Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6

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Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study Hugues Zrounba*, Jean-Christophe Lutz, Simone Zink, Astrid Wilk Service de Chirurgie Maxillo-Faciale (Head: Prof. Astrid Wilk), Hopital Civil, 1, Place de L’hopital, 67000 Strasbourg, France

a r t i c l e i n f o

a b s t r a c t

Article history: Paper received 21 April 2013 Accepted 3 January 2014

Surgical management of mandibular condyle fractures is still controversial. Although it provides better outcome than closed treatment questions still remain about the surgical approach and the osteosynthesis devices to be used. Between 2005 and 2010, we managed 168 mandibular condyle fractures with open treatment. Two surgical approaches were used in this study, a pre-auricular and a high submandibular approach (one or the other or as a combined approach). Internal fixation was performed using TCPÒ plates (Medartis, Basel, Switzerland) or with two lag screws (15 and 17 mm). Delta plates were used in 15 cases (8.9%). We report the epidemiology of these fractures and the outcomes of the surgical treatment. We assessed the complications related to the surgical procedure and those related to the osteosynthesis material. The facial nerve related complication rate was very low and the osteosynthesis materials used proved to be strong enough to realize a stable fixation. The two approaches used in this study appeared to be safe with good aesthetic results. Most of the surgical procedure failures occurred in high subcondylar fractures especially when bilateral. Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Keywords: Mandibular Condyle Fracture Surgery Osteosynthesis

1. Introduction Management of mandibular condyle fractures, one of the most frequent fractures that a maxillofacial surgeon has to handle (Bormann et al., 2009; Chrcanovic et al., 2012; Zachariades et al., 2006; Zhou et al., 2013), remains controversial. The closed reduction has been used for a long time regardless of the type of fracture and displacement. Since then, open reduction internal fixation (ORIF) has become widely used. Surgical management is the only way to achieve the proper reduction of a displaced fracture and should avoid intermaxillary fixation. Despite these advantages, this treatment has a bad reputation due to the possible complications, the main one being damage to the facial nerve with resulting facial palsy. In addition, there are questions remaining about the best osteosynthesis material (OSM) and the surgical approach that should be used. Studies on condylar fracture are often conducted on small samples of patients and/or a wide range of different OSMs.

* Corresponding author. Service de Chirurgie Maxillo-Faciale, Hopital Civil, 1, Place de L’hopital, 67000 Strasbourg, France. Tel.: þ33 669344389. E-mail address: [email protected] (H. Zrounba).

We reviewed the condylar fractures managed with ORIF in our department over 5 years. We mainly used 2 types of OSMs, one for subcondylar fractures and one for diacapitular fractures. We used cutaneous approaches only. We studied: the epidemiology of condylar fractures, the surgical treatment outcomes, types and rates of complications after surgical treatment. The goal of this study is to assess whether or not the surgical treatment of condyle fractures is safe and reliable using specific OSM when possible. This series of patients is different from the one presented by Meyer et al., in 2008 as no patient of this previous study were included in this paper (Meyer et al., 2008). 2. Material and methods 141 patients underwent surgical treatment for mandibular condyle fracture between 2005 and 2010 in the maxillofacial surgery department of the university hospital of Strasbourg (Strasbourg, France). 114 patients (80.9%) had unilateral mandibular condyle fracture and 27 (19.1%) had bilateral fractures for a total of 168 mandibular condyle fractures. Surgical treatment with open reduction internal fixation (ORIF) was chosen in patients who presented clinically with either a

1010-5182/$ e see front matter Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2014.01.002

Please cite this article in press as: Zrounba H, et al., Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.002

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H. Zrounba et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6

dysocclusion or and abnormal relationship of the jaw. Imaging criteria were: displaced fracture and/or loss of mandibular ramus height. These criteria are agreed by most surgical teams managing condylar fractures (Villarreal et al., 2004) (Chrcanovic, 2012). We have recorded for each patient: age, type of fracture, type and number of associated facial fractures, aetiology, type of osteosynthesis material used. In accordance with the Loukota classification, we classified the fractures as: diacapitular, high subcondylar fracture (HSCF) and low subcondylar fracture (LSCF) based on the imaging (Orthopanthomogram and/or CT Scan). HSCF being the condylar neck fracture in Loukota classification and LSCF being the condylar base fracture. Diacapitular fractures are the same as in Loukota classification (Loukota et al., 2005). All of the 141 patients were treated with ORIF. For low subcondylar fractures, the high submandibular approach (or modified Risdon approach) was used in every case (Meyer et al., 2006a,b). For diacapitular fractures, a pre-auricular approach was used. For high subcondylar fractures, the pre-auricular approach and the high submandibular approach (HSMA) were used, one or the other or as a combined approach (Fig. 1). The osteosynthesis material used depended on the type of fracture. For diacapitular fractures we used two 2.0 titanium position screws used as lag screws (15e17 mm). A separate larger drill was used for the lateral fragment. This way, both screws were set in place using the lag-screw technique. For HSCFs, we used MODUSÒ TCP 2.0 4 holes titanium condyle plates (MEDARTIS, Basel, Switzerland). For LSCFs, the 4 holes or 9 holes MODUSÒ TCP titanium condyle plates (MEDARTIS, Basel, Switzerland) (Meyer et al., 2007) were used. The choice was made depending on the fracture level. Few patients (8.9%) were treated with other OSMs including DELTA plates and linear 2.0 titanium plates (Fig. 2). All patients underwent post-operative physiotherapy to support post-operative mandible mobility. After surgery, we had a clinical and radiological follow up and clinical examination a few days after surgery (i.e., stitches removal time), then at 6 weeks, 3 months, 6 months and one year after surgery. Each time, we recorded: mouth opening, left and right laterotrusion. On the 141 patients, 76 underwent the follow up for 3 months or more (53.9%). We also recorded the complications related to the surgical procedure as haematoma, infection, facial palsy, plate fracture/OSM loosening and hypertrophic scar. Haematoma and facial palsy being

immediate complications, we have assessed their incidence on all of the 141 patients who undergone surgery. 3. Results On the 141 patients, 105 (75%) were males and 36 (25%) were females (sex ratio 3:1). Age of the patients ranged from 8 years to 84 years with a mean of 35 years (SD  17.15). The distribution of each type of fracture is summarized in Tables 1 and 2. The LSCFs stand for almost two thirds (64.8%) of mandibular condyle fractures. Falls were found to be the main aetiology for condylar fractures in this study (30%). Two other frequent aetiologies were assaults (25 %) and road traffic accidents (RTA) (27%). Bikes were implied in a third (33%) of RTAs. Work accidents (2%), domestic accidents (4%) and other causes (10%) represent the remaining aetiologies (Table 3). 88 patients (62%) had associated facial fractures which represent 102 fractures. Most of these associated fractures were located at the mandible (81.3%) with the symphysis and parasymphysis area as the main location (81%). The other associated fractures were LEFORT (I, II, III), zygoma and orbital floor fractures. The distribution of concomitant fractures is detailed in Table 4. We frequently used MODUS TCP condylar plates. Two thirds of the fractures (66%) were treated with these miniplates. 50% of the internal fixations were performed with the 4 holes condylar plate. This type of device is not suitable for fixation of diacapitular fractures where two 2.0 titanium lag screws were used. Thus, 27 fractures (16 %) were treated with double screw fixation. At the beginning of the study, some DELTA plates were used in our department. We included 15 fractures (9%) managed with this device. A few cases were treated using other fixation devices (9%). The data of OSMs are summarized in Table 5. On the 76 patients who followed the follow up protocol, we measured a mean mouth opening of 42.10 mm at 3 months (Range: 21e56, SD  7.89). All of these patients, except one, had the same occlusion as before the trauma. Only one dysocclusion was reported (0.7%). Mean right laterotrusion of 9.85 mm (Range: 1e18, SD  3.52) and mean left laterotrusion of 10.27 mm (Range 1e17, SD  2.84) were reported. In these patients, we observed 7 cases of screw loosening or plate fracture, three with DELTA plates, four with TCP 4 holes plates. Five occurred in patients with HSCFs, two of them had bilateral HSCFs. The two others occurred in patients with LSCFs (Table 6).

Fig. 1. From left to right: low subcondylar fracture (LSCF), high subcondylar fracture (HSCF), diacapitular fracture (Green: fracture line, red: approach).

Please cite this article in press as: Zrounba H, et al., Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.002

H. Zrounba et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6

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Fig. 2. From left to right: TCP 9 holes plate, TCP 4 holes plate, Delta plate, 15 and 17 mm 2.0 titanium screws.

Screw loosening occurred in a patient with an edentulous mandible. After reviewing the X-ray exams of those cases, we found out that initial reduction was sub-optimal in those patients. We recorded one case of a misplaced intra-articular screw and one reduction failure in the patients with diacapitular fractures. The patient with the misplaced screw had a trifocal fracture of the mandible (right HSCF, left diacapitular, symphysis). The screw has been removed and further healing of the fracture was uneventful with a 55 mm mouth opening at 6 months. In a patient with bilateral comminuted diacapitular fractures, we were unable to restore a normal occlusion. Both fractures had been handled with ORIF initially. Then the OSM was removed and we switched to closed treatment. None of these treatments managed to restore a normal occlusion. On a total of 27 diacapitular fractures treated with ORIF using 2 lag screws, 25 (92.5%) had an uneventful postoperative course with good functional result. Seven patients (4.9%) of the 141 who underwent surgery had facial nerve damage. Six of them had a pre-auricular approach. In 5 cases the nerve damages resulted in facial palsy in the temporal branch territory, 4 being transient. One had a Frey syndrome after a pre-auricular approach. One had a permanent facial palsy in the buccal branch territory after a high submandibular approach. This is the only case in our study where this approach has produced nerve damage (Table 7). Only one patient had a haematoma in the post-operative time after a pre-auricular approach. A surgical evacuation was done. None of the patient complained about the scar. There were no hypertrophic scars. 4. Discussion Our study shows very good results of ORIF in condylar fractures regardless of the level of fracture. It has been proved that ORIF Table 1 Type of fractures distribution. Type of fracture

Left

Right

Total

Unilateral fractures HSCF LSCF Diacapitular Bilateral

5 (3.5%) 54 (35.76%) 3 (2.12%)

7 (4.96%) 36 (25.53%) 9 (6.38%)

114 (81%) 12 (8.5%) 90 (64.8%) 12 (8.5 %) 27 (19%)

provides the best results with more comfort for the patients (Schneider et al., 2008). Ellis stated that the open treatment was associated with faster recovery of mandibular movements (Throckmorton and Ellis, 2000). Reduction should be particularly good in patients with HSCFs and/or bicondylar fractures, partially edentulous mandible. If the reduction is approximate, the risk of loosening or plate fracture is high. Almost all of the problems we encountered with the osteosynthesis occurred in these cases (Seemann et al., 2011). The good results of osteosynthesis using TCP plates can be explained by the fact that it is a specific device for condylar fractures. Designing of these plates was made considering the biomechanics of the condylar area of the mandible (Meyer et al., 2002; Meyer et al., 2008). Some authors found that using two 4 holes plates was the best way to perform osteosynthesis of condylar fractures (Christopoulos et al., 2012; Lauer et al., 2007; Meyer et al., 2006a,b). This may be true when the two plates are ideally set in place. In clinical practice, it may be hard to put 4 screws in the proximal fragment of the fracture and to set the 2 plates according to strain lines. The TCP plate is much easier to place and makes the procedure faster (Meyer et al., 2008). We recorded a complication rate of 4.8% related to TCP 4 holes plates. On those complications, only one plate fracture occurred on the 83 TCP 4 holes used (1.2%). This rate is lower than most of those reported for other osteosynthesis devices (Seemann et al., 2007; Undt et al., 1999). No complication related to TCP 9 hole plates occurred in the study. These are evidences that the principles which led to the design of TCP plates are appropriate, making it strong enough in clinical application. The HSMA approach should be more widely used regarding our experience. On all the LSCFs we handled, some could be considered

Table 2 Bilateral fractures distribution. Site of fracture

Total

Diacapitular R þ L HSCF R þ L LSCF R þ L LSCF right þ diacapitular left HSCF right þ diacapitular left HSCF right þ LSCF left Diacapitular right þ HSCF left

5 7 7 3 2 1 2

(18.5%) (25.9%) (25.9%) (11.1%) (7.4%) (3.7%) (7.4%)

Please cite this article in press as: Zrounba H, et al., Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.002

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H. Zrounba et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 Table 3 Aetiologies. Fall Road traffic accident (RTA) Assault Work accident Domestic accident Others Epilepsy Total

Table 5 Osteosynthesis material used. 42 37 36 3 6 15 2 141

(29.78%) (26.6%) (25.53%) (2.1%) (4.2%) (10.63%) (1.24%) (100%)

eligible for an intra-oral approach. But we think that we achieved better result with an extra-oral approach as we encountered only 2 cases of plate fracture or screw loosening on the 108 LSCFs fixed (1.8 %). In all of our patients, there was no need for post-operative elastic IMF. Furthermore, we had only one facial palsy on the buccal territory using this approach, which is very low compared to other extra-oral approaches that are more commonly used (Lutz et al., 2010; Manisali et al., 2003). This low rate of facial nerve damages was previously reported by Meyer et al. (Meyer et al., 2006a,b). We think that this rate of facial nerve related complications is acceptable regarding to the outcomes. This approach should be preferred to the classic Risdon approach that is providing more conspicuous cervical scars. HSMA provides a facial scar that is hidden a few millimetres below the mandible basal border being therefore less noticeable (Handschel et al., 2012). In addition, HSMA provides a direct sight to the fracture (Schneider et al., 2007) with less traction on soft tissues, making the reduction and the osteosynthesis easier. Handschel et al. compared the complications related to retromandibular and submandibular approaches. They found that haematomas and temporary salivary fistulas were more frequent in retromandibular approach. On the other hand, permanent facial palsy was more frequent with the submandibular approach. No statistically significant differences in the functional outcome between those two approaches were found, no matter the level of fracture (Handschel et al., 2012). With the HSMA, we recorded only one facial nerve palsy in the buccal territory (less than 1% of the HSMAs performed). No haematoma occurred using that approach. The retromandibular approach seems to be a valid alternative to HSMA. The complication rate is comparable to HSMA and the anatomic and functional outcomes seem to be similar. We think that aesthetic result in HSMA is better than in the retromandibular approach because the scar is hidden below the mandibular border. In addition, salivary fistulas are virtually impossible with HSMA. Some advocate the intra-oral approach for management of mandibular condyle fractures (except diacapitular fractures). The main arguments being that it’s free of risk for the facial nerve and that it leaves no scar. Nevertheless, transient facial palsy is regularly observed in the studies. On the other hand, intra-oral approaches are commonly Table 4 Associated facial fractures. Location

n

Mandible Symphysis and parasymphysis Angle Body TOTAL for mandible LEFORT (I, II or III) Zygoma Others (ex: orbital floor) Total

67 9 7 83 5 7 7 102

(65.6%) (8.8%) (6.9%) (81.37%) (4.9%) (6.9%) (6.9%) (100%)

Type of OSM

n

TCP 4 holes TCP 9 holes DELTA plates Double screw Others

83 28 15 27 15

(49.10%) (16.66%) (8.9%) (16.07%) (8.9%)

associated with higher complication rate such as OSM related complications, bad reductions or loss of reduction. Gonzalez-Garcia et al. performed osteosynthesis of subcondylar fractures on 17 patients with an endoscopic-assisted transoral approach. On these 17 patients, one had a bad reduction. In 15 cases, additional transbuccal incisions were performed and 11 fractures were fixed with one plate instead of two as biomechanical studies suggest (Gonzalez-Garcia et al., 2009). Veras et al. studied intra-oral access on 25 patients with 30 condylar fractures. 28 fractures were LSCFs and only 2 were HSCFs. 17 fractures were fixed with one plate. Some patients had to undergo elastic intermaxillary fixation (IMF) in the post-operative period (Veras et al., 2007). Jensen et al. studied a series of 15 patients with 24 fractures. The fractures were also fixed with one plate. Class II training elastics were applied on the side of the fracture after surgery. The authors stated that the reductions obtained were good but 6 out of the 15 patients presented a dysocclusion after the surgery. They had to undergo grinding of teeth or orthodontic treatment. In addition, 3 plate fractures were recorded and a patient had to be reoperated on for a malposition after initial surgery (Jensen et al., 2006). One of the main goals of ORIF in condylar fracture is to avoid IMF or training elastics. Schmelzeisen et al. carried out a randomized controlled trial to compare extra-oral approaches and endoscopically assisted intraoral approach. No differences were found in the functional outcomes. Most of the patients undergoing intra-oral approaches were treated using one plate. The median operation time was 33 min faster for the extra-oral approaches group. Additional transbuccal incisions were needed in a third of the patients in the intra-oral approach group. The facial nerve related complications in this study are superior to our findings but the authors mostly used the retromandibular approach (29 out of 34 procedures). The study pointed out that the cosmetic result was found acceptable in both groups at one year. This suggests that the overall satisfaction of treatment is more important than the scar induced by the procedure. Intensive training in the endoscopic techniques and handling of the instruments are mandatory before the internal fixation using a transoral approach can be performed (Schmelzeisen et al., 2009). Table 6 Screw loosening/plate fracture. Type of fracture

OSM

Surgical approach

Bilateral HSCF Bilateral HSCF HSCF HSCF HSCF LSCF LSCF Total

2 TCP 4 holes plates

Pre-auricular

2 TCP 4 holes plates TCP 4 holes plate DELTA plate DELTA plate TCP 4 holes plate DELTA plate 4 TCP plates 3 DELTA plates

Complication

Screw loosening on both side Pre-auricular Screw loosening on the left side Modified Risdon Screw loosening Pre-auricular Screw loosening Pre-auricular Plate fracture Modified Risdon Plate fracture Modified Risdon Screw loosening (4.8% of TCP 4 holes plates used) (20% of DELTA plates used)

Please cite this article in press as: Zrounba H, et al., Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.002

H. Zrounba et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e6 Table 7 Facial nerve related complications. Type of fracture

Surgical approach

Complication

HSCF HSCF HSCF HSCF Diacapitular HSCF LSCF Total

Pre-auricular Pre-auricular Pre-auricular Pre-auricular Pre-auricular Pre-auricular HSMA

Facial palsy (temporal territory) Facial palsy (temporal territory) Facial palsy (temporal territory) Facial palsy (temporal territory) Facial palsy (temporal territory) Frey syndrome Facial palsy (buccal territory) 7 patients

As these studies consist of a small number of patients it is hard to make conclusions about the complication rates but the complications related to OSM or reduction seem to be more frequent than when an extra-oral approach is used. Those data suggest that the access to the fracture site is not as good with intra-oral approach even with the help of an endoscope as it is with extra-oral approaches and that reduction of the fracture may be difficult in some cases. For diacapitular fractures, the study shows good results of internal fixation with 2 lag screws. Open treatment of diacapitular fractures provides good enough anatomical and functional results (Hlawitschka et al., 2005). Neff et al. proved with biomechanical studies that osteosynthesis with 3 small fragment screws (1.7 mm) provide a greater stability (Neff et al., 2004). Placement of 3 screws is not possible with the pre-auricular approach in case of using 2.0 screws and regarding our experience, two 2.0 lag screws (length: 15 or 17 mm) are enough for a stable osteosynthesis. Post-operative physiotherapy is essential to prevent scar-induced articular movement limitation. Resorbable OSMs don’t yet seem as strong as titanium OSMs. Titanium seems to be the only available material that can bear occlusal loadings (Neff et al., 2004) (Schneider et al., 2011). Studies have been published on the use of bioresorbable OSMs for subcondylar and condylar head fractures. Suzuki et al. studied Poly-L-lactide plates and screws for LSCFs and HSCFs. On the 14 patients, 8 had fractures without displacement. No screw loosening or plate breakage was observed. The functional results were good but 13 patients had to undergo elastic IMF for 4 weeks (Suzuki et al., 2004). Singh et al. studied the same polymer on 12 patients. In half cases the results were judged unsatisfactory with intraoperative instability of the fractured fragments. To obtain satisfactory occlusion, all patients had to undergo elastic IMF for more than a week. Seven intraoperative screw breakages occurred. These two studies also highlight the fact that the handling of bioresorbable materials is more sophisticated than metal devices (Singh et al., 2013). Regarding the use of bioresorbable materials in diacapitular fractures, in vitro studies are available but very few data dealing with clinical practice are published. Müller-Richer et al. performed 4 osteosynthesis of intracapsular condyle fractures using resorbable pins. One fracture dislocated again after fixation. For the 3 others, the results were good. All patients had to undergo elastic IMF for 14 days. Those results are promising but resorbable pins still have to be studied on larger groups of patients (Muller-Richter et al., 2011). Regarding our experience, locking plates will not improve the result of osteosynthesis as it is less adaptative and interferes with the usual reduction procedure. Locking plates should be reserved for proper indications (Haim et al., 2011; Seemann et al., 2009). According to our experience, the pre-auricular approach is an excellent access to the condylar head. This approach can provide

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temporary facial nerve damages and is more difficult. It has to be used by trained surgeons. For diacapitular fractures, the retroauricular approach can be used. It provides good access to the condylar head with low risk for the facial nerve and leaves an invisible scar. One complication that can occur using this approach is auditory stenosis. Neff et al. provided the largest study using this approach. 58 patients with 74 condylar head fractures were included. Good results were found regarding the reduction and osteosynthesis stability. They stated that the retroauricular approach provides better sight to the dorsal aspect of the condyle (Neff et al., 2004). Arcuri et al. published a series of 14 patients with diacapitular fractures. The transmeatal retroauricular approach was used for all cases. The reduction was good in all but one patient. No complication occurred. The study emphasizes the importance of meticulous multilayer closure to avoid auditory stenosis (Arcuri et al., 2012). No larger study on this approach is available. 5. Conclusion Open reduction internal fixation of condylar fractures is safe and reliable if used within good indications. Anatomical reduction and fixation stability are keys to good healing of the fracture. For best results, it has to be associated with post-operative physiotherapy. HSMA and pre-auricular approaches provide good access to the fracture which allows more precise reduction and fixation. Our study shows good results for the use of specific osteosynthesis materials. These devices allow a stable osteosynthesis while making the procedure easier. Most of the problems occur in high subcondylar fractures, especially when bilateral. Optimal anatomical reduction has to be achieved in such fractures to avoid complications. A technique is tending to be used widely when it is simple, not needing extra hardware, efficient and acceptable for the patient with low morbidity. In addition it has to have if possible a limited cost. Use of TCP plates with HSMA meets those criteria. Conflict of interest statement The senior author was involved in the development of TCP plates in cooperation with MedartisÒ. Nevertheless, the authors received no grants for this study. Grants No grants were received by the authors. References Arcuri F, Brucoli M, Benech A: Analysis of the retroauricular transmeatal approach: a novel transfacial access to the mandibular skeleton. Br J Oral Maxillofac Surg 50: e22ee26, 2012 Bormann KH, Wild S, Gellrich NC, Kokemuller H, Stuhmer C, Schmelzeisen R, et al: Five-year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and complications. J Oral Maxillofac Surg 67: 1251e1255, 2009 Chrcanovic BR: Open versus closed reduction: diacapitular fractures of the mandibular condyle. Oral Maxillofac Surg 16: 257e265, 2012 Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN: 1,454 mandibular fractures: a 3year study in a hospital in Belo Horizonte, Brazil. J Craniomaxillofac Surg 40: 116e123, 2012 Christopoulos P, Stathopoulos P, Alexandridis C, Shetty V, Caputo A: Comparative biomechanical evaluation of mono-cortical osteosynthesis systems for condylar fractures using photoelastic stress analysis. Br J Oral Maxillofac Surg 50: 636e 641, 2012 Gonzalez-Garcia R, Sanroman JF, Goizueta-Adame C, Rodriguez-Campo FJ, ChoLee GY: Transoral endoscopic-assisted management of subcondylar fractures in 17 patients: an alternative to open reduction with rigid internal fixation and closed reduction with maxillomandibular fixation. Int J Oral Maxillofac Surg 38: 19e25, 2009

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Please cite this article in press as: Zrounba H, et al., Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.002

Epidemiology and treatment outcome of surgically treated mandibular condyle fractures. A five years retrospective study.

Surgical management of mandibular condyle fractures is still controversial. Although it provides better outcome than closed treatment questions still ...
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