Condylar Neck Fractures Research Articles

Patient Benefit From Endoscopically Assisted Fixation of Condylar Neck Fractures—A Randomized Controlled Trial

Owing to the risk of facial nerve damage and the creation of visible scars, surgical treatment of condylar mandible fractures using an extraoral approach remains controversial. The transoral endoscopically assisted approach of condylar fractures has been reported to avoid these complications. A prospective, randomized controlled, multicenter trial was performed to quantify the patient benefit after open reduction and internal fixation of condylar mandible fractures using endoscopically assisted treatment compared with surgical treatment without endoscopic assistance. Patients with dislocated uni-/bilateral condylar neck fractures were randomized to receive either nonendoscopic 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 to 12 weeks and 1 year after surgery. A total of 74 patients were recruited between 2003 and 2006; the nonendoscopic extraoral group included 34 patients and the endoscopically assisted open reduction group included 40 patients. Comparable functional results were noted in both groups without any statistical significance. Endoscope-assisted treatment proved to be more time consuming. For the extraoral group, visible scars were rated by most of these patients as being cosmetically acceptable; however, a greater number of facial nerve injuries were reported. The treatment of condylar mandible fractures with a minimal invasive endoscopically assisted technique is reliable and may offer advantages for selected cases, particularly concerning the lower occurrence of facial nerve damage.

Quality and Pain

The retromandibular transparotid approach (RMA) to condylar fractures of the mandible provides excellent access, but can increase the risk of complications. The aim of this study was to estimate the frequency of facial nerve paralysis (FNP) and associated postoperative complications after open reduction and rigid internal fixation (ORIF) of subcondylar fractures through the RMA.This was a retrospective cohort study of patients with condylar fractures requiring ORIF through the RMA. The inclusion criteria were 1) a medical record of surgical treatment of a subcondylar fracture by RMA; 2) preoperative and postoperative radiographs; 3) mental status permitting an adequate neuromotor examination; 4) absence of a post-injury or pretreatment functional facial nerve deficit; and 5) regular postoperative follow-up longer than 6 months with documentation of complications, functional results, and fixation stability. The predictive variables were age, gender, fracture site, fracture pattern, concomitant fractures, etiology, and plate types. The outcome variable was FNP. Univariate, bivariate, and multiple logistic regression statistics were computed.Fifty patients with 55 displaced mandibular subcondylar fractures (35 men, 15 women; mean age, 44.5 yr; range, 17 to 87 yr) met the inclusion criteria. The condylar fracture involved the neck in 35 patients (63.6%) and the base in 20 patients (36.4%). The fracture pattern was deviation in 11 patients (20.0%), displacement in 23 (41.8%), and dislocation in 21 (38.2%). Precise ORIF with double-buttress fixation resulted in immediate functional recovery in all patients. Seven fractures (12.7%) were associated with FNP that resolved completely within 6 months. Further statistical analysis showed that dislocated and displaced condylar neck fractures were significant risk factors for postoperative FNP (P < .05). Other postoperative complications were minimal.The RMA for subcondylar fractures is feasible and safe. Dislocated condylar neck fractures are associated with a highly increased risk of temporary postoperative FNP as a surgical complication.

O.430 Biological properties of adhesives used for osteosynthesis

The aim of the present study was to investigate radiographic and functional long-term results after condylar fractures have been reduced by an exclusively intraoral surgical approach.A total of 25 (21 male, 4 female) consecutive patients with 30 condylar process fractures were retrospectively investigated. Clinical follow-up was performed in 19 patients (16 male, 3 female) with a total of 24 fractures. Median postoperative follow-up time was 19.7 months. Surgical indications followed specific parameters of fracture localization, dislocation, and ramus shortening. All patients were examined in accordance with the Research Diagnostic Criteria for Temporomandibular Dysfunction (RDC/TMD) and the Helkimo Index. Orthopantomograms (OPGs) were analyzed with use of the condylar morphologic scale (CMS), and mandibular ramus position and height were measured.Fractures were classified as condylar neck (n = 2) and basis fractures (n = 28), according to criteria of the Strasbourg Osteosynthesis Research Group (SORG). Mean age of patients was 33 years (standard deviation [SD], 13 yr). RDC/TMD measurements at follow-up showed a mean mouth opening of 48 mm (SD, 9), mandibular laterotrusion right of 11 mm (SD, 3.8), laterotrusion left of 10 mm (SD, 4.5), and protrusion with a mean of 5.83 mm (SD, 3). No joint clicking, weakness of the facial nerve, or joint or muscular pain was observed. Statistical analysis of the CMS showed significantly better postoperative ramus height (P < .05).Reduction achieved by this technique allows reconstruction of anatomic ramus height in combination with excellent functional results.

P.282 Fractures of orbito-zygomatic region

Twenty-five patients with 28 condylar or subcondylar fractures, sustained during their growth period and treated nonsurgically, have been followed for an average period of 15 years. The fractures were classified as intracapsular, high condylar neck and low condylar neck fractures. In 5 patients, two weeks of intermaxillary fixation, followed by elastic traction in order to achieve a proper occlusion, was applied. All the other patients were treated by instruction, exercises and observation. In 4 patients, subsequent orthodontic treatment was provided. It is not advocated to perform orthodontic aftercare as a routine action in all patients. Satisfaction with the treatment results, as measured on a visual analogue scale (VAS), was very high. The masticatory function of all patients at last follow-up was good to excellent. From this study, it appears that especially the commonly occurring high condylar fractures (64%) show good regeneration tendency as observed on radiographs. Low condylar and intracapsular fractures may give rise to some asymmetry. In 4 cases this asymmetry was clearly visible to the experienced observed, but did not concern the patient. One patient (low condylar neck fracture) showed obvious malocclusion and facial asymmetry, which needed to be corrected by orthognathic surgery. Unfortunately, it is impossible to predict which type of fracture is at risk of facial asymmetry. It is concluded that nonsurgical management of condylar fractures of the mandible in children is still the method of choice.

Open Versus Closed Reduction of Condylar Neck Fractures: A Prospective Randomized Multicenter Study With Regard to Fracture Localization

Statement of the problem: Prognosis criteria are essential for making therapy decisions in the treatment of condylar neck fractures. According to the IAOMFS 1997 consensus conference, a proper therapy decision should primarily be based upon fracture localization and the degree of displacement or dislocation. For a long time the localization of condylar neck fracture was assumed to be of vital prognostic and therapeutic importance. An increasing degree of displacement or dislocation of the condyle out of the fossa will cause an increasing degree of damage to the joint capsule and the ligaments. Aim of this prospective, randomized multicenter study was to analyze the results of open and closed treatment. Functional and subjective parameters were evaluated with regard to fracture localization. Materials and Methods: 66 patients from seven international treatment centers with 79 condylar neck fractures were prospectively examined. The decision for open (n 30 patients) or closed (n 36 patients) treatment was randomised. Closed treatment was performed by elastic immobilization for 10 days. In cases of malocclusion a prolonged period of immobilization and, where necessary, physiotherapy followed. In cases of open treatment, the surgeon decided on the appropriate operative technique. Osteosynthesis was performed by miniplates, miniscrews or lag screws. Six months after trauma the patients were examined. Clinical (mouth opening, protrusion, laterotrusion), radiographic (localization) and subjective (pain-visual analogue scale [VAS], impairment – Mandibular Function Impairment Questionnaire [MFIQ]) examination parameters were recorded. Data Analysis: a) 66 patients, 79 condylar neck fractures b) 6 months c) Statistical planning and analysis was performed by the Institute of Biometry University Dresden using SPSS 12.0 (SPSS Inc, Chicago, Illinois, USA). Results: Bilateral fractures receiving closed treatment showed significantly worse results in all categories. The 13 patients had bilateral fractures and exhibited a mouth opening of 36 mm (7 patients, 14 fractures) for closed treatment and 48 mm (6 patients, 12 fractures) for open treatment, p 0.001. Unilateral fractures showed a mouth opening of 42 mm (23 fractures) for closed treatment and 46 mm (30 fractures) for open treatment, p 0.003. Subjective parameters exhibited the highest level of pain with 25 mm VAS for closed treatment of bilateral fractures. Bilateral fractures receiving open treatment showed a VAS of 1 mm, p 0.001. Closed treatment of unilateral fractures showed a VAS 11 mm in contrast to 3 mm for fractures, receiving open treatment. The results were further approved by the measured degree of impairment – MFIQ. With regard to localization, the subjective degree of impairment was less pronounced for high condylar fractures. Conclusion: Open treatment with the aim of anatomical reconstruction of the joint shows significantly better treatment results in all evaluated categories for all fracture localizations. Interestingly, low fractures at the basis of the condylar neck exposed higher degrees of impairment and thus largely benefit from open treatment. Further, especially bilateral fractures benefit from open treatment. In these cases, treatment results of closed treatment are significantly inferior to open treatment which generally advocates open treatment.

Prospective closed treatment of nondisplaced and nondislocated condylar neck and head fractures versus open reposition internal fixation of displaced and dislocated fractures

assessment of open reduction internal fixation in displaced or dislocated fractures of the condylar neck and head assessed versus closed treatment of nondisplaced, nondislocated fractures. One hundred and twenty patients suffering from 158 fractures; classes II to V according to Spiessl and Schroll, e.g., displaced and dislocated fractures were operated on; classes I and VI nondisplaced, nondislocated fractures were treated conservatively. At 1year, facial symmetry, pain, facial nerve function, and scarring were assessed clinically; reossification and fragment angulation were assessed from radiographs; vertical position, incisal maximum movements, and condyle translation were judged by millimeters. Clinical courses were uncomplicated in classes I to IV and did reach horizontal and vertical fragment reposition with minor remodeling in follow-up. Single cases evinced persistent pain, dysocclusion, facial nerve palsy, and plate fractures. Results were less successful in classes V and VI: although open reposition internal fixation showed good repositioning in class V, marked vertical bone remodeling occurred; single cases suffered from pain, dysocclusion, and plate fracture. Class VI cases had the worst translation, likewise marked condyle remodeling, and frequent dysocclusion. Classes V and VI remain challenging to treat, while the other classes can be treated reliably with this study's rationale. Condyle remodeling in classes V and VI, translation in class VI may benefit prospectively from even more careful mobilization, improved osteofixation as minimalized operation trauma.

Long-Term Outcomes After Treatment of Condylar Fracture by Intraoral Access: A Functional and Radiologic Assessment

The aim of the present study was to investigate radiographic and functional long-term results after condylar fractures have been reduced by an exclusively intraoral surgical approach. A total of 25 (21 male, 4 female) consecutive patients with 30 condylar process fractures were retrospectively investigated. Clinical follow-up was performed in 19 patients (16 male, 3 female) with a total of 24 fractures. Median postoperative follow-up time was 19.7 months. Surgical indications followed specific parameters of fracture localization, dislocation, and ramus shortening. All patients were examined in accordance with the Research Diagnostic Criteria for Temporomandibular Dysfunction (RDC/TMD) and the Helkimo Index. Orthopantomograms (OPGs) were analyzed with use of the condylar morphologic scale (CMS), and mandibular ramus position and height were measured. Fractures were classified as condylar neck (n = 2) and basis fractures (n = 28), according to criteria of the Strasbourg Osteosynthesis Research Group (SORG). Mean age of patients was 33 years (standard deviation [SD], 13 yr). RDC/TMD measurements at follow-up showed a mean mouth opening of 48 mm (SD, 9), mandibular laterotrusion right of 11 mm (SD, 3.8), laterotrusion left of 10 mm (SD, 4.5), and protrusion with a mean of 5.83 mm (SD, 3). No joint clicking, weakness of the facial nerve, or joint or muscular pain was observed. Statistical analysis of the CMS showed significantly better postoperative ramus height (P < .05). Reduction achieved by this technique allows reconstruction of anatomic ramus height in combination with excellent functional results.

Bone welding – A histological evaluation in the jaw

The expansion of biodegradable osteosynthesis systems in clinical application correlates well to the progress in development of new materials as to the improvement of application methods. One of those new application methods is the ultrasound-aided insertion of Resorb-X pins. The aim of this study was the histological evaluation of possible thermal damage to bone due to the ultrasound insertion. For this purpose, condylar neck fractures in 12 sheep were produced, repositioned and fixed by Resorb-X plates and pins. The animals were sacrificed in two groups, one after 2 weeks and one after 9 weeks. The bone-pin interlinkage and the structure of the bone were histologically evaluated. After 2 weeks a tight bone-polymer interlinkage was seen. Neither a pronounced foreign body reaction nor an interposition of fibrous tissue at the interface or a thermally induced necrosis was observed. The late phase of wound healing after 9 weeks showed pathomorphological characteristics within the normal range of bone healing. The bone seemed to be free of any alteration caused by process engineering. We conclude that thermal stress caused by ultrasound-aided pin insertion does not lead to cellular reaction in the bone. The fast and easy application of this improved biodegradable osteosynthesis system will bring a clear advantage in clinical use.

Botulinum Toxin in Closed Treatment of Mandibular Condylar Fracture

The topic of condylar injury in adults has generated more discussion and controversy than any other in the field of maxillofacial trauma. The treatment of condylar fractures in adults is still a highly debated theme. Patients with unilateral subcondylar or condylar neck fractures of the mandibula without any significant angulation of the condylar head were managed with closed-treatment protocol. Closed treatment was applied through the injection of 100 units of botulinum toxin A, diluted to a concentration of 20 IU/mL, into the muscles of mastication of the fractured side. Masseter and anterior fibers of temporalis muscles were reached through percutaneous extraoral route and 30 IU of the toxin was injected to each muscle. Additional 40 IU of the toxin was injected around the fractured bone fragments through transmucosal intraoral route to paralyze medial and lateral pterygoid muscles as much as possible. An asymmetric occlusal splint was applied for maxillomandibular fixation to restore the vertical height for 10 days. Functional therapy with intermaxillary guiding elastics was advocated for 2 months. There were no complications related to either toxin injections or splint application procedures. The toxin was effective on all occasions. Fractured condylar process and ramus of the mandibula were in good approximation and remained in reduced positions. None of the patients had any occlusal disturbance, mandibular asymmetry, or joint dysfunction in the follow-up period. We believe that modification of treatment options concerning the clinical situation of the patients is the best method for condylar injury. The purpose of this study is to present and discuss the results achieved in closed treatment of a selected group of patients with mandibular condylar fractures to whom botulinum toxin A was injected to relieve the spasm of muscles of mastication, along with special splint application.

A New 3-Dimensional Plate for Transoral Endoscopic-Assisted Osteosynthesis of Condylar Neck Fractures

Transoral surgical treatment of condylar neck fractures minimizes the risk of damaging the facial nerve. But fracture reduction and plate osteosynthesis remain challenging, especially when using 2 plates, although endoscopic assistance has proven helpful. To further improve and simplify osteosynthesis at the condylar neck, a new delta-shaped osteosynthesis plate that mimics the function of 2 plates has been developed. The present clinical follow-up study was conducted to evaluate this new plate. A total of 16 patients with 19 condylar neck fractures (3 Spiessl I, 13 Spiessl II, 1 Spiessl III, 2 Spiessl IV) and 3 bilateral fractures were treated through an endoscopic-assisted transoral approach. After reduction, the plate was applied, with the screws inserted either transcutaneously or with angulated instruments. The operation time ranged between 55 and 120 minutes. More than 6 months after the operation, functional parameters returned to normal, with an average mouth opening of 41 mm, protrusion of 5 mm, and laterotrusion of 6 mm. Radiographic controls showed good fracture alignment in 15 of 19 cases immediately after the operation, and in 14 of 19 cases 6 months after the operation. No plate fracture or bending was observed. In 3 patients, loose screws were found on plate removal. The clinical data and the engineering and biomechanical background suggest that the new delta-shaped plate can be regarded as 2 miniplates. The new plate is suitable for treatment of condylar neck fractures, particularly when used in an endoscopic-assisted transoral approach.

Development and biomechanical testing of a new osteosynthesis plate (TCP ®) designed to stabilize mandibular condyle fractures

In this paper, the different steps of development and experimental validation of a new type of three-dimensional (3-D) trapezoidal osteosynthesis plate (Modus TCP 2.0, Medartis, Basel, Switzerland) is described. These plates have been designed to stabilize sub-condylar and condylar neck fractures of the mandible. In order to apply the principles of functionally stable osteosynthesis to the mandibular condyle, i.e. to put the plate as close as possible to the tensile strain lines occurring during function, two new 4- and 9-hole 3-D trapezoidal plates were designed. Tests were conducted on fresh human mandibles before and after osteosynthesis of a standardised unilateral sub-condylar 'fracture', and a static biting exercise between the ipsilateral first molars was reproduced on a test bench. The resulting condylar fragment displacement in the sagittal plane was measured and the alterations of the condylar tensile strain lines induced by the osteosynthesis were investigated by using photoelastic strain tests. None of the plates broke. No macroscopic condylar displacement was noted when assessing the quality of the primary stabilization. Strain analysis showed the ability of these 3-D plates to transmit physiological strains across the fracture line and the absence of potentially damaging strains around the plate. These results were accredited to the 3-D and trapezoidal features of the plates. The Modus TCP plates experimentally fulfil the principles of functionally stable osteosynthesis in the condylar region and are able to resist physiological strains.

A comparison of MRI, radiographic and clinical findings of the position of the TMJ articular disc following open treatment of condylar neck fractures

We examined the position and function of the articular disc after open treatment of condylar fractures by comparing magnetic resonance images (MRI) and radiographs with clinical data. MRI and radiographs were taken after treatment of 28 patients with 33 fractures of the mandibular condyles. In all cases, the disc was located in the fossa after open reduction and internal fixation (ORIF). The MRI, radiographic and clinical findings did not correlate, and damage to the temporomandibular joint (TMJ) could be seen more clearly on MRI than on clinical or radiographic examination. Damage to soft tissues seen on MRI after treatment was more pronounced in dislocated than in displaced fractures.

Open Reduction and Internal Fixation of Dislocated Condylar Fractures in Children

The purpose of this study was to investigate the long-term clinical and radiologic outcomes of treating dislocated condylar fractures sustained in childhood with open reduction and internal fixation (ORIF). Six children 14 years or younger with a condylar neck or subcondylar fracture with dislocation of the condyle from the glenoid fossa were treated with ORIF. Patients were followed for 27 to 92 months post-ORIF (mean: 67.6 months) with routine clinical and radiologic examinations. On the dislocated side, all patients radiographically showed signs of remodeling of the condylar process and shortening of the ramus. Subsequent to their fractures, 3 patients were classified with Angle class II malocclusion, retrognathism, and deviation of the mandibular symphysis. Four patients had objective and/or subjective signs of temporomandibular (TMJ) dysfunction. Until open surgery demonstrates a consistent functional advantage, nonsurgical management should be considered the first treatment option for the dislocated pediatric condylar fracture.

O.476 Oral mucosal lesions in adult Finns: health 2000 health examination survey

To document facial nerve (FN) injuries after surgical treatment of mandibular condylar fractures using the retromandibular transparotid approach and to identify risk factors associated with these injuries.A retrospective study of patients surgically treated for mandibular condylar fractures using the retromandibular transparotid approach over seven years was conducted. The primary study variable was the postoperative change in FN function after fracture fixation. Risk factors were categorized as demographic, anatomic, experience of the operator, fracture displacement/dislocation and number of miniplates placed at the fracture site. Appropriate statistics were computed.Ninety patients with 102 fractures were analysed. Thirty two fractures (31%) were located in the condylar neck and 70 fractures (69%) were subcondylar (located below the sigmoid notch). The condylar segment was undisplaced in twelve cases (12%), displaced medially in thirty five (34%), laterally displaced in thirty (29%) and dislocated in 25 (24.5%). In 18 fractures (18%), postoperative examination revealed various degrees of damage to the FN. All nerve injuries recovered completely in 8–24 weeks. In a multivariate model, condylar neck fractures, fracture dislocation and operator inexperience were associated with a statistically significant risk of postoperative deterioration of FN function (P ≤ 0.05).The majority of facial nerve injuries after surgical treatment of condylar fractures by the retromandibular transparotid approach are transient in nature. Condylar neck fractures, fracture dislocation and operator inexperience were associated with an increased risk for FN injury.

Resorbable poly( d, l)lactide plates and screws for osteosynthesis of condylar neck fractures in sheep

We made osteotomies in the condylar neck in 12 adult sheep to simulate fractures, and joined the two ends with 2 poly( d, l)lactide (PDLLA) plates and 8 PDLLA screws 2 mm in diameter. The animals were killed after 2, 6, and 12 months and bony healing was assessed macroscopically and histologically. The plates and screws remained intact and there was no displacement of the bony ends. The degrading plates, which were still visible in the specimens after 6 months, had been replaced by bone. At 12 months the PDLLA had been resorbed with no foreign body reaction and no resorption of underlying bone. The articular discs showed no signs of degeneration.

Mandibular Condyle Dislocation Into the Middle Cranial Fossa: A Case Report and Review of Literature

Impact to the mandible typically results in ipsilateral or contralateral condylar neck fractures. Fracture of the glenoid fossa with a mandibular condyle dislocation into the middle skull base is a rare event. Structural variance is considered to be the determinant for this kind of fracture. Steinhauser proved experimentally that the central part of the glenoid fossa is the weakest part of the skull base. Normally, the lateral and medial elevated margins of the glenoid fossa meet the articular surface, that is the medial and lateral pole, of the mandibular condyle on impact. Da Fonseca remarked that a rounded condyle without any accentuated medial or lateral poles creates a higher pressure onto the bone of the glenoid fossa compared with a scroll shape. The role of the presence of occluding posterior teeth preventing the burst of the glenoid fossa by blocking the upward mandibular thrust, however, is controversial, according to other research. Victims of high-speed accidents with their mouths open who sustain a sudden blow to the chin may possibly be predisposed to undergo these injuries. Until today, only 30 cases have been reported, upon reviewing the English literature, with the first case being reported by Dingman and Grabb in 1963. Among the various nomenclature of this type of injury the term “central dislocation” is spread. Other central dislocations might occur in the hip joint with an intrapelvic dislocation of the femoral head or in the shoulder joint with an intrathoracic dislocation of the humeral head. Clinical features can include preauricular pain, laterognathism, and a limited range of motion without specific neurological signs or symptoms. These often may be misdiagnosed because of joint edema, joint “dislocation,” or radiographically poorly defined subcondylar fractures. Missed or delayed diagnosis of this injury may, therefore, occur. In addition to that, mortality because of intracranial damage from a displaced condyle or from other concomitant cranial injuries might explain the low number of cases reported. Intracranial hematomas, facial nerve paralysis or paresis –22 combined with a unilateral and bilateral cranial base fracture, damages of the eighth cranial nerve with ipsilateral hearing loss, hematorrhoea, leakage of cerebrospinal fluid, and cerebral injuries as contusion or concussion are some of the other findings reported in literature. Because of the complexity of these injuries, a variety of treatment options has been reported in the literature. The overall aim of any treatment, however, is both to prevent additional neurological problems and to obtain a proper occlusion, thus restoring function to avoid future temporomanqibular joint disorders like, for example, ankylosis. This article presents the case of a 9-year-old girl who fell down from a climbing pole in a local playground. The impact on the chin caused a dislocation of the right mandibular condyle into the middle cranial fossa. The treatment and the follow-up of this case is reported to add to the small number of previous case reports and to hopefully be useful for future case management.

Function Impairment and Pain After Closed Treatment of Fractures of the Mandibular Condyle

To determine the prognosis of fractures of the mandibular condyle after closed treatment. Patients (n = 144) with a fracture of the mandibular condyle, all treated closed, were included in the study. Fracture types and position of the fracture parts were determined on radiographs. Follow-up was after 12 months in which the average pain, experienced during the last week (visual analog scale, 100 mm), and mandibular functioning were assessed (mandibular function impairment questionnaire (MFIQ)). Data of 116 (81%) patients, 41 women (35%) and 75 men (65%), were available for analysis. Condylar neck fractures were most common (52%). Bilateral fractures were present in 28% of the patients. Pain (visual analog scale score >0) was found in 9% of the patients. Impaired mandibular function was found in 40% (MFIQ >0) and 24% (MFIQ > or =4) of the patients. The most important risk factor for pain was being a woman. The most important risk factors for function impairment were > or =25 years of age and gross displacement of the fracture parts. The overall prognosis of mandibular function and pain after closed treatment of condylar fractures is good. The most important risk factor for pain persisting for 1 year after closed treatment of a condylar fracture is being a woman. The most important risk factors for function impairment are an age of > or =25 years and gross displacement of the fracture parts.

Free-grafting of mandibular condyle fractures: clinical outcomes in 10 consecutive patients

“Free-grafting” of the superior segment, either alone or in combination with a posterior ramus osteotomy, is occasionally required when managing displaced condylar neck fractures. This allows ideal reduction and fixation, but carries the risk of proximal segment resorption, possibly requiring secondary reconstruction. The purpose of this study was to evaluate the clinical and radiographic outcomes of this technique in all patients who underwent this procedure during a seven-year period at a tertiary care centre. Ten patients who had undergone 11 free graft procedures were included in the study. Three patients required secondary costochondral reconstruction due to advanced resorption of the free-grafted condylar segment, this occurring from 3 to 9 months following the initial trauma surgery. All but one of the remaining patients exhibited varying degrees of condylar resorption/flattening radiographically, occurring within the first year only. However, no occlusal changes occurred in this group either objectively or subjectively during this year or during the subsequent follow-up period. The mean inter-incisal opening was 47 mm (range 40–56). With the exception of one patient that had a non-painful reciprocal click of the treated side, no patients demonstrated either objective or subjective signs of TMJ pathology. No patients reported dietary limitations, and all reported satisfaction with treatment to date. Based on objective and subjective evaluation, free grafting of the fractured condylar segment in this patient population had a 70% success rate. All failures occurred within 9 months and required secondary costochondral reconstruction.

Non-surgical treatment of mandibular fractures—survey of 28 patients: To Prof. Dr. J. Prein on the occasion of his 65th birthday

Between January 1996 and January 2001 28 patients (nine females, nineteen males) with 35 fractures were treated by observation and soft diet only. Patients with isolated high condylar neck fractures were not included. The mean age at time of trauma was 35.6 years (5/80). Only patients with normal occlusion and radiologically undisplaced fractures were included. The follow-up time was 15 weeks on average (8/33). The patients did not undergo any active treatment. They just received the instruction to reduce mouth opening and to take a soft diet for 4 weeks. During the first 2 weeks after the trauma the patients were seen twice a week. Follow-up X-rays were performed after 4 and after 8 to 12 weeks. As a preemptive therapy antibiotics (amoxicillin plus clavulanic acid 2×1g/day) were given for 5 days. Spontaneous healing of all fractures was observed. In two patients a tooth had to be removed out of the fracture line. One patient complained about an occlusal problem after 1 week. In his case intermaxillary fixation was installed for 2 weeks.For forensic reasons the patients have to be fully informed about possible complications before indicating this type of management. Patient selection is crucial and requires a highly experienced surgeon. Patient inconvenience due to frequent consultations must be taken into consideration. This type of treatment can be recommended only in selected cases.

A 3-dimensional finite-element analysis investigating the biomechanical behavior of the mandible and plate osteosynthesis in cases of fractures of the condylar process.

The condylar region is one of the most frequent sites for mandibular fractures, with direct application of miniplates being the most commonly used open-fixation technique today. Yet, anatomic and biomechanical limitations continue to make this application technically challenging with a considerable complication rate. We sought to analyze such incongruencies with respect to the complex biomechanical behavior of the mandible. Individual human mandible geometry, the specific bone density distribution, and the position and orientation of the masticatory muscles were evaluated by performing computed tomography scans and a sequential dissection of the cadaver mandible. Three-dimensional finite-element analysis was performed for different fracture sites, osteosynthesis plates, and loading conditions. Osteosynthesis of fractures of the condylar neck with 1 or 2 miniplates of a diameter of 2.35 x 1.00 mm was found to be an insufficient fixation method. This also applies for plates (3.60 x 1.54 mm), according to Pape et al,(8) when used in singular fashion (high condylar neck fractures excepted). In cases of singular occlusal contacts in the molar region (particularly at the contralateral side of the fracture), the highest stress values inside the mandible and osteosynthetic devices could be observed. With even the static yield limit of titanium being exceeded in such cases, consecutive rapid failure of the miniplates becomes most likely when loading of the condylar region caused by bite forces cannot be prevented. We strongly recommend the use, whenever possible, of 2 plates in the manner described by Pape et al(8) for osteosynthesis of fractures of the condylar neck in combination with bicortically placed screws. The stiffness of a singular osteosynthesis plate made of titanium in a diametrical dimension of approximately 5.0 x 1.75 mm was found to be equivalent to the physiological bone stiffness in the investigated fracture sites. The actual stiffness of such a fixation plate is approximately 3 times higher than the stiffness of devices commonly in use.