Fractures of the mandibular condyle: evidence base and current concepts of management

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1 Available online at British Journal of Oral and Maxillofacial Surgery 48 (2010) Review Fractures of the mandibular condyle: evidence base and current concepts of management Khalid Abdel-Galil, Richard Loukota 1 Oral & Maxillofacial Surgery, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, United Kingdom Accepted 8 October 2009 Available online 8 November 2009 Abstract Management of mandibular condylar fractures remains a source of ongoing controversy. While some condylar fractures can be managed non-surgically, recognition of fracture patterns that require surgical intervention and selection of an appropriate operative procedure are paramount to success in treating these injuries.the objective of this review is to appraise the current evidence regarding the effectiveness of interventions that are used in the management of fractures of the mandibular condyle The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Trauma; Mandibular fractures; Condylar injuries; Systematic review Methods Search strategy An electronic search of the literature directly relating to condylar fracture management was conducted. The databases examined were the Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the Health Technology Assessment database. Electronic searches were also conducted of the National Library of Medicine s (NLM) PubMed, Ovid Medline database, Embase, Cumulative Index to Nursing & Allied Health Literature [CINAHL] and Biosis databases up to Of 1081 studies and publications identified on the initial search of all databases, 858 were excluded as they were not directly relevant to the subject matter studied. The remaining 233 publications were examined and analysed for the purposes of this review. Corresponding author. Tel.: ; fax: addresses: khalidabdelgalil@doctors.org.uk (K. Abdel-Galil), rloukota@doctors.org.uk (R. Loukota). 1 Tel.: ; fax: Fig. 1 summarises the literature search and selection process in the early stages of the review. The majority of identified literature included case reports and series, descriptions of osteosynthesis techniques, technical notes, letters and editorials. Fig. 2 presents level I and II evidence identified in this review. Fracture classification as a guide to treatment selection Classification systems for condylar fractures can offer insight into which fractures might be best treated with open/closed reduction; a usable classification system must be responsive to the contemporary treatment options available to the surgeon. The lack of consistency in terminology relating to fracture patterns, however, poses a problem associated with the management of these injuries among surgeons and researchers and their reporting in the surgical literature. Early attempts at fracture classification were rather simplistic and did not help to direct surgical treatment of these injuries beyond closed reduction and maxillo-mandibular fixation. 1 3 The Lindahl classification considers factors that include the level of fracture, dislocation at the point of fracture, /$ see front matter 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjoms

2 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) height instability were considered the only indications for open reduction and fixation of these injuries. Open reduction and internal fixation (ORIF) was found to provide better functional reconstruction of mandibular condyle fractures than closed reduction (CR) and maxillomandibular fixation. 8 In current day practice, fractures with a deviation of more than 10, or a shortening of the ascending ramus of more than 2 mm, should be treated with open reduction and fixation, irrespective of level of the fracture. 9 Operative techniques Fig. 1. Search strategy. and the relationship of the condylar head to the articular fossa. Although useful, this classification system is rather complex. 4 Similarly the Spiessl & Schroll classification divides condylar fractures into subjectively assessed high and low subtypes, with and without dislocation, but does not allow easy visualisation of the fracture. 5 The sub-classification reported by Loukota et al. (Fig. 3), is also adopted by the Strasbourg Osteosynthesis Research Group (SORG). 6 This classification was analysed retrospectively in a cohort of patients with condylar fractures and found to be simple to use and can help predict treatment need and outcome. 7 The classification of condylar head fractures has been further clarified recently. 36 This should assist and simplify both treatment decision making and standardisation of nomenclature in future work within this field. Indications for treatment/intervention In an earlier review of the literature addressing the evolution of treatment modalities, condylar displacement and ramus Surgical techniques, including approaches to the mandibular condyle and ramus have evolved over the last few decades. This is evidenced by the substantial number of reports identified in the searched literature describing the various techniques, both open and endoscopic, used for rigid fixation of condylar fractures. No trial evidence exists comparing the various approaches described for access to the ramus condyle region. Endoscope-assisted ORIF of condylar fractures is now a viable alternative to traditional closed or open reduction techniques and its acceptance continues to grow as more surgeons gain experience. A recent prospective, randomised controlled, multi-center trial concluded that the treatment of condylar fractures with a transoral endoscopically assisted technique is reliable and may offer advantages for selected cases. 19 This included a tendency towards lower occurrence of facial nerve injury, although this was not supported by comparative statistical analyses. Figs. 4 8 illustrate some of the current osteosynthesis techniques used in condylar fracture fixation. Assessment scores and outcomes Several methods, both objective and subjective, have been described for the assessment of outcome following surgery on the temporomandibular joint complex The Helkimo dysfunction score consists of three indices evaluating anamnestic and clinical dysfunction, occlusion and articulation disturbance. It is an accepted valid and reliable tool used to determine the functional outcome after surgery of mandibular and temporomandibular joint disorders, as well as after orthognathic surgery As in most surgical disciplines, clinicians managing patients with condylar injuries are responsible for monitoring and recording outcomes of treatment. This should include functional assessments of jaw mobility and excursions (opening, lateral excursion and protrusion), occlusal changes as well as subjective pain and discomfort. This will facilitate future clinical decision making and assist in the standardised dissemination of treatment results. Although outcome monitoring and reporting should be encouraged using available validated indices/scores, this is not common practice at present.

3 522 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) Fig. 2. Existing level 1 and 2 evidence (ORIF: open reduction and internal fixation; CR: closed reduction; ENDO: endoscopic reduction and fixation). Open reduction versus closed management level 1 evidence In an early trial, Worsaae and Thorn reported the complications associated with surgical versus non-surgical treatment of unilateral low subcondylar fractures. 30 Although both groups underwent maxillo-mandibular immobilisation for 4 weeks, they reported complication rates of 4% and 39% in the surgical and non-surgical groups respectively. A randomised clinical trial assessing occlusal results following open versus closed management of condylar neck or subcondylar fractures found a significantly greater percentage of malocclusion (22 28%) in the closed treatment group. 31 Earlier non-randomised longitudinal studies from the same group confirmed decreased mandibular motion and reduced posterior facial/ramus height in groups of patients treated with closed reduction and maxillomandibular fixation. 32,33 An international prospective randomised trial involving seven centres compared operative and conservative treatment of displaced condylar fractures and yielded results which were clearly in favour of the operative approach. 16 This reported on 66 patients treated for 79 fractures and followed up for 6 months. Evaluation included radiographic assessment, clinical, functional and subjective parameters including visual analogue scales for pain and the Mandibular Function Impairment Questionnaire index for dysfunction. Operative treatment was found to be superior in all objective and all but one subjective functional parameters. In another prospective single-centre study 22 patients with 26 diacapitular condylar fractures were randomised to receive either ORIF or closed treatment and followed up for 12 Fig. 3. SORG classification: (1) high/condylar neck fracture; (2) low/condylar base fracture; (3) diacapitular fracture (with permission from Loukota et al. 6 ).

4 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) Fig. 4. Osteosynthesis configurations for condylar base fractures (with permission, from: Pilling E, Eckelt U, Loukota R, Schneider K, Stadlinger B. Comparative evaluation of ten different condylar base fracture osteosynthesis techniques).

5 524 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) Fig. 5. Headless bone screw fixation technique. months. 34 This failed to demonstrate a clear benefit to patients of ORIF versus closed treatment and recommended closed management in these cases. The cohort of patients studied was small however, and only included undisplaced fractures, a major weakness of the study. The results of a recent meta-analysis were inconclusive regarding whether open or closed treatment should be used for the management of mandibular condylar fractures. 17 This was attributed to the relatively poor quality of the available data and the lack of other important information. The methodological quality of this study was weak, however, Fig. 7. Schematic illustrating ultrasound activated resorbable osteosynthesis [SonicWeld Rx TM KLSMartin]. and several deficiencies render its conclusions questionable. These include incomplete database exploration, flawed statistical analysis, and lack of adherence to QUOROM standards. 18 In a prospective, randomised controlled multicentre trial invovlving centres from North America, Europe and Asia, patients with condylar neck fractures were randomised to receive either open reduction and internal fixation using an extraoral (submandibular, preauricular, retromandibular) approach or a transoral endoscopic procedure. The primary functional outcome measure was investigated using the asymmetric Helkimo dysfunction score at 8 12 weeks and 1 year after surgery. 19 This showed that comparable functional results were achieved after reduction and internal fixation using either technique. A marginally better early cosmetic outcome and fewer complications were the associated advantages of the transoral approach. Although these included a reduced occurrence of facial nerve damage, this was not supported by comparative statistical analyses. Who should provide care? Fig. 6. Preoperative radiograph of comminuted diacapitular fracture. The increased focus on quality and efficiency improvement within healthcare has put increasing pressure on surgeons to improve outcomes. Exisiting analyses from other surgical disciplines confirm learning curves in which complication rates, variance in

6 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) Conclusion A trend is emerging in the surgical literature confirming superior functional results following open reduction and internal fixation of condylar fractures, where this is indicated. This is supported by existing level I evidence. Endoscopic assistance, performed transorally, may also provide an alternative means for treating a subset of these injuries, reducing visible scar formation and possibly facial nerve damage. There are still areas of condylar trauma surgery which some surgeons consider controversial: condylar head fractures and displaced paediatric fractures. The use of resorbable osteosynthesis techniques may be of benefit in both these clinical settings; further research is needed in this field. A SORG multicentre prospective randomised controlled trial is planned to study the treatment of condylar head fractures. Regarding paediatric injuries, promising outcomes have been anecdotally reported following fixation of such fractures in children as young as 6 years of age. Conflict of interest The authors have no conflict of interest to disclose. References Fig. 8. Post-operative radiograph of comminuted diacapitular fracture fixation using ultrasound activated resorbable osteosynthesis. operative time, and operative time all decrease with surgeon experience. 25 Similarly volume of work has been extensively studied as a surrogate for surgical experience and improved outcomes Given the relatively high incidence of condylar fractures, 29 it is possible to achieve such a volume of work and expertise by a nominated surgeon in most hospital units. Post-operative morbidity to the facial nerve is often a concern for surgeons performing open surgery for condylar fractures. Published reports, including available level I evidence, shows that permanent facial nerve palsy following ORIF of condylar neck and base fractures is not a major concern. 16,20,21,34 The transoral approach is difficult to perform without endoscopic assistance. Intensive training in endoscopic techniques and the handling of relevant instruments is necessary before the transoral approach for the treatment of condylar fractures can be performed safely and competently With increasing experience the technique can also be refined, further improving outcomes. 1. MacLennan WD. Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 1952;5: Rowe NL, Killey HC. Fractures of the facial skeleton. Baltimore: Williams & Silkins; p Dingman RO, Natvig P. Surgery of facial fractures. Philadelphia: Saunders; p Lindahl L. Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and teethsupporting structures, and fractures of the mandibular body. Int J Oral Surg 1977;6: Spiessl B, Schroll K. Gelenkfortsatz und gelenkkopfchenfracturen. In: Higst H, editor. Spezielle frakture und luxationslehre. Stuttgart: Thieme; 1972 [BD. I/I]. 6. Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassification of fractures of the condylar process of the mandible. Br J Oral Maxillofac Surg 2005;43: Cenzi R, Burlini D, Arduin L, Zollino I, Guidi R, Carinci F. Mandibular condyle fractures: evaluation of the Strasbourg Osteosynthesis Research Group classification. J Craniofac Surg 2009;20: 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: Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota RA, Rasse M. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg 2008;66: Clark GT, Seligman D, Solberg WK, Pullinger AG. Guidelines for the examination and diagnosis of temporomandibular disorders. J Craniomand Disord 1989;3: Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:

7 526 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) Stegenga B, de Bont LG, de Leeuw R, Boering G. Assessment of mandibular function impairment associated with temporomandibular joint osteoarthrosis and internal derangement. J Orofac Pain 1993;7: Helkimo M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Sven Tandlak Tidskr 1974;67: Helkimo M. Studies on function and dysfunction of the masticatory system. I. An epidemiological investigation of symptoms of dysfunction in Lapps in the north of Finland. Proc Finn Dent Soc 1974;70: Helkimo M. Studies on function and dysfunction of the masticatory system. 3. Analyses of anamnestic and clinical recordings of dysfunction with the aid of indices. Sven Tandlak Tidskr 1974;67: Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota R, et al. Open versus closed treatment of fractures of the mandibular condylar process a prospective randomized multi-centre study. J Craniomaxillofac Surg 2006;34: Nussbaum ML, Laskin DM, Best AM. Closed versus open reduction of mandibular condylar fractures in adults: a meta-analysis. JOral Maxillofac Surg 2008;66: Clarke M. The QUOROM statement. Lancet 2000;355: Schmelzeisen R, Cienfuegos-Monroy R, Schön R, Chen CT, Cunningham Jr L, Goldhahn S. Patient benefit from endoscopically assisted fixation of condylar neck fractures a randomized controlled trial. J Oral Maxillofac Surg 2009;67: Devlin MF, Hislop WS, Carton ATM. Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: surgical morbidity and informed consent. Br J Oral Maxillofac Surg 2002;40: Downie JJ, Devlin MF, Carton ATM, Hislop WS. Prospective study of morbidity associated with open reduction and internal fixation of the fractured condyle by the transparotid approach. Br J Oral Maxillofac Surg 2009;47: Schon R, Fakler O, Gellrich NC, Schmelzeisen R. Five-year experience with the transoral endoscopically assisted treatment of displaced condylar mandible fractures. Plast Reconstr Surg 2005;116: Loukota RA. Endoscopically assisted reduction and fixation of condylar neck/base fractures the learning curve. Br J Oral Maxillofac Surg 2006;44: Mannion CJ, Loukota RA. Endoscopically-assisted treatment of condylar fractures experiences following an educational course. Br J Oral Maxillofac Surg, doi: /j.bjoms Carty MJ, Chan R, Huckman R, Snow D, Orgill DP. A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement. Plast Reconstr Surg 2009;124: Eastham JA. Do high-volume hospitals and surgeons provide better care in urologic oncology? Urol Oncol 2009;27: Wang TS, Roman SA, Sosa JA. Predictors of outcomes following pediatric thyroid and parathyroid surgery. Curr Opin Oncol 2009;21: Shervin N, Rubash HE, Katz JN. Orthopaedic procedure volume and patient outcomes: a systematic literature review. Clin Orthop Relat Res 2007;457: Ellis 3rd E, Moos KF, el-attar A. Ten years of mandibular fractures: an analysis of 2137 cases. Oral Surg Oral Med Oral Pathol 1985;59: Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral low subcondylar fractures: a clinical study of 52 cases. J Oral Maxillofac Surg 1994;52: Ellis 3rd E, Simon P, Throckmorton GS. Occlusal results after open or closed treatment of fractures of the mandibular condylar process. JOral Maxillofac Surg 2000;58: Palmieri C, Ellis 3rd E, Throckmorton G. Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. J Oral Maxillofac Surg 1999;57: Ellis 3rd E, Throckmorton G. Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 2000;58: Landes CA, Day K, Lipphardt R, Sader R. Closed versus open operative treatment of nondisplaced diacapitular (Class VI) fractures. JOral Maxillofac Surg 2008;66: Nasser M, Fedorowicz Z, Ebadifar A. Management of the fractured edentulous atrophic mandible. Cochrane Database Syst Rev 2007;4(January (1)). CD Loukota RA, Neff A, Rasse M. Nomenclature/classification of fractures of the mandibular condylar head. Br J Oral Maxillofac Surg, doi: /j.bjoms

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