Closed versus open operative treatment of nondisplaced diacapitular (Class VI) fractures.

PURPOSE: The purpose of the study was assessment of whether open reduction and internal fixation of high nondisplaced, nondislocated diacapitular fractures (Class VI according to Spiessl and Schroll) have better 1-year results compared with closed treatment. PATIENTS AND METHODS: Twenty-two patients treated 2001 to 2005 with 26 (4 double) Class VI fractures prospectively entered this evaluation; in randomized fashion 9 (41%) patients had open reduction and internal fixation, 13 (59%) had closed treatment. Facial symmetry, nerve function, scarring, pain, and interincisal maximum distance were judged clinically; condylar translation by sonography; repositioning and reossification upon postoperative and 1-year follow-up radiographs. RESULTS: Altogether 17 (77%) patients presented for follow-up; 8 (47%) closed treatment, 9 (53%) open reduction and internal fixation. All patients evinced normal vertical opening. Insufficient condylar translation (<6 mm opening, <3 mm protrusion and mediotrusion) was prevalent in 2 open reduction and internal fixation and 2 closed treatment patients, persistent pain in 2 open reduction and internal fixation patients, and deflection greater than 4 mm in 2 open reduction and internal fixation patients. Partial facial nerve paresis was not encountered. In 1 open reduction and internal fixation patient a broken osteofixation was removed and 1 closed treatment patient had dysocclusion. Vertical medial fragment position was successfully restored by open reduction and internal fixation with, however, considerable remodeling (lateral condyle support is unaltered in Class VI). Closed treatment did not succeed in vertical repositioning but also evinced less remodeling. Angular fragment rectification in open reduction and internal fixation was successful; in closed treatment slight enlargement of the angulation was encountered at follow-up. CONCLUSIONS: Closed treatment within this study produced 2 of 8 (25%), open reduction and internal fixation compared with 2 of 9 (22%) unacceptable results and postoperative condyle remodeling. Therefore success rates of 75% versus 78% were attained, and closed treatment should therefore be preferred. However, sufficiently retentive resorbable osteofixation with intraosseous localization could permit better open reduction and internal fixation results than the microplates and screws at the dorsal condylar circumference applied within this study.

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.

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.

Prospective closed treatment of nondisplaced and nondislocated condylar neck and head fractures versus open reposition internal fixation of displaced and dislocated fractures.

OBJECTIVE: assessment of open reduction internal fixation in displaced or dislocated fractures of the condylar neck and head assessed versus closed treatment of nondisplaced, nondislocated fractures. MATERIALS AND METHODS: One hundred and twenty patients suffering from 158 fractures; classes II to V according to Spiessl and Schroll, e.g., displaced and dislocated fractures were operated on; classes I and VI nondisplaced, nondislocated fractures were treated conservatively. At 1year, facial symmetry, pain, facial nerve function, and scarring were assessed clinically; reossification and fragment angulation were assessed from radiographs; vertical position, incisal maximum movements, and condyle translation were judged by millimeters. RESULTS AND DISCUSSION: Clinical courses were uncomplicated in classes I to IV and did reach horizontal and vertical fragment reposition with minor remodeling in follow-up. Single cases evinced persistent pain, dysocclusion, facial nerve palsy, and plate fractures. Results were less successful in classes V and VI: although open reposition internal fixation showed good repositioning in class V, marked vertical bone remodeling occurred; single cases suffered from pain, dysocclusion, and plate fracture. Class VI cases had the worst translation, likewise marked condyle remodeling, and frequent dysocclusion. CONCLUSION: Classes V and VI remain challenging to treat, while the other classes can be treated reliably with this study's rationale. Condyle remodeling in classes V and VI, translation in class VI may benefit prospectively from even more careful mobilization, improved osteofixation as minimalized operation trauma.