J Oral Maxillofac Surg 62:155-163, 2004

Mandibular Condyle Fractures: Determinants of Treatment and Outcome

Pedro M. Villarreal, MD, PhD, FEBOMS,* Florencio Monje, MD, PhD, FEBOMS, Luis M. Junquera, MD, DMD, PhD, FEBOMS, Jesu s Mateo, MD, Antonio J. Morillo, MD, FEBOMS, and Cristina Gonza lez, CNS
The objective of this study was to analyze the principal variables that determine the choice of the method of treatment and the outcome in condylar fractures. Materials and Methods: We conducted a retrospective analysis of 104 mandibular condyle fractures to analyze and determine the relation between the principal clinical variables and the postoperative results. All patients underwent a clinic-radiologic investigation focusing on fracture remodeling, evolution, dental occlusion, and symmetry of the mandible. We analyzed the inuence of the preoperative clinical variables (level of fracture, treatment, postoperative physical therapy, displacement and dislocation, comminution, loss of ramus height, patient age, gender, etiology, occlusion, status of dentition, and presence of facial and mandibular fractures) over the postoperative results and outcome. Results: The principal factors that determined the treatment decision were the level of the fracture and the degree of displacement. The level of the fracture inuenced the degree of preoperative coronal and sagittal displacement (neck fractures had greater medial and anterior displacement than head and subcondylar fractures) and the treatment applied. The functional improvement obtained by open methods was greater than that obtained by closed treatment. Open treatment increased the incidence of postoperative condylar deformities and mandibular asymmetry. Conclusion: The variables that inuenced the method of treatment and predicted the prognosis are the level of fracture, degree and direction of displacement of the fractured segments, age, medical status of the patient, concomitant injuries, and status of dentition. 2004 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 62:155-163, 2004 Fractures of the mandibular condylar process are common injuries that account for 29% to 40% of fractures of the facial bones1 and represent 20% to 62% of all mandibular fractures.2 Condylar fractures probably represent the aspect of maxillofacial trauma that is most controversial with respect to classication, diagnosis, and therapeutic management and that has generated the most numerous discussions and arguments in the literature. Evidence for it can be found in the various schemes used to classify and subdivide these fractures.3-5 A simple classication based on the anatomic location of the fracture, condylar head, condylar neck, and subcondylar region, seems adequate,6 although a combination with the degree of displacement of the fractured segment enriches management decisions. Mandibular condyle fractures are managed by 2 methods of treatment, open and closed treatment, without a consensus about the proper management of this injury.7 The advantages of both methods must be compared with the patient disability, morbidity, sequelae, and risks involved,8 because an ethically prospective randomized trial may not be possible.6 As 155
Purpose:

*Staff, Department of Oral and Maxillofacial Surgery, Hospital de Cabuen es, Gijo n, Spain. Staff, Department of Oral and Maxillofacial Surgery, Hospital Infanta Cristina, Badajoz, Spain. Associate Professor, Department of Oral and Maxillofacial Surgery, Hospital Central de Asturias, Oviedo, Spain. Staff, Department of Oral and Maxillofacial Surgery, Hospital Infanta Cristina, Badajoz, Spain. Staff, Department of Oral and Maxillofacial Surgery, Hospital Infanta Cristina, Badajoz, Spain. Clinical Nurse Specialist, Hospital Central de Asturias, Oviedo, Spain. Address correspondence and reprint requests to Dr Villarreal: C/ Monte Auseva 12 4 B, 33012 Oviedo, Spain; e-mail: pedrovillarreal@eresmas.com
2004 American Association of Oral and Maxillofacial Surgeons

0278-2391/04/6202-0006$30.00/0 doi:10.1016/j.joms.2003.08.010

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MANDIBULAR CONDYLE FRACTURES

Table 1. CONDYLAR FRACTURES ACCORDING TO THE LEVEL OF FRACTURE AND YAMAOKA ET ALS AND SPIESSLS CLASSIFICATIONS

Classication Level (n) Classication Yamaoka et al3 Type of Condylar Fractures No displacement Deviation and displacement Dislocation Sagittal splitting Spiessl4 Without angulation and dislocation Basis of the condylar process with angulation Condylar neck with angulation Basis of the condylar process with dislocation Condylar neck with dislocation Diacapitular or intra-articular Total Total (n) 20 (19.2%) 57 (54.8%) 15 (14.4%) 12 (11.5%) 12 (11.5%) 22 (21.2%) 19 (18.3%) 9 (8.7%) 6 (5.8%) 36 (34.6%) 104 (100.0%)
Head Condyle Condylar Neck Subcondylar Region

9 (24.3%) 17 (45.9%) 11 (29.7%) 1 (2.7%)

3 (10.7%) 18 (64.3%) 6 (21.4%) 1 (3.6%) 3 (10.7%) 19 (67.9%)

8 (20.5%) 22 (56.4%) 9 (23.1%) 8 (20.5%) 22 (56.4%) 9 (23.1%)

6 (21.4%) 36 (97.3%) 37 (35.6%) 28 (26.9%) 39 (37.5%)

always, however, the patients best interest must have priority over simple convenience for the surgeon. The objective of this study was to analyze the inuence of the principal clinical variables that determine the choice of the method of treatment, the prognosis, and the results in condylar fractures.

Materials and Methods

From March 1998 to April 2002, 104 condylar process fractures were diagnosed and treated in 84 patients in our department. Sixty-four patients had unilateral fractures (76.2%), and 20 patients had bilateral ones (23.8%). Fifty-two fractures (50%) were on the left and 52 were on the right. Thirty-seven (35.6%) were fractures of the head of the condyle, 28 (26.9%) were condylar neck fractures, and 39 (37.5%) were subcondylar fractures. The fractures were classied according to Yamaoka et al3 and Spiessl4 (Table 1). All patients underwent a clinic-radiologic investigation focusing on fracture remodeling, outcome, dental occlusion, and symmetry of the mandible. We examined the degree of coronal and sagittal displacement of the condylar process fractures, preoperatively and after treatment (6 months), using Towne projections, panoramic radiographs, and computed tomography scans according to Ellis et al.9,10 Seventy-four patients (88.1%) with 92 condylar fractures (88.5%) had closed treatment, and 10 cases (11.9%) with 12 condylar fractures (11.5%) received

open treatment. In the group treated by closed methods, 80 fractures (87.0%) were treated by intermaxillary xation (IMF) (64 patients, 86.5%), 2 fractures (2.2%) by functional treatment (2 patients, 2.7%) and 10 fractures (10.9%) had no treatment rendered (8 patients, 10.8%). In the group treated by open methods, 3 (25%) fractures were treated by open reduction with xation (2 patients, 20%), 1 fracture (10%) by open reduction without xation (1 patient, 10%), 3 fractures (25%) by IMF plus open reduction with xation (3 patients, 30%), 4 fractures (33.3%) by IMF plus open reduction without xation (3 patients, 30%), and 1 fracture (8.3%) by IMF plus resection of condylar fragment (1 patient, 10%). We analyzed the inuence of the preoperative clinical variables (level of the condylar fracture, method of treatment, time from initiating trauma to surgery, length of surgical procedure, use of postoperative physical therapy, magnitude and direction of displacement and dislocation, comminution, loss of preoperative ramus height, patient age, gender, etiology, preoperative occlusion, status of the preexisting dentition, and presence of facial and mandibular fractures) over the postoperative results and outcome (Table 2). The mean follow-up was 8.45 months (range, 0 to 33 months). It was greater in the open group (14.60 months; range, 3 to 31 months) than in the closed group (7.62 months; range, 1 to 33 months).

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157

Table 2. STATISTICALLY SIGNIFICANT RELATIONSHIPS (P < .05) BETWEEN THE CLINICAL VARIABLES AND THE PRINCIPAL PREDICTOR FACTORS (LEVEL OF FRACTURE, TREATMENT APPLIED, DISPLACEMENT, AND DISLOCATION) THAT INFLUENCE THEM

Preoperative Clinical Variable Level of fracture Preoperative coronal and sagittal displacement Dislocation Comminution of the condyle Intraoperative Method of treatment (open and closed) Length of surgical procedure Postoperative Change in coronal and sagittal displacement with treatment Postoperative coronal and sagittal displacement Postoperative MMO Asymmetrical MMO Postoperative loss of ramus height Change in loss of ramus height with treatment Condylar deformities Mandibular asymmetry Complications

Level

Treatment Yes

Displacement No No No

Dislocation No No No

Yes (neck) No Yes (head)

Yes (open) Yes (open) Yes (closed)

Yes (head closed) No

Yes (open)

No No

No Yes

Yes (open) No Yes (head) No Yes (head) Yes (subcondylar) Yes (head and neck) No No

No No No No No Yes Yes Yes Yes (open) (open) (open) (open)

No No No No No No Yes Yes

No No No Yes No No No Yes Yes

Abbreviations: Level, level of the fracture; treatment, method of treatment; MMO, maximum mouth opening. The level of fracture and method of treatment with the best results are given in parentheses.

STATISTICAL ANALYSIS

The relationships between the different variables were analyzed by means of nonparametric statistical test (nonnormal variables) using SPSS 11.0 for Windows software (SPSS Inc, Chicago, IL). The 2 test was used to analyze the relation between qualitative variables (Fisher test when there were only 2 categories per variable). Wilcoxon W test was used to analyze the relation between a qualitative variable (with 2 categories) and a quantitative variable (Kruskal-Wallis test when the qualitative variable have more than 2 categories). To analyze the relationship between quantitative variables, we used Spearman rank correlation coefcients. Differences were considered signicant when P .05.

adults (20 years old or older). There was a statistical signicant difference (P .017) between the mean age of the patients treated by closed treatment (28.09 16.66 years old) and open treatment group (17 8.56 years old). Etiology The most frequent cause was trafc accidents in 53 patients (63.1%). The remainder of the fractures occurred in the setting of casual accidents in 14 patients (16.7%), altercation in 8 patients (9.5%), sports accidents in 8 patients (9.5%), and fall in 1 patient (1.2%). Trafc accidents represented the most frequent cause in all qualitative ranges of age. The second in frequency was sports accidents in children and teenagers, and casual accidents in adults. By gender, the most frequent etiology was trafc accidents in both (43 cases, [66.2%] in men and 10 cases [52.6%] in women). The second most frequent cause was altercations in men and casual accidents in women. Associated Facial and Mandibular Fractures Seventeen patients (20.2%) had associated facial fractures: 6 patients (7.1%) had maxillary fractures, 7 patients (8.3%) had zygomatic fractures, 3 (3.6%) had frontal fractures, 7 (8.3%) had comminuted midface fractures, and 7 (8.3%) had nasal fractures. Forty-six

Results
PREOPERATIVE EVALUATION

Age and Gender There were 65 men (77.4%) and 19 women (22.6%), with an age range of 5 to 81 years (mean, 26.77 16.28 years). Seven patients (8.3%) were children (3 to 11 years old), 32 patients (38.1%) were teenagers (12 to 19 years old), and 45 patients (53.6%)

158 patients (54.8%) had associated mandibular fractures, 11 (23.9%) had ipsilateral ones, 23 (50%) had contralateral fractures, and 12 (26.1%) had fractures in both sides. Thirty-ve patients (76.1%) had symphyseal fractures, 7 (15.2%) had body fractures, 9 (19.6%) had angle fractures, 2 (4.3%) had ramus fractures, and 1 (2.2%) had dentoalveolar fracture. Time From Initiating Trauma to Surgery The mean time from initiating trauma to surgery was 4.36 days (range, 0 to 22 days). It was greater in the open group (mean, 5.9 days; range, 0 to 15 days) than in the closed group (mean, 4.15 days; range, 0 to 22 days) (P .13). Displacement There were 82 fractures (78.8%) with displacement. The most frequent directions of displacement were the anteromedial (34 fractures, 32.7%) and medial (15 fractures, 14.4%). Moreover, there were 9 fractures (8.7%) with isolated anterior displacement, 7 (6.7%) with posterior, 7 (6.7%) with lateral, 3 (2.8%) with posteromedial, 2 (1.9%) with inferior, 2 with anteroinferomedial, 1 (1.0%) with inferolateral, 1 with anterolateral, and 1 with posterolateral displacements. There was a statistical signicant relation between the presence of displacement and the method of treatment (P .048) but not with the level of fracture (P .176). All fractures without displacement and 76.1% of the fractures with displacement were treated by closed methods. Displacement was present in 26 head fractures (70.3%), 25 condylar neck fractures (89.3%), and 31 subcondylar fractures (79.5%). There were 56 fractures with preoperative coronal displacement. The range was between 95 (medial) and 35 (lateral), with a mean of 22.26 32.11 (medial). There were statistical signicant relationships (P .008) with the method of treatment (mean of 44 fractures treated by closed treatment, 13.65; 12 fractures by open treatment, 53.83) and the level of the fracture (P .040). Condylar neck fractures had a greater medial coronal displacement (41.23 29.3) than head (15.61 21.68) and subcondylar (17.2 36.6) fractures. There were 74 fractures with preoperative sagittal displacement. This was between 58 (posterior) and 90 (anterior), with a mean of 9.6 25.92 (anterior). There was a statistical signicant relationship (P .044) with the method of treatment (closed group, 6.95; open, 23.33) and the level of the fracture (P .048). Condylar neck fractures had a greater anterior displacement (15.2 31.6) than head (7.81 22.93) and subcondylar (5.88 22.11) fractures.

MANDIBULAR CONDYLE FRACTURES

Dislocation There were 18 condylar fractures (17.3%) with dislocation outside the glenoid fossa. Thirteen (72.2%) with anteromedial displacement, 3 (16.7%) with anteroinferomedial, 1 (1.0%) with medial, and 1 (1.0%) with superolateral (temporal fossa) displacement. The majority of the fractures treated by closed methods (84, 91.3%) had no dislocation, and 83.3% (10 fractures) of the ones treated by open methods had dislocation (P .015). Dislocation existed in 3 head fractures (8.1%), 6 condylar neck fractures (21.4%), and 9 subcondylar fractures (23.1%) (P .183). Comminution of the Condyle There were 16 fractures (15.4%) with comminution of the condyle. Eleven head fractures (29.7%) were comminuted. Only 2 of the neck (7.1%) and 3 of the subcondylar (7.7%) fractures were comminuted (P .011). Loss of Preoperative Ramus Height Preoperatively, 77 fractures (74.03%) had loss of ramus height, with a maximum of 15 mm and a mean of 5.4 3.12 mm. One patient with an anteromedial dislocated condylar neck fracture had an increase of ramus height (4 mm). There was no statistical relation with the level of the fracture (neck fractures, 5.46 3.55 mm; head fractures, 4.93 2.4 mm; subcondylar fractures, 5.85 3.12 mm). Preoperative Occlusion The preoperative occlusion was good in 17 patients (20.2%), 29 patients (34.5%) had an anterior open bite, and 34 patients (40.5%) had a posterior open bite. Four patients (4.8%) were edentulous. There was a statistical signicant relationship with the presence of displacement (P .005). Only 9.8% of the fractures with displacement had a good preoperative occlusion, whereas 40.9% of the fractures without displacement had good occlusion. Status of Preexisting Dentition The status of preexisting dentition was good in 60 patients (71.4%), 13 patients (15.5%) were partial edentulous, 4 patients (4.8%) were edentulous, and 7 patients (8.3%) had mixed dentition. There was no statistical signicant relationship with the treatment applied and the level of the fracture.
TREATMENT

Rigid IMF was applied in 71 patients (84.5%), with 87 fractures (83.7%). In 58 patients (81.69%), it was obtained by Erich arch bars, in 8 patients (11.26%) by intraoral screws, in 3 patients (4.22%) by Ivy loops, and in 2 patients (2.81%) by brackets. The length of rigid IMF was between 7 and 40 days with a mean of 25.07 9.6 days. It was 25.22 9.64 days in the

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159 There were statistically signicant differences (P .0002) between the preoperative and postoperative coronal displacement. The mean difference between these was 42.06 (lateral displacement) with statistically signicant differences (P .005) between the closed treatment (mean, 7.18) and open treatment (mean, 49.25) groups. There was no statistically signicant relationship with the level of the fracture (P .058). The postoperative sagittal displacement was between 58 (posterior) and 43 (anterior), with a mean of 2.77 17.63 (anterior). There were no statistically signicant relationships with the level of the fracture (P .246) (head, 4.77; neck, 3.52; subcondylar, 0.44), and treatment applied (P .855) (closed, 2.61; open, 3.58). There was a statistically signicant difference (P .001) between the preoperative and postoperative sagittal displacement. The mean difference between these was 15.41 with no statistically signicant differences (P .104) between the closed (4.33) and open treatment (19.75) groups. There was no statistically signicant relationship with the level of the fracture (P .177). Return to the Preinjury Occlusion After Treatment Eighty-one patients (96.4%) return to the preinjury occlusion after treatment. Two patients (2.4%) remained with open bite occlusions (subcondylar fractures, one with dislocation and the other with deviation, both treated by closed treatment), and 1 patient (1.2%) had a posterior cross-bite (bilateral head fracture with parasymphyseal fracture and closed treatment). By treatment groups, 71 patients (95.9%) treated by closed treatment and all of the patients (10, 100%) treated by open methods were able to return to their preinjury occlusion (P .810). There were no statistically signicant relationships (P .05) with the level of fracture, presence of displacement, dislocation, comminution, and status of the preexisting dentition. Maximum Mouth Opening The 1-month postoperative maximum mouth opening (MMO) was 22.90 12.82 mm (range, 0 to 40 mm). It was greater in the open group (24.80 9.40 mm) than in the closed group (22.65 13.25 mm) (P .938). It was greater in head fractures (29.74 7.09 mm) than in condylar neck (29.09 4.94 mm) and subcondylar (24.39 8.70 mm) fractures with statistically signicant differences (P .021). The 6-month postoperative MMO was 40.69 4.36 mm (range, 20 to 50 mm). It was less in the open group (38.80 5.71 mm) than in the closed group (40.95 4.13 mm) (P .230). It was greater in head fractures (41.19 3.81 mm) than in condylar neck (40.96

closed group and 23.71 3.71 days in the open group (P .687). Functional treatment with intermaxillary guiding elastics was applied in 13 patients (15.5%) (11 with closed and 2 with open treatment). The time of physiotherapy was between 7 and 21 days with a mean of 12.77 4.36 days (closed group, 12.36 4.65 days; open group, 15 0 days; P .513). Posterior bite blocks were used in 2 patients (2.4%). The surgical approach was via a preauricular incision in 11 fractures and a coronal incision in 1 patient. The type of xation was by miniplates and screws (2.0 mm) in 5 fractures (41.7%), and by wire in 1 fracture (8.3%). In 5 fractures, the fragment was replaced as a free graft, and in 1 case xation was not possible. There was no correlation (P .05) with the use of rigid IMF, the use of functional treatment, and the length of rigid IMF. Two miniplates were used in 2 cases and 1 plate in 3 cases. The mean length of the surgical procedure was greater in the open group (132.08 minutes; range, 90 to 180 minutes) than in the closed group (71.8 minutes; range, 15 to 200 minutes) with statistically signicant differences (P .0001). There was a statistically signicant relationship (P .024) between the method of treatment and the level of the fracture. All of the head fractures (37 cases) were treated by closed methods, whereas only 82.1% (18 of 23 fractures) of the neck and 78.12% (7 of 32 cases) subcondylar fractures were.
POSTOPERATIVE RESULTS

General Outcome The outcome was successful (normal occlusion, pain-free joint, normal jaw opening, symmetry) in 76 patients (90.5%) and not successful in 8 patients (9.5%). The percentage of patients with a successful outcome was identical in both groups of treatment (67 of 72 in the closed group and 9 of 10 in the open group). The unique variable with a statistically significant relationship (P .036) was the status of the preexisting dentition. Fifty-six patients (93.3%) with good dentition, 4 (100%) who were edentulous, and 7 (100%) with mixed dentition had a successful outcome. Otherwise, only 9 partially edentulous patients (62.9%) had a successful outcome. Postoperative Displacement The postoperative coronal displacement was between 60 (medial) and 20 (lateral) with a mean of 6.07 15.06. There was no statistically signicant relationship with the method of treatment (P .703) (closed, 6.47; open, 4.58), and level of the fracture (P .073) (head, 8.05; neck, 7.15; subcondylar, 4.08).

160 3.55 mm) and subcondylar (40.03 4.97 mm) fractures (P .942). There were no statistically signicant relationships (P .05) between the MMO (1 and 6 months) and the presence of displacement, dislocation, and comminution of the condyle. Postoperative Loss of Ramus Height Postoperatively, the mean loss of ramus height was 4.25 3.22 mm (closed treatment, 4.24 mm; open treatment, 4.27 mm; P .977). There was a signicant difference with the level of the fracture (head, 5.19 mm; neck, 4.46 mm; subcondylar, 3.08 mm; P .018). There were no statistically signicant correlations with the variables of age and gender. The difference between the loss of preoperative and postoperative ramus height was between 12 and 13 mm with a mean of 1.15 3.48 mm (closed treatment, 0.66 mm; open treatment, 4.09 mm; P .043). There were statistically signicant differences with the level of the fracture (P .0002) (head fractures, mean 0.25 2.01 mm; subcondylar fractures, mean 2.76 4.82 mm; neck fractures, mean 1 2.20 mm). Asymmetrical Postoperative Maximum Mouth Opening Sixty-one patients (72.6%) had symmetrical postoperative MMO (59 of closed treatment, 79.7%; 2 of open treatment, 20%) (P .0003). It was related to the presence of dislocation (P .0001) but not to the level of the fracture, presence of displacement, and comminution of the condyle (P .05). Postoperative Condylar Deformities In 50% of the condyles (52 fractures), there were postoperative condylar deformities. In 35 fractures (33.7%), the result was a attening deformity; in 12 (11.5%), there was condylar resorption; in 3 (2.9%), a bid condyle; in 1 (1%), a medially rotated condyle; and in 1 (1%) case, an ankylosis. There was a statistically signicant relationship with the level of the fracture (P .015). There was alteration in 62.2% of the head fractures (23), in 60.7% of the neck fractures (17), but in only 30.8% of the subcondylar fractures (12). Flattening was present in 45.9% of the head fractures (17) and in 46.4% of the neck fractures (13) but in only 12.8% of the subcondylar fractures (5). The percentage of condylar resorption was similar in the 3 levels: 8.1% of head (3), 14.3% of neck (4), and 12.8% of subcondylar (5) fractures. A bid condyle was present in only 3 cases of head fractures (8.1%). The only case of a medially rotated condyle and the other case of ankylosis occurred in patients with subcondylar fractures. There was no alteration in 52.2% of the fractures treated by closed methods (48) but in only 33.3% of the fractures treated by open methods (4) (P .011).

MANDIBULAR CONDYLE FRACTURES

Flattening was present in 34.8% of the closed fractures (32) and in 25% of open ones (3). Condylar resorption was present in 8.7% of the rst group (8) but in 33.3% of the second group (49). A bid condyle was present in only 3 cases of closed treatment (3.3%); all of them were head fractures. The only case of medially rotated condyle had been treated by open methods, and the case of ankylosis had been treated by closed methods. There was no statistically signicant relationship with the displacement of the fracture (P .266) and comminution (P .901). Postoperative Facial and Mandibular Symmetry Postoperative facial symmetry was present in 81 patients (96.4%), without any statistically signicant relationship (P .05). Postoperative mandibular symmetry was present in 79 patients (94%). There were statistically signicant relationships with the presence of displacement (P .049), dislocation (P .035), and type of treatment (P .011). Although 97.3% of the patients treated by closed methods (72) had postoperative mandibular symmetry, only 70% of the patients treated by open methods (7) had it.

Discussion
Decisions on management of mandibular condyle fractures remains a major topic of oral and maxillofacial surgery practice. Some variables affect the decision of closed versus open treatment (Table 2). This includes the level of fracture, the degree and direction of displacement of the fractured segments, the age and medical status of the patient, concomitant facial fractures, and the presence and status of dentition.7 Although areas of disagreement still exist, there are many areas of agreement.6 The majority of fractures of the mandibular condyle heal with functionally acceptable results after closed treatment.11 This method is simpler and easier to perform and in most instances is as effective, if not more effective, as open reduction, with less potential morbidity. The main reasons for open reduction and internal xation of condylar fractures are to permit primary healing of unreducible or unstable fractures, and to avoid IMF.11 Absolute indications for open reduction are rare. Relative indications primarily include adults with persistent malocclusion and condyles displaced out of the fossa.8 The most common surgical approaches, usually used in combinations, are preauricular, retromandibular, and a submandibular approach. The intraoral approach has very limited use, only for very minimally displaced low fractures.6,12 In our hands, a preauricular incision is the surgical approach of choice in the majority of condylar fractures, because it is the easier

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161 relationship, increasing the importance of the level of fracture in the displacement. Both open and closed treatment are useful to improve the displacement of the condyle because there were statistically signicant differences between the preoperative and postoperative coronal and sagittal displacements. Ellis et al9 showed that the position of the condylar process is not static in patients treated for condylar process fractures by closed means. The condylar processes became more medially tilted with application of the arch, and even the postoperative physiotherapy could have contributed to further displacement. However, there was great variability, with some segments becoming more medially displaced and some more laterally displaced. These results suggest that care must be taken in basing treatment decisions on the degree of displacement or dislocation of the condylar process in presurgical radiographs.9 In our study, the improvement obtained by open treatment is greater than that obtained by closed methods, with statistically signicant differences, but the truth is that the preoperative sagittal and coronal displacement in the rst group is comparatively greater and so required a greater amount of movement for reduction. There was no statistically signicant relationship between the level of the fracture and the change (preoperative to postoperative) in sagittal or coronal displacement, in agreement with the results obtained by Ellis et al.9,10 Finally, these authors obtained a signicant correlation between the postoperative sagittal position of the condylar process and level of the fracture (but not with coronal position).9 We did not nd any statistically signicant relationship between the postoperative coronal and sagittal displacement with the method of treatment or the level of the fracture, indicating that the postoperative results are less inuenced by these 2 variables. The outcome was considered successful if the following criteria were met: return to the preinjury occlusion, normal jaw opening, pain-free joint, symmetry of the mandible, and absolutely minimal morbidity of surgery.6,7 Traditional predictors of good results from closed treatment are in fact unreliable.6 Only the variable status of the preexisting dentition was correlated with the general outcome in this study. Partially edentulous patients had the worst results of all, compared with patients with good dentition, who were edentulous, and with mixed dentitions. The 1-month postoperative MMO was greater in the open group and in general in head fractures. All head fractures were treated by closed methods, so the difference between both methods of treatment in subcondylar and neck fractures is perhaps superior than the results reect. Otherwise, the 6-month postoperative MMO was less in the open group (38.80

and more direct way to obtain an optimum surgical eld. Many types of xation have been used, including wire, lag screws, plates, and external xators.7 Miniplates and screws are the gold standard hardware in rigid internal xation of condylar fractures, providing a more precise xation of fragments and good stability for the fractured segments.6,13 Replacement of the condyle as a free graft is an alternative in selected cases,14 although internal xation without disruption of the blood supply gave the most favorable results.15 If malocclusion with condylar fractures is to be treated closed, functional treatment with intermaxillary guiding elastics to control the occlusion seems preferable to rigid IMF, because it may adversely affect future joint function.6 The use and length of IMF, as well as the use and length of active jaw physiotherapy, are considered critical variables in patient management.14,16 Open reduction in our series did not imply a specied IMF treatment. Our results showed no statistically signicant differences between patients treated by closed or open methods, with respect to the use of rigid IMF, duration of rigid IMF, and functional treatment with intermaxillary guiding elastics. Perhaps, the principal reason is that there were 4 cases with replacement of the condyle without internal xation and 1 case of condylar resection, for which we thought that a period of rigid IMF would be necessary. The level of condylar fracture is one of the variables that strongly inuences the choice of a treatment. This is corroborated by our results with a statistically signicant relationship between the method of treatment and the level of the fracture. The degree of displacement is the second important variable when a treatment is being chosen.3,4 The majority of condylar fractures present displacement independent of the level of the fracture.3 Open treatment is justied only with displacement, although some unilateral or bilateral displaced fractures can be successfully treated by closed methods. The degree of displacement that justies open treatment is controversial.2 Our results conrm that the level of the fracture inuences the degree of preoperative coronal and sagittal displacement (condylar neck fractures had a greater medial and anterior displacement than did head and subcondylar fractures) and thus the treatment rendered. This result is in accord with the signicant correlation between the level of the fracture and the sagittal position of the condyle before treatment, obtained by Ellis et al.9 Otherwise, no signicant correlations were found by these authors between the coronal position of the condylar process and level of the fracture. Our results corroborate this

162 mm) than in the closed group (40.95 mm) and similar in the 3 levels of fractures. Curiously, there were no statistical signicant correlations between the MMO (at 1 and 6 months) and the presence of displacement, dislocation, or comminution of the condyle, so that few consequences are possible to obtain. The majority of patients (72.6%) had symmetrical postoperative MMO. The risk of developing asymmetrical postoperative MMO is greater in the patients treated by open methods (80%) than in the closed group (20.3%), with statistically signicant differences. This result is different from those obtained by other authors,15,17 who indicated that asymmetrical movement on maximum opening of the mandible are more often associated with the nonsurgical approach. It was also related with the presence of dislocation and the postoperative position of the condyle in the temporal fossa. If the condyle is out of the fossa, the disc may also be causing alterations in temporomandibular joint function. Loss of ramus height is a factor that seems clinically important for maintaining habitual occlusion and preventing a shortening of the ascending ramus, anterior open bite, and backward position of the mandible.5 It has been present preoperatively in the majority of the fractured condyles (74.03%) without statistically signicant differences between the different levels of fracture. Postoperatively, the mean loss of ramus height was similar in both groups of treatment (closed treatment, 4.24 mm; open treatment, 4.27 mm). Subcondylar fractures had a less postoperative loss of ramus height with statistically signicant differences between the different levels of fracture (head, 5.19 mm; neck, 4.46 mm; subcondylar, 3.08 mm). Other authors indicated that the postoperative loss of ramus height is more often associated with closed treatment.17 Zhang and Obeid15 investigated the results of treatment on unilateral subcondylar fracture, suggesting that open reduction had more favorable results than closed treatment only if the vascular supply is preserved, indicating that returning the condyle to its anatomic position results in an improved morphologic outcome. Although patients treated by both methods of treatment experienced an increase in ramus height after treatment, this is signicant only in the open group (4.09 mm) with statistically signicant differences (closed group, 0.66 mm). Otherwise, it is important to note that although patients with head fractures experienced a little loss of ramus height after treatment (mean, 0.25 2.01), subcondylar fractures (mean, 2.76 4.82) and neck fractures (mean, 1 2.20) increased their ramus height. Postoperative condylar deformities were common in our series (50%), being more frequent in head and neck fractures than in subcondylar fractures, with statistically signicant differences in attening defor-

MANDIBULAR CONDYLE FRACTURES

mity but not in condylar resorption, which was similar in all 3 levels of fracture. Bid condyle is a characteristic deformity after sagittal fractures and was present only in head fractures. Other studies have shown that dislocated fractures are associated with incomplete remodeling, such as abnormal form or morphology of the condylar neck or joint surfaces.18 Open treatment would increase the risk of postoperative condylar deformities with statistically signicant differences, especially in the cases where the condyle is replaced like a free graft. In summary, the principal factors that determine the treatment decision are the level of the fracture and the degree of displacement. Head fractures must be treated closed, but the treatment is inuenced by other variables in neck and subcondylar fractures. The improvement in condylar displacement is greater by open than by closed methods. Open treatment is justied only in adults, with displacement, malocclusion, and unreducible or unstable fractures in which IMF must be avoided. The degree of displacement that justies open treatment is controversial and the best results are obtained after functional treatment with intermaxillary guiding elastics. Acknowledgment
The authors would like to thank Linda Valde s, Orlando, FL, for her help in preparing the manuscript.

References
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