Fractures of the mandibular condyle: a review of 466 cases. Literature review, reflections on treatment and proposals.

INTRODUCTION: The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) 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 the dental occlusion, and the surgeon's experience. PURPOSE: This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment. MATERIAL AND METHODS: The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted. RESULTS: Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively. CONCLUSIONS: Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with 'medical problems' where intermaxillary fixation is not recommended.     

Mini-retromandibular approach to condylar fractures

INTRODUCTION: Among maxillofacial surgeons, a general agreement exists that the therapeutic strategy for intracapsular condylar fractures is conservative, while the treatment of extracapsular fractures of the mandibular condyle is extremely controversial. The indications and choice of treatment are less than uniform, often relying on the surgeon's personal experience and beliefs. The literature increasingly suggests that the surgical management of these fractures is superior to conservative management in functional terms. Nonetheless, the indications for surgically treating condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but is demanding technically, especially for higher neck fractures. In our experience, a 2-cm-long retromandibular access allows straightforward management of condylar fractures, providing as a result a well concealed scar. MATERIALS AND METHODS: From 2006 to 2007, 21 patients with 25 condylar fractures were treated surgically using the mini-retromandibular access. The mean operating time was 32min (range 17-55min). No facial nerve injuries were observed. The first two patients developed postoperative infections. One patient, in whom the first intervention resulted in malreduction of the fracture because the access was insufficient (15mm incision), required a second operation to achieve correct reduction and rigid fixation of the condyle. RESULTS: In all cases, good anatomical stump reduction was achieved. All the patients obtained good articular function, since the access was exclusively extra-articular. CONCLUSIONS: Condylar fracture reduction, fixation and healing can be managed comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are viewed directly.     

全景片诊断髁突骨折的应用价值

目的:评价全景片对髁突骨折的诊断价值,探讨全景片易出现漏诊的髁突骨折的特点.方法:对163例220侧由CT确诊为髁突骨折病例的全景片进行读片,根据CT进行分类,统计各类髁突骨折全景片的检查结果.按骨折类型是否为囊内骨折进行分组,比较两组资料在全景片上的检出率,应用SAS6.12软件包进行统计学分析.结果:囊内骨折、髁颈骨折和髁突下骨折分别为155侧、45侧和20侧,全景片未检出及检出髁突骨折分别为38侧和182侧,囊内骨折中有33侧全景片未检出骨折,122侧检出骨折但均无法定位骨折位置.囊内骨折组检出率显著低于髁颈骨折及髁突下骨折组(P=0.0149).结论:全景片可初步诊断髁突骨折,但对于囊内骨折,特别是细微骨折及无移位的骨折漏诊率较高.对于骨折线的定位、骨折块内外向移位角度的确定,全景片作用有限.     

Early complete bone union after condylar fracture in a child

A 3-year-old boy had unilateral intracapsular condylar fracture due to a fall. Short duration of immobilization using a facial band was performed for 5 days without any surgical intervention. The patient had full recovery in mouth opening with no deviation or asymmetry of the mandible. Posttraumatic 6 weeks later, the patient's computed tomogram revealed complete reduction of fracture, and bone union had occurred. In condylar fractures of children, treatment protocols with short duration of immobilization and early active exercise can obtain complete bone union, contrary to the previously described deformity or remodeling process.     

Retrieval of the displaced condylar fragment with a screw: simple method of reduction and stabilisation of high and intracapsular condylar fractures

We acknowledge the difficulties that arise when attempting to reduce and stabilise some condylar fractures, particularly those that are high or intracapsular. This paper highlights retrieval of the proximal fragment with a screw, and its benefit for reduction and stabilisation of the fractured condylar head before fixation. Eight patients with condylar fractures were treated at two centres, Morriston Hospital, Swansea, South Wales, and the General Hospital St. Jan, Brugge, Belgium between 1998 and 2007. The proximal fragment was retrieved by insertion of a screw in all cases. Three patients had unilateral, and five had bilateral high or intracapsular fractures. In all cases postoperative scans showed excellent anatomical repositioning and fixation of the condylar fragments. Postoperative follow-up showed good, stable occlusion, excellent mouth opening, and no facial nerve weakness even for a temporary period. Once the screw is in position the operator can gain precise control of the reduction, and the ease of manipulation reduces operating time considerably. The technique provides an excellent solution to the difficult task of reduction and stabilisation of the displaced fragment in condylar fractures, particularly in high fractures, and can be extended to other areas of maxillofacial trauma and corrective bone surgery.     

TMJ Remodeling after Condylar Fracture and Functional Jaw Orthopedics A Case Report

BACKGROUND: Condylar fractures in childhood are generally treated in a conservative-functional manner. As a rule, very good healing results are achieved by functional orthodontic treatment alone or, after immobilization, by splinting. HISTORY AND TREATMENT: Here we report on a patient who suffered a deep condylar dislocation fracture as a result of trauma at the age of 5. After initial immobilization with Schuchardt splints she underwent functional jaw orthopedics with activators. Subsequent orthodontic treatment with removable and fixed appliances enabled her to be followed up form functional and radiographic aspects over a period of 13 years. The remodeling process of the condylar head and neck could be clearly seen in the panoramic control radiographs. RESULT: Although the traumatized right TMJ was completely pain-free and fully functional after only a short time, the remodeling of the head and neck of the originally traumatized TMJ took 13 years to correspond fully to the healthy TMJ on the opposing side.     

克氏针内固定治疗髁状突颈部骨折的临床应用

目的：评价克氏针内固定治疗髁状突颈部骨折的临床疗效。方法：采用克氏针内固定治疗髁状突颈部骨折9例，通过摄全景片及关节片，观察髁状突复位情况、咬He关系恨不得情况，下颌运动度及术后随访等综合评价疗效。结果：全部病例均痊愈出院，开口度均在30mm以上，咬He关系恢复良好。本组9例经6个月-3年随访观察，张口度达30mm-37mm，平均约35mm。髁状突复位准确，下颌运动自如，手术效果稳定，令人满意。结论：克氏针内固定是治疗髁状突颈部骨折的一种比较可靠有效的方法。     

34例髁突骨折伴发外耳道骨折临床分析

目的: 探讨髁突骨折与外耳道骨折的关系及同期手术的必要性。方法: 230例320侧髁突骨折根据骨折线位置不同分为矢状（Ⅰ型）、头部 （Ⅱ型）、颈部 （Ⅲ型）、髁突下（Ⅳ型）4种类型, 随访髁突与外耳道骨折同期手术与否的预后差异。采用SPSS 20.0软件包中的χ²检验,比较不同类别髁突骨折伴同侧外耳道骨折之间的差异。结果: 230例320侧髁突骨折伴外耳道骨折34例46侧,Ⅰ~Ⅳ型分别为12侧、16侧、7侧、5侧,另有6侧外耳道骨折无髁突骨折。Ⅲ型髁突骨折伴同侧外耳道骨折发生率显著低于另外3型（P<0.05）;Ⅰ型髁突骨折伴外耳道骨折的发生率显著高于Ⅳ型（P<0.05）,其他各型之间两两比较无显著差异。22例30侧随访至受伤后6个月,5例8侧在排除外耳道脑脊液漏的情况下,同期行髁突及外耳道骨折治疗,术后6个月外耳道无狭窄,听力无下降;另17例22侧均出现不同程度的外耳道狭窄,其中4例5侧出现严重听力障碍（均为外耳道粉碎性骨折）。结论: 髁突颈部骨折伴外耳道骨折的概率较低,而髁突矢状骨折较基底部骨折更易导致外耳道骨折。治疗颌面部骨折,应早期发现、治疗外耳道骨折,积极预防外耳道狭窄、听力下降等并发症。     

A follow-up study of condyle fracture in children

This paper reports a long-term clinical and radiological evaluation of conservatively treated condylar fractures in children. The long-term effects of treating condylar fractures in children with non-surgical therapy were examined in order to resolve the controversial question ‘Does complete remodeling occurs at this age or, if not, is it more likely to be associated with certain types of fractures or other factors?’This study was based on a series of 11 consecutive children and adolescents, aged between 3 and 15 years, with fractures of the condylar process who had been treated with conservative therapy.All patients underwent a clinical investigation with a special emphasis on the temporomandibular joint function and facial asymmetry. The patients also underwent a radiological investigation, focusing on the fracture remodeling and symmetry of the mandible, which consisted of a panoramic radiograph, PA and a lateral cephalogram and 3-D CT.No patient complained of an impaired temporomandibular joint (TMJ) function or pain on the affected side. Two out of eight (25%) unilateral and one bilateral fracture show a slight facial asymmetry. Despite the apparent excellent recovery of function, there were marked remodeling changes evident on the CT scan. Such changes are not usually evident on a panoramic radiograph. The radiological investigation showed an incomplete remodeling (six patients, 54.5%) and an asymmetry of the mandible (three patients, 27.3%) in some patients.Non-surgical treatment of condylar fractures in children results in the satisfactory long-term outcome of the jaw function despite the relative high frequency of radiologically noted aberrations.     

Conservative treatment of unilateral condylar fractures in children: a long-term clinical and radiologic follow-up of 55 patients

The purpose of this prospectively designed study was the long-term clinical and radiological evaluation of conservatively treated unilateral condylar fractures in children. Fifty-five children aged between 2 1/2 and 9 3/4 years, presenting with a singular unilateral fracture of the mandibular condyle, were treated in a nonsurgical-functional way using an intraoral myofunctional appliance. In the follow-up period, patients were investigated by standardized clinical examination and by evaluation of panoramic radiographs taken immediately post-traumatically, after 6, 12, 24, 48 and 72 weeks, and then yearly through the period of growth. With a satisfactory clinical course in all patients, there was no instance of functional disturbance or mandibular asymmetry after the respective follow-up periods. The radiographs showed a fairly good shape of the condyle (no or only slight condylar deformity) in the 47 patients of the 2-6 year age group. In the eight patients of the 7-10 year age group presenting with a class II or III condylar fracture, healing was characterized by incomplete condylar regeneration, resulting in a moderate condylar deformity in two cases, a definite reduction in condylar neck height in two cases, and a hypertrophic condylar deformity in four cases. The positive results of this study confirm the concept of a nonsurgical-functional approach in children presenting with various types of unilateral fractures of the mandibular condyle. Condylar remodeling was the mode of fracture healing in instances of displaced and dislocated condylar fractures.     

颌间牵引钉在髁突囊内骨折保守治疗中的应用

目的:评价颌间牵引钉在治疗髁突囊内骨折中的应用价值。方法:以颌间牵引钉颌间牵引固定,治疗18例髁突囊内骨折患者。结果:18例患者均恢复良好的外形和功能,骨质愈合好,效果满意。结论:颌间牵引钉治疗髁突囊内骨折为一种安全有效、简便易行的治疗手段。     

Mini-retromandibular access to the condyle in panfacial fractures

ABSTRACT: Surgical management of panfacial fractures can be extremely challenging. The many fracture lines and lack of landmarks make it difficult to restore the facial skeletal morphology. Extracapsular fractures of the mandibular condyle require open reduction and internal fixation to restore the vertical and sagittal dimensions of the mandible, representing the base for further facial skeleton reconstruction. Six patients with panfacial fractures, including a bilateral extracapsular condylar fracture, were treated between January 2006 and November 2009. One patient underwent surgical procedure 60 days after the injury. The condylar fractures were treated via a mini-retromandibular access. Overall, the bone morphology restoration was good. In particular, all of the condylar fractures were reduced satisfactorily. No complication was detected, and no facial nerve lesion was observed. The literature contains many proposals for surgically accessing panfacial fractures. Open reduction and internal fixation of condylar fractures are crucial for restoring face height. The mini-retromandibular access is especially suitable, because it allows safe, rapid surgical management.     

髁状突游离再植治疗颞下颌关节髁突颈部骨折的临床研究

目的:探讨髁状突游离再植重建颞下颌关节治疗髁突颈部骨折的方法与疗效.方法:15例17侧髁突颈部骨折患者行髁状突游离再植鈦板复位固定的治疗,术后定期复查患者颞下颌关节功能和X线片检查.结果:患者术区伤口均一期愈合,追踪1～5年颞下颌关节无疼痛、弹响及明显功能障碍,2例面神经颞支有影响,1例轻度错牙合畸形. 结论:本法操作简单易行、复位准确、固定可靠,并发症少,适用于移位的髁突颈部骨折.     

下凳骨髁突骨折轴向拉力螺钉复位固定的应用研究

目的 评估髁突骨折轴向拉力钉复位技术的临床可行性及治疗效果。方法 ６例成人颞下凳关节囊外移位性髁突骨折患者接受了轴向拉力螺钉外科复位手术,其中男性５例,女性１例,平均年龄３２岁,术后追踪平均７个月（３～１３个月）。结果 ６例伤口均Ⅰ期愈合,术后３个月,临床检查无关节区疼痛不适及面部不对称,咬合关系良好,最大开口度除１例外均大于４０ｍｍ,全部患者对手术效果满意。结论 轴向拉力螺钉复位固定技术对于固定     

Open reduction of condylar neck fractures with exposure of the facial nerve.

OBJECTIVE: The purpose of this study was to evaluate the clinical and radiologic results in patients whose condylar neck fractures were reduced and stabilized through use of a standard preauricular approach involving systematic exposure of the facial nerve. STUDY DESIGN: We performed open reductions of high condylar neck fractures with exposure of the facial nerve in a prospective series of 34 patients. In this article, we describe clinical and radiologic results in 25 patients with follow-up longer than 6 months. RESULTS: Immediate postoperative radiographs showed excellent reduction of the fractures in 24 patients. The postoperative course was uneventful in most patients. The incidence of complications was low; there were 5 patients with temporary facial nerve palsies, 3 patients with plate fractures or screw loosenings, 5 patients with transitory auricular hypoesthesia, 1 patient with inadequate reduction, and 1 patient with limited mouth opening. CONCLUSIONS: The results of this study showed that accurate reduction and rigid fixation of high condylar neck fractures were possible through use of an approach in which the facial nerve was exposed.     

下颌下小切口入路行髁突颈部骨折复位固定术的疗效观察

目的：观察下颌下小切口入路用于髁突颈部骨折复位固定的疗效。方法：纳入研究病例26例,术前确诊为髁突颈部骨折并且具备手术适应证。于下颌角位置做小切口,分离并保护面神经下颌缘支,于该神经上横断咬肌后1/3,骨折断端暴露后,解剖复位并钛板固定。结果：26例患者均恢复正常咬合关系,开口度和开口型均正常,面部对称,无面神经损伤。结论：下颌下小切口入路利用面神经下颌缘支和下颊支之间的解剖间隙,在髁突颈部骨折治疗中效果良好。     

Usefulness of the retromandibular transparotid approach for condylar neck and condylar base fractures

Condyle fractures represent 20% to 30% of all mandibular fractures and are thus among the most common facial fractures. The fracture pattern can vary greatly and may occur anywhere along the line from the sigmoid notch to the mandibular angle. The main problems are access, difficulty in repositioning the extremely slender fragments, and fixation of the condyle.Eighty-seven patients were diagnosed with condylar neck or condylar base fractures from January 2007 to December 2009 in the Department of Oral & Maxillofacial Surgery of Kyung Hee University Dental Hospital. In this study, we included 35 patients who underwent open surgery and a total of 28 patients who were treated using a retromandibular transparotid approach.Surgical treatment aims were anatomic repositioning and rigid fixation of the fragments, occlusal stability, rapidly return to function, maintenance of vertical ramus dimension, no airway compromise, and reduced long-term temporomandibular joint dysfunction. Considering the high rate of occurrence of condylar fracture and the importance of the condylar as a growth center of the mandible, extraoral approaches for the open reduction of condylar fractures are considered effective and can be used widely.Short access route, easy reduction, short operating time, and stable postoperative occlusion are the advantages of the retromandibular transparotid approach. Also, there was no permanent damage from facial nerve injury, salivary leakage, or preauricular hypoesthesia. Therefore, the retromandibular transparotid approach is considered a safe and effective method for patients with a condylar neck or condylar base fracture classified according to the Strasbourg Osteosynthesis Research Group's classification, who require surgical treatment with an extraoral approach.     

髁突摘除术治疗粉碎性髁突骨折疗效分析

目的:探讨髁突颈部以上粉碎性骨折行髁突摘除术的可行性及适应证.方法:回顾我院2007年9月-2011年9月间因外伤导致髁突骨折患者61例,其中完全行手术内固定治疗30例,保守治疗15例,髁突颈部以上粉碎性骨折患者16例(18侧)予以髁突摘除术,术后随访5～48个月,观察疗效.结果:16例(18侧)患者中,止血纱布排异反应导致创口愈合不良1例,咬合偏斜1例,开口轻度受限1例,前牙开(牙合)1例,其余患者无明显咬合不适,牙尖窝关系良好,面容基本对称.结论:对于颌面部发育基本完成的患者,其髁突颈部以上粉碎性骨折采取髁突摘除术是可行的治疗方法,术后可能出现咬合偏斜、前牙开(牙合)及开口受限,进一步治疗后可恢复正常.     

髁突骨折手术治疗的临床研究

目的：探讨手术治疗髁突骨折的适应证、技术要点和并发症的发生因素。方法：回顾分析5年来采用手术治疗的116例髁突骨折病例的临床资料,分别采取切开复位内固定术和髁突摘除术,随访3个月至3年,复查内容包括患者咬合关系、开口度、开口型、神经损伤、颞下颌关节症状、面型和X线检查。结果：外形和功能均显著恢复,113例咬合关系恢复正常,占97.4%;115例张口度恢复正常,占99.1%;X线复查髁突骨折解剖复位率94.8%;15例儿童患者恢复良好,无下颌骨发育障碍等严重并发症发生。结论：坚强内固定技术是治疗髁突骨折的较好方法,严重移位或脱位的儿童髁颈和髁颈下骨折应采用可吸收接骨板进行内固定。     

The effect on facial growth of pediatric mandibular fractures

The incidence of facial fractures in the pediatric population is between 1.4% and 15% of all maxillofacial traumas. Forty-one percent of pediatric facial fractures involve the mandible. No study has commented on the incidence of mandibular fractures that go on to develop growth disturbances leading to asymmetry and malocclusion. A retrospective chart review was carried out that identified and followed 88 children who sustained mandibular fractures and presented to The Hospital for Sick Children in Toronto during the 13-year period from 1980 to 1993. Patient follow-up ranged from 2 to 15 years, and was performed via phone survey and medical/orthodontic chart review. Patients who required orthodontics and orthognathic surgery were identified. Results indicated that a pediatric mandibular fracture does not lead to a higher incidence of orthodontic intervention. Furthermore, children younger than 4 years or older than 12 years rarely require orthognathic surgery to correct facial growth disturbances following mandibular fractures. In contrast, 22% of children age 4 to 7 years, and 17% of children age 8 to 11 years required orthognathic surgery to correct facial growth disturbances following mandibular fractures. Condylar fractures were the most common site of mandibular fracture, and led to facial asymmetry most frequently.