CLINICAL PAPER
Management of Malocclusion and Facial Asymmetry Secondary to Fractures of the Mandibular Condyle Process Chien-Tzung Chen, MD,* Sydney Ch’ng, MD, PhD,Þ Faye Huang, MD,þ and Yu-Ray Chen, MD§ Introduction: Most condylar process fractures can be managed conservatively with satisfactory outcome. However, unsuccessful treatment can result in malocclusion and facial asymmetry. We report our experience in surgical management of malunited condylar process fractures. Methods: This is a retrospective review of clinical records, photographs, imaging, and dental models of 12 consecutive patients who presented with malocclusion and facial asymmetry after nonoperative or failed treatment of condylar process fractures. Eight patients who presented relatively early (G6 months) after the initial trauma were treated with subcondylar osteotomy (SCO), whereas 4 patients who presented relatively late (918 months) were treated with sagittal split osteotomy (SSO). These 2 groups were compared in terms of 3 parameters, namely, maximum mouth opening, aesthetic improvement, and patient satisfaction. Results: The 2 groups were statistically similar in all 3 parameters, with the SCO group trending toward higher scores in all 3 parameters. The mean increase in maximal mouth opening in the SCO group was 21 versus 2.5 mm in the SSO group. Conclusions: Subcondylar osteotomy, performed at a relatively early time point, is at least as effective, if not more effective, than traditional SSO in the treatment of subcondylar malunions. Given this finding, a lower threshold should be adopted for the primary treatment of acute subcondylar fractures with open reduction and internal fixation, especially those with moderate displacement that may be at high risk for malunion. Key Words: malocclusion, facial asymmetry, mandibular fracture, condylar fracture (Ann Plast Surg 2013;71: S8YS12)
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ost condylar fractures can be managed conservatively with a satisfactory outcome.1 The choice of conservative or operative management is determined, to an extent, by factors such as level of fracture, degree of displacement, the extent of ramus shortening, the presence of malocclusion, and the likelihood of patient compliance with prolonged intermaxillary fixation. With an appropriate intermaxillary fixation regimen of arch bars and elastics and mouth-opening exercises, it is accepted that most cases of condylar fracture will develop a neoarticulation that is functional and pain-free without necessarily being anatomically correct.1 Rarely, delayed presentation or unsuccessful treatment results in malocclusion, facial asymmetry, and other unfavorable sequelae including restricted motion, and pain in the temporomandibular joint (TMJ).1 Various methods have been reported for Received October 1, 2013, and accepted for publication, after revision, October 6, 2013. From the *Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung, Chang Gung University, College of Medicine, Chang Gung Research Center, Linkou, Taiwan; †Plastic Surgery Department, University of Texas MD Anderson Cancer Center, Houston, TX; ‡Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Kaohsiung, Chang Gung University, Kaohsiung; and §Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Linkou, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Chien-Tzung Chen, MD, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, Chang Gung Research Center, Linkou, Taiwan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7101-S008 DOI: 10.1097/SAP.0000000000000039
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correction of malocclusion in this instance, for example, functional rehabilitation, orthodontics, orthognathic surgery, and TMJ reconstruction.1Y6 Literature on correction of facial asymmetry secondary to condylar fracture is relatively scarce. A period of 9 months or longer after a fracture is considered to be the time necessary for remodeling and establishment of stability of the neoarticulation; surgery performed after this time is considered to be delayed.3 The most common form of orthognathic surgery performed for the correction of malocclusion secondary to delayed or failed fracture treatment of the mandibular condyle is probably the sagittal split osteotomy (SSO). The aim of this study was to analyze and compare the outcomes of 2 different approaches to the repair of malunited condyles with facial asymmetry.
PATIENTS AND METHODS A retrospective review was carried out on 12 consecutive patients (5 men and 7 women; median age, 25 years; range, 18Y38 years) who underwent corrective surgery at our department from April 2005 to March 2009. The surgery for malocclusion and facial asymmetry as a result of condylar process fracture(s) was performed by the senior author. Demographic data of the patients are presented in Table 1. Among these 12 patients, there were 18 condylar process fractures. Fracture configurations included unilateral subcondylar (n = 4), bilateral subcondylar (n = 4), unilateral condylar head (n = 2), bilateral condylar head (n = 1), and one condylar head and opposite subcondylar (n = 1) (Chen’s type 2).7 Eleven patients had an additional fracture at the symphysis (n = 8), body (n = 2), and parasymphysis (n = 1). Five (41.7%) of the 12 patients had concomitant midfacial fracture. However, none of these were in the SSO group. Two patients had previously undergone primary open reduction and internal fixation (ORIF) of their condylar process fractures. Three patients presented initially to our institution, whereas the remaining were referred from other institutions. Presenting complaints after failed primary treatment included anterior or unilateral open bite, chin deviation, and retrognathia. Eight patients who presented with subcondylar fracture less than 6 months after injury were included in our study cohort and treated with subcondylar osteotomy (SCO), and 4, who presented with condylar head/subcondylar fracture more than 6 months ago were treated with SSO (Table 1).
Treatment Strategy Successful management warrants a multidisciplinary approach involving close collaboration with our experienced dental, orthodontic, and prosthodontic colleagues. A thorough clinical history and close examination of facial proportions and occlusion is critical. Anterior and lateral cephalograms, and computed tomography images (axial, coronal, sagittal, and 3-dimensional reconstruction) were obtained. A dental model and an occlusal splint were fashioned preoperatively. A rehabilitation regimen to maximize preoperative mouth opening combined with nonsurgical orthodontic correction of malocclusion to prevent postoperative relapse are an integral part of any successful treatment. For the SCO group, corrective surgery was carried out when the patients’ functional improvement had reached a plateau. All patients within this group underwent surgery within 6 months of their initial trauma (Table 1). A retromandibular approach was used to make an SCO along or near the old fracture site (Fig. 1) to allow realignment of Annals of Plastic Surgery
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Management of Malunited Condylar Process Fractures
TABLE 1. Basic Demographic, Pattern of Facial Fracture, Presentation, and Treatment Information Case
Age, y
Sex
Fracture
1* 2 3 4 5 6 7 8 9
19 28 21 36 32 20 38 21 21
F F M M F F F F M
Left subcondyle Left subcondyle Left subcondyle Right subcondyle Bilateral subcondyle Bilateral subcondyle Bilateral subcondyle Bilateral subcondyle Left condyle head
10* 11 12*
21 18 25
M F M
Right condyle head Bilateral condyle head Right subcondyle/Left condyle head
Associated Mandibular Fractures
Midfacial Fractures
Primary Treatment
Right body Right parasymphysis Symphysis Symphysis Symphysis Right body Symphysis Symphysis Nil
Y N Y Y N Y N Y N
Closed Closed Closed Closed Closed Closed Closed Closed Closed
Symphysis Symphysis Symphysis
N N N
Closed Open Open
Presentation Anterior open bite Right open bite, chin deviation to left Chin deviation to left Anterior open bite Retrognathia, chin deviation to right Retrognathia, chin deviation to right Anterior open bite, retrognathia Anterior open bite, wide face Right open bite, chin deviate to left, retrognathia Anterior open bite Chin deviation to left Retrognathia
Time to Surgery, mo 2 3 3 5 6 6 3 5 38 18 28 18
Patients 1 to 8 underwent SCO and patients 9 to 12 bilateral SSO. *Primary treatment carried out at our institution. F indicates female, M, male; N, no; Y, yes.
the malunited subcondylar fragment. After repositioning of the condylar head back into the glenoid fossa and, more importantly, restoration of the posterior ramus height were achieved, the osteotomy site was fixed with a single 2.0-mm miniplate. An adequate proximal segment should be maintained to ensure viable blood supply to the condylar process. In most cases, a second osteotomy at the mandibular symphysis or body was necessary for optimal correction of the malocclusion and facial asymmetry (Fig. 2). All 4 patients in the SSO group underwent surgery at least 6 months after their initial trauma. Some authors describe first performing an SSO on the ipsilateral side, and, depending on the extent to which the mandible passively rotates toward normal occlusion after the first osteotomy, only on the contralateral side if required. However, we found that bilateral SSO was generally warranted for effective correction.3,6 Two patients required additional LeFort I osteotomy to correct preexisting midfacial retrusion or tilting occlusal plane of the midface (Fig. 3).
SCO. An overall increase in MMO was achieved in both groups, with a mean of 21 mm (range, 10Y44 mm) in the SCO group versus 2.5 mm (range, 0Y5 mm) in the SSO (P = 0.2). No patients experienced aggravation in TMJ symptoms but preexisting TMJ pain persisted postoperatively in 2 patients (1 from each group). Plate exposure was detected in 1 SSO patient, in whom the plate was removed and ceased to be problematic. One patient experienced surgical wound cellulitis which resolved with conservative management. No facial nerve injury was observed in either group. The time interval between fracture and surgical treatment in the SSO group ranged from 18 to 38 months. This was considerably longer
Follow-up At follow-up in the outpatient clinic, patients were requested to score their impression of the aesthetic improvement afforded by the corrective surgery, and their overall satisfaction. A 5-point scoring system was used for both (Table 2). Maximum mouth opening between the incisors was measured, and complications recorded. The mean follow-up period was 17.7 months (range, 10.5Y49 months).
RESULTS Preoperatively, the mean ramus shortening as measured on anterior cephalogram was 7.11 mm (range, 3Y12 mm) and 6 mm (range, 4Y8 mm) for the SCO and SSO groups, respectively. Preoperative mean MMO was 21.75 mm (range, 6Y35 mm) for the SCO group and 32.5 mm (range, 30Y40) for the SSO group (P = 0.26). These parameters were not statistically different between the 2 treatment groups, P = 0.95 and P = 0.26, respectively. There was an overall improvement in cosmesis, but the difference between the 2 groups was not statistically significant [4.33 (0.82) for the SCO group vs 3.25 (1.26) for the SSO group, P = 0.2]. There was, however, a trend toward greater overall satisfaction in the SCO group (4.3 vs 3.5, P = 0.06) (Fig. 4). All patients exhibited stable occlusal results without relapse of malocclusion. The follow-up radiographs did not reveal any arthritic changes of the condylar head after * 2013 Lippincott Williams & Wilkins
FIGURE 1. Subcondylar osteotomies were recreated along the old fracture line (arrow), as demonstrated in the sagittal computed tomography image. www.annalsplasticsurgery.com
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FIGURE 2. Top row (left to right), Frontal and profile views, occlusion and panorex view of a patient who presented with chin deviation and retrognathia after open reduction and internal fixation of fracture of the mandibular symphysis and conservative management of bilateral subcondylar fractures. Bottom row (left to right), Frontal and profile views, occlusion and panorex view after bilateral subcondylar and symphyseal osteotomies. Follow-up at 11 months showed that chin deviation and retrusion remained corrected, and occlusion and posterior facial height were reestablished.
than the SCO group (2Y6 months) mainly because SSO is typically performed in a delayed setting after the effect of physical therapy has plateaued and when the presurgical orthodontic treatment is deemed adequate. SCO group is carried out much sooner after the initial trauma to recreate the fracture line.
DISCUSSION The incidence of malocclusion after malunited condylar process fractures has been reported as 1.4% to 13%. It is a complication that can
occur despite appropriate and timely primary treatment, open or closed. The loss of ramus height is an important contributing factor that is difficult, if not impossible, to correct with conservative treatment except in the mildest of cases. It is likely that loss of posterior facial height on the side of fracture in these patients is an adaptation that helps reestablish a new temporomandibular articulation.8 Severe fracture angulation, displacement and dislocation, and bilaterality increase the likelihood of closed treatment failure. In a randomized study of open versus closed treatment of acute condylar process fractures, Schneider et al9
FIGURE 3. Top row (left to right), Frontal and profile views, occlusion and panorex view of a patient who presented with chin deviation, anterior open bite and progressively tilting occlusal plane after open reduction for right condylar neck fracture and conservative treatment of left condylar head fracture. Bottom row (left to right), The patient was followed up for 4 years and showed improvement in cosmesis and stable occlusion after bilateral sagittal split and Le Fort I osteotomies. S10
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TABLE 2. Patient Self-Assessed Aesthetic Improvement and Overall Satisfaction Scoring System Aesthetic Improvement 5 Very much improved 4 Much improved 3 Improved 2 No change 1 Worse Overall Satisfaction 5 Very much satisfied 4 Very satisfied 3 Somewhat satisfied 2 Neutral 1 Dissatisfied
advocated the use of ORIF for fractures with a deviation of 10 to 45 degrees, or a shortening of the ascending ramus greater than or equal to 2 mm irrespective of the fracture level based on a randomized study of open versus closed treatment of acute condylar process fractures. It is interesting that although Ellis’ group consistently demonstrated in a relatively large series that ORIF for mandibular condylar (neck and subcondylar) fractures resulted in superior outcomes in occlusion, facial symmetry, and TMJ range of motion than closed reduction,8,10,11 they continue to argue against the adoption of a low threshold for primary ORIF. Their justification is based on the premise that secondary orthognathic surgery after failed primary treatment is highly reliable, an opinion shared by Becking et al.3 A recent international prospective randomized study from 7 centers, involving 66 patients and 79 displaced mandibular condyle process fractures, concluded that both closed and open treatment options yielded acceptable results. However, surgical treatment, irrespective of the method of internal fixation used, was statistically superior in all objective (mouth opening/lateral excursion/protrusion) and subjective (pain and discomfort on the Mandibular Function Impairment Questionnaire) functional parameters.12 A trend is emerging in the surgical literature confirming the superior functional results after ORIF of condylar fractures, especially with the advent of endoscopic-assisted surgery that reduces scar visibility and possibly facial nerve damage.13 For dislocated fractures, open approaches are considered the treatment of choice in many units. However, for moderately displaced condylar fractures, the use of ORIF is still controversial.1,9,12Y15 Traditionally, many patients do not receive surgical treatment for subcondylar fracture because delayed orthognathic surgery, which is usually performed as bilateral SSO, produces reliable results. Here, we propose that recreating the subcondylar fracture, that is, SCO, with concomitant mandibular symphyseal or body osteotomy in the subacute setting, produces good results and high patient satisfaction. Extrapolating from these findings, it is reasonable to deduce that ORIF is advisable in the acute setting, especially in cases where conservative management is unlikely to be completely successful. Another contentious issue regarding the approach to these patients is the optimal timing of corrective orthognathic surgery for malunited mandibular condylar fractures. The literature suggests that a minimum interval of 9 months from the initial injury produces satisfactory results.2 After this time, the occlusion will have stabilized after complete fracture healing and remodeling, creating a strong base for surgery. Many reports caution against performing secondary surgery prematurely when the structural integrity of the fracture site cannot withstand internal fixation,1,2 and when surgical dissection around the * 2013 Lippincott Williams & Wilkins
Management of Malunited Condylar Process Fractures
fragile neovascularization may result in fragment necrosis. This concern has not been borne out in our study, where no increased risk of metalware failure or condyle necrosis was encountered in the SCO group. A number of factors may necessitate earlier corrective surgery, including patient expectations, poor compliance, and a progress plateau with conservative management. We have found that recreating the subcondylar fracture after careful dissection, within 6 months of the fracture occurring, generally allows for reasonable morphologic correction and a stable outcome. Anatomical reduction of the condylar fracture, with or without relocation of a displaced condyle, after a prolonged interval, for example, 6 months, will be challenging if not impossible after fracture consolidation, fibro-osseous changes within the TMJ, and the adaptation of fibrotic and atrophied muscles to the deranged skeletal framework.16 An osteotomy at a remote site, for example, sagittal osteotomy, is the method of choice in this instance. A functional occlusion can indeed be achieved with a less than perfect neoarticulation, and/or the mandibular condyle head being positioned out with the glenoid fossa.1 Although a greater increase MMO was obtained in the SCO group than in the SSO group (21 vs 2.5 mm), gain in MMO failed to reach statistical significance in the SCO group, possibly as a result of the small number of patients in this study. The minimal increase in MMO in the SSO suggests that although effective in correcting malocclusion, SSO does not substantially improve MMO. This is probably due to the TMJ being fixed after long-term condylar process fracture and prolonged usage before corrective surgery. It would be imprudent to attempt to explain the better overall patient satisfaction in the SCO group based on the results of this limited report of our early experience in SCO for management of malocclusion and facial asymmetry secondary to condylar fracture. The small number of patients and the nonrandomization of the unmatched groups preclude direct comparison. Furthermore, our results cannot be extrapolated to the pediatric population, in whom excellent results have been consistently demonstrated with conservative management.17,18 The adaptive capacity of the developing occlusion in response to the undamaged functional matrix of the face is considerable. Even when the growth potential of the condylar region is destroyed by early trauma, the development of significant facial asymmetry is rare before puberty if function is maintained.19 Neither of the surgical methods used in this study are appropriate for the treatment of TMJ ankylosis and this condition is, therefore, not considered in our study.
CONCLUSIONS We report the senior author’s experience in the surgical management of malocclusion and facial asymmetry occurring as late
FIGURE 4. There was a trend toward greater overall satisfaction in the SCO group compared with the SSO group (4.3 vs 3.5, P = 0.06). www.annalsplasticsurgery.com
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complications of condylar process fracture. On the basis of these findings, we propose that the threshold for acute surgical intervention in fracture of the mandibular subcondyle be lowered. In addition, these results support the use of SCO instead of SSO for correction of malocclusion and facial asymmetry secondary to subcondylar malunion within 6 months after injury. REFERENCES 1. Ellis E III, Walker RV. Treatment of malocclusion and TMJ dysfunction secondary to condylar fractures. Craniomaxillofac Trauma Reconstr. 2009;2:1Y18. 2. Rubens BC, Stoelinga PJW, Weaver TJ, et al. Management of malunited mandibular condylar fractures. Int J Oral Maxillofac Surg. 1990;19:22Y25. 3. Becking AG, Zijderveld SA, Tuinzing DB. Management of posttraumatic malocclusion caused by condylar process fractures. J Oral Maxillofac Surg. 1998;56:1370Y1377. 4. Bloomquist DS. Mandibular body sagittal osteotomy in the correction of malunited mandibular fractures. J Maxillofac Surg. 1982;10:18Y23. 5. Dahlstro¨m L, Kahnberg K-E, Lindahl L. 15 years follow-up on condylar fractures. Int J Oral Maxillofac Surg. 1989;18:18Y23. 6. Zachariades N, Mezitis M, Michelis A. Posttraumatic osteotomies of the jaw. Int J Oral Maxillofac Surg. 1993;22:328Y331. 7. Chen CT, Feng CH, Tsay PK, et al. Functional outcomes following surgical treatment of bilateral mandibular condylar fractures. Int J Oral Maxillofac Surg. 2011;40:38Y44. 8. Ellis III E, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2000;58:260Y268. 9. Schneider M, Erasmus F, Gerlach KL, et al. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the
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mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg. 2008;66:2537Y2544. 10. Ellis III E, Throckmorton G. Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2000; 58:729Y730. 11. Palmieri C, Ellis III E, Throckmorton G. Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. J Oral Maxillofac Surg. 1999;57:764Y775. 12. Eckelt U, Schneider M, Erasmus F, et al. Open versus closed treatment of fractures of the mandibular condylar processVa prospective randomized multi-center study. J Craniomaxillofac Surg. 2006;34:306Y314. 13. Abdel-Galil K, Loukota R. Fractures of the mandibular condyle: evidence base and current concepts of management. Br J Oral Maxillofac Surg. 2010;48:520Y526. 14. Brandt MT, Haug RH. Open versus closed reduction of adult mandibular condyle fractures: a review of the literature regarding the evolution of current thoughts on management. J Oral Maxillofac Surg. 2003;61:1324Y1332. 15. Spitzer WJ, Vanderborght G, Dumbach J. Surgical management of mandibular malposition after malunited condylar fractures in adults. J Craniomaxillofac Surg. 1997;25:91Y96. 16. Lindahl L, Hollender L. Condylar fractures of the mandible: II. Radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg. 1977;6:153Y165. 17. Gu¨ven O, Keskin A. Remodeling following condylar fractures in children. J Craniomaxillofac Surg. 2001;29:232Y237. 18. Hovinga J, Boering G, Stegenga B. Long-term results of nonsurgical management of condylar fractures in children. Int. J Oral Maxillofac Surg. 1999; 28:429Y440. 19. Banks P. A pragmatic approach to management of condylar fractures. Int J Oral Maxillofac Surg. 1998;27:244Y246.
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Management of Malocclusion and Facial Asymmetry Secondary to Fractures of the Mandibular Condyle Process Chien-Tzung Chen, MD,* Sydney Ch’ng, MD, PhD,Þ Faye Huang, MD,þ and Yu-Ray Chen, MD§ Introduction: Most condylar process fractures can be managed conservatively with satisfactory outcome. However, unsuccessful treatment can result in malocclusion and facial asymmetry. We report our experience in surgical management of malunited condylar process fractures. Methods: This is a retrospective review of clinical records, photographs, imaging, and dental models of 12 consecutive patients who presented with malocclusion and facial asymmetry after nonoperative or failed treatment of condylar process fractures. Eight patients who presented relatively early (G6 months) after the initial trauma were treated with subcondylar osteotomy (SCO), whereas 4 patients who presented relatively late (918 months) were treated with sagittal split osteotomy (SSO). These 2 groups were compared in terms of 3 parameters, namely, maximum mouth opening, aesthetic improvement, and patient satisfaction. Results: The 2 groups were statistically similar in all 3 parameters, with the SCO group trending toward higher scores in all 3 parameters. The mean increase in maximal mouth opening in the SCO group was 21 versus 2.5 mm in the SSO group. Conclusions: Subcondylar osteotomy, performed at a relatively early time point, is at least as effective, if not more effective, than traditional SSO in the treatment of subcondylar malunions. Given this finding, a lower threshold should be adopted for the primary treatment of acute subcondylar fractures with open reduction and internal fixation, especially those with moderate displacement that may be at high risk for malunion. Key Words: malocclusion, facial asymmetry, mandibular fracture, condylar fracture (Ann Plast Surg 2013;71: S8YS12)
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ost condylar fractures can be managed conservatively with a satisfactory outcome.1 The choice of conservative or operative management is determined, to an extent, by factors such as level of fracture, degree of displacement, the extent of ramus shortening, the presence of malocclusion, and the likelihood of patient compliance with prolonged intermaxillary fixation. With an appropriate intermaxillary fixation regimen of arch bars and elastics and mouth-opening exercises, it is accepted that most cases of condylar fracture will develop a neoarticulation that is functional and pain-free without necessarily being anatomically correct.1 Rarely, delayed presentation or unsuccessful treatment results in malocclusion, facial asymmetry, and other unfavorable sequelae including restricted motion, and pain in the temporomandibular joint (TMJ).1 Various methods have been reported for Received October 1, 2013, and accepted for publication, after revision, October 6, 2013. From the *Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung, Chang Gung University, College of Medicine, Chang Gung Research Center, Linkou, Taiwan; †Plastic Surgery Department, University of Texas MD Anderson Cancer Center, Houston, TX; ‡Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Kaohsiung, Chang Gung University, Kaohsiung; and §Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Linkou, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Chien-Tzung Chen, MD, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, Chang Gung Research Center, Linkou, Taiwan. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7101-S008 DOI: 10.1097/SAP.0000000000000039
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correction of malocclusion in this instance, for example, functional rehabilitation, orthodontics, orthognathic surgery, and TMJ reconstruction.1Y6 Literature on correction of facial asymmetry secondary to condylar fracture is relatively scarce. A period of 9 months or longer after a fracture is considered to be the time necessary for remodeling and establishment of stability of the neoarticulation; surgery performed after this time is considered to be delayed.3 The most common form of orthognathic surgery performed for the correction of malocclusion secondary to delayed or failed fracture treatment of the mandibular condyle is probably the sagittal split osteotomy (SSO). The aim of this study was to analyze and compare the outcomes of 2 different approaches to the repair of malunited condyles with facial asymmetry.
PATIENTS AND METHODS A retrospective review was carried out on 12 consecutive patients (5 men and 7 women; median age, 25 years; range, 18Y38 years) who underwent corrective surgery at our department from April 2005 to March 2009. The surgery for malocclusion and facial asymmetry as a result of condylar process fracture(s) was performed by the senior author. Demographic data of the patients are presented in Table 1. Among these 12 patients, there were 18 condylar process fractures. Fracture configurations included unilateral subcondylar (n = 4), bilateral subcondylar (n = 4), unilateral condylar head (n = 2), bilateral condylar head (n = 1), and one condylar head and opposite subcondylar (n = 1) (Chen’s type 2).7 Eleven patients had an additional fracture at the symphysis (n = 8), body (n = 2), and parasymphysis (n = 1). Five (41.7%) of the 12 patients had concomitant midfacial fracture. However, none of these were in the SSO group. Two patients had previously undergone primary open reduction and internal fixation (ORIF) of their condylar process fractures. Three patients presented initially to our institution, whereas the remaining were referred from other institutions. Presenting complaints after failed primary treatment included anterior or unilateral open bite, chin deviation, and retrognathia. Eight patients who presented with subcondylar fracture less than 6 months after injury were included in our study cohort and treated with subcondylar osteotomy (SCO), and 4, who presented with condylar head/subcondylar fracture more than 6 months ago were treated with SSO (Table 1).
Treatment Strategy Successful management warrants a multidisciplinary approach involving close collaboration with our experienced dental, orthodontic, and prosthodontic colleagues. A thorough clinical history and close examination of facial proportions and occlusion is critical. Anterior and lateral cephalograms, and computed tomography images (axial, coronal, sagittal, and 3-dimensional reconstruction) were obtained. A dental model and an occlusal splint were fashioned preoperatively. A rehabilitation regimen to maximize preoperative mouth opening combined with nonsurgical orthodontic correction of malocclusion to prevent postoperative relapse are an integral part of any successful treatment. For the SCO group, corrective surgery was carried out when the patients’ functional improvement had reached a plateau. All patients within this group underwent surgery within 6 months of their initial trauma (Table 1). A retromandibular approach was used to make an SCO along or near the old fracture site (Fig. 1) to allow realignment of Annals of Plastic Surgery
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Volume 71, Supplement 1, December 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 71, Supplement 1, December 2013
Management of Malunited Condylar Process Fractures
TABLE 1. Basic Demographic, Pattern of Facial Fracture, Presentation, and Treatment Information Case
Age, y
Sex
Fracture
1* 2 3 4 5 6 7 8 9
19 28 21 36 32 20 38 21 21
F F M M F F F F M
Left subcondyle Left subcondyle Left subcondyle Right subcondyle Bilateral subcondyle Bilateral subcondyle Bilateral subcondyle Bilateral subcondyle Left condyle head
10* 11 12*
21 18 25
M F M
Right condyle head Bilateral condyle head Right subcondyle/Left condyle head
Associated Mandibular Fractures
Midfacial Fractures
Primary Treatment
Right body Right parasymphysis Symphysis Symphysis Symphysis Right body Symphysis Symphysis Nil
Y N Y Y N Y N Y N
Closed Closed Closed Closed Closed Closed Closed Closed Closed
Symphysis Symphysis Symphysis
N N N
Closed Open Open
Presentation Anterior open bite Right open bite, chin deviation to left Chin deviation to left Anterior open bite Retrognathia, chin deviation to right Retrognathia, chin deviation to right Anterior open bite, retrognathia Anterior open bite, wide face Right open bite, chin deviate to left, retrognathia Anterior open bite Chin deviation to left Retrognathia
Time to Surgery, mo 2 3 3 5 6 6 3 5 38 18 28 18
Patients 1 to 8 underwent SCO and patients 9 to 12 bilateral SSO. *Primary treatment carried out at our institution. F indicates female, M, male; N, no; Y, yes.
the malunited subcondylar fragment. After repositioning of the condylar head back into the glenoid fossa and, more importantly, restoration of the posterior ramus height were achieved, the osteotomy site was fixed with a single 2.0-mm miniplate. An adequate proximal segment should be maintained to ensure viable blood supply to the condylar process. In most cases, a second osteotomy at the mandibular symphysis or body was necessary for optimal correction of the malocclusion and facial asymmetry (Fig. 2). All 4 patients in the SSO group underwent surgery at least 6 months after their initial trauma. Some authors describe first performing an SSO on the ipsilateral side, and, depending on the extent to which the mandible passively rotates toward normal occlusion after the first osteotomy, only on the contralateral side if required. However, we found that bilateral SSO was generally warranted for effective correction.3,6 Two patients required additional LeFort I osteotomy to correct preexisting midfacial retrusion or tilting occlusal plane of the midface (Fig. 3).
SCO. An overall increase in MMO was achieved in both groups, with a mean of 21 mm (range, 10Y44 mm) in the SCO group versus 2.5 mm (range, 0Y5 mm) in the SSO (P = 0.2). No patients experienced aggravation in TMJ symptoms but preexisting TMJ pain persisted postoperatively in 2 patients (1 from each group). Plate exposure was detected in 1 SSO patient, in whom the plate was removed and ceased to be problematic. One patient experienced surgical wound cellulitis which resolved with conservative management. No facial nerve injury was observed in either group. The time interval between fracture and surgical treatment in the SSO group ranged from 18 to 38 months. This was considerably longer
Follow-up At follow-up in the outpatient clinic, patients were requested to score their impression of the aesthetic improvement afforded by the corrective surgery, and their overall satisfaction. A 5-point scoring system was used for both (Table 2). Maximum mouth opening between the incisors was measured, and complications recorded. The mean follow-up period was 17.7 months (range, 10.5Y49 months).
RESULTS Preoperatively, the mean ramus shortening as measured on anterior cephalogram was 7.11 mm (range, 3Y12 mm) and 6 mm (range, 4Y8 mm) for the SCO and SSO groups, respectively. Preoperative mean MMO was 21.75 mm (range, 6Y35 mm) for the SCO group and 32.5 mm (range, 30Y40) for the SSO group (P = 0.26). These parameters were not statistically different between the 2 treatment groups, P = 0.95 and P = 0.26, respectively. There was an overall improvement in cosmesis, but the difference between the 2 groups was not statistically significant [4.33 (0.82) for the SCO group vs 3.25 (1.26) for the SSO group, P = 0.2]. There was, however, a trend toward greater overall satisfaction in the SCO group (4.3 vs 3.5, P = 0.06) (Fig. 4). All patients exhibited stable occlusal results without relapse of malocclusion. The follow-up radiographs did not reveal any arthritic changes of the condylar head after * 2013 Lippincott Williams & Wilkins
FIGURE 1. Subcondylar osteotomies were recreated along the old fracture line (arrow), as demonstrated in the sagittal computed tomography image. www.annalsplasticsurgery.com
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FIGURE 2. Top row (left to right), Frontal and profile views, occlusion and panorex view of a patient who presented with chin deviation and retrognathia after open reduction and internal fixation of fracture of the mandibular symphysis and conservative management of bilateral subcondylar fractures. Bottom row (left to right), Frontal and profile views, occlusion and panorex view after bilateral subcondylar and symphyseal osteotomies. Follow-up at 11 months showed that chin deviation and retrusion remained corrected, and occlusion and posterior facial height were reestablished.
than the SCO group (2Y6 months) mainly because SSO is typically performed in a delayed setting after the effect of physical therapy has plateaued and when the presurgical orthodontic treatment is deemed adequate. SCO group is carried out much sooner after the initial trauma to recreate the fracture line.
DISCUSSION The incidence of malocclusion after malunited condylar process fractures has been reported as 1.4% to 13%. It is a complication that can
occur despite appropriate and timely primary treatment, open or closed. The loss of ramus height is an important contributing factor that is difficult, if not impossible, to correct with conservative treatment except in the mildest of cases. It is likely that loss of posterior facial height on the side of fracture in these patients is an adaptation that helps reestablish a new temporomandibular articulation.8 Severe fracture angulation, displacement and dislocation, and bilaterality increase the likelihood of closed treatment failure. In a randomized study of open versus closed treatment of acute condylar process fractures, Schneider et al9
FIGURE 3. Top row (left to right), Frontal and profile views, occlusion and panorex view of a patient who presented with chin deviation, anterior open bite and progressively tilting occlusal plane after open reduction for right condylar neck fracture and conservative treatment of left condylar head fracture. Bottom row (left to right), The patient was followed up for 4 years and showed improvement in cosmesis and stable occlusion after bilateral sagittal split and Le Fort I osteotomies. S10
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TABLE 2. Patient Self-Assessed Aesthetic Improvement and Overall Satisfaction Scoring System Aesthetic Improvement 5 Very much improved 4 Much improved 3 Improved 2 No change 1 Worse Overall Satisfaction 5 Very much satisfied 4 Very satisfied 3 Somewhat satisfied 2 Neutral 1 Dissatisfied
advocated the use of ORIF for fractures with a deviation of 10 to 45 degrees, or a shortening of the ascending ramus greater than or equal to 2 mm irrespective of the fracture level based on a randomized study of open versus closed treatment of acute condylar process fractures. It is interesting that although Ellis’ group consistently demonstrated in a relatively large series that ORIF for mandibular condylar (neck and subcondylar) fractures resulted in superior outcomes in occlusion, facial symmetry, and TMJ range of motion than closed reduction,8,10,11 they continue to argue against the adoption of a low threshold for primary ORIF. Their justification is based on the premise that secondary orthognathic surgery after failed primary treatment is highly reliable, an opinion shared by Becking et al.3 A recent international prospective randomized study from 7 centers, involving 66 patients and 79 displaced mandibular condyle process fractures, concluded that both closed and open treatment options yielded acceptable results. However, surgical treatment, irrespective of the method of internal fixation used, was statistically superior in all objective (mouth opening/lateral excursion/protrusion) and subjective (pain and discomfort on the Mandibular Function Impairment Questionnaire) functional parameters.12 A trend is emerging in the surgical literature confirming the superior functional results after ORIF of condylar fractures, especially with the advent of endoscopic-assisted surgery that reduces scar visibility and possibly facial nerve damage.13 For dislocated fractures, open approaches are considered the treatment of choice in many units. However, for moderately displaced condylar fractures, the use of ORIF is still controversial.1,9,12Y15 Traditionally, many patients do not receive surgical treatment for subcondylar fracture because delayed orthognathic surgery, which is usually performed as bilateral SSO, produces reliable results. Here, we propose that recreating the subcondylar fracture, that is, SCO, with concomitant mandibular symphyseal or body osteotomy in the subacute setting, produces good results and high patient satisfaction. Extrapolating from these findings, it is reasonable to deduce that ORIF is advisable in the acute setting, especially in cases where conservative management is unlikely to be completely successful. Another contentious issue regarding the approach to these patients is the optimal timing of corrective orthognathic surgery for malunited mandibular condylar fractures. The literature suggests that a minimum interval of 9 months from the initial injury produces satisfactory results.2 After this time, the occlusion will have stabilized after complete fracture healing and remodeling, creating a strong base for surgery. Many reports caution against performing secondary surgery prematurely when the structural integrity of the fracture site cannot withstand internal fixation,1,2 and when surgical dissection around the * 2013 Lippincott Williams & Wilkins
Management of Malunited Condylar Process Fractures
fragile neovascularization may result in fragment necrosis. This concern has not been borne out in our study, where no increased risk of metalware failure or condyle necrosis was encountered in the SCO group. A number of factors may necessitate earlier corrective surgery, including patient expectations, poor compliance, and a progress plateau with conservative management. We have found that recreating the subcondylar fracture after careful dissection, within 6 months of the fracture occurring, generally allows for reasonable morphologic correction and a stable outcome. Anatomical reduction of the condylar fracture, with or without relocation of a displaced condyle, after a prolonged interval, for example, 6 months, will be challenging if not impossible after fracture consolidation, fibro-osseous changes within the TMJ, and the adaptation of fibrotic and atrophied muscles to the deranged skeletal framework.16 An osteotomy at a remote site, for example, sagittal osteotomy, is the method of choice in this instance. A functional occlusion can indeed be achieved with a less than perfect neoarticulation, and/or the mandibular condyle head being positioned out with the glenoid fossa.1 Although a greater increase MMO was obtained in the SCO group than in the SSO group (21 vs 2.5 mm), gain in MMO failed to reach statistical significance in the SCO group, possibly as a result of the small number of patients in this study. The minimal increase in MMO in the SSO suggests that although effective in correcting malocclusion, SSO does not substantially improve MMO. This is probably due to the TMJ being fixed after long-term condylar process fracture and prolonged usage before corrective surgery. It would be imprudent to attempt to explain the better overall patient satisfaction in the SCO group based on the results of this limited report of our early experience in SCO for management of malocclusion and facial asymmetry secondary to condylar fracture. The small number of patients and the nonrandomization of the unmatched groups preclude direct comparison. Furthermore, our results cannot be extrapolated to the pediatric population, in whom excellent results have been consistently demonstrated with conservative management.17,18 The adaptive capacity of the developing occlusion in response to the undamaged functional matrix of the face is considerable. Even when the growth potential of the condylar region is destroyed by early trauma, the development of significant facial asymmetry is rare before puberty if function is maintained.19 Neither of the surgical methods used in this study are appropriate for the treatment of TMJ ankylosis and this condition is, therefore, not considered in our study.
CONCLUSIONS We report the senior author’s experience in the surgical management of malocclusion and facial asymmetry occurring as late
FIGURE 4. There was a trend toward greater overall satisfaction in the SCO group compared with the SSO group (4.3 vs 3.5, P = 0.06). www.annalsplasticsurgery.com
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complications of condylar process fracture. On the basis of these findings, we propose that the threshold for acute surgical intervention in fracture of the mandibular subcondyle be lowered. In addition, these results support the use of SCO instead of SSO for correction of malocclusion and facial asymmetry secondary to subcondylar malunion within 6 months after injury. REFERENCES 1. Ellis E III, Walker RV. Treatment of malocclusion and TMJ dysfunction secondary to condylar fractures. Craniomaxillofac Trauma Reconstr. 2009;2:1Y18. 2. Rubens BC, Stoelinga PJW, Weaver TJ, et al. Management of malunited mandibular condylar fractures. Int J Oral Maxillofac Surg. 1990;19:22Y25. 3. Becking AG, Zijderveld SA, Tuinzing DB. Management of posttraumatic malocclusion caused by condylar process fractures. J Oral Maxillofac Surg. 1998;56:1370Y1377. 4. Bloomquist DS. Mandibular body sagittal osteotomy in the correction of malunited mandibular fractures. J Maxillofac Surg. 1982;10:18Y23. 5. Dahlstro¨m L, Kahnberg K-E, Lindahl L. 15 years follow-up on condylar fractures. Int J Oral Maxillofac Surg. 1989;18:18Y23. 6. Zachariades N, Mezitis M, Michelis A. Posttraumatic osteotomies of the jaw. Int J Oral Maxillofac Surg. 1993;22:328Y331. 7. Chen CT, Feng CH, Tsay PK, et al. Functional outcomes following surgical treatment of bilateral mandibular condylar fractures. Int J Oral Maxillofac Surg. 2011;40:38Y44. 8. Ellis III E, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2000;58:260Y268. 9. Schneider M, Erasmus F, Gerlach KL, et al. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the
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mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg. 2008;66:2537Y2544. 10. Ellis III E, Throckmorton G. Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2000; 58:729Y730. 11. Palmieri C, Ellis III E, Throckmorton G. Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. J Oral Maxillofac Surg. 1999;57:764Y775. 12. Eckelt U, Schneider M, Erasmus F, et al. Open versus closed treatment of fractures of the mandibular condylar processVa prospective randomized multi-center study. J Craniomaxillofac Surg. 2006;34:306Y314. 13. Abdel-Galil K, Loukota R. Fractures of the mandibular condyle: evidence base and current concepts of management. Br J Oral Maxillofac Surg. 2010;48:520Y526. 14. Brandt MT, Haug RH. Open versus closed reduction of adult mandibular condyle fractures: a review of the literature regarding the evolution of current thoughts on management. J Oral Maxillofac Surg. 2003;61:1324Y1332. 15. Spitzer WJ, Vanderborght G, Dumbach J. Surgical management of mandibular malposition after malunited condylar fractures in adults. J Craniomaxillofac Surg. 1997;25:91Y96. 16. Lindahl L, Hollender L. Condylar fractures of the mandible: II. Radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg. 1977;6:153Y165. 17. Gu¨ven O, Keskin A. Remodeling following condylar fractures in children. J Craniomaxillofac Surg. 2001;29:232Y237. 18. Hovinga J, Boering G, Stegenga B. Long-term results of nonsurgical management of condylar fractures in children. Int. J Oral Maxillofac Surg. 1999; 28:429Y440. 19. Banks P. A pragmatic approach to management of condylar fractures. Int J Oral Maxillofac Surg. 1998;27:244Y246.
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