Indications for open reduction and closed reduction treatment

Abstract

The treatment of condylar fractures is still a highly debated theme. With the advent of stable internal fixation devices, open treatment has become more popular. However, there is still no universal agreement on the indications for open or closed treatment. These seem to vary with every surgeon who treats such injuries. This talk will focus on factors that may be taken into account when one decides how a given condyle fracture is to be treated. The basis of the talk, however, will be that the majority of condylar fractures can be treated satisfactorily by closed techniques. The question is, Which fractures might have better outcomes when treated open? Absolute Indications for Open Treatment 1.Displacement of condyle into the middle cranial fossa (with or without fracture)2.Lateral extracapsular displacement of condyle (with or without fracture)3.Impossibility of obtaining proper occlusion by closed techniques4.Condylar fractures associated with comminuted fractures at or above the LF 1 level Relative Indications for Open Treatment All other condylar fractures may be treated closed or open. The decision to choose one method over another will vary depending upon the experience and philosophy of the surgeon, the expected outcomes from either treatment, and the factors discussed below. I therefore will not list any relative indications because what is a relative indication in my opinion may not be in another’s. I. Loss of Ramus Height. Fractures that are displaced will lead to decreases in the height of the ramus. In most cases this loss of ramus height is acceptable and will be manifest by a small cant in the occlusal plane (if the fracture is unilateral). However, if few posterior teeth are present, control of ramus height by functional (non-surgical) therapy will be difficult and large losses of ramus height may occur. II. Skeletal Maturation of Patient. Skeletally immature individuals possess the unique ability to regenerate the entire condylar process after fracture/dislocation. They also function more symmetrically after non-surgical treatment. On the other hand, skeletally mature individuals have a more limited capacity for condyle regeneration/restitution. Further, most studies indicate more functional disturbances to the masticatory system in later years in such individuals than in those injured when skeletally immature. III. Feasibility of Open Reduction and Internal Fixation. High-level fractures pose a problem in that they do not have adequate bulk to perform stable osteosynthesis. In such cases, one may select non-surgical treatment. Other factors that relate to the choice between surgical and non-surgical treatment are the general health of the patient, the pre-traumatic occlusal relationship, and the desire to avoid intermaxillary fixation/traction. IV. Associated Fractures. When bilateral condylar fractures are present, especially those that are displaced, treatment using closed techniques is extremely difficult, even when a full complement of teeth is present. Treatment will be prolonged and many adaptations, including anterior dental extrusion, will occur out of necessity to maintain the pre-trauma occlusal relationship. Open treatment of at least one fracture seems to improve the occlusal outcomes. V. State of the Dentition. Closed techniques all rely on using the dentition to position the mandible while the new articulation is established. Patients who have an incomplete dentition present a challenge for closed treatment of the condylar fracture, and might necessitate the fabrication of splints to maintain the posterior vertical dimension. Open treatment may be more efficient and may produce improved outcomes in such cases. References Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 Konstantinovic VS, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures: Clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 50:349, 1992 Ellis E: Condylar process fractures of the mandible. Fac Plast Surg 16:193, 2000