J Oral Maxillofac Surg

52353-360. 1994

Surgical Versus Nonsurgical Treatment of

Unilateral Dislocated Low
Subcondylar Fractures:
A Clinical Study of 52 Cases

NILS WORSAAE, DDS,* AND JENS J. THORN, DDS, i=tiDt

To compare open versus closed reduction of unilaterally dislocated low subcon-

dylar fractures in adults, 101 consecutive dentulous patients were treated either
by closed reduction with a median of 4 weeks of maxillomandibular fixation, or
with a median of 6 weeks of maxillomandibular fixation after surgical repositioning
and transosseous wiring of the dislocated condylar fragment. No selection of
patients was done for either treatment. Fifty-two patients were seen at a median
of 2 years postoperatively. Complications such as malocclusion, mandibular
asymmetry, impaired masticatory function, and pain located to the affected joint
or masticator-y muscles were seen significantly more frequent in patients treated
with closed reduction compared with those treated surgically (P = .005). Neither
the degree of dislocation of the proximal fragment, concomitant mandibular frac-
tures, nor the absence of posterior occlusal support seemed to influence the
results.

Dislocated low subcondylar fractures (DLSF) have
generally been treated by maxillomandibular fixation
(MMF)l followed by functional training, probably due
to the complex anatomic relations of the temporo-
mandibular region. Several studies of such treatment
of cond.ylar fractures have shown favorable clinical re-
sults l-6 However, other studies show signs of dysfunc-
tion in (about one third of adult patients.7-9 In children,
studies of condylar fractures have shown that a re-
markable remodeling process takes place.5,7,‘0-‘3In ad-
dition, the frequency of complications is lower than in
adults ‘JJ ‘-I3 although hypertrophic growth’0.‘4 and
ankylosis3,’ may occur in rare cases.
Open reduction and fixation of the fractures has been
recommended in selected cases, and different indica-
tions have been proposed. ‘,‘5-‘9A variety of different
approaches also have been suggested in an attempt to
facilitate the surgical method.’
Comparisons between surgical and closed treatment
have been made clinically’2*‘7-2’and experimentally22-24
but, to our knowledge, no clinical studies with ran-
domization of the patients for either treatment have
been performed. The purpose of this study was to de-
termine the frequency of complications associated with
a closed and a surgical approach on nonselected adult
dentulous patients with unilateral DLSF (UDLSF).
Furthermore, an attempt was made to disclose possible
predisposing factors to such complications.

* Fomlerly, Associate Director, Department of Oral and Maxil-

lofacial Surgery, Rigshospitalet, Copenhagen, Denmark: currently.
Co-director, Department of Oral and Maxiilofacial Surgery, Aalborg
Hospital, Aalborg, Denmark.
t Associate Director, Department of Oral and Maxillofacial Sur-
gery, University Hospital, Rigshospitalet, Copenhagen, Denmark.
Address correspondence and reprint requests to Dr Worsaae: De-
partment of Oral and Maxillofacial Surgery, Aalborg Hospital, Hob-
rovej 18-20, DK-9000 Aalborg. Denmark.
0 1994 #American Association of Oral and Maxillofacial Surgeons
0278-2391/94/5204-0004$3.00/O
Materials and Methods
DEFINITIONS
Low subcondylar fractures were defined as fractures
of the condylar neck situated below a horizontal line
drawn from the right to the left sigmoid notch on pan-
oramic radiographs. The lowest fractures of this type
are often referred to as oblique fractures of the superior

353
354 OPEN/CLOSED TREATMENT OF CONDYLAR FRACTURES

Table 1. Signs and Symptoms Registered as verified objectively. Objective criteria for disfiguring
Complications After Treatment of UDLSF and scars were hypertrophy or an exaggerated difference in
the Distribution of These Among the Affected
color from the surrounding skin. Mandibular asym-
Patients (11 Treated Closed and 1 Surgically)
metry was registered when clinically visible, and not
Complications Conservative Surgical from radiologic analysis. Malocclusion consisted of
hyperocclusion posteriorly on the fractured side and
Facial paralysis - 0 contralateral open bite. Pain located in the joints or to
Disfiguring cicatrice - 0
the masticatory muscles (masseter and temporalis
Mandibular asymmetry 3 0
Malocclusion 8 I muscles) was verified by reaction on palpation of these
Reduced interincisal opening (~35 mm) 3 0 structures. Impaired masticatory function and persis-
Persistant headache 2 0 tent headache were only accepted as complications
Pain located to joint/masticatory when combined with either malocclusion or pain lo-
muscles 6 I
cated in the joint or masticatory muscles. Furthermore,
Impaired masticatory function 6 I
impaired masticatory function was accepted as a com-
plication only if the patient had a full natural dentition.
These limitations were used in an attempt to avoid
ramus. Dislocated fractures were defined as those including symptoms not caused by DLSF.
showing an overlap of the fragments and/or dislocation
of the condyle out of its normal position in the glenoid PATIENTS
fossa. Patients were considered to have sufficient pos-
terior occlusal support when at least one pair of molars From 1980 to 1989,389 patients with condylar pro-
were in occlusion on the fractured side. Partial dentures cess fractures were treated at the Department of Oral
were not considered a sufficient replacement for natural and Maxillofacial Surgery, Rigshospitalet, Copenhagen.
teeth in this context. The study group comprised 10 1 patients with UDLSF.
Complications are listed in Table 1. Patients were of whom 52 responded to a follow-up call a minimum
only considered to have a complication when the of 6 months after treatment (Table 2). Of the 49 patients
symptoms were related to the fracture or its treatment who did not present for follow-up, two had died, five
and were recognized as a problem for the patient, and were not possible to locate, six had moved to other
when the complication, with the exception of persistent parts of the country, and 36 did not respond to the
headache and impaired masticatory function, could be follow-up call.

Table 2. Distribution of Patients With UDLSF

Follow-up
No. of Age (yr) MMF (d) (mo) No. With
Follow-up Cases Sex (F/M) Mean Median No. With No. With Mean Median Mean Median Complications
Treatment (n) (t/k) (S,) (Ratio) (Range) AMF (?‘o) IPOS (%) (Range) (Range) (a)

36 42 21
Surgical (40) + 24 8116 36 II 2 42 16 I
(60) (I?) (21-70) (46) (8) (22-63) (6-64) (4)
35 39
_ I6 4/12 32 IO 2 42
(40) (1:3) (22-52) (63) (13) (14-47)

37 28 30
Nonsurgical (6 I) t 28 712I 38 II 4 30 29 II
(46) (l:3) (18-71) (39) (14) (O-47) (6-64) (39)
36 27
_ 33 1l/22 32 14 5 30
(54) (12) (22-74) (42) (15) (O-44)

37 26
Total(lOl) t 52 IS/37 36 22 6 23
(51) (12.5) (18-71) (42) (12) (6-64)
35
_ 49 I s/34 32 24 7
(49) (1:X3) (22-74) (49) (14)

Abbreviations: AMF, associated mandibular fractures; IPOS. insufficient posterior occlusal support.
WORSAAE AND THORN
Excluded from the study were patients with non-
DLSF, patients with high subcondylar fractures (high
condylar neck) or fractures of the condyle, and those
below 18 years of age. Patients with UDLSF but eden-
tulous in one or both jaws, patients with associated
midfacial fractures, and patients with bilateral DLSF
also were excluded, because they were not treated in
the same randomized regimen. The distribution of the
10 1 patients according to sex, age, associated mandib-
ular fractures. and insufficient posterior occlusal sup-
port is shown in Table 2.
TREATMENT
Nonsurgical treatment of patients with major mal-
occlusions or associated mandibular fractures had
MMF for 5 to 6 weeks, and those with more moderate
occlusal disturbances from 0 to 4 weeks. After the pe-
355
riod of rigid MMF patients used training elastics, and
eventually only night elastics, for a median of 7 days.
Jaw exercises were gradually intensified during the re-
habilitation period in an attempt to obtain an increase
of mouth opening of at least 1 to 2 mm per day. These
consisted of protrusive and laterotrusive movements
for 10 minutes, three times daily. Surgical treatment
consisted of open reduction and transosseous wire os-
teosynthesis with double 0.3-mm stainless steel wires
performed via a submandibular approach (Fig 1) under
general anesthesia. This was combined with rigid
MMF, generally for 6 weeks, followed by 1 week of
training elastics and physiotherapy as previously de-
scribed. The distribution of the patients according to
treatment, including length of MMF, is shown in
Table 2.
From 1980 to 1983, all patients with UDLSF were
treated nonsurgically, while from 1983 to 1989 patients
FIGURE I. ‘-1, Schematic illustration of the transosseous wire
osteosynthesis technique used in this study. The hole in the proximal
fragment usually was drilled from the medial side. B. Exposed left-
sided, dislocated, low subcondylar fracture seen from a subangular
aspect. The proximal fragment overlaps the mandibular ramus lat-
erally. C. After repositioning and transosseous wiring of the fracture.
 356 OPEN/CLOSED TREATMENT OF CONDYLAR FRACTURES

were treated in a randomized manner depending on
the day of admission: surgically on even days and non-
surgically on uneven days. All patients presenting for
follow-up underwent a clinical and radiologic exami-
nation. The length of the follow-up periods is shown
in Table 2.
RADIOGRAPHICANALYSIS
Preoperative, nonstandardized, panoramic and pos-
teroanterior radiographs (Towne’s projection) taken on
admission were analyzed. On the panoramic radio-
graphs the vertical overlap of the fragments at the pos-
terior border of the mandibular ramus/condylar pro-
cess were measured in millimeters and calculated in
percent of the ramus height, registered as the distance
between the sigmoid notch and the base of the man-
dible parallel to the posterior border (Fig 2A). On the
posteroanterior radiographs the medial or lateral an-
gulation between the dislocated condyie and ramus was
measured (Fig 2B). All measurements were done in a
blinded fashion.
STATISTICALANALYSIS
For statistical evaluation of the data, the two-sample
rank sum test (Mann-Whitney), two-tailed, and Fisher’s
exact test were used. A P value of .05 or below indicated
the accepted level of significance.
Results
Comparison between characteristics of those patients
who were seen at follow-up and those who did not
attend the examination showed no significant differ-
ence regarding age, sex, length of MMF. associated
mandibular fractures, or insufficient posterior occlusal
support. Comparisons of the 52 patients seen at follow-

a
b

FIGURE 2. A. Schematic illustration of measurement of vertical overlap (a-b) of fragments on panoramic radiograph. The ramus height (A-
B) was measured as the distance from the sigmoid notch to the mandibular base. The distances a-b and A-B were measured parallel to the
posterior border of the ramus. E, Angulation between the axes of the proximal and distal fragments (“) was measured on anteroposterior
radiographs as schematically illustrated here.
WORSAAE AND THORN 357

Table 3. Distribution of the 28 Conservatively Treated Patients With UDLSF Seen at Follow-up

No. of Cases Sex (F/M) (Ratio) Age (yr) MMF (d) Follow-up (mo)

+ Complications II 318 37. 39 (18-46) 33. 34 (O-47) 28. 26 (6-58)

(1:2.7)
- Complications 17 4/13 39. 37 ( 18-7 I ) 35. 27 (O-44) 34, 29 (S-64)
(1:3.3)

Data are mean. median, and (range).

up showed an almost identical sex and age distribution
of the two treatment groups, but the MMF periods
were shorter (P = .OOOl) and the follow-up periods
longer (P = ,025) in the conservatively treated group
of patients (Table 2).
Complications occurred in 11 of the patients treated
nonsurgically (39%) and in one of the patients who had
open reduction and transosseous wireosteosynthesis
(4%; P = ,005; Table 2). An additional four patients
treated nonsurgically had objective, but asymptomatic.
signs of complications.
The distribution of the different complications in
both treatment groups is shown in Table 1. Ten of the
11 nonsurgically treated patients had two or more
complications. In most of the patients with malocclu-
sion, pain located in the joint/muscles and impaired
masticatory function also occurred. All patients with
persistent headache had two or more simultaneous
complications. Of the six patients with impaired mas-
ticatoty function, five also had malocclusion and two
had simultaneous pain located in the joints.
Of tlhe patients treated surgically, one had maloc-
clusion, pain located in the joint on the fractured side.
and impaired masticatory function. Radiographically,
a collapse of the repositioned condylar fragment was
seen. Most of the scars were almost invisible, none were
hypertrophic, and all were without a clear difference
in color compared with the surrounding skin. No pa-
ralysis of the facial nerve was seen at follow-up.
Sex and age distribution, and length of MMF and
follow-up of the nonsurgically treated patients related
to the occurrence of complications are shown in Table
3. Patients with and without complications did not dif-
fer significantly in any of the parameters.
Four of the 28 nonsurgically treated patients had
insufficient posterior occlusal support. Two of these
four patients (50%) had complications. Nine of the re-
maining 24 patients (38%) with sufficient occlusion had
complications. The difference was nonsignificant. Five
of the 1 1 patients (45%) with associated mandibular
fractures developed complications, compared with six
of 17 (35%) without concomitant mandibular fractures
(P> .05). Mouth opening, measured as the maximal
interincisal distance, was a median of 45 mm for both
treatment groups (Table 4). Laterotrusive and protru-
sive movements also are shown in Table 4; no signif-
icant difference was found between patients with open
and closed reduction. Laterotrusive movement toward
the nonfractured side, when compared with laterotru-
sive movements toward the fractured side (Table 4)
was only significantly reduced for nonsurgically treated
patients (P= .05).
The results of the radiographic examination of the
conservatively treated patients are shown in Table 5.
No significant difference in size of overlap or degree
of angulation between fragments were found between
the patients with or without complications.
TREATMENT OF COMPLICATIONS
Two patients with malocclusion, impaired masti-
catory function, and pain located in the joint (one
treated by closed and one by open reduction) had a
sliding vertical ramus osteotomy performed to correct
the malposition of the mandible. The remaining pa-
tients declined corrective therapy such as arthroplasty.
temporomandibular joint prosthesis, or ramus oste-
otomy because no exact prognosis could be given for
these treatments. Most of these patients had accepted
the complications as an inevitable consequence of the
accident.
Discussion
Complications occurred in more than one third of
the nonsurgically treated patients, which is significantly
Table 4. Maximal lnterincisal Mandibular
Opening, and Lateral and Protrusive Mandibular
Movements of Nonsurgically and Surgically
Treated Patients at Follow-up
Laterotrusion(mm)
M~XiIll~l
Opening Contralateral Protrusion
Treatment (mm) Fractured Side Sldr (mm)
Surgical 46. 45 (34-61) IO. IO (5-15) Y. 8 (4.18) 7.7 (4-13)
Nonsurgical 50. 45 (34-65) 9, IO (4.14) 7. 7 1’3.17) 7. 8 (3.12)
Data are mean. median. and (range).
 358
Table 5. Analysis of Preoperative Radiographs
of the 28 Conservatively Treated Patients
With and Without Complications
No. of
Cases Overlap of Fragments (mm)
+ Complications I1 7, 7 (-1-15) 12. I I (~2.24)
- Complications I7 7, 8 (-2-13) II, 12 (~3-21)
Total 28 7. 7 (-2-15) 12. I2 (~3-24)
Size of vertical overlap and medial/lateral angulation between
fragments are related to the occurrence of complications. Data are
mean, median, and (range).
more frequent than in the surgically treated patients
(P = .005). An average complication rate of about 7%
(range, 0% to 30%) has been reported in nonsurgically
treated patients.’ Other studies of such treatment seem
to show approximately the same range of complica-
tions.5~6~8~9~12~20~26 Studies of patients treated by open
reduction show complication rates ranging from 0%
to ~8yo.15.16.20.27-33
The criteria stipulated for complications in previous
studies of condylar fractures have rarely been strictly
defined, and most of the studies dealing with nonsur-
gical treatment include not only adults, but also teen-
agers and children, as well as all categories of condylar
and subcondylar fractures.2~5~798~’r-r3even nondislocated
fractures.2g8,9 Moreover, studies of surgically treated
patients are characterized by a considerable variety of
surgical methods used in adult patients with displaced/
dislocated condylar fractures.’ All these circumstances
could certainly be responsible for the wide range of
complication rates reported. Recent studies comparing
selected groups of patients with condylar fractures,
treated surgically or nonsurgically, have shown no ma-
jor differences in the results obtained with either
method.17*18*2’
In the present study only criteria for complications
that seemed clinically relevant, and mainly those that
could be verified objectively by simple means, were
recorded. Complications registered only by the observer
were not included. Four conservatively treated patients
with no complaints, but with objective signs of com-
plications, were therefore not registered as having
complications.
Possible complications, such as arthrosis, that may
occur after 10, 15, or 20 years were not revealed by
this study due to the short length of the follow-up pe-
riod. However, it seems reasonable to assume that a
careful, nontraumatizing, anatomically correct repo-
sitioning of a dislocated condylar fragment no more
frequently predisposes to such late complications than
a nonreduced, malpositioned condylar process fracture.
Only about half of the patients presented for the
OPEN/CLOSED TREATMENT OF CONDYLAR FRACTURES
follow-up examination, a pattern not much different
from previous studies.‘.4,7.‘3From the comparisons be-
tween patient characteristics of those presenting for the
Angulation follow-up and those who did not, there is no reason to
Between suspect that the drop-out rate would have influenced
Fragments (“)
the number or distribution of complications with the
23. 14 (3-74)
two treatment regimens.
32. 22 (-4-139) The follow-up was significantly shorter in the sur-
28, 20 (-4-139)
gically treated group of patients than in the nonsurgi-
tally treated group, who had a median follow-up of
2Y2years. It has been stated that functional adaption
takes place up to 2 years after conservative treatment
of adults.13 No further improvement in the condition
of the nonsurgically treated patients in this study are
therefore expected.
The surgically treated patients were kept in MMF
for an average of 6 weeks to allow osseous stabilization
at the fracture site. The nonsurgically treated patients
had rigid MMF for approximately 4 weeks before
physiotherapy was started. Although patients treated
with open reduction were immobilized 2 weeks more
on average, the mouth opening of surgically and non-
surgically treated patients was not significantly differ-
ent. Also, no significant difference in laterotrusive or
protrusive movements was found between the two
treatment groups, as reported in a previous study,”
but the nonsurgically treated patients in the present
study showed significantly reduced translation to the
nonfractured side.9s’7
The nonsurgically treated patients with complica-
tions had a median of 1 week longer MMF than those
without complications, but the difference was not sig-
nificant. The importance of an MMF period of only
10 to 14 days has been emphasized by others.’ If such
a short MMF period is crucial for a beneficial outcome
after closed reduction, one should expect a more pro-
nounced difference between the length of MMF periods
for nonsurgically treated patients with and without
complications in the present study. Partly reversible
degenerative changes of the articular cartilage have
been reported after immobilization of the temporo-
mandibular joint34 but, to our knowledge, there are no
clinical or experimental studies demonstrating less
complications in adults after an MMF period of 1 to
2 weeks than 4 to 5 weeks.
It is surprising that insufficient posterior occlusal
support on the fractured side was without significant
influence on the complication rate of the nonsurgically
treated patients. However, there were few patients with
insufficient occlusion in the present study. Concomi-
tant mandibular fractures also did not seem to increase
the number of complications.
Although it has been stated that medial and anterior
dislocation of the proximal condylar fragment predis-
poses to complications,’ the present study seems to be
in accord with others,‘.4.22.35finding no correlation be-
WORSAAE AND THORN
tween the degree of radiographically recorded dislo-
cation or angulation of the condylar fragment and the
number of complications. However, it has to be em-
phasized that the analysis in this study was performed
on nonstandardized radiographs.
Heurlin and others3’j showed in an experimental
study using adult monkeys that nonsurgical treatment
of bilateral fractures produced anterior open bite, and
that unilateral fractures caused facial asymmetry but
no alteration of the occlusal relationship. However,
laterally displaced occlusion in adult rhesus monkeys
is problably prevented by the long and interlocking ca-
nines and the entire occlusal pattern. In a more recent
experimental study by Zhang and Obeid.” open re-
duction and plating of condylar fractures in rabbits
produced more favorable results than closed reduction.
However, good results also were seen with the closed
method, but were mixed with cases of severe asym-
metry, malocclusion, and affected laterotrusive move-
ment towards the nonsurgically treated side, as in the
present study.
Open reduction of dislocated subcondylar fractures
is not an easy procedure, and some of the surgical
methods described are probably technically difficult as
indicated by the high complication rates in some stud-
ies.‘,‘7.‘9.30.” Open reduction necessitates a certain
amount of surgical training, and it is time- and man-
powerconsuming compared with closed reduction be-
cause it has to be done under general anesthesia. How-
ever, with rigid internal fixation, using plates or
lagscrews instead of transosseous wiring of the fracture,
the MMF period and the postoperative follow-up may
be reduced significantly. 1,‘9.28,29.31
Although the major number of condylar process
fractures are treated optimally by closed reduction, the
present study shows that dislocated subcondylar frac-
tures in adults treated conservatively produce compli-
cations that could have been significantly reduced if
open reduction had been performed. No factors pre-
disposing to complications were disclosed, and it is
possible that the main reason for development of many
of the complications was the inability of the patient to
overcome the different neuromuscular and other func-
tional problems induced by an unrepositioned sub-
condylar fracture.
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J Oral Maxillofac Surg
52:360-361, 1994
Discussion
Surgical Versus Nonsurgical Treatment of
Unilateral Dislocated Low Sub-condylar
Fractures: A Clinical Study of 52 Cases
Kyiisti S. Oikarinen, DOS, DMD, PhD
Universil~~of Oulu. Finland
This article discusses an issue in facial traumatology. the
treatment of which has been the topic of several debates. By
excluding all others except unilateral low subcondylar frac-
tures the authors have a rather homogenous group of patients
to illustrate the differences of treatment outcome. The fact
that this material does not include young patients or patients
with no teeth in either of the jaws also makes it fairly reliable.
I was delighted with the nomenclature in this article.
The term nonsurgical treatment, as was used here, is the
opposite of surgical, just as closed reduction is opposite
to open reduction. “Conservative treatment” is some-
what confusing when used to define maxillomandibular
fixation (MMF).
Dividing the patients randomly into two treatment groups
raises some interesting questions. As a scientific study this is
the most acceptable method, but I am not very comfortable
with the fact that the decision of whether to treat surgically
or nonsurgically was based on chance. There are guidelines
as to which of the condylar fractures cannot be treated with
maxillomandibular fixation alone. Also, the fact that these
patients were not followed up prospectively makes the basis
of some of the results observed weak. It cannot be established
clearly whether the symptoms registered at follow-up ex-
amination were decreasing or increasing. Also, the duration
of follow-up differed between the groups. Nonsurgically
treated patients were examined for a longer period after the
accident than the surgically treated patients. This should have
been an important issue for discussion because TMJ dys-
function might decrease with time elapsed since the accident.’
There was no discussion of the possible causes of the com-
plications. Impaction of the displaced condyle, and healing
in an abnormal position and preventing normal mouth
opening, must have been one of the reasons. In low subcon-
dylar fractures direct injury to the condyle and/or disc does
not necessarily occur, which in the case of condylar or intra-
capsular fractures could be the origin of complications.
MMF time in both nonsurgically, and especially in sur-
gically, treated cases was higher than generally has been rec-
ommended for condylar fractures. Most books on this subject
recommend shorter than 4 weeks of immobilization. Physical
DISCUSSION
33. Lachner J, Clanton JT. Waite PD: Open reduction and internal
rigid fixation of subcondylar fractures via an intraoral ap-
proach. Oral Surg Oral Med Oral Pathol 7 1:257.199 I
34. Glineburg RW, Laskin DM, Blaustein DI: The effects of im-
mobilization on the primate temporomandibularjoint: A his-
tologic and histochemical study. J Oral Maxillofacial Surg40:
3, 1982
35. Lindahl L: Condylar fractures of the mandible. III. Positional
155 I.
changes of the chin. Int J Oral Surg 6: 166. 1977
36. Heurlin RJ. Cans BJ. Stuteville OH: Skeletal changes following
fracture dislocation of the mandibular condyle in the adult
rhesus monkey. Oral Surg 14:1490, 1961
,
exercises can be initiated soon after the accident and devel-
opment of permanent damage to the temporomandibular
joint can be avoided in this way. Animal studies have shown
that degenerative changes occur in the condylar cartilage after
prolonged immobilization.* Long-lasting MMF also seemed
to cause more complications, but this could have been due
to other facts besides immobilization.
Indications of surgical and nonsurgical treatment of dis-
placed condylar fractures has also been the interest of our
research group. The most important indication for surgical
intervention is that normal occlusion is not achieved by closed
reduction and that mouth opening is either deviated or limited
due to displacement of the condyl. Another indication for
open reduction would be the presence of dental trauma that
prevents the restoration of occlusion. We have shown that
dental injuries, mostly crown fractures in the molar area, are
present in 38% of condylar fracture cases3 Dental injuries
not only worsen the possibilities for occlusal rehabilitation.
but also they can be harmful, eg, in cases where pulpitis occurs
during long-lasting MMF.
One goal ofdirect internal fixation is to avoid MMF. which
does not take place in surgical treatment such as used by
the authors. There was no thorough discussion of other sur-
gical modalities; particularly. those that produce rigid osteo-
synthesis are more or less lacking. Low subcondylar fractures
can be regarded as ramus fractures and can be treated with
miniplates or screws, without the need for MMF.
There is one important aspect to consider in rigid internal
fixation ofcondylar fractures. The condyle protects the brain
in facial accidents. The weak condylar neck breaks easily and
therefore no intracranial displacement is possible. I do not
dare to imagine a situation in which a patient with a previous
screw fixation receives a similar new injury that does not
cause fracture in the condylar neck. This problem could be
solved by the development of resorbable osteosynthesis ma-
terials. Rigid fixation by means of miniplates is also not with-
out problems since a study by Iizuka et al demonstrated ex-
tensive resorption of the condyle in such cases.4
The method described in this article is in many ways similar
to the one in which the dislocated condyle is repositioned
without osteosynthesis, and MMF with elastics is used for
some weeks after the injury. This type of treatment could be
considered as the most biologic because no foreign material
is needed, but it can be used only if the displaced condyle
can be repositioned firmly in its original anatomic location.
The problem is that this, as well as most other surgical treat-
ments, require an extraoral approach. This increases treat-
ment-related risks, as well as the time of hospitalization and