International Journal of Pediatric Otorhinolaryngology 78 (2014) 1557–1562
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Conservative treatment of bilateral condylar fractures in children: Case report and review of the literature Hai-Hua Zhou a,b,1, Jing Han a,b,1, Zu-Bing Li *,a,b a
The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, Hubei, People’s Republic of China b Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Wuhan University, Wuhan, Hubei, People’s Republic of China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 April 2014 Received in revised form 25 June 2014 Available online 8 July 2014
Two children (11 year old) with bilateral condylar fractures associated with symphysis fracture were conservatively treated. Both of them were followed up for about 1 year. A review of 21 cases of bilateral condylar fracture available in the literature revealed the younger the patient, the better the outcome of TMJ function or in radiographic remodeling. However, the longer the time elapsed, the higher the incidence of remodeling deformity and dysfunction. Thus, it must be better that a close follow-up of bilateral condylar fracture in children should be continued until the end of growth period. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Conservative treatment Bilateral condylar fractures Pediatric
Introduction Maxillofacial fractures in children occur infrequently. This phenomenon is due to many reasons. The high ratio of crania-tobody and crania-to-face, the lack of pneumatization of the facial sinuses, un-erupted teeth, the well padded facial soft tissues; in addition, children usually live in a protected environment. All the latter factors are responsible for the less frequency of facial fractures [1–3]. Interestingly, in children, the mandibular condyle is one of the most common sites of injury to the facial skeleton [4,5], accompanied by minimal pain and discomfort [5]. It is also the most overlooked and least diagnosed trauma site in the head and neck region [4,5]. Condylar fractures in children are of considerable concern in the literature, probably due to their future disturbances in dentofacial development. Many articles have showed good long-term results of condylar fractures in children treated by conservative procedure. However, there are few long-term results regarding bilateral condylar
fractures in children in the literature [4,6–11]. Regarding unilateral condylar fractures, many authors consider conservative treatment and physiotherapy could provide acceptable functional results because of the presence of a normal contra-lateral side [12,13]. When both condyles are fractured and displaced, there is a great tendency for the mandibular ramus to shorten, causing the premature contact of the posterior teeth and an open bite of the anterior teeth [14]. Closed treatment takes much longer, use of elastics and requires more dental adaptations for a good TMJ function and occlusion [14]. It can be assumed that conservative treatment of bilateral condylar fractures produce compromised results than patients with unilateral condylar fractures, especially in children. The purpose of this case report is to report the treatment and long-term results of two cases of bilateral condylar fracture; with average 1 year follow-up, and to analyze the features of previously reported cases of bilateral condylar fractures. Case presentation Case 1
* Corresponding author at: Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan 430079, People’s Republic of China. Tel.: +86 27 87686215; fax: +86 27 87873260. E-mail addresses: [email protected] (H.-H. Zhou), [email protected] (J. Han), [email protected] (Z.-B. Li). 1 Hai-Hua Zhou and Jing Han contributed equally to this manuscript. http://dx.doi.org/10.1016/j.ijporl.2014.06.031 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
In June 2008, a 11-year old boy who fell while at ground level, sustained an abrasion over the chin that had been evaluated and sutured in the emergency room; also had crown fractures of upper central incisors. Clinical examination found the occlusion was
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H.-H. Zhou et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1557–1562
normal with a moderate restriction of mouth opening. Threedimensional computed tomography (CT) revealed a sagittal fracture of the right condylar head and a fracture of the medial part of the left condylar head, with a non-displaced fracture of the left mandibular body. In view of the favorable nature of the fractures, both clinically and radiographically, it was decided to treat the fractures conservatively. This included a normal soft diet plan and functional exercises. Follow-up examinations were carried out including physical and radiographic examinations at 4, 10 months (Fig. 1A–L). Case 2 Diagnosis and treatment In October 2012, a 11-year old boy sustained bilateral condylar fractures, caused by falling from the stairs. The patient was diagnosed with painful facial swelling localized on the right chin. Limited mouth opening and pain during opening and closure was observed. Three-dimensional computed tomography (CT) revealed a fracture of the medial part of the right condylar head (slight displacement) and a sagittal fracture of the left condylar head (displaced inferiorly and medially), with a comminuted fractures of the right symphysis. Systemic examination revealed a fracture of the left femur. Soon afterwards, patient was admitted in local hospital. Open reduction and internal fixation was chosen as treatment method to right symphysis fracture and left femur fracture. One month later, patient was transferred to our hospital. Clinical examination revealed malocclusion complicated by a moderate mouth opening
(2 cm), and mandibular deviation (toward right) during opening and closure. He was also diagnosed with bilateral joint tenderness and a weak mobility capability of condylar processes. Under general anesthesia, titanium screws were planted into the alveolar between the canine and the first pre-molar in both maxilla and mandible, followed by traction with elastics for 4 weeks. Soft diet and functional exercise were also advised. Follow-ups Follow-up examinations were carried out including physical and radiographic examinations at 2, 10 months (Fig. 2A–K). Table 1 shows the details of case reports of bilateral condylar fractures in children and adolescents in published English literature. It seems that the younger the patient, the better the outcome of restoration of TMJ function or in radiographic remodeling. However, the longer the time elapsed, the higher the incidence of remodeling deformity and dysfunction.
Discussion Previous studies revealed that the site of condylar fracture was related to the age of the patients [15]. In children younger than 2 years, the short, stout, and very vascular nature of the condylar head, combined with the thin cortex makes them more prone to intra-capsular fractures [16]. As the mandible grows and develops, the condylar neck becomes longer and thinner, and is therefore more prone to fracture [15]. However, our pediatric patient aged 11 years showed bilateral condylar head fractures.
[(Fig._1)TD$IG]
Fig. 1. (A–D) CT scan in June 2008. (A) CT scan showing bilateral condylar fracture, and the left mandibular body; (B) lateral view of the right condyle; (C) lateral view of the left condyle; (D) limited mouth opening. (E–H) CT scan in October 2008. (E) CT scan showing the remodeling of the condylar processes; (F) remodeling of the right condyle; the lateral head of the condyle resorbed, leaving a spur on the lateral side; (G) remodeling of the left condyle; the lateral head of the condyle resorbed, leaving a spur on the lateral side; (H) showing a normal opening; (I–L) CT scan in April 2009: (I) CT scan showing the remodeling of the condylar processes; the remolded condylar heads appeared smooth; (J) the height of ascending ramus on the right increased significantly; the remolded condylar head appeared smooth; (K) the height of ascending ramus on the left increased significantly; the remolded condylar head appeared smooth; (L) showing a normal opening.
[(Fig._2)TD$IG]
H.-H. Zhou et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1557–1562
1559
Fig. 2. (A–C) CT scan in October 2012: (A) CT scan showing bilateral condylar fracture, and fracture of the right symphysis. Arrow in left condylar head fractures indicates the inferior medial displacement of the fragment; arrow in right side shows a slight displacement of the fragment; (B) lateral view of the right condyle; (C) lateral view of the left condyle. (D–G) CT scan in January 2013: (D) CT scan showing the remodeling of the condylar processes. Arrow in left condylar head shows a significant widened transverse diameter; (E) remodeling of the right condyle; the lateral head of the condyle resorbed, leaving a spur on the lateral side. The symphysis fracture has been treated by open reduction and internal fixation in other hospital; (F) and (G) remodeling of the left condyle; the lateral head of the condyle resorbed remarkably, leaving a spur on the lateral side; arrow (G) in left condylar shows malunion of the fragment, the remarkable absorption of the lateral pole of the left condylar process leads to an increased joint gap. (H–K) CT scan in November 2013: (I) remodeling of the condylar processes; the remolded condylar heads appeared to be normal; (J) the ascending ramus on the left mandible grew and returned to the original height; (K) arrows in both sides show complete remodeling of condylar processes (surrounded by cortical bone). The joint gap in left side returned back to normal and lefts with an enlarged (or hypertrophy) condylar process. There are no signs of temporomandibular joint ankylosis in both sides of the mandible condylar processes.
Good plain radiographs are very difficult to obtain and frequently are of poor quality [16], especially in the young pediatric patient. The projection of the condyle in only one anatomic plane and overlap with maxillary sinus may not allow the clinician to determine if an injury is actually present, which may lead to false-positive results and unnecessary treatment in some pediatric patients [16]. Comparatively, CT scanning showed a greater sensitivity and accuracy; especially 3-D CT imaging appears to be a valuable diagnostic equipment in the evaluation of pediatric patients with mandibular condylar fractures [4,9,16,17]. In the present case, the use of 3-D CT has also demonstrated its excellence in diagnosis and tracking the remodeling process of our patient. Condylar processes are development centers of the mandible in children [18]. The development of the mandible or face is relatively less affected in children with unilateral condylar fracture, due to the compensatory role of the normal contra-lateral side. In contrast, the treatment of bilateral condylar fractures in pediatric patients should be given more attention, especially during the child’s growth stages between years 5 and 7, and between years 12 and 15 [19]. Mis-diagnosis or treatment failure of bilateral condylar fractures in children will most likely result in facial growth disturbance like hypoplasia of the mandible or even micrognathia [4,16,20,21]. This could translate in the future need of orthognathic surgery or TMJ surgery, and possible permanent joint dysfunction [21]. Review of the cases with bilateral condylar fractures showed 11 (47.8%) of the 23 pediatric patients presented with associated remodeling deformity; of the 11 pediatric patients, 8 of the them associated with serious remodeling deformity, including deformation of the joint, fragment angulation, hyperplastic condyle and the formation of bifid condylar head, also development of TMJ ankylosis. A previous study focusing on only unilateral condylar fractures (55 cases) by Strobl et al. [22] showed only a moderate condylar deformity in 2 cases, a definite ramus height reduction in
2 cases, and a hypertrophic condylar deformity in 4 cases. Boffano et al. [23] had also reported only one patient with abnormal shape in their 14 pediatric patients with unilateral condylar fracture. It is of the preliminary view that the remodeling capacity in cases with bilateral condylar fractures is significantly worse than pediatric patients with unilateral condylar fractures. Whether or not the remodeling capacity correlated to the age of the pediatric patient continues to be a subject of debate. Dimitroulis et al. [24] reported that pediatric patients under 10 years showed the greatest remodeling potential, whereas the older children showed a reduced growth and remodeling potential on the side of the fractured condyle. Norholt et al. [25] also found that younger children had fewer long-term problems than older ones. However, Rowe [26] stated that injuries occurring before 3 years of age produced a severe asymmetric deformity; patients older than 6 years of age, a moderate deformity; and those after 12 years of age, only slight deformity. It has also been suggested that younger children are especially prone to permanent damage [27]. Favorable remodeling usually occurs if the fracture has been sustained before the growth is drawing to a close [28]. Nevertheless, other authors hold the view that the remodeling depended significantly on the type of fracture but not on the age of the patient at the time of the injury [29]. Based on the above findings, we confirmed the statement that the influence of the child’s age at the time of injury on remodeling outcome remains unclear and controversial [29]. In the present case 1, we did not use inter-maxillary fixation because of the normal occlusion observed. We support the point of view that no benefits can be gained by using maxillo-mandibular fixation (MMF) [30,31]. Soft diet, early mobilization, and close observation of the occlusion is the treatment of choice [32,33]. In a situation whereby patients have sustained serious displacement of the condylar fracture, we recommend use of inter-maxillary elastic traction plus functional exercises (in the present case 2). Active movement of the jaw is particularly important in combating ankylosis in this highly vascularized and osteogenic environment [3].
1560
Table 1 Analysis of the features of reported cases with bilateral condylar fractures in English literature and the present cases. Sex
Age
Etiology
Right (displacement)
Left (displacement)
Associated fractures
Follow up
Radiographic remodeling
TMJ function
Conservative treatment
Miller et al. [6]
Male
9 years
Fallen from bicycle
Condylar head (medially displaced)
Comminution
-
9 months
Complete remodeling
Good
Kaplan et al. [7]
Female
1.5 years
Fall at ground level
Subcondylar (marked angulation)
Symphysis; right coronoid fractures
26 months
Male
14 years 8 months
–
Condylar head
–
4.5 years
TMJ dysfunction
IMF (3 days)
Choi et al. [4]
Female
11 years
–
Condylar neck
Condylar neck
Symphysis
4 years + 1 month
TMJ dysfunction
IMF (
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Conservative treatment of bilateral condylar fractures in children: Case report and review of the literature Hai-Hua Zhou a,b,1, Jing Han a,b,1, Zu-Bing Li *,a,b a
The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, Hubei, People’s Republic of China b Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Wuhan University, Wuhan, Hubei, People’s Republic of China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 April 2014 Received in revised form 25 June 2014 Available online 8 July 2014
Two children (11 year old) with bilateral condylar fractures associated with symphysis fracture were conservatively treated. Both of them were followed up for about 1 year. A review of 21 cases of bilateral condylar fracture available in the literature revealed the younger the patient, the better the outcome of TMJ function or in radiographic remodeling. However, the longer the time elapsed, the higher the incidence of remodeling deformity and dysfunction. Thus, it must be better that a close follow-up of bilateral condylar fracture in children should be continued until the end of growth period. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Conservative treatment Bilateral condylar fractures Pediatric
Introduction Maxillofacial fractures in children occur infrequently. This phenomenon is due to many reasons. The high ratio of crania-tobody and crania-to-face, the lack of pneumatization of the facial sinuses, un-erupted teeth, the well padded facial soft tissues; in addition, children usually live in a protected environment. All the latter factors are responsible for the less frequency of facial fractures [1–3]. Interestingly, in children, the mandibular condyle is one of the most common sites of injury to the facial skeleton [4,5], accompanied by minimal pain and discomfort [5]. It is also the most overlooked and least diagnosed trauma site in the head and neck region [4,5]. Condylar fractures in children are of considerable concern in the literature, probably due to their future disturbances in dentofacial development. Many articles have showed good long-term results of condylar fractures in children treated by conservative procedure. However, there are few long-term results regarding bilateral condylar
fractures in children in the literature [4,6–11]. Regarding unilateral condylar fractures, many authors consider conservative treatment and physiotherapy could provide acceptable functional results because of the presence of a normal contra-lateral side [12,13]. When both condyles are fractured and displaced, there is a great tendency for the mandibular ramus to shorten, causing the premature contact of the posterior teeth and an open bite of the anterior teeth [14]. Closed treatment takes much longer, use of elastics and requires more dental adaptations for a good TMJ function and occlusion [14]. It can be assumed that conservative treatment of bilateral condylar fractures produce compromised results than patients with unilateral condylar fractures, especially in children. The purpose of this case report is to report the treatment and long-term results of two cases of bilateral condylar fracture; with average 1 year follow-up, and to analyze the features of previously reported cases of bilateral condylar fractures. Case presentation Case 1
* Corresponding author at: Department of Oral and Maxillofacial Surgery, College and Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan 430079, People’s Republic of China. Tel.: +86 27 87686215; fax: +86 27 87873260. E-mail addresses: [email protected] (H.-H. Zhou), [email protected] (J. Han), [email protected] (Z.-B. Li). 1 Hai-Hua Zhou and Jing Han contributed equally to this manuscript. http://dx.doi.org/10.1016/j.ijporl.2014.06.031 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
In June 2008, a 11-year old boy who fell while at ground level, sustained an abrasion over the chin that had been evaluated and sutured in the emergency room; also had crown fractures of upper central incisors. Clinical examination found the occlusion was
1558
H.-H. Zhou et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1557–1562
normal with a moderate restriction of mouth opening. Threedimensional computed tomography (CT) revealed a sagittal fracture of the right condylar head and a fracture of the medial part of the left condylar head, with a non-displaced fracture of the left mandibular body. In view of the favorable nature of the fractures, both clinically and radiographically, it was decided to treat the fractures conservatively. This included a normal soft diet plan and functional exercises. Follow-up examinations were carried out including physical and radiographic examinations at 4, 10 months (Fig. 1A–L). Case 2 Diagnosis and treatment In October 2012, a 11-year old boy sustained bilateral condylar fractures, caused by falling from the stairs. The patient was diagnosed with painful facial swelling localized on the right chin. Limited mouth opening and pain during opening and closure was observed. Three-dimensional computed tomography (CT) revealed a fracture of the medial part of the right condylar head (slight displacement) and a sagittal fracture of the left condylar head (displaced inferiorly and medially), with a comminuted fractures of the right symphysis. Systemic examination revealed a fracture of the left femur. Soon afterwards, patient was admitted in local hospital. Open reduction and internal fixation was chosen as treatment method to right symphysis fracture and left femur fracture. One month later, patient was transferred to our hospital. Clinical examination revealed malocclusion complicated by a moderate mouth opening
(2 cm), and mandibular deviation (toward right) during opening and closure. He was also diagnosed with bilateral joint tenderness and a weak mobility capability of condylar processes. Under general anesthesia, titanium screws were planted into the alveolar between the canine and the first pre-molar in both maxilla and mandible, followed by traction with elastics for 4 weeks. Soft diet and functional exercise were also advised. Follow-ups Follow-up examinations were carried out including physical and radiographic examinations at 2, 10 months (Fig. 2A–K). Table 1 shows the details of case reports of bilateral condylar fractures in children and adolescents in published English literature. It seems that the younger the patient, the better the outcome of restoration of TMJ function or in radiographic remodeling. However, the longer the time elapsed, the higher the incidence of remodeling deformity and dysfunction.
Discussion Previous studies revealed that the site of condylar fracture was related to the age of the patients [15]. In children younger than 2 years, the short, stout, and very vascular nature of the condylar head, combined with the thin cortex makes them more prone to intra-capsular fractures [16]. As the mandible grows and develops, the condylar neck becomes longer and thinner, and is therefore more prone to fracture [15]. However, our pediatric patient aged 11 years showed bilateral condylar head fractures.
[(Fig._1)TD$IG]
Fig. 1. (A–D) CT scan in June 2008. (A) CT scan showing bilateral condylar fracture, and the left mandibular body; (B) lateral view of the right condyle; (C) lateral view of the left condyle; (D) limited mouth opening. (E–H) CT scan in October 2008. (E) CT scan showing the remodeling of the condylar processes; (F) remodeling of the right condyle; the lateral head of the condyle resorbed, leaving a spur on the lateral side; (G) remodeling of the left condyle; the lateral head of the condyle resorbed, leaving a spur on the lateral side; (H) showing a normal opening; (I–L) CT scan in April 2009: (I) CT scan showing the remodeling of the condylar processes; the remolded condylar heads appeared smooth; (J) the height of ascending ramus on the right increased significantly; the remolded condylar head appeared smooth; (K) the height of ascending ramus on the left increased significantly; the remolded condylar head appeared smooth; (L) showing a normal opening.
[(Fig._2)TD$IG]
H.-H. Zhou et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1557–1562
1559
Fig. 2. (A–C) CT scan in October 2012: (A) CT scan showing bilateral condylar fracture, and fracture of the right symphysis. Arrow in left condylar head fractures indicates the inferior medial displacement of the fragment; arrow in right side shows a slight displacement of the fragment; (B) lateral view of the right condyle; (C) lateral view of the left condyle. (D–G) CT scan in January 2013: (D) CT scan showing the remodeling of the condylar processes. Arrow in left condylar head shows a significant widened transverse diameter; (E) remodeling of the right condyle; the lateral head of the condyle resorbed, leaving a spur on the lateral side. The symphysis fracture has been treated by open reduction and internal fixation in other hospital; (F) and (G) remodeling of the left condyle; the lateral head of the condyle resorbed remarkably, leaving a spur on the lateral side; arrow (G) in left condylar shows malunion of the fragment, the remarkable absorption of the lateral pole of the left condylar process leads to an increased joint gap. (H–K) CT scan in November 2013: (I) remodeling of the condylar processes; the remolded condylar heads appeared to be normal; (J) the ascending ramus on the left mandible grew and returned to the original height; (K) arrows in both sides show complete remodeling of condylar processes (surrounded by cortical bone). The joint gap in left side returned back to normal and lefts with an enlarged (or hypertrophy) condylar process. There are no signs of temporomandibular joint ankylosis in both sides of the mandible condylar processes.
Good plain radiographs are very difficult to obtain and frequently are of poor quality [16], especially in the young pediatric patient. The projection of the condyle in only one anatomic plane and overlap with maxillary sinus may not allow the clinician to determine if an injury is actually present, which may lead to false-positive results and unnecessary treatment in some pediatric patients [16]. Comparatively, CT scanning showed a greater sensitivity and accuracy; especially 3-D CT imaging appears to be a valuable diagnostic equipment in the evaluation of pediatric patients with mandibular condylar fractures [4,9,16,17]. In the present case, the use of 3-D CT has also demonstrated its excellence in diagnosis and tracking the remodeling process of our patient. Condylar processes are development centers of the mandible in children [18]. The development of the mandible or face is relatively less affected in children with unilateral condylar fracture, due to the compensatory role of the normal contra-lateral side. In contrast, the treatment of bilateral condylar fractures in pediatric patients should be given more attention, especially during the child’s growth stages between years 5 and 7, and between years 12 and 15 [19]. Mis-diagnosis or treatment failure of bilateral condylar fractures in children will most likely result in facial growth disturbance like hypoplasia of the mandible or even micrognathia [4,16,20,21]. This could translate in the future need of orthognathic surgery or TMJ surgery, and possible permanent joint dysfunction [21]. Review of the cases with bilateral condylar fractures showed 11 (47.8%) of the 23 pediatric patients presented with associated remodeling deformity; of the 11 pediatric patients, 8 of the them associated with serious remodeling deformity, including deformation of the joint, fragment angulation, hyperplastic condyle and the formation of bifid condylar head, also development of TMJ ankylosis. A previous study focusing on only unilateral condylar fractures (55 cases) by Strobl et al. [22] showed only a moderate condylar deformity in 2 cases, a definite ramus height reduction in
2 cases, and a hypertrophic condylar deformity in 4 cases. Boffano et al. [23] had also reported only one patient with abnormal shape in their 14 pediatric patients with unilateral condylar fracture. It is of the preliminary view that the remodeling capacity in cases with bilateral condylar fractures is significantly worse than pediatric patients with unilateral condylar fractures. Whether or not the remodeling capacity correlated to the age of the pediatric patient continues to be a subject of debate. Dimitroulis et al. [24] reported that pediatric patients under 10 years showed the greatest remodeling potential, whereas the older children showed a reduced growth and remodeling potential on the side of the fractured condyle. Norholt et al. [25] also found that younger children had fewer long-term problems than older ones. However, Rowe [26] stated that injuries occurring before 3 years of age produced a severe asymmetric deformity; patients older than 6 years of age, a moderate deformity; and those after 12 years of age, only slight deformity. It has also been suggested that younger children are especially prone to permanent damage [27]. Favorable remodeling usually occurs if the fracture has been sustained before the growth is drawing to a close [28]. Nevertheless, other authors hold the view that the remodeling depended significantly on the type of fracture but not on the age of the patient at the time of the injury [29]. Based on the above findings, we confirmed the statement that the influence of the child’s age at the time of injury on remodeling outcome remains unclear and controversial [29]. In the present case 1, we did not use inter-maxillary fixation because of the normal occlusion observed. We support the point of view that no benefits can be gained by using maxillo-mandibular fixation (MMF) [30,31]. Soft diet, early mobilization, and close observation of the occlusion is the treatment of choice [32,33]. In a situation whereby patients have sustained serious displacement of the condylar fracture, we recommend use of inter-maxillary elastic traction plus functional exercises (in the present case 2). Active movement of the jaw is particularly important in combating ankylosis in this highly vascularized and osteogenic environment [3].
1560
Table 1 Analysis of the features of reported cases with bilateral condylar fractures in English literature and the present cases. Sex
Age
Etiology
Right (displacement)
Left (displacement)
Associated fractures
Follow up
Radiographic remodeling
TMJ function
Conservative treatment
Miller et al. [6]
Male
9 years
Fallen from bicycle
Condylar head (medially displaced)
Comminution
-
9 months
Complete remodeling
Good
Kaplan et al. [7]
Female
1.5 years
Fall at ground level
Subcondylar (marked angulation)
Symphysis; right coronoid fractures
26 months
Male
14 years 8 months
–
Condylar head
–
4.5 years
TMJ dysfunction
IMF (3 days)
Choi et al. [4]
Female
11 years
–
Condylar neck
Condylar neck
Symphysis
4 years + 1 month
TMJ dysfunction
IMF (
