Surgical versus non-surgical treatment of fractures of the articular process of the mandible Johannes Hidding 1, Raphael Wolff, Dieter PingeP
1Dept of Oral and Maxillo-Facial Surgery (Head." Univ.-Prof. U. Joos, MD, DMD), ~Dept of Dental Prosthetics B (Head." Univ.-Prof. F. Bollmann, MD, DMD), University of Miinster, Germany.
S U M M A R Y . In a clinical, radiographic and axiographic study, we reinvestigated 34 patients with dislocated fractures of the condylar neck. 20 of them had been treated by open reduction, 14 in a conservative-functional way. The clinical results were nearly equal in both groups. The instrumental registration and the X-ray findings showed considerable deviations in the joint physiology in the conservative group. 19 of 20 patients operated on showed nearanatomical reconstruction with good functional results. KEY W O R D S : Dislocated condylar neck fracture - Surgical treatment - Axiography and radiography of the T M J - Clinical study
open reduction. These two patients-groups are comparable. The following important major examinations were carried out:
INTRODUCTION The primary aim in the treatment of fractures of the articular process of the mandible is the restoration of an undisturbed function of the TMJ. Reichenbach (1957) suggested an exclusively conservative-functional treatment and achieved good clinical results. Some authors, however, preferred an operative procedure (Petzel, 1982; Kitayama, 1989; Takenoshita et al., 1989; Eckelt, 1991) with regard to dislocated fractures of the articular process. In a recent paper, Eckelt (1991) has pointed out that the operative treatment of 103 very displaced and dislocated fractures of the articular process has led to better results than conservative therapy.
1. clinical and functional examination - mobility of the joint - subjective symptoms 2. axiography - length of protrusive movement - quality of the registration path - degree of condyle inclination 3. radiography - O P T in function - Runstr6m IV The OPT in function shows the sagittal mobility, structure and position of the condyle. We determined the degree of the condyle axis dislocation by Runstr6m 1V radiographic examination (Krenkel et al., 1982).
MATERIAL AND METHODS Within a period of 1-5 years after condylar fracture, we re-examined 34 patients with fractured condylar processes dislocated out of the fossa. The operative procedure was only performed in cases of dislocated condylar neck or subcondylar fractures. This open reduction of the fracture was done in 20 cases (7 females, 13 males) with a median age of 31 years (range: 17-60 years), via a submandibular approach, with wire or plating osteosynthesis and intermaxillary fixation for 2 weeks. Most patients were treated conservatively with intermaxillary fixation for 2 weeks and postoperative training with a jaw exerciser for 2-3 months. Out of a collective of more than 150 patients receiving conservative treatment, we found 14 cases (4 females, 10 males) with a median age of 29 years (range: 18-50 years) with fractures of the condylar process dislocated out of the fossa similar to the patient group with
RESULTS
In our examination, we found quite good results with only slight dysfunction. The average mouth opening in both groups was more than 40 mm with deviations in 64 % of the patients in the conservative group as opposed to 10 % in the operation group (Table 1). We found limitation of the lateroduction only in the nonsurgical group. As far as subjective symptoms are concerned we found no differences in mastication and incidence of headache (Table 2). The subjectivelynoticed limitation of mouth opening could not be confirmed by our clinical findings (compare with Table 1). 345
346 Journal of Cranio-Maxillo-Facial Surgery Table 1 - Clinical findings of joint mobility
Mouth opening < 30 mm Lateral deviation > 3ram Limitation of lateroduction < 5 mm Limitation of protrusive movement < 5 mm
Operative group n = 20 patients
Conservative group n = 14 patients
0 (0 %)
0 (0 %)
2 (10 %)
9 (64 %)
0 (0 %)
1 (7 %)
1 (5 %)
1 (7 %)
Table 3 - Examination with the axiographic technique (Slavicek and Mack, 1982) Operative group Conservative group n = 20 patients n = 14 patients 1. Regular axiography pattern 2. Slightly shortened path with alteration in curvature 3. Considerable shortening of the path with irregular pattern 4. Loss of curvature and no condyle inclination
12 (60%)
4 (29%)
5 (25 %)
4 (29%)
3 (15%)
2 (14%)
0 (0 %)
4 (29 %)
Table 2 - Subjective complaints after surgical and non surgical treatment of fractures of the condylar neck Operative group n = 20 patients Mastication disorder 4 (20 %) Headaches 6 (30 %) Mouth opening problems 7 (35 %)
Conservative group n = 14 patients 2 (14 %) 4 (29 %) 2 (14%)
The axiographic e x a m i n a t i o n was carried out mechanically following the technique of Slavicek a n d Mack (1982). The results of the axiography were classified into four groups: 1. regular axiographic p a t t e r n 2. slightly shortened p a t h with alterations in curvature 3, considerable shortening of the path with irregular p a t t e r n 4. loss of curvature a n d n o condyle i n c l i n a t i o n = sliding joint.
1 - The axiographic path corresponding to the clinical case in Figure 2. Right side: regular axiographic pattern. Left side: loss of curvature and no condyle inclination = sliding joint. Fig.
I n the n o n s u r g i c a l group we f o u n d m o v e m e n t disorders of the T M J in 43 % showing b a d a n d unphysiological paths in the registration (Table 3). W e f o u n d a h o r i z o n t a l path with loss of curvature (Fig. 1, left side) in 4 cases (29 %). The reason for this m o v e m e n t disorder m a y be a neoarthrosis at the skull base a n d a n empty glenoid fossa. I n c o n t r a s t to this, 85 % of the patients operated o n had regular patterns (Fig. 1, right side) sometimes with slight s h o r t e n i n g of the c o n d y l a r path. We f o u n d n o sliding j o i n t in the o p e r a t i o n group.
Fig. 2 - (a) OPT with dislocation of both articular processes. Right side: anatomical reconstruction with wire osteosynthesis. Left side : conservative therapy with a condyle in malposition. (b) OPT in function (open and closed mouth position) showing the limitation of function on the left side and good sagittal movement of the condyle on the right side.
Surgical versus non-surgical treatment of fractures of the articular process of the mandible 347 H o w mobile the particular joint actually was could also be seen in the length of the protrusive path. We found good results in both clinical groups with an average length of 10 m m and no significant difference between both groups. The sagittal angle of condyle inclination was flat in the nonsurgical group with a medium decrease of 34 degrees from the norm of 45 degrees. In the surgical group we found an average angle of 45 degrees with deviations of __ 11 degrees, showing the nearly anatomical reduction. These registration findings were confirmed by diagnostic radiography. In the operation group, 19 out of 20 joints (95 %) were anatomically reconstructed (Fig. 2a, right side), with only one displacement. In the nonsurgical group there was only one joint in correct alignment whereas 13 joints were in malposition (93 %) (Fig. 1, left side). We determined the degree of condyle axis dislocation with the help of the Runstr6m IV radiographic examination. In the surgical group we found a deviation of 10 degrees in contrast to 37 in the nonsurgical group. Another X-ray technique (OPT in function) shows the sagittal mobility of the condyle during mouth opening. The results correlated with the protrusive movement in the registration findings.
DISCUSSION The clinical results of our treatment were nearly equal in both groups. There was no correlation between subjective findings and the objective instrumental and clinical analysis. Similar observations have already been mentioned by Rahn et al. (1989) in conservatively treated patients. They found no relationship between the degree of dislocation of the condylar process, subjective complaints and objective dysfunction. The observed loss of curvature with no condyle inclination in the protrusion path is, in our opinion, a dislocated condylar process with a new flat glenoid fossa at the skull base. Similar flattening of the protrusive path was found by R a s s e et al. (1991). We found the described new glenoid fossa at the skull base in a case of ankylosis. We found the dislocated condyle at the skull base in articulation with a new fossa and a bony ankylosis in the region of the temporo-mandibular joint. The near-anatomical reconstruction of the operatively treated condylar neck led to good clinical and instrumental findings. In the conservative group we found considerable deviations in the joint's physiology. 13 of 14 joints were markedly changed but still showed adequate function. In not exactly repositioned
condylar fractures, unphysiological loading can lead to arthrosis of the joint ( S t e i n h a r d t , 1967), while M i i l l e r (1969) described an ankylosis of the T M J after a complicated fracture of the condyle. CONCLUSION The good clinical results in the conservatively treated group should not camouflage the p o o r results in instrumental and X-ray findings. Open reduction of displaced condylar fractures led to excellent results in the clinical, instrumental and X-ray analysis. Surgery should be performed whenever the vascular supply of the displaced part of the condyle is compromised. Therefore we recommend open reduction in cases of dislocated subcondylar or condylar neck fractures. References Eckelt, U. : Zugschraubenosteosynthese bei
Unterkiefergelenkfortsatzfrakturen. Dtsch. Z. Mund. Kiefer GesichtsChir. 15 (1991) 51-57 Kitayama, S. : A new method of intra-oral open reduction using a screw applied through the crest of condylar fractures. J. Cranio-Max.-Fac. Surg. 17 (1989) 16-23 Krenkel, Ch, S. Kulmer, S. Poisel: Die modifizierte Runstr6m-IVR6ntgenaufnahme als Grundlage ffir ein individuell eingestelltes Kiefergelenkr6ntgen, Osterr. Z. Stomatol. 79 (1982) 4-16 Miiller, W.: Die Verletzungen des Kiefergelenkesund ihre Behandlung. In: Reichenbach, E. (ed.) Traumatologie im Kiefer-Gesichts-Bereich, Barth, M/inchen (1969) Petzel, J. R. : Functionally stable traction-screw osteosynthesis of condylar fractures. J. Oral Maxillofac. Surg. 40 (1982) 108-110 Rahn, R., G. Thomaidis, G. Frenkel, P. Frank, U. Kinner :
Sp/itergebnisse der konservativen Behandlung von Kiefergelenkfrakturen, Dtsch. Z. Mund. Kiefer GesichtsChir. 13 (1989) 197-202 Rasse, M., Ch. Schober, E. Piehslinger, R. Scholz, K. Hollmann :
Intra- und extrakapsul~/reKondylusfrakturen im Wachstumsalter. Dtsch. Zahnarztl. Z. 46 (1991) 49-51 Reiehenbach, E. : Verletzungen der Kiefer- und Gesichtsknochen und der benachbarten Weichteile. In: H/iupl, K., Meyer, W., Schuchardt, K. : Die Zahn-, Mund- und Kieferheilkunde, Bd. III. Urban und Schwarzenberg, Mfinchen (1957) Slavicek, R., H. Mack: Der Axiograph, Inf. Orthod. Kieferorthop. 14 (1982) 53-62 Steinhardt H. : Sp/itfolgen nach Trauma der Kiefergelenke, Fortschr, Mund. Kiefer GesichtsChir. 12 (1967) 46-50 Takenoshita, Y., M. Oka, H. Tashiro : Surgical treatment of fractures of the mandibular condylar neck. J. Cranio-Max.Fac. Surg. 17 (1989) 1192124 Priv.-Doz Dr Dr J. Hidding
Department of Oral and Maxillofacial Surgery University of Mfinster Waldeyerstr. 30 D-4400 Miinster Germany Paper received 27 February 1992 Accepted 29 June 1992
1Dept of Oral and Maxillo-Facial Surgery (Head." Univ.-Prof. U. Joos, MD, DMD), ~Dept of Dental Prosthetics B (Head." Univ.-Prof. F. Bollmann, MD, DMD), University of Miinster, Germany.
S U M M A R Y . In a clinical, radiographic and axiographic study, we reinvestigated 34 patients with dislocated fractures of the condylar neck. 20 of them had been treated by open reduction, 14 in a conservative-functional way. The clinical results were nearly equal in both groups. The instrumental registration and the X-ray findings showed considerable deviations in the joint physiology in the conservative group. 19 of 20 patients operated on showed nearanatomical reconstruction with good functional results. KEY W O R D S : Dislocated condylar neck fracture - Surgical treatment - Axiography and radiography of the T M J - Clinical study
open reduction. These two patients-groups are comparable. The following important major examinations were carried out:
INTRODUCTION The primary aim in the treatment of fractures of the articular process of the mandible is the restoration of an undisturbed function of the TMJ. Reichenbach (1957) suggested an exclusively conservative-functional treatment and achieved good clinical results. Some authors, however, preferred an operative procedure (Petzel, 1982; Kitayama, 1989; Takenoshita et al., 1989; Eckelt, 1991) with regard to dislocated fractures of the articular process. In a recent paper, Eckelt (1991) has pointed out that the operative treatment of 103 very displaced and dislocated fractures of the articular process has led to better results than conservative therapy.
1. clinical and functional examination - mobility of the joint - subjective symptoms 2. axiography - length of protrusive movement - quality of the registration path - degree of condyle inclination 3. radiography - O P T in function - Runstr6m IV The OPT in function shows the sagittal mobility, structure and position of the condyle. We determined the degree of the condyle axis dislocation by Runstr6m 1V radiographic examination (Krenkel et al., 1982).
MATERIAL AND METHODS Within a period of 1-5 years after condylar fracture, we re-examined 34 patients with fractured condylar processes dislocated out of the fossa. The operative procedure was only performed in cases of dislocated condylar neck or subcondylar fractures. This open reduction of the fracture was done in 20 cases (7 females, 13 males) with a median age of 31 years (range: 17-60 years), via a submandibular approach, with wire or plating osteosynthesis and intermaxillary fixation for 2 weeks. Most patients were treated conservatively with intermaxillary fixation for 2 weeks and postoperative training with a jaw exerciser for 2-3 months. Out of a collective of more than 150 patients receiving conservative treatment, we found 14 cases (4 females, 10 males) with a median age of 29 years (range: 18-50 years) with fractures of the condylar process dislocated out of the fossa similar to the patient group with
RESULTS
In our examination, we found quite good results with only slight dysfunction. The average mouth opening in both groups was more than 40 mm with deviations in 64 % of the patients in the conservative group as opposed to 10 % in the operation group (Table 1). We found limitation of the lateroduction only in the nonsurgical group. As far as subjective symptoms are concerned we found no differences in mastication and incidence of headache (Table 2). The subjectivelynoticed limitation of mouth opening could not be confirmed by our clinical findings (compare with Table 1). 345
346 Journal of Cranio-Maxillo-Facial Surgery Table 1 - Clinical findings of joint mobility
Mouth opening < 30 mm Lateral deviation > 3ram Limitation of lateroduction < 5 mm Limitation of protrusive movement < 5 mm
Operative group n = 20 patients
Conservative group n = 14 patients
0 (0 %)
0 (0 %)
2 (10 %)
9 (64 %)
0 (0 %)
1 (7 %)
1 (5 %)
1 (7 %)
Table 3 - Examination with the axiographic technique (Slavicek and Mack, 1982) Operative group Conservative group n = 20 patients n = 14 patients 1. Regular axiography pattern 2. Slightly shortened path with alteration in curvature 3. Considerable shortening of the path with irregular pattern 4. Loss of curvature and no condyle inclination
12 (60%)
4 (29%)
5 (25 %)
4 (29%)
3 (15%)
2 (14%)
0 (0 %)
4 (29 %)
Table 2 - Subjective complaints after surgical and non surgical treatment of fractures of the condylar neck Operative group n = 20 patients Mastication disorder 4 (20 %) Headaches 6 (30 %) Mouth opening problems 7 (35 %)
Conservative group n = 14 patients 2 (14 %) 4 (29 %) 2 (14%)
The axiographic e x a m i n a t i o n was carried out mechanically following the technique of Slavicek a n d Mack (1982). The results of the axiography were classified into four groups: 1. regular axiographic p a t t e r n 2. slightly shortened p a t h with alterations in curvature 3, considerable shortening of the path with irregular p a t t e r n 4. loss of curvature a n d n o condyle i n c l i n a t i o n = sliding joint.
1 - The axiographic path corresponding to the clinical case in Figure 2. Right side: regular axiographic pattern. Left side: loss of curvature and no condyle inclination = sliding joint. Fig.
I n the n o n s u r g i c a l group we f o u n d m o v e m e n t disorders of the T M J in 43 % showing b a d a n d unphysiological paths in the registration (Table 3). W e f o u n d a h o r i z o n t a l path with loss of curvature (Fig. 1, left side) in 4 cases (29 %). The reason for this m o v e m e n t disorder m a y be a neoarthrosis at the skull base a n d a n empty glenoid fossa. I n c o n t r a s t to this, 85 % of the patients operated o n had regular patterns (Fig. 1, right side) sometimes with slight s h o r t e n i n g of the c o n d y l a r path. We f o u n d n o sliding j o i n t in the o p e r a t i o n group.
Fig. 2 - (a) OPT with dislocation of both articular processes. Right side: anatomical reconstruction with wire osteosynthesis. Left side : conservative therapy with a condyle in malposition. (b) OPT in function (open and closed mouth position) showing the limitation of function on the left side and good sagittal movement of the condyle on the right side.
Surgical versus non-surgical treatment of fractures of the articular process of the mandible 347 H o w mobile the particular joint actually was could also be seen in the length of the protrusive path. We found good results in both clinical groups with an average length of 10 m m and no significant difference between both groups. The sagittal angle of condyle inclination was flat in the nonsurgical group with a medium decrease of 34 degrees from the norm of 45 degrees. In the surgical group we found an average angle of 45 degrees with deviations of __ 11 degrees, showing the nearly anatomical reduction. These registration findings were confirmed by diagnostic radiography. In the operation group, 19 out of 20 joints (95 %) were anatomically reconstructed (Fig. 2a, right side), with only one displacement. In the nonsurgical group there was only one joint in correct alignment whereas 13 joints were in malposition (93 %) (Fig. 1, left side). We determined the degree of condyle axis dislocation with the help of the Runstr6m IV radiographic examination. In the surgical group we found a deviation of 10 degrees in contrast to 37 in the nonsurgical group. Another X-ray technique (OPT in function) shows the sagittal mobility of the condyle during mouth opening. The results correlated with the protrusive movement in the registration findings.
DISCUSSION The clinical results of our treatment were nearly equal in both groups. There was no correlation between subjective findings and the objective instrumental and clinical analysis. Similar observations have already been mentioned by Rahn et al. (1989) in conservatively treated patients. They found no relationship between the degree of dislocation of the condylar process, subjective complaints and objective dysfunction. The observed loss of curvature with no condyle inclination in the protrusion path is, in our opinion, a dislocated condylar process with a new flat glenoid fossa at the skull base. Similar flattening of the protrusive path was found by R a s s e et al. (1991). We found the described new glenoid fossa at the skull base in a case of ankylosis. We found the dislocated condyle at the skull base in articulation with a new fossa and a bony ankylosis in the region of the temporo-mandibular joint. The near-anatomical reconstruction of the operatively treated condylar neck led to good clinical and instrumental findings. In the conservative group we found considerable deviations in the joint's physiology. 13 of 14 joints were markedly changed but still showed adequate function. In not exactly repositioned
condylar fractures, unphysiological loading can lead to arthrosis of the joint ( S t e i n h a r d t , 1967), while M i i l l e r (1969) described an ankylosis of the T M J after a complicated fracture of the condyle. CONCLUSION The good clinical results in the conservatively treated group should not camouflage the p o o r results in instrumental and X-ray findings. Open reduction of displaced condylar fractures led to excellent results in the clinical, instrumental and X-ray analysis. Surgery should be performed whenever the vascular supply of the displaced part of the condyle is compromised. Therefore we recommend open reduction in cases of dislocated subcondylar or condylar neck fractures. References Eckelt, U. : Zugschraubenosteosynthese bei
Unterkiefergelenkfortsatzfrakturen. Dtsch. Z. Mund. Kiefer GesichtsChir. 15 (1991) 51-57 Kitayama, S. : A new method of intra-oral open reduction using a screw applied through the crest of condylar fractures. J. Cranio-Max.-Fac. Surg. 17 (1989) 16-23 Krenkel, Ch, S. Kulmer, S. Poisel: Die modifizierte Runstr6m-IVR6ntgenaufnahme als Grundlage ffir ein individuell eingestelltes Kiefergelenkr6ntgen, Osterr. Z. Stomatol. 79 (1982) 4-16 Miiller, W.: Die Verletzungen des Kiefergelenkesund ihre Behandlung. In: Reichenbach, E. (ed.) Traumatologie im Kiefer-Gesichts-Bereich, Barth, M/inchen (1969) Petzel, J. R. : Functionally stable traction-screw osteosynthesis of condylar fractures. J. Oral Maxillofac. Surg. 40 (1982) 108-110 Rahn, R., G. Thomaidis, G. Frenkel, P. Frank, U. Kinner :
Sp/itergebnisse der konservativen Behandlung von Kiefergelenkfrakturen, Dtsch. Z. Mund. Kiefer GesichtsChir. 13 (1989) 197-202 Rasse, M., Ch. Schober, E. Piehslinger, R. Scholz, K. Hollmann :
Intra- und extrakapsul~/reKondylusfrakturen im Wachstumsalter. Dtsch. Zahnarztl. Z. 46 (1991) 49-51 Reiehenbach, E. : Verletzungen der Kiefer- und Gesichtsknochen und der benachbarten Weichteile. In: H/iupl, K., Meyer, W., Schuchardt, K. : Die Zahn-, Mund- und Kieferheilkunde, Bd. III. Urban und Schwarzenberg, Mfinchen (1957) Slavicek, R., H. Mack: Der Axiograph, Inf. Orthod. Kieferorthop. 14 (1982) 53-62 Steinhardt H. : Sp/itfolgen nach Trauma der Kiefergelenke, Fortschr, Mund. Kiefer GesichtsChir. 12 (1967) 46-50 Takenoshita, Y., M. Oka, H. Tashiro : Surgical treatment of fractures of the mandibular condylar neck. J. Cranio-Max.Fac. Surg. 17 (1989) 1192124 Priv.-Doz Dr Dr J. Hidding
Department of Oral and Maxillofacial Surgery University of Mfinster Waldeyerstr. 30 D-4400 Miinster Germany Paper received 27 February 1992 Accepted 29 June 1992
