Management of posttraumatic malocclusion caused by condylar process fractures

PURPOSE: The aim of the study was to evaluate the results of orthognathic surgery in cases with posttraumatic malocclusion as a long-term complication of condylar process fractures. PATIENTS AND METHODS: A retrospective study on 21 patients with posttraumatic malocclusions attributable to condylar process fractures was performed. In group I, 15 patients were treated for asymmetric malocclusion with unilateral or bilateral mandibular ramus osteotomies. In group II, six patients were treated for anterior open bit with either a Le Fort I osteotomy (n=5) or a bilateral ramus osteotomy (n=1). All patients had clinical and radiographic follow-up for at least 1 year. RESULTS: Stable dental and cephalometric results were obtained in all patients except the one in group II who was treated with bilateral sagittal split osteotomies. In two cases, both in the asymmetric group, minor occlusal interferences had to be treated by equilibration in the early postoperative period. CONCLUSIONS: Orthognathic surgery is a predictable and stable method for the treatment of posttraumatic malocclusion due to condylar process fractures. Maxillary orthognathic surgery is successful in correcting symmetric anterior open bites due to bilateral condylar process fractures. Because posttraumatic malocclusion is a rare complication after closed treatment of condylar process fractures, and it can be treated satisfactorily using orthognathic surgery, routine open reduction and fixation of condylar process fractures is not indicated to prevent posttraumatic malocclusion.     

Longitudinal fractures of the condyles of the third metacarpal and metatarsal bones in racehorses: 224 cases (1986-1995)

OBJECTIVE: To determine type, distribution, and radiographic appearance of condylar fractures of the third metacarpal bone (MC-3) or third metatarsal bone (MT-3) in Thoroughbreds (TB), Standardbreds (SB), and Arabians, to assess long-term outcome of horses in which fractures were repaired surgically, and to identify variables associated with prognosis for return to racing. DESIGN: Retrospective study. ANIMALS: 224 horses with 233 fractures. PROCEDURE: Medical records and radiographs obtained before and after treatment were reviewed. Racing performance before and after treatment was determined by reviewing race records. RESULTS: TB were overrepresented and SB were underrepresented, compared with the hospital population. Thoroughbreds had significantly more lateral condylar fractures and significantly more forelimb fractures than did SB. Thoroughbreds were less likely to race after treatment if they had complete, rather than incomplete, lateral condylar fracture or had concurrent proximal sesamoid bone fracture. Convalescent time for TB with medial condylar fractures of MT-3 was significantly longer than that for TB with lateral condylar fractures of MT-3. CLINICAL IMPLICATIONS: Horses with condylar fractures of MC-3 and MT-3 that had minimal pathologic changes in the involved joint had a favorable prognosis for returning to racing after surgical treatment. Prognosis for horses with complete condylar fractures, particularly those with substantial pathologic changes in the involved joint, was worse.     

Endoscope-assisted fixation of mandibular condylar process fractures

PURPOSE: Reduction and plate osteosynthesis of condylar fractures often require a wide extraoral approach with the risk of aesthetic impairment and possible facial nerve palsy. To avoid complications, the purpose of this pilot study was to use an endoscopic device for the treatment of condylar fractures also allowing for endoscopically assisted plate application. PATIENTS AND METHODS: Seven condylar fractures were operated under endoscopic control. In three patients, a newly developed device for endoscopically controlled plate application was clinically tested. The new device and the application technique is described in detail. RESULTS: In two of three cases using this approach, fracture healing was achieved with the condyle in the anatomically correct position. In the third case the plate had to be removed early because of insufficient screw fixation. CONCLUSION: This technique may be helpful to further minimize surgical trauma in head and neck fracture treatment. The newly developed plate application device may also be used to approach other regions of the skull eg, the skull base, the zygoma, or the orbit.     

Outcomes of macrosomic infants in a nurse-midwifery service

Pseudoarthrosis and cubitus valgus as main complications following displaced fractures of the radial condyle in children can be prevented by open reduction and fixation by K wires. However, delayed union and stimulation of the radial physis with condylar overgrowth and varisation of the elbow as well as fishtail deformities of the distal end of the humerus are reported nevertheless. To prevent those growth disturbances all primary and secondary (4-day X-ray control) displaced fractures of the radial condyle, i.e. those with a central gap of more than 2 mm, were prospectively treated by open reduction and osteosynthesis with a metaphyseal lag screw beginning 1974. Sixty-six patients (41 boys, 25 girls) with an average follow-up of 10 years (2-22 years) sustained 28 primary and 6 secondary displaced fractures. In 5 cases a K wire fixation was performed in view of the smallness of the fragment. Two children with conservative treatment following overlooked displaced fractures showed condylar overgrowth and varisation of the elbow. Screw osteosynthesis led to symmetric elbow angles and function in all cases, whereas fishtail deformities could be observed in 8 of 27 children, probably as a consequence of the remaining central fracture instability. CONCLUSION: Open reduction and osteosynthesis with a metaphyseal lag screw prevents condylar overgrowth in displaced fractures of the radial condyle by guaranteeing fracture healing in anatomic position within 3-4 weeks. However, fishtail deformity can not be prevented by metaphyseal compression only.     

Use of activator appliances in pediatric patients treated with costochondral grafts for temporomandibular joint ankylosis: analysis of 13 cases

PURPOSE: The long-term outcomes and clinical results of costochondral transplants used for the treatment of condylar ankylosis of the mandible in children with and without application of postoperative activator appliances are evaluated and compared. MATERIALS AND METHODS: A nonrandomized, retrospective clinical study of 13 cases of condylar ankylosis (16 joints) of the mandible surgically treated during a 9-year period from 1988 to 1997 was performed. All 13 patients were treated by condylectomy and immediate costochondral rib grafts. Nine of these patients underwent long-term postoperative therapy using removable activator appliances. Four patients did not undergo activator therapy postoperatively. Casts, radiographs, photographs, computed tomography (CT) scans, magnetic resonance imaging (MRI) and 99Tc bone scans were used postsurgically to evaluate graft take, condylar growth and function, occlusion, and facial and condylar symmetry. RESULTS:The postoperative and long-term clinical results in both groups showed costochondral growth center transplants to be effective in restoring mandibular growth of the affected side. However, symmetry, arch coordination, correction of occlusal canting, mandibular deviation, facial growth, and prevention of reankylosis were obtained and better controlled only in those cases that underwent long-term orthodontic activator therapy postoperatively and were followed closely. CONCLUSIONS: Children with long-standing condylar ankylosis of the mandible and its resultant facial asymmetry and occlusal canting (secondary to a nonfunctional joint and maxillary compensation) treated with condylectomy and immediate costochondral rib graft reconstruction of the affected joint were treated more favorably when activators were used postsurgically. The patients that failed to comply with or continue activator therapy postsurgically developed complications relating to mandibular deviation, occlusal dysharmony, asymmetry and, in one case, reankylosis of the temporomandibular joint (TMJ).     

Condylar restoration after early TMJ fractures and functional appliance therapy. Part I: Remodelling

The aim of this study was to measure quantitatively and to analyze the process of condylar restoration during and after functional appliance therapy with an activator in children and juveniles who had sustained condylar fractures. Spiral computed measurement of condylar morphology was performed in order to quantify the association described in the literature between condylar remodelling and age as well as certain types of fracture. Nineteen patients with an average age of 13.4 years, who had sustained a functionally treated unilateral condylar fracture 4.9 years earlier on average, were included in the present study as the follow-up group. Twenty patients, who had sustained a unilateral fracture at an average age of 8.1 years and had been treated functionally for 6 to 8 months, formed the treatment group. The condylar dimension and the condylar neck length of the ipsilateral and of the contralateral temporomandibular joints were measured from the axial and parasagittal reconstructions and were compared on the basis of sex, age and fracture type. The mediolateral condylar dimension of the follow-up group showed a sex-specific difference of 0.2 cm on the contralateral side and 0.4 cm on the ipsilateral side. The fracture side condyle indicated a relative mediolateral decrease of 4.2% and an anteroposterior increase of 12.6%. Shortening of the condylar neck and excessive bony overgrowth were found to occur more often in fractures with displacement and in low fracture types. The "10-plus" subgroup at time of trauma showed a significantly greater variation and greater differences in mediolateral and anteroposterior condylar dimension than the younger patients.     

An epidemiological study of patterns of condylar fractures in children

OBJECTIVE: To find out how the site and type of condylar fracture are affected by its aetiology and the age and sex of the patient. DESIGN: Retrospective study. SETTING: Tertiary referral centre, Finland. MATERIAL: Radiographs of 101 children (aged 15 years or less) with 119 condylar fractures. MAIN OUTCOME MEASURES: Site of fracture and degree of displacement. RESULTS: A total of 26 of the 119 fractures were intracapsular (22%) and 93 (78%) extracapsular. Only among patients less than 6 years of age was there a preponderance of intracapsular fractures (7/12 fractures in 10 patients, 58%). In the older children 78% (83/107) were in the condylar neck. There were few subcondylar fractures (5/119, 4%). Only 6 fractures were displaced (5%). Dislocation of the condyle from the glenoid fossa was common in all age groups. CONCLUSION: The site of condylar fracture is age related, but not associated with sex or aetiology.     

The assessment of fracture of the mandibular condyle by use of computerized tomography. Incidence of sagittal split fracture

A survey was carried out to clarify the incidence of sagittal splitting fracture of the mandibular condyle using computerized tomography. There were 33 patients, between 11 and 67 years of age, with displaced or dislocated mandibular condylar process fractures (41 cases), seen at our clinic between 1986 and 1992. The incidence of no displacement was 4.9%; deviation and displacement, 34.1%; dislocation, 46.3%; and complete avulsion, 4.9%. A sagittal splitting fracture of condyle occurred with an incidence of 9.8%. Conservative treatment was effective in the treatment of sagittal splitting fracture. Therefore, classification of fracture of mandibular condyle should include the sagittal split fracture, and investigations should include computerized tomography.     

Condylar plate fixation of subtrochanteric femoral fractures

We describe our experiences in 40 consecutive patients with subtrochanteric fractures treated with an AO 95 degrees condylar blade plate. Three patients died early due to multiple injuries. One patient developed a delayed union which ultimately resulted in repeated plate fractures due to fatigue. All other fractures heated despite deep postoperative wound infection in three cases. Based on our favourable results, we consider the condylar blade plate fixation of subtrochanteric fractures to be an excellent method, especially if an image intensifier and/or fracture table are not available.     

Treatment of mandibular fractures with rigid osteosynthesis: using the AO system

PURPOSE: This study evaluated the results achieved in the surgical treatment of all mandibular fractures at two university centers using the 2.7 AO mandibular system. PATIENTS AND METHODS: A total of 227 patients presenting with 180 single fractures and 47 with double fractures (274 osteosyntheses) were included in this prospective study. RESULTS: During a mean follow-up of 27.5 months (minimum, 12 months), an overall complication rate of 7% was observed. No infection justified early removal of the osteosynthesis material. CONCLUSIONS: The systematic use of the technique recommended by AO for treating mandibular fractures, performed by thoroughly experienced operators on a compliant population, results in a low rate of complications and an early return to normal function.     

Treatment of condylar hyperplasia of the mandible using unilateral ramus osteotomies

PURPOSE: The long-term outcome of bilateral and unilateral ramus osteotomies used for the treatment of unilateral condylar hyperplasia of the mandible are evaluated and compared. MATERIALS AND METHODS: Thirteen cases of unilateral condylar hyperplasia of the mandible were surgically treated during a 10-year period from 1985 to 1995. Seven of the patients were treated by bilateral ramus osteotomies alone; six were treated by unilateral ramus osteotomies of the affected side. Unilateral ramus osteotomy was combined with a maxillary Le Fort I procedure in two of the six cases. Preoperative analysis of patients, indications for case selection, and postoperative results relating to facial symmetry, temporomandibular joint (TMJ) pain, occlusion, and stability were compared in the two groups. RESULTS: The postoperative findings and long-term results in both groups of patients were favorable. Symmetry, arch coordination, and occlusion remained stable. TMJ pain and dysfunction were invariably cured postoperatively. Unilateral ramus osteotomies alone, or in combination with maxillary surgery when deemed feasible and applicable by preoperative clinical analysis, was sufficient to restore symmetry and occlusion in dentally compensated cases. CONCLUSIONS: This study shows that patients with unilateral condylar hyperplasia of the mandible and deviation can be treated favorably by unilateral ramus osteotomy of the affected side; bilateral ramus osteotomy did not have any advantage in such cases. In addition, this procedure, combined with a Le Fort I osteotomy of the maxilla, was also effective in restoring occlusal canting and facial symmetry in dentally compensated cases. However, bilateral ramus osteotomy was required in prognathic cases and in cases in which a unilateral procedure would cause excessive rotation of the contralateral condyle.     

Open bite deformity in amelogenesis imperfecta. Part 2: Le Fort I osteotomies and treatment results

Functional conditions, skeletal and dento-alveolar stability and condylar changes in 15 patients with mandibular hypoplasia, anterior open bite (AOB) and amelogenesis imperfecta (AI), who had undergone a Le Fort I osteotomy, were analysed after a mean follow-up of 5 years. Two patients underwent a one-piece Le Fort I intrusion osteotomy and 13 patients a multi-segment Le Fort I osteotomy. In three of these patients, an additional bilateral sagittal split osteotomy was performed. Thirteen patients underwent a genioplasty. Surgery was followed by prosthetic rehabilitation in 10 patients. Skeletal and dento-alveolar stability were analysed on lateral cephalometric radiographs and condylar changes on orthopantomographic radiographs. Transverse stability of the dental arches was analysed on dental casts. The treatment results in this group were compared with patients with similar skeletal features but without amelogenesis imperfecta. The harmony of the long faces was restored and a reasonable vertical stability of the maxilla was achieved, however, a slight open bite and tongue interposition was still present. The transverse stability of dental arches (60%) was disappointing. Rigid internal fixation produced better transverse stability. Progressive condylar resorption was seen in two patients (13%). Less occlusal stability could be achieved in patients with AI, but resulted neither in less skeletal stability nor in more susceptibility to morphological condylar changes.     

Therapeutic management in trochanteric fractures

The authors present the management of trochanteric fractures based on 343 fractures treated in Department of Orthopaedics and Trauma in Clinical Hospital of Emergencies of Ia?i for 5 years. The non-operative treatment was used in 17.2% of cases and the conservative methods were plaster immobilization, continuous traction and early mobilization. The surgical treatment was used in 82.8% of cases. The reduction of the fractures was usually possible using closed methods. For fixation, the authors used four types of implants: the 135 degrees blade-plate in 9.2% of cases, the condylar blade plate in 44.7%, Ender nails in 45.4% and DHS in 0.6% of cases. The choice of one of this methods depends on the type of fracture, age of the patient and on his biological status.     

Interface pressure measurements of support surfaces with subjects in the supine and 45-degree Fowler positions

The results of treatment of 35 intraarticular distal fractures of the femur are presented. Treatment was performed in 8 cases with a condylar plate, in 8 cases with dynamic compression screw (DCS), in 2 cases with two plates, in 9 cases with screws only, and eight times the fracture was treated with a combination of lag screws and locking nail. Examination took place at an average of 45.5 months after the accident. 19 patients had an isolated fracture, 8 patients one accidental injury and 8 patients had more than one fracture or were polytraumatised. In 75% of the patients treatment lasted for between day 1 and 5. We found 17.1% open fractures and had to face infections in 5.7% (two cases). Bone healing occurred in all fractures, the reported infections could be overcome by early revision and the use of gentamycin-PMMA beds. It is remarkable that locking nails were successfully used in 8 cases of fractures with intraarticular component of the distal femur.     

Patellofemoral complications in symmetrical total knee arthroplasty

A review of 356 Kinemax (Howmedica, Inc, Rutherford, NJ) cemented posterior cruciate ligament-retaining condylar total knee arthroplasties employing a symmetrical femoral component articulating with a medially offset symmetrical dome patella component was carried out to examine the results and determine the incidence and nature of the patellofemoral complications. Follow-up was from 3 to 8 years, with a mean of 5.1 years. A review of patellofemoral complications in previously reported homogeneous series of symmetrical and asymmetrical implants is presented. Mean postoperative Knee Society scores improved to 91, function scores to 86, and Hospital of Special Surgery scores to 90 yielding 95% good and excellent results. Mean postoperative range of motion was -1.5 degrees extension to 113 degrees flexion. There were five patellofemoral complications (1.4%), including two symptomatic subluxations, two distal pole avulsion fractures, and one lateral facet fracture. There were two reoperations necessary for patellofemoral problems (0.56%), one to correct subluxation and one for excision of the fractured lateral facet. These rates are lower than those previously reported for asymmetrical implants as well as current and phased-out symmetrical designs of total knee arthroplasty in the intermediate term. This review suggests that cemented total knee arthroplasty with symmetrical patellofemoral resurfacing with an offset patella dome and posterior cruciate ligament retention yields low patellofemoral complications and reoperations. The symmetrical femoral component appears to be a satisfactory compromise of "normal" femoral anatomy, which decreases inventory and cost without adversely affecting patellofemoral function and complications.     

Indications for surgical treatment of tibial condyle fractures

The residual radioanatomic changes influencing the functional, subjective, and clinical outcome of 131 tibial condyle fractures were studied. Clinical function was found to deteriorate rapidly with increasing values of residual medial tilt of the tibial plateau, whereas lateral tilt of the plateau was well tolerated up to 5 degrees. Articular step-off up to 3 mm and condylar widening up to 5 mm had no adverse effects. Seventy percent of knees with moderate or severe instability were functionally unacceptable. It was concluded that a medial unicondylar fracture with any displacement, and all medially tilted bicondylar fractures, should be operated upon. In fracture of the lateral condyle, open reduction and internal fixation is indicated when lateral tilt or valgus malalignment exceeds 5 degrees, articular step-off exceeds 3 mm, or condylar widening exceeds 5 mm. The same limits apply to laterally tilted bicondylar fractures, provided that the medial condyle is undisplaced. Any displacement seen in the axial bicondylar fracture is an indication for surgical treatment. If there is any mediolateral instability in the extended knee joint after rigid internal fixation, repair of a collateral ligament should be considered. An avulsed anterior cruciate ligament should be fixed, if pathologic laxity exists, but the torn ligament can be ignored and reconstructed later if needed.     

Use of liver allografts from carbon monoxide poisoned cadaveric donors

Carbon monoxide (CO) inhalation leads to cerebral, cardiac, and, more rarely, liver damage. The use of liver allografts from CO poisoned donors with evidence of liver damage has not previously been reported. In this report we describe two recipients, both in fulminant hepatic failure, who received liver grafts from such donors. One donor had markedly abnormal liver function tests (LFTS), and in the other LFTS were mildly abnormal. In both, the liver appeared normal at procurement. There was satisfactory early function of both allografts, although marked patchy necrosis was seen on the postreperfusion biopsy (case 1), and on a 10 day postoperative biopsy (case 2). In both cases the changes were considered to be related to damage sustained from CO inhalation. Both allografts soon achieved normal function and both recipients are well. We conclude that CO poisoning can cause liver damage that can recover completely following liver transplantation.     

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The authors report 10 segmental fractures of the femoral head associated with a dislocation of the hip. Using PIPKIN's classification, they noted 1 type I, 7 type II and 2 type III fractures. The initial treatment of the hip dislocation was conservative in all cases. Failure of reduction was noted in 6 cases and was complicated by fracture of the femoral neck in 2 cases. The attitude regarding the head fragment was: conservative in 5 cases, the reduction was considered satisfactory in 4 cases and poor in 1 case; surgical in the other 5 cases: screw fixation in 1 case, excision of the fragment in 1 case and prosthetic replacement of the femoral head in 3 cases. After a mean follow-up of 5 years, functional results were satisfactory in the majority of cases. The radiological assessment showed malunion without osteoarthrosis in one case and avascular necrosis of the femoral head in three cases. The authors propose a treatment policy based upon their experience and a review of the literature.     

Use of rigid external fixation in fractures of the mandibular condyle

In this article the use of a rigid external fixation system is proposed for the early treatment of condylar fractures. This method offers the advantage of not damaging the articular structures during reduction and allows early mobilization for a rapid recovery. In our Centre 28 patients have been treated with the rigid external fixation system, with good functional results. Of these 15 men and 13 women, 22 had a monocondylar fracture and 6 had a bicondylar fracture. In all the cases there was complete recovery of the occlusal stituation and of the mouth opening; no patient surgically treated with this method has ever presented problems of a local or general nature. The purpose of this report was to evaluate the use of external fixation for the treatment of extracapsular condylar fractures with luxation of the fragment out of the glenoid cavity.     

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The defective bone resorption in the osteopetrotic op/op mouse brings about cranio-facial deformation and failure of tooth eruption. This study was conducted to elucidate the morphological changes of the condylar head and mandibular ramus in growing op/op mice. In normal mice, the condylar head is much broader than the ramus beneath it, enlargement and ossification of the condylar head begin after weaning, and the ramus becomes compact bone tissue. None of these changes were found in the op/op mice in the present observation. The condylar head was small, and its inner side was occupied by hypertrophic cartilage cells. In spite of the lack of bone resorption in op/op mice, the compaction of the mandibular ramus, which was composed of bone trabeculae, occurred later than that in normal mice. In view of recently studies reported evidence that local mechanical stress regulates the bone formation, we consider that undergrowth of the condylar head and the ramus in the op/op mouse results from not only a deficiency of osteoclasts but also insufficient mechanical stress from mastication.