CLINICAL PAPER
The Radiographic and Functional Outcome of Bilateral Mandibular Condylar Head Fractures A Comparison Between Open and Closed Treatment Susan Yu-Chen Ho, MD,* Han-Tsung Liao, PhD, MD,* Chih-Hao Chen, MD,* Yi-Chieh Chen, MD,* Yu-Ray Chen, MD,* and Chien-Tzung Chen, MD† Bilateral mandibular condylar fractures accounts for 24% to 33% of condylar fractures but the indications of open reduction of bilateral condylar fracture are still controversial. It is generally accepted that displaced subcondylar fractures are indicated for open reduction, but the proper treatment of condylar head fractures are still variable. This retrospective study compares the radiographical and functional outcomes of bilateral condylar head fractures between open and closed reduction groups. Materials and Methods: From February 1994 to June 2012, a total of 85 patients with bilateral condylar head fractures were retrospectively reviewed. Among this group, 41 cases underwent open reductions while the other 44 cases had closed reductions. Only adult patients with adequate follow-up and complete radiographic study were included in this study: consisting of 20 patients in the open group and 18 patients in the closed group. The subjective symptoms including temporomandibular joints (TMJ) symptoms, complications or adverse sequelae, and functional results, such as maximal mouth opening, were recorded. The outcome of patient's satisfaction was individually assessed by an independent reviewer. The computed tomographic results after treatment were evaluated between both groups. Results: The mean follow-up period was 25.5 ± 13.3 months. The open reduction group had better postoperative chewing functions, less malocclusion rates, less degree of TMJ pain (p = 0.046), better radiographic outcome (p = 0.036), and an overall satisfaction rate (p = 0.039). There were 4 cases of failure in the closed reduction group. Subsequent open reduction (n = 2) and redo closed reduction with intermaxillary fixation (n = 2) were performed. Eleven patients in the close reduction group presented persistent malocclusion through objective evaluation. The subsequent treatment included further orthognathic surgery (n = 1) and orthodontic treatment (n = 7). Three of the patients refused further treatment. Conclusions: Open reduction for bilateral condylar head fractures presented an overall better functional and radiographic outcome, with higher patient satisfaction if condylar fracture segments were still feasible for rigid fixation. Key Words: bilateral mandibular high condylar fractures, open reduction, closed (Ann Plast Surg 2015;74: S93–S98)
M
andibular fractures are common in facial trauma with 26% to 57% involving the condyles.1 The management of mandibular condylar fractures is variable throughout the literatures.2–4 Some surgeons adopted more aggressive surgical method by open reduction Received September 11, 2014, and accepted for publication, after revision, December 17, 2014. From the *Department of Plastic and Reconstructive Surgery, Chang Gung Memorial, Hospital in Linkou, College of Medicine, Chang Gung University, Craniofacial Center in Taoyuan, Taiwan; †Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, College of Medicine, Chang Gung University, Craniofacial Research Center in Taoyuan, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Chien-Tzung Chen, MD, Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, 222, Maijin Road, Keelung, Taiwan. Email: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405–S093 DOI: 10.1097/SAP.0000000000000457
Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015
and internal fixation (ORIF) of condylar fractures to achieve satisfactory anatomical reduction with better bone healing and faster functional recovery.5 However, the complexity of anatomical structure around the temporaomadibular joint (TMJ) and the related complications, such as temporomandibular joint absorption/osteoarthritic change, facial nerve injury, and wound infections, refrained some surgeons from doing open reduction procedure.2,6–9 Because of the greater remodeling capacity, especially in children, closed reduction may achieve satisfactory longterm results.2,5,8,10 Nevertheless, closed reduction in adult patients might result in some serious problems, such as chin deviation, trismus, malocclusion, and temporomandibular joint discomforts especially in bilateral condylar fractures.6,7 Occasionally, patients who undergo initial conservative treatment may need secondary orthognathic surgery or orthodontics treatment during long-term follow-up.6,11 Bilateral condylar fractures account for 24% to 33% of mandibular condyle fractures.1 Most studies present the results of a mixed population of bilateral and unilateral condylar fracture patients.2–5,8,9,12–17 The studies exclusively aimed at the outcomes of bilateral condylar fractures because of inconsistent results1,6,7,11,18 and lack of logical and convincing outcome evaluation. However, the functional outcome varied with fracture levels,6,19 and it was also recognized that open reduction was superior in all objective and subjective functional parameters for subcondylar fracture patients.7,9,20 Regarding the condylar head fractures, open reduction might carry the risk of postoperative bone resorption and osteoarthrosis which lead to less satisfactory results.6,21 The purpose of this study is to clarify the outcomes of bilateral condylar head fractures after open reduction and compare the difference between closed and operative treatment.
MATERIALS AND METHODS The medical records and images from the department of plastic surgery at Chang Gung Memorial Hospital were retrospectively reviewed in the period between February 1994 and June 2012. There were 176 consecutive patients with bilateral condylar process fractures. All of these patients were on the service of 4 experienced facial trauma surgeons. According to Chen's classification, we divided all bilateral condylar process fractures patients into 3 types: type I, bilateral condylar fractures (condylar neck or head); type II, 1 condylar plus 1 subcondylar fracture; and type III, bilateral subcondylar fractures.6 In the current study, however, we selected patients from type I as our study group. Our inclusion criteria were bilateral condylar head fractures in adult patients with an adequate follow-up period (of over 12 months) and complete preoperative and postoperative radiographic study. The 2 patients who failed closed reduction and then later received subsequent open reduction were also excluded. Therefore, in this study, the bilateral condylar head fractures had 20 patients in the open reduction group with 18 patients in the closed treatment group (Fig. 1).
Operative Techniques Two surgeons (H.T.L. and C.T.C.) preferred anatomical reduction by the open method unless the fracture type was a nondisplaced fracture www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S93
Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015
Yu-Chen Ho et al
Closed Method For the closed reduction group, the treatment was IMF after manual reduction, without the intervention of TMJ joint space. After the operation, all patients would receive IMF via elastic rubber bands to maintain occlusion. The period of intermittent IMF under rubber bands guidance ranged from 4 to 8 weeks according to the patients' occlusion condition. Intensive physiotherapy was initiated postoperatively with routine dental and visits our clinic to resume early mouth opening. All patients adopted a liquid diet for 1 week, followed by a soft diet in subsequent month after the operation.
Subjective Function Evaluation The subjective function evaluation includes 2 parts: the TMJ discomforts such as pain, clicking, and tightness sensations; and overall satisfaction of the whole treatment including the treatment course, functional results, and any influences on life quality. The postoperative TMJ pain and overall satisfaction of treatment were further assessed by patient himself with visual analogue scale (VAS, from 0 to 10). Operationally, a VAS is a horizontal line, 100 mm in length, anchored by word descriptors at each end. The left end was defined as totally unsatisfied about the whole procedure or less TMJ pain and the right one was defined as extremely satisfied or TMJ pain. The patient marks on the line the point that they feel represents their perception of their current state. The satisfactory rate or TMJ pain is determined by measuring in millimeters from the left hand end of the line to the point that the patient marks and then divided by 100.
Objective Function Evaluation FIGURE 1. Flow Chart of Selecting Patients of Bilateral Condylar Head Fracture(Type I). *Chen’s Classification: type I, bilateral condylar fractures (condylar neck or head); type II, one condylar plus one subcondylar fracture; and type III, bilateral subcondylar fractures.
or a comminuted fracture, which was treated by closed reduction. The other 2 surgeons (C.H.C. and Y.C.C.) exclusively adopted closed treatment of bilateral condylar head fractures whether the fracture fragment is displaced or not or comminuted fracture.
Open Method The open reduction group's treatment was performed through a 3-cm preauricular incision. The dissection proceeded in the space between ear cartilage and superficial temporal vessels to safely approach the zygomatic arch until the anterior border of the zygomatic eminence was met. The joint capsule was opened, and medial displaced fracture segment was reduced back to the glenoid fossa with the preservation of the attachment of lateral pterygoid muscle and the cartilaginous surface. If there was sufficient space for placement of a plating system, we adopted a semirigid fixation with a microplate (Leibinger 1.3 mm) system for condylar head fractures. Otherwise, the displaced condylar head would be fixed with 1 long microscrew (1.3 mm) with a 12 mm length similar to a lag screw fashion. Then, the resultant occlusion and TMJ mobility would be evaluated. Displaced discs were reduced if found, and finally the joint capsule was repaired. All concomitant mandible and maxillary fractures also underwent open reduction and rigid fixation by rigid plating systems at the same time. After the operation, all patients would receive intermaxillary fixation (IMF) via elastic rubber bands to maintain occlusion. The period of intermittent IMF under rubber bands guidance ranged from 2 to 6 weeks according to the patients' occlusion condition. All patients adopted a liquid diet for 1 week, followed by a soft diet in subsequent month after the operation. S94
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Functional Outcome The postoperative function outcome was evaluated by occlusion status, chin deviation when mouth opening, chewing function and maximal mouth opening (MMO). Occlusal relationship was evaluated by both plastic surgeon and orthodontist. Malocclusion including crossbite or open bite was considered significant when further orthodontic treatment or surgical correction was required. A mandibular midline shift of more than 5 mm during MMO was regarded as significant chin deviation. The chewing function was assessed according to the food hardness they can eat without any discomfort. It was recorded as the chewing function score (from 1 to 4) as follows: (1) liquid diet; (2) soft diet; (3) normal diet; and (4) hard diet. The liquid diet and soft diet were considered as a less satisfactory function that might reduce life quality. The MMO was defined as the distance between the upper and lower incisors while the patients opened their mouth extremely. The pretreatment and posttreatment MMO and the differences between them were recorded and compared between the 2 groups. The MMO less than 35 mm22 was recognized as trismus which represented limited range of TMJ motion.
Radiographic Evaluation The preoperative fracture type evaluation with computed tomography (CT) was categorized according to the classification of He23 which was modified from Neff et al24 as following: type A, fracture line through lateral third of condylar head with reduction of ramus height; type B, fracture line through middle third of condylar head; type C, fracture line through medial third of condylar head; and type M, comminuted fracture of condylar head. For the postoperative radiographic outcome analysis, we adapted the Iizuka classification25 as: class A, a normal condylar structure without any signs of change; class B, slight changes and remodeling consisting of an irregular condylar surface; class C, moderate changes and remodeling consisting of a flattening of the condyle; and class D, signs of osteoarthrosis with marked irregularity of the condylar surface and total or partial resorption of the condyle. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015
Open and Closed Treatment of Mandibular Condylar Head
TABLE 3. Objective Functional Outcomes Between Closed and Open Reduction of Bilateral Condylar Fractures
TABLE 1. Patient Demographics Closed (N=18) Open (N=20) Total(N=38)
Age Gender(M/F) Follow-up (M) Concomitant Fractures Maxillary Alveolar bone (%) Le Fort (%) Zygoma (%) Symphysis/Parasymphysis (%) Mandibular Alveolar bone (%) Orbital(%) Other association injury (%) Etiology Traffic accident Fall
28.6 ± 9.6 10/8 16.9 ± 4.9
32.7 ± 13.5 12/8 33.3 ± 11.4
30.7 ± 9.7 22/16 25.5± 13.3
4 (22.2) 3 (16.7) 3 (16.7) 15 (83.3) 0 (0.0) 1 (5.6) 4 (22.2)
2 (10.0) 5 (25.0) 7 (35.0) 16 (80.0) 4 (20.0) 1 (5.0) 5 (25.0)
6 (15.8) 8 (21.1) 10 (26.3) 31 (81.6) 4 (10.5) 2 (5.3) 9 (23.7)
13 5
13 7
26 12
Statistical Analysis Nonparametric hypothesis testing was adopted to analyze nonnormalized variables. The Mann-Whitney U test was used for univariate analysis of continuous data (final MMO, MMO difference, VAS score of pain, overall satisfaction) whereas Fisher exact test or Pearson χ2 test was used for categorical variables (CT classification, chin deviation, malocclusion, TMJ symptoms, and chewing functions). A P value less than 0.05 was regarded as showing the existence of significant differences.
RESULTS Among the total 38 patients, the mean age was 30.7 years. Among the patients, 33 (86.8%) had concomitant mandibular fractures, in which the mandibular symphysis and parasymphysis fractures accounted for the majority. The mean follow-up period was 25.5 ± 13.3 months. The age, distribution of sex, and other patient demographics information is listed in Table 1.
Subjective Comparison Regarding TMJ symptoms (Table 2), 9 patients (50%) of the closed reduction group complained of a clicking sound, and 7 patients (38.9%) of a joint tightness sensation while opening the mouth. As for the open reduction cases, there were 5 cases (25%) with clicking
Closed (N=18) (%) Open (N=20) (%) P Value
Malocclusion Chin deviation (>5 mm) Chewing function (score
The Radiographic and Functional Outcome of Bilateral Mandibular Condylar Head Fractures A Comparison Between Open and Closed Treatment Susan Yu-Chen Ho, MD,* Han-Tsung Liao, PhD, MD,* Chih-Hao Chen, MD,* Yi-Chieh Chen, MD,* Yu-Ray Chen, MD,* and Chien-Tzung Chen, MD† Bilateral mandibular condylar fractures accounts for 24% to 33% of condylar fractures but the indications of open reduction of bilateral condylar fracture are still controversial. It is generally accepted that displaced subcondylar fractures are indicated for open reduction, but the proper treatment of condylar head fractures are still variable. This retrospective study compares the radiographical and functional outcomes of bilateral condylar head fractures between open and closed reduction groups. Materials and Methods: From February 1994 to June 2012, a total of 85 patients with bilateral condylar head fractures were retrospectively reviewed. Among this group, 41 cases underwent open reductions while the other 44 cases had closed reductions. Only adult patients with adequate follow-up and complete radiographic study were included in this study: consisting of 20 patients in the open group and 18 patients in the closed group. The subjective symptoms including temporomandibular joints (TMJ) symptoms, complications or adverse sequelae, and functional results, such as maximal mouth opening, were recorded. The outcome of patient's satisfaction was individually assessed by an independent reviewer. The computed tomographic results after treatment were evaluated between both groups. Results: The mean follow-up period was 25.5 ± 13.3 months. The open reduction group had better postoperative chewing functions, less malocclusion rates, less degree of TMJ pain (p = 0.046), better radiographic outcome (p = 0.036), and an overall satisfaction rate (p = 0.039). There were 4 cases of failure in the closed reduction group. Subsequent open reduction (n = 2) and redo closed reduction with intermaxillary fixation (n = 2) were performed. Eleven patients in the close reduction group presented persistent malocclusion through objective evaluation. The subsequent treatment included further orthognathic surgery (n = 1) and orthodontic treatment (n = 7). Three of the patients refused further treatment. Conclusions: Open reduction for bilateral condylar head fractures presented an overall better functional and radiographic outcome, with higher patient satisfaction if condylar fracture segments were still feasible for rigid fixation. Key Words: bilateral mandibular high condylar fractures, open reduction, closed (Ann Plast Surg 2015;74: S93–S98)
M
andibular fractures are common in facial trauma with 26% to 57% involving the condyles.1 The management of mandibular condylar fractures is variable throughout the literatures.2–4 Some surgeons adopted more aggressive surgical method by open reduction Received September 11, 2014, and accepted for publication, after revision, December 17, 2014. From the *Department of Plastic and Reconstructive Surgery, Chang Gung Memorial, Hospital in Linkou, College of Medicine, Chang Gung University, Craniofacial Center in Taoyuan, Taiwan; †Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, College of Medicine, Chang Gung University, Craniofacial Research Center in Taoyuan, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Chien-Tzung Chen, MD, Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, 222, Maijin Road, Keelung, Taiwan. Email: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7405–S093 DOI: 10.1097/SAP.0000000000000457
Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015
and internal fixation (ORIF) of condylar fractures to achieve satisfactory anatomical reduction with better bone healing and faster functional recovery.5 However, the complexity of anatomical structure around the temporaomadibular joint (TMJ) and the related complications, such as temporomandibular joint absorption/osteoarthritic change, facial nerve injury, and wound infections, refrained some surgeons from doing open reduction procedure.2,6–9 Because of the greater remodeling capacity, especially in children, closed reduction may achieve satisfactory longterm results.2,5,8,10 Nevertheless, closed reduction in adult patients might result in some serious problems, such as chin deviation, trismus, malocclusion, and temporomandibular joint discomforts especially in bilateral condylar fractures.6,7 Occasionally, patients who undergo initial conservative treatment may need secondary orthognathic surgery or orthodontics treatment during long-term follow-up.6,11 Bilateral condylar fractures account for 24% to 33% of mandibular condyle fractures.1 Most studies present the results of a mixed population of bilateral and unilateral condylar fracture patients.2–5,8,9,12–17 The studies exclusively aimed at the outcomes of bilateral condylar fractures because of inconsistent results1,6,7,11,18 and lack of logical and convincing outcome evaluation. However, the functional outcome varied with fracture levels,6,19 and it was also recognized that open reduction was superior in all objective and subjective functional parameters for subcondylar fracture patients.7,9,20 Regarding the condylar head fractures, open reduction might carry the risk of postoperative bone resorption and osteoarthrosis which lead to less satisfactory results.6,21 The purpose of this study is to clarify the outcomes of bilateral condylar head fractures after open reduction and compare the difference between closed and operative treatment.
MATERIALS AND METHODS The medical records and images from the department of plastic surgery at Chang Gung Memorial Hospital were retrospectively reviewed in the period between February 1994 and June 2012. There were 176 consecutive patients with bilateral condylar process fractures. All of these patients were on the service of 4 experienced facial trauma surgeons. According to Chen's classification, we divided all bilateral condylar process fractures patients into 3 types: type I, bilateral condylar fractures (condylar neck or head); type II, 1 condylar plus 1 subcondylar fracture; and type III, bilateral subcondylar fractures.6 In the current study, however, we selected patients from type I as our study group. Our inclusion criteria were bilateral condylar head fractures in adult patients with an adequate follow-up period (of over 12 months) and complete preoperative and postoperative radiographic study. The 2 patients who failed closed reduction and then later received subsequent open reduction were also excluded. Therefore, in this study, the bilateral condylar head fractures had 20 patients in the open reduction group with 18 patients in the closed treatment group (Fig. 1).
Operative Techniques Two surgeons (H.T.L. and C.T.C.) preferred anatomical reduction by the open method unless the fracture type was a nondisplaced fracture www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S93
Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015
Yu-Chen Ho et al
Closed Method For the closed reduction group, the treatment was IMF after manual reduction, without the intervention of TMJ joint space. After the operation, all patients would receive IMF via elastic rubber bands to maintain occlusion. The period of intermittent IMF under rubber bands guidance ranged from 4 to 8 weeks according to the patients' occlusion condition. Intensive physiotherapy was initiated postoperatively with routine dental and visits our clinic to resume early mouth opening. All patients adopted a liquid diet for 1 week, followed by a soft diet in subsequent month after the operation.
Subjective Function Evaluation The subjective function evaluation includes 2 parts: the TMJ discomforts such as pain, clicking, and tightness sensations; and overall satisfaction of the whole treatment including the treatment course, functional results, and any influences on life quality. The postoperative TMJ pain and overall satisfaction of treatment were further assessed by patient himself with visual analogue scale (VAS, from 0 to 10). Operationally, a VAS is a horizontal line, 100 mm in length, anchored by word descriptors at each end. The left end was defined as totally unsatisfied about the whole procedure or less TMJ pain and the right one was defined as extremely satisfied or TMJ pain. The patient marks on the line the point that they feel represents their perception of their current state. The satisfactory rate or TMJ pain is determined by measuring in millimeters from the left hand end of the line to the point that the patient marks and then divided by 100.
Objective Function Evaluation FIGURE 1. Flow Chart of Selecting Patients of Bilateral Condylar Head Fracture(Type I). *Chen’s Classification: type I, bilateral condylar fractures (condylar neck or head); type II, one condylar plus one subcondylar fracture; and type III, bilateral subcondylar fractures.
or a comminuted fracture, which was treated by closed reduction. The other 2 surgeons (C.H.C. and Y.C.C.) exclusively adopted closed treatment of bilateral condylar head fractures whether the fracture fragment is displaced or not or comminuted fracture.
Open Method The open reduction group's treatment was performed through a 3-cm preauricular incision. The dissection proceeded in the space between ear cartilage and superficial temporal vessels to safely approach the zygomatic arch until the anterior border of the zygomatic eminence was met. The joint capsule was opened, and medial displaced fracture segment was reduced back to the glenoid fossa with the preservation of the attachment of lateral pterygoid muscle and the cartilaginous surface. If there was sufficient space for placement of a plating system, we adopted a semirigid fixation with a microplate (Leibinger 1.3 mm) system for condylar head fractures. Otherwise, the displaced condylar head would be fixed with 1 long microscrew (1.3 mm) with a 12 mm length similar to a lag screw fashion. Then, the resultant occlusion and TMJ mobility would be evaluated. Displaced discs were reduced if found, and finally the joint capsule was repaired. All concomitant mandible and maxillary fractures also underwent open reduction and rigid fixation by rigid plating systems at the same time. After the operation, all patients would receive intermaxillary fixation (IMF) via elastic rubber bands to maintain occlusion. The period of intermittent IMF under rubber bands guidance ranged from 2 to 6 weeks according to the patients' occlusion condition. All patients adopted a liquid diet for 1 week, followed by a soft diet in subsequent month after the operation. S94
www.annalsplasticsurgery.com
Functional Outcome The postoperative function outcome was evaluated by occlusion status, chin deviation when mouth opening, chewing function and maximal mouth opening (MMO). Occlusal relationship was evaluated by both plastic surgeon and orthodontist. Malocclusion including crossbite or open bite was considered significant when further orthodontic treatment or surgical correction was required. A mandibular midline shift of more than 5 mm during MMO was regarded as significant chin deviation. The chewing function was assessed according to the food hardness they can eat without any discomfort. It was recorded as the chewing function score (from 1 to 4) as follows: (1) liquid diet; (2) soft diet; (3) normal diet; and (4) hard diet. The liquid diet and soft diet were considered as a less satisfactory function that might reduce life quality. The MMO was defined as the distance between the upper and lower incisors while the patients opened their mouth extremely. The pretreatment and posttreatment MMO and the differences between them were recorded and compared between the 2 groups. The MMO less than 35 mm22 was recognized as trismus which represented limited range of TMJ motion.
Radiographic Evaluation The preoperative fracture type evaluation with computed tomography (CT) was categorized according to the classification of He23 which was modified from Neff et al24 as following: type A, fracture line through lateral third of condylar head with reduction of ramus height; type B, fracture line through middle third of condylar head; type C, fracture line through medial third of condylar head; and type M, comminuted fracture of condylar head. For the postoperative radiographic outcome analysis, we adapted the Iizuka classification25 as: class A, a normal condylar structure without any signs of change; class B, slight changes and remodeling consisting of an irregular condylar surface; class C, moderate changes and remodeling consisting of a flattening of the condyle; and class D, signs of osteoarthrosis with marked irregularity of the condylar surface and total or partial resorption of the condyle. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015
Open and Closed Treatment of Mandibular Condylar Head
TABLE 3. Objective Functional Outcomes Between Closed and Open Reduction of Bilateral Condylar Fractures
TABLE 1. Patient Demographics Closed (N=18) Open (N=20) Total(N=38)
Age Gender(M/F) Follow-up (M) Concomitant Fractures Maxillary Alveolar bone (%) Le Fort (%) Zygoma (%) Symphysis/Parasymphysis (%) Mandibular Alveolar bone (%) Orbital(%) Other association injury (%) Etiology Traffic accident Fall
28.6 ± 9.6 10/8 16.9 ± 4.9
32.7 ± 13.5 12/8 33.3 ± 11.4
30.7 ± 9.7 22/16 25.5± 13.3
4 (22.2) 3 (16.7) 3 (16.7) 15 (83.3) 0 (0.0) 1 (5.6) 4 (22.2)
2 (10.0) 5 (25.0) 7 (35.0) 16 (80.0) 4 (20.0) 1 (5.0) 5 (25.0)
6 (15.8) 8 (21.1) 10 (26.3) 31 (81.6) 4 (10.5) 2 (5.3) 9 (23.7)
13 5
13 7
26 12
Statistical Analysis Nonparametric hypothesis testing was adopted to analyze nonnormalized variables. The Mann-Whitney U test was used for univariate analysis of continuous data (final MMO, MMO difference, VAS score of pain, overall satisfaction) whereas Fisher exact test or Pearson χ2 test was used for categorical variables (CT classification, chin deviation, malocclusion, TMJ symptoms, and chewing functions). A P value less than 0.05 was regarded as showing the existence of significant differences.
RESULTS Among the total 38 patients, the mean age was 30.7 years. Among the patients, 33 (86.8%) had concomitant mandibular fractures, in which the mandibular symphysis and parasymphysis fractures accounted for the majority. The mean follow-up period was 25.5 ± 13.3 months. The age, distribution of sex, and other patient demographics information is listed in Table 1.
Subjective Comparison Regarding TMJ symptoms (Table 2), 9 patients (50%) of the closed reduction group complained of a clicking sound, and 7 patients (38.9%) of a joint tightness sensation while opening the mouth. As for the open reduction cases, there were 5 cases (25%) with clicking
Closed (N=18) (%) Open (N=20) (%) P Value
Malocclusion Chin deviation (>5 mm) Chewing function (score
