Edward Ellis, Robert Kellman, and Emre Vural address questions for discussion and debate:
- 1.
Are there specific indications for open versus closed treatment of subcondylar fractures? Are there any contraindications to open treatment, and do they supercede the indications for open treatment?
- 2.
Does the presence of other fractures (mandible and/or midface) affect your choice of open versus closed treatment? (Is the selection of closed vs open treatment the same for unilateral vs bilateral fractures?)
- 3.
If one chooses to perform closed treatment, how long a period of MMF is required?
- 4.
What are the most important factors for success when closed treatment is used?
- 5.
What is the best surgical approach to ORIF of subcondylar fractures?
- 6.
Analysis: Over the past 5 years, how has your technique or approach evolved or what is the most important thing you have learned/observed in working with subcondylar fractures?
Edward Ellis III, Robert M. Kellman, and Emre Vural address questions for discussion and debate:
- 1.
- 2.
- 3.
- 4.
What are the most important factors for success when closed treatment is used?
- 5.
What is the best surgical approach to open reduction and internal fixation of subcondylar fractures?
- 6.
Are there specific indications for open versus closed treatment of subcondylar fractures? Are there any contraindications to open treatment, and do they supersede the indications for open treatment?
Ellis
I applaud this debate because I believe it is time we stopped arguing about whether condylar fractures should be treated open or closed, and instead ask which condylar fractures might have better outcomes when treated open.
I find it pejorative to come up with specific “indications” for open or closed treatment. I prefer to use the term “considerations,” for which there are many. I can think of only 1 situation in which I believe open treatment should almost always be used, and it is addressed later (condylar fractures associated with comminuted maxillary fracture[s]). However, there are other considerations that may push one toward one treatment or the other and I address these now.
However, to fully understand condylar fractures, one has to understand the adaptations in the masticatory system that occur when these injuries are treated closed or open. I refer readers to an article on this topic by Ellis and Throckmorton.
First, I believe that any unilateral condylar fracture can be treated closed, with the following prerequisites:
- 1.
The patient must have a good complement of teeth, especially posterior teeth. Without them, there is a significant loss of posterior vertical dimension and an increase in the mandibular and occlusal plane angles. The loss of posterior vertical dimension makes future prosthetic reconstruction difficult.
- 2.
The patient must be cooperative. They must wear their elastics, do their functional exercises, and return often for follow-up.
- 3.
The surgeon must be willing to see the patient often to assess treatment and alter functional therapy as necessary.
It does not matter to me whether the unilateral condylar fracture is intracapsular, condylar neck, or subcondylar. Nor does the degree of displacement matter to me. (It does not matter to me if there is a condyle. Unilateral condylectomy patients can readily be treated nonsurgically with excellent outcomes.) They can all be managed effectively if the criteria listed earlier are met. However, one must understand completely that, when one chooses closed treatment, especially those with large displacements, the neoarticulation does not translate as much as the nonfractured side. The consequence of this situation in the skeletally mature patient is that they often deviate toward the side of fracture when the mouth is opened (see Fig. 1 A in the techniques section) and they have limited lateral excursion away from the side of fracture ( Fig. 1 ). When they protrude their mandible, they also deviate toward the side of fracture. This deviation is not a failure of treatment; it is a consequence of the alteration in biomechanics secondary to the displaced condyle and the altered lateral pterygoid function. It is of no clinical consequence to the patient. That is not to say that patients treated open for unilateral condylar fractures do not do well. They usually do well, assuming that no injuries occur from the surgery to reduce and stabilize the condyle. However, one has to consider the risk/benefit ratio when deciding on treatment. If one can obtain a good occlusion, good facial symmetry, and pain-free function by treating someone closed, why should they risk the potential intraoperative and postoperative complications that are associated with open treatment?
Unlike the unilateral condylar fracture, I do not believe that I can satisfactorily treat all bilateral condylar fractures closed. Some have good outcomes; some do not. The problem is that I cannot predict which ones will do well with closed treatment and which will not. The bilateral condylar fracture, especially those that are displaced, creates a biomechanical alteration that is a challenge to the masticatory system. Bilateral loss of vertical and horizontal support from disruption of the craniomandibular articulation means that the mandible is essentially a free-floating bone, positioned only by the muscles and ligaments attached to it, and the dentition. Some patients have the neuromuscular ability to adapt to the alteration in biomechanics and others do not. A successful outcome requires the muscle coordination to be such that the patient can carry the mandible in the proper position while a new craniomandibular articulation is established. The reestablishment of a new articulation always occurs. The only question is whether the mandible will be in a favorable position at the conclusion of the process by which the neoarticulation is established. Because I cannot predict who will and will not readily adapt, I tend to treat bilateral condylar fractures, especially those that are displaced, by open reduction and internal fixation (ORIF) of at least one of the fractured condylar processes. However, the literature shows that perhaps only 10% of patients with bilateral condylar fractures develop malocclusions that are beyond the capability of orthodontic or prosthetic reconstruction, requiring orthognathic surgery. It is always hard to recommend that 100% of patients should undergo open treatment of their condylar fractures when 90% of them do not need it. The clinicians need to keep this in mind. Again, it is the risk/benefit ratio of open versus closed treatment that must be considered.
When a patient has the combination of a very mobile, very comminuted maxillary fracture and condylar fracture(s), I usually perform ORIF of the condylar process fracture(s). I do this because with a panfacial fracture, I choose to reconstruct the mandible first. This procedure requires that all fractures of the mandible undergo open reduction and stable internal fixation. I essentially turn a panfacial fracture into an isolated midfacial fracture. When one has an isolated midface fracture, the nonfractured mandible serves as a platform on which the maxillary arch can be positioned through maxillomandibular fixation (MMF). Because the mandible still maintains its position with respect to the cranium through the craniomandibular articulation, using the mandible provides the proper mediolateral and anteroposterior position of the maxilla. The only dimension one needs to obtain at surgery is the vertical dimension, rotating the maxillomandibular complex around the temporomandibular joint (TMJ). When the mandibular condyle is also fractured and the mandible is used to position the maxilla, one must reestablish the continuity of the mandible. Otherwise, the midface is positioned off-midline because of the tendency of the mandible to deviate to the side of the condylar fracture. That is not to say that one must always treat a panfacial fracture in this manner. The other way is to stabilize the midfacial bones, including the maxilla, using bony interfaces as guides. Once stabilized, the condylar fracture could even be treated closed. However, in my experience, it is difficult to properly position the maxilla in all 3 planes of space when the bony articulations, especially those along the anterior maxilla, are comminuted.
Another injury for which one might consider the open treatment of condylar fracture(s) is the edentulous patient. As noted earlier, if the patient has no teeth, especially posterior teeth, it is difficult to prevent the posterior mandible from moving superiorly during the formation of the neoarticulation. Even with insertion of the patient’s dentures, there is no evidence that they can prevent the tendency for loss of posterior vertical dimension. The consequence of that loss is difficulty in future prosthetic reconstruction. Treating condylar fracture(s) closed in such patients not only requires that they wear their dentures but that the dentures be secured to the jaws. Otherwise, there is no way to control the tendency for deviation of the mandible toward the side of a unilateral condylar fracture or the anterior open bite tendency in bilateral fractures. Performing open treatment in these patients allows them to go back to wearing the dentures immediately.
A discussion on this topic is not complete without discussing the skeletal maturation of the patient. This is another major consideration for me. Every study in the literature that has studied this topic suggests that skeletally immature patients have a better ability to adapt to a condylar fracture than skeletally mature patients when treated closed ( Fig. 2 ). Therefore, there is less need to perform open treatment of condylar process fractures in young patients. That is not to say that open treatment is not also effective. However, it comes back to the risk/benefit ratio. The bone in the young does not always allow secure purchase for the bone screws. The last thing one would like is loose hardware in the wound. Therefore, before performing ORIF, one has to be able to convince oneself that open treatment provides better outcomes than closed treatment.
