Functional results of unilateral mandibular condylar process fractures after open and closed treatment

BACKGROUND: This retrospective study compared the functional results of unilateral mandibular condylar process fractures treated either by open reduction or by closed treatment. METHODS: Sixty-six patients with unilateral mandibular condylar process fractures were reviewed. Thirty-six patients received open reduction, and the other 30 underwent closed treatment (intermaxillary fixation only). Each group was further divided into condylar and subcondylar subgroups according to fracture level. The functional outcome was evaluated by posttreatment occlusion status, maximal mouth opening, facial symmetry, chin deviation, and temporomandibular joint symptoms. RESULTS: Patients undergoing closed treatment exhibited more condylar motility than those treated by open reduction. Patients in the condylar subgroup with open reduction presented less chin deviation (21.43%) compared with those with closed treatment (56.25%; p = 0.072). Although a greater severity of subcondylar fractures existed in patients treated with open reduction, patients treated with open reduction or closed treatment did not reveal a significantly functional difference. CONCLUSION: The present study revealed that patients with condylar neck or head fractures gained more benefits from open reduction in terms of chin deviation and temporomandibular joint pain. For subcondylar fractures, open reduction provides satisfactory functional results in patients with severely displaced fractures.     

Manually provided temporary maxillomandibular fixation in the treatment of selected mandibular fractures.

OBJECTIVE: To report the occlusal outcomes of manually provided temporary intraoperative maxillomandibular fixation (MMMF) for the open repair of selected mandibular fractures. STUDY DESIGN/SUBJECTS AND METHODS: A retrospective chart review of the patients who underwent open reduction and internal fixation of mandibular fractures with MMMF was performed. RESULTS: Twenty-six patients underwent open reduction and internal fixation with MMMF. Postoperative data were available for only 16 patients who kept their follow-up appointments. With the exception of one patient who experienced minimal cross-bite in the right molar region, all of the patients had their original normocclusion. CONCLUSION: Preliminary results of MMMF suggest that satisfactory postoperative occlusal outcomes may be obtained without the use of wire-based maxillomandibular fixation methods in selected mandibular fractures.     

Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction

In the treatment of mandibular condyle fracture, conservative treatment using closed reduction or surgical treatment using open reduction can be used. Management of mandibular condylar fractures remains a source of ongoing controversy in oral and maxillofacial trauma. For each type of condylar fracture,the treatment method must be chosen taking into consideration the presence of teeth, fracture height, patient'sadaptation, patient's masticatory system, disturbance of occlusal function, and deviation of the mandible. In the past, closed reduction with concomitant active physical therapy conducted after intermaxillary fixation during the recovery period had been mainly used, but in recent years, open treatment of condylar fractures with rigid internal fixation has become more common. The objective of this review was to evaluate the main variables that determine the choice of an open or closed method for treatment of condylar fractures, identifying their indications, advantages, and disadvantages, and to appraise the current evidence regarding the effectiveness of interventions that are used in the management of fractures of the mandibular condyle.     

Key points in surgical management of mandibular condylar fractures

Mandibular condylar fractures are among the most common facial fractures and some of the most difficult to manage.Opinions about the management of mandibular condylar fractures differ among surgeons.With the implementation of new technology,an increased understanding of fracture man-agement,and better functional and morphological outcomes reported in the literature,open reduction and internal fixation is becoming many surgeons preferred choice for the treatment of condylar fractures.Because surgical treatment of such fractures is complex,certain factors must be considered to achieve satisfactory outcomes.In this article,we summarise six key points in the management of mandibular condylar fractures:virtual evaluation of condylar fracture,a suitable surgical approach,good reduction,stable internal fixation,repair of the articular disc,and restoration of the mandibular arch width.We believe that these points will help to improve the prognosis of mandibular condyle fractures.     

Transoral versus extraoral reduction of mandible fractures: a comparison of complication rates and other factors.

OBJECTIVE: This retrospective study evaluates results and complications of the transoral and extraoral approaches for open reduction and internal fixation of mandibular body, angle, and ramus fractures. Our aim was to describe advantages and disadvantages of the techniques and to develop criteria for choosing between surgical approaches. STUDY DESIGN AND SETTING: A retrospective chart review was performed on patients with mandible fractures occurring between August 1999 and October 2001 at a level I trauma center. Only mandibular body, angle, and ramus fractures requiring open reduction were selected for this study. Cases were evaluated for cause, age, gender, dentition, site and extent of fractures, surgical approach, postoperative complications, operative time, and postoperative occlusion. RESULTS: Of the 227 patients with mandibular fractures, 78 had body, angle, or ramus fractures requiring open reduction. Of these, 36 were treated extraorally, and 42 were treated transorally. Criteria for selecting one procedure over another often involved training and surgeon experience and those factors normally considered important in defining the difficulty of treatment and prognosis of the patient. Seven of the 42 patients were converted from a transoral to an extraoral approach because of inadequate exposure. Similar complication rates occurred for the transoral and extraoral approaches, but because of the time required for converting from the transoral to extraoral approach, the average operative time was found to be increased in patients undergoing the transoral approach. CONCLUSION AND SIGNIFICANCE: Decisions regarding treatment approaches for open reduction of mandible fractures often relate to surgeon experience and training, modified by factors that can affect uncomplicated healing such as fracture locations and displacement, comminution of the fracture, infection, dentition, and atrophic changes of the mandible. In some cases, the choice is affected by availability of equipment and experience of operating room personnel. More difficult cases involving an edentulous, atrophic mandible or comminution should be considered for extraoral exposure.     

Plate and screw fixation of selected condylar fractures of the mandible.

The majority of condylar fractures can be treated with closed reduction and intermaxillary fixation. In this study, we examine the use of open reduction with plate and screw fixation for the treatment of condylar fractures. Fourteen patients with 18 subcondylar fractures underwent open reduction and fixation using miniplates (12 patients) and lag screws (two patients). Thirteen patients and 16 condylar fractures had adequate follow-up for analysis of results. The follow-up period ranged from 7 to 46 months with a mean of 24 months. Bony union was obtained in all fractures with no permanent facial nerve injuries and good mandibular opening (average of 45 mm). We conclude that condylar fractures can be opened and fixed with plates and screws with good results without the use of intermaxillary fixation. This technique can be an effective approach for the treatment of selected condylar fractures.     

Traumatologie des Unterkiefergelenkfortsatzes

The indications for closed or open treatment of fractures of the mandibular condylar process are a controversial subject. Closed treatment is currently predominant for pediatric fractures and for adults with minimally or non-displaced fractures. In contrast closed treatment in adults with displaced and dislocated fractures will usually show less favorable results. Currently, there is an increasing agreement that the indications for open reduction are displaced fractures and particularly in cases of dislocated and bilateral fractures. Open reduction and internal fixation are aimed at restoring correct anatomy and thus physiological joint function. At present surgeons should be able to use safe operative approaches for the different fracture levels (base, neck and condylar head), which allow the application of stable osteosynthesis methods especially designed for the individual fracture patterns. The challenge is therefore to choose the optimum treatment for the individual case, i.e. an efficient quick and as least traumatic as possible recovery of function.     

Management of Mandibular Fractures in a Developing Country: A Review of 314 Cases from Two Urban Centers in Nigeria

BACKGROUND: This study was designed to establish the current demographic and treatment patterns of mandibular fractures in two urban centers (Lagos University Teaching Hospital, Lagos, and National Hospital, Abuja) in Nigeria. METHODS: All cases of mandibular fractures diagnosed and treated at the Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos (1998-2007) and Department of Oral and Maxillofacial Surgery, National Hospital, Abuja, Nigeria (2001-2007) were reviewed. Data collected included age, sex, etiology of fracture, anatomic site of fracture, associated maxillofacial fracture, types of treatment, and postoperative complications. RESULTS: The highest incidence of mandibular fractures (49.3%) occurred in the age group 21-30 years and the lowest in the age group 0-10 years, with male preponderance in nearly all age groups. Road traffic crashes (RTC) were the leading cause (67.5%), followed by assault (18.8%), and gunshot. Of the RTC cases, 85 (40%) were sustained from motorcycle-related crashes. The commonest site of fracture was the body of the mandible (n = 137), followed by the angle (n = 114). The majority (83.1%) were treated by closed reduction using intermaxillary fixation, 13.1% by open reduction and internal fixation, and 3.8% had conservative treatment. CONCLUSIONS: Mandibular fractures are commonest during the third decade of life and in men, with almost half of the cases due to of road traffic crashes. RTC was the leading cause of mandibular fractures in all age groups. Motorcycle-related mandibular fractures seem to be increasing in Nigeria. There is a need to enforce legislation designed to prevent RTC to reduce maxillofacial fractures in Nigeria.     

Rigid internal fixation of mandibular fractures using autologous bone grafts: the autologous bone plate

The mandible is the second most commonly fractured part of the maxillofacial skeleton because of its position and prominence. Over the past three decades, many different techniques and approaches have been described in the literature to surgically correct facial fractures. The present study has attempted to study the role of bone grafts in open reduction and internal fixation of mandibular fractures. Fourteen patients with mandibular fracture were considered for the study from August 2006 to August 2008. Autologous bone grafts were used for rigid fixation of these fractures in all the cases. Patients presenting with unilateral fractures of the body of the mandible were considered and enrolled for rigid internal fixation using autologous bone grafts. Fourteen patients were included in the study of which 11 were males and the rest were females. The average age at presentation was 30.4 years (18–62 years). Unicortical outer table parietal calvarial bone graft was used in all patients. The size of bone graft harvested ranged from 55 × 20 mm to 60 × 20 mm. Autologous calvarial bone graft harvested from the outer table appears to be a safe, cheaper, and effective alternative to miniplates in selected cases of mandibular fractures.     

Monocortical non-compression miniplate osteosynthesis of mandibular angle fractures

The technique of monocortical non-compression miniplate fixation of mandibular angle fractures is reviewed. A study of our first 50 patients treated using this technique reveals that consistent reduction and stabilization of these mandibular fractures can be achieved without the requirement for intermaxillary fixation. Such results were produced with minimal postoperative morbidity.     

Current concepts in the mandibular condyle fracture management part I: overview of condylar fracture

The incidence of condylar fractures is high, but the management of fractures of the mandibular condyle continues to be controversial. Historically, maxillomandibular fixation, external fixation, and surgical splints with internal fixation systems were the techniques commonly used in the treatment of the fractured mandible. Condylar fractures can be extracapsular or intracapsular, undisplaced, deviated, displaced, or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and dental occlusion, and the surgeonnds on the age of the patient, the co-existence of othefrom which it is difficult to recover aesthetically and functionally;an appropriate treatment is required to reconstruct the shape and achieve the function ofthe uninjured status. To do this, accurate diagnosis, appropriate reduction and rigid fixation, and complication prevention are required. In particular, as mandibular condyle fracture may cause long-term complications such as malocclusion, particularly open bite, reduced posterior facial height, and facial asymmetry in addition to chronic pain and mobility limitation, great caution should be taken. Accordingly, the authors review a general overview of condyle fracture.     

上下颌骨联合骨折治疗的临床观察

目的：回顾总结上下颌骨联合骨折病例,探讨合理的临床治疗方案。方法：回顾性分析2007年2月～2009年2月在陕西正和医院口腔科及西安交大口腔医院就诊的10例上下颌骨联合骨折患者,包括骨折发生时间、类型、治疗方法、随访结果等。结果：9例恢复原有咬合关系,1例轻度咬合关系不良,其中1例术后感染,积极抗感染治疗后治愈。结论：严格遵循治疗原则,正确选择治疗方案,对于上下颌骨联合骨折可以获得良好的疗效。     

Analysis of 115 mandibular angle fractures.

PURPOSE: This retrospective study reviewed cases of fractures of the mandibular angle to identify personal data, social traits, fracture characteristics, treatment modalities, and postoperative complications. PATIENTS AND METHODS: From April 1999 until July 2004, 114 patients were treated for 115 fractures of the mandibular angle by the Division of Oral and Maxillofacial Surgery at Piracicaba Dental School-Unicamp, in Brazil. RESULTS: More angle fractures were observed in Caucasian (55%) men (89%) with some kind of drug addiction (62%). Patient mean age was 27 years. The majority of fractures in this study were sustained in altercations, including gunshot wounds (43%), followed by vehicle accidents, including bicycles and being struck by a car (39%). Open fractures were the most frequent (90%), with prevalence of the left side (57%). Only 1 patient sustained bilateral angle fractures. Ninety-seven patients (85%) underwent open reduction. Complications occurred in 19 patients (17%); 10 (9%) were infections. Of the total number of complications, 3 underwent another surgical intervention for refixation. The factors that contributed to the development of postoperative complications were social risks that included alcohol abuse, smoking, and intravenous and nonintravenous drug abuse. CONCLUSIONS: Angle fracture management outcomes are affected by many factors beyond method of fixation.     

Open reduction and internal fixation of dislocated condylar fractures in children: long-term clinical and radiologic outcomes

The purpose of this study was to investigate the long-term clinical and radiologic outcomes of treating dislocated condylar fractures sustained in childhood with open reduction and internal fixation (ORIF). Six children 14 years or younger with a condylar neck or subcondylar fracture with dislocation of the condyle from the glenoid fossa were treated with ORIF. Patients were followed for 27 to 92 months post-ORIF (mean: 67.6 months) with routine clinical and radiologic examinations. On the dislocated side, all patients radiographically showed signs of remodeling of the condylar process and shortening of the ramus. Subsequent to their fractures, 3 patients were classified with Angle class II malocclusion, retrognathism, and deviation of the mandibular symphysis. Four patients had objective and/or subjective signs of temporomandibular (TMJ) dysfunction.Until open surgery demonstrates a consistent functional advantage, nonsurgical management should be considered the first treatment option for the dislocated pediatric condylar fracture.     

Nasal spine suspension for reduction and immobilization of mandibular fractures

Successful treatment of mandibular fractures involves proper fracture reduction and immobilization for an adequate length of time. A simple wire fixation technique that can be used in many situations involves suspension wiring from the base of the anterior nasal spine to a pair of circummandibular wires. The technique may be used alone or adjunctively with other methods of fixation. It offers several advantages over other methods, particularly in the treatment of pediatric mandibular fractures.     

Beware of ulnar nerve entrapment in flexion-type supracondylar humerus fractures

Purpose A recent study reported a higher incidence of pre-operative ulnar nerve symptoms in patients with flexion-type supracondylar fractures than in those with the more common extension supracondylar fractures and a greater need for open reduction (Kocher in POSNA paper #49 2006). We have encountered a specific pattern of flexion supracondylar fractures that often require open reduction with internal fixation (ORIF) due to entrapment of the ulnar nerve within the fracture. Methods Medical records and X-rays from 1997 to 2005 at our children’s hospital were examined to identify flexion supracondylar fractures that required open reduction. The operative reports were reviewed to identify cases that had the ulnar nerve blocking the reduction. Results During the 8 years examined, 1,650 supracondylar fractures had been treated by means of closed reduction and percutaneous pinning. Of these, only 1.8% or 30 cases could not be reduced closed and required open reduction internal fixation, excluding 11 open fractures. Of the 30 fractures requiring open reduction internal fixation, 24 were of the extension type needing ORIF because of interposed periosteum/muscle. The other 6 patients had flexion-type supracondylar fractures that failed closed reduction. All had a persistent medial gap at the fracture site. All 6 fractures had interposed periosteum or muscle, while in 3 cases the ulnar nerve was also entrapped within the fracture site (Figs. 1, 2) Conclusion Flexion-type supracondylar fractures remain a relatively uncommon variant (2–3%) of supracondylar fractures. Recent reports have noted that open treatment of these fractures is required more frequently than for extension fractures. In our series, 20% of the open cases were flexion-type fractures and in half of these the ulnar nerve was found to be entrapped in the fracture, preventing reduction. Study conducted at Rady Children’s Hospital and Health Center. No financial support was received for this project.     

Factors associated with conversion to open reduction of type 3 supracondylar humerus fractures in children

BackgroundThe US News and World report utilizes the number of supracondylar humerus fractures treated in an open procedure, excluding open fractures and vascular exploration, as a metric in assessing Pediatric Orthopedic trauma care. The purpose of this study was to identify factors that increase the likelihood of a patient needing open reduction for Gartland Type 3 SCH fractures.MethodsAll pediatric patients who underwent surgical management of closed, Type 3 SCH fractures at our Pediatric Level 1 Trauma Center between 2011 and 2017 were considered for inclusion. Patient age greater than 16 years, patients with closed physes and open fractures were excluded. Electronic medical records and radiographic imaging were reviewed. Student's t- and chi-squared tests were used, and logistic regression was performed comparing closed v open reduction.Results362 subjects were included in this study. 318/362 (87.8%) were treated with closed reduction. 44/362 (12.2%) required open reduction. There were no statistically significant differences in age, gender, BMI, concomitant ipsilateral extremity fractures, Type 4 unstable fracture or patients that underwent hospital transfer. The mechanisms of injury with the greatest percentage requiring open reduction were fall from furniture and trampoline. Of those patients that underwent open reduction, 65.9% had posterolateral displacement of the fracture. Those with displacement >4 mm had 3.14 higher odds of requiring an open reduction (p = 0.002). The anterior spike fracture pattern had the highest rate of failed closed reduction of 66.7%. Of those patients that had an open reduction, 13/44 (29.5%) had a neuropraxia and 5/44 (11.4%) had vascular compromise. Those with neuropraxia had 3.26 higher odds of requiring an open reduction (p = 0.005). Time to operating room was significantly shorter in patients that underwent open reduction (p < 0.001).ConclusionOur rate of open reduction for Type 3 SCH fractures, 12.2%, is consistent with previously described rates. Posterolateral displacement of fractures, displacement >4 mm, fractures with an anterior spike and fractures associated with neurovascular compromise are more likely to undergo open reduction. Transfer status, BMI and patient age were not associated with open reduction. Open reduction was associated with shorter time to the operating room, likely representing the urgent care of significantly displaced fractures associated with neurovascular compromise.Level of evidenceLevel III.     

介绍一种管状骨骨折复位维持器

目的 改进设计一种新的管状骨骨折复位维持器。方法 改进设计新型管状骨骨折复位维持器并应用到26例胫骨、股骨骨折切开复位交锁钉内固定手术中。结果 所有病例骨折均解剖复位，一次交锁成功并牢固固定。结论 该复位维持器具有设计合理、操作简单、维持复位关系牢固的特点，适宜于管状骨骨折切开复位交锁钉内固定手术。     

Open reduction and internal fixation of displaced intra-articular fractures of the calcaneus

BACKGROUND: Thirty-two displaced intra-articular fractures of the calcaneus in 30 patients were treated with open reduction and internal fixation. Fracture classification was based on Sanders computed tomographic classification. There were 18 type II fractures, 10 type III fractures, and 4 type IV fractures. METHODS: The operations were performed using a standard extended lateral approach, and the fractures were fixed with small-fragment AO T-plates without bone grafting. Average follow-up was 35.4 months (range, 24-53 months). The Creighton-Nebraska Health Foundation Assessment score for fractures of the calcaneus was used for evaluation. RESULTS: The average score was 86.7 for type II, 82.3 for type III, and 59.2 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures (p < 0.0001). CONCLUSION: On the basis of our result, we recommend that type II and type III fractures be treated with open reduction and internal fixation. Despite the results of type IV fractures being significantly worse than that of type II and type III fractures, we recommend open reduction and internal fixation for type IV fractures to restore the hindfoot architecture and the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond the surgeon's ability to reconstruct, primary subtalar arthrodesis should be performed in addition to open reduction and internal fixation.     

Open reduction and interfragment wire fixation of comminuted nasal fractures

Manual reduction is the first choice for all types of acute nasal fractures; open reduction is the choice for fractures that do not respond to manual reduction or complicated fractures at the base of the nasal pyramid. From 1968 to 1986, 564 cases of nasal fractures were treated at the Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo. Of these, 241 were acute nasal fractures, 52 of which were associated with facial bone fractures. Deviated types of fractures that cannot be correctly repositioned by manual reduction and some depressed fractures often require a surgical approach for reduction and fixation. In our series of 241 patients with acute nasal fractures, 43 (18%) were treated by open reduction and fixed with soft stainless steel wires.