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Clinical Paper
Trauma
fracture in children
J. Choi, N. Oh, I.-K. Kim: A follow-up study of condyle fracture in children. Int. J. Oral
Maxillofac. Surg. 2005; 34: 851–858. # 2005 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Although the mandibular condyle is one of Managing condylar fractures in children condylar fractures in children has been
the most common sites of injury to the continues to be a subject of debate. It has non-surgical with a reestablishment of
facial skeleton, it is also the most over- been suggested that these fractures may the normal occlusion with or without max-
looked and least diagnosed trauma site in create serious problems if not properly illomandibular fixation (MMF) followed
the head and neck region. In particular, managed, for example, growth distur- by physiotherapy12. In conservative treat-
mandibular fractures in children differ bances of the face on the injured side ment, the functional rehabilitation relies
greatly from mandibular fractures in and temporomandibular joint disorders on the remodeling capacity of the joint.
adults because of the incomplete dentition on both the injured and non-injured side. This is particularly the case in children,
and the growth of the mandible3. The usually recommended treatment of because the condyle is a remodeling center
0901-5027/080851+08 $30.00/0 # 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
852 Choi et al.
that responds to changes in the relation- of the other part of mandible. The follow-up angle was made. The ramus height was
ship of its surrounding structure during period ranged from 1 to 6 years with a mean measured as the distance from the gonion
development in an adoptive manner, follow-up of 3.27 years. to a line drawn tangentially to the top of
thereby maintaining the normal integrity All condylar fractures were treated non- the condyle (Fig. 1). The differences in the
of the joint during growth2. surgically. A short period (2–10 days) of length of the ascending ramus were then
Several investigators have reported the intermaxillary fixation was used where measured.
treatment results of condylar fractures in there was excessive pain and/or persistent On the cephalogram, lateral projections
children. It appears from these studies that malocclusion. When present, fractures of were performed to assess the growth and
satisfactory treatment results have been the mandibular body were treated with an development of the jaws and the angles
observed following condylar fractures in acrylic splint or rigid internal fixation SNA, SNB and ANB measured. Frontal
children1,6,16. However, some patients depending on the patient’s age and the projections were also used to assess the
show altered growth of the mandible. displacement of the fracture. facial asymmetry (Fig. 2).
PROFFIT et al.13 reported that out of 121 Fractures were classified as being uni- A CT examination of the condyle was
patients with severe mandibular asymme- lateral or bilateral, and the following three performed at the Department of Diagnos-
try, 5–10% probably were caused by con- levels of the fracture line location were tic radiology, Inha University Hospital
dylar fractures. The sequelae to condylar distinguished: condylar head or intra-cap- (Inchon, Korea) with a high-speed advan-
fractures includes ankylosis. In an analysis sular fractures, high condylar fractures tage (General Electrics, USA). Patients
of 44 cases of ankylosis of the temporo- and low condylar neck fractures. were placed in the supine position. The
mandibular joint, TOPAZIAN19 reported 17 The clinical examination was primarily head position was stabilized by elastic
cases correlating with a previous trauma to aimed at detecting possible joint disorders attachments and the scans was recorded
the joint. or growth disturbances. Both TMJs were with the teeth in habitual occlusion. Spiral
The aim of this study was to examine assessed with regard to pain, clicking, CT scanning was performed with a
the long-term clinical and radiological locking and crepitus. The maximum 170 mA scan electric current and a
results of non-surgically treated condylar mouth opening and deviation from the 3 mm slice thickness. 3-D reconstructions
fractures in children. Therefore, the long- midline during mouth opening were were obtained using Virtual work 4.0 soft-
term effects conservative therapy in treat- recorded. Excursions in the horizontal ware (3-D analysis software) in various
ing condylar fractures in children were plane were also measured. projections. According to the TMJ struc-
analyzed in order to resolve the contro- The facial asymmetry and dental mid- ture revealed by 3-D CT, the TMJ mor-
versial question ‘does complete remodel- line deviation were documented in the phometry (size, condylar angle, position)
ing occurs at this age or, if not, is it more case of a unilateral fracture. In bilateral was determined by the linear and angular
likely to be associated with certain types cases, the anterior–posterior position of measurements (Fig. 3).
of fractures or other factors?’ The study the mandible and sagittal and vertical open
also evaluated whether or not the treat- bite as well as the facial asymmetry was
ment results were satisfactory. recorded.
Panoramic radiographs were taken dur- Results
ing the follow-up period 4, 12, 24, and 48
Materials and methods Unilateral condylar fractures
weeks after the trauma. At the follow-up,
This study was based on a series of 11 each patient had a panoramic radiograph, Eight patients had unilateral fractures (five
consecutive children and adolescents, aged frontal and lateral cephalogram and three- boys, three girls: mean age 8.1 years,
between 3 and 15 years, with fractures of dimensional CT taken. range 3–15 years), five on the left side
the condylar process who had previously On the orthopantomogram, the shape of and three on the right. Of the five condylar
been treated non-surgically. Table 1 shows the condyle was compared with that on the neck fractures, three were classified as
the data from the 11 patients with 14 frac- non-fractured side. In the cases of bilateral being high condylar fractures and two as
tured condyles. Patients with isolated con- fracture, it was judged as being normal or being low. Three fractures were consid-
dylar fractures as well as patients with having persistent signs of an earlier frac- ered to be intra-capsular fractures
additional mandibular fractures were ture. A tracing of the condylar head and (Table 1). Of these patients, five had addi-
included. Seven of 11 patients had fractures neck, the ascending ramus and mandibular tional fractures of the mandible; three had
Table 1. Patients with respect to age, sex and type of condylar fracture
Number Sex Age Fx. side Type of Fx. F/U time IMF (days)
1 M 15 years 2 months Lt Condyle head 4 years 10 months 4
2 M 14 years 8 months Both Rt; condyle head 4 years 6 months 3
Lt; condyle head
3 F 13 years Lt High condyle neck 2 years 7 months 10
4 M 11 years 1 month Lt High condyle neck 1 years 9 months 3
5 F 11 years Both Rt; High condyle neck 4 years 1 month 0
Lt; High condyle neck
6 M 7 years 3 months Lt Low condyle neck 2 years 10 months 0
7 F 6 years 11 months Both Rt; Intra-capsular 3 years 11 months 7
Lt; High condyle neck
8 M 6 years Lt High condyle neck 3 years 1 month 0
9 M 4 years 10 months Lt Intra-capsular 1 years 5 months 0
10 F 3 years 7 months Rt Intra-capsular 1 years 7 months 0
11 F 3 years 3 months Rt Low condyle neck 5 years 10 months 2
A follow-up study of condyle fracture in children 853
Fig. 1. Measurement of ramus height. Con: the most superior point of the condyle; Cor: the most superior point of the coronoid process; Inc: the
most inferior point of the mandibular notch; C: the intersection of the RL and a perpendicular line from Con; I: the intersection of the RL and a
perpendicular line from Inc; G: the intersection of the RL and ML; RL: a tangent line of the mandibular ramus; and ML: a tangent line of the
mandibular body.
a fracture in the symphysis and two in the The mean maximum mouth opening lity in the three types of fractures was
parasymphysis region. was 48.62 mm (range 33–58) in two similar.
The mean follow-up period was 2 years patients with a slight deviation to the A chin point deviation in the centric
and 11 months, range 1.5–5.8 years and fractured side. The mean maximum pro- occlusion to the fracture side was observed
the mean age at follow-up was 11 years. trusive movement was 7.88 mm, and the in one patient and the non-injured side in
There were no complaints of pain or sub- mean maximum laterotrusive movement one. A midline deviation in the dentition
jective restriction of mouth opening. One to the side of fracture and to the contra- to the injured side was registered in one
patient recorded TMJ clicking. No patient lateral side was 7.80 mm (range 5.3–12) patient and to the non-injured side in one
reported tenderness upon palpation of the and 8.32 mm (range 5.9–11), respec- case. There was no clear relationship with
joint area. tively (Table 2). The degree of jaw mobi- the type of fracture (Table 3).
Table 2. Mean values (mm) and standard deviations for mandibular mobility One patient had high condylar fractures
Unilateral Bilateral on both sides. In the other two patients, an
fracture (N = 8) fracture (N = 3) intracapsular fracture on one side was
Maximal opening 48.62 (8.87) 45.0 (2.12) combined with a low and high condylar
neck fracture on the other side, respec-
Lateral excursion tively. Two patients had associated frac-
Right 7.80 (2.46) 9.67 (0.58) ture of the symphysis.
Left 8.32 (2.27) 8.0 (1)
Protrusion 7.88 (2.85) 6.83 (0.29)
The mean follow-up period was 4.17
years (range 3.9–4.5 years) and the mean
age at the follow-up was 14.69 years
(range 10.8–18.2). There were no com-
Table 3. Clinical evaluation of TMJ and growth disturbance plaints of pain or restriction in mouth
Clinical findings Unilateral Bilateral opening. One patient reported TMJ click-
fracture (N = 8) fracture (N = 3) ing, and another reported tenderness upon
Deviation of Mn. midline in C.O 2 (25%) 0 palpation of the joint area (Table 3).
Deviation of midline during M.O 2 (25%) 1 The mean maximum mouth opening
Noises in joint 1 (12.5%) 0 was 45 mm, and deviation from the mid-
TMJ pain during mouth opening 0 0 line was observed in one patient. The
TMJ pain during palpation 0 1 mean maximal protrusive movement
Malocclusion 2 (25%) 2 was 6.83 mm and the mean maximal later-
Facial asymmetry 2 (25%) 1 otrusive movement to both sides was
9.67 mm on the right side, and 8.0 mm
on the left (Table 2).
Table 4. Difference in ramal height among patients with unilateral condylar fractures Complete clinical recovery was
Degree of difference in ramal height observed in all bilateral cases. Signs of
facial asymmetry were observed in one
Fracture type N None Mild Severe
case and slight retrognathia with a class II
Low condylar neck 2 1 1 0 malocclusion were noted in two patients.
High condylar neck 3 1 2 0 However, there was no open-bite. In one
Intracapsular 3 1 2 0
patient, a small midline deviation of the
Total 8 3 5 0 dentition was present.
None; 0–2 mm mild; 2–4 mm severe; >4 mm. In two patients, a restoration of the
normal shape of the condyle was achieved.
However, in one patient, a shortening of
Complete clinical and functional recov- of the articular eminence was noted in four 3 mm on the right side was observed
ery was observed in all patients, while a joints (50%) (Table 5). (Fig. 5)
slight facial asymmetry remained in two Six out of eight patients (75%) showed The 3-D reconstruction of the one
patients. Two patients showed malocclu- no facial asymmetry. In two patients, a patient showed a deformed and hyperplas-
sion and one patient had orthodontic treat- slight facial asymmetry remained, which tic condyle. The remodeled condylar head
ment. was of no concern to the patient. was located more anteriorly than on the
On orthopantomogram, the non-surgi- contralateral side. The condyle was dis-
cal treatment resulted in a healing process located moderately anteriorly and some
Bilateral condylar fractures
leading to a normal condyle and condylar asymmetry was noted (Fig. 5). The other
neck. This favorable healing process Only three patients sustained bilateral con- two cases showed an almost normal TMJ
occurred in 5 (63%) of the patients. In dylar fractures (one boy, two girls; mean structure, except for a slight flattening of
37%, the restoration of the condyle to a age 10.86 years, range 6.9–14.7 years). the temporal bone.
normal form had not occurred completely
(Fig. 4). However, this had no functional
or aesthetic consequences. A difference in Table 5. Radiographic findings on 3-D CT scans in 9 patients with 12 fractured condyles
length between the fractured and contral-
ateral ascending ramus was observed in Frequency Percentage
five patients (63%; Table 4). Shape
The frequency of the abnormalities Ellipsoid 3 25.0
determined by CT analysis is summarized Concavo-convex 7 58.3
in Table 5. The shape of the fractured Ovoid 1 8.3
Other 1 8.3
condyles varied: three were ellipsoid, seven
were concavoconvex and one case was Alteration in shape
ovoid. The remaining patient had variable Deformed 2 25.0
shapes. Differences in the condylar angles Hypoplastic 3 37.5
of the fractured and non-fractured sides, Hyperplastic 3 37.5
which indicated a deviation of the condylar Cortical irregularity 8 67
axis, were noted in four patients. Three Condylar angle compared with the normal side (n = 8) 4 50
(37.5%) condylar heads were displaced Condyle position 3 25
anterior to the glenoid fossa. Flattening Flattening of glenoid fossa and articular eminence 4 50
A follow-up study of condyle fracture in children 855
Fig. 5. TMJ images of a 15-year-old female who sustained a dislocated high condyle neck fracture of the right and displaced high condyle neck
fracture of the left at the age of 11. (A) Coronal CT image and (B) panoramic radiograph show bilateral fracture immediately after trauma. (C)
Severe deformity of the right condyle after follow-up period of 4 years in same patient. (D and E) 3-D reconstruction of right and left TMJ viewed
from infero-lateral aspect; the right is hypoplastic and deformed.
A follow-up study of condyle fracture in children 857
teria, the clinical results of this study are their problems and associate fracture of the position after fractures as well as in
favorable and satisfactory. the mandible. diagnosis. Computed tomography (CT)
MCGUIRT11 reported that 13 out of the Ankylosis of the TMJ is an extremely offers the possibility of examining the
28 (46%) subjects reported TMJ popping rare and a serious complication of a con- state of the TMJ without a superimposition
noises, and 5 of these 13 complained of dylar fracture but there was no ankylosis of the adjacent structures. Recent devel-
discomfort when they yawned or opened noted in this series opments in CT technology have enabled
their mouths widely. HOVINGA et al.6 stated Regarding the relationship between age excellent 2-D and 3-D reformatted images
that TMJ function was undisturbed in all and the remodeling capacity, DAHLSTRÖM in different anatomic planes to allow a
of his patients. STROBL et al.16, GUVEN & et al.2 reported that almost twice as many detailed examination. From this study,
KESKIN5, and THOMPSON et al.17 reported subjects in the oldest group experienced 3-D CT imaging appears to be a valuable
that the symptoms and signs of a dysfunc- symptoms of dysfunction. In 1997, DIMI- diagnostic aid in cases of condyle fractures
3
tion were very slight. In this study, click- TROULIS reported that a favorable outcome where severe morphological changes were
ing of the joint was observed in one case was most likely to occur in patients under not recognized in earlier conventional X-
with unilateral fracture and TMJ tender- 10 years of age where the remodeling ray examinations. It was possible to eval-
ness to palpation existed in another case potential was greatest, and in some post- uate both quantitatively and qualitatively
with a bilateral fracture, which is consis- pubertal adolescents, dysplastic growth the effects of treatment on the condyle size
tent with the long-term findings of the might occur, whereby the growth of the and shape, sclerosis and cortical irregula-
TMJ function from other authors. mandible may become progressively rities, condylar and intercondylar angle,
Numerous reports on mandibular asymmetrical as a result of a reduced joint position, neck length, depth of gle-
growth following pediatric condylar frac- growth and remodeling potential on the noid fossa, and flattening of the articular
ture suggest that non-surgical manage- side of the fractured mandibular condyle. eminence. A similar view was expressed
ment produces satisfactory results. ROWE14 stated that injuries inflicted before by SAHM & WITT15 and KAHL et al.7.
LUND10 reported six patients (22%) 3 years of age will produce a severe In 1995, using 3-D CT, KAHL et al.7
showed evidence of retarded growth on asymmetric deformity; those inflicted reported that 11 patients with 13 different
the fractured side. GILHUUS-MOE4 found a after 6 years of age, a moderate deformity; types of condyle fractures showed a
deviation of the mandible toward the frac- and those after 12 years of age, only slight restoration of the normal function with a
tured side in 14 out of 43 patients with deformity. LINDAHL & HOLLENDER9 com- favorable remodeling and the remaining
unilateral fractures (33%). He also pared the process of remodeling the con- eight patients had only a good function
reported an overgrowth of the fractured dylar after a fracture in children and with a deformed condyle and significant
condyle. HOVINGA et al.6 stated that a adults, and reported that between 3 and asymmetry in the condylar angle and
considerable growth disturbance was 11 years of age, extensive remodeling of length of the condylar neck. From the
observed in two patients in their study. the condylar fractures generally resulted in results of this study, 25% of the patients
THOMPSON et al.17 identified seven class II a normal anatomy. NORHOLT et al.12 also showed a change in the condyle position,
malocclusion and one open bite in 23 found that younger children had fewer 50% had asymmetric condylar angles and
cases. From this study, there were two long-term problems from their injuries eight condyles showed abnormal shapes.
patients with unilateral fractures who than their older counterparts. It was not Despite the apparent excellent functional
had a malocclusion and somewhat facial possible to demonstrate any correlation recovery, there was marked remodeling
asymmetry. Two out of three bilateral between the age and the remodeling capa- changes evident on the CT scan. Such
condylar fractures had a slight malocclu- city in this study. In general, a tendency changes were not usually evident on the
sion and one patient showed facial asym- toward an increasing possibility of dys- panoramic radiograph.
metry. The results might show that a plastic growth with increasing age at the Several examples of a bifid condyle
growth disturbance was more frequent time of trauma was noted. were reported in the literature11,12. Many
when associated with bilateral condylar In the past, a morphologic evaluation authors, such as LUND10 and LINDAHL &
fractures. This is in accordance with the has been based primarily on the panoramic HOLLENDER9, suggested it to be caused by
results reported by THOMPSON et al.17. radiographic film. In this study, on the an insufficient remodeling capacity or by
HOVINGA et al.6 reported that 54.5% of orthopantomogram, the ramus height an abnormal growth generated by the
the unilateral and 83.3% of the bilateral was measured and the shape of the con- position of the articular disc. In this series,
fractures did not show any growth distur- dyle was compared with that on the non- one patient, who sustained bilateral con-
bance. They showed that low condylar and fractured side. Bilateral fractures were dyle fractures, showed bony exostosis of
intracapsular fractures gave rise to the judged as either being normal or having the condyle head (Fig. 5).
largest number of facial asymmetries. This persistent signs of the earlier fracture. The remodeling process after a condylar
study was unable to show any correlation Using panoramic radiographs, GUVEN & fracture is not limited to the condyles but
between the type of condyle fracture and KESKIN5 reported that the remodeling of also involves a flattening of the mandib-
the growth disturbance, which will be the condyle head was good in 17, while ular fossa. This was histologically demon-
examined in a further investigation. moderate remodeling occurred in the other strated proved by GILHUUS-MOE4 using
In this study, of five patients with facial four condyles. Three out of eight unilateral animal experiments. Similar observations
asymmetry or malocclusion, four patients condyle fracture patients did not show any were reported by THOMPSON et al.17, LIN-
9 15
had additional fracture of mandible. difference in the ramus height in this DAHL & HOLLENDER and SAHM & WITT in
Nearly all the patients with facial asym- study, five patients showed mild differ- their studies of condylar fracture in chil-
metry or malocclusion had other fracture ences (4 mm) in the ramus height and dren. There were four cases of a slight
of the mandible, which might be another none of these patients showed severe dif- glenoid flattening in this study. In cases
factor that contribute to these problems. ference (4 mm). where there was a significant difference in
Because of relatively small size of our Nowadays, CT scanning plays a key the ramus height with a consequent resorp-
study population, we were unable to relate role in assessing the condylar state and tion of the proximal segment, the facial
858 Choi et al.
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