Plate osteosynthesis of condylar fractures:A retrospective study of 45 patients

George Rallis, DDS, MD, Dr DentVCoslas Mourouzis, DDS /̂Michael Ainatzoglou, DDS, MD,Michael Mezitis, DDSVNicholas Zachariades, DDS, MD, Dr Denf

Objective: This retrospective study presents the type ol osteosynthesis used tor the fixation oí condyiarfractures and the postoperativ9 results and complications observed. Method and materials: Forty-five pa-ti9nts with fractures of the mandibular condyle underwent open reduction and osteosynthesis with platesand screws. The surgical approach was. in most cases, via a submandibular incision. Stabilization wasachieved ¡n the majority of the cases with a 2.0-mm singie or double miniplate, but 2.0-mm mini dynamiccompression plates were also used. Results: The complications ware mainly inadequate reduction, screwloosening, and limitation of mouth opening. No plate fractures or infections were observed. Conclusion:The use of a single plate (miniplate or dynamic compression plate) often produces inadequate stabilityand reduction postoperatively. The placement of two 2 0-mm zygomatic dynamic compression plates de-mands great tissue dissection and detachment and can lead to limitation of mouth opening. The use of two2.0-mm miniplates seems to produce better stability and fewer complications. (Quintessence Int 2003:34:45-^9)

Key words: oondylar fracture, dynamic compression plate, fixation, mandible, miniplate, open reduction,osteosynthesis

CLINICAL RELEVANCE: For fixation of condylar frac-tures after open reduction, the use of two 2.0-mm mini-plates seems to produce better results.

D ifferent methods have been used for the osteosyn-thesis of condylar fractures. Plates, and especially

miniplates, seem to produce better, more precise, andmore stable fixation of fragments.' This article pre-sents clinical experience with different lypes of platesand discusses the postoperative results and the com-plicafions observed.

'Senior Specialist, Oral a rd Maxillofacial Surgeon, Department of Oral andMaxillolacial Surgery, General District Hospital of Athens 'KAT.' Athens.Greece.

^Residem, Department ot Oral and Maxillofacial Surgery. General DistrictHospital of Athens 'KAT.' Athens, Greece.

=PrTvate Practice. Athens. Greece.

'Head. Department of Oral and Maxillofacial Surgery. General District

Hospital of Athens "KAT," Athens, Greece.

Reprint requests: Dr George Rallis, 9, Eshilou Street, Halandri, Athens

152 34. Greece. E-mail; rallis@liol.gr

METHOD AND MATERIALS

From the archives of the Department of Oral andMaxillofacial Surgery. General District Hospital ofAthens "KAT," Athens, Greece, the condylar fracturescases treated with bone plating between 1990 and1997 were reviewed. Forty-five patients with 47 condy-lar fractures underwent open reduction and internalfixation with a variety of plates and screws. Among thepatients, 34 were men and 11 were women. Their agesranged from 18 to 77 years (mean of 32 years).

The time interval between trauma and operationranged from 3 to 15 days (mean of 7 days). Open re-duction was undertaken for different reasons, but inthe majority of cases, tbe procedure was cbosen toavoid maxillomandibular fixation after discharge firomthe hospitai [Table 1).

There were 41 subcondylar and six condyiar neckfractures. To ciassify the type of the fractures and toassess the position of the condylar fragments and thestate of the screws and plates, radiographie analyses,including panoramic and Towne's views, were per-formed preoperatively and postoperatively. Two pa-tients suffered bilateral fractures. Eight of the patients

Quintessence Intecnation^45

Rallis et al

TABLE 1 Criteria for using open reduction

Criterion

Bilateral fracturesMedical reasons (epilepsy, alcoholism)Dislocation of the cpndyleAssociation with panfacial fracturesFractures with shortening of theascending ram usMalocclusion in spite of maxillomandibularfixationTo avoid maxillomandibular fixationTotai

237

133

4

1547

4.36.4

14.927.6

6.4

8,5

31.9100.0

TABLE 2 Type of osteosynthesis used

O steo synthesis

Doubie miniplate (2,0 mm)Double zygomatic DCP (3.0 mm)Single miniplate (2.0 mm)Single zygomatic DCP (2.0 mm)Total

189

U6

47

38.019.529,812.7

100.0

DCP = dynarnic compression piale.

Fig la Condylar fracture (arrowsy Fig 1b Osteosynthesis of the condyiar fracture withtwo miniplates.

Fig 2a Condylar fraclure. Fig 2b Osteosynthesis ot the condylar fracture withtwo minipiates, placed in a different manner tfian theywere in Fig Ib.

had a single condylar fracture, and four had additionalfractures of the midface. Thirty-five patients had atleast another mandibular fracture, and nine of themhad also midfacial fractures.

All of these concomitant fractures were operatedon and rigid internal fixation was applied. TFie surgicalapproach was a submandibuiar incision for subcondy-lar fractures and a preauricular incision for the sixfractures of the neck of the condyle, fn two cases, thetwo incisions had to be combined. Different types andnumber of plates and screws were used {Table 2 andFigs 1 to 4).

Immediately after surgery, maxillomandibular guid-ing eiastics were kept in place for 4 to 5 days, to allowedema, hemarthrosis, and muscular spasm to subside.The patients were advised to maintain a soft diet for30 days.

The follow-up (range between 6 and 14 months) con-sisted of clinical and radiographie evaluations as well asan assessment of occlusion, the presence of infection, fa-cial nerve function, and maximum interincisal opening.

The chi-square test was used to assess the signifi-cance of differences, and probability values of P < .05were considered significant.

Volume 34, Number 1, 2003

• Rallis et al

Fig 3a Dislocated condyle (ouUim Fig 3b Osteosynthesis ot the dislocatedcondyle wilh two minjplates.

Fig 4a Dislocateo condyle Fig 4b Osteosynthesis or the dislocated condylewith two zygoniatic dynamic compression plates.

RESULTS

In 27 cases, two 2,0-mm plates were applied, whereasin 20 cases only one was used (see Table 2).

A total of 15 complications (32'*/o) were recorded(Table 3). One case of a single miniplate's screw loos-ening (the patient's complaints were slight pain andedema) reqtiired reoperation and removal of the plate.Facial nerve weakness was temporary and of short du-ration (1 to 2 months). Three cases of facial nerveweakness involved the frontal branch and two in-volved the mandibular branch.

Interincisal opening less than 35 mm (28 to 34mm) occurred in six patients. The rest of the patientspresented with mouth opening of more than 40 mm.Intense physiotherapy was introduced in all six pa-tients with limited mouth opening, and three experi-enced good results (more than 40 mm). The three pa-tients with permanent limitation of mouth openinghad double zygomatic dynamic compression plates(DCPs) . Tbe occurrence of this complication was sig-

nificantly greater than it was with the use of doubleminiplates (P<.01).

Inadequate reduction was observed in three pa-tients with dislocated subcondylar fractures in whomonly one plate was used. In one patient, the postoper-ative occlusion was acceptable, not necessitating reop-erafion: in the other two cases, the patients did not ac-cept surgical revision. The latter two cases and the onecase of screw loosening, mentioned earlier, could beconsidered true failures {6%). Concerning the pres-ence of inadequate reduction, there was a statisticallysignificant difference between tbe use of one or twoplates (P<.05).

The seven patients with dislocated fractures pre-sented with a number of significant complications(Table 4). In two patients in whom two DCF plateswere used, permanent limitation of mouth openingwas observed. Inadequate reduction was detected inthree patients with a single miniplate or DCP. In con-trast, no complications were obser\'ed in the two pa-tients in whom two minipiates were used.

Quintessence International 47

• Raiiis et ai

TABLE 3 Complications of 47 fractures

Criterion

Temporary limitation of mouth openingPermanent limitation of mouth openingTemporary facial nerve weaknessInadequate reductionScrew looseningTotal

33

5

31

15

6.46.4

10.66,4

2.2

32.0

TABLE 4 Dislocated fractures

Patient

1

2

3

4

5

6

7

Osteosyn thesis

2 DCPs

2DCPS

1 DCP

2 mini pistes2 miniplates1 miniplate1 minipiate

Compiications

Permanent limitation of mouthopeningPermanent limitation of mouthopeningTemporary limitation of mouthopening and inadequate reductionNoneNoneInadequatereductiohInadequatereduotion

DCP = dynamic compression piale.

DISCUSSION

For the suhcondylar fractures, level 3 or 4 accordingto Kent et al,̂ the use of the submandibular surgicalapproach proved to be effective and safe. Further-more, the surgeon has the opportunity to access themandibular angle to place a wire for inferior distrac-fion, which is often necessary, mainly for the rcduc-fion of dislocated fractures. In two pafients with level3 fractures, the submandibular approach proved to beinadequate for the placement of the upper screws, andit was necessary to use a preauricular incision as wellFor fractures of the condylar neck, the preauricular in-cision is the appropriate one.

Apart from the absolute and relative indications foropen reduction of a condylar fracture,'•'' the patients'desire to avoid maxillomandibular fixation and returnto their previous activities as soon as possible played asignificant role and influenced the decision to performan operation. Consequently, the authors agree withthe statement by Hayward and Scott' that the surgeonfor each particular case must determine the risk-bene-fit ratio in the choice of treatment.

Handling and placement is much easier using a sin-gle 2.0-mm minipiate, or a single 2.0-mm zygomaficDCP. However, the use of only one 2.0-mm plate didnot seem to offer adequate stability. In three pafientswith dislocated subcondylar fractures, in whom a sin-gle minipiate or DCP was used, inadequate stabilityand reduction were observed postoperatively. In anycase, two plates seem to produce better and three-di-mensional stability, as discussed by Choi et al.'-''

An intcrincisal opening of less than 35 mm follow-ing condylar fractures has been reported to occur in

around 8% to 10% of patients.' Three patients (6.4%),each with two DCPs, presented with permanent limi-tation of mouth opening. Two of them had suffereddislocated fractures. The placement of two 2.0-mm zy-gomatic DCPs is rather more difficult than that of two2.0-mm miniplates. The DCPs are thicker, larger platesand demand greater fissue dissection and detachment.It is possible that greater surgical injury, in combina-tion with damage of the joint because of dislocafion,could have led to mandibular hypomobility.

According to Hammer et al,* screw loosening couldbe the result of either surgical error or the fact thattwo monocortical screws per fragment are not strongenough to anchor the plate to the bone. In the presentstudy, there was one case of screw loosening in a sub-condylar fracture, where only one minipiate was used.

It is unusual that no cases of plate fracture were de-tected, as have been reported by other authors."-"Perhaps functional and rotational forces are weaker inlow-type condylar fractures (subcondylar).

CONCLUSION

The treatment of condylar fractures remains contro-versial,'^" The use of a single plate (minipiate or dy-namic compression plate) often produces inadequatestability and reduction postoperatively. The placementof two 2.0-mm zygomatic DCPs demands great tissuedissection and detachment and can lead to limitationof mouth opening. In cases of open reduction andplate osteosynthesis, the use of two 2.0-mm mini-plates seems to produce more stähle results withfewer complications.

48 Volume 34, Number 1. 2003

Rallis et al

REFERENCES

1. Hayward JR, Scott RE Fractures ofthe mandibular condyie.J Oral Maxillofac Surg 1993 ;51:57-61.

2. Kent JN. Neary JP. Silvia C, Zide ME Open redtiction offractured mandibular condyles. Oral Maxillofac Surg ClinNorth Am 1990;2:69-102.

3. Zide ME, Kent fN. Indications for open reduction ofmandibuiar condyie fractures. J Oral Maxillofac Surg 1983-41:89-98.

4. Zide MF. Open reduction of mandibular condyie fractures.Indications and technique. Chn Plast Surg 1989:16:69-76.

5. Choi BH, Kim KN, Kim HJ. Kim MK. Evaluation of condy-lar neck fracture plating techniques. J Craniomaxillofac Surg1999:27:109-112.

6. Choi BH, Yi CK. Yoo JH. Clinical evaluation of 3 types ofplate OSteosynthesis for fixation of condylar neck fractures. JOral Maxillofac Surg 2001:59:734-737.

7 Ellis E in. Complications of mandibular condyie fractures.Int J Oral Maxillofac Surg 1998:27:255-257.

g. Hammer B, Schier P. Prein J. Osteosynthesis of condylarneck fractures: A review of 30 patients. Br J Oral MaxillofacSurg 1997;55:288-291.

9. Iizuka T, Lindqvist C. Hallikainen D, Mikkonen P, PaukkuP. Severe bone résorption and osteoarthrosis after miniplatefixation of high condylar fractures. A clinical and radioiogicstudy of thirteen patients. Oral Surg Oral Med Oral Pathoi1991:72:400-407

10. Klotch DW. Lundy LB. Condylar neck fractures of themandible. Otolaryngol Clin North Am 1991:24:181-194.

11. Ellis E III, Dean J. Rigid fixation of mandibuiar condyiefractures. Oral Surg Oral .Med Oral Pathoi 1993:76:6-15.

12. Moos KF, Banks P, Joos U. et al. Consensus conference.Open or closed management of eondylar fractures. Int JOral Maxillofac Surg 1998;27:243-267

13. Bos RRM, Ward Bootb RP, De Bont LGM. Mandibularcondyie fractures: A consensus [editorial]. Br J OralMaxillofac Surg 1999:37:87-89.

Quintessence International 49

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