|ORIGINAL ARTICLE - EVALUATIVE STUDY
|Year : 2021 | Volume
| Issue : 1 | Page : 37-41
Unilateral condylar fracture with review of treatment modalities in 30 cases - An evaluative study
Hirakben Bhagyendrakumar Patel, Nimisha N Desai, Ridhi G Matariya, Kalpesh G Makwana, Pratap N Movaniya
Department of Oral and Maxillofacial Surgery, Karnavati School of Dentistry, Gandhinagar, Gujarat, India
|Date of Submission||09-Aug-2020|
|Date of Decision||02-Mar-2021|
|Date of Acceptance||10-Mar-2021|
|Date of Web Publication||24-Jul-2021|
Dr. Hirakben Bhagyendrakumar Patel
Department of Oral and Maxillofacial Surgery, Karnavati School of Dentistry, Uvarsad, Gandhinagar - 382 422, Gujarat
Introduction: The treatment of subcondylar mandible fractures is a topic of debate and can be variable even though these fractures are commonly seen. The present study aimed at evaluation of various treatment modalities for unilateral condylar fracture in adults. Materials and Methods: Thirty patients with unilateral condylar fractures between the age of 18 and 60 years were evaluated. Treatment protocol included closed reduction for 15 patients and open reduction for 15 patients. Results: Assessment was done functionally for maximum interincisal mouth opening, deviation on maximum interincisal mouth opening, occlusion and facial nerve function, and radiologically for ramus height shortening. In general, there were no statistically significant differences between closed and open methods. Discussion: Both the treatment options for condylar fractures of the mandible yielded acceptable results. Closed treatment appears to be a safe and appropriate modality for most unilateral condylar fractures. Although the open group, in general, showed similar outcomes, this treatment should be reserved for limited indications. The present study has confirmed that both treatment options can yield acceptable results. On clinical examination, there was no significant difference in mouth opening measures, the incidence of occlusal disturbances or in the degree of pain perception.
Keywords: Closed reduction, open reduction, unilateral mandibular condylar fracture
|How to cite this article:|
Patel HB, Desai NN, Matariya RG, Makwana KG, Movaniya PN. Unilateral condylar fracture with review of treatment modalities in 30 cases - An evaluative study. Ann Maxillofac Surg 2021;11:37-41
|How to cite this URL:|
Patel HB, Desai NN, Matariya RG, Makwana KG, Movaniya PN. Unilateral condylar fracture with review of treatment modalities in 30 cases - An evaluative study. Ann Maxillofac Surg [serial online] 2021 [cited 2021 Dec 5];11:37-41. Available from: https://www.amsjournal.com/text.asp?2021/11/1/37/322246
| Introduction|| |
The mandible is the most prominent facial bone and a common site of trauma, constituting 12-56% of facial fractures. Condylar fractures account for about 29-52% of all mandibular fractures., Injury to the condylar region deserves special consideration apart from the rest of the mandible because of its unique anatomy and healing potential.
Treatment of condylar fractures primarily aims at the re-establishment of undisturbed joint function with physiologic occlusion and recovery of the osseo-discoligamentary structures. Complications of trauma to the condylar region are far reaching in their effects and not always immediately apparent. Disturbance of occlusal function, deviation of the mandible, internal meniscal derangements of the temporomandibular joint (TMJ), ankylosis of the joint with a resultant inability to move the jaw, and growth disruption are all sequel of this injury. Thus, proper assessment and choosing an appropriate treatment strategy is of paramount importance.
Broadly, the two main treatment modalities for fractured condyle are defined as conservative (closed reduction) or surgical (open reduction and direct fixation). Although there are equal studies supporting both open and closed reductions, there is still a dilemma about clear guidelines for treatment and precise functional evaluation of surgical treatment of condylar fractures and long-term complications associated with closed reductions. For any given patient, fracture, or incident, advantages and disadvantages are specific to each potential treatment plan.
In this study, 30 patients of unilateral condylar fracture either alone or with associated other mandibular fractures have been included. Patients were treated either by closed or open reduction and the results were then evaluated.
| Materials and Methods|| |
This evaluative study protocol was approved by the Ethical Committee of our college (KSDEC), approval number KSDEC/17-18/Apr/30. All the protocols of the Helsinki Declaration were followed. It was carried out between December 2017 and December 2019. All the patients during this time period with unilateral fracture of mandibular condyle with or without any other facial fracture were selected. After considering exclusion criteria, 30 patients were included (27 males and 03 females) and their ages ranged between 18 and 60 years. Patients with bilateral mandibular condylar fracture or comminuted or infected fracture or malunited or nonunited fracture and patients with fracture and bone loss which needed bone graft were excluded from the study. Informed written consent was obtained from all individual participants included in the study.
Patients were clinically evaluated and treated either by closed reduction (maxillomandibular fixation [MMF]) only or MMF with open reduction and internal fixation (ORIF).
For closed reduction, elastic bands were given for 24 h and were replaced with MMF wires and kept for 4–6 weeks. For ORIF, MMF was given for 1 week postoperatively.
For open reduction, either preauricular [Figure 1] or retromandibular [Figure 2] approaches were used depending on the level of fracture. Fixation was done by titanium miniplates [Figure 3] or delta plate [Figure 4] or lambda plates [Figure 5].
|Figure 1: (a) Marking of preauricular incision. (b) Incision. (c) Exposure of fracture site|
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|Figure 2: (a) Marking of retromandibular incision. (b) Incision. (c) Exposure of fracture site|
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Subsequent follow-up was done at 1 week, 1 month, and 6 months. During every follow-up occlusion, range of motion, maximum mouth opening, jaw deviation, oral hygiene, malunion, nonunion as well as other complications were evaluated. The required radiographs were taken and the patients were assessed for any further complaints. In the open reduction group, facial nerve function was also assessed.
| Results|| |
A total of 30 patients were enrolled in the study under two treatment groups, conservative treatment group and ORIF group each had an equal number of patients (n = 15).
Maximum active interincisal opening
The mean preoperative maximal active interincisal opening was 26.6 mm (range: 24–30 mm with standard deviation [SD] of 1.5 mm) in the closed group and 22.66 mm (range: 21–25 mm with SD of 1.54 mm) in the open reduction group.
The mean postoperative maximal active interincisal opening after 1 month reached up to 33.46 mm (range: 30–36 mm with SD 2.03 mm) in the closed group and 28.6 mm (range 28–32 mm with SD 1.2 mm) in the open reduction group.
It increased to 45.86 mm (range: 43–48 mm with SD 2.23 mm) in the closed group and 46.33 mm (range: 43–49 mm with SD 1.17 mm) in the open reduction group after 6 months [Figure 6].
Deviation on maximum mouth opening
Twenty-four out of 30 (80%) cases had a deviation on maximum mouth opening during preoperative evaluation. Fifteen out of 24 (62.5%) cases had a deviation on maximum mouth opening at 1-week follow-up out of which 9 out of 15 (60%) cases were of closed reduction and 6 out of 15 (40%) cases were of open reduction. At the end of 6 months, 6 out of 9 (66%) cases of closed reduction and 3 out of 6 (50%) cases of open reduction had a mild deviation on maximum mouth opening [Figure 7].
Preoperative and postoperative occlusion
Twenty-five out of 30 (83.3%) cases were suffering from a preoperative malocclusion. Nearly 14 out of 25 (56%) were associated with other mandibular fractures.
Four out of 30 (13.3%) cases showed malocclusion postoperatively. Three (75%) cases were in the closed group and 1 (25%) in the open group had occlusal discrepancy, which was corrected by giving elastics for 10 days postoperatively. Only one patient in the closed treatment had mild occlusal discrepancy after 3 months which was corrected by selective occlusal grinding.
Assessment of facial nerve function
Two out of 15 (13.33%) cases in the open reduction group showed postoperative transient weakness of the marginal mandibular branch of the facial nerve. They showed temporary moderate weakness in Grade 2 according to the House–Brackmann Facial Nerve Grading System., Weakness of facial nerve was transient and lasted for 1-1/2 months in one patient and for 3 months in the other one [Figure 8].
Ramus height difference
The mean preoperative ramus height shortening was 3.01 mm (range: 1.18–5.14 mm with SD of 1.18 mm) in the closed group and 3.33 mm (range: 2.12–6.1 mm with SD of 1.07 mm) in the open reduction group.
The mean postoperative ramus height shortening after 6 months was 2.07 mm (range: 0.42–3.57 mm with SD 0.93 mm) in the closed group and 1.13 mm (range: 0.71–1.89 mm with SD 0.3 mm) in the open reduction group [Figure 9].
| Discussion|| |
There are two principal management procedures for condylar fractures: conservative treatment and surgical treatment. Many authors have described the conservative treatment as safe, noninvasive, easy, and low cost, but they have also described complications including poor oral hygiene, gingivitis, facial deformity, TMJ dysfunction, and even TMJ ankylosis.,,, Surgical treatment also has disadvantages such as its high cost, scar formation, intraoperative haemorrhage, facial nerve injury, and others.
In the field of maxillofacial trauma, the management of condylar fracture is still the most controversial issue generating more discussions. These debates have been continuing for six decades with no general agreement yet. Although there are clearly defined guidelines for when an open or closed reduction is indicated in the management of fractures in most areas of the mandible, there are still continuing arguments over how to best manage fractures of the condylar process. To date, the literature on condylar fractures has reported good outcomes for both open and closed treatment methods.,,
In this study, no significant difference was noted in maximum mouth opening between surgically and conservatively treated fractures. Similar results were noted by Santler et al., Khiabani et al., Haug and Assael. Although immediate postoperatively maximum mouth opening was significantly higher (26.6 mm ± 1.50 mm) in conservatively treated patients than surgically treated patients (22.66 mm ± 1.54 mm), the patients treated by open methods may have had less mouth opening at 6 weeks because surgery induced some hypomobility due to joint and incisional pain, or possibly because scarring occurred during healing of the surgical site.
In this study, deviation occurred in 6 patients (40%) out of 15 in the closed treatment group and in 3 patients (20%) out of 15 in the ORIF group. These findings are consistent with the findings of Hidding et al. and Murakami et al.
In this study when comparing the occlusal outcomes postoperatively, no statistically significant difference was noted. This was also the result reported by Santler et al., Haug and Assael, Singh et al., and Merlet et al. On the other hand, Worsaae and Thorn. reported a complication rate of 39% in the nonsurgical group with eight patients complaining of malocclusions. In addition, Ellis et al. concluded that after 3 years, patients treated via the closed approach had a significantly greater percentage of malocclusion (22.2% to 28.6%) when compared to those treated by ORIF (0%).
Garcia-Guerrero et al. reviewed the main intra- and postoperative complications in ORIF versus conservative treatment, finding that differences in asymmetry, residual pain, TMJ and articular imbalance, and malocclusion were minimal and infrequent.
In this study, transient facial nerve palsy occurred in 15% of the surgical group and the patients made a full recovery in 6 months. We observed that transient facial nerve weakness occurred more frequently in fractures that located in a high position where the duration of the operation was long, and the procedure required extensive stretching of nerve branches when exposing the condylar region. Similar observations were made by Ellis et al. and Imai et al.
In this study, there was a very minor difference noted between postoperative ramal height shortening in open reduction and closed reduction. However, functional results can still be satisfactory as no correlation exists between the clinical and radiographic results.,
One patient who underwent open reduction developed infection 2 weeks postoperatively. Incision (on the same site of the preauricular incision of ORIF) and drainage was performed to relieve the infection. Patient was prescribed antibiotics course for 5 days. However, 3 months later, the patient underwent another operation for plate removal due to recurrent episodes of infection.
There are limitations that must be acknowledged in this study. The primary limitation is the extent to which the findings can be generalized to cases outside the study. First, the study may be compromised by the single hospital approach. The other factor which may affect the external validity of this study was the small sample size. Time and budget constraints have limited the scope of this study, yet it does present valuable insight on the effective management options for condylar fractures to be used in future researches. Future research should compare the outcomes of many more cases with long-term follow-up.
| Conclusion|| |
The present study has confirmed that both the treatment options can yield acceptable results. On clinical examination, there was no statistically significant difference in mouth opening measures, the incidence of occlusal disturbances, or in the degree of pain perception. Surgical intervention through a preauricular or retromandibular approach provides adequate functional results in facial symmetry and fair esthetics. The results of the closed treatment were satisfactory and may provide a safer option since the surgical approach involves a number of variables which may affect the outcome.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Shakya S, Zhang X, Liu L. Key points in surgical management of mandibular condylar fractures. Chin J Traumatol 2020;23:63-70.
Li H, Zhang G, Cui J. A modified preauricular approach for treating intracapsular condylar fractures to prevent facial nerve injury: The supratemporalis approach. J Oral Maxillofac Surg 2016;74:1013-22.
Abu Eldahab M, Shoushan M, Elshall M, Nowair I. Evaluation of rhombic three dimentional plate in fixation of displaced low subcondylar mandibular fractures. Egypt J Oral Maxillofac Surg 2018;9:126-34.
Ellis E, Throckmorton GS. Treatment of mandibular condylar process fractures: Biological considerations. J Oral Maxillofac Surg 2005;63:115-34.
Hackenberg B, Lee C, Caterson EJ. Management of subcondylar mandible fractures in the adult patient. J Craniofac Surg 2014;25:166-71.
House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93:146-7.
Fonseca KM, Moura˜o AM, Motta AR, Vicente LC. Scales of degree of facial paralysis: Analysis of agreement. Braz J Otorhinolaryngol 2015;81:288-93.
Choi KY, Yang JD, Chung HY, Cho BC. Current concepts in the mandibular condyle fracture management part II: Open reduction versus closed reduction. Arch Plast Surg 2012;39:301-8.
Valiati R, Ibrahim D, Abreu ME, Heitz C, de Oliveira RB, Pagnoncelli RM, et al
. The treatment of condylar fractures: To open or not to open? A critical review of this controversy. Int J Med Sci 2008;5:313-8.
Shiju M, Rastogi S, Gupta P. Fractures of the mandibular condyle – Open versus closed – A treatment dilemma. J Craniomaxillofac Surg 2015;43:448-51.
Rozeboom AV, Dubois L, Bos RR, Spijker R, de Lange J. Closed treatment of unilateral mandibular condyle fractures in adults: A sys-tematic review. Int J Oral Maxillofac Surg 2016;46:456-64.
Rozeboom A, Dubois L, Bos R, Spijker R, de Lange J. Open treatment of unilateral mandibular condyle fractures in adults: A systematic review. Int J Oral Maxillofac Surg 2017;46:1257-66.
Rozeboom AV, Klumpert LT, Koutris M, Dubois L, Speksnijder CM, Lobbezoo F, et al
. Clinical outcomes in the treatment of unilateral condylar fractures: A cross-sectional study. Int J Oral Maxillofac Surg 2018;47:1132-7.
Santler G, Kärcher H, Ruda C, Köle E. Fractures of the condylar process: Surgical versus nonsurgical treatment. J Oral Maxillofac Surg 1999;57:392-7.
Khiabani KS, Raisian S, Khanian Mehmandoost M. Comparison between two techniques for the treatment of mandibular subcondylar fractures: Closed treatment technique and transoral endoscopic-assisted open reduction. J Maxillofac Oral Surg 2015;14:363-9.
Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001;59:370-5.
Hidding J, Wolf R, Pingel D. Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J Craniomaxillofac Surg 1992;20:345-7.
Murakami K, Yamamoto K, Sugiura T, Yamanaka Y, Kirita T. Changes in mandibular movement and occlusal condition after conservative treatment for condylar fractures. J Oral Maxillofac Surg 2009;67:83-91.
Singh V, Kumar N, Bhagol A, Jajodia N. A comparative evaluation of closed and open treatment in the management of unilateral displaced mandibular subcondylar fractures: A prospective randomized study. Craniomaxillofac Trauma Reconstr 2018;11:205-10.
Merlet FL, Grimaud F, Pace R, Mercier JM, Poisson M, Pare A, et al
. Outcomes of functional treatment versus open reduction and internal fixation of condylar mandibular fracture with articular impact: A retrospective study of 83 adults. J Stomatol Oral Maxillofac Surg 2018;119:8-15.
Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: A clinical study of 52 cases. J Oral Maxillofac Surg 1994;52:353-60.
Ellis E 3rd
, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 2000;58:260-8.
García-Guerrero I, Ramírez JM, Gómez de Diego R, Martínez-González JM, Poblador MS, Lancho JL. Complications in the treatment of mandibular condylar fractures: Surgical versus conservative treatment. Ann Anat 2018;216:60-8.
Ellis E 3rd
, McFadden D, Simon P, Throckmorton G. Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2002;58:950-8.
Imai T, Fujita Y, Motoki A, Takaoka H, Kanesaki T, Ota Y, et al
. Surgical approaches for condylar fractures related to facial nerve injury: Deep versus superficial dissection. Int J Oral Maxillofac Surg 2019;48:1227-34.
Ikemura K. Treatment of condylar fractures associated with other mandibular fractures. J Oral Maxillofac Surg 1985;43:810-3.
Snyder SK, Cunningham LL Jr. The biology of open versus closed treatment of condylar fractures. Atlas Oral Maxillofac Surg Clin North Am 2017;25:35-46.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]