Condylar #

CONDYLAR FRACTURES

PRESENTED BYDR.SUJAY PATIL

II MDS

Introduction

Fractures of mandibular condyle are common and account for 20-30% of all mandibular fractures.

Forms imp component for TMJ

Surgical Anatomy• Elliptical in shape, long

axis angled backwards between 15-33 0 to frontal plane.

• Long axes of 2 condyle meet at basion on anterior ligament of foramen magnum forming an angle 0f 145-160 degrees.

• Mediolateral width: 15-20 mm

• Anteroposterior width: 8-10mm

• Lateral pole: roughened, bluntly pointed, projects from plane of ramus

• Medial pole: rounded, extends from plane of ramus

• Fibrous layer thin on posterior aspect and thick over convexity

Parameter Child AdultCortical bone Thin ThickCondylar neck Broad ThinArticular surface Thin ThickCapsule Highly vascular Less vascularPeriosteum Highly active

osteogenic phaseLess active in latent stage

Intracapsular fracture & hemarthrosis

Very common Rare

Remodellin capacity following trauma

Present Absent

Disturbance in growth

Likely N.A.

Blood supply

TMJ area is highly vascular and innervated

Mainly from • Superficial temporal artery• Transverse facial artery• Posterior tympanic artery• Posterior deep temporal artery

Neural structures

• Facial nerve

• Auriculotemporal nerve

Incidence

Aetiology∏ Assault∏ RTA∏ Sport injuries∏ Falls ∏ Work-related incidents

Mechanism of injury

Classification

Wassmund classification(1934)Type I- slight displacement The angle between the head and the .long axis of the ramus :10 to 45 degrees.

Type II- angle of 45 to 90 degrees, resulting in tearing of the medial portion of the capsule.

Type III- The fragments are not in contact, and the head is displaced mesially and forward owing to traction of the lateral pterygoid muscle. confined to within the glenoid fossa.

Type IV- fractures where the condylar head articulates in an anterior position to the articular eminence.

Type V- vertical or oblique fractures through the head of the condyle.

Mac Lennan classification (1952)

Type I Non-displaced fracture

Type II Fracture deviation, where there is simple angulation of the condylar process to the major fragment. (e.g. greenstick fracture)

Type IIIFracture displacement, where there is simple overlap of the condylar process and major mandibular fragments.

Type IVFracture dislocation, where the head of the condyle is completely disrupted from the articular fossa.

Rowe & Killey 's classification(1968)

Intracapsular Fractures or High Condylari. Fractures involving the articular surfaceii. Fractures above or through the anatomical neck, which do not involve the articular surface

Extracapsular or Low Condylar Fractures

Fractures associated with injury to the capsule, ligament and meniscus

Fractures involving adjacent bone

Lindahl classification(1977) Anatomic location of the fracture

Condylar head Condylar neck Subcondylar

Relationship of condylar fragment to mandible

NondisplacedDeviatedDisplacement with medial or lateral overlapDisplacement with anterior

or posterior overlapNo contact between

fractured segments

Relationship of condylar head & fossa

NondisplacedDisplacementDislocation

Diagnosis

1. History2. Clinical examination3. Radiological

examination

Management of Traumatic Dislocation of the Mandibular Condyle into the Middle Cranial Fossa; Robert P. Barron, J Can Dent Assoc 2002;

68(11):676–80

Signs and symptomsEvidence of trauma. Bleeding from external auditory canal.Noticeable or palpable swelling – haemotoma / edema.Facial asymmetry – foreshortening of ramus.Pain & tenderness.Crepitation over the joint.Malocclusion Deviation of mandibular condyle.Muscle spasm.Dentoalveloar injuries.

Radiologic evaluationA. Conventional Radiography

a. P A- Viewb. Lateral Obliquec. Towne's Projectiond. Panoramic view

e. TMJ viewsB. CTC. MRI

Definitive treatment Aims for surgery:

1. Relief from pain2. Stable occlusion3. Restoration of inter- incisal opening 4. Full range of mandibular movements 5. To minimize deviation6. Avoid growth disturbances7. Avoid Ankylosis

2 schools of thought:

• Conservative-functional therapy

• Surgical treatment

Conservative-functional therapy

• Involves no surgical intervention of the fracture site instead it reduces the fracture taking occlusion as a key factor.

• Immobilization usually involves fixation with arch bars, eyelet wires or splints.

• Period of immobilization varies from 7days to 4 weeks

Indications:

• Condylar neck # with little or no displacement

• # occuring in child (10-12 yrs)

• Intracapsular #

Recently thermoforming plates is used for the sameFixation strength is less than wiring so contraindicated in bilateral fracturesAdvantage:

• Smooth surface• Transparent

Closed treatment of condylar fractures by intermaxillary fixation with thermoforming plates; Haruhiko Terai et al, British Journal, 2004,

Pg. 61-63

Advantage Disadvantage• Relatively safe

• No injury of nerves and blood vessels

• No postoperative complications such as infection or scar occurs.

• Fracture, loss, and eruption delay of the growing teeth can be avoided in pediatric patients as no tooth germ injury occurs because of no establishment of the crown of the permanent teeth

• Injury of the periodontal tissue and buccal mucosa

• Poor oral hygiene,

• Pronunciation disorder

• Imbalanced nutrition

• Growth disorder and excessive growth of the injured mandible may occur

• Facial asymmetry may occur in pediatric patients aged 10 to 15 years due to growth disorder or functional disorder, and that in particular, the growth and functional disorders of the TMJ may occur in 20% to 25% of pediatric patients aged 7 to 10 years

Closed Reduction

Open reduction

Treatement protocol for different type of condylar fractures1. FOR CHILDREN UNDER 10 YEARS OF AGE The treatment is complete functional for

both unilateral and bilateral condylar fracture IMF may be required for 7- 10 days.

2. ADOLESCENTS BETWEEN 10 AND 17 YEARS OF AGE

Treatment protocol is same but IMF may be required for 2-3 weeks.

3. UNILATERAL INTRACUPSULAR FRACTURE IN ADULTS

IMF for 2-3 weeks in case of malocclusion.4. BILATERAL INTRACAPSULAR FRACTURE

IN ADULTS IMF for 3-4 weeks physiotherapy for

preventing restricted mouth opening.

5. UNILATERAL EXTRACAPSULAR FRACTURE IN ADULTS

open reduction in case of displaced fragment and maloclusion.

6. BILATERAL EXTRACAPSULAR FRACTURE IN ADULTS

open reduction of atleast of 1 side to establish normal height

If the discripancy is large both the sides should be considered.

Surgical approaches

Preauricular Incision

Al-Kayat& Bramley -> identifiable landmarks

End aural Incision

Post auricular Incision

Submandibular Incision

Retromandibular Incision

Intraoral Incisione e

Approach Advantage Disadvantage

Preauricular Endaural

• Exposure of lateral and anterior part of condyle

• Cosmetic (Endaural)

• Injury to facial nerve• Injury to

auriculotemporal • Damage to middle ear• Hemorrhage• Parotid fistula

Postauricular • Esthetic • Minimum risk of facial

nerve injury• Permits harvest of

conchal cartilage for grafting

• Infection• Hematoma• Cartilage necrosis

Intraoral • No visible scar• Adequate access to

condylar neck

• Injury to buccal, IAN• Injury to lingual

vessels • Damage to maxillary

arterySubmandibular (Risdon)

• Adequate access to condylar neck & subcondyle

• Injury to MMB

Retromandibular

• Adequate access to condyle

• Less risk of injury to MMB

• Scar• Parotid fistula

The risks & benefits of surgery for temporomandibular joint internal derangements; Simon Weinberg et al

CONDYLAR TRAUMA?

Clinical SignMalocclusion Deviation Range of motion

Negative clinical exam(-) MalocclusionMinimal painNormal range of motionNo deviation on opening

Observation

RadiographsLateral obliquesPanorexCT scan

No radiographic evidence of condylar #

R/O hemathrosis Joint effusion

(+) Condylr fractre

Normal occlusion

Malocclusion

ORIF? ROMPainDeviation

Conservative

IMF (7-21 days)

ORIF Other # ?

IMF (7-21 days)

Reduction/fixation of other #

Follow up

YesYe

sNo N

o

No

Yes

Current concepts

Open vs closed reductionEllis and Throckmorton conducted study with open or closed

treatment for fractures of the mandibular condylar process, in one hundred forty-six patients, 81 treated by closed and 65 by open methods. The patients treated by closed methods developed asymmetries characterized by shortening of the face on the side of injury.

In the study of the Santler et al. two hundred 34 patients with fractures of the mandibular condylar process were treated by open or closed methods. No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve disorders were observed when the surgically and non-surgically treated patients were compared. Surgically treated patients showed significantly more weather sensitivity and pain on maximum mouth opening.Renato VALIATI, 2008, The treatment of condylar fractures: to open or not to open? A critical review of this controversy

To compare the occlusal relationships after open or closed treatment for fractures of the mandibular condylar process, a total of 137 patients with unilateral fractures of the mandibular condylar process (neck or subcondylar), 77 treated closed and 65 treated open, were included in the study of Ellis, Simon and Throckmorton. The patients treated by closed techniques had a significantly greater percentage of malocclusion compared with patients treated by open reduction, in spite of the initial displacement of the fractures being greater in patients treated by open reduction.

Renato VALIATI, 2008, The treatment of condylar fractures: to open or not to open? A critical review of this controversy

Mini-retromandibular approach to condylar fractures ; Federico BIGLIOLI, Giacomo COLLETTI; Journal of Cranio-Maxillofacial

Surgery (2008) 36, 378e383

No visible scar Less complication rate

Intraoral approach for treatment of displaced Condylar fractures: case report; valfrido pereira-filho et al; craniomaxillofacial trauma &

reconstruction/volume 4, number 2 2011

Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment Philosophy ;Reid V. Mueller et al, Facial Plast

Surg Clin N Am 14 (2006) 1–9

Resorbable triangular plate for osteosynthesis of fractures of the condylar neck; Günter Lauer et al; British Journal of Oral and

Maxillofacial Surgery 48 (2010) 532–535

Transmasseteric Anteroparotid Approach for Mandibular Condylar Fractures-Merits and Demerits; AHMAD MAHROUS MOHAMAD, Egypt, J. Plast. Reconstr. Surg., Vol. 35, No. 2, July: 227-232, 2011

ComplicationsEarly complications:

1. Fracture of the tympanic plate2. Fracture of the glenoid fossa with or without displacement

of the condylar segment into the middle cranial fossa3. Damage to cranial nerves V & VII4. Vascular injury

Late complications:

5. Malocclusion6. Growth disturbance7. Temporomandibular joint dysfunction8. Ankylosis9. Asymmetry 10. Frey’s syndrome

ConclusionFractures of the mandibular condyle constitute a

significant portion of mandibular fractures. A number of clinical signs and symptoms are characteristic of injury to the condylar apparatus. The use of plain radiographs in multiple view, or CT scans discloses most condylar fractures and displacements, if any. A number of classification systems are available to help in treatment planning and record keeping.

Non-surgical treatment is adequate for a majority of condylar fractures. A period of immobilisation followed by active functional therapy is indicated for most cases. Surgical management has specific indications, and can be accomplished through a wide variety of techniques. In general, complications are not common following condylar trauma. Important among the possible complications are ankylosis, growth disturbances and internal derangement.