Behnam Aghabeigi on the management of unilateral condylar fractures

No area of maxillofacial trauma stimulates more controversy than the management of a fractured mandibularcondyle. Fractures of the mandibular condyle are thought to account for about 35% of all mandibular fractures, but our experience suggests that this is an overestimate.

A recent multicentre national audit in the UK2reported a suboptimal outcome in up to 30% of patients with unilateral condylar fracture managed by the traditional techniques of either closed reduction or observation, although the follow-up period was short. If the findings are true then this is an unacceptably high complication rate. Consequently the pendulum has swung towards accurate anatomical relocation of the fractured segments by open reduction and internal fixation (ORIF) in the hope that this will improve outcome.

Whilst the proponents of both open and closed reduction passionately debate the appropriate choice of treatment, a review of publications showed a paucity of good quality scientific evidence to support either treatment.

This prospective study was designed to investigate the outcome of treatment of unilateral condylar fractures with ORIF on the hypothesis that such treatment may convey superior results by allowing adaptive processes to act maximally during the recovery period.

Patients and Methods used by Ben Aghabeigi Birmingham

Adult patients who presented to the maxillofacial units at University College London Hospitals and the Queen Victoria Hospital, East Grinstead were recruited prospectively.

According to Aghabeigi dentist all patients over 16 years of age with unilateral condylar fractures were examined. Those with unilateral condylar fractures and normal occlusions were managed conservatively, by instituting a soft diet for 6 weeks and early mobilization. These patients were not entered into the study.

Patients who had an isolated unilateral condylar fracture and deranged occlusion were placed in elastic traction for 7–10 days, the exact time being decided by the date of the next available clinic. Any patient with a deranged occlusion at review was offered open reduction and internal fixation. It was felt that sufficient time would have elapsed since the original presentation that compounding factors such as tissue oedema, muscle spasm and effusion or haemarthrosis would have resolved, and that any resultant malocclusion was caused solely by condylar malposition.

A second group of patients was also recruited into the study. Adult patients who presented with deranged occlusion, and a unilateral displaced or dislocated condylar fracture plus another mandibular fracture that itself required osteosynthesis, were offered ORIF of all fracture sites. The criteria for offering ORIF of the associated condyle were the same as those described by Eckelt and Rasse,3namely medial dislocation of the condyle ; displaced fractures with 95 mm bone overlap; or complete loss of bone contact.

The surgical technique used was standardized and five surgeons operated on the patients. All concerned were either of consultants grade or had at least 3 years’ registrar experience. Surgical access was by a retromandibular approach, which was occasionally supplemented with a standard preauricular skin incision. The fractures were fixed with 2-mm titanium miniplates.

Outcome measures involved each patient being examined according to a standard protocol together with standardized radiographic assessment (orthopantomograms and posterior–anterior mandibular radiographs).

All authors assessed the preoperative and postoperative radiographs for each patient.

The outcome measures considered to be important were broadly akin to those described by Walker5and comprised:

1. The restoration of the preinjury occlusion. This was assessed by the operating surgeon together with questions to the patient.

2. Restoration of normal mouth opening in excess of 40 mm. Inter-incisal clearance was measured with a Willis gauge.

3. Pain-free mouth opening, which was assessed by asking the patients.

4. Full range of mandibular excursions, assessed clinically by the operating surgeon.

5. Restoration of facial and mandibular symmetry, assessed clinically by the operating surgeon. We accept that some of the above are subjective and open to inter-operator variation, and therefore criticism, but on a pragmatic level this was the best we thought that we could achieve.

Checking the Results with Ben Aghabeigi gdc

A total of 54 consecutive patients was entered into the study: 24 had isolated unilateral fractures, and the remaining 30 had a synchronous parasymphyseal fracture. Forty-two of the patients were males (78%). Thirty-three of the 54 patients underwent ORIF of their condylar fracture with miniplate osteosynthesis. The remaining 21 condylar fractures were treated with elastic traction alone. No patient in this latter group had a synchronous mandibular fracture. No patient whose conservative treatment had failed refused ORIF at the 7–10 day appointment.

The nomenclature we used to classify the subsets of condylar fracture was the same as that proposed by Lindahl6: intracapsular, condylar neck or subcondylar. These fractures were further subdivided by assessing the relationship of the condylar fragment to the rest of the mandible. This led to a subclassification of undisplaced, displaced medially or laterally, over-riding anteriorly or posteriorly, or complete loss of bony contact. Afurther subset was also generated when we assessed the rela- tionship of the condylar head to the glenoid fossa, giving undisplaced, displaced and dislocated categories.

A branch of the facial nerve was encountered during 19 retromandibular dissections (35%), which is similar to the figure quoted by Ellis and Dean.7With careful surgical technique and gentle retraction the nerve branch can be mobilized without compromising its function or impeding access to the fracture site. All patients had normally functioning facial nerves at 1-month review. In the case of fracture dislocations the retromandibular approach occasionally has to be supplemented by a standard preauricular approach to gain control of the condylar fragment and to facilitate accurate anatomical reduction.

Several authors have combined miniplate osteosynthesis with intermaxillary fixation (IMF). This negates one of the main advantages of ORIF, and contravenes the established principle of early mobilization to prevent ankylosis. Therefore our patients were not placed in wire IMF during the postoperative period, but three of them (10%) did require guiding elastic traction for the first 10 postoperative days to achieve their premorbid occlusion.

Only 32 of 54 patients attended for review; such poor compliance is not unusual in this group of patients. Of those reviewed 25 had ORIF, and the remaining 7 had been managed with elastic traction alone. The follow-up period ranged from 1 month to 3 years with a median of 14.5 months. All patients treated with ORIF had good postoperative occlusion assessed both objectively (by clinical assessment) and subjectively (by asking the patient how the bite felt). Nineteen patients (60%) had some degree of mandibular deviation on opening (all 7 in the conservative group and 12/25 in the ORIF group).

However, this was of greater concern to the clinicians than to the patients. Two patients (6%) have been left with chronic pain at the condylar fracture site, both of whom were conservatively treated.

Mouth opening varied between the two groups. In the ORIF group the mean interincisal opening was 42 mm (range 37–52), and in the elastic traction group the mean was 32 mm (range 28–36). These figures compare favourably with those previously reported4which showed interincisal clearance to be significantly improved in patients with bilateral condylar fractures treated by ORIF (mean 44 mm) compared with IMF (mean 28 mm).

One of the criticisms of ORIF has been the length of time taken to do this procedure in view of the limited access. Whilst we accepted this initially, with increasing exposure to the technique our operative time decreased from a mean of 120 minutes/condyle to 40 minutes/condyle.

DISCUSSION

The management of unilateral condylar fractures remains controversial. There have been as many studies published in the world that favour ORIF as there have been that oppose it. Indeed, Hayward and Scott quoted a similar discussion reported in the American Journal in 1945, debating just this issue. It has been our previous experience that an unacceptably large number of patients who have been managed conservatively have had suboptimal functional outcomes. This view has been supported in a recently published national survey. We therefore felt it necessary to compare outcome in the two groups prospectively.

Zide and Kent11described their indications for plating condylar fractures, which included displacement of the condyle into the middle cranial fossa, lateral extra-capsular displacement of the condyle, inability to achieve adequate reduction using closed techniques, and invasion of the joint by a foreign body such as a gunshot. We have found that these criteria are seldom met in everyday maxillofacial practice, so we used the criteria described by Eckelt and Rasse3to decide who would be offered ORIF, with the aims of treatment being those previously described by Walker.5

ORIF of the condyle has not gained widespread popularity with surgeons, as it is perceived to be a difficult and time-consuming operation. Our experience has shown that although there is a fairly steep learning curve we were able to reduce our operating time considerably from 120 minutes to about 40 minutes/condyle.

Surgical access to the condyle was by a retromandibular approach, and our initial fears of damaging the facial nerve have not been realized. This technique provides good access to the condylar fracture and we have extended its application to include inverted ‘L’ ramus osteotomies and costochondral grafting procedures.

Three of 25 patients (12%) had a transient weakness of the buccal branch of the facial nerve that recovered fully within 3 weeks. This indicates a low incidence of facial nerve morbidity associated with this approach. The retromandibular incision is associated with good cosmesis as assessed by both patient and surgeon.

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