226 MANDIBULAR STAPLE BONE PLATE

mandibular alveolar ridge. The skin in the sub- mental region is then prepared. The oral cavity is isolated from the sterile field by placing an eye Steri-drape@ with the opening over the submental region. The excess Steri-drape from the periphery of the field is then placed intraorally, which permits the assistant to manipulate the template while re- maining sterile. Two l-mm slits are cut in the Steri- drape directly over the template to accommodate the director rods, and the rods are positioned (Fig. 1). The assistant, shielded from the oral cavity by the Steri-drape (Fig. 2), may then stabilize the tem- plate and director rods. When the drill guide rack is disassembled, the template can easily be manip- ulated out of the oral cavity without contaminating the field.

Summary

The technical modifications suggested for place- ment of the mandibular staple bone plate include

the positioning of the acrylic template at the onset of the procedure and the insertion of an excess amount of Steri-drape intraorally at the time the patient is draped. The assistant can then manipulate the acrylic template and director rods from a sterile field. The perception of when the drill bit has com- pletely traversed the alveolar bone is improved by relieving the acrylic template at the site at which the transosteal pins penetrate into the oral cavity. The advantages of these modifications are three- fold: the entire surgical team remains sterile, the risk of contaminating the surgical field is reduced, and the procedure is rendered more time-efficient.

References

1. Small IA, Stines AV: Mandibular Staple Bone Plate-A Re- constructive Operation for the Atrophic Edentulous Man- dible. Surgical Technique, Zimmer, Inc., 1976.

J Oral Maxillofac Surg

43:226-228, 1985

Functional Therapy for Fractures of the Condyloid Process in Adults

RODERICK B. THIELE, DDS,*

The most common unilateral mandibular fracture is one of the condyloid process, and the most common bilateral mandibular fracture is a condy- loid fracture associated with a fracture on the con- tralateral side.’ The treatment of such fractures in adults is controversial. One approach calls for open surgical reduction and fixation2-3 for the selected cases that involve severely dislocated fractures with gross malalignment of the segments, severe pain, or decreased function. A second approach is closed reduction using maxillomandibular fixation. The usual course of treatment is to maintain fixation for

* Captain, Dental Corps, United States Army, Smith Dental Clinic, Fort Leavenworth, Kansas.

t Colonel, Dental Corps, United States Army, Chief, Depart- ment of Dentistry, 97th General Hospital, Germany.

The opinion or assertions contained herein are the private views of the authors and are not to be construed as offkial or as reflecting the views of the Department of the Army or the Department of Defense.

Address correspondence and reprint requests to Cpt. Thiele: 2315 S. 16th Terrace, Leavenworth, KS 66048.

4ND RALPH M. MARCOOT, DDSt

approximately three weeks to prevent ankylosis.4 A third approach is functional therapy, which is fre- quently used for the treatment of condyloid frac- tures in children.s-8

Review of Cases Unilateral fractures of the condyloid process, one with

a concomitant parasymphyseal fracture, were treated without maxillomandibular fixation in four adults aged 15, 19,20, and 49 years. All patients were evaluated clinically and radiographically and observed for 24 to 48 hours for the first one to two weeks and then weekly for eight weeks. The patient who sustained the parasymphyseal fracture had that problem treated by closed reduction using a clear acrylic lingual splint wired interdentally. In all cases, the patients were initially placed on liquid diets, which gradually changed to soft and then to regular diets as was individually tolerated. Analgesics were initially prescribed as indicated. Mandibular function was allowed within the limits that pain allowed. As pain subsided and function increased, mandibular exercises were prescribed to preclude abnormal mandibular deviation. The mandib- ular lingual splint for the concomitant parasymphyseal

THIELE AND MARCOOT 227

symphyseal fracture in a 20-year-old patient.

fracture was removed after approximately six weeks. At six to eight weeks, patients were asymptomatic, with good mandibular function and normal occlusion.

To date, the patients have been followed for from three months to one year. At last examination, no residual problems such as clicking, popping, joint pain, deviation, or malocclusion were noted, and all patients were func- tioning normally.

Discussion

Successful functional treatment of fractures of the condyloid process in adults depends on careful case selection based on the following criteria:

1. Presence of a unilateral nondisplaced or min- imally displaced fracture.

2. At least one nondisplaced condyloid process when both are fractured.

3. An associated body or symphyseal fracture may be present but should be nondisplaced or min- imally displaced and reducible by a lingual splint.

4. Reasonably attainable and reproducible normal occlusion. Occlusion should improve as the acute phase resolves. If this is not obtainable within three to five days after injury, functional treatment should not be used.

Counselling, treatment, and evaluation after di- agnosis is as follows:

1. Patients should have a thorough understanding of the problem as well as their role in its correction.

2. Muscle exercises should be initiated to achieve a repeatable occlusion and function without mandibular deviation as mobility increases and pain decreases. The patient is taught to stand in front of

a mirror and practice contralateral mandibular movements by applying hand pressure to the frac- tured side to counteract the usual deviation toward that side. This exercise should be practiced for a few minutes several times a day and before retiring at night. By following these exercises, any adhe- sions will be stretched and external pterygoid tone and capacity will be improved. The patient should be followed closely for the first one to two weeks to intercept early deviations from normal occlusion or mandibular excursions.

3. Patients should initially be placed on a liquid diet with no forced mandibular function. As symp- toms subside, a soft diet is started, usually two weeks after fracture, and is gradually progressed to a regular diet as this is tolerated, usually within four weeks after fracture.

4. Immediate trismus is normal and desirable. This, together with intracapsular hematoma. acts as a self-induced splinting mechanism.

5. The lingual splint is removed in approximately six weeks after fracture in those patients who have concomitant symphyseal or body fractures.

There are a number of advantages to using func- tional therapy. It eliminates surgical risks, permits earlier mobilization, and avoids the possibility of aspiration during maxillomandibular fixation. It also eliminates the need for maxillomandibular fix- ation, a procedure that may cause periodontal prob- lems and extruded and sensitive teeth. In each case in our series, encouraging results were achieved over a relatively short period of time. However, if there had been no resolution of the signs or symp-

228 CONDYLOID PROCESS THERAPY

toms, maxillomandibular fixation could still have been instituted, as the patients were under close follow-up observation.

References

1. Killey HC: Fractures of the mandible. Bristol, John Wright and Sons, 1974

2. Hoopes W, Hoopes J: Operative treatment of fractures of the mandibular condyle in children. Plast Reconstr Surg 461357, 1970

3. Tasanen A, Lamberg MA: Transosseous wiring in the treat-

FIGURE 2. Radiograph she ing left condylar fracture in a year-old patient.

FIGURE 3. Radiograph she ing right condylar fracture in a year-old patient.

3W-

49-

3W-

15-

ment of condylar fractures of the mandible. J Maxillofac Surg 4:200, 1976

4. Russell D, Nosti JC, Reavis C: Treatment of fractures of the mandibular condyle. J Trauma 12:704, 1972

5. Balaban B. Mueller BH. Marcoot RM. et al: Functional treatment of condylar fractures in children. J Pedo 4:88, 1979

6. Leake D, Doykos J, Habal MB, et al: Long term follow-up of fractures of the mandibular condyle in children. Plast Reconstr Surg 47:127, 1971

7. Archer WH: Oral and Maxillofacial Surgery, 5th ed. Phil- adelphia, WB Saunders, 1975, pp 1157, 1174, 1187

8. Hollender L, Lindahl RL: Radiographic study of articular remodeling in the temporomandibular joint after condylar fractures. Stand J Dent Res 82:462, 1974