Prospective Evaluation Of Closed Treatment

J Oral Maxillofac Surg 66:1184-1193, 2008

Prospective Evaluation of Closed Treatment of Nondisplaced and Nondislocated Mandibular Condyle Fractures Versus Open Reposition and Rigid Fixation of Displaced and Dislocated Fractures in Children Constantin A. Landes, MD, DMD,* Kai Day, DMD,† Bettina Glasl, DMD,‡ Björn Ludwig, DMD,§ Robert Sader, MD, DMD, PhD,储 and Adorján F. Kovács, MD, DMD, PhD¶ Purpose: The purpose of the study was to evaluate open reposition and internal fixation of displaced

or dislocated child mandibular condyle fractures, and closed treatment of nondisplaced, nondislocated fractures of the condyle with long-term follow-up outcomes. Patients and Methods: Twenty-four patients less than 14 years of age were included from 2000 to 2005. Classes II to V after Spiessl and Schroll, eg, displaced or dislocated fractures were surgically treated; Class I and VI nondisplaced, nondislocated fractures were treated closed. At yearly intervals, facial symmetry, pain, nerve function, bone repositioning, scarring, and reossification were evaluated. Incisal opening, protrusion, laterotrusion and sonographic condylar translation were measured in mm. Results: Nineteen (79%) patients presented for follow-up: Class I, 8; Class II, 3; Class III, 0; Class IV, 2; Class V, 5; and Class VI, 1. After 1 year, 11 patients (58%) presented for follow-up; after 2 years, 4 (21%) patients, and after 5 years, 4 (21%) patients presented for follow-up. The reasons for not presenting for follow-up given by the parents upon telephone interview were no symptoms and absent motivation. All patients exhibited sufficient opening; 1 Class IV patient had insufficient translation; 3 patients had opening deflection; 2 patients’ partial facial nerve paresis subsided after 1 year; in 2 cases broken osteosyntheses were removed. Vertical and horizontal condyle support was successfully reconstructed; considerable bone resorption occurred in Class V; failure rate was 4 (17%). Of 5 Class V, 3 were failures (60%). Conclusions: The evaluated treatment rationale attained 83% treatment success; Class V should be repositioned with careful mobilization to not risk impaired perfusion and considerable remodeling. Patient number is limited; a negative bias for follow-up can be supposed, eg, symptom-free patients avoided a follow-up interview. Prospectively small, rigid, mainly intraosseous and hopefully resorbable osteofixation should be assessed. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:1184-1193, 2008 Closed treatment (CTR) of mandibular condyle fractures is generally recommended in children up to 14 years due to high local remodeling capacity.1-4 However increasing dysfunction indexes and incomplete *Assistant Professor, Oral-, Maxillofacial and Plastic-Facial Surgery, Frankfurt University Medical Center, Frankfurt, Germany. †Research Fellow, Oral-, Maxillofacial and Plastic-Facial Surgery, Frankfurt University Medical Center, Frankfurt, Germany. ‡Consultant, Department of Orthodontics, Carolinum Foundation and Private Clinic, Frankfurt, Germany. §Consultant, Department of Orthodontics, Carolinum Foundation and Private Clinic, Frankfurt, Germany. 储Professor and Chairman, Oral-, Maxillofacial and Plastic-Facial Surgery, Frankfurt University Medical Center, Frankfurt, Germany.

remodeling in dislocated fractures proportional with age at the time of trauma are also reported.3,5-7 Therefore several authors recently favor open reduction and internal fixation (ORIF), even in patients under 12 ¶Professor, Oral-, Maxillofacial and Plastic-Facial Surgery, Frankfurt University Medical Center, Frankfurt, Germany. Address correspondence to Dr Landes: Oral-, Maxillofacial and Plastic-Facial Surgery, Frankfurt University Medical Center, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany; e-mail: c.landes@ lycos.com © 2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6606-0014$34.00/0 doi:10.1016/j.joms.2007.06.667

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years of age. This is mainly due to the safety and acquired experience with ORIF.8-10 While reviewing the recent literature mainly concentrating on adults, a general tendency was shown to operate on displaced and dislocated fractures and treat nondisplaced fractures closed.11-21 The question as to which degree of displacement and angle of dislocation benefit from ORIF for superior results compared with CTR is still open. Some authors consider greater than 30 degrees of dislocation an indication for ORIF.12,22-24 In previous reports,16,17 the degree of initial post-traumatic malocclusion and impairment of joint function did not prove to be reliable for a treatment decision in adults, being itself forged by concomitant mandibular fractures. Therefore this study promised to perform ORIF even in child patients when a radiologically displaced or dislocated mandibular condyle fracture was present and to treat nondisplaced with CTR. In this study a full randomization of CTR versus ORIF was originally intended, similar to the study of Worsaae and Thorn.25 Full randomization was, however, not judged ethically acceptable after the literature had been reviewed.16,17 Bilateral fractures were treated in the same manner, ie, the displaced or dislocated sides had ORIF, nondisplaced fractures CTR.

Patients and Methods For 60 (January 2000 to January 2005) months, patients under 14 years who were legally represented by their parents or guardians, were offered to participate in this study. They were informed of the mandatory 1 year and if possible 2 and 5 year follow-up. The principles outlined in the declaration of Helsinki were thoroughly adhered to in this study. Inclusion criteria were unilateral or bilateral condyle fractures of any location from the very condylar head to subcondylar, and age under 14 at the time of trauma. All patients had to be operable even if their treatment was closed. Parental or guardian informed consent was mandatory. Exclusion criteria were theoretically patients with a previous history of temporomandibular joint (TMJ) dysfunction and insufficient dentition to reproduce an occlusion, cases not fit for operative treatment, and severe pretraumatic dysgnathia; however, these did not occur within this collective. Lastly, absent parental or guardian consent led to exclusion from this study, but all guardians or parents agreed to participate. The total patient number willing to participate was 24 patients. From this group, 1 (4%) had a bilateral fracture, therefore 25 fractures were treated in total; 11 (42%) fractures had ORIF (the Class V fracture of the bilateral case included) and 14 (58%) had CTR (the Class I fracture of the bilateral case included).

1185 Unacceptable clinical function was predefined as malocclusion: unilateral slipping of double folded occlusal paper (200 ␮m articulating paper; Bausch Dental, Cologne, Germany). If this occurred and the patient’s history did not reveal a preoperatively compromised occlusion and the family dentist did not report a pretraumatic problem, the function was defined as unacceptable. Furthermore persistent pain, persistent nerve paresis, swelling and locking at the fractured joint with vertical mouth opening below 35 mm, translation less than 6 mm on vertical opening, and less than 3 mm on protrusion and mediotrusion were determined as unacceptable. Diagnostic imaging was performed with mandibular tomograms and Towne views, taken at one of 2 machines located in the department’s radiology section. These radiographs were used exclusively after patient history and clinical examination suggested a condyle fracture.26 Polytraumatized patients with comminuted facial fractures and cranial contusion had a preoperative CT scan instead and were followed up with tomograms. Fracture classification was performed according to the radiological findings27 to separate condyle and subcondylar from high condylar and condylar head fractures, and whether they were nondisplaced/nondislocated or displaced/dislocated. If the radiological finding was not clear, it was compared with the intraoperative finding. Bilateral condyle fractures were counted once as patients in the more severe fracture class (ie, Class V); the second fracture was evaluated within its proper fracture class (ie, Class I). The condyle fractures at the lower condylar neck, at or below the sigmoid notch were surgically treated via the retromandibular approach technique28-30; the osteosynthesis performed with 2.0 mm 4-hole miniplates and 7 mm to 10 mm screws of 1.3 mm diameter (Leibinger, Tuttlingen, Germany; MedArtis, Basel, Switzerland; Synthes, Oberdorf, Switzerland) or 2.0 strength poly-L70/30DL-lactide (P[L70/30DL]LA) copolymer with 6 mm and 8 mm screws (Synthes). In 45% of cases, a single plate adapted to the dorsal rim was clinically judged to provide insufficient stabilization and a second plate was adapted to the lateral cortex.31 A preauricular approach was chosen in all cases of high condylar fractures and the osteofixation was performed with microplates of 1.2 mm strength in H-, L-, and T-shape, 6 mm to 8 mm length screws of 1 mm diameter (Leibinger).13,32,33 Closed treatment was performed with 2 weeks intermaxillary guided occlusion using 2 maxillomandibular 1.5 mm diameter rubber bands. These were suspended over 14 ⫻ 2.4 mm set screws (Normed, Tuttlingen, Germany), inserted between the canine and first premolar root in all 4 quadrants if the permanent teeth had erupted. CTR patients younger than

1186 12 years had guided occlusion by a removable orthodontic appliance for an average of 3 months to spare the tooth buds a traumatization by set screw insertion. Therefore convenient functional jaw orthopedic appliances in a monoblock design were used as a guiding, exercise, and training device. The appliances were controlled and activated in orthodontically usual intervals. When a concomitant permanent tooth subluxation was present, archbars were administered, followed by identical rubber band-guided occlusion for 2 weeks. In the third week vertical opening exercises and contralateral excursion exercises were begun with thorough instruction also to the parents or guardians. In the fourth week, patients were trained to keep their mandible in the midline during vertical opening and protrusion. Physiotherapy was administered for 2 weeks or longer and the set screws were removed after the third week if the occlusion remained stable. Follow-up was intended at 12, 24, and 60 months. The clinical measures of maximum interincisal distance on vertical opening, protrusion, and laterotrusion were performed using an orthodontic slide gauge. Local inflammation, scarring, pain, facial nerve function, occlusion, and static and functional asymmetry were evaluated. Inflammation was scored if 1 classical symptom was found (ie, swelling, pain, hyperpyrexia, or redness). Scarring was scored as present if the scar was greater than 2 mm wide and greater than 1 mm elevated. Facial nerve paresis was scored present if visible asymmetry to the nonfractured side existed with functional movements after 3 months and after 12 months. Malocclusion was assessed as in the predefinitions of unacceptable clinical function; asymmetry when the chin deviated visibly from the facial vertical in occlusion or greater than 2 mm in maximum vertical opening. Sonographic assessment of the condyle translation was performed by 2 independent, experienced observers (C.L, K.D.) with a Voluson 530D equipment and an S-NLP5-10 transducer (General-Electric-Kretz, Zipf, Austria),16,17 The transducer was held horizontally inferior to the zygomatic arch with a slight upward angulation so that the echoes from the lateral condylar neck circumference, lateral disc, and joint capsule could be seen. The linear condyle translation in mouth vertical opening, protrusion, and mediotrusion was measured. Starting from the habitual occlusion the distance the condyle moved to the extreme position in vertical opening, protrusion, or mediotrusion was measured. Movement irregularity, disc position, dislocation, scarring, and degeneration were evaluated. The distance and angle of displacement of the proximal fragment were evaluated retrospectively by 2 independent observers (C.L, K.D.) on mandibular tomograms and the Towne views.

CHILD CONDYLE FRACTURES: CTR VS ORIF

The pretherapeutic vertical difference to the nonfractured condyle was measured tangential to the dorsal border of the mandibular ramus on the fractured and the nonfractured side. The nonfractured side’s value was subtracted from the fractured side’s value. In bilateral fractures this was not possible. The angulation of the nonfractured condyle to the ascending ramus’ dorsal rim was taken as 0 degrees and the deviation from this value on the fractured side was measured as angular dislocation on mandibular tomograms. In bilateral fractures, an average value from all nonfractured sides was used for reference (15 degrees). The angular and vertical pretherapeutic to post-therapeutic rectification were compared on the tomograms and Towne views.34

Results The CTR versus ORIF treatment decision was based upon the radiological degree of displacement or dislocation, not on malocclusion or locking joint, which was abandoned because it was too frequently influ-

FIGURE 1. The sequence of dental pantomograms of a Class I fracture before (top) and after (middle) closed treatment 2 intermaxillary guiding elastics were applied for 2 weeks. Twelve month follow-up (bottom) shows nonproblematic ossification. Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

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enced by concomitant mandibular fractures. The mean age in the surgery group was 10.4 (range, 7-14) years, and in nonsurgical patients 9.3 (range, 5-14) years. Twenty-four (100%) patients had diagnostic mandibular tomograms, 16 (67%) had Towne views, and 1 (4%) had a CT scan. Postoperatively all (100%) had a mandibular tomogram, and 7 (29%) had a Towne view. Towne view was not performed if the reduction was excellent upon the mandibular tomogram to prevent unnecessary unethical radiation exposure. Class I nondisplaced low condyle/subcondylar fractures (Fig 1) included 10 (42%) patients. All had CTR. Class II displaced low condyle/subcondylar fractures (Fig 2) included 4 (17%) patients; all had ORIF. Class III high displaced condylar/condylar head fractures could not be included, as none presented. In the Class IV dislocated low condyle/subcondylar fractures (condyle not within the temporal fossa) group were 2 (8%) patients treated with ORIF (Fig 3). Class V dislocated high condylar/condylar head fractures, altogether were 5 (21%) patients treated with ORIF (Fig 4). For Class VI nondisplaced high condylar/ condylar head fractures, 3 (13%) patients had CTR (Fig 5). Classes I and VI fracture patients underwent CTR on the same day. Surgery for Classes II to V

FIGURE 3. A sequence of dental pantomograms in an open reduction and internal fixation Class IV case. Top left, Preoperative pantomogram; top right, appendent Towne view; middle right, detail of top right. Middle left, The condyle fracture was fixed using Microplus microplates and screws (Leibinger, Tuttlingen, Germany) and the follow-up (bottom) shows uncomplicated ossification. Although clinical and sonographic examination was performed after 2 years, the radiological follow-up was only permitted by the parents after 3 years and the ending of orthodontic treatment and metal removal likewise was refused. Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

patients was on an urgent schedule the following day, or after traumatic swelling had subsided, and at the latest on the fifth day. All surgical patients were treated by standard technique as given in the Patients and Methods section, the place of fixation was always the dorsal aspect of the condyle with greater than 80% extra-articular plate position.35 All patients were operated on by 2 consultant surgeons (C.L, A.K.) in otherwise unchanged routine. CTR was done according to the outline in the Patients and Methods section (Table 1). FOLLOW-UP

FIGURE 2. The sequence of dental pantomograms of a Class II case including a detail (top right) from the anterior-posterior Towne view with a median displacement. The otherwise complex mandibular fracture was entirely osteosynthesed with PolyMax (Synthes, Oberdorf, Switzerland). The 12 month follow-up again shows uncomplicated ossification. Top left, Preoperative pantomogram; middle, postoperative pantomogram; bottom, follow-up pantomogram. Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

Nineteen patients with 20 fractures were evaluated (Table 2). Class I included 7 patients after 1 year, 1 patient after 2 years, and no patients after 5 years. In Class II, follow-up included 3 patients at 5 years. Class III was not present within this evaluation. Class IV patients presented in 2 cases after 2 years (in 1 case the parents only permitted a follow-up dental tomography after 3 years and ending of orthodontic therapy). In Class V, follow-up included 5 patients, 4 patients after 1 year and 1 patient after 5 years. Class VI included 1 patient after 2 years. Rectification or changes to the condylar vertical height and angulation can be seen in Table 3. The

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CHILD CONDYLE FRACTURES: CTR VS ORIF

Discussion

FIGURE 4. A sequence of Class V dental pantomograms (intraoperative verification, could be Class III from the x-ray only). Top, Preoperative dental pantomography; middle, postoperative radiograph. Microplus microplates and screws were used (Leibinger, Tuttlingen, Germany). Uncomplicated ossification goes hand in hand with major remodeling in this case (bottom). Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

vertical height differences to the contralateral side were bigger in Classes IV and V. The vertical differences in Class II did not change; in Class IV height differences could well become reduced. In Class V a marked condylar remodeling occurred postoperatively. This may be due to forced reposition under mobilization and partial dissection of the lateral pterygoid muscle. Angular displacement was biggest in the dislocated Classes IV and V. While bigger angular displacements could well become rectified, small angular displacements changed only minimally. Apart from remodeling, reossification of the fractures was always inconspicuous. Malocclusion, condyle translation, and appending incisal movement can be seen in Table 4. Pain or nerve paresis lasting more than 3 months or dysocclusion did not occur. Fractures of the osteosynthesis suffered 2 cases of Class V fractures; in these patients in spite of a metal removal most probably due to scarring, a marked asymmetry upon mouth opening was associated with deflection.

General justifications for ORIF include anatomical reduction, occlusal stability, rapid function, maintenance of vertical support, avoidance of facial asymmetry, less postoperative TMJ disorder incidence and no maxillomandibular fixation. Arguments for CTR include reduced overall morbidity, in most cases acceptable occlusal results, avoidance of typical surgical complications, simpler procedure, less risk of ankylosis and avascular necrosis. For the restoration of the mandibular morphology and continuity, with potential operative complications in mind, 57% of surgeons in a 1996 survey were in favor of ORIF for the adult population, 64% when a bilateral fracture was present.11 Although osseous union is generally achieved irrespective of treatment modality, this result illustrates the popularity of the method in adults and is probably due to frustration of the CTR results in displaced and dislocated cases.36 High condylar fractures, however, within the same 1996 survey were considered to be preferably treated closed as their exposure, reposition, and stabilization were considered unreliable.11 Trying to fulfill the requirements for a prospective study for children patients as pointed out by Banks in 1998: “Evidencebased guidelines are difficult to provide, yet a realistic protocol would be a step forward,”37 our prospective protocol included the following framework: an agreed quantification of the deformity, a predefined statement of unacceptable function, timing of intervention, agreed operative method, subsidiary postoperative management, follow-up protocol, and quanti-

FIGURE 5. A sequence of Class VI before (top) and after (bottom) closed treatment of 2 guiding elastics for 2 weeks, with an inconspicuous follow-up radiogram. Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

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Table 1. ABSOLUTE INCIDENCE AND RELATIVE DISTRIBUTION OF STUDY PATIENTS

Fracture Class After Spiessl and Schroll27

Total Patients (n)

Relative Incidence (%)

Bilateral Fractures (n)

I II III IV V VI ⌺ (Total)

10 4 0 2 5 3 24

42 17 0 8 21 13

1 0 0 0 1 0

Other Mandibular Fractures CTR (n)

ORIF (n)

(n)

(%)

11 0 0 0 0 3 14

0 4 0 2 5 0 11

2 1 0 1 2 1

8 4 0 4 8 4

NOTE. The most frequent was by far Class I, not represented was Class III. One case had a Class V and a Class I fracture and was counted in Class V as 1 patient and the fractures once in each of Class I and Class V. Abbreviations: CTR, closed treatment; ORIF, open reduction and internal fixation. Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

fication of outcome for a population of children less than the age of 14, as in adults which has been previously reported.16,17 An agreed quantification of the deformity was conferred by the assignment of cases into Classes I to VI.4,16,17,27 The classification of Spiessl and Schroll has been broadly used principally in European reports since its inauguration27,38-41; and provides a comprehensive differentiation into nondisplaced, displaced and dislocated, and either high or low fractures from a surgical standpoint. Although it is a simplification, it allows differentiation of outcome depending upon the degree of dislocation and vertical loss of support. The classification excludes freak injuries, eg, dislocation into the cranial base or gunshot defect fractures. Unacceptable function was predefined and was kept comprehensive for a short clinical follow-up examination using standard radiograms (95% of colleagues in other reports use mandibular tomograms, 56% use reverse Towne view, and 41% use CT).26,37

The timing of intervention was consistent as an agreed operative method15,28,32,42-49 maintained by intermaxillary guiding elastics for 2 weeks or orthodontic activator in CTR (40% in other reports37) and submandibular, retromandibular, or preauricular approach for ORIF (36% and 47% of other reports37) with miniplate osteosynthesis in Classes II and IV (79% in previous reports37). The Class III and V patients were exposed by preauricular approach and fixated by microplates. Class VI fractures with mere displacement of medial condylar pole were treated closed as no vertical loss of support was present and fixation should be exceptionally difficult in minors. Hand T-shaped microplates showed insufficient retention in class V fractures and prospectively more rigid, comparably small, and ideally resorbable osteofixation should be applied. CT scans were more comfortable for differentiating Classes V to VI fractures but were not generally necessary. However some fractures such as shown in Figure 4 could only be classified intraoperatively.11,50

Table 2. ABSOLUTE AND RELATIVE DISTRIBUTION OF FOLLOW-UP INTERVIEWS

Class

Total Patients (n)

Relative Patient Distribution (%)

I II III IV V VI ⌺ (Sum)

8 3 0 2 5 1 19

42 16 0 11 26 5

12-Month Recall

24-Month Recall

60-Month Recall

(n)

(%)

(n)

(%)

(n)

(%)

7 0 0 0 4 0 11

88 0 0 0 80 0

1 0 0 2 0 1 4

12 0 0 100 0 100

0 3 0 0 1 0 4

0 100 0 0 20 0

NOTE. The willingness for a follow-up was generally bad which may be due to the patients having to deal with few long-term problems. Alternatively, though it was excluded by telephone survey, unhappiness with the current treatment and change of doctor may be a cause. Landes et al. Child Condyle Fractures: CTR vs ORIF. J Oral Maxillofac Surg 2008.

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NOTE. Vertical dimensions were measured pretherapeutically, post-therapeutically, and after follow-up and compared for their difference to the nonfractured side in all unilateral fractures. In the case of bilateral fracture this was not possible for the vertical dimension and the angular dimension was compared with 15 degrees average. Angular measurements were performed in a similar manner.

3 15 Ø 4 13 2 16 17 Ø 5 ⫺3 20 4 12 Ø 3.5 23 Ø 17 15 Ø 6.5 ⫺6 Ø 4.6 15 Ø 76 44 ⫺24 14 16 Ø ⫺65 ⫺28 ⫺10 ⫺0.2 ⫺1.5 Ø 0 ⫺4.8 ⫺1 67 68 Ø 68 64 71 ⫺0.4 ⫺1 Ø ⫺1 ⫺1.8 Ø I II III IV V VI

68 70 Ø 67 66 Ø 64 70 Ø 62 64 64

Class

⫺0.6 ⫺1.5 Ø ⫺6.5 ⫺5.2 ⫺2

Difference to Contralateral (mm) Vertical Postherapeutic (mm) Difference to Contralateral (mm) Vertical Pretherapeutic (mm)

Table 3. MEASUREMENTS OF THE ORAL PANTOMOGRAPHS

Vertical Follow-Up

Difference to Contralateral (mm)

Angular Pretherapeutic (degrees)

Difference to Contralateral (degrees)

Angular Posttherapeutic (degrees)

Difference to Contralateral (degrees)

Angular Follow-Up (degrees)

Difference to Contralateral (degrees)

CHILD CONDYLE FRACTURES: CTR VS ORIF

Physiotherapy in earlier reports use 4 weeks in all degrees of displacement and dislocation with CTR11 while this study only submitted Classes I and VI to CTR applying 2 weeks of guided occlusion followed by 2 weeks of physiotherapy. Subsidiary protocol for postoperative management included physiotherapy and soft diet (90% previous reports) and follow-up controls. Quantification of outcome was measured as condylar translation as it is the most sensitive parameter of joint function. Earlier studies measure maximum incisal movement to determine TMJ-movement restriction and not condyle translation, which is more accurate. Incisal movement does not differentiate condyle rotation from anterioposterior translation and therefore may give the impression of good restitution when severe shortness of translation is compensated by rotation.51,52 At 12 months all patients were symptom-free and most refused further follow-up at 24 and 60 months. This study’s follow-up was corrupted by bad compliance. On telephone survey the patient’s parents/ guardians or the children patients themselves said they faced no problems. There was no financial incentive to influence action by the patients. Recall was only 58%, better than 46% at 1 year of the adult population of an earlier study.16,17 Other authors likewise reported 13% to 52% recall in follow-up even when offering financial compensation.34,35,39 Nerve paresis was not a major problem with the chosen operative approach by an experienced surgeon. Facial nerve palsy of the marginal mandibular branch at 3 months in 11% of patients resolved after 6 months, similar to 13% to 17% transient, and 4.2% persistent paresis reported previously in adults.9,10,15,23,39,48,53 Earlier surveys54 of complications with the identical approach (n ⫽ 93) showed 7.5% hypertrophic or wide scars. No patient (0%) developed a hypertrophic visible scar in this evaluation or complained of unfavorable scar formation. It can therefore be concluded that Class I fractures in children have an uncomplicated prognosis when treated closed. Occlusal correction is performed by functional training, orthodontics, and in severe cases, orthognathic surgery. Surgical Class II cases in children have a good prognosis with ORIF; Class IV fractures do as well recuperate full incisal movement with ORIF. Class V cases are the most critical for several reasons: ORIF faces major bone remodeling after surgery; current microplate osteosyntheses may be overstrained and break, resulting in even further scarring and movement asymmetry once the broken material is removed. Class VI cases tend to have little translation which may indicate intra-articular scarring and adhesion formation which is further evaluated with an exclusively Class VI CTR versus ORIF study. Frag-

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NOTE. As in an earlier report,16,17 the class VI case has the least translation that may indicate intra-articular scarring and adhesion formation which is further evaluated with an exclusively Class VI study closed treatment versus open reduction and internal fixation in adults. A “⫹” indicates present, “⫺” indicates absent, and Ø indicates did not occur within this study. Number of “⫹” indicates number of cases with a positive finding (1 or 2).

⫺ ⫺ Ø ⫺ ⫺ ⫺ ⫺ ⫺ Ø ⫺ ⫺ ⫺ ⫺ ⫹ Ø ⫺ ⫹⫹ ⫺ ⫺ ⫺ Ø ⫺ ⫹⫹ ⫺ ⫺/⫺ ⫹/⫺ Ø ⫹/⫺ ⫺/⫺ ⫺/⫺ ⫺ ⫺ Ø ⫺ ⫺ ⫺ ⫺ ⫺ Ø ⫺ ⫺ ⫺ 50 49 Ø 46 51 42 I II III IV V VI

9.8 10.8 Ø 11.2 11 4.5

8.3 6.3 Ø 9.5 9.8 4

7.6 5.8 Ø 7.3 7.1 4.5

10.5 8 Ø 12.1 10.8 2

8.3 7.1 Ø 10.4 7.5 2.7

Dysocclusion Pain Translation (mm) Incisal (mm) Translation (mm) Incisal (mm) Translation (mm) Incisal (mm)

Class

Laterotrusion/ Mediotrusion Protrusion Vertical Opening

Table 4. INCISAL MAXIMUM DISTANCES AS MAXIMUM TRANSLATION DISTANCES

Nerve Paresis 3 Months/12 Months

Broken Osteosynthesis

Deflection ⬎3 mm

Local Inflammation

Visible Scarring

LANDES ET AL

ment rectification was reported in Classes II and IV by Ellis et al36 to be 5.2 ⫾ 3.6 mm, 1.3 ⫾ 20 degrees preoperatively; and ⫺0.5 ⫾ 3.9 mm, ⫺1.3 ⫾ 7.9 degrees postoperatively in adults. While this study’s vertical rectification was comparable (preoperatively ⫺4 mm, postoperatively ⫺1 mm) the number of cases was too small for standard deviations. Angular dislocation was bigger in the present study; preoperative 45-degree dislocation in Classes II and IV were corrected to 8 degrees postoperative. Authors, who evaluate fragment rectification by CTR in Classes V and VI fractures in adults, find these to have 35% to 70% clinical joint dysfunction.55-57 In a recent 1 and 2 year follow-up study,39 39 adult ORIF patients evaluated by axiography and magnetic resonance imaging were compared with 16 CTR patients: ORIF patients had 11 mm average condylar mobility versus 6 mm after CTR; vertical support loss 1.3 mm to 4.8 mm, disc mobility 5.8 mm to 3.8 mm; periarticular scarring and impaired disc mobility significantly correlated. All Class V cases with CTR are reported to articulate at the articular eminence with 7 mm vertical difference, 10 mm anterior condyle position, and 4 mm translation. ORIF cases had 4 mm vertical and 3 mm sagittal position differences, translation of 10 mm. Class VI CTR fractures had 2 mm vertical difference and 4 mm anterior condyle displacement, and translation was 10 mm. In ORIF cases, there was 1 mm vertical and 0.4 mm sagittal positioning difference, with translation of 12 mm. This study’s Class V cases had a vertical deficit of ⫺5.2 mm rectified to ⫺1.8 mm, however, after 1 year ⫺4.8 mm resulted from condylar remodeling. Angular difference to the nonfractured side of 44 degrees was rectified to postoperative 23 degrees and 13 degrees after follow-up. Classes V and VI may benefit from future developments in intraosseous, small but rigid and hopefully resorbable, osteosynthesis material.39 From the bad results in Class V, CTR for these cases may be also considered as very difficult to treat operatively. But loss of vertical height is a predicator for malocclusion as neoarthrosis with the articular eminence and asymmetry. Therefore the literature and the findings in adults support ORIF in all cases of vertical loss of support. A greater fragment dislocation is the result of a stronger traumatic impact leading to capsular rupture and scar formation.41,58 The influence of soft tissue ligament-damage and consecutive scar formation has been discussed as the origin of reduced translation after successful repositioning in adults. In high intra- and extracapsular fractures, published results34,39,59-61 bolster the concept of open reduction in dislocated and displaced fractures in adults when evidence for loss of vertical support is given. However, higher local remodeling capacity in children remains to be further investigated with long-

1192 term results using TMJ sonography or magnetic resonance imaging. Evaluation of disc mobility as stated by the authors can be approximated by real time sonography. With sufficient experience, the disc position and mobility can be measured in real time over several cycles of translation by sonography and our data supported this concept in cases of restricted translation as we saw them.62,63 This study documents 83% primarily successful condylar fracture management in children applying gradual differentiation: nondislocated, nondisplaced fractures treated with CTR versus ORIF in displaced and dislocated fractures. Bilateral fractures can be treated with the identical approach. Surgical risk can be avoided with CTR in nondislocated fractures that have a mostly intact anatomical basis for function. Displaced and dislocated fractures treated with ORIF have fewer incidences of facial asymmetry, locking, and occlusal imbalance. However, Class V cases still have high rates of postoperative functional deficit. Bigger, ideally multicenter collectives are mandatory to further support the results.

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