J Oral Maxillofac Surg 64:1771-1779, 2006

Open Reduction and Rigid Internal Fixation of Mandibular Condylar Fractures by an Intraoral Approach: A Long-Term Follow-Up Study of 15 Patients
Thomas Jensen, DDS,* John Jensen, DDS, PhD, Sven Erik Nrholt, DDS, PhD, Martin Dahl, DDS, Lone Lenk-Hansen, DDS, and Peter Svensson, DDS, PhD, DrOdont
Purpose: To evaluate the long-term results obtained with open reduction and rigid internal xation of

mandibular condylar fractures by an intraoral approach. Patients and Methods: Fifteen patients with 24 mandibular condylar fractures were retrospectively examined with an average follow-up of 23 months (range, 6-63 months). Clinical and radiographic examination was conducted according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), including an evaluation of maximum voluntary bite force measurements and facial nerve function. Statistical analysis was performed on maximum voluntary bite force measurements and maximum pressure pain threshold. Results: Two patients fullled the criteria for a RDC/TMD diagnosis. Myofacial pain (group I) and bilateral arthralgia (group III), combined with a moderate nonspecic physical symptom score, was diagnosed in 1 patient and 1 patient received a diagnosis of disc displacement with reduction (group II). Satisfying radiographic fracture healing was seen in 12 joints. However, miniplate fracture occurred in 3 patients and severe bone resorption of the condylar head was seen in one patient. Minor adjustment of the postoperative occlusion was necessary in 6 patients. No signicant difference between maximum voluntary isometric bite force measurements or maximum pressure pain threshold was found between the fracture side and the opposite side in unilateral cases or between the operated and nonoperated side in bilateral cases. None of the patients showed facial nerve injury or visible facial scars. Conclusion: Within the limitations of a retrospective study, the present study emphasized that optimal management of dislocated bilateral condylar injuries combined with other fractures of the facial skeleton constitute a challenging issue in maxillofacial trauma. Moreover, open reduction and rigid internal xation of mandibular condylar fractures by an intraoral approach is a technically demanding surgical procedure associated with a high risk of postoperative complications in these injuries. 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:1771-1779, 2006

Received from Aalborg Hospital, Aarhus University Hospital, Denmark. *Consultant, Department of Oral and Maxillofacial Surgery, Aalborg Hospital. Consultant and Head of Department, Department of Oral and Maxillofacial Surgery. Consultant, Department of Oral and Maxillofacial Surgery. Consultant, Department of Oral and Maxillofacial Surgery. Resident, Department of Oral and Maxillofacial Surgery. Professor, Department of Oral and Maxillofacial Surgery, Aarhus

University Hospital and Department of Clinical Oral Physiology, School of Dentistry, Faculty of Health Sciences, University of Aarhus. Address correspondence and reprint requests to Dr Jensen: Department of Oral and Maxillofacial Surgery, Aalborg Hospital, Aarhus University Hospital, Hobrovej 18-22 DK-9000 Aalborg, Denmark; e-mail: u00250@aas.nja.dk
2006 American Association of Oral and Maxillofacial Surgeons

0278-2391/06/6412-0011$32.00/0 doi:10.1016/j.joms.2005.12.069

1771

1772 Fractures of the mandibular condylar and articular joint represent 20% to 52% of all mandibular fractures, and are thus among the most common facial fractures.1-3 Nondislocated mandibular condylar fractures and condylar fractures in children are successfully treated conservatively.4 Dislocated condylar fractures have traditionally been managed by closed reduction using a period of maxillomandibular xation succeeded by jaw exercise. However, this conservativefunctional treatment may cause malocclusion, restricted forward motion of the lower jaw, degenerative joint disease, facial asymmetries or functional disabilities, especially in cases with bilateral or severely displaced fractures.5-11 Open reduction and rigid internal xation of dislocated mandibular condylar fractures has, in the last decades, become more prevalent because it provides the possibility of restoring the pretraumatic anatomic relationships, gives adequate stability to the fracture, facilitates rapid fracture healing including restoration of early function, and avoids prolonged maxillomandibular xation. Many studies have shown that open reduction and rigid internal xation of isolated unilateral condylar fractures provides similar or better functional outcome compared with closed treatment.10,12,13 A variety of surgical techniques and xation modalities have been advocated for repositioning and stabilization of the mandibular condylar fracture. The majority of surgeons prefer the extraoral approach, in contrast to the intraoral approach, because it gives a good visualization and ability to achieve a better alignment of the bony fragment. However, open reduction by an extraoral approach leaves a facial scar and has the potential to cause facial nerve injury.14,15 The intraoral approach minimizes the risk of facial nerve damage and leaves no facial scar. However, the intraoral approach has been described in only a few reports and has solely been recommended for treatment of low condylar fractures due to restricted surgical eld and limited access to the condylar neck.16,17 The purpose of the present retrospective study was to assess subjective and functional measures of jaw function in addition to a radiological examination of the mandibular condylar and temporomandibular joint after open reduction and rigid internal xation of mandibular condylar fractures by an intraoral approach.

MANDIBULAR CONDYLAR FRACTURES

including 81 unilateral and 24 bilateral. A total of 21 patients with mandibular condylar fracture were treated surgically by an intraoral approach, of whom 15 responded to a follow-up call of at least 6 months after surgical intervention. The study group consisted of 9 men and 6 women, average age 42 years (range, 18 to 85 years). Six patients had unilateral condylar fracture and 9 patients sustained bilateral condylar fractures. Fifteen of the condylar fractures were classied as subcondylar and 9 were condylar neck or intracapsular, according to the nomenclature described by Lindahl.6 Isolated fracture of the mandibular condylar was observed in 3 patients. Eight patients had additional fracture of the mandible, and 4 patients had both additional mandibular and midfacial fractures. The distributions of fractures are outlined in Table 1. The mechanism of injury was bike accidents (40%), road trafc accidents (27%), falls (20%), and accidents at work (13%).
SURGICAL PROCEDURE

Patients and Methods

PATIENTS

From January 1997 to June 2002, 377 patients with fractures of the mandible were treated at the Department of Oral and Maxillofacial Surgery, Aarhus University Hospital. There were 105 patients who had isolated or concomitant mandibular condylar fracture,

Indications for open reduction and rigid internal xation of mandibular condylar fractures are listed in Table 2. All patients underwent open reduction and rigid internal xation under general anesthesia. The time interval between trauma and operation ranged from 0 to 3 days (mean of 2 days). Initially, dental arch bars were applied and other fractures of the mandible were stabilized by miniplate osteosynthesis. The incision was similar to the surgical approach for sagittal ramus osteotomy. The periosteum and masseter muscle were elevated over the ascending mandibular ramus and the fracture site was exposed. The periosteum was stripped off from the inferior part of the condylar fragment. A downward force was applied to the mandibular ramus to allow manipulation and repositioning of the condylar fragment into normal position. After the mandibular condylar fracture was temporarily repositioned to its normal anatomical position, a transcutaneous trochar opening was made to facilitate osteosynthesis. A 6-hole 2-mm miniplate (Wrzburg titanium system; Stryker Leibinger, Freiburg, Germany) was placed along the posterior border of the condylar neck and rst attached to the proximal bony segment. The patient was temporarily placed in maxillomandibular xation and the fracture was aligned anatomically and stabilized with 3 screws on each side of the fracture. In cases with lack of space, a 4-hole plate was used instead, eventually in combination with an extra plate. Class II training elastics were applied on the side of condylar process fracture to assist the patient to occlude into the proper occlusal relationship. A uid diet was permitted until postoperative day 14, and the patient continued with soft diet for another 28 days.

JENSEN ET AL

1773

Table 1. DISTRIBUTION OF MANDIBULAR CONDYLAR FRACTURES (n

24)

Unilateral Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Right Left Right

Bilateral
Left

Additional Fractures Symphysis, coronoid process Mandibular body Mandibular body, coronoid process Symphysis, Le Fort I Symphysis, Le Fort I/II Symphysis Symphysis Symphysis Mandibular angle Symphysis Symphysis, coronoid process Le Fort I, Palatum durum Mandibular body

Subcondylar Subcondylar Subcondylar Condylar neck Subcondylar Subcondylar Condylar neck Subcondylar Subcondylar Intracapsular Condylar neck Condylar neck Subcondylar Subcondylar Subcondylar

Intracapsular Intracapsular Condylar neck Subcondylar Subcondylar Subcondylar Subcondylar Condylar neck Intracapsular

Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

CLINICAL EXAMINATION

The follow-up call consisted of a questionnaire and a clinical and radiological evaluation. The questionnaire, which was answered using 0-10 visual analog scale (VAS) ratings, included the patients perception of mouth opening, restriction of jaw movement, bite force, pain located to joint/masticatory muscles, impaired masticatory function, malocclusion, facial paralysis, and headache, as compared with preoperative level. The clinical examination was conducted according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) involving clinical assessments of temporomandibular disorders signs and symptoms including pain, mandibular range of motion and associated pain, joint sounds, and tenderness upon muscle and joint palpation.18 Patients with temporomandibular disorders were categorized according to RDC/TMD diagnostic groups: myofacial pain (group I), disc displacements (group II), and other joint conditions (group III). Psychological status was assessed by measuring the depression score and the nonspecic physical symptoms score with the subscales of the symptom checklist-90, revised (SCL-90R).19 Psychosocial functioning was assessed through the graded chronic pain scale, which yields a score of 0-IV (0 no TMD pain, I low disability/low intensity pain, II low disability/high intensity pain, III high disability/moderately limiting pain, IV high disability/severely limiting pain), reecting the severity of the temporomandibular joint symptoms on interferences with everyday life. Furthermore, an evaluation of the maximum voluntary occlusal bite force measurements including pressure pain thresholds (PPT) of, respectively, the temporoman-

dibular joint and masticatory muscles, were obtained. A pressure algometer (Somedic; Somedic AB, Sollentuna, Sweden) was used to measure the PPT of the temporomandibular joint and masticatory muscles. The PPT was dened as the amount of pressure (kPa) that the patients rst perceived as painful.20 The patients pushed a button to stop the pressure stimulation when the threshold was reached. The PPTs were determined twice and the mean was calculated. The interval between successive pressure stimuli was about 1 minute. In addition, the maximum pressure pain threshold the patient could withstand was measured correspondingly. Maximum voluntary occlusal bite force between the molars on both sides was measured using an occlusal force transducer, which was covered with plastic

Table 2. INDICATIONS FOR SURGICAL INTERVENTION

Unilateral mandibular condylar fractures Impossibility of obtaining proper occlusion by closed reduction Impairment by condylar fragment of mandibular mobility Severely dislocated condylar fragment with considerable vertical shortening of the ascending ramus and pronounced malocclusion Bilateral mandibular condylar fractures Combined with comminuted midface fractures Vertical shortening of the ascending ramus and pronounced malocclusion Maintain posterior vertical dimension in edentulous patients when splints cannot be used
Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

1774 tubes to protect the teeth.20 The patients were instructed to clench their teeth as hard as they could for 3 to 4 seconds. The peak value represented the maximum voluntary occlusal bite force. The measurement was repeated twice and the mean was calculated. Finally, an examination of the facial nerve functions was conducted according to Lindsay et al,21 comprising assessments of asymmetrical elevation of lower lip, eye closure, pursing lips, attening of naso-labial fold, smiling, and wrinkling forehead.
RADIOGRAPHICAL EXAMINATION

MANDIBULAR CONDYLAR FRACTURES

ed as fracture healing in correct anatomic position, fracture healing in a displaced position, and inadequate fracture healing. All preoperative and postoperative radiographs were assessed independently by 2 observers, a resident and a consultant, for characteristics of the dislocated mandibular condylar fracture, with regard to classication, dislocation, and postoperative reduction. The observers independently completed a registrar form. When there was disagreement, both observers reviewed the case together to arrive at a consensus.
STATISTICAL EVALUATION

The follow-up radiographic examination included a standard Townes view and orthopantomogram. The success of fracture healing was evaluated and classi-

A paired t test was used to determine maximum voluntary bite force measurements between the frac-

FIGURE 1. A, 3D CT reconstruction showing severely dislocated bilateral condylar fracture and symphysis fracture combined with a Le Fort I/II fracture. B, 3D reconstruction illustrates a subcondylar fracture with vertical ramus shortening. C, Coronal CT scan obtained postoperatively showing condyle position in the glenoid fossa. Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

JENSEN ET AL

1775

tured side and the nonfractured side in unilateral condylar fracture and between open reduction and close reduction in bilateral condylar fractures. PPT and maximum pressure pain threshold were compared between open reduction and close reduction/ nonfractured side with a paired t test. P .05 is considered signicant.

Results
A total of 15 patients with 24 mandibular condylar fractures were enrolled in this study. Of the 9 patients with bilateral injuries, only 1 was stabilized with miniplates on both sides (Fig 1). The average period of follow-up was 23 months, ranging from 6 months to 63 months.
QUESTIONNAIRE
FIGURE 2. Follow-up orthopantomogram demonstrating severe bone resorption and collapse of the right condylar head. Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

Nine patients complained of restricted maximum mouth opening compared with preinjury level, which on average was rated as 3 on the VAS (range, 1-7). Limited excursion of the mandible was expressed by 5 patients, which on average was estimated as 4 on the VAS (range, 2-7). Impaired masticatory function was described by 6 patients, which on average was rated as 4 on VAS (range, 1-7). However, they all expressed an unambiguous and stable occlusion with the capability to eat and chew all food products, although 2 of the 6 patients complained of pain located on the fractured side during chewing. Joint sounds located on the fractured side were described by 3 patients.
CLINICAL EVALUATION

Mean unassisted interincisal opening without pain was 47 mm (range, 32-64 mm) and mean maximum unassisted and assisted interincisal opening was 48 mm (range, 32-66 mm) and 49 mm (range, 33-66 mm), respectively. Unassisted interincisal opening less than 40 mm was found in 4 patients. In all the unilateral fractures, minor deviations to the operated side during maximal mouth opening was observed and mean laterotrusion to the fractured side was 11 mm (range, 7-13 mm) compared with 9 mm (range, 7-11 mm) to the nonfractured side. In bilateral cases, mean laterotrusion was 7.5 mm (range, 3-12) and 9 mm (range, 7-14 mm) to the operated and nonoperated side, respectively. Maximal protrusion ranged from 2 to 13 mm (mean 7 mm). Four patients complained of temporomandibular joint (TMJ) pain. Follow-up orthopantomogram showed severe bone resorption and collapse of the right condylar head in one of the painful joints (Fig 2), whereas the TMJ pain was located on the nonoperated joint in 2 patients with bilateral fractures. The fourth patient with TMJ pain, who was treated for a unilateral condylar fracture and symphysis fracture, fullled the

RDC/TMD criteria for myofacial pain (group I) and bilateral arthralgia (group III). Joint sounds located to the fractured side were found in 3 patients. Open reduction was performed in 2 of the joints and disc displacement with reduction (group II) was diagnosed in 1 of the joints, whereas severe bone resorption of the condylar head was observed in the latter. SCL-90R scores showed moderate nonspecic physical symptom score in the patient diagnosed with myofacial pain and arthralgia. The remaining patients showed no depression or somatization tendencies. The graded chronic pain scale showed 4 patients with score I and 1 patient with score II. The patient with myofacial pain and bilateral arthralgia achieved score II, and 2 of the patients who complained of TMJ pain gained score I. A satisfying occlusion was observed in all patients. However, 40% of the patients had previously minor postoperative occlusal disturbances which needed correction. Grinding of the teeth was performed in 3 patients due to premature contact. Orthodontic treatment and prosthetic rehabilitation was required in 3 patients in order to establish a functional occlusion due to traumatic tooth loss and persistent postoperative malocclusion. Maximum voluntary isometric bite force measurements and pressure pain threshold of the TMJ and masticatory muscles showed no signicant differences between the fracture side and the opposite side in unilateral cases. Similar answers were found in bilateral cases between the operated and nonoperated side (Tables 3, 4).
RADIOGRAPHICAL EVALUATION

Immediate postoperative radiographs showed correct anatomic reposition in 6 joints, acceptable repo-

1776

MANDIBULAR CONDYLAR FRACTURES

Table 3. PRESSURE PAIN THRESHOLD (kPa)

Open Reduction Masseter Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Mean P value

P M

Closed Reduction/Nonfractured Side TMJ

P M

Temporalis
P M

Masseter
P M

Temporalis
P M P

TMJ
M

202 116 144 159 100 236 128 139 223 72 64 241 160 230 158 .821

503 148 288 180 219 272 406 261 375 180 264 257 292 389 288 .626

209 215 126 187 132 304 166 121 260 90 152 376 201 222 197 .663

437 238 494 246 395 410 377 344 453 230 319 422 342 712 387 .438

156 100 166 138 90 222 158 105 225 67 81 265 193 258 159 .525

288 115 294 196 311 248 254 230 357 156 200 300 198 302 246 .430

165 73 139 151 97 235 146 141 259 63 94 257 154 221 157

609 196 379 187 204 388 223 178 420 217 204 312 317 352 299

328 136 142 244 113 274 169 148 265 79 131 398 193 226 203

460 162 414 328 312 464 284 305 427 238 216 406 347 844 372

175 104 141 186 93 221 156 164 220 71 100 298 134 235 164

395 213 275 194 247 265 221 231 426 192 179 356 179 242 258

Patient no. 5 is excluded because open reduction was performed on both sides. Abbreviations: P, pressure pain which the patient rst perceived to be painful; M, maximum pressure pain threshold. Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

sition was observed in 10 joints (measured as lack of 1-3 mm bone contact or less than 15 degrees angulations of the proximal fragment). Inadequate reduction of the fragments was seen in 1 patient.
Table 4. MAXIMUM VOLUNTARY BITE FORCE MEASUREMENTS (kg)

Follow-up radiographs showed successful bone healing in 12 of the surgically treated joints. In 3 of the remaining joints, medial displacement of the condylar head was observed due to fracture of the miniplate, and 1 patient had severe bone resorption of the condylar head.
COMPLICATIONS

Unilateral Condylar Fracture Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Mean P value

Fractured Side Nonfractured Side

Bilateral Condylar Fracture

Open Reduction Closed Reduction

45 26 83 94 62 40 51 46 59 51 30 54 .409 41 52 55 44 62 18 33 57 42 .328

32 21 44 49 61 49 16 25 37

Complications are listed in Table 5. One patient had to be reoperated on the second day after primary surgery due to malposition of the fragment detected in the postoperative radiographic control. The revision was performed by a submandibular approach. Follow-up radiography 20 months after surgery showed severe bone resorption of the condylar head. The condylar head and the osteosynthesis miniplate were subsequently removed.
Table 5. TYPE OF COMPLICATIONS

No. of Patients Reoperation Plate fracture Resorption of the condylar head Infection Malocclusion Reduced range of mouth opening ( 40 mm) Facial nerve injury Visible facial scar 1 3 1 1 6 4 0 0

Patient no. 5 is excluded because open reduction was performed on both sides. Patient no. 6 used upper denture and is therefore excluded. Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

JENSEN ET AL

1777 has made the intraoral approach more feasible in the treatment of mandibular condylar fractures.22-25 A review of the English literature has disclosed 7 reports that have evaluated the long-term outcome after open reduction and rigid internal xation of mandibular condylar fractures by an intraoral approach.22,24-29 In 4 of the reports, endoscopic-assisted procedures were used.22,24,25,29 Although bilateral injuries and high condylar fractures were treated by an intraoral approach, similar functional outcome and radiographic fracture healing were obtained, compared with reports using the extraoral approach. In the present study, we found a relatively high rate of subjective symptoms and complications compared with the aforementioned studies (Tables 5, 6). Severely dislocated bilateral condylar fractures generate more complications and functional disturbances, particularly if the condylar fractures are associated with other injuries of the mandible or facial skeleton.30 In our study, 80% of the patients had unilateral or bilateral condylar fractures combined with other injuries of the mandible and the facial skeleton. Re-establishment of the pretraumatic occlusion as well as normal mandibular motion is essential in the treatment of condylar fractures. In the present study, 6 patients, sustaining bilateral condylar injuries combined with additional fractures of the mandible or midface, had persistent minor postoperative maloc-

Miniplate fracture was observed in 3 joints. Although, the proximal fragment was medially displaced in all 3 cases, the occlusion remained stable. The fractured plates were left in place, because no signs of infection were present. Postoperative wound infection due to screw loosening was seen in 1 case. The patient was successfully treated with antibiotics and removal of the screw. None of the patients showed facial nerve injury or visible scars.

Discussion
Among the various surgical approaches reported in the literature, the retromandibular and submandibular approaches emerge as the most commonly used procedures to expose the condylar fracture, and the intraoral approach has been suggested only for low condylar fractures.16,17 However, no comparative studies of the intraoral approach versus the extraoral approach have ever been conducted. In our opinion, the intraoral approach offers great advantages compared with the extraoral approach. It minimizes the risk of visible scars and facial nerve injury, and the incision is basically similar to the approach for a sagittal ramus osteotomy and therefore very well known to oral and maxillofacial surgeons. Additionally, the introduction of endoscopic-assisted surgery

Table 6. A COMPARISON OF TREATMENT OUTCOME BETWEEN UNILATERAL AND BILATERAL CONDYLAR FRACTURES

Patient

Interincisal Opening (mm)

Adjustment of Occlusion

Plate Fracture

RDC/TMD

Reoperation

Resorption of Condylar Head

Additional Fractures Yes

Unilateral condylar fractures 3 62 6 44 9 45 11 45 13 50 15 40 Bilateral condylar fractures 1 32 Grinding 2 46 4 42 Grinding 5 57 Orthodontic treatment and prosthetic rehabilitation 7 41 8 42 10 52 Grinding 12 37 Orthodontic treatment 14 35 Orthodontic treatment

Yes Group I/III Yes Yes Yes Yes Yes Yes Yes Yes

Yes Group II

Yes Yes Yes Yes Yes Yes

Jensen et al. Mandibular Condylar Fractures. J Oral Maxillofac Surg 2006.

1778 clusion. Similar studies have shown that 10% of the patients with bilateral injuries require postoperative surgical correction, due to persistent malocclusion.30 Secondary surgical correction of the malocclusion was not needed in any of the patients in our study, but minor postoperative grinding, orthodontic treatment, and prosthetic rehabilitation were required in order to establish a functional occlusion due to concurrent traumatic dental injuries. Persistent limited mouth opening and restricted mandibular movement are among the most common complaints after open or closed treatment of condylar fractures. In our study, 9 patients complained of persistent limited mouth opening and restricted mandibular motion. Clinical examination showed normal values of interincisal opening in 11 patients and insufcient maximum interincisal opening of less than 40 mm in 4 patients. Bilateral condylar fractures associated with either comminuted mandibular symphysis/body fracture or midfacial fractures were found in all 4 patients with diminished mouth opening. Moreover, the condylar head was severely displaced in each case, with the probability of TMJ injuries and loss of muscular attachment. These ndings emphasized that displaced condylar injuries combined with other facial fractures may lead to more postoperative complications. Deviation toward the side of injury during maximum mouth opening is a frequent complaint after open or closed treatment of mandibular condylar fractures, presumably due to reduced function of the pterygoid muscles or mechanical hindrances. In our study, only a minor deviation toward the fractured side was observed in the unilateral cases, whereas symmetric mouth opening was seen in bilateral injuries. However, in unilateral as well as bilateral injuries, mean lateroprotrusion towards the nonfractured or nonoperated side was reduced compared with the opposite side. These ndings are parallel to other reports. The mandibular condyle is a vital component during masticatory movements. Injuries to the condylar head or neck may cause reduced maximum bite forces and discomfort during chewing. Tate et al31 reported signicant reduced molar bite force on the fractured side in patients with unilateral mandibular angle fractures. In the present study, 6 patients complained of impaired masticatory function, of which 2 patients described pain located to the fractured side during chewing. However, no signicant differences were observed in maximum voluntary isometric bite forces between the operated side and the nonoperated side in bilateral cases or the nonfractured side in unilateral cases, respectively. Corresponding to our ndings, Ellis and Throckmorton32 reported equal maximum voluntary bite forces in patients treated for

MANDIBULAR CONDYLAR FRACTURES

mandibular condylar fractures when treatment was either open or closed. Follow-up radiographic examination showed successful fracture healing in 12 joints. However, miniplate fracture was observed in 3 patients and severe bone resorption of the condylar head was seen in one joint. Miniplate fracture occurred only in patients stabilized with a single plate. Moreover, inadequate stability of the fracture due to lack of bone contact between the fragments, combined with functional loads of the miniplates during bone healing, involve a certain risk for bending or fractures of the plates. In 2 of the patients with miniplate fracture, postoperative radiograph showed fracture reposition with a minor diastase. When 2 miniplates were used, no plate fracture or bending was observed. Previous clinical and experimental studies assessing the biomechanical behavior of various rigid internal xation techniques for mandibular condylar fractures have shown that only one monocortical miniplate results in inadequate stability, plate fracture, and screw loosening.33,34 Therefore, the ndings in this study emphasize that condylar fractures should be stabilized with at least 2 miniplates or plates with high rigidity to withstand the functional load during the period of bone healing. Resorption of the condylar head after open reduction and internal rigid xation has been reported by Iizuka et al.35 In the present study, follow-up radiographs showed severe bone resorption and collapse of the condylar head in 1 patient sustaining an isolated unilateral high condylar fracture that was severely displaced from the glenoid fossa. The fracture was initially treated by an intraoral approach, but the patient was reoperated by a submandibular approach due to postoperative malposition of the bony fragments. Displacement of the condylar fragment from the glenoid fossa may cause nutritional disturbances, and detachment of the periosteum during surgery may result in inadequate vascularity, which can potentially lead to ischemic necrosis and resorption of the condyle. The patient in the present study sustained a high condylar fracture that was operated on twice. Long-term resorption of the condylar head was therefore at a high risk. Mandibular condylar fractures may increase the risk of TMJ pain, disc displacement, restricted mouth opening, or other temporomandibular disorders.29,36,37 Psychological factors can play an important role in the maintenance of facial pain and temporomandibular disorders. In addition, chronic pain might lead to depression. Therefore, we found it relevant to evaluate the association between mandibular condylar fractures, temporomandibular disorders, and psychosocial dysfunction in our study. The RDC/TMD is a useful method to classify and quantify both the physical and the psychosocial components of temporomandibular

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1779
14. Ellis E, McFadden D, Simon P, et al: Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 58:950, 2000 15. Choi BH, Yoo JH: Open reduction of condylar neck fractures with exposure of the facial nerve. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:292, 1999 16. Ellis E, Dean J: Rigid xation of mandibular condylar fractures. Oral Surg Oral Med Oral Pathol 76:6, 1993 17. Jeter TS, Sickels JEV, Nishioka GJ: Intraoral open reduction with rigid internal xation of mandibular subcondylar fractures. J Oral Maxillofac Surg 46:1113, 1988 18. Dworkin SF, LeResche L: Research diagnostic criteria for temporomandibular disorders. J Craniomandib Disord 6:301, 1992 19. Derogatis LR: SCL-90R: Administration, Scoring and Procedures Manual-II for the Revised Version. Towson, MD, Clinical Psychometric Research, 1983 20. Svensson P, Arendt-Nielsen L, Nielsen H, et al: Effect of chronic and experimental jaw muscle pain on pressure-pain thresholds and stimulus-response curves. J Orofac Pain 9:347, 1995 21. Lindsay KW, Bone I, Callander R: Neurology and Neurosurgery Illustrated (ed 3). London, Churchill Livingstone, 1997 22. Chen CT, Lai JP, Tung TC, et al: Endoscopically assisted mandibular subcondylar fracture repair. Plast Reconstr Surg 103:60, 1999 23. Kellman RM: Endoscopically assisted repair of subcondylar fractures of the mandible: An evolving technique. Arch Facial Plast Surg 5:244, 2003 24. Miloro M: Endoscopic-assisted repair of subcondylar fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 96:387, 2003 25. Schn R, Gutwald R, Schramm A, et al: Endoscopy-assisted open treatment of condylar fractures of the mandible: Extraoral vs intraoral approach. Int J Oral Maxillofac Surg 31:237, 2002 26. Lachner J, Clanton JT, Waite PD: Open reduction and internal rigid xation of subcondylar fractures via an intraoral approach. Oral Surg Oral Med Oral Pathol 71:257, 1991 27. Suzuki T, Kawamura H, Kasahara T, et al: Resorbable Poly-LLacyide plates and screws for the treatment of mandibular condylar process fractures: A clinical and radiologic follow-up study. J Oral Maxillofac Surg 62:919, 2004 28. Undt G, Kermer C, Rasse M, et al: Transoral miniplate osteosynthesis of condylar neck fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:534, 1999 29. Yang WG, Chen CT, Tsay PK, et al: Functional results of unilateral condylar process fractures after open and closed treatment. J Trauma 52:498, 2002 30. Banks P: A pragmatic approach to the management of condylar fractures. Int J Oral Maxillofac Surg 27:244, 1999 31. Tate GS, Ellis E, Throckmorton G: Bite forces in patients treated for mandibular angle fractures. J Oral Maxillofac Surg 52:734, 1994 32. Ellis E, Throckmorton GS: Bite forces after open or closed treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 59:389, 2001 33. Hammer B, Schier P, Prein J: Osteosynthesis of condylar neck fractures: A review of 30 patients. Br J Oral Maxillofacial Surg 35:288, 1997 34. Haug RH, Peterson GP, Goltz M: A biomechanical evaluation of mandibular condyle fracture plating techniques. J Oral Maxillofac Surg 60:73, 2002 35. Iizuka T, Lindqvist C, Hallikainen D, et al: Severe bone resorption and osteoarthrosis after miniplate xation of high condylar fractures. Oral Surg Oral Med Oral Pathol 72:400, 1991 36. Choi BH, Yi CK, Yoo JH: MRI examination of the TMJ after surgical treatment of condylar fractures. Int J Oral Maxillofac Surg 30:296, 2001 37. Silvennoinen U, Raustia AM, Lindqvist C, et al: Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. A prospective one-year study. Int J Oral Maxillofac Surg 27:280, 1998

disorders. However, only 2 patients fullled the criteria for a RDC/TMD diagnosis. Myofacial pain and bilateral arthralgia combined with a moderate nonspecic physical symptom score was diagnosed in 1 patient, and 1 patient received a diagnosis of disc displacement with reduction. The sample in the present study is very small and nonhomogenous, including both unilateral and bilateral condylar fractures combined with additional midface fractures. It is therefore difcult to sort out whether a given complication is secondary to the treatment of the condylar fracture, another mandibular fracture, or an associated midface fracture. Nevertheless, this retrospective study emphasizes that optimal management of bilateral condylar fractures combined with other fractures of the facial skeleton comprise a problematic issue in maxillofacial trauma. Moreover, open reduction and rigid internal xation of mandibular condylar fractures by an intraoral approach is a technically demanding surgical procedure associated with a high risk of complications in these injuries.

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