Management of Condylar fractures

Management of Condylar fractures:

Management of Condylar fractures DR.MUHAMMAD SIBGHAT ULLAH KHAN

INTRODUCTION.:

INTRODUCTION. RTA are responsible for majority of the patients reporting with maxillofacial trauma. Mandibular fractures are more common among fractures in maxillofacial region. Among mand.fracture condylar region is the most frequent site accounting for about 25-35%. Only facial bone fracture which involve a synovial joint.

TYPES::

TYPES: 1)Contusion-Injuries to the soft tissues around the joint or an effusion within the joint. 2)Dislocation- Displacement of condylar head from glenoid fossa but still within capsule. 3)Fracture. a)Intracapsular-condylar head or neck b)Extracapsular-condylar neck or sub condylar

CLASSIFICATION.:

CLASSIFICATION. 1.Age: a)Under 10 years. b)10-17 years. c)Adults. 2.Surgical anatomy: a)Involving joint surface-intra capsular. b)Not involving joint surface-extracapsular: i)High condylar neck. ii)Low condylar neck.

CLASSIFICATION::

CLASSIFICATION: 3.Site: a)Unilateral. b)Bilateral. 4.Occlusion: a)Undisturbed. b)Malocclusion.

CLINICAL FEATURES::

CLINICAL FEATURES: 1.Teemporomandibular joint effusion/haemarthrosis. a)ipsilateral posterior open bite b)midline shift to contralateral side 2.Unilateral fracture . a)Ipsilateral premature contact posteriorly. b)Ipsilateral midline shift.

CLINICAL FEATURES::

CLINICAL FEATURES: 3.Bilateral fracture dislocation. a)Anterior open bite due to shortening of both mandibular rami. 4.Bilateral dislocation of condylor heads . a)Pseudoprognathism. b)Inability to occlude teeth. c)Elongated face. d)Condyle palpable anterior to articular eminence with preauricular hollow.

CLINICAL FEATURES::

CLINICAL FEATURES:

INVESTIGATIONS::

INVESTIGATIONS: Panoramic radiography is a useful study. 30° anteroposterior (AP) skull radiography (i.e, Towne view). CT scanning in axial and coronal planes

OPG.:

OPG.

TREATMENT::

TREATMENT: There are three treatment options: 1.Functional 2.Indirect immobilization. 3.Osteosynthesis.

TREATMENT::

TREATMENT: Conservative . 1.Minimal displacement- No active treament . 2.Persistent malocclusion or severe pain - A short period of IMF(7-10 days) until oedema and muscle spasm disappear . 3.Bilateral fractures-A longer period of IMF (3-4 weeks)with posterior distraction blocks e.g.gutta percha.Elastic traction may be necessary to close anterior open bite.

Maxillomandibular fixation:

Maxillomandibular fixation

Edentulous Fractures::

Edentulous Fractures: Pre-existing dentures or gunning splints may be wired in and adapted for interarch elastics. In most cases, an equally good outcome can be obtained with careful physical therapy . Some patients require preexisting dentures to be remade or relined. For cases of bilateral edentulous fractures, the second indication is the most common reason for opening at least one side

Treatment of dislocations::

Treatment of dislocations: Acute dislocation: 1.Causes. a)Trauma. b)Tooth extraction. c)Habitual attention-seekers. d)Drugs. e)Spontaneous.

Cont…:

Cont… 2.Treatment: a)Intracapsular local anaesthesia-to reduce reflex spasm of muscles of mastication. b)Digital manipulation with or without sedation. c)Reduction under general anaesthesia. d)Instructions to avoid wide opening for 14 days.

Chronic dislocations::

Chronic dislocations: 1.Less than months: a)Manipulation-LA,sedation,GA with IMF for 14 days to allow healing. i)Digital-downward and backword pressure with thumbs on posterior mandibular teeth. ii)Wire traction or hooks at angles or coronoid process of mandible. iii)Direct surgical exposure of joint.

Cont…:

Cont… 2.Greater than 3 months: a)Condylotomy-closed or open approach. b)Condylectomy. c)Osteotomy.

Recurrent dislocation::

Recurrent dislocation: May be possible to prevent by eliminating predisposing factors.e.g. ill fitting dentures or class II malocclusion. Restricting condylar movement. a)IMF B)Condylotomy-rarely used.

SURGICAL INDICATIONS::

SURGICAL INDICATIONS: 1.Compound and comminuted fractures. 2.Condylar displacements including fracture-dislocations with gross occlusal disruption,or mechanical interference. 3.Multiple facial fractures where mandible is used to stabilise mid-face.

SURGICAL APPROACHES::

SURGICAL APPROACHES: 1.Pre-auricular. 2.Retroauricular approach 3.Intraoral-difficult.

SURGICAL APPROACHES::

SURGICAL APPROACHES: 4.Mini retromandibular approach. 5.Submandibular or retromandibular.

REDUCTION::

REDUCTION: Difficult to reposition.Lateral pterygoid muscle may require detachment to allow reduction of fractured condyle .Sometimes condyle totally removed and repositioned in glenoid fossa. FIXATION: 1.Suture. 2.Wires. 3.Plates. 4.Pins-rarely.

Specific management of special cases::

Specific management of special cases: Children under 12 years old. 1.Conservative non-immobilisation (most cases). 2.Immobilization less than 2weeks-for gross displacement or a fracture when malocclusion may develop. 3.Surgery-condylectomy for severe compound comminuted fractures,which have a high risk of ankylosis.this can be followed by costochondral graft.

Cont…:

Cont… Temporomandibular joint contusion. Soft diet,analgesics and exercises when pain subsides.Bite raising appliances may be used to distract the joints. Compound fractures. Antibiotics,early surgical debridement and closure minimise the length of intermaxillary fixation.Encourage early function.

COMPLICATIONS::

COMPLICATIONS: 1.Temporomandibular joint pain/dysfunction syndrome - Tearing and stretching of disc attachment may lead to this. 2.Disturbance in mandibular growth . 3.Ankylosis-Predisposing factors include: a) Children<10 years old. b) Intracapsular fractures. c) Lengthy periods of immobilization,>2weeks. d) Compound/comminuted fractures where coronoid and zygoma are involved.

COMPLICATIONS::

COMPLICATIONS: e)Related to severe trauma – in the western world frequently seen after cycle accidents or a fall from a window.

CONCLUSION::

CONCLUSION: Intracapsular fractures are best treated closed. Fractures in children are best treated closed except when the fracture itself anatomically prohibits jaw function. Most fractures in adults can be treated closed. Physical therapy that is goal-directed and specific to each patient is integral to good patient care and is the primary factor influencing successful outcomes, whether the patient is treated open or closed. When open reduction is indicated, the procedure must be performed well, with an appreciation for the patient's occlusal relationships, and it must be supported by an appropriate physical therapy and follow-up regimen.

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