A Systematic Review on Controversies Related to Management of Condylar Fractures

Deshmukh S¹, Nayyar AS²*, Sabnis R¹, Panda A¹ and Bonde R¹

¹Department of Oral and Maxillofacial Surgery, Saraswati-Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, India

²Department of Oral Medicine and Radiology, Saraswati- Dhanwantari Dental College and Hospital and Post- Graduate Research Institute, India

*Corresponding author: Abhishek Singh Nayyar, Department of Oral Medicine and Radiology, Saraswati- Dhanwantari Dental College and Hospital and Post- Graduate Research Institute, India

Received: May 30, 2015; Accepted: September 10, 2015; Published: September 12, 2015

Abstract

In Maxillofacial Trauma, condylar fractures are the most common with a high incidence among the mandibular fractures. Management of the condylar fractures always remained a source of ongoing controversy in oral and maxillofacial trauma. Condylar fractures can be intracapsular or extracapsular, displaced, undisplaced, deviated or dislocated. There are various factors which have remained the deciding for the treatment indicated including presence of teeth, status of occlusion, unilateral or bilateral fracture, age of the patient, level and displacement of fracture, co-existence of other maxillary or mandibular fracture and other form of fractures which are difficult to recover functionally and aesthetically. Most of the researchers favor closed reduction with maxillomandibular fixation, but in the recent era, open reduction with internal fixation has become the most common. To overcome this problem, we are presenting this review to ascertain the main variables that determine the choice of treatment and to appraise the current evidence regarding the effectiveness of the treatment.

Keywords: Condylar fractures; Maxillofacial trauma

Introduction

The incidence of mandibular fractures has a highest next to nasal fractures among facial bone fractures and approximately 30% involve the condyle [1]. The reason for high incidence of condylar fractures is attributable to binding of mandibular ramus with high stiffness and condylar head with low stiffness, due to the indirect force that is delivered to the condylar head [2]. There are several causative factors responsible for this; most common external factors being physical trauma, accident, fall, sports injury, gunshot wounds and industrial hazard while internal factors being, benign and malignant tumors, osteomyelitis and muscle spasms due to any reason. After the development of osteosynthesis materials, there has been an ongoing debate about the management of condylar fractures. There are two therapeutic approaches for management of condylar fractures: Functional (closed reduction) and Surgical (open reduction). In the past literature, closed reduction with concomitant active physical therapy after intermaxillary fixation during recovery period has been advisable. However, due to metastasis of fractured bone by muscle strength, inappropriate temporomandibular joint (TMJ) function, abnormal occlusion and disuse muscular atrophy, open reduction has overtaken attention. Many authors still recommend closed reduction because problems related to open reduction, nerve and blood vessel injury, scars, infections are over-ruled in the previously accepted method of treatment [3,4]. Decision in the management of condylar fractures is still controversial. So, we are presenting this systematic review to evaluate the main variables to determine the correct method for treatment of condylar fractures.

Discussion

Klotch and Lundy [5] and Widmarket al [6] noted that closed reduction should be considered especially in situations such as elderly or pediatric patients or where there is difficulty in open reduction and in case of secured stable occlusion while open reduction is indicated if fractured mandibular condyle is severely displaced. Haug and Assael [7] showed that there was no statistically significant difference in occlusion status and complications between open and closed reduction. Differences were noted between groups for time since operation, scar perception and perception of pain. Ellis et al [8] reported that closed reduction is more advantageous than open reduction due to complications like intraoperative bleeding and postoperative infections, condylar growth disturbances, injury to auriculotemporal nerve and facial nerve paralysis. During this period, Brown and Jones [9] reported in their study that rigid fixation using miniplates did not require intermaxillary fixation. Tu and Tenhulzen [10] mentioned that screws and miniplates shortened period required for intermaxillary fixation and prevented disuse atrophy of masticatory muscles, thereby achieving early opening, in addition to the fact that postoperative complications were significantly reduced in this line of treatment. Ellis and Throckmorton [11] reported that those fractures which were treated by closed reduction had significantly shorter posterior facial and ramus heights on the side of injury and more tilting of occlusal and bigonial planes towards ipsilateral side than those treated by open reduction. Marker et al [12] recorded the results to find out there were any variables that were predictive of complications and concluded that closed reduction for management of condylar fractures is non-traumatic, safe and reliable and in only few cases, they were supposed to cause disturbances of function and malocclusion. With the objective of analyzing the main variables that determine the choice of method of treatment and outcome in condylar fractures, Villarreal et al [13] conducted a retrospective study to analyze and determine the relationship between the principal clinical variables and postoperative results. They analyzed the influence of preoperative variables, level of fracture, treatment, postoperative physical therapy, displacement and dislocation, comminution, loss of ramus height, age, gender, etiology, occlusion, dentition status, and presence of facial and mandibular fractures. The principal factors that determined the treatment decision were the level of fracture and degree of displacement. The functional improvement obtained by open methods was greater than that obtained by closed treatment. In the study conducted by Ellis et al [14] to compare the occlusal relationships after open and closed reductions for unilateral condylar fractures, the authors concluded that patients treated by closed reduction had a significantly greater percentage of malocclusion compared with those treated by open reduction, inspite of initial displacement of fractures greater in open reduction.

Mandibular condylar fractures are the most common facial fractures and there in enormous controversy in the management of it as mentioned in literature. Since Zide and Kent [15] (Table 1) reported the relative and absolute indications for condylar fractures in 1983, management became controversial and new approaches of surgical reduction and fixation were introduced and developed. In the same year, Mathes [16] (1983) (Table 2) mentioned that angulation between the fractured fragments, lateral override and lack of contact of fracture segments should be considered before open reduction and this was also suggested by Klotch and Lundy [5].

Table 1: Zide and Kent’s Criteria for Open Reduction (1983).




  
    Absolute Indication:
  
  
    
      Lateral    Extra-capsular Displacement
      Impossibility    of obtaining adequate occlusion by closed reduction
      Displacement    into middle cranial fossa
      Invasion    by Foreign Body
    
  
  
    Relative Indication:
  
  
    
      Unilateral    or Bilateral condylar fractures when splinting cannot be accomplished for    medical reasons or because physiotherapy is impossible
      Bilateral    condylar fractures with comminuted midfacial fractures, prognathism or retro-prognathism
      Bilateral    condylar fractures in an edentulous patient without a splint
      Periodontal    problems, Loss of teeth
      Unilateral    condylar fracture with unstable base



Table 1:  Zide and Kent’s Criteria for Open Reduction (1983).

Table 2: Mathe’s Treatment Protocol.




  
    Open Reduction Indication:
  
  
    
      Malocclusion    with Centric Relation
      Bone    Gap more than 4-5 mm
      Fragment    Angulation more than 30⁰
      Lateral    Override
      Lack    of contact of the fractured fragment
    
  
  
    Preferred for Open Reduction:
  
  
    
      Low    condylar fracture with displacement of condylar head out of the glenoid fossa
      Low    condylar fracture with multiple fractured mandible or maxillary or Le Fort    fracture
      Any    low, dislocated sub-condylar fracture
      Ramus    shortening � 5%
      Condylar    fragment 14⁰ � medial tilt
      Bilateral    fracture with open bite
      Gross    fracture end mal-alignment
      Fracture    � Dislocation
      Abnormal    function, malocclusion



Table 2:  Mathe’s Treatment Protocol.

Mitchell [17], Haug and Assael [7], Brandt and Haug [18] (Table 3) presented their views regarding the management of condylar fractures mentioning the absolute indications and contraindications for the choice of treatment after Zide and Kent’s criteria. In 2003, American Association of Oral and Maxillofacial Surgeons [19] suggested an international guideline on treatment of condylar fractures according to which open reduction was recommended to prevent complications of growth and functional disorders (Table 4). Table 5 highlights advantages and disadvantages of both open and closed reduction procedures used for treatment in different situations as per the discretion of the surgeon and the clinical situation.

Table 3: Indications and Contraindications for Open Reduction: [7,17,18].




  
    Absolute Indications:
  
  
    
      Patient    Preference (when no absolute or relative contraindications co-exist)
      When    stability of the occlusion is limited (eg. Less than 3 teeth per quadrant,    gross periodontal disease, skeletal abnormality)
      Displacement    into the middle cranial fossa
      When    manipulation and closed treatment cannot re-establish the pre-traumatic    occlusion
      When    rigid internal fixation is being used to address another facial fracture    affecting the occlusion
      Lateral    extra-capsular deviation
      Open    fracture with potential for fibrosis
      Invasion    by foreign body.
      When    closed treatment does not re-establish occlusion
    
  
  
    Relative Indications:
  
  
    
      Edentulous    Jaws, Periodontal Problems, Noncompliance
      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
      Unilateral    condylar fracture with unstable base
      Displaced    condyle with edentulous or partially edentulous mandible with posterior bite    collapse
      Uncontrolled    seizure disorders, Status Asthamaticus, Substance abuse
      Obtunded    neurologic status with documentation of predicted improvement
      Psychologic    compromise (eg. Mental retardation, organic mental syndrome, psychosis)
    
  
  
    Absolute Contraindications:
  
  
    
      Condylar    head fractures (at or above the ligamentous attachment � Single fragment,    comminuted, or medial pole)
      When    medical illness or systemic injury add undue risk to an extended general    anesthetic
      Good    Occlusion, Minimal pain, Acceptable mandibular movement
    
  
  
    Relative Contraindications:
  
  
    
      When    a simpler method is as effective
      Condylar    neck fractures (thin, constricted region inferior to condylar head)
      Obtunded    neurologic status when there is no documented hope for improvement



Table 3:  Indications and Contraindications for Open Reduction: [7,17,18].

Table 4: AAOMS Special committee on parameters of care, Indications for Open Reduction (2003).




  
    
      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
      Hemo-tympanum
      Cerebrospinal    fluid otorrhea
      Effusion
      Haemarthrosis



Table 4:  AAOMS Special committee on parameters of care, Indications for Open
Reduction (2003).

Table 5: Advantages and Disadvantages of Open and Closed Reduction.




  
    
      Open    Reduction
    
  
  
    Advantages
    Disadvantages
  
  
    
      Reduction    of displaced fragment to most ideal anatomic site by direct approach
      Prevents    nutritional imbalance, difficulty in speaking, respiration
      Prevents    facial asymmetry
    
    
      Injury to nerves    and blood vessels
      Postoperative    complication like infection
      Permanent scar    through surgery compromising aesthetics
    
  
  
    Closed Reduction
  
  
    Advantages
    Disadvantages
  
  
    
      Relatively    Safe treatment
      No    injury to nerves and blood vessels
      No    postoperative complications like infections, scars
      Loss,    or delay in developing teeth avoided
      No    tooth buds injury
    
    
      Injury to    periodontal tissues, buccal mucosa
      Poor oral hygiene,    difficulty in speaking
      Imbalanced    nutrition, mouth opening and respiration difficulty
      Facial asymmetry    due to growth and functional disorder



Table 5:  Advantages and Disadvantages of Open and Closed Reduction.

Condylar fractures may be intracapsular or extracapsular and in children, whatever might be the case, the most accepted line of treatment in the existing literature is closed reduction. Nowadays, some researchers challenged this plan of management and tried open reduction in children, using minimally invasive endoscopic surgery. Nevertheless, there is no consensus as regards in the management of condylar fractures in adults. In adults, the condylar fractures can be treated on the basis of case and personal experience of the researcher. There are three main treatment options advocated for adult condylar fractures which include period of intermaxillary fixation followed by functional therapy; functional therapy without a period of intermaxillary fixations; and open reduction with or without internal fixations. Most important thing is the decision of which treatment is best so taking this into consideration some of the factors should be kept in mind including unilateral or bilateral fractures, total or partial loss of teeth, height and quantity of the fracture traces, degree and direction of condylar dislocation, general health of the patient, effect on temporomandibular joint on mandibular movements and neuromuscular adaptations in addition to difficulty of surgical access, risk of lesion being in critical anatomic structures, hypertrophic scars and presence of other compounding maxillofacial fractures. Treatment of condylar fractures with closed reduction in adults is indicated in minimum and high dislocations, fractures of the head of condyles, and systemic risks to surgery [20]. The complications related to it are chronic pain, shortening of the face leading to asymmetry, alteration of the occlusal and bigonial planes and high percentage of malocclusions [11]. There were several complications reported in literature regarding open reduction of the condylar fracture also including difficulty of surgical access, extra-oral scars, lesions of the facial nerve, plate fracture, and aseptic necrosis of condylar segment secondary to loss of periosteal blood supply during dissection. The blood supply has been discussed a great deal in open reductions because researchers argue that surgical access to condylar process to perform open reduction and internal fixation requires exposure and dissection of some of the soft tissues of the condylar process to allow manipulation and attachment of fixation devices. Therefore, surgery further diminishes the blood supply to a segment of bone that has already been severely compromised. One should choose an approach that can minimize the soft tissue stripping from fractured condylar process and retain the attachment of capsule and lateral pterygoid muscle to maintain the blood supply to the condyle [21]. The temporomandibular joint, a ginglymoarthrodial joint, is necessary for the masticatory system to function efficiently and maximally, but it is also unclear whether open reduction would provide a more effective temporomandibular articulation than closed reduction [22].

Nussbaum et al [23] provided a critical analysis of the past studies that have directly compared open and closed reduction for condylar fractures and which produces best results. The results though were largely inconclusive and because of the relatively poor quality of the data available and a lack of exacting information, the question of the preferred treatment in case of condylar fractures still remains unanswered mandating need for further research.

Conclusion

Nevertheless, after reviewing the various articles published over last few years, it is believed that with exception of absolute indication of closed treatment used in children, there are still no rules or norms defined for treating condylar fractures. The decision about the choice of the treatment must always take some factors into consideration such as general condition of the patient, diagnostic precision, type of the fracture and mainly the experience, skill and the capability of the surgeons in that fracture.

References

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Citation: Deshmukh S, Nayyar AS, Sabnis R, Panda A and Bonde R. A Systematic Review on Controversies Related to Management of Condylar Fractures. J Dent App. 2015; 2(8): 287-290. ISSN:2381-9049

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Open Reduction
Advantages	Disadvantages
Reduction of displaced fragment to most ideal anatomic site by direct approach Prevents nutritional imbalance, difficulty in speaking, respiration Prevents facial asymmetry	Injury to nerves and blood vessels Postoperative complication like infection Permanent scar through surgery compromising aesthetics
Closed Reduction
Advantages	Disadvantages
Relatively Safe treatment No injury to nerves and blood vessels No postoperative complications like infections, scars Loss, or delay in developing teeth avoided No tooth buds injury	Injury to periodontal tissues, buccal mucosa Poor oral hygiene, difficulty in speaking Imbalanced nutrition, mouth opening and respiration difficulty Facial asymmetry due to growth and functional disorder