Surgical Evolution in the Treatment of Mandibular Condyle Fractures

Evaristo Belli; Gianmauro Liberatore; Mici Elidon; Giovanni Dell'Aversana Orabona; Pasquale Piombino; Fabio Maglitto; Luciano Catalfamo; Giacomo De Riu

Disclosures

BMC Surg. 2015;15(16) 

In This Article

Discussion

Fractures of the condyle are still today the subject of much discussion, especially as regards standardizing the therapy, due to the wide variety of forms this may take, and because of the numerous therapeutic methods available.

The necessity for a simple classificatory criterion is of fundamental importance to correctly apply any therapy, which must necessarily take into account parameters such as the age of the patient, the intra- or extra-capsular location of the fracture, whether it is mono- or bi-lateral, the kind of dislocation of the stumps and the presence or absence of luxation of the condylar head from the glenoid cavity.

Also the age of the patient governs the type of therapeutic treatment. During the years of growth some authors have found a greater capacity for morphofunctional recovery of the fractured condyle in comparison with adult patients. Thus the therapeutic approach can vary not only according to the type of fracture, but also the type of patient. The two main therapeutic directions envisage on the one hand orthopaedic-functional treatment and on the other surgical treatment. Orthopaedic-functional therapy remains the most commonly used by various authors, permitting as it does an optimal functional recovery. Here it must be underlined that an inter-maxillary blockage determines two main problems; as well as immediate morphofunctional limitations due to the complex nature of the temporal-mandibular joint, there are often further psychological problems for the patient. However, despite these, the bibliography is lavish in its support of the efficacy of this particular therapeutic approach. The orthopaedic-functional approach has always been practiced in condylar fractures in the pediatric age, and for intra- and extra-capsular fractures without serious condylar dislocation in adult subjects.[6–8] Delaire, in 1975, held functional therapy to be necessary with early mobilization in cases of dislocated subcondylar fractures, whether high or low, and in every type of fracture of the condylar head. This treatment is performed to avoid tardive complications such fibrosis and ankilosis.[9,10] The results described are, on the whole, positive. In fact, according to Delaire they are particularly encouraging in young children. Takenoshita in comparing 16 cases of condylar fractures treated surgically with 20 cases treated in a conservative manner with a minimum follow-up of 2 years, found no important functional differences between the two groups, even if in the first group there were fractures with notable luxation and displacements.[11] Surgical therapy is generally adopted in cases where it is not possible to make use of a conservative treatment, or where this would not guarantee an adequate recovery ad integrum. In 1983, the various indications for surgical treatment were schematized by Zide and Kent in absolute and relative terms. In the latter case, the possibility of surgical treatment is particularly important in as much as such fractures provoke a reduction in the posterior facial height which must necessarily be recovered through surgery, to give an adequate guide parameter for successive threedimensional reconstruction of the face.[12,13]

Various authors maintain that surgical therapy is indicated in cases of mono-condylar fractures in adults or adolescents, not only where it is impossible to achieve normal occlusion, but also where there is noteworthy dislocation, with an angle of the small fragment greater than 45°[4] or simply where the condylar head has luxated from the glenoid cavity.[14] In fact, in these cases, conservative therapy, whilst assuring good dental occlusion in general terms, often does not allow complete recovery of the mandibular movements.[15] Moreover, in the opinion of other authors too, it is difficult to achieve completely satisfactory results from both an aesthetic viewpoint (due to the reduction in height of the ramus) and a gnathological standpoint because of the frequent presence of pre-contact during mandibular movements. Very recently, the direction of the treatment to resolve the greatest possible number of problems linked to fractures of the mandibular condyle, is fast tending towards a surgical approach, thanks not only to new physio-biomechanical acquisitions of the complex temporal-mandibular joint, but also to the development of new surgical techniques such as REFs which allow an optimal adaptation of the fractured fragments without the need for inter-maxillary blockage and the resultant immobilisation of the temporal-mandibular joint. Broadly speaking, the choice of surgical technique is conditioned by various factors such as :the focus of the fracture, the position of the condyle, the time elapsed from the traumatism,the extent of local oedema the type of surgical.

Until only a few years ago, the concept reigned that surgical access had to be such as to allow the most direct approach possible to the dislocated condyle stump.

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