International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Open reduction and internal fixation of severely dislocated fractures of condylar neck and base using bioabsorbable miniplate in children: A 3–10 years follow-up study Bo Zhang
a,
*, Zhao-Hui Liu b, Jian Li a, Kevin Zhang c, Jing-Jing Chen d, Ricardo M. Zhang e
a
Department of Oral and Maxillofacial Surgery, Hunan Provincial People’s Hospital and The First Affiliated Hospital of Hunan Normal University, Hunan Normal University, Changsha, PR China Xin-Cheng Hospital of Gu-Zhang County, Hunan Province, PR China c Department Family and Preventive Medicine, School of Medicine, University of Utah, UT, USA d Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland, Baltimore, MD, USA e Division of International, Hunan Normal University, Changsha, PR China b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 June 2014 Received in revised form 2 September 2014 Accepted 3 September 2014 Available online 16 September 2014
Objective: To evaluate the long-term clinical and radiologic outcomes of treating severely dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth sustained in childhood using bioabsorbable miniplate with open reduction and internal fixation (ORIF). Methods: Five children (age ranged from 3 to 11 years old averaged 8.2 years; 3 boys and 2 girls) with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth were treated with ORIF using 1 or 2 bioabsorbable miniplates (through preauricular approach and an oral vestibular approach). All patients have been followed-up clinically and radiographically for a mean of 5.6 years (range, 3–10 years). Results: All patients were cured satisfactorily with excellent occluding relation without restricted mandibular movement, facial asymmetry, retrognathism and ankylosis. 3–10 years follow-up study did not occur any mandibular development disorder. Conclusion: The results suggested that ORIF using bioabsorbable miniplate was a reliable fixation technique for use in the treatment of severely dislocated fractures of the condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in children when the non-invasive or occlusal therapies were ineffective. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Bioabsorbable miniplate Open reduction and internal fixation (ORIF) Dislocated condylar fracture Mandible Children
1. Introduction Mandibular condylar fractures (MCFs) are a type of facial bone fractures in children. About 14.8% of all facial fractures and 24–72% of all mandibular fractures are fractures of the mandibular condyle in children [1,2]. The dislocated fractures of condylar neck and base
* Corresponding author at: Department of Oral and Maxillofacial Surgery, Hunan Provincial People’s Hospital and The First Affiliated Hospital of Hunan Normal University, Hunan Normal University, Changsha 410005, PR China. Tel.: +86 13787789811. E-mail address: [email protected] (B. Zhang). http://dx.doi.org/10.1016/j.ijporl.2014.09.004 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
under 12 years of age were often treated conservatively in the past, such as a short course of maxillomandibular fixation (MMF), followed by physiotherapy [3,4]. MCFs are those most commonly missed by the parents and may not be treated promptly, so all kinds of complications have been associated with previous MCFs, such as pain, restricted mandibular movement, muscle spasm and deviation of the mandible, malocclusion, pathological changes in the temporomandibular joint (TMJ), osteonecrosis, facial asymmetry, retrognathism and TMJ ankylosis [5,6]. In children, the specific age-related status of the growing mandible and dentition development should be a major consideration when choosing the mode of treatment, so internal fixation with the metal plates is not recommended for the treatment of
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
1988
fractures of the condylar neck or base under 12 years of age [7,8], because there is a need to do secondary surgery for the metal plates and screws removal to avoid significant growth disturbance of mandible. In some countries removal of the metal plates and screws is recommended, but this exposes children to the risks of a second operation [9]. Operative treatment of fractures of the condyle is still controversial, however Eckelt et al. [10] considered that the operative treatment, irrespective of the method of internal fixation used, was superior in all objective and subjective functional parameters. Bioabsorbable osteosynthesis materials can be used in the ORIF of fractures, and should be considered for use in the treatment of severely dislocated fractures of condylar neck and base. Such fractures treated by osteosynthesis with two bioabsorbable miniplates showed good stability of the fragments in sheep [11]. There are few published reports about the long-term observation of treatment of fractures of mandibular condyle neck and base using bioabsorbable miniplate. Since May 2003, we have been used bioabsorbable poly-Llactide acid (PLLA) miniplates in ORIF for use in the treatment of severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in the fracture lline under 12 years of age when the noninvasive or occlusal therapies were ineffective and observed the long-term therapeutic effects of bioabsorbable miniplate fixation. This paper presents the results of ORIF (using bioabsorbable miniplates) treatment of severely dislocated condylar neck and base fractures in 5 children (age at trauma from 3 to 11 years old, mean 8.2 years old).
Hospital of Gu-Zhang County. Patients with skull base fractures or intracapsular were excluded [6,13]. The ORIF with the bioabsorbable miniplate was first done in a patient (patient 1, male, aged 10 years old, admission number 164173) with a severely dislocated fracture of condylar neck with the comminuted fractures of the right mental foramen, specially with crown fracture of deciduous molar and permanent molar in May 2003 (Fig. 2A and Table 1). This study was approved by the Institutional Review Board of Hunan Provincial People’s Hospital, and informed consents were obtained from the parents of all children. All patients returned for routine follow-up clinical and radiologic examinations, with the last follow-up 3–10 years post-ORIF (Table 1). 2.2. Materials
2. Patients and methods
The bioabsorbable miniplates and screws (GRAND FIXTM, PLLA: poly-L-lactic acid, Gunze Ltd., Kyoto, Japan) used consisted of an amorphous injection-molded copolymer of bioabsorbable bone fixation devices (GRAND FIXTM, Gunze Ltd., Kyoto, Japan) [15]. In this devices the 1.5 mm Mini plate is for mandibular neck and base fracture fixation (Fig. 1A). According to this company, the Gunze bioabsorbable bone fixation devices have the following characteristics. This product is made by blending rigid and elastic polymer components including the following: poly-Llactic acid/trimethylene carbonate, and polyglycolic acid. These bioabsorbable miniplates and screws have been reported to resorb slowly within 3–5 years as reported by the manufacturer (data on file with Gunze). The mechanism for resorption is hydrolysis and absorbed in the human body. The plates are activated and become malleable by bending smoothly by Heat Bender for easyadaptation (Fig. 1B). These plates can be bent to match the curve of the bone, but they cannot be bent to change vertical orientation [15].
2.1. Patients
2.3. Operation methods
This study was conducted on five children with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of the condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in the fracture line diagnosed by orthopantomograms, coronal computed tomography (CT) or computed tomographic 3D reconstruction [12]. Their ages ranged from 3 to 11 years old with a mean age of 8.2 years old, 3 patients were males and 2 patients were females (Table 1). Four cases were collected from the oral and maxcillofacial surgery outpatient clinic of hunan provincial people’s hospital and one case was referred from Xin-Cheng
All cases were evaluated clinically and radiographically with orthopantomograms, coronal CT or computed tomographic 3D reconstruction (Fig. 3A) on initial presentation to the emergency department. The main criteria for performing an open reduction using bioabsorbable miniplate fixation was the condyle dislocated from the glenoid fossa with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in the fracture line (Figs. 2A and 3A). All patients should be observed closely for 48 h after injury and be made sure that no upper respiratory tract infection, skull base fractures or intracranial injury. The all of surgical procedures were performed by
Table 1 Patient and fracture characteristics. Patient
Age (y)
Sex
Type of fracture*
Year of ORIF with bioabsorbable miniplate
Condyle removed
Follow-up (y)
1
10
M
R neck (IV) Body (R)
2003 2003
No
10 10
2
3
F
R neck (IV) Parasymphyseal
2006 2006
No
7 7
3
11
M
L neck (IV) Parasymphyseal
2008 2008
No
5 5
4
6
M
2011
5
11
F
L neck (IV) R neck (III) L subcond. (IV) R neck (III) Body (L)
No No No No
3 3 3 3 3
*
2011 2011
MacLennan type III = displacement with the condyle still in the glenoid fossa [14], MacLennan type IV = dislocation (the condyle dislocated from the glenoid fossa).
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
1989
Fig. 1. (A) The 1.5 mm bioabsorbable miniplate. (B) Heat bender.
1 group comprising a singal experienced senior surgeon (Dr. Michael Bo Zhang) and 2 residents. All patients were subjected to undergo operations under general anesthesia with oral endotracheal intubation. All patients underwent through a preauricular approach. After the condyle was placed back into the glenoid fossa and to achieve anatomic reduction without removal of the condyle from the glenoid fossa, one or two of 4-hole noncompression 1.5 mm bioabsorbable miniplates were bent
by Heat Bender and adapted along the lateral or posterior border of condylar neck or base, 4–6 screws were inserted (before plates inserting, bone tapping was done) (Fig. 2B). The incision was closed with cosmeticl suture. All patients were on a full liquid diet for at least 2 weeks after surgery. All patients were instructed to have soft diet at 4 weeks after surgery with progression gradually to a regular nutrition. Postoperative MMF was not used in any child and all patients did not receive any form of orthodontic care.
Fig. 2. Patient 1. (A) A 10-year-old boy with severely dislocated (the condyle dislocated from the glenoid fossa) fractures of condylar neck on the right with the comminuted fractures of the right mental foramen, specially with crown fracture of deciduous molar and permanent molar. (B) The bioabsorbable plate used for ORIF of the right condylar neck fracture and 4 bioabsorbable screws were inserted. (C) A full frontal view at pre-ORIF. (D) A right lateral view at pre-ORIF. (E) The follow-up of 10 years situation showing a normal full frontal view. (F) The follow-up of 10 years situation showing a normal mouth opening. (G) The follow-up of 10 years situation showing a normal right lateral view. (H) The follow-up of 10 years situation showing a normal left lateral view. (I) A normal remodeling of the condylar process after 10 years.
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
1990
Fig. 3. Patient 5. (A) A 11-year-old girl with severely dislocated fractures of condylar base on the left and with the comminuted fractures of the left mental foramen, specially with crown fracture of deciduous molar and permanent molar. (B) A normal remodeling of the condylar process after 3 years. (C) The follow-up of 3 years situation showing a normal full frontal view. (D) The follow-up of 3 years situation showing a normal mouth opening. (E) The follow-up of 3 years situation showing a normal right lateral view. (F) The follow-up of 3 years situation showing a normal left lateral view.
2.4. Post-operative evaluation On the 7th day following surgery, wound healing, the function of facial nerve, the post-operative dental occlusion and mouth opening were checked by Dr. Michael Bo Zhang in this study for all patients. All patients were asked if they experienced pain in the TMJ when chewing, a reduced range of mouth opening, joint sounds, or locking of the joints. Clinical follow-up examination included palpation, auscultation of both TMJs, dental occlusion (according to Angle Class), assessment of gape (interincisal distance when opening the mouth) and measurement of the maximal lateral excursions of the mandible in May 2014 by Dr. Michael Bo Zhang and Dr. Zhao-Hui Liu. Deviation of mandibular movement with mouth opening of 2 mm or more and a lateral excursion less than 7 mm were considered abnormal [16]. Three standardized photographs were taken of the patient’s occlusion at follow-up: a frontal, a frontal view (with open mouth), a right lateral, and a left lateral. Then, all patients were examined with the radiologic images: panoramic imaging.
orthopantomograms showed that the fracture lines were visible and there was no postoperative displacement of fragments at the follow-up appointment with 2 weeks after surgery. After follow-up of 3–10 years, all patient’s fractures had healed completely; no fracture lines or callus formation were visible, which is evident that there had been complete remodeling of condyle. We observed that all patient’s dental occlusion, mouth opening, the TMJ’s function and developing of mandible were all normal in our this study population. Patient 1 (male, aged 10 years old) (Fig. 2E–I) had followed up for ten years and patient 5 (female, aged 11 years old) (Fig. 3B–F) for three follow-up years with no TMJ diseases, retrognathism and TMJ ankylosis. All patient radiographically showed a normal remodeling of the condylar process, no deviation of symphysis, no shortening in ramus height and no retrognathism at last follow-up on the dislocated and fixated side. The clinical outcomes also showed no malocclusion or ankylosis, no auscultation of both TMJs, normal jaw opening, no deviation to dislocated side with mouth opening and no TMJ objective or subjective symptoms in all patients (Table 2). 4. Discussion
3. Results Surgery spot slightly edemaed after 1–3 days surgery, usually after a week of time swelling would subside and there were no dead space and pitting edema. Clinical examination showed that the patient’s occlusion and mouth opening were normal and
A two-day international conference to review the management of MCFs held in Groningen in the Netherlands in 1999 had a consensus: MCFs could simply be divided into three types: intracapsular, condylar neck and subcondylar (base) and treated by closed treatment or open reduction [17]. The 2nd International
Table 2 Clinical outcomes. Patient
Angle Class
Auscultation of TMJs
Maximum incisal opening (mm)
Deviation to dislocated side with mouth opening
TMJ objective symptoms
TMJ subjective symptoms
1 2 3 4 5
I I I I II
None None None None None
55 50 50 40 45
None None None None None
None None None None None
None None None None None
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
Bone Research Association (IBRA) Symposium for Condylar Fracture Osteosynthesis 2012 was held at Marseille [18]. The goal of this IBRA symposium was to evaluate current trends and potential changes of treatment strategies for mandibular condylar fractures, which remain controversial over the past decades. The experts and participants had comparable opinion on management of condylar fractures and complications of ORIF. Compared to the first Condylar Fracture Symposium 2007 in Strasbourg, ORIF may now be considered as the gold standard for both condylar base and neck fractures with displacement and dislocation. Although ORIF in condylar head fractures in adults and condylar fractures in children with mixed dentition is highly recommended, but this recommendation requires further investigations. Managing MCFs in children continues to be a subject of debate now. The focus of the controversy is how to manage the treatment of dislocated fractures of the condylar neck and subcondylar in children. Children’s condylar process has a special physiological characteristic. It is one of the mandibular growth centers, children after MCFs treated by closed treatment often appear some complications in adulthood, usually with serious sequel such as TMJ dysfunction, retcrognathism and TMJ ankylosis. Most of patients with retcrognathism and TMJ ankylosis have a traumatic history of condylar process in childhood and had been treated nonsurgically reported by Raveh et al. [19]. Tabrizi et al. [20] reported a prospective study about comparing rigid intermaxillary fixation and guiding elastic for treatment of condylar fractures in pediatric patients. Their study showed that the same results using guiding elastics as using rigid intermaxillary fixation in pediatric condylar fractures. They considered that guiding elastic is more tolerable, and children have function during treatment. Bruckmoser and Undt [21] reviewed the literature using a PubMed search, they concluded that despite frequently encountered radiologic abnormalities, conservative management of condylar fractures in children usually yields satisfactory to excellent clinical results; however, in adolescents the outcome is often reported to be less favorable; good prospective randomized multicenter studies would clarify from which age on patients could probably benefit from operative treatment. Boffano et al. [22] used the placement of fixed orthodontic appliances, the preparation of a maxillary acrylic splint, and functional exercises to treat unilateral displaced condylar fractures in a series of children with mixed dentition, and they got a conclusion that conservative treatment of displaced condylar fractures in children, using a progressively remodeled splint, showed satisfactory functional outcomes at 12 months of follow-up. The bilateral condylar fracture in children represents a completely different condition in comparison with the unilateral fracture, so there is a great different between the therapeutic modalities of the bilateral condylar fracture and that of the unilateral fracture. But if children present the dislocated conylar fracture with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth, at this situation, non-surgical treatment is not the choice for children. In our study population, all patients were with crown fracture of deciduous molar and permanent molar. Of these 5 patients, 4 cases with dislocation of the teeth in the fracture line, 2 cases with the comminuted fractures of parasymphysis and 2 cases with the comminuted fractures of mental foramen. Usually non-surgical treatment should be the first choice for children
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Open reduction and internal fixation of severely dislocated fractures of condylar neck and base using bioabsorbable miniplate in children: A 3–10 years follow-up study Bo Zhang
a,
*, Zhao-Hui Liu b, Jian Li a, Kevin Zhang c, Jing-Jing Chen d, Ricardo M. Zhang e
a
Department of Oral and Maxillofacial Surgery, Hunan Provincial People’s Hospital and The First Affiliated Hospital of Hunan Normal University, Hunan Normal University, Changsha, PR China Xin-Cheng Hospital of Gu-Zhang County, Hunan Province, PR China c Department Family and Preventive Medicine, School of Medicine, University of Utah, UT, USA d Department of Epidemiology and Public Health, University of Maryland School of Medicine, University of Maryland, Baltimore, MD, USA e Division of International, Hunan Normal University, Changsha, PR China b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 June 2014 Received in revised form 2 September 2014 Accepted 3 September 2014 Available online 16 September 2014
Objective: To evaluate the long-term clinical and radiologic outcomes of treating severely dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth sustained in childhood using bioabsorbable miniplate with open reduction and internal fixation (ORIF). Methods: Five children (age ranged from 3 to 11 years old averaged 8.2 years; 3 boys and 2 girls) with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth were treated with ORIF using 1 or 2 bioabsorbable miniplates (through preauricular approach and an oral vestibular approach). All patients have been followed-up clinically and radiographically for a mean of 5.6 years (range, 3–10 years). Results: All patients were cured satisfactorily with excellent occluding relation without restricted mandibular movement, facial asymmetry, retrognathism and ankylosis. 3–10 years follow-up study did not occur any mandibular development disorder. Conclusion: The results suggested that ORIF using bioabsorbable miniplate was a reliable fixation technique for use in the treatment of severely dislocated fractures of the condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in children when the non-invasive or occlusal therapies were ineffective. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Bioabsorbable miniplate Open reduction and internal fixation (ORIF) Dislocated condylar fracture Mandible Children
1. Introduction Mandibular condylar fractures (MCFs) are a type of facial bone fractures in children. About 14.8% of all facial fractures and 24–72% of all mandibular fractures are fractures of the mandibular condyle in children [1,2]. The dislocated fractures of condylar neck and base
* Corresponding author at: Department of Oral and Maxillofacial Surgery, Hunan Provincial People’s Hospital and The First Affiliated Hospital of Hunan Normal University, Hunan Normal University, Changsha 410005, PR China. Tel.: +86 13787789811. E-mail address: [email protected] (B. Zhang). http://dx.doi.org/10.1016/j.ijporl.2014.09.004 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
under 12 years of age were often treated conservatively in the past, such as a short course of maxillomandibular fixation (MMF), followed by physiotherapy [3,4]. MCFs are those most commonly missed by the parents and may not be treated promptly, so all kinds of complications have been associated with previous MCFs, such as pain, restricted mandibular movement, muscle spasm and deviation of the mandible, malocclusion, pathological changes in the temporomandibular joint (TMJ), osteonecrosis, facial asymmetry, retrognathism and TMJ ankylosis [5,6]. In children, the specific age-related status of the growing mandible and dentition development should be a major consideration when choosing the mode of treatment, so internal fixation with the metal plates is not recommended for the treatment of
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
1988
fractures of the condylar neck or base under 12 years of age [7,8], because there is a need to do secondary surgery for the metal plates and screws removal to avoid significant growth disturbance of mandible. In some countries removal of the metal plates and screws is recommended, but this exposes children to the risks of a second operation [9]. Operative treatment of fractures of the condyle is still controversial, however Eckelt et al. [10] considered that the operative treatment, irrespective of the method of internal fixation used, was superior in all objective and subjective functional parameters. Bioabsorbable osteosynthesis materials can be used in the ORIF of fractures, and should be considered for use in the treatment of severely dislocated fractures of condylar neck and base. Such fractures treated by osteosynthesis with two bioabsorbable miniplates showed good stability of the fragments in sheep [11]. There are few published reports about the long-term observation of treatment of fractures of mandibular condyle neck and base using bioabsorbable miniplate. Since May 2003, we have been used bioabsorbable poly-Llactide acid (PLLA) miniplates in ORIF for use in the treatment of severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in the fracture lline under 12 years of age when the noninvasive or occlusal therapies were ineffective and observed the long-term therapeutic effects of bioabsorbable miniplate fixation. This paper presents the results of ORIF (using bioabsorbable miniplates) treatment of severely dislocated condylar neck and base fractures in 5 children (age at trauma from 3 to 11 years old, mean 8.2 years old).
Hospital of Gu-Zhang County. Patients with skull base fractures or intracapsular were excluded [6,13]. The ORIF with the bioabsorbable miniplate was first done in a patient (patient 1, male, aged 10 years old, admission number 164173) with a severely dislocated fracture of condylar neck with the comminuted fractures of the right mental foramen, specially with crown fracture of deciduous molar and permanent molar in May 2003 (Fig. 2A and Table 1). This study was approved by the Institutional Review Board of Hunan Provincial People’s Hospital, and informed consents were obtained from the parents of all children. All patients returned for routine follow-up clinical and radiologic examinations, with the last follow-up 3–10 years post-ORIF (Table 1). 2.2. Materials
2. Patients and methods
The bioabsorbable miniplates and screws (GRAND FIXTM, PLLA: poly-L-lactic acid, Gunze Ltd., Kyoto, Japan) used consisted of an amorphous injection-molded copolymer of bioabsorbable bone fixation devices (GRAND FIXTM, Gunze Ltd., Kyoto, Japan) [15]. In this devices the 1.5 mm Mini plate is for mandibular neck and base fracture fixation (Fig. 1A). According to this company, the Gunze bioabsorbable bone fixation devices have the following characteristics. This product is made by blending rigid and elastic polymer components including the following: poly-Llactic acid/trimethylene carbonate, and polyglycolic acid. These bioabsorbable miniplates and screws have been reported to resorb slowly within 3–5 years as reported by the manufacturer (data on file with Gunze). The mechanism for resorption is hydrolysis and absorbed in the human body. The plates are activated and become malleable by bending smoothly by Heat Bender for easyadaptation (Fig. 1B). These plates can be bent to match the curve of the bone, but they cannot be bent to change vertical orientation [15].
2.1. Patients
2.3. Operation methods
This study was conducted on five children with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of the condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in the fracture line diagnosed by orthopantomograms, coronal computed tomography (CT) or computed tomographic 3D reconstruction [12]. Their ages ranged from 3 to 11 years old with a mean age of 8.2 years old, 3 patients were males and 2 patients were females (Table 1). Four cases were collected from the oral and maxcillofacial surgery outpatient clinic of hunan provincial people’s hospital and one case was referred from Xin-Cheng
All cases were evaluated clinically and radiographically with orthopantomograms, coronal CT or computed tomographic 3D reconstruction (Fig. 3A) on initial presentation to the emergency department. The main criteria for performing an open reduction using bioabsorbable miniplate fixation was the condyle dislocated from the glenoid fossa with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in the fracture line (Figs. 2A and 3A). All patients should be observed closely for 48 h after injury and be made sure that no upper respiratory tract infection, skull base fractures or intracranial injury. The all of surgical procedures were performed by
Table 1 Patient and fracture characteristics. Patient
Age (y)
Sex
Type of fracture*
Year of ORIF with bioabsorbable miniplate
Condyle removed
Follow-up (y)
1
10
M
R neck (IV) Body (R)
2003 2003
No
10 10
2
3
F
R neck (IV) Parasymphyseal
2006 2006
No
7 7
3
11
M
L neck (IV) Parasymphyseal
2008 2008
No
5 5
4
6
M
2011
5
11
F
L neck (IV) R neck (III) L subcond. (IV) R neck (III) Body (L)
No No No No
3 3 3 3 3
*
2011 2011
MacLennan type III = displacement with the condyle still in the glenoid fossa [14], MacLennan type IV = dislocation (the condyle dislocated from the glenoid fossa).
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
1989
Fig. 1. (A) The 1.5 mm bioabsorbable miniplate. (B) Heat bender.
1 group comprising a singal experienced senior surgeon (Dr. Michael Bo Zhang) and 2 residents. All patients were subjected to undergo operations under general anesthesia with oral endotracheal intubation. All patients underwent through a preauricular approach. After the condyle was placed back into the glenoid fossa and to achieve anatomic reduction without removal of the condyle from the glenoid fossa, one or two of 4-hole noncompression 1.5 mm bioabsorbable miniplates were bent
by Heat Bender and adapted along the lateral or posterior border of condylar neck or base, 4–6 screws were inserted (before plates inserting, bone tapping was done) (Fig. 2B). The incision was closed with cosmeticl suture. All patients were on a full liquid diet for at least 2 weeks after surgery. All patients were instructed to have soft diet at 4 weeks after surgery with progression gradually to a regular nutrition. Postoperative MMF was not used in any child and all patients did not receive any form of orthodontic care.
Fig. 2. Patient 1. (A) A 10-year-old boy with severely dislocated (the condyle dislocated from the glenoid fossa) fractures of condylar neck on the right with the comminuted fractures of the right mental foramen, specially with crown fracture of deciduous molar and permanent molar. (B) The bioabsorbable plate used for ORIF of the right condylar neck fracture and 4 bioabsorbable screws were inserted. (C) A full frontal view at pre-ORIF. (D) A right lateral view at pre-ORIF. (E) The follow-up of 10 years situation showing a normal full frontal view. (F) The follow-up of 10 years situation showing a normal mouth opening. (G) The follow-up of 10 years situation showing a normal right lateral view. (H) The follow-up of 10 years situation showing a normal left lateral view. (I) A normal remodeling of the condylar process after 10 years.
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
1990
Fig. 3. Patient 5. (A) A 11-year-old girl with severely dislocated fractures of condylar base on the left and with the comminuted fractures of the left mental foramen, specially with crown fracture of deciduous molar and permanent molar. (B) A normal remodeling of the condylar process after 3 years. (C) The follow-up of 3 years situation showing a normal full frontal view. (D) The follow-up of 3 years situation showing a normal mouth opening. (E) The follow-up of 3 years situation showing a normal right lateral view. (F) The follow-up of 3 years situation showing a normal left lateral view.
2.4. Post-operative evaluation On the 7th day following surgery, wound healing, the function of facial nerve, the post-operative dental occlusion and mouth opening were checked by Dr. Michael Bo Zhang in this study for all patients. All patients were asked if they experienced pain in the TMJ when chewing, a reduced range of mouth opening, joint sounds, or locking of the joints. Clinical follow-up examination included palpation, auscultation of both TMJs, dental occlusion (according to Angle Class), assessment of gape (interincisal distance when opening the mouth) and measurement of the maximal lateral excursions of the mandible in May 2014 by Dr. Michael Bo Zhang and Dr. Zhao-Hui Liu. Deviation of mandibular movement with mouth opening of 2 mm or more and a lateral excursion less than 7 mm were considered abnormal [16]. Three standardized photographs were taken of the patient’s occlusion at follow-up: a frontal, a frontal view (with open mouth), a right lateral, and a left lateral. Then, all patients were examined with the radiologic images: panoramic imaging.
orthopantomograms showed that the fracture lines were visible and there was no postoperative displacement of fragments at the follow-up appointment with 2 weeks after surgery. After follow-up of 3–10 years, all patient’s fractures had healed completely; no fracture lines or callus formation were visible, which is evident that there had been complete remodeling of condyle. We observed that all patient’s dental occlusion, mouth opening, the TMJ’s function and developing of mandible were all normal in our this study population. Patient 1 (male, aged 10 years old) (Fig. 2E–I) had followed up for ten years and patient 5 (female, aged 11 years old) (Fig. 3B–F) for three follow-up years with no TMJ diseases, retrognathism and TMJ ankylosis. All patient radiographically showed a normal remodeling of the condylar process, no deviation of symphysis, no shortening in ramus height and no retrognathism at last follow-up on the dislocated and fixated side. The clinical outcomes also showed no malocclusion or ankylosis, no auscultation of both TMJs, normal jaw opening, no deviation to dislocated side with mouth opening and no TMJ objective or subjective symptoms in all patients (Table 2). 4. Discussion
3. Results Surgery spot slightly edemaed after 1–3 days surgery, usually after a week of time swelling would subside and there were no dead space and pitting edema. Clinical examination showed that the patient’s occlusion and mouth opening were normal and
A two-day international conference to review the management of MCFs held in Groningen in the Netherlands in 1999 had a consensus: MCFs could simply be divided into three types: intracapsular, condylar neck and subcondylar (base) and treated by closed treatment or open reduction [17]. The 2nd International
Table 2 Clinical outcomes. Patient
Angle Class
Auscultation of TMJs
Maximum incisal opening (mm)
Deviation to dislocated side with mouth opening
TMJ objective symptoms
TMJ subjective symptoms
1 2 3 4 5
I I I I II
None None None None None
55 50 50 40 45
None None None None None
None None None None None
None None None None None
B. Zhang et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 1987–1992
Bone Research Association (IBRA) Symposium for Condylar Fracture Osteosynthesis 2012 was held at Marseille [18]. The goal of this IBRA symposium was to evaluate current trends and potential changes of treatment strategies for mandibular condylar fractures, which remain controversial over the past decades. The experts and participants had comparable opinion on management of condylar fractures and complications of ORIF. Compared to the first Condylar Fracture Symposium 2007 in Strasbourg, ORIF may now be considered as the gold standard for both condylar base and neck fractures with displacement and dislocation. Although ORIF in condylar head fractures in adults and condylar fractures in children with mixed dentition is highly recommended, but this recommendation requires further investigations. Managing MCFs in children continues to be a subject of debate now. The focus of the controversy is how to manage the treatment of dislocated fractures of the condylar neck and subcondylar in children. Children’s condylar process has a special physiological characteristic. It is one of the mandibular growth centers, children after MCFs treated by closed treatment often appear some complications in adulthood, usually with serious sequel such as TMJ dysfunction, retcrognathism and TMJ ankylosis. Most of patients with retcrognathism and TMJ ankylosis have a traumatic history of condylar process in childhood and had been treated nonsurgically reported by Raveh et al. [19]. Tabrizi et al. [20] reported a prospective study about comparing rigid intermaxillary fixation and guiding elastic for treatment of condylar fractures in pediatric patients. Their study showed that the same results using guiding elastics as using rigid intermaxillary fixation in pediatric condylar fractures. They considered that guiding elastic is more tolerable, and children have function during treatment. Bruckmoser and Undt [21] reviewed the literature using a PubMed search, they concluded that despite frequently encountered radiologic abnormalities, conservative management of condylar fractures in children usually yields satisfactory to excellent clinical results; however, in adolescents the outcome is often reported to be less favorable; good prospective randomized multicenter studies would clarify from which age on patients could probably benefit from operative treatment. Boffano et al. [22] used the placement of fixed orthodontic appliances, the preparation of a maxillary acrylic splint, and functional exercises to treat unilateral displaced condylar fractures in a series of children with mixed dentition, and they got a conclusion that conservative treatment of displaced condylar fractures in children, using a progressively remodeled splint, showed satisfactory functional outcomes at 12 months of follow-up. The bilateral condylar fracture in children represents a completely different condition in comparison with the unilateral fracture, so there is a great different between the therapeutic modalities of the bilateral condylar fracture and that of the unilateral fracture. But if children present the dislocated conylar fracture with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth, at this situation, non-surgical treatment is not the choice for children. In our study population, all patients were with crown fracture of deciduous molar and permanent molar. Of these 5 patients, 4 cases with dislocation of the teeth in the fracture line, 2 cases with the comminuted fractures of parasymphysis and 2 cases with the comminuted fractures of mental foramen. Usually non-surgical treatment should be the first choice for children
