Neff A, Kolk A, Neff F, Horch H H
Klinik und Poliklinik für Mund-Kiefer-Gesichtschirurgie, Klinikum rechts der Isar, Technische Universität München.
Mund Kiefer Gesichtschir. 2002 Mar;6(2):66-73. doi: 10.1007/s10006-001-0345-4.
At present the discussion about the correct management of high condylar and diacapitular fractures has been reopened. The aim of the present prospective study was to evaluate the role of condylar mobility, disk mobility, and vertical dimension regarding the postoperative functional outcome after open reduction and osteosynthesis compared to nonsurgical treatment.
Since 1993 a total of 130 high condylar and diacapitular fractures have been treated by open reduction and osteosynthesis. Thirty-nine subjects with 51 fractures classes V and VI according to Spiessl and Schroll (surgical treatment, ST) were assessed postoperatively (mean 24 months) including magnetic resonance imaging (MRI) and axiography. Sixteen conservatively treated fractures served as a reference (conservative treatment, CT).
Surgically treated temporomandibular joints presented a better condylar mobility (11.4 mm after ST, 5.9 mm after CT) and a less remarked loss of vertical ramus height (1.6 mm after ST, 5.4 mm after CT). Conservatively treated high condylar fractures formed a nearthrosis with the articular eminence in an anteromedial malposition (x axis 6.9 mm, y axis 10.3 mm). Disk mobility was reduced in both groups (3.8 mm after CT, 5.8 mm after ST), with major interindividual variations after ST. Significant correlations were found in the surgically treated group between axiographic limitations and limitations of disk mobility (p < 0.01) or periarticular scar formations (p < 0.01). Helkimo indices after ST (31% symptom free, 67% light symptoms < 5 points) were clearly superior (p < 0.01) to conservative treatment, with 63% of the subjects presenting craniomandibular symptoms > 5 points.
According to the functional results observed, high condylar and diacapitular fractures will profit by open reduction and osteosynthesis. Only effective surgical procedures can preserve both disk mobility and vertical ramus height.
目前，关于髁突高位骨折和双髁突骨折正确治疗方法的讨论再次展开。本前瞻性研究的目的是评估与非手术治疗相比，髁突活动度、盘状软骨活动度和垂直维度在切开复位内固定术后功能结局中的作用。
自1993年以来，共有130例髁突高位骨折和双髁突骨折接受了切开复位内固定治疗。根据Spiessl和Schroll分类法，对39例51处V类和VI类骨折患者（手术治疗，ST）进行术后评估（平均24个月），包括磁共振成像（MRI）和颌轴位片测量。16例保守治疗的骨折作为对照（保守治疗，CT）。
手术治疗的颞下颌关节髁突活动度更好（ST后为11.4 mm，CT后为5.9 mm），下颌支垂直高度丢失较少（ST后为1.6 mm，CT后为5.4 mm）。保守治疗的髁突高位骨折在关节结节前内侧位置形成近关节强直（x轴6.9 mm，y轴10.3 mm）。两组的盘状软骨活动度均降低（CT后为3.8 mm，ST后为5.8 mm），ST后个体间差异较大。在手术治疗组中，颌轴位片测量受限与盘状软骨活动度受限（p < 0.01）或关节周围瘢痕形成（p < 0.01）之间存在显著相关性。ST后的Helkimo指数（31%无症状，67%轻度症状<5分）明显优于保守治疗（p < 0.01），63%的保守治疗患者出现颅下颌症状>5分。
根据观察到的功能结果，髁突高位骨折和双髁突骨折通过切开复位内固定治疗会取得更好效果。只有有效的手术方法才能保留盘状软骨活动度和下颌支垂直高度。
