Functional reconstruction of the TM joint in cases of severely displaced fractures and fracture dislocation

In a clinical and axiographic study the outcome of patients with severely displaced fractures and fracture dislocations of the mandibular condyle was evaluated. Two operation methods were compared one via an intraoral approach without joint revision and another via a preauricular approach with open reduction of the joint. In the group with joint revision, resorbable material was used for osteosynthesis. Twenty-eight patients (32 joints) treated without revision of the joint and 26 patients (29 joints) with open reduction of the joint were evaluated. The mean observation time following surgery was 3 years and 10 months (range 1-7.5 years). Clinical examination utilized the Helkimo-index, while the electronic axiographical results were evaluated by using a five point scheme of joint-mobility. Concerning clinical evaluation, 20 out of 28 patients (71%) without joint revision and 23 out of 26 (89%) patients with joint revision had none or only slight dysfunction of the stomatognathic system. When focusing on arthralgia and pain in motion (part D and E of Helkimo's-index) significantly better results were achieved by open joint revision (Helkimo D: p< or =0.007; Helkimo E: p = 0.0029). No patient exhibited severe dysfunction (group D3). In axiographic evaluation optimal results (group A1) were achieved in seven joints (24%) with revision and four joints (12%) without revision. Twelve out of 29 joints with revision (41%) and six out of 32 joints without revision (19%) were classified as group A2 with a slightly shortened condylar excursion. Revision of joints with disc reduction and reconstruction of ligaments in cases of severely displaced or dislocated fractures resulted in better mobility and less pain. This was seen clinically and in the axiographic results. Looking at the long-term outcome of patients better mobility of the joint without internal derangement due to surgical repair also protects the contralateral (nonoperated) joint. When managing severe TMJ-trauma we suggest that both, bony and soft tissue structures should be reconstructed if there are any signs of internal derangement. However, the limits between bony reconstruction with or without joint revision are still not defined. Our results appear to be promising concerning mobility and absence of pain of the joints after open reduction. Further research comparing the two operative treatment regimes in a randomized controlled clinical trial will be necessary.