Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941

Contents lists available at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery

journal homepage: www.jcmfs.com

Dislocated pediatric condyle fractures d should conservative

treatment always be the rule?
Ales Vesnaver
Department of Maxillofacial and Oral Surgery (Head: Assoc. Prof. Andrej A. Kansky, DMD, PhD), University Medical Centre Ljubljana, Zaloska 2, SI-1000,
Ljubljana, Slovenia

a r t i c l e i n f o a b s t r a c t

Article history: Aim: The results of conservative treatment of pediatric dislocated (luxative) condyle fractures are usually
Paper received 20 February 2020 unsatisfactory. We therefore decided to present and analyze the results of surgical treatment of these
Accepted 9 August 2020 fractures.
Available online 14 August 2020
Patients and methods: Children with dislocated condyle fractures were treated surgically, with the
approach always including opening the temporomandibular joint (TMJ).
Keywords:
Postoperatively, patients had regular controls at 1 week, 1 month, 3 months, and 6 months, and then
Pediatric condyle fracture
yearly thereafter. At each control visit, facial symmetry, maximal mouth opening, lateral chin deflection
Facial symmetry
Surgical fracture treatment
upon mouth opening, TMJ pain, condylar motion, palpable pathological phenomena, and occlusion were
Conservative fracture treatment all checked clinically. Healing of the fracture site, condylar height, shape and growth were assessed on
panoramic radiographs. Possible surgical complications were noted: temporary facial nerve palsy,
development of a parotid salivary fistula, disturbance of auricle sensibility due to injury of the greater
auricular nerve, miniplate fracture, intraoperative bleeding, postoperative hematoma formation, infec-
tion, and reoperation due to fragment malposition. The postoperative scars were assessed.
Results: Over the 6-year period from 2013 until the end of 2018, seven children with dislocated condyle
fractures were treated surgically. Six of the seven patients were treated with open reduction and internal
fixation, and the plates and screws were deliberately not removed. The age range of the patients was 1.5
e14 years (average 6.1 years). Follow-up time was 15 months to 6 years. No growth disturbances or facial
asymmetries were seen over this follow-up period, with all patients maintaining proper occlusion, joint
movement, and mouth opening. Fracture healing and condylar growth were clearly demonstrated with
serial control panoramic radiographs. Condylar height asymmetry was observed only in one case, in
which only reduction of the fracture with no fixation was performed. In all other cases, condylar height
was symmetric. None of the children presented with chewing difficulties or joint pain. No intra- or
postoperative surgical complications were noted. The preauricular scars were all very discreet, and none
of the patients or parents complained about them.
Conclusion: Surgical treatment in cases of dislocated (luxative) condylar fractures in children and small
infants restores anatomy and thus securely enables further symmetric growth of the condyles, mandible,
and the entire facial skeleton.
© 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction that proper conservative treatment with mouth opening exercises

and a soft diet, sometimes combined with orthodontic in-
The general rule in treatment of pediatric condyle fractures is terventions, are enough to restore normal condylar height, as well
that it should be conservative (Andrade et al., 2015; Zhao et al., as normal function of the TMJ (Andrade et al., 2015; Zhao et al.,
2014; Thoren et al., 2001; Nørholt et al., 1993). In children, con- 2014). But is this always true? Moreover, what about the injured
dyles are still growing and spontaneously remodeling, and it is articular disc and its effects on TMJ function (Weinberg et al., 2019;
widely claimed that this bony remodeling capacity is so intense Zhang and He, 2006)?
The claim of an almost limitless remodeling capacity is chal-
lenged by young adults who come to our office because of facial
E-mail address: [email protected]. asymmetry, and whose history, clinical examination, and imaging

https://doi.org/10.1016/j.jcms.2020.08.001
1010-5182/© 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
934 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941

(panoramic radiographs and CT/CBCT) clearly reveal that their The zygomatic arch periosteum was separated from the TMJ
asymmetry is posttraumatic (Bae and Aronovich, 2018; Thore n capsule and elevated off the arch to about 1 cm anterior to the
et al., 2001). These patients d and even more so their parents d articular eminence. Gradually the parotid gland capsule was
often recall once falling on their chin, that their TMJ hurt for a day sharply separated from the entire TMJ capsule and an additional
or two, but that the pain later went away. 1 cm caudally, and then the whole soft tissue flap was retracted
Some of the joints in these patients are tender on examination; anteriorly. In this way, complete exposure of the entire TMJ capsule
others are not. Most exhibit absent or diminished translation upon was achieved.
mouth opening, usually with some clicking or crepitations. The chin The dislocated fragment was aproached through the lower joint
is deviated to the side of the affected TMJ, and upon mouth opening space, which was opened with an inverted L incision. In most cases,
the deviation increases (Thore n et al., 2001). Often, the maxilla is when dissecting further caudally, this approach also adequately
tilted and shorter on the injured side. CT scans typically reveal a exposed the fracture. When fracture exposure with the described
shortened, hypoplastic, flattened condyle, an asymmetric preauricular approach was inadequate, an additional, more inferior,
mandible, and often an asymmetric maxilla. retromandibular transparotid approach to the fracture was per-
Clearly, in these cases, the remodeling capacity of the condyles formed, thus avoiding injury to the facial nerve.
had been exceeded d the fractured condyles had not remodeled In this phase, caudal traction on the mandibular ramus using a
well enough. The growth center in the fractured condyle had been Wilkes retractor is very helpful, as it widens the joint space. The
damaged, causing hindered growth and subsequent development condylar head was often displaced so far anteromedially that it
of facial asymmetry. Could this have been avoided with immediate could not be seen straight away. Any intra-articular hematoma was
and proper surgical intervention? removed by suction and thorough irrigation. The position of the
With this in mind, we started operating the worst cases d dis- disc was also assessed. In all cases from this series, the disc was
located, i.e. luxative, fractures of the condyle, where the condylar head lying in its position in the glenoid fossa, which meant that the
is knocked out of the fossa, with an anteromedial angulation of about inferior part of its posterior ligament had been torn off the condyle.
45e90 . In our experience, conservative treatment in these cases has The head of the dislocated condyle was then grabbed using Neff
never yielded acceptable long-term results (Thore n et al., 2001). hooks and slowly elevated posterolaterally, reducing it into its
Moreover, based on our experience of operating on adults, in these correct position, while at the same time straightening the condyle.
cases the disc or its ligaments are torn and require revision and repair. The patients in this phase were in complete relaxation in order to
We decided to analyze and present the results of surgical ease reduction without stripping the lateral pterygoid muscle,
treatment of dislocated condyle fractures in the pediatric which inserts into the medially dislocated condylar fragment.
population. Fixation was then performed in several different ways,
depending on the height of the fracture and the size of the frag-
2. Material and methods ment: with two 1.5 miniplates and screws (Fig. 2), or with a single
rectangular 0.9 plate and screws. In one case (the youngest patient
All of the patients were children with dislocated condyle frac- d 1.5 yrs), only reduction was performed, as the greenstick fracture
tures who had been treated surgically. appeared completely stable after reduction.
Upon admission after injury, all the patients were examined for After fracture fixation, the TMJ soft tissues were addressed. The
the following clinical signs: a laceration or bruise of the chin, pre- disc's posterior ligament was sutured to either the upper part of the
auricular pain and palpatory tenderness, trismus, and plate or to the periosteum, using non-absorbable polypropylene 5/
malocclusion. 0 or 6/0 sutures. Disc and TMJ mobility were checked. The same
A classical X-ray or a panoramic radiograph was usually per- sutures were then used for the horizontal part of the TMJ capsule
formed first, followed by a CT scan in two planes d axial and cor- incision. TMJ mobility was rechecked (as was occlusion), an active
onal d with 3D reconstructions. CT scans precisely outline the site suction drain was placed in the subcutaneous pocket, the incision of
and size of the fracture, the degree and direction of displacement the superficial leaf of the temporal fascia was closed with resorb-
and dislocation, as well as possible comminution (Fig. 1aed). able 4/0 polyglactin sutures, and the rest of the wound was closed
In all of the patients, the surgical approach included opening the by layers.
temporomandibular joint (TMJ). Most of the patients were treated
with open reduction and internal fixation, and the plates and 2.2. Postoperative care and follow-up
screws were deliberately not removed. One patient was treated
with open reduction alone. Control imaging was performed on the first or second day
following surgery (Fig. 3aed). Imaging was always performed in
2.1. Surgical procedure two planes: a panoramic radiograph for height and anteroposterior
control, and a Towne's view X-ray for mediolateral control. CTs
With the patient in general anesthesia and nasotracheal intu- were not performed routinely in order to minimize radiation
bation, skin markings were made for a preauricular hockey-stick exposure.
incision. The skin incision was superiorly deepened to the tempo- Active drainage, if placed, was removed 1e2 days post-
ral fascia. Inferiorly, the skin incision was made on top of the tragus operatively, and patients were discharged 1e5 days post-
and dissection performed along the external ear canal cartilage. The operatively. Sutures were removed 7 days postoperatively. All of
superficial leaf of the deep temporal fascia was incised obliquely, the patients were placed on a soft diet for 6 weeks, and were
and the temporal fat pad entered cranially to the course of the advised to restrain from physical activity for the same time period.
temporal branch of the facial nerve, which courses within the These precautions helped to avoid postoperative displacement of
temporoparietal fascia, thus keeping it out of harm's way. Dissec- fixed fractured fragments.
tion within the fat pad proceeded caudally, down to the zygomatic All of the patients and their parents were taught mouth-opening
arch. Below the zygomatic arch, the parotid capsule was sharply exercises and encouraged to practice them regularly from the 2nd
dissected off the cartilage of the external ear canal and retracted postoperative day onwards. No IMF was used in any of the cases.
anteriorly and inferiorly, exposing the posterior part of the joint Patients had regular controls at 1 week, 1 month, 3 months, and
capsule and condylar neck. 6 months postoperatively, and yearly thereafter.
 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941 935

Fig. 1. Axial (a), coronal (b) and 3D (c and d) CT scans of a right-sided pediatric dislocated condyle fracture in an 11-year-old boy. Observe the greenstick nature of the fracture, the
empty glenoid fossa, and the severe anteromedial angulation.

2.3. The following clinical parameters were noted

1. Facial symmetry e patients were photographed en face and the

photos analyzed. Additionally, the height and lateral protrusion
of both mandibular angles were assessed by inspection and
palpation.
2. Maximal mouth opening e easy insertion of three fingers be-
tween the upper and lower incisors was considered normal.
3. Lateral chin deflection upon maximal mouth opening e lateral
deflection of inferior dental midline from resting position.
4. TMJ pain e subjectively (rest, palpation, opening, chewing) and
upon examination (tenderness on direct palpation, pressure on
chin).
5. Palpatory assessment of condylar motion e preauricular
palpation of both TMJs upon mouth opening.
6. Palpatory assessment of pathological phenomena (clicking and
Fig. 2. View of a reduced and fixed dislocated condyle fracture in a 3-year-old girl, crepitus) in the TMJs e preauricular palpation of both TMJs upon
with everything performed via a preauricular approach, as used for TMJ exposure.
mouth opening.
7. Occlusion.
The plates and screws were not removed, as this would require
another operation under general anesthesia and a second Serial panoramic radiographs were also assessed. The following
arthrotomy. parameters were noted:
936 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941

Fig. 3. X-ray control images of two reduced and fixed dislocated condylar fractures: (a and b) in an 11-year-old boy; (c and d) in a 5-year-old girl.

1. Healing of the fracture site double approach was necessary because dissection from the TMJ
2. Condylar height downwards via the periauricular approach did not expose the fracture
3. Condylar shape well enough for fixation, so an additional retromandibular trans-
4. Condylar growth parotid approach was employed. In the other five, a single preaur-
icular approach gave adequate exposure of the fracture.
Intraoperative and postoperative complications were noted: In all children save one, the time between fracture and surgery
temporary facial nerve palsy, development of a parotid salivary was up to 5 days. In one girl, this time was 9 days because her
fistula, disturbance of auricle sensibility due to injury of the greater fracture was not diagnosed on her first visit at another institution
auricular nerve, miniplate fracture, as well as intraoperative and she was referred to us after a delay. All of the children were
bleeding, postoperative hematoma formation, infection, reopera- operated within 1e4 days after admission to our Department. They
tion due to fragment malposition, and other complications. Post- were discharged from hospital 1e5 days after surgery (Table 2).
operative scars were also assessed. Postoperatively, facial symmetry was observed in all of the pa-
tients. In six cases, mouth opening returned to normal range within
3. Results 1e4 months after surgery, while in one patient the return to normal
mouth opening took 1 year (Table 3, Fig. 4aec) There remained a
Over the 6-year period from 2013 until the end of 2018, seven slight, 1e2 mm ipsilateral deflection of the midline upon maximal
children (four boys, three girls) with dislocated condyle fractures opening in two patients (Fig. 4c).
were treated surgically at the Department of Maxillofacial and Oral None of the operated TMJs remained painful at rest or upon
Surgery of the University Medical Centre Ljubljana, Slovenia. In all chewing, and none were tender on palpation. There were no cases
seven children, the mechanism of injury was a fall on their chin. In five of palpable clicking or crepitation (although one of the patients
cases, the reason was a bicycle accident. Two fractures were right- reported an occasional painless click).
sided, and five were left-sided. All of the injured joints were tender In all seven patients, rotation and translation became palpable
on palpation, and all of the patients had limited mouth opening. Six bilaterally. In four cases, translation was completely symmetric on
had evident chin trauma, most with contusions and excoriations, and both sides, while in the other three, translation was slightly
one with a laceration. Occlusion was obviously altered in five patients, diminished on the injured side.
while in two it was impossible to assess. The age range of the patients Occlusion remained undisturbed in all cases (Table 3).
was 1.5e14 years (average 6.1 years) (Table 1). Panoramic radiographs showed uneventful healing of the reduced
In six patients, open reduction and internal fixation with mini and fixed fractures in all cases. All the reduced and fixed condyles
plates and screws was performed d in five cases with two mini plates, exhibited vertical growth, symmetric with the uninjured side
and in one with a single rectangular plate. In the youngest patient (Fig. 5aeh), although some asymmetry of condylar shape was noted
(1.5 years old), no fixation was performed because the greenstick in three of them (Fig. 6). None of the screws showed any signs of
fracture was completely stable after open reduction. In two patients, a loosening. In the youngest patient, in whom only open reduction was
 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941 937

Table 1
Descriptive data for patients upon injury.

Patient Age (yrs) Sex Fx side Mechanism Chin trauma Mouth opening TMJ pain and tenderness Occlusion

K.L. 14 M R Bike Laceration Limited Yes Altered


N.B.Z. 3 F L Fall, running Contusion Limited Yes ?
E.G. 11 M R Bike Contusion, excoriation Limited Yes Altered
D.R. 1.5 M L Baby bike Contusion, excoriation Limited Yes Altered
P.P. 5 M L Bike Contusion, excoriation Limited Yes Altered
V.P. 2.5 F L Fall, climbing None Limited Yes ?
L.M. 5.5 F L Bike Contusion Limited Yes Altered

?: occlusion was impossible to assess due to the patient's non-cooperation.

Table 2
Descriptive data for surgery.

Patient Traumaesurg (days) Surg-disch (days) Fixation type Posterior disc sutures Approach

K.L. 2 5 Two plates Yes Double


N.B.Z. 2 3 Two plates Yes Preauricular
E.G. 3 1 Two plates Yes Preauricular
D.R. 3 1 None Yes Preauricular
P.P. 5 2 Two plates Yes Double
V.P. 2 1 Two plates Yes Preauricular
L.M. 9 2 Rectangular plate Yes Preauricular

Traumaesurg (days): the number of days between the date of fracture and the date of surgery.
Surgedisch (days): The number of postoperative days at the hospital until discharge.
Approach: preauricular involved approaching both the joint and the fracture through only the preauricular approach used for TMJ exposure; double involved using an
additional, lower approach to the fracture d in both cases retromandibular transparotid d as the fracture was too caudal to allow for reduction and fixation through only the
preauricular approach, without putting the facial nerve at risk.

Table 3
Descriptive data for long-term clinical follow-up.

Patient Facial symmetry Mouth opening Time until normal opening (months) Lateral deflection TMJ pain Clicking, crepitus Translation Occlusion

K.L. Yes Normal 12 None None None Symmetric Normal


N.B.Z. Yes Normal 1 None None None Symmetric Normal
E.G. Yes Normal 3 None None None Symmetric Normal
D.R. Yes Normal 1 None None None Slight shortening Normal
P.P. Yes Normal 3 2 mm ipsilateral None None Slight shortening Normal
V.P. Yes Normal 1 None None None Symmetric Normal
L.M. Yes Normal 4 2 mm ipsilateral None None Slight shortening Normal

Mouth opening: normal opening means the patient can easily insert three fingers between the upper and lower incisors.
Lateral deflection: in two patients there was a 1e2 mm ipsilateral deflection upon maximal mouth opening.
TMJ pain: there was no pain at rest, upon chewing, or upon palpation.
Clicking, crepitus: assessed clinically by palpation.
Translation: assessed clinically by palpation.

Fig. 4. Mouth opening 1 year or more after surgery, showing central opening and complete facial symmetry. In (c) there is a 2 mm deflection toward the injured side upon maximal
mouth opening.

performed, a shortening of 4 mm, as compared to the uninjured side, hematoma, wound dehiscence, or infections. There were no
was observed in the panoramic radiographs (Fig. 7 and Table 4). transient facial nerve palsies, auricular paresthesias, or salivary
There were no unwanted sequelae intraoperatively or fistulas. In one patient, minimal temporal paresthesias were
postoperatively: no cases of bleeding, postoperative present.
938 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941

Fig. 5. Postoperative panoramic radiographs (a, c, e, g) compared with control panoramic radiographs (b, d, f, h) performed a year or more later. Normal growth is observed. (a and
b) 11-year-old boy at time of treatment and 2 years later. (c and d) 14-year-old boy at time of treatment and 6 years later. (e and f) 3-year-old-girl at time of treatment and 2 years
later. (g and h) 2-year-old girl at time of treatment and 1 year later.

Fig. 6. Slight asymmetry of condylar head shape 1 year after surgical treatment of a left-sided dislocated condyle fracture (5-year-old boy at time of treatment).
 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941 939

Fig. 7. Growth disturbance of the left condyle 2.5 years after surgical treatment, in which only reduction of a greenstick fracture with no fixation was performed (1.5-year-old boy at
time of treatment).

Table 4
Descriptive data for postoperative panoramic radiographs.

Patient Bony healing Condylar height Condylar shape Condylar growth Screw loosening

K.L. Uneventful Symmetric Symmetric Visible None


N.B.Z. Uneventful Symmetric Slightly asymmetric Visible None
E.G. Uneventful Symmetric Symmetric Visible None
D.R. Uneventful Shortened Asymmetric Visible None
P.P. Uneventful Symmetric Slightly asymmetric Visible None
V.P. Uneventful Symmetric Symmetric Visible None
L.M. Uneventful Symmetric Symmetric Visible None

Condylar height: measured bilaterally from the upper border of the condylar head to the angle, with both heights compared.
Condylar shape: visual assessment and comparison of both sides.
Condylar growth: comparing condylar height on serial panoramic radiographs.

All of the scars were very discrete and none of the patients or With this in mind, and after gaining a lot of experience with
parents complained about them. surgical treatment of extra- and intraarticular fractures in adults
Follow-up time was 15 months to 6 years after surgery. (Vesnaver et al., 2005, 2012; Vesnaver, 2008), we decided to apply
surgical treatment in pediatric fractures that had no real possibility
of adequate remodeling, where not only the bone, but also intra-
4. Discussion articular soft tissues, were severely injured d i.e. in cases of dis-
located (luxative) fractures.
In the adult population, surgical treatment of displaced In dislocated fractures, the head of the condyle is totally (or sub-
mandibular condyle fractures is steadily gaining ground over totally) knocked out of the glenoid fossa, with a medial fracture
conservative treatment (Eckelt et al., 2006). In children, however, angulation of the fractured condyle of 45 or more. The old rule
there is still consensus among surgeons that treatment of dis- ‘wherever the condyle goes, the disc goes with it’ does not apply (Choi
placed condylar fractures should be strictly conservative and Yoo, 1999). Most often, the posterior ligament is torn off the
(Andrade et al., 2015; Zhao et al., 2014; Thore n et al., 2001). The dislocated condylar head only, and the disc lies in its anatomic posi-
argument supporting this consensus is based on the regenerative tion in the glenoid fossa d this was indeed the case in all of our pe-
and remodeling capacity of the fractured and displaced condyle, diatric patients from this series. In other cases, the posterior ligament
which, according to some authors, is almost limitless (Nørholt is torn from both the temporal bone and condyle head, and the disc is
et al., 1993). However, after seeing many young adults with either folded in front of the dislocated head or wedged between the
facial asymmetries requiring orthognathic surgery (OGS), whose condylar head and the articular eminence d this was observed in
asymmetry evidently originated from a hypoplastic, post- several of our adult cases. Therefore, there is no general rule as to
traumatically deformed condyle, one starts to question the where the disc will be found. Another general rule applies: a thorough
limits of this capacity to remodel (Bae and Aronovich, 2018; revision of intraarticular soft tissues has to be performed in all dis-
Thoren et al., 2001). located condyle fractures, and the disc reduced and fixed into its
The TMJ is often perceived as simply two bones in contact, as proper position, and in contact with the condyle d what is referred to
seen in a panoramic radiograph. In reality, the TMJ is a loose hinge as functional open treatment (Weinberg et al., 2019). Only this will
joint, with the articular disc between the condylar head and fossa. enable proper functioning of the TMJ. Of course, this requires opening
Forces that are great enough to fracture bones would be expected to the joint.
cause damage to the articular disc as well (Weinberg et al., 2019; There is another rationale for opening the TMJ in dislocated
Bae and Aronovich, 2018). It is trully amazing how often this is fractures. Previously, dislocated condyle fractures in adults were
ignored (Thore n et al., 2001). Even if the fractured and displaced/ treated at our department using the same approach as in other
dislocated condyle remodels to a certain degree, the ruptured and extraarticular condyle fractures d i.e. without opening the joint.
displaced disc will not. This often results in painful clicking and/or However, when treating dislocated condyle fractures with only an
crepitations in TMJs after condylar fractures (Weinberg et al., 2019; extraarticular approach, it is often difficult to reduce these fractures
Nørholt et al., 1993). properly, and sometimes impossible. Moreover, in the past 15 years
940 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941

I have personally had two cases of postoperative avascular necrosis exercising on the 2nd postoperative day, with the importance of
of the condyle d both in patients with dislocated fractures treated this being clearly explained.
using the classical, extraarticular approach. In both cases, reduction Mouth opening returned to normal in 1e4 months in most
lasted for more than 30 min. patients. In only one patient, normalization took nearly 1 year. This
The reason for condylar resorption in these cases was lodging of patient was uncompliant and did not perform the required mouth
the condylar head in front of, and medially to, the articular opening exercises. We believe that this was the only reason for
eminence, thereby preventing reduction. After forcefully repeating prolonged normalization.
the reducing motion many times, the lateral pterygoid muscle was It has to be stressed that surgical treatment should not be
finally stripped off the condylar fragment, leaving an avascular, routinely applied in all pediatric condyle fractures. The remodeling
freely mobile condyle. This suddenly became easy to reduce and fix, capacity of a pediatric condyle is indeed considerable, and in cases
but later sadly resorbed. of greenstick fractures with mild deviations of up to 30 , conser-
Therefore, in cases of dislocated fractures in both adults and vative therapy is probably sufficient. In cases of larger deviations
children, it is necessary to make an approach as for an intraarticular and true dislocations, however, the remodeling capacity is excee-
fracture d requiring opening of the TMJ (Vesnaver, 2008; Eckelt ded. Additionally, the greater the post-traumatic condylar devia-
and Rasse, 1995). In this way, the dislocated condylar head can be tion, the greater the chance of articular disc injury. These are the
grabbed directly with special retractors (e.g. Neff's hooks) and fractures that we believe require surgery, which, in cases of pedi-
slowly reduced into place, while at the same time applying atric condyle fractures, should only be performed by surgeons who
downward traction to the ramus. Such a maneuver prevents further are highly experienced in trauma and TMJ surgery.
injury to the lateral pterygoid muscle, which is crucial for the blood All of the obtained results indicated better outcomes compared
supply to the fractured fragment. With this approach, the intra- with those experienced with pediatric patients after conservative
articular hematoma can also be removed, the disc repaired and treatment of dislocated condyle fractures. Patients treated conserva-
sutured into place, and intraarticular mobility checked directly. In tively regularly present with a certain degree of limited mouth
small children with short condyles, adequate fracture exposure and opening, deflection of the chin to the injured side upon mouth
fixation can often be performed through the same approach (i.e. opening, diminished condylar translation on the injured side, and a
preauricular). Older children and adults with subcondylar dis- shortened, deformed condyle in panoramic radiographs. Some may
located fractures require an additional, lower approach to the also have facial asymmetry, joint pain, pathological TMJ phenomena
fracture site (e.g. retromandibular transparotid), as the fracture it- (crepitus and/or clicking), and occlusal disturbances (Bae and
self is usually too caudal to allow for proper fracture alignment and Aronovich, 2018; Thore n et al., 2001). The results of our series were
fixation through only the upper, preauricular approach. strikingly better. However, we do realize that this was a very small
Opponents of surgical treatment in pediatric condyle fractures series, and that most of the results were qualitative. Therefore, a
often claim that surgical treatment will hinder growth (Zhao et al., prospective multicentric long-term study would be beneficial.
2014; Zide, 1989). In dislocated condyle fractures, this is not the As a general rule, surgery should be opted for only if it yields
case. The condyle, with its growth centre, is knocked out of the significantly better results than conservative treatment, causes
fossa and is in a completely wrong anatomic position, often at a little collateral damage and few or no defects in cosmetically sen-
60e90 angle. Concerns about surgically induced growth hindrance sitive areas, such as the face. We believe that in surgical treatment
in such circumstances have no basis. On the contrary, opening the of dislocated condyle fractures, even (or, rather, especially) in
fracture and reducing and fixing the condyle in its anatomic posi- children, these goals have been achieved.
tion enables further normal growth of the condyle (Bae and
Aronovich, 2018). This was observed in serial postoperative pano-
5. Conclusion
ramic radiographs of our patients.
As pointed out before, we purposely decided to leave the plates
The preliminary results of this study indicate that surgical
and screws in place, as removing them would have meant a second
treatment of dislocated condyle fractures should be employed in
arthrotomy. Bone grows by apposition, not by distension; therefore,
the pediatric population, as it not only restores normal condylar
we anticipated no growth disturbance in the region of osteosyn-
anatomy, but also enables revision and repair of the articular disc
thesis (Bae and Aronovich, 2018). This was confirmed by condylar
and capsule, which is crucial for normal function of the TMJ.
growth observed on serial panoramic radiographs. Therefore, a
Restoring normal anatomy and function results in normal growth of
crucial goal was achieved with surgical treatment, whereby
the condyle and, indeed, of the whole facial skeleton. Further
reduction and fixation of the fractured condyle enabled not only
research in this field is necessary, as the presented series was small.
proper function of the TMJ and restoration of occlusion, but also
normal and symmetric development of the facial skeleton.
The only patient who showed growth hinderance was a 1.5- Compliance with ethical standards
year-old boy in whom only reduction was performed d after Before obtaining consent for surgery, parents were informed, in
reduction, the greenstick fracture seemed completely stable, so we detail, of the nature of the injury and of the goals we wished to ach-
decided to perform no fixation. This was a poor decision, because ieve. They were explained the possible risks of surgery, as well as the
anterior traction of the lateral pterygoid muscle probably caused possible risks of conservative treatment. Our work was performed in
the reduced fractured fragment to redisplace to a certain degree. accordance with The Code of Ethics of the World Medical Association.
Thus, it is our belief that fixation has to be performed in all cases of
reduction in greenstick fractures, as only this will ensure healing in
Financial support
the proper position and further adequate growth.
Our retrospective analysis received no financial support. All the
IMF was never used. In our opinion, IMF in cases of condyle
data (X-rays, CT scans, photographs, and clinical measurements)
fractures and open joint surgery is contraindicated, because
was collected routinely. There were no additional costs.
immobilizing an injured joint can facilitate the development of
intraarticular fibrosis (Zhao et al., 2014; Satler and Oglivie-Harris,
1979). Patients and their parents were encouraged to begin Declaration of competing interest
None.
 A. Vesnaver / Journal of Cranio-Maxillo-Facial Surgery 48 (2020) 933e941 941

References Thoren H, Hallikainen D, Iizuka T, Lindqvist C: Condylar process fractures in chil-

dren: a follow-up study of fractures with total dislocation of the condyle from
the glenoid fossa. J Oral Maxillofac Surg 59: 768e773, 2001
Andrade NN, Choradia S, Sririam G: An institutional experience in the management
Vesnaver A: Open reduction and internal fixation of intraarticular fractures of the mandibular
of pediatric mandibular fractures. J Craniomaxillofac Surg 43: 995e999, 2015
condyle e our first experiences. J Oral Maxillofac Surg 66: 2123e2129, 2008
Bae SS, Aronovich S: Trauma to the pediatric temporomandibular joint. Oral Max-
Vesnaver A, Gorjanc M, Eberlinc A, Dovsak DA, Kansky A: The periauricular trans-
illofac Surg Clin N Am 30: 47e60, 2018
parotid approach for open reduction and internal fixation of condylar fractures.
Choi BH, Yoo JH: Open reduction of condylar neck fractures with exposure of the
J Craniomaxillofac Surg 33: 169e179, 2005
facial nerve. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88: 292e296,
Vesnaver A, Ah can U, Rozman J: Evaluation of surgical treatment in mandibular
1999
condyle fractures. J Cran Maxillofac Surg 40: 647e653, 2012
Eckelt U, Rasse M: Clinical, radiographic and axiographic control after traction
Weinberg FM, Speksnijder CM, Forouzanfar T, Rosenberg AJWP: Articular soft tissue
screw osteosynthesis of fractures of the mandibular condyle region. Rev Sto-
injuries associated with mandibular condyle fractures and the effects on oral
matol Chir Maxillofac 96: 158e165, 1995
function. Int J Oral Maxillofac Surg 48: 746e758, 2019
Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota R, Rasse M,
Zhang Y, He DM: Clinical investigation of early post-traumatic temporomandibular
Schubert J, Terheyden H: Open versus closed treatment of fractures of the
joint ankylosis and the role of repositioning disks treatment. Int J Oral Max-
mandibular condylar process e a prospective randomized multi-center study.
illofac Surg 35: 1096e1101, 2006
J Craniomaxillofac Surg 34: 306e314, 2006
Zhao YM, Yang J, Bai RC, Ge LH, Zhang Y: A retrospective study using removable
Nørholt SE, Krishnan V, Sindet-Pedersen S, Jensen IB: Pediatric condylar fractures: a
occlusal splint in the treatment of condylar fracture in children. J Cran Max-
long-term follow-up study of 55 patients. J Oral Maxillofac Surg 51: 1302e1310,
illofac Surg 42: 1078e1082, 2014
1993
Zide MF: Open reduction of mandibular condyle fractures. Indications and tech-
Satler RB, Oglivie-Harris DJ: Healing of intra-articular fractures with continuous
nique. Clin Plast Surg 16: 69e76, 1989
passive motion. Am Acad Ortop Surg 28: 102e115, 1979