J. Maxillofac. Oral Surg.

DOI 10.1007/s12663-014-0644-6

CLINICAL PAPER

Comparison Between Two Techniques for the Treatment

of Mandibular Subcondylar Fractures: Closed Treatment
Technique and Transoral Endoscopic-Assisted Open Reduction
Kazem S. Khiabani • Shahrokh Raisian •

Meghdad Khanian Mehmandoost

Received: 8 October 2013 / Accepted: 14 June 2014

Ó The Association of Oral and Maxillofacial Surgeons of India 2014

Abstract Keywords Mandibular subcondylar fracture

Purpose The endoscopic-assisted technique for the Endoscopic assissted reduction
Closed treatment
treatment of subcondylar fractures has been used success- techniques
fully and its acceptance develops as more surgeons gain
experience. We present the short term results of this
technique in a randomized prospective clinical trial. Introduction
Methods and Materials A total of 40 patients with man-
dibular subcondylar fracture were included in our study in The topic of condylar injury has generated a lot of discus-
two groups randomly. Patients of first group were treated by sion and controversy in the field of maxillofacial trauma
closed treatment technique and patients of second group by [1–4] and the treatment of subcondylar fracture is one of
transoral endoscopic-assisted open reduction. All patients these controversies. The existence of this controversy is
were followed for minimum of 12 weeks and occlusion, based on the positive and negative aspects of open tech-
Mandibular Anterior Opening (MAO), mandibular devia- niques and closed techniques [1]. Mandibular condylar
tion, and posterior ramal height were assessed. injuries are common among populations and their preva-
Results In the endoscopic group the MAO was signifi- lence in different societies have been reported between 9
cantly greater and mandibular deviation was lesser at 2nd and 45 percent based on different studies [5, 6]. By the
and 4th week of follow up. Posterior ramal height showed conventional open techniques (preauricular, retromandibu-
significant increase in the endoscopic group rather than lar, submandibular and endaural approaches) we can
closed treatment group. achieve an anatomic and favorable reduction, so function of
Conclusion The transoral endoscopic-assisted technique the TMJ can be rapidly achieved and better results con-
is a reliable and successful technique to address subc- cerning function have been reported [1]. By this technique,
ondylar fractures. The patients who were treated by this osteosynthesis is done and better bone to bone fusion is
technique showed better results in the fields of mandibular achieved but there is higher risk of complications such as
function and patient satisfaction and comfort, although it is facial nerve injury and presence of visible scar on the face.
time consuming and needs expensive instruments. Also, salivary fistulas have been reported [1, 6]. Closed
treatment technique is a more appropriate designation than
closed reduction, because in most cases no ‘‘reduction’’ of
the fracture is performed [7], (include intermaxillary fixa-
K. S. Khiabani (&)
S. Raisian
M. Khanian Mehmandoost
tion and elastic therapy) will not show aforementioned
Ahwaz Jundishapur University of Medical Sciences, Ahwaz,
Iran complications of open techniques, but since one cannot
e-mail: [email protected] achieve an anatomic reduction the function of the TMJ can
S. Raisian take longer time to improve and can be compromised.
e-mail: [email protected] Possible complications are shortening of the ascending
M. Khanian Mehmandoost mandibular ramus, open bite, malocclusion, decreased
e-mail: [email protected] Mandibular Anterior Opening (MAO), lateral deviation of

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the mandible during opening, avascular condylar necrosis

and so on [1–4]. Presently closed treatment is the most widely
used method even for treatment of dislocated condylar frac-
tures because experimental studies have shown that the
conservative method of treating these fractures is apparently
complication free and has satisfactory results [1, 3, 8].
Improvements in instrumentation, particularly endo-
scope techniques have made minimally invasive approa-
ches to the maxillofacial skeleton possible [2, 9, 10].
Endoscope has been used successfully for the treatment of
TMJ (arthroscopy), salivary glands disease and skull base
surgery since many years [11–13]. Transoral endoscopic-
assisted open reduction is used to cumulate advantages of
both open and closed techniques [14]. The advantages of
endoscope techniques are limited transoral incision, supe-
rior visibility for the surgeon, minimal risk of facial nerve
palsy and no need for dissection of the masseter muscle [4].
Despite these advantages, endoscope technique has not
become popular because of its steep learning curve, time
consumption and need for special instruments [1–4]. On
the other hand, lack of a prospective clinical trial with high
level of evidence forced us to design a study to compare the
results of subcondylar fractures treatment by two tech- Fig. 1 Preoperative orthopantomography to determine Go and Gln
niques: (1) closed treatment and (2) transoral endoscopic- points
assisted open reduction.
mandibular postero-anterior radiography before surgery.
We identified the highest point of the glenoid fossa on the
Materials and Methods side of fracture in panoramic radiography which was
named Gln. Then we drew tangents of the lower border and
The local ethics committee of the university approved the the distal border (ascending ramus) of the mandible. The
study design, and informed consent was obtained from all angle formed by these two lines was named external gonial
the patients. The patients with subcondylar fractures pre- angle. Then we drew the line of intersection of external
sented to the maxillofacial surgery department of Ahwaz gonial angle, and the point produced by reaching this line
Imam Khomeini hospital (from May 2011 to Aug 2012) to the mandibular angle region is Go (Fig. 1). The distance
randomly were included in two groups in this randomized between Gln and Go (posterior ramal height) was measured
controlled trial. All the following conditions were required to compare by follow up panoramic.
as inclusion criteria:
1. Displaced unilateral mandibular subcondylar fracture
Surgical Technique
2. Deranged occlusion
3. Females aged more than 15 years and males aged more
Closed treatment group The procedure was done under
than 16 years
general anesthesia and on the operating table. First we set
There were three exclusion criteria for our study: the Erich arch bars on the both jaw arches and if con-
comitant mandibular fractures other than subcondylar were
1. Patients with maxillary fracture
present, Open Reduction and Rigid Fixation of these
2. Angle fracture on the side of subcondylar fracture
fractures in the proper dental occlusion were performed
3. Absolute indication of open reduction
in the usual fashion by miniplates (using non compression
Each group consisted of 20 patients. The first group was 2.0 AO/ASIF miniplates—Synthes AG, Solothurn,
named closed treatment group and the second group was Switzerland).
named endoscopic group. Finally after achieving occlusion with manipulation, we
In all patients, subcondylar fracture and degree of dis- placed heavy elastic bands (3/16 inch–6.5 oz). After this
placement were assessed by orthopantomography and period, we changed the elastic bands to light type (3/16 inch–

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2.5 oz). Active physiotherapy was started at the end of 4th

week.
Endoscopic group Like in the previous group, we treated
the concomitant mandibular fractures first rigidly, and then
addressed the subcondylar fractures. A vertical incision
was made following the anterior border of the ascending
ramus of the mandible. The subperiosteal dissection was
performed widely at the lateral aspect of the ramus into
posterior border to allow for an optical cavity to be created.
Then we inserted the standard 30° endoscope (Karl
Storz, Tuttlingen, Germany) with a Xenon light source to
the optical cavity to evaluate the location of fractured
region, degree of segments overlap and so on (Fig. 2).
Then the fractured segments were reduced by pulling down
the distal segment and manipulation of condylar segment
and the adequacy of the reduction was judged by endo-
scope. We used a right-angled drill screw driver (Synthes
90° screw driver—Synthes company—Switzerland) for
fixation of the fracture line using miniplates (non com-
pression 2.0 AO/ASIF miniplates—Synthes company— Fig. 2 Evaluation of subcondylar fracture site by endoscope
Switzerland) with at least two holes and screws at either
sides of fracture line (Fig. 3). After the first plate insertion,
we checked stability of fragments and if it was incomplete,
then the second plate was inserted.
After operation, patients were placed on light elastic
bands (3/16 inch–2.5 oz) for 1 week and then mobilized
with physiotherapy exercises.
All patients (groups one and two) were followed up 1, 2,
4, 6 and 12 weeks postoperation.
At the follow up sessions we assessed dental occlusion,
MAO, mandibular deviation on opening and complications
of surgery (facial nerve weakness, and presence of infec-
tion). In order to assess the mandibular deviation we
measured deviation of the mandible from midline during
opening.
At the last follow up session (end of 12 weeks) we
assessed patients’ satisfaction and posterior ramal height
(Gln–Go distance). To address the patients’ satisfaction,
the patients were asked to give a subjective opinion of Fig. 3 Endoscopic evaluation of subcondylar fracture reduction and
treatment. In order to measure the postoperation Gln–Go fixation
indictor, we used the final panoramic X-ray performed at
the 12th week of follow up (Fig. 4).
The statistical evaluation of the findings was performed Data Related to Group One (Closed Treatment):
with the help of the SPSS (Statistical Package for Social (Table 1)
Sciences) software.
The mean age was 32.45 ± 12.03 (min = 17, max = 59)
years with 14 males (70 %) and 6 females (30 %).
The most concomitant fracture was contralateral para-
Results symphysis fracture (5 cases) (25 %), and 8 cases (40 %) had
isolated subcondylar fracture with no concomitant fracture.
A total of 40 patients with subcondylar fracture were At the last follow up session (end of 12 weeks), there were
included in two groups randomly and treated by closed 3 instances of disturbed occlusion (15 %) that were believed
treatment technique and endoscopic-assisted open reduction. to be minor and were tolerated by those patients easily. The

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Fig. 4 Postoperation panoramic x-ray

Table 1 Summary of the study samples in the closed reduction group and acquired results at the end of 12 weeks
Patient Sex/age Disturbed MAO Mandibular Gln–Go Gln–Go Gln–Go changes Concomitant fractures
number occlusion (mm) deviation (preop) (at the 12th from preop to
(mm) (mm) week) (mm) postop (mm)

1 M/23 – 40 6 61 62 1 –
2 M/26 ? 37 3 69 70 1 –
3 M/50 – 39 0 64 72 8 Bilal. Body
4 F/55 – 42 2 54 54 0 Contra. parasymphysis
5 F/39 – 42 0 50 53 3 Contra. Body
6 M/42 – 33 0 58 58 0 –
7 M/17 – 39 0 51 55 4 Contra. Parasymphysis
8 M/21 – 43 3 45 46 1 Ipsi. parasymphysis
9 M/31 ? 25 0 51 55 4 Contra. body and parasymphysis
10 F/24 – 41 4 59 60 1 –
11 F/33 – 37 0 68 68 0 –
12 M/26 – 41 0 78 78 0 –
13 M/29 – 39 0 58 59 1 Contra. Angle
14 M/59 – 40 0 72 72 0 Ipsi. Body
15 M/23 ? 35 0 60 60 0 Bilat. Body
16 M/21 – 39 0 62 63 1 Contra. Body
17 M/36 – 37 0 64 64 0 Contra. parasymphysis
18 F/36 – 46 0 59 60 1 Contra. parasymphysis
19 M/39 – 39 2 49 52 3 –
20 F/19 – 44 1 43 43 0 –
F female, M male, MAO Maximum Anterior Opening, Bilat. Bilateral, Ipsi ipsilateral, Contra contralateral

means of MAO were 28.2 ± 5.45, 34.75 ± 5.84, (min = 0, max = 6 at the last follow up session) mm, at the
36.75 ± 5.77 and 38.9 ± 4.45 (min = 25, max = 46 at the end of 2nd, 4th, 6th and 12th week postoperatively. Other
last follow up session) mm, at the end of 2nd, 4th, 6th and 12th functions of TMJ were not impaired in any patient. The mean
week postoperatively. The means of mandibular deviation Gln–Go changes showed 1.45 ± 2.03 (min = 0, max = 8)
were 2.1 ± 2.44, 1.55 ± 1.73, 1.05 ± 1.73 and 1.05 ± 1.73 mm increase.

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As subjective evaluation, patients complained of difficulty the last follow up session) mm, at the end of 2nd, 4th, 6th
in nutrition, oral hygiene maintenance, breathing and speech, and 12th week postoperatively. The means of mandibular
limitation of jaw movement and pain on the condylar fracture deviation were 0.75 ± 1.44, 0.45 ± 1.09, 0.35 ± 0.87 and
side in particular during heavy elastic therapy period. 0.25 ± 0.78 (min = 0, max = 3 at the last follow up
During the first week of surgery one patient (5 %) presented session) mm, at the end of 2nd, 4th, 6th and 12th week
with pus at the site of surgery (left body) which was not related postoperatively. Other functions of TMJ were not impaired
to the subcondylar fracture. He was treated by drainage and in any patient. The mean Gln–Go changes showed
irrigation and antibiotic therapy with no more complication. 5.8 ± 3.41 (min = 2, max = 12) mm increase.
As a subjective evaluation, patients complained of pain
Data Related to Group Two (Endoscopic): (Table 2) and edema on condylar surgical area especially during 1st
and 2nd weeks.
The mean age was 34.25 ± 13.26 (min = 17, max = 58) Just the day after surgery we found two patients (10 %)
years with 16 males (80 %) and 4 females (20 %). with facial nerve weakness due to subcondylar surgery.
The most concomitant fracture was contralateral paras- After 2 weeks all of these patients had recovered and there
ymphysis fracture (3 cases) (15 %), and 10 cases (50 %) was no facial nerve disturbance due to surgery. There were
had isolated subcondylar fracture. no instances of infection in the surgery site.
Average operating time from ramus incision start to
completion of plate fixation for the subcondylar fracture
was 80.35 ± 25.37 (min = 47 and max = 125) minutes. Comparison
At the first follow up session (end of 1 week), there was
1 instance of disturbed occlusion (5 %) which was minor We analyzed measured MAO and mandibular deviation at
and addressed by continuing elastic therapy after first week the end of 2, 4, 6 and 12 weeks between the two groups by
and at the end of 12 weeks we found acceptable occlusion means of Mann–Whitney test and these differences were
in that patient. statistically significant at 2nd and 4th weeks. After 4 weeks
The means of MAO were 35.30 ± 4.62, 38.5 ± 4.04, in the closed treatment group results improved and differ-
39.1 ± 3.95 and 41.25 ± 2.97 (min = 36, max = 46 at ence was not significant.

Table 2 Summary of the study samples in the endoscopic group and acquired results at the end of 12 weeks
Patient Sex/age Disturbed MAO Mandibular Gln–Go Gln–Go Gln–Go changes Concomitant fractures
number occlusion (mm) deviation (preop) (at the 12th from preop to
(mm) (mm) week) (mm) postop (mm)

1 M/58 - 40 0 45 55 10 Bilat. Body

2 M/29 - 42 0 59 61 2 Contra. parasymphysis
3 M/40 - 43 0 53 59 6 –
4 F/39 ? 45 0 49 61 12 Contra. Angle
5 M/49 - 45 0 61 69 8 –
6 F/34 - 40 2 68 68 0 –
7 F/18 - 37 0 75 77 2 –
8 M/17 - 46 0 69 79 10 Contra. parasymphysis
9 M/28 - 45 0 58 61 3 Contra. Body
10 M/33 - 44 0 67 69 2 –
11 M/36 - 42 0 64 72 8 –
12 F/35 - 36 3 79 80 1 Contra. Angle
13 M/21 - 39 0 62 66 4 Ipsi. Body
14 M/18 - 41 0 54 59 5 Contra. Body and parasymphysis
15 M/17 - 44 0 64 72 8 –
16 M/33 - 40 0 58 65 7 Ipsi. parasymphysis
17 M/52 - 37 0 51 58 7 –
18 M/49 - 39 0 60 65 5 –
19 M/23 - 41 0 53 59 6 –
20 M/56 - 39 0 42 52 10 Contra. parasymphysis
F female, M male, MAO Maximum Anterior Opening, Bilat. Bilateral, Ipsi ipsilateral, Contra contralateral

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Finally comparing Gln–Go changes from preoperation 6th and 12th weeks. We concluded due to anatomic reduction,
to postoperation by means of non parametric test (Mann– fixation and sooner physiotherapy, functional restore of the
Whitney) revealed that the mean changes in the endoscopic TMJ in short term was predictable and reliable in endoscopic
group were higher than closed treatment group and P value group. By start of active physiotherapy in closed treatment
of 0.00 indicates the significance statistically. On the other group (after 4 weeks), TMJ function and bone consolidation
hand, we compared preop Gln–Go and postop Gln–Go improved and difference between the two groups decreased.
based on each treatment group by Wilcoxon test, and in the Also a study with long term follow up is advocated.
closed treatment group and endoscopic group 0.02 and 0.00 We used Gln–Go as an indicator of posterior ramal height.
were achieved as P value respectively, both of which are Our study showed that the mean value of Gln–Go changes
significant. from preop to postop which was greater in the endoscopic
group and the difference between the two groups was statis-
tically significant (P = 0.00). It means endoscopic technique
Discussion has better short-term effect to restore normal posterior ramal
height of each patient and it is probably one of the factors
Although traditional approaches to the subcondylar frac- affecting the improved TMJ function, higher MAO and lower
tures are reliable, the presence of visible scars, technical mandibular deviation during opening achieved by endoscopic
problems and complications such as facial nerve palsy have technique. We believe facial soft tissue coverage compensates
led to the relatively recent development of endoscopic posterior ramal height decrease in closed treatment group. On
approaches to these injuries. the other hand, cooperation of masticatory muscles, extrusion
Although endoscopic approaches have steep learning and intrusion of teeth compensate occlusal changes in this
curves and are time consuming, the surgeon could over- group.
come these problems by improved training and experience. Cho-lee et al. [1] treated 3 patients with subcondylar
Ducic [15] has presented mean operating time of 32 versus fractures of the mandible by an endoscopically-assisted
our 80 min. transoral approach. After 6 months follow-up, postsurgical
Meuller et al. [16] noted that traditional treatment of radiographs revealed good reduction in fractures in all three
subcondylar fractures with maxillomandibular fixation cases and no sign of temporomandibular dysfunction [1].
often results in a malreduction and significant functional In our study we found two patients with facial nerve
and aesthetic sequelaes, including facial asymmetry, weakness just after the surgery. We consider two possible
decreased jaw opening, and potential for late derangements reasons: First, use of right angled screw driver needs soft
of the TMJ. Thus the authors strongly advocated endoscopic tissue flap to be elevated much more than only optical
repair of adult condylar neck and subcondylar fractures that cavity and transcutaneos stab incision (the technique used
demonstrate displacement or dislocation and have adequate by Ducic [15], and this causes more retraction of buccal
proximal bone stock to accept miniplate fixation [16]. flap which performs pressure on the buccal soft tissue and
Based on Buschang’s study in 1999, the peak of ado- facial nerve branches. Second, excessive pressure on the
lescent mandibular condylar growth spurt occurs in 12.2 and retromandibular soft tissue and parotid gland during
14.3 years for females and males respectively and then in 1 manipulation can cause facial nerve damage. This com-
or 2 years the growth velocity decreases incrementally. So plication has been recovered in 1 week.
we selected age groups of more than 15 years for females Choi and et al. [18] reported one patient with transient
and more than 16 years for males, to decrease as much as total facial nerve paralysis after endoscopic-assisted man-
possible the effects of condylar growth as an interventional agement of subcondylar fracture. In their case, no damage
factor [17]. to the facial nerve was observed intraoperatively, but the
In our study we found in the closed treatment group patient had total facial paralysis, immediately postopera-
(traditional treatment) three patients and in the endoscopic tively. At long term follow up, the facial nerve function
group 1 patient with disturbed occlusion and for none of was recovered well within 6 months [18].
them reoperation was necessary. Although disturbed Arcuri et al. [19] based on their data records from 14
occlusion is more in the closed treatment group but the patients who underwent surgical repair of subcondylar
difference is not statistically significant. On the other hand fractures by transoral endoscopic-assisted technique showed
3 of 4 disturbed occlusions were in patients with con- 4 complications experienced by 4 different patients: (1)
comitant fractures which makes it difficult to diagnose arterial hemorrhage, (2) facial nerve injury, (3) nonunion, (4)
which one is the reason of disturbance. partial condylar reabsorption.
The average MAO and mandibular deviation at 2nd and 4th Gonzalez-Garcia [20] used angulated drills and screw-
weeks follow up in the endoscopic group was higher and sta- drivers in two subcondylar patients but no damage to the
tistically significant but this difference was not significant at facial nerve was observed.

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Generally, patient’s satisfaction was higher in the the 2.0 AO/ASIF miniplate system. Br J Oral Maxillofac Surg
endoscopic group. Probably this depends on following 39:145
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factors which are advantages of endoscopic open reduction ciples of oral and maxillofacial surgery, vol 1, Chap. 19. PMPH,
versus closed treatment: Using no IMF and heavy elastic Shelton, p 445
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fixation of subcondylar fractures. J Oral Maxillofac Surg
62:1269–1271
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