%), with statistically signi cant differ-ences. This result is different from those obtained by other authors, 15,17 who indicated that asymmetricalmovement on maximum opening of the mandible aremore often associated with the nonsurgical approach.It was also related with the presence of dislocationand the postoperative position of the condyle in thetemporal fossa. If the condyle is out of the fossa, thedisc may also be causing alterations in temporoman-

dibular joint function.Loss of ramus height is a factor that seems clinically

important for maintaining habitual occlusion and pre- venting a shortening of the ascending ramus, anterior open bite, and backward position of the mandible. 5 Ithas been present preoperatively in the majority of thefractured condyles (74.03%) without statistically sig-nicant differences between the different levels of fracture. Postoperatively, the mean loss of ramusheight was similar in both groups of treatment (closedtreatment, 4.24 mm; open treatment, 4.27 mm). Sub-condylar fractures had a less postoperative loss of

ramus height with statistically signi cant differencesbetween the different levels of fracture (head, 5.19mm; neck, 4.46 mm; subcondylar, 3.08 mm). Other authors indicated that the postoperative loss of ramusheight is more often associated with closed treat-ment. 17 Zhang and Obeid 15 investigated the results of treatment on unilateral subcondylar fracture, suggest-ing that open reduction had more favorable resultsthan closed treatment only if the vascular supply ispreserved, indicating that returning the condyle to itsanatomic position results in an improved morpho-logic outcome. Although patients treated by both methods of treatment experienced an increase in ra-mus height after treatment, this is signi cant only inthe open group (4.09 mm) with statistically signi -cant differences (closed group, 0.66 mm). Otherwise,it is important to note that although patients with head fractures experienced a little loss of ramusheight after treatment (mean, 0.25 2.01), subcon-dylar fractures (mean, 2.76 4.82) and neck fractures(mean, 1 2.20) increased their ramus height.

Postoperative condylar deformities were commonin our series (50%), being more frequent in head andneck fractures than in subcondylar fractures, with statistically signi cant differences in attening defor-

mity but not in condylar resorption, which was simi-lar in all 3 levels of fracture. Bi d condyle is a char-acteristic deformity after sagittal fractures and waspresent only in head fractures. Other studies haveshown that dislocated fractures are associated with incomplete remodeling, such as abnormal form or morphology of the condylar neck or joint surfaces. 18Open treatment would increase the risk of postoper-ative condylar deformities with statistically signi cantdifferences, especially in the cases where the condyleis replaced like a free graft.

In summary, the principal factors that determinethe treatment decision are the level of the fractureand the degree of displacement. Head fractures mustbe treated closed, but the treatment is in uenced by other variables in neck and subcondylar fractures.The improvement in condylar displacement is greater by open than by closed methods. Open treatment is justied only in adults, with displacement, malocclu-

sion, and unreducible or unstable fractures in which IMF must be avoided. The degree of displacementthat justi es open treatment is controversial and thebest results are obtained after functional treatment with intermaxillary guiding elastics.

Acknowledgment

The authors would like to thank Linda Valde s, Orlando, FL, for her help in preparing the manuscript.

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