Establishing a protocol for closed treatment of mandibular condyle fractures with dynamic elastic therapy
George N. Kamel, MD, Daniel Baghdasarian, Brandon De Ruiter, Avinoam Levin, Evan Mostafa, Edward H. Davidson, MD.
Albert Einstein College of Medicine, Montefiore Medical Center, NEW YORK, NY, USA.
Treatment of mandibular condyle fractures is controversial. Open treatment can achieve anatomic reduction with better bone healing and faster functional recovery but can jeopardize joint capsule circulation, resulting in bone resorption, and also risks facial nerve injury. Traditional closed treatment avoids these risks but involves discomfort of prolonged maxillomandibular fixation, possible resultant facial asymmetry, occlusal disturbance and increased incidence of ankylosis. Rather than wires, elastics have the potential to allow for customizable management of a healing fracture with the ability to alter vector and degree of traction to restore vertical height and occlusion whilst allowing for progressive return of function with less discomfort and decreased risk of ankylosis.
To determine the clinical efficacy of dynamic elastic therapy in closed treatment of mandibular condyle fractures.
Condylar fractures were treated with class II elastics ipsilateral and class I contralateral to fracture with sufficient vector to re-establish centric occlusion and midline congruency. Class III elastics were used contralaterally if required to establish this (more severe displaced/dislocated fractures) and class II elastics bilaterally for bilateral fractures. All 6oz 3/8-inch figure-of-8 elastics. Any extracondylar concomitant fractures underwent ORIF. Patients were followed frequently until fracture healing and arch bar removal (6 weeks or until resolution of tenderness in smokers) with sequential advancement from fixation (as placed in OR) to guiding (6oz 1/4-inch OR class maintained) to supportive (6oz 1/4-inch Class I) elastics with simultaneous sequential advancement of diet from liquid to blenderized to soft. Patients were advanced through the protocol by titrating to any dental midline incongruence and chin deviation on mouth opening. Occlusion, facial profile and temporomandibular dysfunction was also assessed at longer term follow up.
Five patients to date have been treated with this protocol and >6 months follow up. Mean age 29.2 (17-51). Fracture patterns included displaced and dislocated intracapsular and extracapsular fractures. Mean of 3 (2-5) postoperative visits and 53 days until arch bar removal. All patients had resolution of objective centric occlusion with no subjective malocclusion, chin deviation, facial asymmetry, nor TMJ symptoms at completion of treatment. 60% (n=3) advanced straight through the protocol and 40% (n=2) developed late subjective malocclusion salvaged with a return to a prior protocol phase without extending treatment course.
This preliminary data demonstrates a safe and efficacious protocol for closed treatment of mandibular condylar fractures with dynamic elastic therapy that may be superior to both open and traditional closed treatment methods.
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