OPEN VS CLOSE REDUCTION OF MANDIBULAR CONDYLER FRACTURES

BY Brig Waseem Ahmed AFID

GOALS OF TREATMENT

Functional Goal:Reestablishment of preoperative function of

masticatory system

Anatomical Goal:Reestablishment of preoperative occlusion and

facial symmetry

VARIABLES INFLUENSING THE SELECTION OF TREATMENTLevel of #Degree of displacement of Proximal SegStatus of dentitionConcomitant injuries AgeMedical status

TREATMENT OPTIONSBroadly divided into:

Conservative (Non-surgical)

Open (Surgical)

WHAT IS CONSERVATIVE MANAGEMENTMay be as simple as observation and soft diet

Or

variable periods of immobilization

SIMPLE OBSERVATIONOnly responsible patients committed to period of close

follow up to be considered

Strict soft diet and medication.

Be on guard: first signs of occlusal instability, deviation

with pain or increasing paan

An immediate clinical and radiographic reevaluation has

out has to be carried out.

INDICATIONS OFCONSERVATIVE MANEGMENTMinimal condyler displacementEasily achievable occlusionMinimum painAcceptable range of mand movementsDifficult repositiong of prox segmentFracture of Condyler head / Neck

IMMOBILIZATION If some degree of malocclusion, deviation with opening or

pain

IMF with any means

: Eyelet wiring, arch bars, splints

Depends on confounding factors: age, level of fracture, degree of displacement, additional fractures etc

HIGH CONDYLER #

HIGH LEVEL FRACTURE

COMPLICATIOS OF CLOSE REDUCTIONChronic painGreater percentage of malocclusionMean shortening of Post Facial height (2-5

mm or 5%).Diagnosed asAnatomical shortening

Superiorly displayed Gonion.Functional shortening

ipsilateral persistent occlusal prematurity Inability to achieve contra lateral occlucion Asymmetry

WHAT IS SURGICAL MANAGEMENT Open reduction & Internal fixation

(ORIF)

INDICATIONS OF OPEN REDUCTION ABSOLUTE

When occlusion by close reduction is not achievable

Condyler dislocation Lateral extra cap displacementDisplacement Into middle cranial fossa.Foreign body in joint cap.

RELATIVEBilateral cond # in edentulous Pts.Bilateral cond # with mid face #sIF IMF not possible- Medically comp Pts.

ADVATAGES OF OPEN REDUCTION Posterior Facial height is maintainedGreater & early functional improvements

COMPLICATIONS OF OPEN TREATMENTDifficult surgical accessUnsightly Hypertrophic scarFacial nerve deficitInfection, malunionMalocclusionAvascular cond necrosisLonger procedure / Expertise /Facilities

OPEN vs CLOSE REDUCTION Location of fracture and degree of

displacement primarily determines selection of approach

Functional improvement by open method is greater than with closed

Open treatment is associated with perceptible scar but early mobility and less pain.

Closed treatment is associated with higher percentage of malocclusion and chronic pain

REVIEW OF LITERATUREThere is no strong correlation between

radiographic finding and choice of treatmentIdeal management of condylar fractures is

still controversial . Considering different variables various

treatment options are considered adequateFocus on SIGNS & SYMPTOMS rather than

on condyler # itself.

CONCLUSION A careful assessment of the literature and

experiences of surgeons indicates that there is no significant difference between surgical and non surgical treatment modalities.

Acceptable outcomes have been achieved with both techniques. Assessment of factors peculiar to the individual case must be made to determine the mode of therapy most likely to produce a favorable outcome.