Can Condylar Fracture Still Be Treated with Conservative Approach?? – A Retrospective Study

Introduction

Maxillofacial injuries are not very uncommon and fracture of mandible is commonest among them.¹ The prevalence of condylar fractures is highest among them accounting for about 25% to 40%.^2-4 The management of akin fractures can be done conservatively i.e. closed reduction + immobilization and/or surgically i.e. via open reduction + internal fixation.⁵ These two modalities differ in their indications, contraindications, associated advantages, disadvantages, the outcomes and many other aspects. Since ages, an ongoing controversy is present related to the modalities for being ideal for the management of fractures of condyle.⁶

Before the advent of advanced imaging techniques, it was very difficult to assess the result of Open Reduction with Internal Fixation (ORIF). Traditionally, it was difficult to explore the condyle due to its critical anatomy and limited resources including the armamentarium. Therefore, it resulted in several complications, thereby discouraging the surgeons and made them rely on non-surgical treatment for fractures of condyle.⁷ In the recent scenario, due to the improvements in diagnostic and surgical equipment, the surgical method was documented to be better in some cases.^8-11 Several factors are to be considered while choosing the suitable treatment modality such as age, level of fracture, malocclusion, degree of dislocation or displacement, other related fractures, loss of ramal height, and facial asymmetry.¹² Although several efforts and researches have been made to determine the gold standard in the management of fractures of condyle, it still continues to be a dilemma for the surgeons. The aim of our study was to analyze various aspects and outcomes of two different treatment modalities retrospectively in the management of condylar fractures of mandible.

Materials and Method

The post-treatment outcomes for each patient having mandibular condylar fracture were evaluated through a 13 year (January 2006 to January 2019) retrospective study. The data collection and treatment was done independently by different people to avoid any observer bias. Out of 264 patients having maxillofacial fractures reporting to our Department of Oral & Maxillofacial Surgery in Central India, 78 patients had condylar fractures, from which 56 were included in the study. Due to insufficient records and follow-up, twenty-two patients were excluded. Every patient was screened for age and gender distribution. Etiology such as road traffic accident (RTA), accidental falls, assaults and others such as sports, violence, self-inflicted injuries and various modalities of management related to fractures of condyle were recorded for them. Patients with fracture of condyle (unilateral & bilateral) with or without other associated mandibular fractures and non-infected fractures with proper follow-up records were included. Patients with deficient medical records, pre-existing temporomandibular joint pathology and completely edentulous were excluded. For both treatment modalities, various parameters were assessed such as MMO (maximum mouth opening), deviation of jaws, occlusal disturbances. A pair of calipers were used to measure the inter-incisal distance. An inter-incisal distance of at least 35 mm was considered as normal MMO. All the data was tabulated and the variables were analyzed.

Results

This study comprised of 56 patients having condylar fractures over a span of 13 years.

Prevalence

Considering all the other maxillofacial trauma recorded over a period of 13 years i.e 208 patients (79%), the prevalence of condylar fractures, both unilateral and bilateral and high or low was found to be of 21% i.e. 56 patients (Figure 1).

Demographic Data

It was seen that condylar fracture (bilateral & unilateral) was predominant among the male population i.e. 51 in number in comparison to females i.e. only 5 (Figure 2). The reason could be RTA, accidental falls or interpersonal violence in which the male population is more frequently involved.

Age Predilection

During our study, we found that cases with fractures of condyle were maximally seen in the age group ranging from 35 to 40 years, with a mean age of 32 years (according to our data). Total of 14 cases were within this age group (Figure 3), which can be correlated with the etiology for such fractures.

Etiology

From the data, it was clear that among all the etiological factors, RTA tend to be the commonest as 43 patients who reported with fracture of condyle gave a history of RTA (Figure 4). This was followed by accidental falls in six patients, while four patients gave history of assault and lastly other reason such as sports, violence, selfinflicted injuries were accounted in about three patients.

Clinical Data

There were seven patients treated with ORIF, whereas 49 were managed through conservative approach. Amongst the 56 patients, only seven were planned to require ORIF, while conservative approach (Figure 5) was thought to be sufficient for the rest due to reasons such as undisplaced fracture or patient not willing for ORIF or financial crisis or patient being medically unfit for the general anesthesia and lastly because of limited resources.

Mouth Opening

When mouth opening was measured using a pair of calipers, it was found that the average mouth opening was 39cms in those treated with closed reduction which was satisfactory, but is less in comparison to 42cms achieved in every patient treated with ORIF (Figure 6). It is to be noted that an inter-incisal distance of at least 35mm was considered as normal MMO in our study.

Deviation of Jaw

In our retrospective study, deviation of jaw was reported in two patients who underwent closed reduction, whereas no such complication was noted with any of them treated with ORIF (Figure 7).

Occlusal Disturbances

It was observed that marked occlusal disturbances were seen post-operatively in four patients treated through closed reduction. However, mild discrepancy was present in occlusion in a single patient amongst the group of ORIF, which resolved over some time (Figure 8).

Kind of Fracture

According to our retrospective study, it can be inferred that the occurrence of unilateral fracture of condyle is more common than that of the bilateral. Out of 56 cases, 47 of them were unilateral i.e. 84% (Figure 9).

Discussion

In today’s era where nothing seems impossible or disputable, treatment protocol for condylar fractures is still contentious. Surgical opening of the condyle is till date a topic of concern and discussion for maxillofacial surgeons. A classic report submitted by Zide and Kent in 198313 very well explains the indications of open reduction for condylar fracture which has been considered as the gold standard and is followed worldwide. The recent modification to the criteria advocates that conservative treatment should be undertaken when (i) the shortening of ramal height <2mm and (ii) deviation is <10°. It becomes essential to choose surgical modality when (i) >15mm of shortening of ramal height (ii) > 45° deviation. The fractures which are in between these extremities should be managed using both the techniques.⁶

Several surgical approaches like preauricular, submandibular, postauricular, retromandibular and many more have been mentioned in the literature, but because of close approximation of the anatomic structures, these approaches may cause more damage to the important structures, accompanied with visible scars.¹⁴ The possibility of injury to facial nerve acts as the main reason to adopt closed over open.¹⁵ Following these words as wisdom, we also treated more than 50% of cases with closed approach.

In due course of time, many Randomized Controlled Trials (RCTs) conducted on this particular topic revealed the disadvantages of closed approach in relation to the functional and post-operative outcomes. Hence, numerous studies advocate the use of ORIF, as it lessens the overall treatment time and facilitates primary bone healing. In addition, open approach can improve the nutritional maintenance and hygiene by minimizing or eradicating the necessity for maxillomandibular fixation.¹⁶ Results obtained after closed reduction compelled us to treat such fractures with surgical procedure and hence the outcomes were positive and satisfactory.

According to a study conducted by Kumar and his team, the incidence of subcondylar and condylar fractures was 7.9%.¹ Another study by Karan et al. reported that amongst several mandibular fractures, condylar fractures are the most usual injuries which accounts for 20% to 62% approximately.⁵ We acknowledged similar results in this study too, which inferred 21% cases to be condylar amidst all the other maxillofacial fractures.

Larsen and Nielsen in 1960s mentioned the ratio of male to female for condylar fractures to be 3:1, whereas a prospective study conducted in 2000 revealed the ratio of only condylar fractures as 2:1.2 Supporting these values, our study also showed predominance of male population over female. Nowadays, the geographical and traffic conditions make the population mostly dependent on private transport instead of public. Therefore, this is probably the important and appropriate explanation for dominance of male population in our results. This may also be the reason for RTA being the commonest of etiologic factors and was included in the history of 43 patients among 56.

A review conducted in 2017¹¹ interpreted the mean age of patients for condylar fractures as ranging from 20 to 40 years and this finding was also supported by two other studies conducted by Sawazaki et al¹⁷ and Singh et al¹⁸ in 2010 and 2012 respectively. Our study is in support of this analysis and resulted in age range of 35 to 40 years, with a median age of 32 years.

Initially, in the pre-antibiotic era, more chances of wound infection and less adequate osteosynthesis materials caused the surgeons to choose conservative treatment for such fractures. Lately, with the invention of new anaesthetic procedures and antibiotics, better techniques and instruments, the surgeons are compelled to give a thought regarding open approach for fractures of condyle. Furthermore, a recent review by Kommers et al¹⁹ demonstrated the absence of research data related to the comparison of quality of life of patients with fracture of condyle, who underwent open versus closed treatment. At times when the medical care system is confronted, the higher costs of surgery, following longer hospitalization time, and expensive osteosynthesis material must be weighed against the advantage of early mobilization and integration of the bone.²⁰

Hence, selecting a pertinent treatment option for fractures was based on some important criteria like mouth opening, occlusion, age, and kind of fracture either displaced, dislocated or deviated. We planned all the fracture treatments on the basis of these criteria. In cases with no occlusal disruption and no displacement of fracture, a regimen of analgesics and soft diet with closed reduction was best approach. However, in displaced and dislocated fractures, open approach was considered supreme. Total of 49 were treated with conservative approach and seven with ORIF. In our study, the outcomes of both conservative and surgical approaches were discussed in terms of certain parameters, involving maximal inter-incisal mouth opening, status of occlusion, and deviation of the jaw. Hence, the mean mouth opening was 39cms in patients treated with conservative approach, whereas 42cms in patients treated with ORIF.

Similar results were acknowledged in a recent study by Muhammad Adil Asim et al in 2019 measuring the inter-incisal distance which was 33.74±4.72mm in closed treatment group, while 36.39±4.72mm in open treatment group.⁴

According to a similar prospective study conducted in 2010, the average deflection from the midline was 1.18 mm in closed group and in contrast, a deflection was observed only in four cases (22%) with an average of 0.38 mm in the surgically treated group.³ Our study also showed deviation of jaw in two of them who underwent closed reduction, and no complications were seen in patients with ORIF.

A similar study conducted in 2013 revealed reduced occlusal discrepancy in patients treated with open approach.²¹ Concerned about the occlusal status, ORIF group was found to be superior in reduction of postoperative malocclusion.⁸ This finding is in accordance with our results where mild discrepancy was present in only one patient managed by ORIF and this resolved within some time.

A systematic review conducted in 2016 explained that the best management for unilateral fractures of condyle was through closed reduction.²² In our study, out of 56 cases, 47 were unilateral and each was treated through conservative approach. The etiology of the fracture and the intensity of force are factors which decide the fracture to be unilateral or bilateral in nature.

Despite the large benefits of open reduction, there are some complications associated with it. In a study conducted by Van Hevele and Nout, 7.5% of patients who underwent ORIF of condylar fractures using a retro-mandibular approach developed salivary fistula.²³ Temporary injury to the facial nerve was estimated to occur in 0 to 21% of cases. There are risks of plates and screws loosening over time, its extrusion, and infection.8 Fortunately, in our study there were no cases with such complications.

Limitations

The constraints of this study included:

1. Smaller sample size of fractures of condyle

2. Number of fractures dealt through open approach were less in number

Despite of these limitations, our study results were authentic and recommended open over closed treatment for the displaced, dislocated and bilateral condylar fractures.

Conclusion

The results and views of present study supports the superiority of ORIF for treatment of fractures of condyle, but still due to controlled resources for equipment availability in this scenario, closed treatment can always be an option to manage adult condylar fractures adequately. However, more studies with larger sample size and treated by a single surgeon would give better and definitive results.

Conflicting Interest

None.