Discussion
Discussion: Which Factors Are Associated with Open
Reduction of Adult Mandibular Condylar Injuries?
Edward Ellis III, D.D.S., M.S.
San Antonio, Texas
T he management of mandibular condylar
fractures is perhaps the most controversial
topic in maxillofacial trauma. Many studies have
attempted to answer the question: “Should condy-
lar fractures undergo open or closed treatment?”
However, this is the wrong question. We will never
be able to answer that question. There are just
too many variables to be able to make a blanket
statement that places all condylar fractures into
the same basket. What we should instead be ask-
ing is: “Are there some condylar fractures that
would have better outcomes when treated open?”
And, if so, “How do we identify them?
The study by Wang et al. is an attempt to
answer the latter question, and I applaud them
for undertaking such an exhaustive analysis of
their cases. They painstakingly considered as
many variables as possible. However, their study
is just that—an analysis of how patients with con-
dylar process fractures were treated at their insti-
tution. It is easy to make the assumption that,
because most of the surgeons involved seemed to
provide similar treatment (open versus closed),
this is the correct treatment. Unfortunately, with
limited follow-up and measureable outcomes, we
really do not know whether the treatment that
was rendered was in fact the best treatment. That
is the main problem with retrospective studies—
especially those with poor follow-up.
Additional problems that were well-addressed
in the Discussion section of this article are the
multiple variables associated with each case. And
there are many. The variables that should be con-
sidered when deciding on a treatment plan for
a given patient with a condylar process fracture
include the following:
1. Maturational age of the patient.
2. Bilateral versus unilateral condylar
fracture(s).
From the Department of Oral and Maxillofacial Surgery,
University of Texas Health Science Center at San Antonio.
Received for publication December 7, 2015; accepted Janu-
ary 13, 2016.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002154
1822 www.PRSJournal.com
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
3. Displacement/dislocation of the fracture(s).
4. Level of the fracture (head, neck, subcondylar).
5. State of the dentition (complete, incom-
plete, edentulous).
6. Concomitant injuries (including other
fractures).
7. Adaptability of the masticatory system.
8. Quality of treatment.
9. Quality of the rehabilitation process.
10. Treatment (closed versus open).
Many if not most of the first six variables were
consciously or subconsciously considered by the
clinicians in developing a treatment plan. How-
ever, variables 7 through 9 are perhaps even more
important and certainly not measureable in ret-
rospective studies. Variable 7, adaptability of the
masticatory system, is not measureable at all and
yet might be one of the most important variables.
Differences in adaptability of the masticatory sys-
tem might explain why some patients with bad
condylar process fractures do well regardless of
what treatment is rendered and others do not.
Each person’s ability to adapt to a given injury var-
ies and is so far not quantifiable.
What we need to prove is whether the treat-
ment that was rendered by the surgeons at this
institution was in fact the best treatment. Such a
question cannot be answered in a retrospective
study because of the multitude of uncontrolled
variables that were present and discordant among
patients. Such questions have to be sorted out in
prospective studies that limit and/or control the
variables so that we can glean information about
what benefit a given treatment really provides.
Until such studies have been performed, the
management of condylar process fractures will be
determined by the experience and beliefs of the
surgeon. In the study by Wang et al., they found
that open treatment was associated with other
noncondylar mandibular fractures, condylar
Disclosure: The author has no financial interest to
declare in relation to the content of this Discussion or
of the associated article.
 Volume 137, Number 6 • Discussion
neck or subcondylar involvement, and fractures
with increasing magnitude of dislocation. How
can one use this information in clinical practice?
Unfortunately, it is not very useful information.
For instance, if a patient is seen with the combi-
nation of condylar fracture(s) and a symphysis
fracture, should we perform open treatment of
the condylar process fracture(s) because, in this
study, that was done with some frequency? Until it
has been proven that this treatment is better than
closed treatment, I do not think so.
Inherent in the decision about open versus
closed treatment is another variable that is not
usually mentioned: the ability of the surgeon.
One must remember that when open treatment is
selected, the possibility of intraoperative and post-
operative complications arises. One must there-
fore understand what the goals of treatment are
and decide whether they, with their skill set, can
obtain those goals better with one form of treat-
ment over another.
The goals of treatment of condylar process
fractures are the establishment of the pretrauma
occlusion, good mandibular mobility, facial sym-
metry, and pain-free function. The goals are inde-
pendent of the characteristics of the patient’s
other injuries, demographics, or the treatment
they receive. The goals are always the same. For
surgeons to select open treatment, they must be
able to convince themselves that they, with their
skill set, can better achieve the above goals with
open treatment than they can with closed treat-
ment. The risk-to-benefit ratio has to be consid-
ered in light of the patient’s injuries and the skill
of the surgeon. One must recognize that not all sur-
geons are facile with open treatment of condylar
process fractures, and for them, the risks of open
treatment may outweigh the potential benefit.
If surgeons cannot convince themselves that the
risks of open treatment increase the likelihood of
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
satisfying the above treatment goals, closed treat-
ment should probably be selected.
This is undoubtedly the reason why most of
the condylar process fractures that were treated
open in this study were those that were the easi-
est ones to treat open—low neck and subcondy-
lar fractures. It is likely that the surgeons decided
either consciously or subconsciously that their
ability to perform open treatment of intracapsular
fractures was not worth the risk, and yet at some
centers around the world, mostly in Europe and
China, open treatment of intracapsular fractures
is performed routinely. The surgeons in those
centers obviously feel differently about their abili-
ties to perform open treatment of intracapsular
fractures.
I would again like to applaud Wang et al. for
their contribution. Their study was based on good
intentions. Unfortunately, there is not much use-
ful information resulting from this study that can
help direct clinicians when they are next con-
fronted with a condylar process fracture.
Lastly, I would like to put the treatment of
condylar fractures into perspective. If I had to
distill the world literature on the topic of out-
comes in patients treated for condylar process
fractures, it would be as follows: “Although objec-
tive outcome measures vary with the level of frac-
ture (head, neck, subcondylar), displacement/
dislocation, bilateral versus unilateral, and associ-
ated injuries—irrespective of whether the patient
was treated open or closed—the vast majority
of patients have few subjective complaints.” This
should be kept in mind when making treatment
decisions for patients with condylar fractures.
Edward Ellis III, D.D.S., M.S.
Department of Oral and Maxillofacial Surgery
University of Texas Health Science Center at San Antonio
8210 Floyd Curl Drive, MC 8124
San Antonio, Texas 78229-3923
ellise3@uthscsa.edu
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