Vol. 115 No. 1 January 2013

Closed reduction of mandibular condyle fractures using C-armfluoroscopy: a technical noteTomoaki Imai, DDS, PhD,a Masahiro Michizawa, DDS, PhD,b Naofumi Yamamoto, DDS, PhD,c andTatsuro Kai, MDd

Saiseikai Senri Hospital, Suita, Osaka, Japan

We describe a C-arm technique for mandibular condylar fractures in an anatomic study using a model skull andshow its feasibility in a clinical case. The C-arm allowed posterior-anterior visualization of the condylar process. The X-rayaxis was canted �15 degrees cranially to the Frankfort horizontal line. The skull’s sagittal plane was rotated �15 degreesipsilaterally to the X-ray axis. This technique facilitates clear visualization of the condylar neck with easy, flexible, and timelyadjustments. In selected cases, this method would convert the clinical settings of the condylar fracture pattern to that whichwould not be amenable to an open approach, making possible minimally invasive surgical procedures. (Oral Surg Oral Med

Oral Pathol Oral Radiol 2013;115:e4-e9)

Mandibular fractures are a commonly occurring problemin maxillofacial surgery, particularly condylar fracturesfor which management techniques remain controversial.1

Refinements in surgical methods and improvements ininstrumentation have increased in the application of openreduction and internal fixation (ORIF) to condylar frac-tures.2,3 However, postoperative sequelae, including di-minished facial nerve function, unesthetic visible scarring,and unexpected bleeding, are occasionally nagging con-cerns for surgeons and patients. Although endoscope-assisted systems have improved these problems some-what, the dissection required for this technique still posesrisks.4 Nonsurgical treatment using maxillomandibularfixation (MMF) accompanied by adequate physiotherapycan also yield acceptable results.1,5 These 2 alternativesare preoperatively evaluated based on clinical assessmentand imaging modalities,3,4 in accordance with the wishesand general status of the patient and the surgeon’s profes-sional judgment and experience. In some cases, the ap-propriate management of condylar fractures needs to bedecided intraoperatively.3

Intraoperative real-time visualized closed reductionusing convenient modalities is preferred in a traumacenter operating room, and may help reduce complica-tions arising from invasive surgery. Notably, the C-armfluoroscopic technique, routinely used in orthopedicsurgery, has not been widely applied to the maxillofa-cial region.6 Although its utility in midfacial fractures,

aChief consultant, Department of Oral and Maxillofacial Surgery.bFormer chief, Department of Oral and Maxillofacial Surgery.cConsultant, Department of Oral and Maxillofacial Surgery.dDirector, Senri Critical Care Medical Center.Received for publication Aug 11, 2011; accepted for publication Aug23, 2011.© 2013 Elsevier Inc. All rights reserved.2212-4403/$ - see front matter

doi:10.1016/j.oooo.2011.08.018

e4

such as zygomatic6-10 or nasal bone fractures,10 hasbeen demonstrated, few papers have focused on man-dibular fractures, particularly those of the condyle, andthose only to a very limited extent.11 Herein, we de-scribe a C-arm technique for repairing mandibular con-dylar fractures in an anatomic study and demonstrate itsclinical feasibility.

TECHNIQUEWe used a standard C-arm system, the OEC 9800 Plus(GE OEC Medical Systems, Salt Lake City, Utah). Adry cadaver skull was positioned on the operating tablewith the Frankfort horizontal (FH) line perpendicular tothe tabletop. Irradiation was directed from the bottomup to the intensifier above the table (Figure 1). Becausethe X-ray axis was parallel to the FH line, and theimage of the mandibular condyle was masked by thezygoma, the axis was canted about 15 degrees craniallyto the FH line. The skull’s sagittal plane was rotatedabout 15 degrees ipsilaterally to the X-ray axis, free ofthe mastoid bone’s image. These positions allowed forposterior-anterior visualization of the condylar process,suitable for displaying the condylar neck and mediolat-eral malpositioning of the condylar process (Figure 2).

In the clinical case using fluoroscopy, the operatormanipulated the mandible to reduce the fractured con-dyle, followed by assessment of the bone alignment andits relapse during simulated jaw movements. A defini-tive plan for repairing these fractures by either surgicalor nonsurgical treatment was based on reduction statusmentioned above and confirming improved occlusalstability.

CLINICAL CASEA 19-year-old Japanese man involved in a motorbikeaccident suffered a laceration to the chin with trismus

and open bite. Plain X-ray and computerized tomo-

clearl

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graphic (CT) analyses revealed multiple mandibularfractures involving the symphysial body, bilateral con-dyles, and an alveolar maxillary fracture (Figure 3). Inrepairing these fractures, the patient expressed hiswishes to avoid additional skin incisions wherever pos-

Fig. 1. Optimized positioning for C-arm fluoroscopy of theintensifier above the table (arrowheads). A, Operator’s side. A(black line) perpendicular to the tabletop. The X-ray axis isskull’s sagittal plane (black line) is rotated 10-15 degrees ipthe operative procedure.

Fig. 2. A, Close-up photograph of a model skull. The needfluoroscopic view of the mandibular condyle. The condyle is

sible. We thus preferentially arranged ORIF under

MMF for the symphysial fracture using titanium mini-plates through the chin laceration to obtain anatomicreduction and mandibular body immobilization. Afterremoval of MMF, the mandible was angled back pos-teriorly and the occlusion indicated open bite. The right

bular condyle. Irradiation is directed from bottom up to thedaver skull is positioned at the Frankfort horizontal (FH) line10-15 degrees cranially to the FH line. B, Cranial side. Theally to the X-ray axis. This position does not interfere with

cates a virtual fracture line at the condylar neck. B, C-Army displayed with the virtual fracture line (arrow).

mandidry ca

cantedsilater

le indi

condyle was fractured at the lower neck level with

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medial inclination (moderate displacement3). Manipu-lative reduction was applied under fluoroscopic obser-vation, resulting in perpendicular repositioning of thecondyle, little relapse of the displacement, and satisfac-tory stability of the occlusal position (Figure 4). Wethus abbreviated the open surgery of the right condylarfracture. Because the left condyle was fractured at thehigher neck level (maximal displacement3), closedtreatment with postoperative MMF was planned.12 Cu-mulative fluoroscopic time was no longer than half aminute.

Postoperative X-ray revealed restoration of mandib-ular ramus height. Additional MMF was applied for aweek. Daily jaw exercises commenced 1 week after

Fig. 3. A clinical case of a 19-year-old man involved in a moimaging, showing multiple mandibular fractures involving tfracture of the maxilla. B, The right condyle is fractured at thhigher neck, and dislocated from the glenoid fossa. The sympfacial bone fractures are evident.

operation, and the degree of mouth opening gradually

increased to �45 mm with maintenance of a stableocclusal position. Finally, chin deviation and temporo-mandibular joint pain were not evident when the mouthwas opened.

DISCUSSIONGiven that not all types of condylar fractures haveclear-cut preoperative indicators that specify usingopen or closed methods,1 treatment strategy is preop-eratively planned based primarily on the site of thefracture line and degree of displacement. Ellis3 raised aquestion with this modality because it is too reliant onpreoperative imaging. He emphasized that surgeonsshould attach importance to intraoperative assessment

e accident. A, Three-dimensional computerized tomographicphysial body and bilateral condyles, and an alveolar bone

er neck with medial inclination. C, The left condyle is at thefracture leads to widening of the interramus width. No other

torbikhe syme lowhysial

without relying only on fracture patterns.3 Here, we

cessfu

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present the concept that the combination of dynamicfluoroscopic closed reduction and the assessment ofmandible stability, including occlusion, can intraoper-atively manage treatment strategy of these common andoften challenging fractures.

Intraoperative modalities have been applied to themaxillofacial region, including a portable plain X-ray,intraoperative CT technique,13 ultrasonography,14 C-arm fluoroscopy,7 and 3-dimensional navigation sys-tem.15 Plain X-ray and intraoperative CT techniquesdisplay a static image during the operation, whereas thelatter 3 modalities allow dynamic assessment throughcontinuous imaging during the operator’s manipula-tions. Ultrasonography is used to repair midfacial frac-tures primarily because of the instruments’ portability

Fig. 4. Closed reduction of the right side of the condyle. Arrocondyle with medial inclination. The condyle was not reducedto be 20-45 degrees, which corresponds to “moderate displaceThe fluoroscopic image provides real-time observation for rednearly perpendicular reduction. C-Arm–guided reduction suc

and does not use ionizing radiation. However, mandib-

ular condylar fractures may be difficult to assess byultrasound, because the small segment is positioned3-dimensionally and its interactions with the adjacenttissues are usually complex. Although surgical naviga-tion has become a useful technique for craniofacialsurgery, particularly for complex unilateral fractures,such as in the orbital wall or lateral midface,16 availablenavigation systems are cumbersome, experimental, andexpensive, raising uncertainties for their application tomandibular surgery.17 In contrast, the C-arm system isflexible, maneuverable, and can be quickly positioned.Furthermore, it can be operated without a radiologictechnologist and is widely availability in trauma cen-ters.6,9 It is important to note that Badjate and Cari-appa8 caution that even though the C-arm emits low-

cate a fracture line; arrowheads, the condyle. A, Preoperativexillomandibular fixation. Condylar process tilting is estimatedaccording to Ellis’s classification.3 B, Intraoperative condyle.control of the inclined condyle. C, Postoperative condyle withlly achieved this outcome.

ws indiby mament”uction

dose radiation for only a few minutes’ duration,

ORAL AND MAXILLOFACIAL SURGERY OOOOe8 Imai et al. January 2013

medical staff within a 2-m zone should wear a 0.25-mmlead-equivalent light apron.

From the standpoint of minimal surgical interventionin treating condylar fractures occurring simultaneouslywith fractures of the mandible, Ellis3 described amethod that recognizes cases not requiring open treat-ment and noted that nonsurgical treatment would bealmost universally valid where the mandible has notdropped posteriorly with malocclusion, even in maxi-mally displaced fractures. For cases involving an an-gled-back mandible, open surgery would be indicatedbecause closed treatment is likely to be labor-intensivefor the caregiver and patient alike. Furthermore, closedtreatment would involve using guiding elastics for alonger period to regain normal occlusion with stabil-ity.3 In this strategy, the C-arm technique for the an-gled-back cases may contribute to repositioning thecondyle, leading to reassessing the requirement for adefinitive open approach. An important considerationhere is that if this technique achieves satisfactory con-dylar reduction and restores normal occlusion by sim-ply closing the mouth, the condyle’s condition wouldbe converted to that of a case not requiring surgery.

We do not advocate that the method presented iseither mandatory or useful for all types of condylarfractures. When considering fractures at the condylarhead and comminuted condylar fractures, this tech-nique might be unsuitable, because of the fractureslikely being masked by surrounding bones and the lackof resolution under fluoroscopy. In fractures with dis-location, this technique is not indicated, owing to dif-ficulty of its repositioning. Essential to the success ofthe fluoroscopic reduction technique would be the pres-ence of bony continuity or residual periosteal envelope,to some extent, at fracture lines.

Gupta et al.18 have noted that cases with mild tomoderate condylar displacement with slight malocclu-sion seem to be best treated by closed treatment, andthat severely displaced fractures with malocclusion,especially in bilateral cases, should be treated withORIF. Consistent with the conversion of clinical set-tings by fluoroscopic reduction from fractures of onedislocated condyle and the other displaced with openbite to fractures of one dislocated condyle and the othernondisplaced with reproducible normal occlusion,treatment of the present case decreased the requirementfor condylar surgery and resulted in good functionaloutcomes. Malocclusion due to condylar displacementcertainly might be treated by only maintaining MMFfor a longer time. Considering open reduction withoutinternal fixation as a treatment option by which a se-verely displaced fracture is converted to a nondisplaced

fracture,19 anatomic repositioning using the C-arm may

contribute to postoperative occlusal stability and func-tional therapy.

In conclusion, applying this methodology to selectedcases of condylar fractures would convert a fracturepattern to one which would not benefit from the openapproach and would serve to extend patient manage-ment by nonsurgical treatment. Future studies shouldinclude additional cases with quantitative clinical andimaging assessments and simulation for minimizingexposure to direct and scatter radiation.

The authors thank Yoshiki Kimoto for support of theanatomic study.

REFERENCES1. Laskin DM. Management of condylar process fractures. Oral

Maxillofac Surg Clin North Am 2009;21:193-6.2. Abdel-Galil K, Loukota R. Fractures of the mandibular condyle:

evidence base and current concepts of management. Br J OralMaxillofac Surg 2010;48:520-6.

3. Ellis E 3rd. Method to determine when open treatment of con-dylar process fractures is not necessary. J Oral Maxillofac Surg2009;67:1685-90.

4. Chen CT, Feng CH, Tsay PK, Lai JP, Chen YR. Functionaloutcomes following surgical treatment of bilateral mandibularcondylar fractures. Int J Oral Maxillofac Surg 2011;40:38-44.

5. Smets LM, van Damme PA, Stoelinga PJ. Nonsurgical treatmentof condylar fractures in adults: a retrospective analysis. J Cran-iomaxillofac Surg 2003;31:162-7.

6. Imai T, Michizawa M, Fujita G, Shimizu H, Ota Y, Kitamuta T,et al. C-Arm–guided reduction of zygomatic fractures revisited.J Trauma 2011;71:1371-5.

7. Griffin JE Jr, Max DP, Frey BS. The use of the C-arm inreduction of isolated zygomatic arch fractures: a technical over-view. J Cranio Maxillofac Trauma 1997;3:27-31.

8. Badjate SJ, Cariappa KM. C-Arm for accurate reduction ofzygomatic arch fracture—a case report. Br Dent J 2005;199:275-7.

9. Czerwinski M, Parker WL, Beckman L, Williams HB. Rapidintraoperative zygoma fracture imaging. Plast Reconstr Surg2009;124:888-98.

10. Chen RF, Chen CT, Hao Chen C, Liao HT, Chen YR. Optimiz-ing closed reduction of nasal and zygomatic arch fractures witha mobile fluoroscan. Plast Reconstr Surg 2010;126:554-63.

11. Boutros SG. Closed reduction and fluoroscopically assisted per-cutaneous stabilization of displaced subcondylar mandible frac-tures. Plast Reconstr Surg 2005;116:971-7.

12. Brandt MT, Haug RH. Open versus closed reduction of adultmandibular condyle fractures: a review of the literature regardingthe evolution of current thoughts on management. J Oral Max-illofac Surg 2003;61:1324-32.

13. Stanley RB Jr. Use of intraoperative computed tomography dur-ing repair of orbitozygomatic fractures. Arch Facial Plast Surg1999;1:19-24.

14. Adeyemo WL, Akadiri OA. A systematic review of the diagnos-tic role of ultrasonography in maxillofacial fractures. Int J OralMaxillofac Surg 2011;40:655-61.

15. Gellrich NC, Schramm A, Hammer B, Rojas S, Cufi D, LagrèzeW, Schmelzeisen R. Computer-assisted secondary reconstructionof unilateral posttraumatic orbital deformity. Plast Reconstr Surg2002;110:1417-29.

16. Yu H, Shen G, Wang X, Zhang S. Navigation-guided reduction

OOOO CASE REPORTVolume 115, Number 1 Imai et al. e9

and orbital floor reconstruction in the treatment of zygomatic-orbital-maxillary complex fractures. J Oral Maxillofac Surg2010;68:28-34.

17. Siessegger M, Mischkowski RA, Schneider BT, Krug B, KlesperB, Zöller JE. Image guided surgical navigation for removal offoreign bodies in the head and neck. J Craniomaxillofac Surg2001;29:321-5.

18. Gupta M, Iyer N, Das D, Nagaraj J. Analysis of different treat-ment protocols for fractures of condylar process of mandible.J Oral Maxillofac Surg 2012;70:83-91.

19. Iizuka T, Lädrach K, Geering AH, Raveh J. Open reduction

without fixation of dislocated condylar process fractures: long-

term clinical and radiologic analysis. J Oral Maxillofac Surg1998;56:553-61.

Reprint requests:

Dr. Tomoaki ImaiDepartment of Oral and Maxillofacial SurgerySaiseikai Senri Hospital1-1-6 Tsukumodai, SuitaOsaka 565-0862Japan

hsc12@hotmail.com