J Oral Maxillofac 50:349-352,
Surg
1992
Surgical Versus Conservative Treatment of Unilateral Conciyiar Process Fractures: Clinical and Radiographic Evaluation of 80 Patients VITOMIR S. KONSTANTINOVle, DDS,* AND BRANISLAV DIMITRIJEVIC, DDS, PtiDt Treatment results of 26 surgically and 54 conservatively treated unilateral condylar process fractures were investigated by standardized clinical examination and by evaluation of computer-simulated graphic presentations of posteroanterior (PA) radiographs of the mandible. The radiographic evaluation compared the relation of actual reduction of the condylar process fractures with ideally reduced fractures produced on the computer. Using clinical parameters (maximal mouth opening, deviation, protrusion), no statistical differences between surgically and conservatively treated fractures were found. However, the radiographic examinations showed a statistically better position of the surgically reduced condylar process fractures.
The treatment of condylar process fractures is a problem because of the limited surgical access and difficulties in restoring function.’ The majority of investigators recommend conservative treatment and they report satisfactory results based on radiographic and clinical findings, especially when patients are in childhood and adolescence. 24 Surgical treatment is recommended in severe cases when the condyle is displaced out of the glenoid fossa.7-g However, there are certain cases that cannot be treated surgically (intracapsular, or so-called “high” condylar fractures). Evaluation of the success of the healing after treatment usually is done on the basis of standard radiographs of the mandible on which both qualitative and quantitative measurements are made.4,6,‘0 Quantitatively, evaluation usually means absolute symmetry of both condyles and their relation to the glenoid fossa, ie, registrations on the fractured side are compared with
the nonfractured side.4 Clinical evaluation (maximal mouth opening, deviation, movements on protrusion) has also been done.2,3*5,1 ’ Despite these numerous studies, however, the real indication for surgical treatment of these fractures is still debated. The aim of this study was to evaluate the results of both surgically and conservatively treated condylar process fractures by standardized clinical examination and evaluation of computer-simulated graphic presentations of posteroanterior (PA) radiographs of the mandible. Materials and Methods Eighty patients with unilateral condylar process fractures were included in this study. Fifty-four had been treated conservatively and 26 surgically by wire osteosynthesis via a submandibular approach. The age distribution of the patients in both groups is presented in Table 1. The radiographic examination included standard posteroanterior views of the mandible that were taken after trauma and 1 year or more after completion of the treatment (mean, 2.5 years). The radiographs were stored in the memory of an IBM-compatible personal computer (Sperry-It, Unysis) with the aid of a graphic tablet, using the Auto Cad (Autodesk) software. On the graphic presentations of these radiographs, the axis of individual symmetry, which is a curved line, as well as
Received from the Maxiliofacial Surgery Clinic, Faculty of Stomatology, University of Belgrade. * Junior Lecturer, Resident in Maxillofacial Surgery. t Associate Professor. Supported by a grant from the Republic Science Foundation of Serbia. Address correspondence and reprint requests to Dr KonstantinoviC: Stjepana RadiEa 19, 11040 Belgrade, Yugoslavia. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5004-0007$3.00/O
349
350
EVALUATION OF CONDYLAR PROCESS FRACTURES
Table 1. Age Distribution of Patients in Conservatively and Surgically Treated Groups No. of Conservative Treatment Patients (%)
No. of Surgical Treatment Patients (%)
21-30 31-40 241
4 (7.4) 8 (14.8) 22 (40.7) 7 (12.9) 13 (24.2)
0 (0.0) 1 (4.0) 13 (50.0) 6 (23.0) 6 (23.0)
Total
54 (100.0)
26 (100.0)
Age Group (yr) O-10
1l-20
reduction and postreduction radiographs. The difference between them was represented as the measurement error. Any difference of 4” or more was corrected by subtracting or adding the degree difference to the angle of the actually positioned, reduced condyle. The results of the radiographic examination were presented as the ratio of the difference of the angles between the actual axis and the axis of the ideally reduced condylar process and a horizontal line by using the formula
IRC - I IRC - ARCI IRC
x
1oo
_
ARC10/
)
0
the condylar axis, were determined. The axis of individual symmetry was determined by means of the adequate bone points of the both sides of the skull and maxilla (Fig 1). The fixed points were the following: Cg, the middle of the crista gali; SNA, spina nasalis anterior; Ls, the section of the external contour of the lateral side of orbit and the shadow of the external side of the ala major sphenoid bone; MS, the section of the medial contour of orbit and the shadow of medial surface of ala major sphenoid bone; Mx, the point on the most concave part of the contour of the lateral side of maxilla. The points Ls and Mx were connected by a straight line from the left and right; thus, the point Is was obtained by cutting. The bilateral points Mx and MS also determined two more straight lines, with the intersection at point Ax. By connecting the points Ax, Cg, SNA, and Is, which was done by the computer, the axis of individual symmetry was obtained. Then, the angles between the condylar axis and a horizontal line were measured: DC, dislocated position before treatment; IRC, ideally reduced position; and ARC, actual position of reduced condylar process. The horizontal line was determined as a normal to the vertical axis of the radiographs, namely to the straight line obtained by connecting the points Cg and SNA (Fig 1). The degree of dislocation (DC)(%), was presented as ratio of the difference of angles between the axis of the dislocated and ideally reduced position of condylar process and a horizontal line using the formula IRC-
[IRC-DC( IRC
X 100 = DC(%)
The ideally reduced condylar process (IRC) was determined in the following way. On the screen, a drawing of the proximal fragment was placed in the best vertical position and then the angulation was adjusted visually to mimic the anatomic continuity of the undamaged condyle. The angle between the axis of the nonfractured condyle and a horizontal line was measured on pre-
FIGURE 1. Diagram of measurements made. DC, Dislocated condyle (before treatment); IRC, ideally reduced condyle (done by the computer); NC, nonfractured condyle; cg, the middle of the ctista gali; sN,4,spina nasalis anterior, Ls, the section of the external contour of the lateral side of orbit and the shadow of the external side of the ala major sphenoid bone; MS, the section of the medial contour of orbit and the shadow of medial surface of ala major sphenoid bone; MX,the point on the most concave part of the contour of the lateral side of maxilla; and AX,cg, SNA, IS, axis of individual symmetry.
KONSTANTINOVIC
351
AND DIMITRIJEVIC
Maximal mouth opening and deviation of the chin were measured by clinical examination. The ratio between these two variables was calculated from the formula DEV X lOO-DI maximal opening and was called the deviation index (DI). Protrusive movements were classified as none, limited, and normal, and deviation during protrusion as yes or no. Complications during the treatment were also recorded. Results of both the radiographic and clinical examinations were evaluated using t test of proportions, Student’s t test, and Fisher’s exact test.
Table 3. Actual Degree of Reduction in Surgically and Conservatively Treated Groups
ARC %
No. of Surgical Treatment Patients (%)
No. of Conservative Treatment Patients (%)
81-100 61-80
Surg
1992
Surgical Versus Conservative Treatment of Unilateral Conciyiar Process Fractures: Clinical and Radiographic Evaluation of 80 Patients VITOMIR S. KONSTANTINOVle, DDS,* AND BRANISLAV DIMITRIJEVIC, DDS, PtiDt Treatment results of 26 surgically and 54 conservatively treated unilateral condylar process fractures were investigated by standardized clinical examination and by evaluation of computer-simulated graphic presentations of posteroanterior (PA) radiographs of the mandible. The radiographic evaluation compared the relation of actual reduction of the condylar process fractures with ideally reduced fractures produced on the computer. Using clinical parameters (maximal mouth opening, deviation, protrusion), no statistical differences between surgically and conservatively treated fractures were found. However, the radiographic examinations showed a statistically better position of the surgically reduced condylar process fractures.
The treatment of condylar process fractures is a problem because of the limited surgical access and difficulties in restoring function.’ The majority of investigators recommend conservative treatment and they report satisfactory results based on radiographic and clinical findings, especially when patients are in childhood and adolescence. 24 Surgical treatment is recommended in severe cases when the condyle is displaced out of the glenoid fossa.7-g However, there are certain cases that cannot be treated surgically (intracapsular, or so-called “high” condylar fractures). Evaluation of the success of the healing after treatment usually is done on the basis of standard radiographs of the mandible on which both qualitative and quantitative measurements are made.4,6,‘0 Quantitatively, evaluation usually means absolute symmetry of both condyles and their relation to the glenoid fossa, ie, registrations on the fractured side are compared with
the nonfractured side.4 Clinical evaluation (maximal mouth opening, deviation, movements on protrusion) has also been done.2,3*5,1 ’ Despite these numerous studies, however, the real indication for surgical treatment of these fractures is still debated. The aim of this study was to evaluate the results of both surgically and conservatively treated condylar process fractures by standardized clinical examination and evaluation of computer-simulated graphic presentations of posteroanterior (PA) radiographs of the mandible. Materials and Methods Eighty patients with unilateral condylar process fractures were included in this study. Fifty-four had been treated conservatively and 26 surgically by wire osteosynthesis via a submandibular approach. The age distribution of the patients in both groups is presented in Table 1. The radiographic examination included standard posteroanterior views of the mandible that were taken after trauma and 1 year or more after completion of the treatment (mean, 2.5 years). The radiographs were stored in the memory of an IBM-compatible personal computer (Sperry-It, Unysis) with the aid of a graphic tablet, using the Auto Cad (Autodesk) software. On the graphic presentations of these radiographs, the axis of individual symmetry, which is a curved line, as well as
Received from the Maxiliofacial Surgery Clinic, Faculty of Stomatology, University of Belgrade. * Junior Lecturer, Resident in Maxillofacial Surgery. t Associate Professor. Supported by a grant from the Republic Science Foundation of Serbia. Address correspondence and reprint requests to Dr KonstantinoviC: Stjepana RadiEa 19, 11040 Belgrade, Yugoslavia. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5004-0007$3.00/O
349
350
EVALUATION OF CONDYLAR PROCESS FRACTURES
Table 1. Age Distribution of Patients in Conservatively and Surgically Treated Groups No. of Conservative Treatment Patients (%)
No. of Surgical Treatment Patients (%)
21-30 31-40 241
4 (7.4) 8 (14.8) 22 (40.7) 7 (12.9) 13 (24.2)
0 (0.0) 1 (4.0) 13 (50.0) 6 (23.0) 6 (23.0)
Total
54 (100.0)
26 (100.0)
Age Group (yr) O-10
1l-20
reduction and postreduction radiographs. The difference between them was represented as the measurement error. Any difference of 4” or more was corrected by subtracting or adding the degree difference to the angle of the actually positioned, reduced condyle. The results of the radiographic examination were presented as the ratio of the difference of the angles between the actual axis and the axis of the ideally reduced condylar process and a horizontal line by using the formula
IRC - I IRC - ARCI IRC
x
1oo
_
ARC10/
)
0
the condylar axis, were determined. The axis of individual symmetry was determined by means of the adequate bone points of the both sides of the skull and maxilla (Fig 1). The fixed points were the following: Cg, the middle of the crista gali; SNA, spina nasalis anterior; Ls, the section of the external contour of the lateral side of orbit and the shadow of the external side of the ala major sphenoid bone; MS, the section of the medial contour of orbit and the shadow of medial surface of ala major sphenoid bone; Mx, the point on the most concave part of the contour of the lateral side of maxilla. The points Ls and Mx were connected by a straight line from the left and right; thus, the point Is was obtained by cutting. The bilateral points Mx and MS also determined two more straight lines, with the intersection at point Ax. By connecting the points Ax, Cg, SNA, and Is, which was done by the computer, the axis of individual symmetry was obtained. Then, the angles between the condylar axis and a horizontal line were measured: DC, dislocated position before treatment; IRC, ideally reduced position; and ARC, actual position of reduced condylar process. The horizontal line was determined as a normal to the vertical axis of the radiographs, namely to the straight line obtained by connecting the points Cg and SNA (Fig 1). The degree of dislocation (DC)(%), was presented as ratio of the difference of angles between the axis of the dislocated and ideally reduced position of condylar process and a horizontal line using the formula IRC-
[IRC-DC( IRC
X 100 = DC(%)
The ideally reduced condylar process (IRC) was determined in the following way. On the screen, a drawing of the proximal fragment was placed in the best vertical position and then the angulation was adjusted visually to mimic the anatomic continuity of the undamaged condyle. The angle between the axis of the nonfractured condyle and a horizontal line was measured on pre-
FIGURE 1. Diagram of measurements made. DC, Dislocated condyle (before treatment); IRC, ideally reduced condyle (done by the computer); NC, nonfractured condyle; cg, the middle of the ctista gali; sN,4,spina nasalis anterior, Ls, the section of the external contour of the lateral side of orbit and the shadow of the external side of the ala major sphenoid bone; MS, the section of the medial contour of orbit and the shadow of medial surface of ala major sphenoid bone; MX,the point on the most concave part of the contour of the lateral side of maxilla; and AX,cg, SNA, IS, axis of individual symmetry.
KONSTANTINOVIC
351
AND DIMITRIJEVIC
Maximal mouth opening and deviation of the chin were measured by clinical examination. The ratio between these two variables was calculated from the formula DEV X lOO-DI maximal opening and was called the deviation index (DI). Protrusive movements were classified as none, limited, and normal, and deviation during protrusion as yes or no. Complications during the treatment were also recorded. Results of both the radiographic and clinical examinations were evaluated using t test of proportions, Student’s t test, and Fisher’s exact test.
Table 3. Actual Degree of Reduction in Surgically and Conservatively Treated Groups
ARC %
No. of Surgical Treatment Patients (%)
No. of Conservative Treatment Patients (%)
81-100 61-80
