Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2014 41; 141--147

Clinical comparison between arthrocentesis and conventional conservative treatment with maxillomandibular fixation for unilateral high condylar fractures S. NOGAMI*, K. YAMAUCHI*, Y. KATAOKA†, H. TAKANO‡, Y. YAMASHITA§ & T . T A K A H A S H I * *Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Tohoku University Graduate School of Dentistry, Aoba-ku, Sendai, Miyagi, †Division of Oral and Maxillofacial Reconstructive Surgery, Department of Oral and Maxillofacial Surgery, Kyushu Dental University, Kokurakita-ku, Kitakyushu, Fukuoka, ‡Division of Dentistry and Oral Surgery, Akita University School of Medicine, Akita, and §Division of Oral and Maxillofacial Surgery, Department of Sensory and Motor Organs, Faculty of Medicine, Miyazaki University, Miyazaki, Japan

SUMMARY This study aimed to compare the effects of arthrocentesis and conventional closed reduction for unilateral mandibular condyle fractures. A total of 30 patients with unilateral condylar fractures were evaluated. Patients with a high condylar fracture and magnetic resonance evidence of joint effusion (JE) were divided into two groups: those treated with intra-articular irrigation and betamethasone injection (group I) and those given conservative treatment and rigid maxillomandibular fixation (MMF) (group II). All patients were assessed for mandibular range of motion (ROM), protrusive movements, lateral excursion movements on the fractured and nonfractured sides, pain in the temporomandibular joint and malocclusion, both before and after treatment. There were no significant differences in

Introduction Although mandibular condylar fractures are common injuries that account for 17
5–50% of all mandibular fractures (1), the choice between conservative (2) and surgical (3) treatment remains controversial (4). Although closed reduction was previously preferred as treatment (5), this conservative method requires varying periods (0–4 weeks) of maxillomandibular fixation (MMF), followed by aggressive physiotherapy (6). In © 2013 John Wiley & Sons Ltd

regard to protrusion, lateral excursion movement and incidence of malocclusion at 12 months after treatment between the groups (P > 0
05). In group I, ROM and joint pain showed good improvement from the early stages of treatment, and those patients had better outcomes as compared to group II for those parameters at 1 and 3 months after injury. The present findings indicate that arthrocentesis may be more effective and provide faster healing than conventional closed reduction. KEYWORDS: mandibular condyle fracture, arthrocentesis, maxillomandibular fixation, intraarticular irrigation, mandibular range of motion, joint pain Accepted for publication 29 November 2013

addition, closed reduction has been shown to be associated with development of long-term complications such as pain, arthritis, open bite, mandibular deviation on opening and closing, malocclusion caused by inadequate restoration of vertical height of the ramus, and ankylosis; thus, surgical treatment is favoured by many surgeons (7). The intended aim of such an operation is to restore the pre-existing anatomic relationships and achieve acceptable function by stable fixation (8). In our department, we select surgical doi: 10.1111/joor.12124

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S . N O G A M I et al. treatment for cases with lower neck and sub-condylar fractures, because we think that open reduction and internal fixation (ORIF) for a lower condylar fracture lead to a shorter rehabilitation period (9). However, ORIF is difficult to perform for patients with an upper neck, head or intracapsular fracture. Furthermore, the risk of avascular necrosis, osseous and fibrous ankylosis is high in such patients when treated with ORIF; thus, we select conservative treatment in those cases. In addition, we perform conservative treatment for children and elderly patients who are unable to undergo surgical treatment. Recently, we have begun to use arthrocentesis for management of mandibular condyle fractures in cases of upper neck and head fractures with magnetic resonance (MR) evidence of joint effusion (JE), because of the need for shorter and less-painful treatment in patients with a condylar fracture. Arthrocentesis is a well-established method that provides pain relief and improves function in patients with temporomandibular joint (TMJ) disorders. Segami et al. (10) found that synovial fluid from the TMJ with internal derangement in patients with osteoarthrosis with JE contained higher concentrations of total proteins as well as the pro-inflammatory cytokines interleukin (IL)-6 and IL-8, as compared to samples from TMJs without JE. We also reported that the detection rate and concentration of IL-6 were significantly higher in patients with MR evidence of JE and those with high condylar fractures, while a correlation between JE grade and IL-6 concentration was also found (11). We considered that those results may provide support for arthrocentesis as a reasonable treatment modality for high condylar fractures. In the present clinical study, we aimed to compare arthrocentesis and conventional closed reduction for patients with a unilateral upper neck or head condylar fracture.

Patients and methods

The local ethics committee approved this study, and informed consent was obtained from all patients after they received an explanation of the advantages and disadvantages of treatment. Randomisation was performed by lot using closed envelopes. All patients were postoperatively evaluated by a single assessor who was blinded to the treatment protocol. A total of 30 patients were selected, comprised of 19 (63
3%) men and 11 (36
7%) women. The aetiology of the fractures was assault in 18 (60
0%) and a fall in 12 (40
0%) patients. In all cases, the TMJs were evaluated based on MR imaging performed before treatment, and MR evidence of JE was observed in each patient. Radiographic examinations included a panoramic transcranial view (open and closed mouth) and computed tomography to determine the position of the mandibular fracture (Fig. 1a–c). The inclusion criteria were (i) age older than 18 years, (ii) unilateral condylar fracture with localisation of the fracture in the condylar upper neck or head, (iii) degree of deviation between the small fragment and ascending ramus of the mandible in a medial or lateral direction (as measured in the frontal plane) from 10 to 45°, or (iv) shortening of the height of the ascending ramus of the mandible by >2 mm. Exclusion criteria included (i) history of occlusal disturbances or skeletal malocclusions, (ii) history of TMJ disorder or (iii) inability to follow the instructions of the study protocol, because the patient was unconscious, or unable to comprehend information regarding the study and give voluntary consent. As shown in Table 1, the enrolled patients were divided into two groups: those with head or upper neck fractures who were treated with intra-articular irrigation (IR) and betamethasone injection without MMF, followed by elastic training for 4 weeks (group I, n = 15), and those who under-

(a)

(b)

(c)

Subjects The study sample for the present prospective, randomised clinical trial was derived from patients who came to Kyushu Dental University hospital between November 2006 and November 2011 for evaluation and management of a unilateral upper neck or head condylar fracture without an associated mandibular or mandibular condyle fracture, and without dislocation.

Fig. 1. (a) Panoramic radiograph views of mandibular condyle fractures. (b) Computed tomography views of mandibular condyle fractures. (c) Magnetic resonance evidence of joint effusion of mandibular condyle fractures. © 2013 John Wiley & Sons Ltd

ARTHROCENTESIS FOR UNILATERAL HIGH CONDYLAR FRACTURES Table 1. Summary of patients and age (IR: intra-articular irrigation, group I and MMF: rigid maxillomandibular fixation, group II) Treatment group I (IR) Males Females Total II (MMF) Males Females Total

No

Age range (years)

Mean age (years)

9 6 15

23–82 31–85 23–85

56
9 57
9 55
7

10 5 15

19–72 21–60 19–72

56
3 53
7 54
6

went conservative treatment and rigid MMF for 1 week, followed by elastic training for 3 weeks (group II, n = 15). The fracture levels in all patients are summarised in Table 2. For all patients, the time from injury to first visit ranged from 0 to 21 days (average, 7
0 days), while that from injury to initial MR examination ranged from 3 to 24 days (average, 11
3 days). Outcome measures included mandibular range of motion (ROM), protrusive movements, lateral excursion movements on the fractured and nonfractured sides, pain in the TMJ and malocclusion. In group I, ROM and incidence of joint pain were clinically evaluated at the first visit, 1 day and 1 week after arthrocentesis, and 1, 3, 6 and 12 months after injury. In group II, ROM and incidence of joint pain were clinically evaluated at the first visit, and 1, 3, 6 and 12 months after injury. Pain/discomfort in the joint at 12 months after injury was measured using a metric visual analog scale (VAS) ranging from 0 (no pain/ discomfort) to 100 mm (most severe imaginable pain/ discomfort). As a sensitive subjective measurement of the function of the TMJ at 12 months after injury, the mandibular function impairment questionnaire (MFIQ) index reported by Stegenga et al. (12) was

applied. In both groups, protrusive movements, lateral excursion movements on the fractured and non-fractured sides, and malocclusion were evaluated at 12 months after injury, with the latter assessed based on patient complaint using the metric VAS protocol. Statistical analysis Differences in ROM at pretreatment between the groups were assessed using Student’s t-test, while within-group differences for improved ROM were assessed using a paired t-test and between-group differences for improvement of ROM were assessed using a Wilcoxon matched-pairs signed-ranks test. The parameters protrusive movement, lateral excursion movement on the fractured and non-fractured sides, and malocclusion were compared statistically between the groups using an independent t-test. Differences in the incidence of joint pain at each follow-up between the groups were assessed using a chi-squared test. Statistical significance was established at P < 0
05.

Results There were no significant differences in regard to patient age (P > 0
05) and ROM (P > 0
05) at the initial visit between groups I and II (Table 1, Fig. 2).

Table 2. Summary of fracture level and condylar fracture position (IR: intra-articular irrigation, group I and MMF: rigid maxillomandibular fixation, group II) Group I Fracture level Condylar head Condylar upper neck Fragment position Deviation Dislocation

© 2013 John Wiley & Sons Ltd

Group II

19 11

9 6

10 5

30 0

15 0

15 0

Fig. 2. Changes in range of mandibular motion (range of motion) in the two treatment groups (IR: intra-articular irrigation, group I, MMF: rigid maxillomandibular fixation, group II).

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S . N O G A M I et al. In group I, ROM was increased from 22
2  3
7 mm (mean  SD) (range, 16–28 mm) prior to irrigation to 43
4  1
6 mm (41–46 mm) at 12 months after injury, while in group II, those were 20
3  4
5 mm (10–25 mm) and 39
5  2
4 mm (34–41 mm), respectively. At 1 and 3 months after injury, ROM was significantly higher in group I than in the MMF group (1 month, z = 2
06, P < 0
05; 3 months, z = 1
98, P < 0
05), while there was no significant difference after 6 months (Fig. 2). Mean protrusion was 7
4 mm (5–9 mm) and 7
0 mm (4–8 mm) in groups I and II, respectively, which was not significantly different (P > 0
05, Table 3). The values for mean lateral excursion movement on the fractured and non-fractured sides in group I were 7
3 mm (4–9 mm) and 7
6 mm (4–8 mm), respectively, while those in group II were 7
0 mm (5–9 mm) and 7
2 mm (5–9 mm), respectively, with no significant differences between the groups (P > 0
05, Table 3). In group I, joint pain was controlled at the early stage of treatment, as the incidence rate decreased from 86
7% prior to treatment to 33
3% at 1 month after IR and betamethasone injection (v2 = 8
94, P = 0
03), then continued to decrease to 13
3% at 6 months and remained at that level at 12 months after injury. In group II, the incidence of joint pain also decreased over time. Although there was no significant difference between pretreatment (93
3%) and 1 month after injury (66
7%), there was a significant difference between pretreatment and 6 months after injury (33
3%) (v2 = 8
72, P = 0
03), while that was 20
0% at 12 months after injury in group II (Fig. 3). Table 3. Summary of the parameters protrusive movement, lateral excursion movement on fractured and non-fractured sides, VAS for temporomandibular joint (TMJ) pain and malocclusion, and MFIQ for TMJ pain (IR: intra-articular irrigation, group I and MMF: rigid maxillomandibular fixation, group II)

Parameter

Group I (n = 15)

Protrusion (mm) LEFS (mm) LENFS (mm) TMJ pain VAS TMJ pain MFIQ Malocclusion VAS

7
4 7
3 7
6 1
3 3
3 3
3

     

0
9 1
1 1
1 3
5 4
9 6
2

Group II (n = 15) 7
0 7
0 7
2 2
0 4
7 4
0

     

1
2 1
1 0
9 4
1 5
2 6
3

P value 0
14* 0
17* 0
08* 0
33* 0
33* 0
75*

LEFS, lateral excursion movement on fractured; LENFS, nonfractured sides. *Not statistically significant.

Fig. 3. Changes in incidence of joint pain (IR: intra-articular irrigation, group I: MMF: rigid maxillomandibular fixation, group II).

As for subjective outcome parameters, patients in group I reported a mean pain level of 1
3 mm (VAS maximum, 100 mm) after 12 months, while those in group II reported a mean level of 2
0 mm after 12 months, both of which were confirmed through assessment of functional impairment with the MFIQ index (Table 3). Patients in group I scored 3
3 points for the MFIQ, while those in group II scored 4
7 points. There was no significant difference between VAS score and MFIQ index in each group. As for the VAS score for malocclusion, after 12 months, group I had 3
3 points and group II 4
0 points, which was not significantly different (Table 3).

Discussion A number of studies have investigated open reduction and closed reduction procedures for condylar fractures, with various findings reported (5), and the choice of treatment (i.e. surgical or conservative) remains controversial. In earlier investigations, the indications for open reduction were limited, as shown by the criteria used by Zide and Kent in 1983 (4), because they were limited by the techniques, materials and scientific reports available at that time. Thereafter, the concept of rigid internal fixation has been increasingly applied for craniomaxillofacial skeleton injuries and, with improved materials for fixation and © 2013 John Wiley & Sons Ltd

ARTHROCENTESIS FOR UNILATERAL HIGH CONDYLAR FRACTURES refinement of surgical techniques, a paradigm shift has occurred, with acceptance and even reliance on rigid internal fixation by both the surgeon and patient commonly seen in the present era. We generally select surgical treatment for lower neck and sub-condylar fractures with or without the presence of a dislocated fracture (9), while we choose conservative treatment for head and upper neck fractures, because a predictable amount of bone is not always available to allow placement of two screws per segment in those cases. Conservative treatment of a mandibular condyle fracture generally consists of MMF and rehabilitation including jaw motion exercises. Based on experimental findings, Ellis suggested that MMF delays the recovery of mandibular ROM following orthognathic surgery (13). We consider that there is a need for a shorter and less-painful treatment protocol for patients with a condylar fracture. Therefore, we compared between arthrocentesis and conservative treatment with MMF for management of mandibular condyle fractures in the present study. We found no statistically significant differences between the groups in regard to protrusion, lateral excursion movement and malocclusion, whereas a statistically significant difference was seen for ROM and incidence of joint pain. In group I, mean ROM exceeded 40 mm at 3 months after treatment, whereas that in group II was not achieved until 6 months after treatment, likely because rigid MMF treatment for 1 week in those patient may have delayed recovery of jaw motion. In addition, we speculate that the rapid improvement in jaw motion in group I resulted from the anti-inflammatory effects of IR and betamethasone injection. Furthermore, earlier elastic rehabilitation without MMF may also have contributed to the more rapid improvement. In group I, the incidence of joint pain was decreased within 1 month after treatment, and it continued to decrease with time. In contrast, in the MMF group, 66
7% of the patients group II still reported joint pain at 1 month after treatment, with a decrease in the incidence finally noted at 12 months. These findings suggest that arthrocentesis effectively relieves joint pain due to a condylar fracture in the early stages following treatment. Santler et al. (14) also reported that joint pain remained as a sequel in 6
2– 15% of their patients with condylar fractures who were treated by closed reduction with MMF at 1 year after the fracture occurred. © 2013 John Wiley & Sons Ltd

Intra-articular irrigation into the superior joint compartment of the TMJ was introduced as arthrocentesis by Nitzan et al. (15), and clinical outcomes in cases of TMJ dysfunction have been well documented (16). The effectiveness of arthrocentesis is presumably due to a reduction in negative pressure in the superior joint compartment (15) or washing out of the inflammatory products that accumulate in the joint compartment of a dysfunctional TMJ (17). Our findings, including clinical results of ROM and incidence of joint pain, indicate that washing out of the inflammatory products by IR can also be expected to reduce inflammatory reactions in fractured TMJs. Tumour necrosis factor alpha, IL-1 and IL-6, primarily produced by activated macrophages, have similar biologic activities and play crucial roles in the pathogenesis of rheumatoid arthritis and osteoarthritis with respect to the acceleration of cartilage degradation (18). Hamada et al. (19) reported that the presence of IL-6 in synovial fluid is a significant indicator of unsuccessful outcome arthrocentesis in the TMJ underwent, while that IL-10 is a significant predictor of successful outcome. In our previous study, the detection rate and concentration of IL-6 were significantly increased in patients with MR evidence of JE as compared to those with high condylar fractures (11). In short, arthrocentesis may reduce the levels of pro-inflammatory cytokines, leading to quick recovery of jaw function. As for corticosteroid injection, although there is some controversy about the deleterious effects of corticosteroids on the articular cartilage (20), clinically successful intra-articular injections to treat TMJ pain and dysfunction have been reported (21). Furthermore, Swall et al. (22) presented experimental findings showing that intra-articular injection of a betamethasone suspension had no harmful effects on TMJs in goats. Malocclusion is a serious complication following conservative treatment of a condylar fracture, with a frequency ranging from 17
2% to 39% at more than 1 year after conservative treatment (23). In the present study, slight malocclusion was seen in both groups at 12 months after injury, which suggests that arthrocentesis did not influence the frequency of postoperative malocclusion. The main limitation of this study is that the sample size was inadequate to conclude that no significant differences existed between the two groups. Studies with a greater number of patients and longer follow-

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S . N O G A M I et al. up period are required to confirm our findings. In addition, objective evaluation of occlusion including occlusal and chewing function will provide important information.

Conclusions The results of this randomised prospective study indicate that arthrocentesis for patients with an upper neck or head fracture and showing evidence of JE in MR images provided quick recovery of jaw function and a shortened duration of distress in patients with a mandibular condyle fracture, when compared to the conventional conservative treatment with MMF.

6.

7.

8.

9.

Acknowledgments This study was approved by the Ethics Committee of Kyushu Dental University (Approval No. 12-1).

10.

Source of funding We performed this research without receiving any financial support or incentive from any third party.

11.

Conflict of interest The authors declare that they have no conflict of interest.

12.

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13.

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