a comparison of open and closed reduction

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Int. J. Oral Maxillofac. Surg. 2001; 30: 384–389doi:10.1054/ijom.2001.0103, available online at http://www.idealibrary.com on

Clinical paper:

Trauma

A comparison of open andclosed treatment of condylarfractures: a change in

philosophyG. De Riu, U. Gamba, M. Anghinoni, E. Sesenna: A comparison of open and closed treatment of condylar fractures: a change in philosophy. Int. J. Oral Maxillofac.

Surg. 2001; 30: 384–389. 2001 International Association of Oral andMaxillofacial Surgeons

Abstract. A comparison between two samples of patients with condylar fractures is

reported: the first treated non-surgically and the second with open reduction andrigid internal fixation. The functional results for both groups were similar.

However, open reduction gave better occlusal results, anatomic restoration andfaster recovery rates than non-surgical techniques.

Giacomo De Riu, Ugo Gamba,Marilena Anghinoni,Enrico SesennaMaxillofacial Surgery Department, Parma, ItalyDivisione di Chirurgia Maxillo-Facciale,Ospedale Maggiore di Parma, Parma, Italy

Key words: mandibular fractures; condylarfractures; surgical treatment.

Accepted for publication 23 March 2001

Mandibular fractures are extremely fre-

quent in facial trauma, and 25–35%

involve the condyle. Condylar fractures

are classified according to the anatomic

location (intracapsular and extracapsu-

lar) and according to the degree of dis-

location of the articular head. There are

two principal therapeutic approaches tothese fractures: functional and surgical.

Functional therapy is adopted mostfrequently, since it permits early mobiliz-

ation and adequate functional stimu-lation of condyle growth (in growingsubjects) and bone remodelling (in all

subjects). It is indicated in almostall condylar fractures that occur in

childhood, that in intracapsular andextracapsular fractures that do notinclude serious condylar dislocation in

adults6,10,12,13. Furthermore, D2

recommends functional therapy in cases

of both high and lower condylar frac-tures, regardless of displacement. Theresults of functional therapy described

in the literature are generally good. In

contrast, surgical treatment is indicatedprimarily for adults with displaced frac-

tures or with dislocation of the condylarhead19. However, there is no consensuson the therapeutic approach.

Recently, we switched from a func-tional approach to the open technique,

to avoid aesthetic and gnathologic prob-lems related to functional methods. Inthis study, we compare the results that

we obtained in a homogenous sample of

surgically treated condylar fractureswith those for a group of patients withsimilar fractures treated with functional

therapy at our centre several years ago12.

Materials and methods

In a period of approximately 4 years, we

surgically treated 64 mandibular con-dylar fractures in 49 patients, aged 13–69

(15 were bilateral). Out of the 49patients, we excluded 16 who did notshow up for postoperative clinical

examination, 10 who had insuff icient fol-

low up, two who underwent reduction

without rigid fixation, and one who had

infection of the condylar fragment. The

20 remaining subjects represent a hom-

ogeneous group that had open reductionand rigid fixation with plates and screws.

The non-surgical group included 19patients aged 13–25, treated from 1979–

1983 (Table 1). Functional treatmentconsisted of: (1) individual occlusionrestoration with MMF for 5–7 days;

(2) achievement of lateral protrusion onthe contralateral side with horizontal

light training elastics and nocturnal ver-tical traction to maintai the midline for40–60 days2; and (3) a lateral propulsion

splint for a further 40–50 days, in caseswith less favourable progress (approxi-

mately 60%). During therapy, clinicalchecks were performed twice in the

first 2 weeks and on a weekly basissubsequently12.

The clinical diagnosis was always sup-ported by radiological analysis of the

mandible with an orthopantomogram,

0901-5027/01/050384+ 06 $35.00/0 2001 International Association of Oral and Maxillofacial Surgeons



A/P X-rays, and a CT scan of the tem-

poromandibular joints when standardX-rays indicated surgical reduction.

Surgical access was obtained eitherwith a submandibular or preauricular

approach. More recently, we adopteda variant of the retromandibularapproach. It consists of making a

cutaneous incision on the surface of the

mandibular angle and over the massetermuscle between the buccal and marginalrami of the facial nerve (Fig. 1). Thispermits better control of the condylar

neck region, although it can produce amore prominent scar.

In all surgical cases, MMF wasperformed for 3 – 5 days followed bylight functional therapy for periods

varying from 1 – 2 months (weeklycontrols).

Pre-treatment X-rays of fracturedcondyles were selected to obtain two

groups of patients with similar kinds of

fractures; only neck and lower condylar

fractures with or without dislocationwere included in the study (Table 1).

Comparison of the two groups wasbased on pre- and post-treatment X-raysand clinical data. In both groups, frac-

ture level and degree of dislocation,mandibular deviation and movements,

articular noise and pain, and TMJanatomic alterations were assessed.

Radiographic analysis (panoramicand Town’s views) included evaluationof anatomic restoration and direct

measure of the total height of the rami(from the condylar head to the mandibu-

lar angle) and TMJ regions (Table 3).Mandibular movements were re-

corded by digital calipers and reported

to 1/10 mm. TMJ signs and symptomswere evaluated and reported (Table 2).

Follow-up was 5 – 6 years for thesurgical group, and 8 – 12 years for the

non-surgical group.

Results

No significant diff erences were observedbetween the surgical and non-surgical

groups for protrusive, lateral protrusive,or opening movements. Both groups

showed similar signs of mandibularrecovery and absence of muscular and

Table 1. Kind of fracture

Kind of fracture Functional patients Surgical patients

Number of patients 19 20Neck fractures without dislocation* 6 2Neck fractures with dislocation* 6 5Lower condylar fractures without dislocation* 2 10Lower condylar fractures with dislocation* 8 5Total number of condylar fractures 22 (3 fr. bilateral) 27 (7 bicondylar,

among which only 2

surgically treated onboth sides)

*Dislocation of the condylar head outside the glenoid fossa.

Fig. 1. Buccal and marginal branch of VII

c. n.

Table 2. Clinical analysis

Clinical analysis

Funct ional patients Surgical patients

Mean mm(range)

SDmm

Mean mm(range)

SDmm

Maximum opening 46 7 43.7 5.9(37 – 52) (28 – 55)

Protrusion 6.3 2.5 7.4 2.2(4 – 10) 7.4(4 – 10) (1 – 15)

Lateral protrusion(*homolateral to theside of the fracture)

8.5 3.5 Overall average8.6

2.2(5 – 13)

(4 – 13)Bilateral average

(2 patients) 11

0

(11 – 11)Average operated on one sideand functionals on theother side (5 patients)

6.2

1.4

(5 – 9)Lateral protrusion(*contralateral to theside of the fracture)

7.5 2.9 Overall average8.6

1.8(3 – 12)

(4 – 13)Bilateral average (2 patients)

110

(11 – 11)Average operated on one sideand functionals on theother side (5 patients)

6.2

1.7

(5 – 9)

Number % Number %

Lateral deviation duringmax opening <3 mm

4 21 6 30

Lateral deviation duringmax opening >3 mm

2 10.5 2 10

Articular noise 3 16 8 40Articular pain 0 0 0 0Diff erence MI-RC (>2 mm) 5 26.3 0 0Total number patients 19 100 20 100

In the bilateral fractures, the terms homo- and contralateral refer to the fracture with the largerdislocation.

Open and closed treatment of condylar fractures 385



joint pain. Surgically treated patients,

however, experienced a greater hom-ogeneity of results, and none showed

more than 2 mm diff erence betweenmaximum intercuspation and centricrelationship (MI-RC) (Table 2). On

radiographic analysis, surgical patientsshowed TMJ morphology similar to that

on the contralateral unaff ected side.Neither diff erences in the height of therami nor alterations of the glenoid fossa

were recorded, compared to the frequentrami asymmetry observed in non-

surgical patients (Table 3).

Case reports

We present three case histories: two

patients treated surgically and onetreated non-surgically.

Case 1

A 24-year-old patient presented with

facial injuries and multiple fracturesof the lower limbs following a traff ic

accident. The CT scan revealed a rightmandibular fracture (symphysis) and adisplaced fracture of the base of the left

condyle, with dislocation of the headfrom the glenoid fossa (Fig. 2).

Through a retromandibular approach,the buccal branch of the facial nerve was

isolated to reach the mandible. Byretracting the nerve and the masseter

muscle, exposure of the fracture wasachieved. The condylar fragment wasrepositioned correctly and the fracture,

once reduced, was stabilized with a mini-plate (Fig. 3). In addition, the symphysisfracture was stabilized with miniplates.

MMF was maintained for 5 days. Asecond CT showed reduction of the con-

dylar head in the fossa and correct pos-itioning of the ramus (Fig. 4). For thenext 60 days, the patient performaned

forced mobilization exercises of the jawto obtain good TMJ function: mouth

opening 40 mm, right and left lateral

movements 14 mm, and mandibular pro-trusion 9 mm. Posterior facial height(measured from the tragus to the man-

dibular angle) was the same for bothsides. Eighteen months following the

intervention, no TMJ symptoms wereevident during normal movement of the

joint. Slight asymmetry during opening

(2 mm to the left) remains.

Case 2

A 17-year-old patient presented with a

left parasymphyseal fracture and frac-tures of the condyles resulting from a caraccident. The Towne’s view showed

medial displacement of both condyles(right >90, left <60) (Fig. 5).

The first step in treatment was condylereduction through a retromandibularapproach. Then, the symphysis fracture

was reduced, controlling the transverse

dimension by manual pressure on the

mandibular angles bilaterally. The para-symphyseal fracture was stabilized by

applying two miniplates. The next stepwas more precise reduction of the con-dylar fractures, which were then stabi-

lized with a miniplate (Fig. 6). MMFwas maintained for 5 days, followed by

functional therapy. Five years later,mouth opening measured 49 mm, andthe right and left lateral movements

measured 2 and 8 mm, respectively,with 8 mm protrusion. There was no

diff erence in ramus height between the

Table 3. X-ray analysis

Radiographicanalysis

Functional patients Surgical patients

Number % Number %

Restitutio ad integrum 9 40.9 21 95.45Minor condylar alterations 6 27.2 0 0Major condylar alterations 7 31.8 1 4.54Alteration of the fossa 3 13.6 0 0Decrease of ramus height (>3 mm) 2 9 0 0

Alteration of the fossa anddiminution of ramus height

4 18.1 1 4.54

Alteration of the fossa, decrease of ramus height and increase of thecondyle-fossa distance

4 18.1 0 0

Total number of fractures 22 100 22 (surgically treated) 100

Fig. 2. Case 1 — CT preoperatively.

Fig. 3. Case 1 — miniplate fixation.

Fig. 4. Case 1 — CT postoperatively.

386 De Riu et al.



two sides. A 2 mm lateral deviation on

protrusion remains.

Case 3

A 16-year-old patient presented with adislocated and displaced fracture of the

right condyle resulting from a sportingaccident (Fig. 7). The patient also pre-

sented with homolateral deviation andright posterior premature contact.

Non-surgical treatment was used for

the fracture: MMF for 7 days, followedby 40 days of functional therapy with

both passive and active mobilization(by means of horizontal, intermaxillary

elastic traction during the day). Follow-ing this treatment, the open bite wasclosed and mandibular movements were

suff iciently re-established.

Five years later, at a clinic check,

the patient did not experience pain or jaw noise. Right lateral deviation of

approximately 3 mm remains in protru-sion and in opening (47 mm). X-raysshowed right condylar deformation,

with shortening of the ramus partially

compensated by flattening of the glenoidfossa.

Discussion

Most authors treat fractures that occurin childhood with non-surgical methods

in order to exploit the capacity of thegrowing skeleton to be remodelled with

normal functional stimulus.In a recent overview of 25 paediatric

patients with unilateral condylar frac-

tures treated non-surgically (mean fol-

low up: 15 years), 77.2% had no facialasymmetry, 90.4% had restoratin of theanatomy without important functional

or aesthetic consequences (54.5% hadcomplete anatomic restoration on

X-rays), and only one patient showedclear occlusal disturbance and facialasymmetry7. These results confirm once

more that non-surgical therapy is theprocedure of first choice in childhood.

In adult patients, treatment possibili-ties vary according to the location anddislocation of the fracture. Non-surgical

Fig. 5. Case 2 — X-ray preoperatively.

Fig. 6. Case 2 — X-ray postoperatively.

Fig. 7. Case 3 — Condylar fracture.

Fig. 8. Case 3 — Condylar deformation after

functional treatment.




treatment may be indicated in intra-

capsular fractures of the condylar head.

In comminuted bicondylar fractures inpanfacial trauma, which generally

includes a decreased height of the pos-terior face, treatment should be surgical,

in order to provide three-dimensionalreconstruction of the midfacial bones4.

Between these extremes, a wide rangeof options exists. Indeed, the incidenceof cases requiring surgical treatment

varies from 5%9 to 30%16 according toauthor. Z & K19 described the

classical absolute and relative indi-cations for surgical reduction in 1983;however, the indication for surgical

therapy in relation to the dislocationangle in monocondylar fractures is still

under discussion. Surgical therapy isgenerally adopted in cases where non-

surgical treatment cannot be used orcannot guarantee restitutio ad integrum.Several authors suggest surgical therapy,

in cases of unilateral fractures in adults,when the dislocation is more than 45 to

the ramus axis in a frontal view3,16, orwhen the condylar head is dislocatedfrom the glenoid fossa1,11,15. W

et al.17 indicate surgical treatment whenthe dislocation is greater than 30 with

respect to the longitudinal axies, in bothlateral and frontal projections, or whenshortening of the ramus of at least 5 mm

(as seen radiographically) accompaniesthe dislocation. In such cases, although

non-surgical therapy generally obtainsgood dental occlusion, it often does not

permit complete restoration of man-dibular movements1. According toL8, persistent dislocation of the

condylar fragment must be consideredone of the principal causes of masti-

catory functional disorders followingcondyle fractures in adults.

The review of S et al.

of problems related to non-surgicaltreatment of disarticulated condylar

fractures reports a 17.4% incidence of occlusal disturbance or marked opening

deviation. These functional compli-cations, which were attributed to re-

duction in ramus height or to condyledislocation from the fossa, suggestadopting open reduction14. H et

al.5 compared patients treated surgicallyand non-surgically, and found no sub-stantial functional diff erence, although

the comparison showed a deviation inopening in 64% of the patients treated

with non-surgical therapy and in only10% of surgically treated patients. Fur-thermore, lateral movements were

limited in the former group, but not inthe latter. Anatomic restoration of the

mandibular ramus was successful in 95%

of surgically treated patients (approx.

10% deviation from normal angulationof the condyle), while in non-operated

patients radiological analysis showedincorrect positioning of the condyle in

93% of cases.W & T18 demonstrated

that, in adults, non-surgically treateddislocated subcondylar fractures pro-duced more complications compared to

those treated with open reduction.Finally, T16 compared 16

cases of condylar fracture treated surgi-cally with 20 cases that were treatednon-surgically (average follow-up was

approximately 2 years) and found nosignificant functional diff erences be-

tween the two groups. However, itshould be noted that the first group in

this study included fractures with moresevere dislocation and displacement.

From our experience, non-surgical

management of condylar fractures pro-duces good restoration of jaw move-

ment. However, lateral protrusionmovements and morphologic alterationsof the ramus have been less satisfac-

tory12. Moreover, we have observedthat reduced ramus height can cause

asymmetry of the jaw and aestheticproblems.

In this study, there was no diff erence

greater than 2 mm between maximumintercuspation and centric relationship

(MI-RC) in the surgically treated group.This diff erence was marked in the

non-surgically treated group, despite thepartial compensation derived from pro-gressive flattening of the fossa (Table 2).

The physiological MI-RC distanceobtained in surgical patients produced

more pleasing aesthetic (symmetry of thelower border and mandibular angles)and occlusal results, owing to the

absence of posterior premature contactin lateral and protrusive movement.

Our results suggest that, in the longterm, incomplete anatomical restoration

in non-surgical methods can cause facialasymmetry and inclination of the occlu-

sal plane, as well as functional occlusalproblems, such as premature contact inprotrusion and lateral protrusion. More-

over, non-surgical treatment, evencorrectly performed, is lengthy, requirescontinuous adjustment of the elastics

applied to the arch bars2, and is moreuncomfortable for the patient than open

reduction and rigid fixation. Conversely,the relative simplicity of the surgicaltechnique, the absence of complications

or negative results (except minimal skinscarring), the faster and better recovery

rates, the shorter duration of MMF, and

the easier functional therapy, haveencouraged us to adopt the surgical

approach for borderline cases, such asslightly dislocated or displaced fractures.

References

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Address:

Dr Giacomo De Riu

Divisione di Chirurgia Maxillo-Facciale

Ospedale Maggiore di Parma

Via Gramsci 14

43100 Parma

ItalyTel: 0521/259243

Fax: 0521/259109

E-mail: [email protected]


a comparison of open and closed reduction

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