CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART ONE

J Oral Maxillofac Surg 61:1324-1332, 2003

Open Versus Closed Reduction of Adult Mandibular Condyle Fractures: A Review of the Literature Regarding the Evolution of Current Thoughts on Management
M. Todd Brandt, DDS,* and Richard H. Haug, DDS
For decades, conventional wisdom has suggested that closed reduction of mandibular condyle fractures has been the preferred approach to treatment. This widely held belief has been fostered by such statements as complications arising from fractures of the mandibular condyle are conspicuous by their absence.1 While cutting edge research at the time, a review of the literature from which this conventional wisdom was based reveals completely different interpretations when scrutinized by todays standards. MacLennan, in 1952, arrived at the aforementioned conclusion regarding the absence of complications when reviewing 180 cases of typical fractures of the mandibular condylar process.1 This retrospective review actually retrieved information from only 120 patients53 by questionnaire and 67 who underwent physical examination. Data accumulated by questionnaire are subject to multiple and imprecise interpretations and thus must be held in question. Seventy-nine percent of these patients were managed by closed reduction and maxillomandibular xation (CRMMF) for 0 to 14 days, and the remainder by observation, bandage, wiring, cast cap splints, and direct wire. From the 120 patients, the author identied the following complications: 2 patients with pain, 29 with deviation, 7 with visual deformity, and 73 with radiographic deformity, for complication rates of 2%, 24%, 6%, and 61%, respectively, and because specic patients were not identied, any combination or permutation of these rates could have been possible.
Received from the Division of Oral and Maxillofacial Surgery, University of Kentucky, College of Dentistry, Lexington, KY. *Resident. Professor and Associate Dean. Address correspondence and reprint requests to Dr Haug: Division of Oral and Maxillofacial Surgery, University of Kentucky, College of Dentistry, 800 Rose St, Lexington, KY 40536-0297.
2003 American Association of Oral and Maxillofacial Surgeons

Blevins and Gores2 obtained similar results in a review of conservative treatment in 140 patients with fractures of the mandibular condyloid process. Among the 140 patients, 127 were treated by CRMMF and 13 were managed by observation. Ninety patients answered a postoperative questionnaire. The authors concluded that 12 patients (13%) had good to excellent results, yet 20 (22%) had minor problems, 32 (36%) had some problems, and 45 (50%) could open to only 28 mm. Again, because individual patients were not identied, many combinations or permutations of these rates of complications are feasible. In 1994, Silvennoinen et al3 evaluated 92 adult dentate patients with mandibular condyle fractures treated conservatively. In this group, 42 (46%) were treated without maxillomandibular xation, and 50 (54%) by CRMMF. The mean follow-up was 2 months (range, 1 to 15 months). Reduced ramus height resulting in malocclusion was noted in 12 (13%) patients and persistent mandibular deviation in 4 (4.4%) additional patients, resulting in an overall complication rate of 17.4%. Among the investigations with more favorable results was presented as the 1947 Chalmer Lyons lecture.4 One percent of the patients were treated with open reduction, 11% with a soft diet, and 88% by CRMMF. Of 120 patients with mandibular condyle fractures, 60 were contacted by questionnaire and 60 were examined. The authors concluded that 7 patients (5.8%) had functional disturbances. From this critical review of the most frequently quoted literature regarding CRMMF, complications arising from the management of mandibular condyle fractures by CRMMF are actually conspicuous by their presence, and not absence.

Classication of Mandibular Condyle Fractures

It is important when considering a particular intervention or management strategy that similar problems

0278-2391/03/6111-0015$30.00/0 doi:10.1016/S0278-2391(03)00735-3

1324

BRANDT AND HAUG

1325

are being addressed under similar circumstances. This suggests that a uniform classication scheme or system of terminology and similar indications for therapy should exist. Unfortunately, when dealing with mandibular condyle injuries, a multitude of classication schemes and considerations for indications exist. Until a widely accepted classication system exists, it will remain difcult to make consistent decisions regarding management of condylar fractures. The rst system attempting to categorize mandibular condyle injury was created without the aid of radiography. The initial categorization systems were largely anatomically or vector based noting a particular region involved and/or the direction and magnitude of displacement. As an example, in 1915, Brophy classied fractures of the condyloid process by the location and direction of the fracture. These were through the neck; from above and without; downward and inward; or reversed; from above and in front; backward and downward.5 Thoma6 categorized mandible condyle fractures by the degree of displacement as well as dislocation. He considered 4 typesa fracture with displacement, a fracture without displacement, a fracture-dislocation, and fracturedislocation with complete displacement of the condyle. The MacLennan classication system considered deviation, displacement, and dislocation as key issues.1 It considered condyle fractures to be high or low, with deviation and displacement; dislocation; no displacement, or avulsion. In 1955, Rowe and Killey7 devised a classication system based on the relationship to the temporomandibular joint capsule and concomitant injury. Their categories were intracapsular fractures, extracapsular fractures; fractures associated with injury to the capsule, ligaments, and meniscus, and fractures involving the adjacent bone. Intracapsular fractures included those that involved the articular surface, or those that occurred above or through the condylar neck. Extracapsular fractures were those that run from the lowest point of the sigmoid notch downwards and backwards below the surgical neck of the condyle to the posterior aspect of the upper part of the ramus. Dingman and Natvig,8 in 1964, classied fractures of the condylar process as high, middle, and low. High fractures occurred at or above the level of the lateral pterygoid muscle; middle, below this attachment; and low, at the base of the condylar process. Unfortunately, these systems were rather simplistic and did not help to direct management alternatives beyond CRMMF. As radiographic techniques improved, so did the classication systems. The Lindahl Classication system (Table 1) was based on a very well-conceived and well-designed prospective investigation of 123 patients with 138 mandibular condyle fractures.9 The system considered the level of frac-

Table 1. THE LINDAHL CLASSIFICATION SYSTEM FOR MANDIBULAR CONDYLE FRACTURES

Fracture level Condylar head at or above the ligamentous attachment Horizontal may be difcult to differentiate between condylar neck Vertical Compression Condylar neck thin, constricted region below head of condyle Subcondylar from the sigmoid notch to the posterior mandible just below the neck of the condyle Dislocation at fracture level of condylar neck, subcondylar Angulation with medial override Angulation with lateral override Angulation without override Fissure Position of condylar head to articular fossa No displacement Slight displacement Moderate displacement Dislocation
Data from Lindahl.9

ture, dislocation at the point of fracture, and relationship of the condylar head to the articular fossa. Although an excellent system to identify the various clinical and radiographic patterns, it was rather complex. The most useful component of the system was the delineation of the levels of fracture as condylar head, condylar neck, and subcondylar. A subcondylar fracture is one from the sigmoid notch to the region of the posterior mandible just below the neck of the condyle. A condylar neck fracture is through that thin, constricted region just below the head of the condyle. A condylar head fracture occurs at or above the ligamentous attachment, whether single fragment (horizontal), comminuted (compression), or medial pole (vertical).9,10 Krenkel,11 in a similar system, expanded condylar neck fractures into low, medium, and high. Krenkels intracapsular fracture was Lindahls condylar head fracture; Krenkels high condylar neck fracture, Lindahls condylar neck fracture; Krenkels medium condylar neck fracture, Lindahls subcondylar fracture; and Krenkels low condylar neck fracture, actually an ascending ramus fracture. From the standpoint of the surgeon considering the open maxillomandibular xation (ORIF) of condylar fractures, Lindahls is the most germane system of nomenclature (Table 1).

Indications for Management

The indications for the management of mandibular condyle fractures have been variable and inconsistent throughout the literature.1,5-23 Many authors have

1326

OPEN VS CLOSED REDUCTION OF CONDYLES

Table 2. ZIDE AND KENTS 1983 INDICATIONS FOR OPEN REDUCTION

Table 3. ZIDES 1989 INDICATIONS FOR OPEN REDUCTION

Absolute Displacement into middle cranial fossa Impossibility of obtaining adequate occlusion by closed reduction Lateral extracapsular displacement Invasion by foreign body Relative Bilateral condylar fractures in an edentulous patient without a splint Unilateral or bilateral condylar fractures where splinting cannot be accomplished for medical reasons or because physiotherapy is impossible Bilateral condylar fractures with comminuted midfacial fractures, prognathia or retrognathia Periodontal problems Loss of teeth Unilateral condylar fracture with unstable base
Data from Zide and Kent.14

Absolute Fracture into middle cranial fossa Foreign body in the joint capsule Lateral extracapsular deviation Inability to open mouth or achieve occlusion after one week Open fracture with potential for brosis Possible indications Bilateral or unilateral condylar fractures with a crushed midface Comminuted symphysis and condyle fracture with tooth loss Displaced fracture resulting in open bite or retrusion in mentally retarded or medically compromised adults Displaced condyle with edentulous or partially edentulous mandible with posterior bite collapse
Data from Zide.15

based their indications solely on anecdotal evidence. In 1975, Archers indications for the management of mandibular condyle fractures were unconditional. He stated, there is no indication for the open reduction of subcondylar fractures. . .meddlesome surgery in the form of open reduction frequently results in trismus or ankylosis, or sterile or suppurative resorption of the condyle.12 The current literature does not support his statements. Coupling Lindahls nomenclature with clinical indications, Walker and Kerr,13 in The Consultant series in the Journal of Oral Surgery, created a management scheme that included both conservative and surgical management. In this regimen, patients with an acceptable occlusion and minimal pain required no xation but rather active physiotherapy. Those with a poor occlusion received a CRMMF for 10 to 14 days, night elastics for 7 to 10 days more, and, if continued deviation occurred, occasionally 4 to 6 weeks more of night elastics. For concomitant, multiple or comminuted facial fractures other than the condyle, CRMMF for 6 weeks followed by physical therapy was indicated. Open reduction was reserved for only those patients with a dislocated condylar fracture concurrent with multiple and comminuted facial fractures. Zide and Kents14 report regarding the indications for open reduction of mandibular condyle fractures has been the gold standard for the past decade and a half (Table 2). Yet, as meaningful as it was during the early 1980s, indications for care were based on the materials and surgical techniques available at that time. With the initial application of rigid internal xation techniques to the craniomaxillofacial skeleton in the mid-1980s, new indications and contraindications have slowly evolved based on the perceived advantages or disadvantages of one technique over

another. This slow transition is observed as the absolute, relative, and possible indications of Zide and Kent,14 Zide,15 and Kent et al16 evolved over a period of 7 years (Tables 2-4). While another attempt at rening the absolute and relative indications and contraindications was made by Haug and Assael in 2001,10 Zides discussion of the article points out that this attempt to bring order to chaos will still perplex surgeons.17 He appropriately states that the only true indications for open reduction and rigid internal xation are condylar displacement and ramus height instability. Regarding condylar head or intracapsular fractures, Walker and Kerr13 state that conservative therapy is indicated for high condylar fractures in children. Haug and Assael10 suggest that open reduction for intracapsular fractures is contraindicated in all circumstances. That thought is echoed by Konstantinovic and Dimitrijevic.18 Other attempts to select appropriate indications for open reduction have incorporated components of

Table 4. KENT, NEARY, SILVA, AND ZIDES 1990 INDICATIONS FOR OPEN REDUCTION

Displacement into middle cranial fossa Tympanic plate injury Impossibility of obtaining adequate occlusion Lateral extracapsular displacement Invasion by foreign body Failure to obtain segment contact because of intervening soft tissue Blocked mandibular opening Facial nerve paresis secondary to initial injury Contraindicated intermaxillary xation Open wounds from initial injury
Data from Kent et al.16

BRANDT AND HAUG

1327 In summary, these reviews of indications for management suggest that if a patient has an acceptable range of motion, good occlusion, and minimal pain, observation or CRMMF is preferred, no matter what the level of fracture. Condylar head fractures (intracapsular); whether single fragment, medial pole or comminuted, should be managed in the same fashion. Zides discussion points out that condylar displacement and ramus height instability are really the only orthopedic indications for the ORIF of mandibular condyle fractures.7 Thus, for displaced or unstable low condylar neck or subcondylar fractures, ORIF is indicated.

Table 5. AAOMS SPECIAL COMMITTEE ON PARAMETERS OF CARE INDICATIONS FOR OPEN REDUCTION

Physical evidence of fracture Imaging evidence of fracture Malocclusion Mandibular dysfunction Abnormal relationship of jaw Presence of foreign bodies Lacerations and/or hemorrhage in external auditory canal Hemotympanum Cerebrospinal uid otorrhea Effusion Hemarthrosis
Data from Haug et al.23

Outcomes of ORIF Versus CRMMF

other systems. Thoma6 considered operative treatment for unilateral fractures to prevent contralateral derangement, bilateral fractures with an open bite, gross malalignment, fracture dislocations, and partly or completely healed fractures with arthralgia and abnormal function or malocclusion. Raveh et al19 simply state that open reduction is indicated when the condyle is displaced out of the glenoid fossa. Undt et al20 considered indications for open intervention to be a medial tilt of the condylar fragment of more than 14, shortening of the ramus by more than 5%, insufcient contact of fragment, minor dislocation, and/or when other fracture require general anesthesia to avoid maxillomandibular xation. Takenoshita et al21 suggested that indications for open reduction include luxation of the condylar head out of the glenoid fossa in adults or teenagers, when an anterior open bite exists, where signicant deviation exists between bone fragments, and when conservative therapy has failed. Jeter and Hackney22 reordered and eliminated components of Zides systems when creating their value system. At the time of this writing, the last attempt at listing indications for the management of condylar injuries was by the American Association of Oral and Maxillofacial Surgery Special Committee on Parameters of Care. The Subcommittee on Trauma created a list of indications for care (Table 5).23 All of the current classication schemes regarding open versus closed management focus on signs and symptoms, rather than on the condylar fracture itself. Moreover, circumstances such as medical illness or multisystem trauma would contraindicate all surgery and not just condylar surgery. Entities such as middle cranial fossa displacement again do not address a condylar fracture but an injury to the tympanic plate of the sphenoid. These situations should be considered beyond the parameters of most classication schemes. Thus, open versus closed treatment is rendered on a case-by-case basis and their overall management is the subject of other publications. A number of outcomes investigations have appeared in the literature recently that have compared CRMMF with ORIF of mandibular condyle fractures (Table 6). In 1999, Hidding et al24 compared the 1- to 5-year postoperative ndings of 20 patients treated with ORIF to 14 who were managed conservatively. The conservative group was treated with maxillomandibular xation for 2 weeks and then postoperative physiotherapy. The ORIF group was managed with wire or rigid osteosynthesis and then maxillomandibular xation for 2 weeks. They found that deviation on opening occurred in 64% of patients treated conservatively compared with 10% managed with ORIF. No differences were found in headaches, mastication, or maximum interincisal opening between groups. Radiographic ndings noted anatomic reconstruction in 93% of ORIF patients but only 7% of the conservative group. Konstantinovic and Dimitrijevic18 reviewed 80 patients with unilateral mandibular condyle fractures, 26 managed surgically with wire osteosynthesis, and 54 treated conservatively. The patients were examined clinically and radiographically 1 or more years after completion of treatment (mean, 2.5 years). The radiographic evaluation was performed by obtaining posteroanterior views of the mandible, recording data on a computer, and comparing the treated side with the noninjured side for the percentage of reduction achieved. One hundred percent of the ORIF patients had a reduction between 81% and 100% of ideal. For the conservatively treated group, 77.7% had a reduction between 81% and 100% of ideal; 18.5%, between 61% and 80%; and 3.8%, less than 60%. No statistically signicant differences were found between groups for maximal mouth opening, deviation on opening, or protrusion. Oezmen et al25 evaluated 30 patients with healed condylar fractures 6 to 24 months after treatment. Ten were managed conservatively and 30 by ORIF. The patients were evaluated clinically, radiographi-

1328

OPEN VS CLOSED REDUCTION OF CONDYLES

Table 6. OUTCOMES OF ORIF VERSUS CRMMF

Author Hidding et al24 Konstantinovic and Dimitrijevic18 Oezmen et al25

Total No. of Patients 20 ORIF/14 CRMMF 26 ORIF/54 CRMMF 20 ORIF/10 CRMMF

Follow-up 5 yr 2.5 yr 2 yr

Results Deviation 64% CRMMF versus 10% ORIF Anatomic reconstruction 93% ORIF versus 7% CRMMF No difference in headaches, mastication, or MIIO 100% Of ORIF were 81% to 100% of ideal 77.7% Of CRMMF were 81% to 100% of ideal No difference in deviation or MIIO MRI revealed 30% disc displacement in CRMMF and 10% in ORIF MRI revealed 80% of CRMMF with malaligned or deformed condyles 39% Complication rate in CRMMFasymmetry, malocclusion, reduced MIIO, headaches, pain 4% Complication rate in ORIFmaloccusion, impaired mastication, pain No statistically signicant differences found for ROM, occlusion, contour, or motor or sensory function ORIF associated with perceptible scars CRMMF associated with chronic pain No perceivable differences noted between CRMMF versus ORIF for mandibular motion or muscle activity ORIF patients had greater mobility Position of the condylar process is not static Anatomic reduction possible, but changes in the condylar process position may result from a loss of xation CRMMF had signicantly greater percentage of malocclusion CRMMF had shorter posterior facial and ramus heights on the side of injury ORIF17.2% facial nerve weakness at 6 weeks with 0% at 6 mo and 7.5% scarring judged as hypertrophic No difference noted between ORIF versus CRMMF for maximum bite forces

Worsae and Thorn26

61 CRMMF/40 ORIF

2 yr

Haug and Assael10

10 CRMMF/10 ORIF

6 yr

Throckmorton et al27 Palmieri et al29 Ellis et al30 Ellis et al31 Ellis et al32 Ellis and Throckmorton33 Ellis et al34 Ellis and Throckmorton35

14 CRMMF/6 ORIF 74 CRMMF/62 ORIF 65 CRMMF 61 ORIF 77 ORIF/65 CRMMF 81 CRMMF/65 ORIF 93 ORIF/85 CRMMF 91 CRMMF/64 ORIF

3 yr 3 yr 6 wk 6 mo 3 yr 3 yr 3 yr 3 yr

Abbreviations: ORIF, open reduction, rigid internal xation; CRMMF, closed reduction and maxillomandibular xation; MIIO, maximum interincisal opening; MRI, magnetic resonance imaging; ROM, range of motion.

cally, and with magnetic resonance imaging (MRI). The MRI examination revealed 3 cases (30%) of disc displacement in the conservative group but only 2 (10%) in the ORIF group. Seven patients (70%) in the conservative group were noted to have disc remodeling compared with 2 (10%) in the ORIF group. The MRI was also able to identify 8 patients (80%) in the conservatively treated group with malaligned or deformed condyles, but none (0%) for the ORIF group. The functional component of the clinical examination revealed similar results for both groups. Worsae and Thorn26 reported the complications associated with surgical versus nonsurgical treatment of unilateral low subcondylar fractures in 1994. For 101 dentate patients, of whom 61 were treated with CRMMF for 4 weeks and 40 were treated with open reduction and wire osteosynthesis for 6 weeks, 52

returned for examination a mean of 2 years after treatment. A complication rate of 4% was noted for the 24 patients in the surgical group, all occurring in 1 patient; this included malocclusion, impaired masticatory function, and pain located to the joint or masticatory muscles. A complication rate of 39% was noted for the 28 patients in the nonsurgical group. These occurred in 11 patients and included 3 with mandibular asymmetries, 8 with malocclusions, 3 with reduced interincisal openings, 2 with persistent headaches, 6 with pain located to the joint or masticatory muscles, and 6 with impaired masticatory function. In 2000, Haug and Assael10 reported the long-term postoperative results of 10 patients treated with CRMMF and 10 by ORIF. The patients were examined for gender, race, diagnosis, age at injury, time since

BRANDT AND HAUG

1329 of 61 patients treated by ORIF were evaluated using similar techniques and time intervals as for the closed investigation.30 The nonfractured condyle was used as a control, and an additional set of images were obtained at 6 months postoperatively. No statistically signicant differences were noted between the control and operated sides postoperatively, yet between 10% and 20% of the condylar processes had postsurgical changes in position of more than 10. These reports indicate that condylar position is not static postoperatively for either closed management or treatment by ORIF. In 2000, Ellis et al32 assessed the occlusal results of 142 patients with unilateral neck or subcondylar fractures77 treated with ORIF and 65 closed. An orthodontist and surgeon made the assessment from photographs taken at the same time intervals as the previous studies. The investigators concluded that after 3 years, patients treated closed had a signicantly greater percentage of malocclusion (22.2% to 28.6%) than did those treated by ORIF (0%). The next in Ellis series was a comparison of postoperative measures of mandibular and facial morphology.33 One hundred forty-six patients, 81 treated closed and 65 by ORIF, were assessed with Townes and panoramic radiographs taken at several intervals and by posteroanterior cephalograms taken at 6 weeks, 6 months, and 1, 2, and 3 years. The investigators found that patients whose condylar process was treated closed had shorter posterior facial and ramus heights on the side of the injury, and more tilting of the occlusal and bigonial planes toward the fractured side, than those treated by ORIF. Most asymmetry was present by 6 weeks. Surgical complications were addressed by Ellis group during a prospective evaluation of 178 patients.34 Ninety-three patients treated by ORIF and 85 treated by closed methods were included and assessed for intraoperative hemorrhage and/or encounter with the facial nerve, wound infection, Freys syndrome, salivary stula, seventh nerve palsy, and quality of surgical scar. Evaluations were made at several intervals. Facial nerve weakness was found to occur at a rate of 17.2% for the ORIF group at 6 weeks but totally resolved by 6 months. Incisions were considered to have become wide or hypertrophic 7.5% of the time. No other problems were identied. The latest in Ellis series was an evaluation of postoperative bite forces. This investigation included 155 patients, 91 treated closed and 64 treated by ORIF.35 Maximum bite forces were measured at 4 different tooth positions with a standard transducer at the same time intervals as for the previous investigations. Moreover, electromyographic measurements of the masseter muscle were also taken during bite force measurement, and working/balancing side ratios were

operation, and etiology of the fracture. Each group was assessed by 2 blinded investigators for maximum interincisal opening, right lateral excursion, left lateral excursion, protrusive movement, deviation on opening, scar perception, motor function, sensory perception, contour perception, occlusion, and perception of pain. There were no statistically signicant differences between the ORIF and CRMF groups for ranges of motion, occlusion, contour, and motor or sensory function. The ORIF group was associated with perceptible scars, and the CRMMF group with chronic pain. Ellis et al provided the most detailed and thorough comparison of the outcomes of the closed and open approaches to mandibular fractures in a series of 9 publications at the time of this writing. For example, Throckmorton et al27 assessed changes in masticatory patterns after bilateral fractures of the mandibular condylar process. They examined incisor movements in 3 dimensions, along with the activity of the temporalis and masseter muscles during mastication. Evaluations were performed at 6 weeks, 6 months, and 1, 2, and 3 years with a jaw-tracking device and electromyogram. Six patients were treated by ORIF, 14 treated with closed, and 2 treated with a combination of both. The authors noted that although the population sample sizes were too small to provide statistically signicant comparisons, no perceivable differences existed between the closed and ORIF groups for mandibular motion or muscle activity. Next, Ellis group evaluated the rate of recovery of mandibular motion in 136 patients, of whom 74 were treated by closed methods and 62 by ORIF with a minidynamic compression plate.28,29 Testing was accomplished at 6 weeks, 6 months, and 1, 2, and 3 years postsurgery with a jaw-tracking device and radiographs that were traced, digitized, and assessed. Ellis and coworkers concluded that patients treated with ORIF had greater mobility than those treated closed. Subsequently, their group reviewed the changes in condylar position after being managed by a closed approach and with ORIF.30,31 Sixty-ve patients over the age of 16 underwent closed treatment and were evaluated with Townes and panoramic radiographs before treatment, immediately after the placement arch bars, and at 6 weeks. Condylar position at each interval was evaluated in the coronal and sagittal view. A statistically signicant difference was noted in the coronal position between initial examination and after the placement of arch bars, but not after 6 weeks or between any of the intervals for the sagittal position.31 Although statistically signicant differences may not have been observed, great variability existed within groups, with standard deviations ranging from 2 times to more than 60 times the mean. Radiographs

1330

OPEN VS CLOSED REDUCTION OF CONDYLES

Table 7. METHODS OR TECHNIQUES THAT HAVE BEEN USED TO STABILIZE MANDIBULAR CONDYLE FRACTURES IN OPEN REDUCTION

Use of a urethral sound45 Condylectomy46-51 Intraosseous or transosseous wire xation46,51-56 Intramedullary pins57-62 Traction screw osteosynthesis with combination nut at angle63 Long screw placement64 Onlay-inlay splint65 Miniaturized dynamic compression plates designed for zygoma fractures66 Extraoral pinning with biphasic connector51,67,68 Free graft with wire xation after extracorporeal avulsion46,51,69 Disk repair with silicone rubber implantation70,71 Axial anchor screws72 Rigid plates and screws73-75 Bioabsorbable plates and screws76

calculated. No differences were noted between groups for maximum bite forces at any time period during the study. Bite forces recovered between the 6-week and 6-month periods. The working/balancing electromyogram ratios were greater on the side opposite the fracture, but no statistically signicant differences were noted between experimental groups. In summarizing the outcomes literature regarding the closed approach versus ORIF, ORIF has been associated with scar development and temporary ( 6 months) paralysis of facial nerve branches, whereas the closed approach is associated with numerous problems. These include chronic pain, malocclusion, asymmetry, limited mobility, and gross radiographic abnormalities. These results suggest that under similar indications and conditions, ORIF is the preferred approach.

Open Reduction
Open reduction does not necessarily mean rigid xation. Open reduction merely means that a fracture has been anatomically reduced with verication via direct visualization through an open approach. Subsequent to reduction, some form of xation may be used to stabilize the fracture. Virtually every conceivable form of open approach and xation scheme has at some time or another been attempted (Table 7), ranging from maxillomandibular xation with no direct xation attempt to wire osteosynthesis to bioresorbable xation to absolute rigid internal xation.36-67 Although the majority of the surgical literature favors the AO/ASIF (Arbeitsgemeinschaft fur Osteosynthesefragen/Association for the Study of Internal Fixation) minidynamic compression plate (Synthes Maxillofacial, Paoli, PA) for stabiliza-

tion,10,29-35 few side-by-side comparisons of condylar xation devices appear in the maxillofacial surgical literature. Those that do appear in the discussion are to follow. Hammer et al68 reviewed 31 condylar neck fractures in 30 patients treated between January 1988 and March 1994 at the University Hospital in Basel, Switzerland. The patients were treated with 5 different plating techniques (4-screw monocortical adaptation miniplates [n 20], 6-screw minidynamic compression plates [n 3], 4- or 6-screw 2.4-mm plate [n 2], double miniplates [n 2], and condylar prosthesis [n 1]) and followed for a minimum of 6 months. Seven failures requiring reoperation were found in the monocortical adaptation miniplate group. Choi and Yoo69 compared the biomechanical stability of 4 different mandibular condyle plating techniques in formalin-xed cadaver mandibles. The xation systems that were compared were a 4-screw monocortical miniplate, 4-screw bicortical minidynamic compression plate, 4-screw 2.4-mm plate, and a double monocortical miniplate technique. The loading was carried out on an Instron (Instron, Canton, MA) machine according to the Ziccardi technique,70 an adaptation of the Koolstra model.71 The authors found the double miniplate technique to be the most stable under the conditions tested. Ziccardi et al70 evaluated the biomechanical stability of the Wurzburg lag screw plate and a 4-hole adaptation miniplate. Their testing was performed using polyurethane mandible replicas and an MTS (MTS Systems, Inc, Minneapolis, MN) servohydraulictesting machine. Loading was performed according to the Koolstra model. Under the conditions evaluated, Ziccardis group found the Wurzburg lag screw to be superior in stability to the 4-hole adaptation miniplate. Haug et al72 evaluated the biomechanical behavior of various rigid internal xation techniques that address mandibular condylar fractures including a 2.0-mm zygomatic dynamic compression plate, 2.0-mm locking adaptation plates, 2.0-mm adaptation plates, and 2.0-mm minidynamic compression plates (Synthes Maxillofacial). Each system was xated with 6 monocortical screws (6.0 mm), 3 in each segment. Each group was subjected to torsional loading as well as linear loading in lateral-to-medial, medial-to-lateral, and posterior-to-anterior directions by an Instron servohydraulic mechanical testing unit. While differences were noted between each of the xation systems in their abilities to resist loads under the conditions tested, the minidynamic compression plate provided the most favorable mechanical behavior and the adaptation plate, the least. In summary, the literature directly comparing stabilization hardware shows that the adaptation plate is

BRANDT AND HAUG

1331
5. Brophy TW: Oral Surgery: A Treatise on the Diseases, Injuries and Malformations of the Mouth and Associated Parts. Philadelphia, PA, B Blakistons Sons and Co, 1915, p 407 6. Thoma KH: Oral Pathology: A Histological, Roentgenological and Clinical Study of the Diseases of the Teeth, Jaws and Mouth. St Louis, MO, CV Mosby, 1941, p 787 7. Rowe NL, Killey HC: Fractures of the Facial Skeleton. Edinburgh, UK, E & S Livingstone Ltd, 1955, pp 202-204 8. Dingman RO, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, p 177-184 9. Lindahl L: Condylar fractures of the mandible. I: Classication and relation to age, occlusion, and concomitant injuries of the teeth and teeth-supporting structures, and fractures of the mandibular body. Int J Oral Surg 6:12, 1977 10. Haug RH, Assael LA: Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 59:370, 2001 11. Krenkel C: Treatment of mandibular-condylar fractures. Atlas Oral Maxillofac Surg Clin North Am 5:191, 1998 12. Archer HW: Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 1975, p 1157 13. Walker RV, Kerr HR: The consultant. J Oral Surg 24:367, 1966 14. Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 15. Zide MF: Open reduction of mandibular condyle fractures. Clin Plast Surg 16:69, 1989 16. Kent JN, Neary JP, Silvia C, et al: Open reduction of mandibular condyle fractures. Oral Maxillofac Clin North Am 2:69, 1990 17. Zide MF: Outcomes of open versus closed treatment of mandibular subcondylar fractures (discussion). J Oral Maxillofac Surg 59:375, 2001 18. Konstantinovic V, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures: Clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 50:349, 1992 19. Raveh J, Vuillemin T, Ladrach K: Open reduction of the dislocated, fractured condylar process: Indications and surgical procedures. J Oral Maxillofac Surg 47:120, 1989 20. Undt G, Kermer C, Rasse M, et al: Transoral miniplate osteosynthesis of condylar neck fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:534, 1999 21. Takenoshita Y, Oka M, Tashiro H: Surgical treatment of fractures of the mandibular condylar neck. J Craniomaxillofac Surg 17:119, 1989 22. Jeter TS, Hackney FL: Open reduction and rigid xation of subcondylar fractures, in Yaremchuck MJ, Gruss JS, Manson PN (eds): Rigid Fixation of the Craniomaxillofacial Skeleton. Boston, MA, Butterworth-Heineman, 1992, p 121 23. Haug RH, Dodson TB, Morgan JP: Trauma surgeryParameters and Pathways: Clinical Practice Guidelines for Oral and Maxillofacial Surgery. Rosemont, IL, AAOMS, 2001, p TRA/15 24. Hidding J, Wolf R, Pingel D: Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J Craniomaxillofac Surg 20:345, 1999 25. Oezmen Y, Mischkowski R, Lenzen J, et al: MRI examination of the TMJ and functional results after conservative and surgical treatment of mandibular condyle fractures. Int J Oral Maxillofac Surg 27:33, 1998 26. Worsae N, Thorn JJ: Surgical versus nonsurgical treatment of unilateral low subcondylar fractures: A clinical study of 52 cases. J Oral Maxillofac Surg 52:353, 1994 27. Throckmorton GS, Talwar RM, Ellis E: Changes in masticatory patterns after bilateral mandibular condylar process fractures. J Oral Maxillofac Surg 57:500, 1999 28. Throckmorton GS, Ellis E: Recovery of mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. Int J Oral Maxillofac Surg 29:421, 2000 29. Palmieri C, Ellis E, Throckmorton G: Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. J Oral Maxillofac Surg 57:764, 1999 30. Ellis E, Palmieri C, Throckmorton G: Further displacement of condylar process fractures after closed treatment. J Oral Maxillofac Surg 57:1307, 1999

the least favorable for use and the minidynamic compression plate is the most favorable.

The Future
Although it has now been recognized that ORIF provides better functional reconstruction of mandibular condyle fractures than CRMMF, attempts have been made to limit the potential adverse postoperative sequelae associated with ORIF. Although concern over the facial nerve continues to exist, this has been proved not to be a long-term issue in case-controlled cohort studies.10,34 What has been conrmed as an adverse outcome is the appearance of postoperative scars.10,34 Endoscopic surgical techniques for ORIF (EORIF) of mandibular condyle fractures are now in their infancy with the specic aims of eliminating concern for damage to the facial nerve and of reducing or eliminating facial scars.73-76 New instrumentation and techniques have been developed in the United States and Europe that claim uniformly successful access to the mandibular condyle for reconstruction. Troulis and Kaban73 claim that the time differences between performing conventional and EORIF are not an issue, but they also identied no postoperative marginal mandibular nerve weakness. Although claiming technical success with access and instrumentation, as well as elimination of the risks for facial nerve palsy and aesthetic impairment, other authors have noted problems with healing, hardware, and time. After approaching 7 condylar fractures with endoscopic control, Lauer and Schmelzeisen74 noted that in 1 of 3 patients, loose hardware required early removal due to insufcient xation. In addition, Lee et al76 found that 37 of 40 patients treated with EORIF went on to uneventful healing. Three (7.5%) had either incomplete fracture reduction or re-fracture through the plate. Although perhaps an unacceptable rate of complications at this time, the instruments that have been developed for the EORIF have improved the performance of conventional ORIF. The endoscopic approach shows promise, and once techniques are improved and instrumentation is rened, it could replace conventional techniques as the standard.

References
1. MacLennan WD: Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 5:122, 1952 2. Blevins C, Gores RJ: Fractures of the mandibular condyloid process: Results of conservative treatment in 140 patients. J Oral Surg Anesth Hosp Dent Serv 19:28, 1961 3. Silvennoinen V, Iizuka T, Oikarinen K, et al: Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. J Oral Maxillofac Surg 52:793, 1994 4. Goodsell JO: Chalmer Lyons lecture: Fractures involving the mandibular condyle: A post-treatment survey of 120 cases. J Oral Surg 5:45, 1947

1332
31. Ellis E, Throckmorton G, Palmieri C: Open treatment of condylar process fractures: Assessment of adequacy of repositioning and maintenance of stability. J Oral Maxillofac Surg 58:27, 2000 32. Ellis E, Simon P, Throckmorton GS: Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 58:260, 2000 33. Ellis E, Throckmorton G: Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 58:719, 2000 34. Ellis E, McFadden D, Simon P, et al: Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 58:950, 2000 35. Ellis E, Throckmorton GS: Bite forces after open or closed treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 59:389, 2001 36. Silverman SL: New operation for displaced fractures at the neck of the condyle. Int J Orthod 67:876, 1925 37. Wassmund M: Uber Luxations frakturen des Kiefernglenkes. Dtsch Kieferchir 1:27, 1934 38. Walker DB: Fractures of ramus, condyloid and coronoid processes of the mandible. Br Dent J 72:265, 1942 39. Bellinger DH, Henny FA, Peterson LW: Fractures of mandibular condyle. J Oral Surg 1:48, 1943 40. Stromberg N: Fracture with luxation of collum mandibulae and its surgical treatment. Acta Chir Scand 74:379, 1934 41. Berger A: Fracture of mandibular condyle. J Am Dent Assoc 30:819, 1943 42. Thoma KH: Fractures and fracture dislocation of the mandibular condyle: A method for open reduction and internal wiring and one for skeletal xation with a report of 32 cases. J Oral Surg 3:3, 1945 43. Steinhardt G: Entstchung, Heilung and Behandlung des Luxations frakturen. Dtsch Zahn-Mund Kieferhlk 3:662, 1936 44. Henny FA: Technique for open reduction of fracture of the mandibular condyle. J Oral Surg 9:233, 1951 45. Tassen A, Lamberg MA: Transosseous wiring in the treatment of condyle fractures of the mandible. J Maxillofac Surg 4:200, 1976 46. Messer EG: A simplied method for xation of the fractured mandibular condyle. J Oral Surg 30:442, 1972 47. Peters RA, Caldwell JB, Olsen TW: Technique for open reduction of subcondylar fracture. Oral Surg 41:273, 1976 48. Stephenson KL, Graham WC: The use of the Kirschner pin in fractures of the condyle. Plast Reconstr Surg 10:19, 1952 49. Lund K: Unusual fracture dislocation of the mandibular condyle in a 6-year-old child. Int J Oral Surg 1:52, 1972 50. Cadenat HR, Cambelles F, Boutault J: Osteosynthesis of subcondylar fractures in the adult. J Maxillofac Surg 11:20, 1983 51. Brown AE, Obeid G: A simplied method for the internal xation of fractures of the mandibular condyle. Br J Oral Maxillofac Surg 22:145, 1984 52. Wennogle CF, Delo RI: A pin-in-groove technique for reduction of displaced subcondylar fractures of the mandible. J Oral Maxillofac Surg 43:659, 1985 53. Takenoshita Y, Oka M, Tashiro H: Surgical treatment of fractures of the mandibular condylar neck. J Craniomaxillofac Surg 17:119, 1989 54. Petzel J: Functionally stable traction-screw osteosynthesis of condylar fractures. J Oral Maxillofac Surg 40:108, 1982 55. Kitayama S: A new method of intraoral open reduction using a screw applied through the mandibular crest of condylar fractures. J Craniofac Surg 17:16, 1989

OPEN VS CLOSED REDUCTION OF CONDYLES

56. Robinson M, Yoon C: New onlay-inlay metal splint for immobilization of mandibular subcondylar fractures. Am J Surg 100: 845, 1960 57. Koberg W, Momma WG: Treatment of fractures of the articular process by functional stable osteosynthesis using miniaturized dynamic compression plates. Int J Oral Surg 7:1, 1978 58. Morris JH: Biphase connector, external skeletal splint for reduction and xation of mandibular fractures. J Oral Surg 2:1382, 1949 59. Georgiade N, Pickrell K, Douglas W, et al: Extraoral pinning of displaced condylar fractures. Plast Reconstr Surg 18, 1956 60. Boyne PJ: Free grafting of traumatically displaced or resected mandibular condyles. J Oral Maxillofac Surg 47:228, 1989 61. Choung R, Piper M: Open reduction of the condylar fractures of the mandible in conjunction with repair of discal injury: A preliminary report. J Oral Maxillofac Surg 46:262, 1988 62. Copenhaver RH, Dennis MJ, Kloppedel E, et al: Fracture of the glenoid fossa and dislocation of the mandibular condyle into the middle cranial fossa. J Oral Maxillofac Surg 43:974, 1985 63. Krenkel C: Biomechanics and Osteosynthesis of Condylar Neck Fractures of the Mandible. Carol Stream, IL, Quintessence, 1994 64. Ellis E III, Reynolds ST, Park HS: A method to rigidly x high condylar fractures. Oral Surg Oral Med Oral Pathol 68:369, 1989 65. Ellis E III, Dean J: Rigid xation of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol 76:6, 1993 66. Lachner J, Clanton JT, Waite PD: Open reduction and internal xation of subcondylar fractures via an intraoral approach. Oral Surg Oral Med Oral Pathol 17:257, 1991 67. Suuronen R, Kallela I, Lindquist C: Bioabsorbable plates and screws: Current state of the art in facial fracture repair. J Craniomaxillofac Trauma 6:19, 2000 68. Hammer B, Schier P, Prein J: Osteosynthesis of condylar neck fractures: A review of 30 patients. Br J Oral Maxillofacial Surg 35:288, 1997 69. Choi BH, Yoo JH: Open reduction of condylar neck fractures with exposure of the facial nerve. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:292, 1999 70. Ziccardi VB, Schneider RE, Kummer FJ: Wurzburg lag screw plate versus four-hole miniplate for the treatment of condylar process fractures. J Oral Maxillofac Surg 55:602, 1997 71. Koolstra JH, van Eijden TMGJ, Weijs WA, et al: A three-dimensional mathematical model of the human masticatory system predicting maximum possible bite forces. J Biomechan 21:563, 1988 72. Haug RH, Peterson G, Goltz MA: Biomechanical evaluation of mandibular condyle fracture plating techniques. J Oral Maxillofac Surg 60:149, 2002 73. Troulis MJ, Kaban LB: Endoscopic approach to the ramus/ condyle unit: Clinical applications. J Oral Maxillofac Surg 59: 503, 2001 74. Lauer G, Schmelzeisen R: Endoscope-assisted xation of mandibular condylar process fractures. J Oral Maxillofac Surg 57: 36, 1999 75. Sandler NA, Andreasen KH, Johns FR: The use of endoscopy in the management of subcondylar fractures of the mandible: A cadaver study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:529, 1999 76. Lee C, Stiebel M, Young DM: Cranial nerve VII region of the traumatized facial skeleton: Optimizing fracture repair with the endoscope. J Trauma 48:423, 2000