Discusión

Conservative treatment of condyle fractures: Radiological and clinical evaluation

Tratamiento conservador de las fracturas del cóndilo: Evaluación radiológica y clínica

The treatment of fractures of the mandibular condyle is a permanent motive for controversy. This type of fracture has always been treated with a conservative approach based on the use, for a more or less long period of time, of intermaxillary fixation. In some cases the treatment is given in conjunction with functional rehabilitation, which is playing an ever more preponderant role with regard to intermaxillary fixation by reducing the periods. The incorporation into our therapeutic arsenal of fracture fixation systems by means of osteosynthesis has had a noticeable effect at a treatment level with respect to condylar fractures, with surgical indications becoming widespread.¹

The fundamental objective of the treatment we provide should be to restore function while harming the patient as little as possible. What does acceptable post-treatment functional consist of? Ideally it should consist in the TMJ being asymptomatic, having movement in all directions, with good dental occlusion and with no asymmetries either when in motion or stationary. The closer to the target the better the treatment.

But what type of treatment should we use when faced with a condylar fracture? Different authors have used a series of variables (degree of displacement of the fragments, age of the patients. location of the fracture line...) in order to make their choice.

We have evolved in this way from the classical indications of Zide and Kent in 1983² to the more recent ones of Haug and Assael³ that give more importance to the patient being well-informed as to the techniques at his disposal, the advantages and disadvantages of these, and the functional results obtained on application.

Drs. Wassouf, Verdeja and Grätz present a retrospective revision of conservative treatment by means of intermaxillary fixation over a variable period, 35 condylar fractures in 30 patients. They use Köhler’s classification in order to locate at five points the fracture line and they study the shortening of the ramus and the dislocation angle of the condyle by orthopantomography using the criteria of Iizuka and Lindqvist.⁴ The medial dislocation angle of the condyle is measured by postero-anterior radiography. The treatment applied is traditional intermaxillary fixation with a splint for 2 weeks in unilateral cases, and for 3 to 4 weeks in bilateral fracture cases (5 patients). Clinical and radiological follow- ups are carried out at 6 weeks, and at 3, 6 and 12 months. The type of intermaxillary fixation used is not described (rigid or elastic). Their objective is to apply conservative treatment through the fixation of all the fractures and to analyze the results according to the different types of fractures.

The analysis of the results that the authors carry out needs, in our opinion, more rigorous systemization. We are given details with regard to the material and methods; the results are not linked to the location of the fracture lines and the results are only analyzed in relation with the fractures being unilateral or bilateral. The ambitious and interesting design of the study should permit a statistical analysis of all the data collected, which would provide conclusions of greater relevance than those set out.

The discussion gives us the adaptive base for conservative treatment. We do not agree with the authors when they state that by avoiding surgery considerable benefits and better results are gained with this type of fracture. Analyzing the functional results provided is enough (deviation on mouth opening in 14/27, reduction of lateral movements 15/29,...) to see that they are at least similar to those that appear in the literature.

The last paragraph of the discussion informs us that the treatment applied consists in rigid fixation (2 weeks for unilateral fractures and 3 to 4 for bilateral ones) followed by a period of elastic fixation for improving results. It is true that surgical treatment can lead to resorption of the condyle, but we believe that the authors should take into account that a period of prolonged rigid fixation in bilateral fractures can be the cause of a considerable aperture limitation and even ankylosis. The evaluation of individual oral aperture posttreatment would have been of great help in this sense.

In our opinion, for the treatment of condylar fractures to evolve individualization is required, which means taking into account the location of the fracture line (inter-capsular, cervical and subcondylar), the age of the patient and the state of their general health, the surgical skills of the team providing the treatment, and the freedom of the patient to choose once duly informed of the indications and contraindications of each technique.

All this should be completed with early functional treatment. It is important for this to be carried out during the elastic fixation period, making sure the movements are those allowed while correcting functional loss; restoring practically ad integrum function is fundamental, particularly in children during the post-treatment period (be it conservative or surgical).

We consider that conservative treatment, according to the principles out, should be applied to condylar fractures in children, fractures within the condylar head, (although one should take into account that the results are disappointing for comminuted and lateral fractures), neck fractures and subcondylar fractures if the patient prefers avoiding surgery.

Lastly, we consider the aims of the study carried out by the authors to be of great interest, although we feel that better systemization for analyzing the results would have shed more light on the eternal discussion as to what treatment is of greater benefit for the patient with a mandibular condyle fracture.

J.I. Iriarte Ortabe
Servicio de Cirugía Oral y Maxilofacial
Hospital Son Dureta. Palma de Mallorca. España

Bibliografía

1. Iriarte Ortabe JI, Caubet Biayna J, Morey Más MA. Tratamiento quirúrgico de las fracturas del cóndilo mandibular. Rev Esp Cir Oral Maxilofac 2003; 25: 199-212.

2. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983; 41: 89-98.

3. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001; 59: 370-5.

4. Iizuka T, Lindqvist C, Hallikainen D, Mikkonen P, Paukku P. Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures. A clinical and radiologic study of thirteen patients. Oral Surg 1991; 72: 400-7.