Closed Versus Open Operative Treatment of Nondisplaced Diacapitular (Class VI) Fractures

Abstract

The purpose of the study was assessment of whether open reduction and internal fixation of high nondisplaced, nondislocated diacapitular fractures (Class VI according to Spiessl and Schroll) have better 1-year results compared with closed treatment. Twenty-two patients treated 2001 to 2005 with 26 (4 double) Class VI fractures prospectively entered this evaluation; in randomized fashion 9 (41%) patients had open reduction and internal fixation, 13 (59%) had closed treatment. Facial symmetry, nerve function, scarring, pain, and interincisal maximum distance were judged clinically; condylar translation by sonography; repositioning and reossification upon postoperative and 1-year follow-up radiographs. Altogether 17 (77%) patients presented for follow-up; 8 (47%) closed treatment, 9 (53%) open reduction and internal fixation. All patients evinced normal vertical opening. Insufficient condylar translation (<6 mm opening, <3 mm protrusion and mediotrusion) was prevalent in 2 open reduction and internal fixation and 2 closed treatment patients, persistent pain in 2 open reduction and internal fixation patients, and deflection greater than 4 mm in 2 open reduction and internal fixation patients. Partial facial nerve paresis was not encountered. In 1 open reduction and internal fixation patient a broken osteofixation was removed and 1 closed treatment patient had dysocclusion. Vertical medial fragment position was successfully restored by open reduction and internal fixation with, however, considerable remodeling (lateral condyle support is unaltered in Class VI). Closed treatment did not succeed in vertical repositioning but also evinced less remodeling. Angular fragment rectification in open reduction and internal fixation was successful; in closed treatment slight enlargement of the angulation was encountered at follow-up. Closed treatment within this study produced 2 of 8 (25%), open reduction and internal fixation compared with 2 of 9 (22%) unacceptable results and postoperative condyle remodeling. Therefore success rates of 75% versus 78% were attained, and closed treatment should therefore be preferred. However, sufficiently retentive resorbable osteofixation with intraosseous localization could permit better open reduction and internal fixation results than the microplates and screws at the dorsal condylar circumference applied within this study.