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Oral Maxillofac Surg8:1304-1309, 2010

Outcomes of Open Versus Closed Treatmentof Mandibular Subcondylar Fractures: A

Prospective Randomized StudyVirendra Singh, MDS,* Amrish Bhagol,† Mahesh Goel, MDS,‡

Ish Kumar,§ and Ajay Verma, MDS�

Purpose: To compare open reduction and internal fixation with closed treatment and maxilloman-dibular fixation for the management of subcondylar fractures of the mandible.

Patients and Methods: Forty patients with subcondylar fractures of the mandible were evaluated. Allfractures were displaced; either angulated between 10° and 35° or the ascending ramus was shortenedby more than 2 mm. Clinical and radiographic evaluation was performed 6 months after the trauma.Clinical parameters included mouth opening, protrusion, laterotrusion, deviation on mouth opening, andocclusion. Radiographic parameters included level of the fracture, deviation of the fragment, andshortening of the ascending ramus. Subjective parameters included pain according to a visual analogscale. Nonparametric data were compared for statistical significance with a �2 analysis and parametricdata with an independent samples t test (P � .05).

Results: Correct anatomical position of the fragments was achieved significantly more accurately in theoperative group in contrast to the closed treatment group. Regarding mouth opening/lateral excursion/protrusion, significant (P � .00) differences were observed between both groups (open 39.6/12.5/5.9mm vs closed 33.5/9.8/4.1 mm). The visual analog scoring revealed significant (P � .00) difference withless pain in the operative treatment group (1.1 open vs 5.2 closed). No statistically significant differencewas found between the 2 groups for occlusion (P � .86).

Conclusion: Both treatment options for condylar fractures of the mandible yielded acceptable results.However, operative treatment was superior in all objective and subjective functional parameters exceptocclusion.© 2010 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 68:1304-1309, 2010

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ractures of the mandibular condyle are common andccount for 25% to 35% of all mandibular fractures.1,2

lthough there are various guidelines regarding theanagement of condylar fractures of the mandible by

pen or closed treatment, there is still a continuingebate over how to best manage this type of fractures.or decades closed reduction has been the preferredreatment,3 but closed treatment requires varying peri-ds of maxillomandibular fixation (MMF) (0 to 4 weeks)ollowed by aggressive physiotherapy.4 Also, long-termomplications like pain, arthritis, open bite, deviation ofhe mandible on opening and closing movement, inad-

eceived from the Department of Oral and Maxillofacial Surgery,

overnment Dental College, Pt. B.D. Sharma University of Health

ciences, Haryana, India.

*Professor and Head.

†Postgraduate Student.

‡Assistant Professor.

§Postgraduate Student.

�Assistant Professor.d

1304

quate restoration of vertical height of the ramus leadingo malocclusion, and ankylosis do exist with the closededuction method. If there is severe displacement orislocation, surgical management is preferred.2,5,6 It al-

ows good anatomical repositioning and immediateunctional movement of the jaw.7 There is consensushat the correct anatomical reconstruction of the con-ylar process is an important prerequisite for re-estab-

ishing function.8 In recent times, the attitude towardreatment of a condylar process fracture has changedrom an exclusively nonsurgical approach toward anperative treatment in selected cases.

Address correspondence and reprint requests to Dr Bhagol:

epartment of Oral and Maxillofacial Surgery, Government Dental

ollege, Pt. B.D. Sharma University of Health Sciences, Rohtak-

24,001, Haryana, India; e-mail: bhagol.amrish@gmail.com

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/6806-0014$36.00/0

oi:10.1016/j.joms.2010.01.001

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SINGH ET AL 1305

The aim of this prospective study was to comparepen and closed treatment outcomes of subcondylarractures with deviation (10° to 35°), and/or fracturesith shortening of the ascending ramus (�2 mm).

atients and Methods

All the patients treated in the Department of Oralurgery, Government Dental College, Rohtak, be-ween November 2007 and March 2009 (17 months)ere offered participation in this prospective study.hey were informed of the need for 6 months, follow-p. The patients had to give informed consent orefusal regarding participation in the study. The pa-ient information was documented on a consent form.atients were thoroughly informed of the possibledvantages and disadvantages of the open and closedreatment options. To ensure randomization andvoid any bias, selection of 1 of the 2 treatmentodalities for any of these patients was done by

pening lots in sealed envelopes. Before beginninghe study, the design and method of randomizationad been approved by the Ethics Committee of Pt..D. Sharma University of Health Science, Rohtak,ndia. The inclusion criteria were as follows:

1) Age of the patient �18 years2) Unilateral subcondylar fracture as classified by

Lindhal9 and illustrated by Ellis and Throckmor-ton10

3) Sufficient dentition to reproduce the occlusalrelationships

4) Patient’s consent to participate5) Degree of displacement of the condylar frag-

ment in the coronal plane: 10° to 35°6) and/or shortening of the height of the ascending

ramus of the mandible �2 mm

he exclusion criteria were as follows:

1) Previous history of temporomandibular jointdysfunction

2) Severe pretraumatic dysgnathia3) Condylar head or neck fractures

dditional fractures of the mandible were treatedith open or closed treatment independent of ran-omization. Patients who were not able to follow the

nformation given or to make a decision themselvesue to mental or any other disability were also ex-luded from the study (eg, multiply injured patients inntensive care units).

Follow-up examinations were performed 6 monthsfter the trauma and included assessment of the fol-

owing clinical parameters: a

1) Range of motion of the injured joint together withthe contralateral joint as given by the mouth open-ing (maximum interincisal distance) and by theextent of lateral excursion and of protrusion

2) Deviation or deflection during mouth opening3) Assessment of pain with a visual analog scale

with values from 0 (no pain) to 100 (strongestpain or discomfort)

4) Occlusion (1: identical to pretraumatic; 2: slightdifference; 3: functional malocclusion; 4: re-quires occlusal adjustment; 5: gross malocclu-sions)

5) Motor nerve function (1: no deficit; 2: mildweakness; 3: moderate weakness; 4: severeweakness; 5: absence of function)

6) Sensory perception (1: full sensation; 2: candistinguish cotton/wood/pin; 3: not full but notdistracting; 4: can discern pressure; 5: pro-foundly numb)

These observations were recorded by 2 oral andaxillofacial surgery residents who were not in-

olved in the treatment planning and subsequent op-rative procedures of the patients and were thuslinded to the treatment the patient had received.

adiographic Assessment

The accuracy of fracture reduction and the stabilityf fixation were assessed by radiographs obtainedreoperatively and 6 weeks and 6 months postoper-tively.

The following method was used to measure theegree of displacement of the fracture in the Towne’sadiograph: a line was drawn between the medial andateral poles of the condyle. Another line was drawnangent to the ramus. The inner angle formed by thentersection of the 2 lines was calculated. The differ-nce between the angle on the nonfractured and theractured sides was used as a measure of coronalisplacement11 (Fig 1).Furthermore, the loss of ramus height was mea-

ured on the panoramic radiograph: a reference lineas drawn through both gonial angles. The perpen-icular distance between the most superior point onhe condyle and the reference line was calculated.he difference between the nonfractured and the

ractured sides was used as a measure of difference inamus length (loss of ramus height)11 (Fig 2).

reatment

Closed treatment consisted of MMF with elastics forperiod of 7 to 35 days (mean, 20 days). After thiseriod of MMF, guiding elastics were used for a vari-

ble period in most cases, to maintain proper occlu-

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1306 OUTCOMES OF TREATMENT OF MANDIBULAR SUBCONDYLAR FRACTURES

ion and at the same time to enable mouth opening.ostoperative instructions regarding mouth openingxercises and physiotherapy were given to all theatients.In open treatment, standardized surgical treatmentas used by 2 surgeons of consultant grade using

etromandibular, anteroparotid approach for surgicalccess. The fractures were fixed with 2 mm titaniuminiplates. MMF with light elastics was kept for 3 todays postoperatively. Postoperative instructions re-

IGURE 1. Illustration showing the method to measure the degreef displacement of the fracture in Towne’s radiograph.

ingh et al. Outcomes of Treatment of Mandibular Subcondylarractures. J Oral Maxillofac Surg 2010.

IGURE 2. Illustration showing the method to measure loss ofamus height on panoramic radiograph.

iingh et al. Outcomes of Treatment of Mandibular Subcondylarractures. J Oral Maxillofac Surg 2010.

arding mouth opening exercises and physiotherapyere given to all the patients.In this study, follow-up data of up to 6 months were

eported. The results of the clinical and radiologicalxaminations were recorded on a specific form. Para-etric data were evaluated with an independent sam-les t test. Nonparametric data were analyzed with a2 analysis. A P value of less than .05 was consideredtatistically significant.

esults

A summary of results and statistical analysis appearsn Tables 1 and 2.

emographic Results

In the present study, mean age at the time of injuryas 30.6 years. Among 40 patients, 33 were male andwere female with a male:female ratio of 4.7:1.In the etiology, road traffic accidents were found to

e responsible for the majority of the fractures, ie, in4 patients (60%).No statistically significant difference existed be-

ween the 2 groups for age at the time of injury,ender, diagnosis, and cause. Thus, 2 identical popu-ations were identified for injuries sustained (Table 1).

linical Results

MOBILITY OF THE MANDIBLE

The range of movement was assessed by maximalouth opening, protrusion, and lateral excursion. In

he closed treatment group, the average interincisalistance postoperatively (sixth-month follow-up) was3.54 mm (range, 30 to 37 mm; SD, 1.89) and in theurgically treated group, 39.6 mm (range, 36 to 44m; SD, 2.22). The difference was statistically signif-

Table 1. SUMMARY OF RESULTS ANDSTATISTICAL ANALYSIS

ClosedReduction(n � 22)

OpenReduction(n � 18) P Value

ender M/F 17/5 16/2 P � .33iagnosisRight 12 10 P � .94Left 10 8

auseMotor vehicle 13 11 P � .95Assault 7 5Others 2 2

ingh et al. Outcomes of Treatment of Mandibular Subcondylarractures. J Oral Maxillofac Surg 2010.

cant (P � .00) (Table 2).

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SINGH ET AL 1307

A similar situation was observed in the protrusion.n the closed treatment group, the average range ofrotrusion was 4.13 mm (range, 3 to 5 mm; SD, 0.77),hich was significantly less (P � .00) when com-ared with 5.94 mm (range, 4 to 8 mm; SD, 1.10) inhe surgically treated group.

The range of lateral excursion was 9.86 mm (range,to 13 mm; SD, 1.64) in closed treatment and 12.55m (range, 10 to 15 mm; SD, 1.33) in the surgically

reated group, the difference of which was statisti-ally significant (P � .00).

DISTURBANCES OF FUNCTION

Deflection and lateral shift of the mandible duringouth opening is often a sign of compensatory move-ents of the contralateral joint due to shortening of

he ascending ramus height on the affected side. In 12f 22 (54%) patients in the closed treatment group,erminal lateral shifts were observed. The averageeflection from the midline was 1.18 mm (range, 0 tomm; SD, 1.29) in this group. In contrast, in the

urgically treated patients, a deflection was observedn 4 cases (22%) with an average of 0.38 mm (range,

to 3 mm; SD, 0.84). There was a statistically signif-cant difference between the 2 groups (P � .03).

OCCLUSAL DISTURBANCES

In the closed treatment group, 2 of 22 (9%) patientseported occlusal disturbances after 6 months (meancclusal disturbance, 1.09).In the surgically treated group, 1 of 18 (5%) patients

eported occlusal disturbances (mean occlusal distur-ance, 1.11). No statistically significant differenceas found between the 2 groups for occlusion (P �

86).

SUBJECTIVE PAIN

The results of the visual analog scale (0 to 100) painssessment were 5.27 (range, 0 to 14; SD, 5.43) in the

Table 2. SUMMARY OF RESULTS AND STATISTICAL ANA

(n

ge at injury (yr)aximum interincisal opening (mm)

ateral excursion (sum total of both sides in mm)rotrusive movement (mm)eviation on opening (mm)otor function

ensory functionain (visual analog scale)cclusion

Cannot be determined statistically because the standard de

ingh et al. Outcomes of Treatment of Mandibular Subcondylar

losed treatment group with 10 of 22 patients having d

o pain after 6 months. In the surgically treatedroup, the corresponding value was 1.11 (range, 0 to2; SD, 3.30) with 16 of 18 patients reporting no painfter 6 months. Comparison of the arithmetic meansevealed a significant difference (P � .00).

NEUROLOGICAL ASSESSMENT

Although impossible to evaluate statistically (be-ause the standard deviations in each group were 0),o practical differences were noted in motor functionr sensory perception at 6 months, follow-up.

adiographic Results

The accuracy of fracture reduction and the stabilityf fixation were assessed by radiographs obtainedreoperatively, immediate postoperatively, and at 3nd 6 months, follow-up. In the surgically treatedroup, the average preoperative shortening of thescending ramus was 6.88 mm (range, 3 to 15 mm;D, 2.86). The average degree of preoperative frac-ure angulation was 19.3° (range, 10° to 35°; SD,.21). Six months after the surgical treatment, theverage shortening of the ascending ramus height was.38 mm (range, 0 to 2 mm; SD, 0.69) and the averageesidual angulation was 1.1° (range, 0° to 6°; SD,.67).In the closed treatment group, the average pretreat-ent shortening was 5.90 mm (range, 2 to 14 mm;

D, 3.03) and the angulation was 15.9° (range, 10° to0°; SD, 5.08). Thus, both treatment groups wereomparable preoperatively with no significant differ-nces in these parameters (shortening P � .30; de-ree of angulation, P � .06). At 6 months, follow-upn the closed treatment group, shortening was still.68 mm (range, 2 to 14 mm; SD, 2.93) and had notubstantially improved when compared with the pre-perative values. A similar situation occurred in the

Reduction(Mean � SD)

Open Reduction(n � 18) (Mean � SD) P Value

2 � 8.69 30.55 � 6.62 P � .944 � 1.89 39.61 � 2.22 P � .006 � 1.64 12.55 � 1.33 P � .003 � 0.77 5.94 � 1.10 P � .008 � 1.29 0.38 � 0.84 P � .030 � 0.00 1.00 � 0.00 *0 � 0.00 1.00 � 0.00 *7 � 5.43 1.11 � 3.30 P � .009 � 0.29 1.11 � 0.47 P � .86

of both groups was zero. No practical difference existed.

res. J Oral Maxillofac Surg 2010.

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1308 OUTCOMES OF TREATMENT OF MANDIBULAR SUBCONDYLAR FRACTURES

roved with 15.27° (range, 10° to 28°; SD, 4.46)hen compared with the preoperative situation.

iscussion

The treatment of condylar fractures remains con-roversial among maxillofacial surgeons. Earlier, thendications for the open reduction were limited asvident in criteria given by Zide and Kent in 1983,ecause they were based on the techniques, materi-ls, and scientific reports available at that time. Overime, however, the concept of rigid internal fixationas been increasingly applied to the injured cranio-axillofacial skeleton. With development of im-roved materials for fixation and refinement of surgi-al techniques, a paradigm shift has occurred, withcceptance and even reliance on rigid internal fixa-ion by both the surgeon and the patient. The result ishat new considerations regarding the indications orontraindications and advantages or disadvantages ofpen treatment over closed treatment have evolved.Today, the patient is more involved in the health

are decision-making process. This is based on moral,s well as medicolegal, considerations. Thus, afterppropriate informed discussion as to the risks, ben-fits, and alternatives, patient consent is taken regard-ng his or her willingness and preference for the

ode of treatment.When considering the best treatment for adult pa-

ients with fractures of the mandibular condyle, therst decision is whether the patient requires any ac-ive treatment. In cases where there is no occlusalisruption and no displacement of the fracture, aegimen of analgesics and soft diet with close moni-oring, both clinically and radiographically, is the bestpproach. If the patient requires active intervention,hen the options are either open reduction or closedreatment.12

Today, for dislocated fractures, open approachesre considered the treatment of choice in many sur-ical units. However, for moderately displaced con-ylar fractures, open treatment is still controver-ial.8,13-15

In our series, in the closed treatment group, short-ning of the ascending ramus, and angulation of theragments were minimally changed after 6 months.hese 2 criteria were significantly improved in thepen treatment group postoperatively. Previously, re-orted retrospective studies demonstrated a betternatomical position after operative treatment, buthey showed no significant difference in the func-ional clinical results.16,17 In our study, all functionalarameters except occlusion showed significantlyetter outcomes in patients of the open treatmentroup. We did not find any statistically significant

ifference in the occlusal status between the 2 treat- d

ent groups. These occlusal findings are similar tohose of Takenoshita et al16 but different from that of

orsaae and Thorn18 and Ellis et al,19 who reportedore malocclusion in patients treated by the closed

echnique. We also found better treatment results andess pain and discomfort in the patients of the openreatment group.

In this study, the improvement obtained by openreatment is greater than that obtained by closedethods, with statistically significant differences.here are limited studies available for comparison and

hey also have varied results. Retrospective studiesrom Hidding et al20 and Konstantinovic and Dimitri-evic21 reported no functional advantages for the op-rative option. In contrast, the studies of Worsaae andhorn18 found better results from the operative op-

ion in a prospective study. In those studies, wiresteosynthesis was applied in conjunction with 4eeks of MMF. However, a postoperative MMF of 4eeks is undesirable for rapid restoration of function.herefore, it is difficult to compare the present studyith those studies, as functionally stable methods of

nternal fixation with 3 to 5 days of postoperativeMF was used in this study. A prospective, but not

andomized, study by Haug and Assael22 with 10 pa-ients in each treatment group found no statisticaldvantage for either of the 2 treatment options. How-ver, there was more chronic pain in the closedreatment group. It is of importance that in all non-andomized studies, there is the shortcoming thatsually the more complicated displaced or dislocatedractures were more likely to receive operative treat-ent and less displaced fractures to receive closed

reatment. Thus, there is a bias due to patient selec-ion. In our study, similar moderately displaced frac-ures were compared between the 2 groups.

Finally, only subcondylar fractures were comparedn the study; condylar head and neck fractures werexcluded. Open reduction and internal fixation isontraindicated for the management of condylar headractures, as there is a high risk of avascular necrosisith the associated loss of a functioning condyle and

he potential for development of a fibrous or osseousnkylosis and the need for removal of loose hard-are.22

A relative contraindication to open reduction andnternal fixation is the condylar neck fracture (thehin constricted region inferior to the condylar head).n the case of condylar neck fractures, a predictablemount of bone is not always available to permit thelacement of 2 screws per segment.22 Therefore, ifondylar head and neck fractures had been included,hey would have been included in the closed treat-ent group. Their inclusion would have been a seri-

us flaw in the study design and would have invali-

ated the investigation.

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SINGH ET AL 1309

The data provided by this randomized prospectivetudy indicated that better functional results can bexpected by open reduction and internal fixation foroderately displaced subcondylar fractures comparedith closed treatment.

eferences1. Manisali M, Amin M, Aghabeigi B, et al: Retromandibular ap-

proach to the mandibular condyle: A clinical and cadavericstudy. Int J Oral Maxillofac Surg 32:253, 2003

2. De Riu G, Gamba U, Anghinoni M, et al: A comparison of openand closed treatment of condylar fractures: A change in philos-ophy. Int J Oral Maxillofac Surg 30:384, 2001

3. Brandt MT, Haug RH: Open versus closed reduction of adultmandibular condyle fractures: A review of the literature regard-ing the evolution of current thoughts on management. J OralMaxillofac Surg 61:1324, 2003

4. Suzuki T, Kawamura H, Kasahara T, et al: Resorbable poly-L-lactide plates and screws for the treatment of mandibularcondylar process fractures: A clinical and radiologic follow-upstudy. J Oral Maxillofac Surg 62:919, 2004

5. Sagiura T, Yamamoto K, Murakami K, et al: A comparativeevaluation of osteosynthesis with lag-screws, miniplates, orKirschner wires for mandibular condylar process fractures.J Oral Maxillofac Surg 59:1161, 2001

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8. Baker AW, McMahon J, Moos KJ: Current consensus on themanagement of fractures of the mandibular condyle. A methodby questionnaire. Int J Oral Maxillofac Surg 27:258, 1998

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3. Silvennoinen U, Iizuka T, Oikarinen K, et al: Analysis of possi-ble factors leading to problems after nonsurgical treatment ofcondylar fractures. J Oral Maxillofac Surg 52:793, 1994

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7. Hayward JR, Scott RF: Fractures of the mandibular condyle.J Oral Maxillofac Surg 51:57, 1993

8. Worsaae N, Thorn JJ: Surgical versus nonsurgical treatment ofunilateral dislocated low subcondylar fractures: A clinical studyof 52 cases. J Oral Maxillofac Surg 52:353, 1994

9. Ellis E, Simon P, Throckmorton G: Occlusal results after openor closed treatment of fractures of the mandibular condylarprocess. J Oral Maxillofac Surg 58:260, 2000

0. Hidding J, Wolf R, Pingel D: Surgical versus non-surgical treat-ment of fractures of the articular process of the mandible. JCraniomaxillofac Surg 20:345, 1992

1. Konstantinovic V, Dimitrijevic B: Surgical versus conservativetreatment of unilateral condylar process fractures: Clinical andradiographic evaluation of 80 patients. J Oral Maxillofac Surg50:349, 1992

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