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OP-Journal 2013; 29(2): 156-163
DOI: 10.1055/s-0033-1350818
Georg Thieme Verlag KG Stuttgart · New York

Kiefergelenkfortsatzbasis- und Kiefergelenkhalsfrakturen bei Kindern und Jugendlichen – Plädoyer für eine transoral endoskopisch assistierte operative Versorgung bei starker Dislokation und Luxation

Condylar Base and Neck Fractures in Children and Adolescents – A Plea for Transoral Endoscopically Assisted Management of Severe Dislocations and Luxations
Sebastian Schiel
,
Florian Probst
,
Peter Mayer
,
Gabriele Kaeppler
,
Carl Peter Cornelius
Further Information

Publication History

Publication Date:
20 January 2014 (online)

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Zusammenfassung

Während bei Erwachsenen weitgehend klare Indikationen für die operative Versorgung von Kiefergelenkfortsatzfrakturen bestehen und diese Frakturen mehrheitlich operativ versorgt werden, wird bei Kindern und Jugendlichen immer noch ein nicht operatives (konservatives) Behandlungskonzept bevorzugt. Argument dafür ist das vermeintlich hohe spontane Regenerationspotenzial bis ins frühe Teenageralter. Stark dislozierte (> 45° Achsabweichung) und luxierte Kiefergelenkfortsatzbasis- und Kiefergelenkhalsfrakturen, die nicht operativ behandelt wurden, führen bei Kindern und Jugendlichen nicht selten zu Wachstumsstörungen mit Gesichtsasymmetrien, Bissstörungen und Dysplasien im Kiefergelenkbereich. Aktuelle Therapiekonzepte tendieren deshalb auch bei Kindern und Jugendlichen mit Luxationen oder erheblichen Dislokationen zu einer operativen Versorgung mit anatomisch korrekter Reposition und rigider Fixierung. Dieser Paradigmenwechsel von geschlossener Behandlung zur Osteosynthese über einen transfazialen oder insbesondere den hier dargestellten transoralen Zugangsweg hat sich erst auf der Grundlage von Fortschritten in der Behandlung von Kiefergelenkfortsatzfrakturen bei Erwachsenen entwickelt. Im Folgenden werden Überlegungen zu einem Klassifikationsvorschlag für pädiatrische Kiefergelenkbasis- und Kiefergelenkhalsfrakturen, die typische klinische Symptomatik einschließlich der bildgebenden Diagnostik und das derzeitige Behandlungskonzept mit dem operativ-technischen Vorgehen dargestellt.

Abstract

While indications for the surgical treatment of condylar base and neck fractures in adults are rather well defined with most fractures being treated by open reduction and fixation, the preference in children and adolescents is still for non-operative therapy. The argument in favour of this is the presumably high remodelling potential up to the early adolescent age. However, non-operative treatment of severely displaced and dislocated condylar neck and base fractures in children and adolescents may result in growth disturbances with facial asymmetry, malocclusion and dysplastic shape of the condylar process. Thus, present day concepts suggest, even for these age groups, the use of open surgical treatment for displaced and dislocated condylar neck and base fractures with anatomic reduction and rigid fixation. The paradigm shift from closed treatment to open reduction and osteosynthesis using a transfacial or, as emphasised here, a transoral approach could be developed only on the basis of recent advances in the treatment of condylar process fractures. Some basic thoughts about a classification proposal for paediatric condylar base and neck fractures, the clinical symptomatology including diagnostic imaging and an actual treatment concept, emphasising a transoral endoscopically assisted approach and its surgical technique are presented in this article.

 

  • Literatur

  • 1 Chen CT, Lai JP, Tung TC et al. Endoscopically assisted mandibular subcondylar fracture repair. Plast Reconstr Surg 1998; 103: 160-165
    PubMedGoogle Scholar
  • 2 Cornelius C et al. AO CMF Frakturen Klassifikation. OP Journal 2013; 29: 109-128
    PubMedGoogle Scholar
  • 3 Cornelius CP, Ehrenfeld M, Laubengeiger M et al. Ergebnisse eines konservativ-funktionellen Therapiekonzepts bei kindlichen Kondylusfrakturen. Dtsch Zahnärztl Z 1991; 46: 46-49
    PubMedGoogle Scholar
  • 4 Deleyiannis FW, Vecchione L, Martin B et al. Open reduction and internal fixation of dislocated condylar fractures in children: long-term clinical and radiologic outcomes. Ann Plast Surg 2006; 57: 495-501
    CrossrefPubMedGoogle Scholar
  • 5 Dodson TB. Condyle and ramus-condyle unit fractres in growing patients: management and outcomes. Oral Maxillofac Surg Clin North Am 2005; 17: 447-453
    CrossrefPubMedGoogle Scholar
  • 6 Eckelt U, Schneider M, Erasmus F et al. Open versus closed treatment of fractures of the mandibular condylar process-a prospective randomized multi-centre study. J Craniomaxillofac Surg 2006; 34: 306-314
    CrossrefPubMedGoogle Scholar
  • 7 Ellis III E, Throckmorton GS. Treatment of mandibular condylar process fractures: biological considerations. J Oral Maxillofac Surg 2005; 63: 115-134
    PubMedGoogle Scholar
  • 8 Fritzemeier CU, Bechthold H. Die Osteosynthese von Unterkiefergelenkfortsatzfrakturen mit alleinigem Zugang von intraoral. Dtsch Z Mund Kiefer Gesichtschir 1993; 17: 66-68
    PubMedGoogle Scholar
  • 9 Hammer B, Schier P, Prein J. Osteosynthesis of condylar neck fractures: a review of 30 patients. Br J Oral Maxillofac Surg 1997; 35: 288-291
    CrossrefPubMedGoogle Scholar
  • 10 Iatrou I, Theologie-Lygidakis N, Tzerbos F. Surgical protocols and outcome for the treatment of maxillofacial fractures in children: 9 yearsʼ experience. J Craniomaxillofac Surg 2010; 38: 511-516
    CrossrefPubMedGoogle Scholar
  • 11 Jacobovicz J, Lee C, Trabulsky PP. Endoscopic repair of mandibular subcondylar fracture. Plast Reconstr Surg 1998; 101: 160-165
    PubMedGoogle Scholar
  • 12 Kaeppler G, Cornelius CP, Ehrenfeld M et al. Diagnostic efficacy of cone-beam computed tomography for mandibular fractures. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116: 98-104
    PubMedGoogle Scholar
  • 13 Lang J, Öder M. Über die Biomorphose der Mandibula. Gegenbaurs Morph Jahrb 1984; 130: 185-234
    PubMedGoogle Scholar
  • 14 Lekven N, Neppelberg E, Tornes K. Long-term follow-up of mandibular condylar fractures in children. J Oral Maxillofac Surg 2011; 69: 2853-2859
    CrossrefPubMedGoogle Scholar
  • 15 Lindahl L. Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and teeth-supporting structures, and fractures of the mandibular body. Int J Oral Surg 1977; 6: 12-21
    CrossrefPubMedGoogle Scholar
  • 16 Lindahl L, Hollender L. Condylar fractures of the mandible. II. A radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 1977; 6: 12-21
    CrossrefPubMedGoogle Scholar
  • 17 Lindahl L. Condylar fractures of the mandible. III. Positional changes of the chin. Int J Oral Surg 1977; 6: 166-172
    CrossrefPubMedGoogle Scholar
  • 18 Loukota RA, Eckelt U, De Bont L et al. Subclassification of fractures of the condylar process of the mandible. Br J Oral Maxillofac Surg 2005; 43: 72-73
    CrossrefPubMedGoogle Scholar
  • 19 Lund K. Mandibular growth and remodeling processes after condylar fracture. A longitudinal roentgencephalometric study. Acta Odontol Scand Suppl 1974; 32: 3-117
    PubMedGoogle Scholar
  • 20 Rasse M. Neuere Entwicklungen der Therapie der Gelenkfortsatzbrüche der Mandibula. Mund Kiefer Gesichtschir 2000; 4: S69-S87
    CrossrefPubMedGoogle Scholar
  • 21 Rowe NL. Fractures of the jaws of children. J Oral Surg 1969; 27: 497-507
    PubMedGoogle Scholar
  • 22 Schiel S, Smolka W, Leiggener C et al. „Open book“-Frakturen des Mandibularbogens: Bilaterale Gelenkfortsatzfrakturen in Kombination mit Paramedian-/Medianfrakturen des Unterkiefers. Operative Behandlungsstrategien. OP Journal 2012; 28: 194-210
    PubMedGoogle Scholar
  • 23 Schiel S, Mayer P, Probst FA et al. Transoral open reduction and fixation of condylar base and neck fractures in children and young teenagers – a beneficial treatment option?. J Oral Maxillofac Surg 2013; 71: 1220-1230
    CrossrefPubMedGoogle Scholar
  • 24 Schmelzeisen R, Cienfuegos-Monroy R, Schön R et al. Patient benefit from endoscopically assisted fixation of condylar neck fractures–a randomized controlled trial. J Oral Maxillofac Surg 2009; 67: 147-158
    CrossrefPubMedGoogle Scholar
  • 25 Schneider M, Erasmus F, Gerlach KL et al. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg 2008; 66: 2537-2544
    CrossrefPubMedGoogle Scholar
  • 26 Schön R, Fakler O, Gellrich NC et al. Five year experience with the transoral endoscopic-assisted treatment of displaced condylar mandible fractures. Plast Reconstr Surg 2005; 116: 44-50
    PubMedGoogle Scholar
  • 27 Schön R, Gellrich NC, Schmelzeisen R. Minimal invasive open reduction of dislocated pediatric condylar fracture. Brit J Oral Maxillofac Surg 2005; 43: 258-260
    CrossrefPubMedGoogle Scholar
  • 28 Silverman S. A new operation for displaced fractures at the neck of the mandibular condyle. Dental Cosmos 1925; 67: 876-877
    PubMedGoogle Scholar
  • 29 Strobl H, Emshoff R, Rothler G. Conservative treatment of unilateral condylar fractures in children: a long-term clinical and radiologic follow-up of 55 patients. Int J Oral Maxillofac Surg 1999; 28: 95-98
    PubMedGoogle Scholar
  • 30 Thoren H, Hallikainen D, Iizuka T et al. Condylar process fractures in children: a follow-up study of fractures with total dislocation of the condyle from the glenoid fossa. J Oral Maxillofac Surg 2001; 59: 768-774
    CrossrefPubMedGoogle Scholar
  • 31 Thoren H, Iizuka T, Hallikainen D et al. An epidemiological study of patterns of condylar fractures in children. Br J Oral Maxillofac Surg 1997; 35: 306-311
    CrossrefPubMedGoogle Scholar
  • 32 Valiati R, Ibrahim D, Abreu ME et al. The treatment of condylar fractures: to open or not to open? A critical review of this controversy. Int J Med Sci 2008; 5: 313-318
    PubMedGoogle Scholar
  • 33 Veras RB, Kriwalsky MS, Eckert AW et al. Long-term outcomes after treatment of condylar fracture by intraoral access: a functional and radiologic assessment. J Oral Maxillofac Surg 2007; 65: 1470-1476
    CrossrefPubMedGoogle Scholar
  • 34 Widmark G, Bagenholm T, Kahnberg KE et al. Open reduction of subcondylar fractures. Int J Oral Maxillofac Surg 1996; 25: 107
    CrossrefPubMedGoogle Scholar