J Oral Maxillofac Surg

66:1184-1193, 2008

Prospective Evaluation of Closed Treatment

of Nondisplaced and Nondislocated
Mandibular Condyle Fractures Versus Open
Reposition and Rigid Fixation of Displaced
and Dislocated Fractures in Children
Constantin A. Landes, MD, DMD,* Kai Day, DMD,†
Bettina Glasl, DMD,‡ Björn Ludwig, DMD,§
Robert Sader, MD, DMD, PhD,储 and
Adorján F. Kovács, MD, DMD, PhD¶
Purpose: The purpose of the study was to evaluate open reposition and internal fixation of displaced
or dislocated child mandibular condyle fractures, and closed treatment of nondisplaced, nondislocated
fractures of the condyle with long-term follow-up outcomes.
Patients and Methods: Twenty-four patients less than 14 years of age were included from 2000 to
2005. Classes II to V after Spiessl and Schroll, eg, displaced or dislocated fractures were surgically treated;
Class I and VI nondisplaced, nondislocated fractures were treated closed. At yearly intervals, facial
symmetry, pain, nerve function, bone repositioning, scarring, and reossification were evaluated. Incisal
opening, protrusion, laterotrusion and sonographic condylar translation were measured in mm.
Results: Nineteen (79%) patients presented for follow-up: Class I, 8; Class II, 3; Class III, 0; Class IV, 2;
Class V, 5; and Class VI, 1. After 1 year, 11 patients (58%) presented for follow-up; after 2 years, 4 (21%)
patients, and after 5 years, 4 (21%) patients presented for follow-up. The reasons for not presenting for
follow-up given by the parents upon telephone interview were no symptoms and absent motivation. All
patients exhibited sufficient opening; 1 Class IV patient had insufficient translation; 3 patients had opening
deflection; 2 patients’ partial facial nerve paresis subsided after 1 year; in 2 cases broken osteosyntheses were
removed. Vertical and horizontal condyle support was successfully reconstructed; considerable bone resorp-
tion occurred in Class V; failure rate was 4 (17%). Of 5 Class V, 3 were failures (60%).
Conclusions: The evaluated treatment rationale attained 83% treatment success; Class V should be repo-
sitioned with careful mobilization to not risk impaired perfusion and considerable remodeling. Patient
number is limited; a negative bias for follow-up can be supposed, eg, symptom-free patients avoided a follow-up
interview. Prospectively small, rigid, mainly intraosseous and hopefully resorbable osteofixation should be assessed.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:1184-1193, 2008

Closed treatment (CTR) of mandibular condyle frac- remodeling in dislocated fractures proportional with
tures is generally recommended in children up to 14 age at the time of trauma are also reported.3,5-7 There-
years due to high local remodeling capacity.1-4 How- fore several authors recently favor open reduction
ever increasing dysfunction indexes and incomplete and internal fixation (ORIF), even in patients under 12

*Assistant Professor, Oral-, Maxillofacial and Plastic-Facial Sur-
gery, Frankfurt University Medical Center, Frankfurt, Germany.
†Research Fellow, Oral-, Maxillofacial and Plastic-Facial Surgery,
Frankfurt University Medical Center, Frankfurt, Germany.
‡Consultant, Department of Orthodontics, Carolinum Founda-
tion and Private Clinic, Frankfurt, Germany.
§Consultant, Department of Orthodontics, Carolinum Founda-
tion and Private Clinic, Frankfurt, Germany.
储Professor and Chairman, Oral-, Maxillofacial and Plastic-Facial Sur-
gery, Frankfurt University Medical Center, Frankfurt, Germany.
¶Professor, Oral-, Maxillofacial and Plastic-Facial Surgery, Frank-
furt University Medical Center, Frankfurt, Germany.
Address correspondence to Dr Landes: Oral-, Maxillofacial
and Plastic-Facial Surgery, Frankfurt University Medical Center,
Theodor-Stern-Kai 7, 60596 Frankfurt, Germany; e-mail: c.landes@
lycos.com
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6606-0014$34.00/0
doi:10.1016/j.joms.2007.06.667

1184
LANDES ET AL
years of age. This is mainly due to the safety and
acquired experience with ORIF.8-10
While reviewing the recent literature mainly con-
centrating on adults, a general tendency was shown
to operate on displaced and dislocated fractures and
treat nondisplaced fractures closed.11-21 The question
as to which degree of displacement and angle of
dislocation benefit from ORIF for superior results
compared with CTR is still open. Some authors con-
sider greater than 30 degrees of dislocation an indica-
tion for ORIF.12,22-24 In previous reports,16,17 the de-
gree of initial post-traumatic malocclusion and
impairment of joint function did not prove to be
reliable for a treatment decision in adults, being itself
forged by concomitant mandibular fractures.
Therefore this study promised to perform ORIF
even in child patients when a radiologically displaced
or dislocated mandibular condyle fracture was
present and to treat nondisplaced with CTR. In this
study a full randomization of CTR versus ORIF was
originally intended, similar to the study of Worsaae
and Thorn.25 Full randomization was, however, not
judged ethically acceptable after the literature had
been reviewed.16,17 Bilateral fractures were treated in
the same manner, ie, the displaced or dislocated sides
had ORIF, nondisplaced fractures CTR.
Patients and Methods
For 60 (January 2000 to January 2005) months,
patients under 14 years who were legally represented
by their parents or guardians, were offered to partic-
ipate in this study. They were informed of the man-
datory 1 year and if possible 2 and 5 year follow-up.
The principles outlined in the declaration of Helsinki
were thoroughly adhered to in this study.
Inclusion criteria were unilateral or bilateral con-
dyle fractures of any location from the very condylar
head to subcondylar, and age under 14 at the time of
trauma. All patients had to be operable even if their
treatment was closed. Parental or guardian informed
consent was mandatory. Exclusion criteria were the-
oretically patients with a previous history of temporo-
mandibular joint (TMJ) dysfunction and insufficient
dentition to reproduce an occlusion, cases not fit for
operative treatment, and severe pretraumatic dysg-
nathia; however, these did not occur within this col-
lective. Lastly, absent parental or guardian consent led
to exclusion from this study, but all guardians or
parents agreed to participate.
The total patient number willing to participate was
24 patients. From this group, 1 (4%) had a bilateral
fracture, therefore 25 fractures were treated in total;
11 (42%) fractures had ORIF (the Class V fracture of
the bilateral case included) and 14 (58%) had CTR
(the Class I fracture of the bilateral case included).
1185
Unacceptable clinical function was predefined as
malocclusion: unilateral slipping of double folded oc-
clusal paper (200 ␮m articulating paper; Bausch Den-
tal, Cologne, Germany). If this occurred and the pa-
tient’s history did not reveal a preoperatively
compromised occlusion and the family dentist did not
report a pretraumatic problem, the function was de-
fined as unacceptable. Furthermore persistent pain,
persistent nerve paresis, swelling and locking at the
fractured joint with vertical mouth opening below 35
mm, translation less than 6 mm on vertical opening,
and less than 3 mm on protrusion and mediotrusion
were determined as unacceptable.
Diagnostic imaging was performed with mandibu-
lar tomograms and Towne views, taken at one of 2
machines located in the department’s radiology sec-
tion. These radiographs were used exclusively after
patient history and clinical examination suggested a
condyle fracture.26 Polytraumatized patients with
comminuted facial fractures and cranial contusion
had a preoperative CT scan instead and were fol-
lowed up with tomograms.
Fracture classification was performed according to
the radiological findings27 to separate condyle and
subcondylar from high condylar and condylar head
fractures, and whether they were nondisplaced/non-
dislocated or displaced/dislocated. If the radiological
finding was not clear, it was compared with the in-
traoperative finding. Bilateral condyle fractures were
counted once as patients in the more severe fracture
class (ie, Class V); the second fracture was evaluated
within its proper fracture class (ie, Class I).
The condyle fractures at the lower condylar neck,
at or below the sigmoid notch were surgically treated
via the retromandibular approach technique28-30; the
osteosynthesis performed with 2.0 mm 4-hole
miniplates and 7 mm to 10 mm screws of 1.3 mm
diameter (Leibinger, Tuttlingen, Germany; MedArtis,
Basel, Switzerland; Synthes, Oberdorf, Switzerland) or
2.0 strength poly-L70/30DL-lactide (P[L70/30DL]LA)
copolymer with 6 mm and 8 mm screws (Synthes). In
45% of cases, a single plate adapted to the dorsal rim
was clinically judged to provide insufficient stabiliza-
tion and a second plate was adapted to the lateral
cortex.31 A preauricular approach was chosen in all
cases of high condylar fractures and the osteofixation
was performed with microplates of 1.2 mm strength
in H-, L-, and T-shape, 6 mm to 8 mm length screws of
1 mm diameter (Leibinger).13,32,33
Closed treatment was performed with 2 weeks in-
termaxillary guided occlusion using 2 maxilloman-
dibular 1.5 mm diameter rubber bands. These were
suspended over 14 ⫻ 2.4 mm set screws (Normed,
Tuttlingen, Germany), inserted between the canine
and first premolar root in all 4 quadrants if the per-
manent teeth had erupted. CTR patients younger than
1186 CHILD CONDYLE FRACTURES: CTR VS ORIF

12 years had guided occlusion by a removable orth- The pretherapeutic vertical difference to the non-
odontic appliance for an average of 3 months to spare fractured condyle was measured tangential to the
the tooth buds a traumatization by set screw inser- dorsal border of the mandibular ramus on the frac-
tion. Therefore convenient functional jaw orthopedic tured and the nonfractured side. The nonfractured
appliances in a monoblock design were used as a side’s value was subtracted from the fractured side’s
guiding, exercise, and training device. The appliances value. In bilateral fractures this was not possible.
were controlled and activated in orthodontically usual The angulation of the nonfractured condyle to the
intervals. When a concomitant permanent tooth sub- ascending ramus’ dorsal rim was taken as 0 degrees
luxation was present, archbars were administered, and the deviation from this value on the fractured side
followed by identical rubber band-guided occlusion was measured as angular dislocation on mandibular
for 2 weeks. In the third week vertical opening exer- tomograms. In bilateral fractures, an average value
cises and contralateral excursion exercises were be- from all nonfractured sides was used for reference (15
gun with thorough instruction also to the parents or degrees). The angular and vertical pretherapeutic to
guardians. In the fourth week, patients were trained post-therapeutic rectification were compared on the
to keep their mandible in the midline during vertical tomograms and Towne views.34
opening and protrusion. Physiotherapy was adminis-
tered for 2 weeks or longer and the set screws were
Results
removed after the third week if the occlusion re-
mained stable. The CTR versus ORIF treatment decision was based
Follow-up was intended at 12, 24, and 60 months. upon the radiological degree of displacement or dis-
The clinical measures of maximum interincisal dis- location, not on malocclusion or locking joint, which
tance on vertical opening, protrusion, and laterotru- was abandoned because it was too frequently influ-
sion were performed using an orthodontic slide
gauge. Local inflammation, scarring, pain, facial nerve
function, occlusion, and static and functional asym-
metry were evaluated. Inflammation was scored if 1
classical symptom was found (ie, swelling, pain, hy-
perpyrexia, or redness). Scarring was scored as
present if the scar was greater than 2 mm wide and
greater than 1 mm elevated. Facial nerve paresis was
scored present if visible asymmetry to the nonfrac-
tured side existed with functional movements after 3
months and after 12 months. Malocclusion was as-
sessed as in the predefinitions of unacceptable clinical
function; asymmetry when the chin deviated visibly
from the facial vertical in occlusion or greater than 2
mm in maximum vertical opening. Sonographic as-
sessment of the condyle translation was performed by
2 independent, experienced observers (C.L, K.D.)
with a Voluson 530D equipment and an S-NLP5-10
transducer (General-Electric-Kretz, Zipf, Austria),16,17
The transducer was held horizontally inferior to the
zygomatic arch with a slight upward angulation so
that the echoes from the lateral condylar neck circum-
ference, lateral disc, and joint capsule could be seen.
The linear condyle translation in mouth vertical open-
ing, protrusion, and mediotrusion was measured.
Starting from the habitual occlusion the distance the
condyle moved to the extreme position in vertical
opening, protrusion, or mediotrusion was measured.
Movement irregularity, disc position, dislocation,
scarring, and degeneration were evaluated. FIGURE 1. The sequence of dental pantomograms of a Class I
fracture before (top) and after (middle) closed treatment 2 intermaxillary
The distance and angle of displacement of the prox- guiding elastics were applied for 2 weeks. Twelve month follow-up
imal fragment were evaluated retrospectively by 2 (bottom) shows nonproblematic ossification.
independent observers (C.L, K.D.) on mandibular to- Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Max-
mograms and the Towne views. illofac Surg 2008.
LANDES ET AL
enced by concomitant mandibular fractures. The
mean age in the surgery group was 10.4 (range, 7-14)
years, and in nonsurgical patients 9.3 (range, 5-14)
years.
Twenty-four (100%) patients had diagnostic man-
dibular tomograms, 16 (67%) had Towne views, and 1
(4%) had a CT scan. Postoperatively all (100%) had a
mandibular tomogram, and 7 (29%) had a Towne
view. Towne view was not performed if the reduction
was excellent upon the mandibular tomogram to pre-
vent unnecessary unethical radiation exposure.
Class I nondisplaced low condyle/subcondylar frac-
tures (Fig 1) included 10 (42%) patients. All had CTR.
Class II displaced low condyle/subcondylar fractures
(Fig 2) included 4 (17%) patients; all had ORIF.
Class III high displaced condylar/condylar head frac-
tures could not be included, as none presented. In the
Class IV dislocated low condyle/subcondylar fractures
(condyle not within the temporal fossa) group were 2
(8%) patients treated with ORIF (Fig 3). Class V dislo-
cated high condylar/condylar head fractures, alto-
gether were 5 (21%) patients treated with ORIF
(Fig 4). For Class VI nondisplaced high condylar/
condylar head fractures, 3 (13%) patients had CTR
(Fig 5). Classes I and VI fracture patients underwent
CTR on the same day. Surgery for Classes II to V
FIGURE 2. The sequence of dental pantomograms of a Class II case
including a detail (top right) from the anterior-posterior Towne view
with a median displacement. The otherwise complex mandibular frac-
ture was entirely osteosynthesed with PolyMax (Synthes, Oberdorf,
Switzerland). The 12 month follow-up again shows uncomplicated
ossification. Top left, Preoperative pantomogram; middle, postopera-
tive pantomogram; bottom, follow-up pantomogram.
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Max-
illofac Surg 2008.
1187
FIGURE 3. A sequence of dental pantomograms in an open reduc-
tion and internal fixation Class IV case. Top left, Preoperative panto-
mogram; top right, appendent Towne view; middle right, detail of top
right. Middle left, The condyle fracture was fixed using Microplus
microplates and screws (Leibinger, Tuttlingen, Germany) and the fol-
low-up (bottom) shows uncomplicated ossification. Although clinical
and sonographic examination was performed after 2 years, the radio-
logical follow-up was only permitted by the parents after 3 years and
the ending of orthodontic treatment and metal removal likewise was
refused.
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Max-
illofac Surg 2008.
patients was on an urgent schedule the following day,
or after traumatic swelling had subsided, and at the
latest on the fifth day.
All surgical patients were treated by standard tech-
nique as given in the Patients and Methods section,
the place of fixation was always the dorsal aspect of
the condyle with greater than 80% extra-articular
plate position.35 All patients were operated on by 2
consultant surgeons (C.L, A.K.) in otherwise un-
changed routine. CTR was done according to the
outline in the Patients and Methods section (Table 1).
FOLLOW-UP
Nineteen patients with 20 fractures were evaluated
(Table 2). Class I included 7 patients after 1 year, 1
patient after 2 years, and no patients after 5 years. In
Class II, follow-up included 3 patients at 5 years. Class
III was not present within this evaluation. Class IV
patients presented in 2 cases after 2 years (in 1 case
the parents only permitted a follow-up dental tomog-
raphy after 3 years and ending of orthodontic ther-
apy). In Class V, follow-up included 5 patients, 4
patients after 1 year and 1 patient after 5 years. Class
VI included 1 patient after 2 years.
Rectification or changes to the condylar vertical
height and angulation can be seen in Table 3. The
1188
FIGURE 4. A sequence of Class V dental pantomograms (intraoper-
ative verification, could be Class III from the x-ray only). Top, Preop-
erative dental pantomography; middle, postoperative radiograph.
Microplus microplates and screws were used (Leibinger, Tuttlingen,
Germany). Uncomplicated ossification goes hand in hand with major
remodeling in this case (bottom).
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Max-
illofac Surg 2008.
vertical height differences to the contralateral side
were bigger in Classes IV and V. The vertical differ-
ences in Class II did not change; in Class IV height
differences could well become reduced. In Class V a
marked condylar remodeling occurred postopera-
tively. This may be due to forced reposition under
mobilization and partial dissection of the lateral ptery-
goid muscle. Angular displacement was biggest in the
dislocated Classes IV and V. While bigger angular
displacements could well become rectified, small an-
gular displacements changed only minimally. Apart
from remodeling, reossification of the fractures was
always inconspicuous.
Malocclusion, condyle translation, and appending
incisal movement can be seen in Table 4. Pain or
nerve paresis lasting more than 3 months or dysoc-
clusion did not occur. Fractures of the osteosynthesis
suffered 2 cases of Class V fractures; in these patients
in spite of a metal removal most probably due to
scarring, a marked asymmetry upon mouth opening
was associated with deflection.
CHILD CONDYLE FRACTURES: CTR VS ORIF
Discussion
General justifications for ORIF include anatomical
reduction, occlusal stability, rapid function, mainte-
nance of vertical support, avoidance of facial asym-
metry, less postoperative TMJ disorder incidence and
no maxillomandibular fixation. Arguments for CTR
include reduced overall morbidity, in most cases ac-
ceptable occlusal results, avoidance of typical surgical
complications, simpler procedure, less risk of anky-
losis and avascular necrosis.
For the restoration of the mandibular morphology
and continuity, with potential operative complica-
tions in mind, 57% of surgeons in a 1996 survey were
in favor of ORIF for the adult population, 64% when
a bilateral fracture was present.11 Although osseous
union is generally achieved irrespective of treatment
modality, this result illustrates the popularity of the
method in adults and is probably due to frustration of
the CTR results in displaced and dislocated cases.36
High condylar fractures, however, within the same
1996 survey were considered to be preferably treated
closed as their exposure, reposition, and stabilization
were considered unreliable.11 Trying to fulfill the re-
quirements for a prospective study for children pa-
tients as pointed out by Banks in 1998: “Evidence-
based guidelines are difficult to provide, yet a realistic
protocol would be a step forward,”37 our prospective
protocol included the following framework: an
agreed quantification of the deformity, a predefined
statement of unacceptable function, timing of inter-
vention, agreed operative method, subsidiary postop-
erative management, follow-up protocol, and quanti-
FIGURE 5. A sequence of Class VI before (top) and after (bottom)
closed treatment of 2 guiding elastics for 2 weeks, with an inconspic-
uous follow-up radiogram.
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Max-
illofac Surg 2008.
LANDES ET AL 1189

Table 1. ABSOLUTE INCIDENCE AND RELATIVE DISTRIBUTION OF STUDY PATIENTS

Other
Mandibular
Fracture Class After Total Relative Bilateral Fractures
Spiessl and Schroll27 Patients (n) Incidence (%) Fractures (n) CTR (n) ORIF (n) (n) (%)

I 10 42 1 11 0 2 8
II 4 17 0 0 4 1 4
III 0 0 0 0 0 0 0
IV 2 8 0 0 2 1 4
V 5 21 1 0 5 2 8
VI 3 13 0 3 0 1 4
⌺ (Total) 24 14 11
NOTE. The most frequent was by far Class I, not represented was Class III. One case had a Class V and a Class I fracture and was counted
in Class V as 1 patient and the fractures once in each of Class I and Class V.
Abbreviations: CTR, closed treatment; ORIF, open reduction and internal fixation.
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

fication of outcome for a population of children less
than the age of 14, as in adults which has been
previously reported.16,17
An agreed quantification of the deformity was con-
ferred by the assignment of cases into Classes I to
VI.4,16,17,27 The classification of Spiessl and Schroll
has been broadly used principally in European reports
since its inauguration27,38-41; and provides a compre-
hensive differentiation into nondisplaced, displaced
and dislocated, and either high or low fractures from
a surgical standpoint. Although it is a simplification, it
allows differentiation of outcome depending upon
the degree of dislocation and vertical loss of support.
The classification excludes freak injuries, eg, disloca-
tion into the cranial base or gunshot defect fractures.
Unacceptable function was predefined and was
kept comprehensive for a short clinical follow-up
examination using standard radiograms (95% of col-
leagues in other reports use mandibular tomo-
grams, 56% use reverse Towne view, and 41% use
CT).26,37
The timing of intervention was consistent as an
agreed operative method15,28,32,42-49 maintained by
intermaxillary guiding elastics for 2 weeks or orth-
odontic activator in CTR (40% in other reports37) and
submandibular, retromandibular, or preauricular ap-
proach for ORIF (36% and 47% of other reports37)
with miniplate osteosynthesis in Classes II and IV
(79% in previous reports37). The Class III and V pa-
tients were exposed by preauricular approach and
fixated by microplates. Class VI fractures with mere
displacement of medial condylar pole were treated
closed as no vertical loss of support was present and
fixation should be exceptionally difficult in minors. H-
and T-shaped microplates showed insufficient reten-
tion in class V fractures and prospectively more rigid,
comparably small, and ideally resorbable osteofix-
ation should be applied.
CT scans were more comfortable for differentiating
Classes V to VI fractures but were not generally nec-
essary. However some fractures such as shown in
Figure 4 could only be classified intraoperatively.11,50

Table 2. ABSOLUTE AND RELATIVE DISTRIBUTION OF FOLLOW-UP INTERVIEWS

12-Month 24-Month 60-Month

Total Relative Patient Recall Recall Recall
Class Patients (n) Distribution (%) (n) (%) (n) (%) (n) (%)

I 8 42 7 88 1 12 0 0
II 3 16 0 0 0 0 3 100
III 0 0 0 0 0 0 0 0
IV 2 11 0 0 2 100 0 0
V 5 26 4 80 0 0 1 20
VI 1 5 0 0 1 100 0 0
⌺ (Sum) 19 11 4 4
NOTE. The willingness for a follow-up was generally bad which may be due to the patients having to deal with few long-term problems.
Alternatively, though it was excluded by telephone survey, unhappiness with the current treatment and change of doctor may be a cause.
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.
1190 CHILD CONDYLE FRACTURES: CTR VS ORIF

NOTE. Vertical dimensions were measured pretherapeutically, post-therapeutically, and after follow-up and compared for their difference to the nonfractured side in all unilateral fractures. In
the case of bilateral fracture this was not possible for the vertical dimension and the angular dimension was compared with 15 degrees average. Angular measurements were performed in a similar
Physiotherapy in earlier reports use 4 weeks in all

Difference to
Contralateral
(degrees)
degrees of displacement and dislocation with CTR11

3
15

4
13
2
Ø
while this study only submitted Classes I and VI to
CTR applying 2 weeks of guided occlusion followed
by 2 weeks of physiotherapy.
Follow-Up
(degrees)
Angular
Subsidiary protocol for postoperative management

16
17

5
⫺3
20
Ø
included physiotherapy and soft diet (90% previous
reports) and follow-up controls.
Quantification of outcome was measured as condy-
Difference to
Contralateral
(degrees)

lar translation as it is the most sensitive parameter of

3.5
Ø

Ø
4
12

23 joint function. Earlier studies measure maximum in-

cisal movement to determine TMJ-movement restric-
tion and not condyle translation, which is more accu-
Posttherapeutic

rate. Incisal movement does not differentiate condyle

(degrees)
Angular

rotation from anterioposterior translation and there-

6.5
Ø

Ø
17
15

⫺6

fore may give the impression of good restitution

when severe shortness of translation is compensated
by rotation.51,52
Difference to
Contralateral

At 12 months all patients were symptom-free and

(degrees)

4.6

most refused further follow-up at 24 and 60 months.

15

76
44
⫺24
Ø

This study’s follow-up was corrupted by bad compli-

ance. On telephone survey the patient’s parents/
guardians or the children patients themselves said
Pretherapeutic

they faced no problems. There was no financial in-

(degrees)
Angular

14
16

⫺65
⫺28
⫺10

centive to influence action by the patients. Recall was

Ø

only 58%, better than 46% at 1 year of the adult

population of an earlier study.16,17 Other authors like-
wise reported 13% to 52% recall in follow-up even
Difference to
Contralateral

when offering financial compensation.34,35,39

(mm)

⫺0.2
⫺1.5

⫺4.8
Ø
0

⫺1

Nerve paresis was not a major problem with the

chosen operative approach by an experienced surgeon.
Facial nerve palsy of the marginal mandibular branch at
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.
Follow-Up

3 months in 11% of patients resolved after 6 months,

Vertical

67
68

68
64
71
Ø

similar to 13% to 17% transient, and 4.2% persistent

paresis reported previously in adults.9,10,15,23,39,48,53
Table 3. MEASUREMENTS OF THE ORAL PANTOMOGRAPHS

Earlier surveys54 of complications with the identi-

Difference to
Contralateral

cal approach (n ⫽ 93) showed 7.5% hypertrophic or

(mm)

⫺0.4

⫺1.8
Ø

Ø
⫺1

⫺1

wide scars. No patient (0%) developed a hypertrophic

visible scar in this evaluation or complained of unfa-
vorable scar formation.
Postherapeutic

It can therefore be concluded that Class I fractures

Vertical

in children have an uncomplicated prognosis when

(mm)

68
70

67
66
Ø

treated closed. Occlusal correction is performed by

functional training, orthodontics, and in severe cases,
orthognathic surgery. Surgical Class II cases in chil-
Difference to
Contralateral

dren have a good prognosis with ORIF; Class IV frac-

(mm)

⫺0.6
⫺1.5

⫺6.5
⫺5.2

tures do as well recuperate full incisal movement with

Ø

⫺2

ORIF. Class V cases are the most critical for several

reasons: ORIF faces major bone remodeling after sur-
gery; current microplate osteosyntheses may be over-
Pretherapeutic

strained and break, resulting in even further scarring

Vertical

(mm)

64
70

62
64
64

and movement asymmetry once the broken material

Ø

is removed. Class VI cases tend to have little transla-

tion which may indicate intra-articular scarring and
manner.

adhesion formation which is further evaluated with

Class

III
IV

VI
II

V
I

an exclusively Class VI CTR versus ORIF study. Frag-

LANDES ET AL 1191

NOTE. As in an earlier report,16,17 the class VI case has the least translation that may indicate intra-articular scarring and adhesion formation which is further evaluated with an exclusively Class
VI study closed treatment versus open reduction and internal fixation in adults. A “⫹” indicates present, “⫺” indicates absent, and Ø indicates did not occur within this study. Number of “⫹”
ment rectification was reported in Classes II and IV by

Scarring
Visible
Ellis et al36 to be 5.2 ⫾ 3.6 mm, 1.3 ⫾ 20 degrees

⫺
⫺

⫺
⫺
⫺
Ø
preoperatively; and ⫺0.5 ⫾ 3.9 mm, ⫺1.3 ⫾ 7.9
degrees postoperatively in adults. While this study’s

Inflammation
vertical rectification was comparable (preoperatively
⫺4 mm, postoperatively ⫺1 mm) the number of cases
Local

⫺
⫺

⫺
⫺
⫺
Ø
was too small for standard deviations. Angular dislo-
cation was bigger in the present study; preoperative
45-degree dislocation in Classes II and IV were cor-
Deflection

rected to 8 degrees postoperative.

⬎3 mm

⫹⫹
Ø Authors, who evaluate fragment rectification by
⫺
⫹

⫺
CTR in Classes V and VI fractures in adults, find these
to have 35% to 70% clinical joint dysfunction.55-57 In a
recent 1 and 2 year follow-up study,39 39 adult ORIF
Osteosynthesis

patients evaluated by axiography and magnetic reso-

Broken

nance imaging were compared with 16 CTR patients:

⫹⫹
⫺
⫺

⫺
Ø

ORIF patients had 11 mm average condylar mobility

versus 6 mm after CTR; vertical support loss 1.3 mm
to 4.8 mm, disc mobility 5.8 mm to 3.8 mm; periar-
ticular scarring and impaired disc mobility signifi-
3 Months/12 Months

cantly correlated. All Class V cases with CTR are

Nerve Paresis

reported to articulate at the articular eminence with 7

⫺/⫺
⫹/⫺

⫹/⫺
⫺/⫺
⫺/⫺

mm vertical difference, 10 mm anterior condyle po-

Ø

sition, and 4 mm translation. ORIF cases had 4 mm

vertical and 3 mm sagittal position differences, trans-
lation of 10 mm. Class VI CTR fractures had 2 mm
vertical difference and 4 mm anterior condyle dis-
Dysocclusion

placement, and translation was 10 mm. In ORIF cases,

Table 4. INCISAL MAXIMUM DISTANCES AS MAXIMUM TRANSLATION DISTANCES

there was 1 mm vertical and 0.4 mm sagittal position-

⫺
⫺

⫺
⫺
⫺
Ø

ing difference, with translation of 12 mm.

This study’s Class V cases had a vertical deficit of
⫺5.2 mm rectified to ⫺1.8 mm, however, after 1 year
Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

⫺4.8 mm resulted from condylar remodeling. Angular

Pain

⫺
⫺

⫺
⫺
⫺
Ø

difference to the nonfractured side of 44 degrees was

rectified to postoperative 23 degrees and 13 degrees
Translation

after follow-up. Classes V and VI may benefit from

Laterotrusion/
Mediotrusion

8.3
7.1

10.4
7.5
2.7
(mm)

future developments in intraosseous, small but rigid

and hopefully resorbable, osteosynthesis material.39
From the bad results in Class V, CTR for these cases
Incisal

10.5

12.1
10.8
(mm)

indicates number of cases with a positive finding (1 or 2).

Ø

may be also considered as very difficult to treat oper-

8

atively. But loss of vertical height is a predicator for

malocclusion as neoarthrosis with the articular emi-
Translation
(mm)

7.6
5.8

7.3
7.1
4.5

nence and asymmetry. Therefore the literature and

Protrusion

the findings in adults support ORIF in all cases of

vertical loss of support. A greater fragment dislocation
Incisal
(mm)

is the result of a stronger traumatic impact leading to

8.3
6.3

9.5
9.8
Ø

capsular rupture and scar formation.41,58 The influ-

ence of soft tissue ligament-damage and consecutive
Translation

scar formation has been discussed as the origin of

9.8
10.8

11.2

4.5
(mm)

11
Opening
Vertical

reduced translation after successful repositioning in

adults. In high intra- and extracapsular fractures, pub-
lished results34,39,59-61 bolster the concept of open
Incisal
(mm)

50
49

46
51
42
Ø

reduction in dislocated and displaced fractures in

adults when evidence for loss of vertical support is
Class

given. However, higher local remodeling capacity in

III
IV

VI
II

V
I

children remains to be further investigated with long-

1192
term results using TMJ sonography or magnetic reso-
nance imaging. Evaluation of disc mobility as stated
by the authors can be approximated by real time
sonography. With sufficient experience, the disc po-
sition and mobility can be measured in real time over
several cycles of translation by sonography and our
data supported this concept in cases of restricted
translation as we saw them.62,63
This study documents 83% primarily successful
condylar fracture management in children applying
gradual differentiation: nondislocated, nondisplaced
fractures treated with CTR versus ORIF in displaced
and dislocated fractures. Bilateral fractures can be
treated with the identical approach. Surgical risk can
be avoided with CTR in nondislocated fractures that
have a mostly intact anatomical basis for function.
Displaced and dislocated fractures treated with ORIF
have fewer incidences of facial asymmetry, locking,
and occlusal imbalance. However, Class V cases still
have high rates of postoperative functional deficit.
Bigger, ideally multicenter collectives are mandatory
to further support the results.
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