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CONDYLAR FRACTURES:

CONDYLAR FRACTURES - Dr. Dona Bhattacharya

Contents:

Contents Introduction Surgical anatomy Classification Etiology Diagnosis Management Current concepts Conclusion References

Introduction :

I ntroduction Fractures of mandibular condyle are common and account for 20-30% of all mandibular fractures. Forms imp component for TMJ

Surgical Anatomy:

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.

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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

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Parameter Child Adult Cortical bone Thin Thick Condylar neck Broad Thin Articular surface Thin Thick Capsule Highly vascular Less vascular Periosteum Highly active osteogenic phase Less active in latent stage Intracapsular fracture & hemarthrosis Very common Rare Remodellin capacity following trauma Present Absent Disturbance in growth Likely N.A.

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Blood supply TMJ area is highly vascular and innervated Mainly from Superficial temporal artery Transverse facial artery Posterior tympanic artery Posterior deep temporal artery

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Neural structures Facial nerve Auriculotemporal nerve

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Al- Kayat & Bramley -> identifiable landmarks

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Dingman & Grabb -> course of marginal mandibular nerve Posterior to facial artery it runs above the inferior border of mandible in 81%, in rest it coursed in an arc with lowest border being with in 1 cm from it. Anterior to the artery the nerve ran above the inferior border in 100% cases.

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Incidence

Aetiology:

Aetiology Assault RTA Sport injuries Falls Work-related incidents Less obvious causes are: Orotracheal intubation Whiplash injury( Royd house,1973) Childbirth

Predisposing factors:

Predisposing factors Age Socioeconomic factors Geographic location Presence/absence of dentition Occlusion, mandibular position Dir & magnitude of force Muscle pull

Muscle pull:

Muscle pull

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Mechanism of injury

Classification:

Classification

Brophy classification:

Brophy classification Given in 1915 Acc to location & direction of fracture: From above, downward & inward or reversed From above, backward & downward

Wassmund classification(1934):

Wassmund classification(1934) Type I- 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):

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 III Fracture displacement, where there is simple overlap of the condylar process and major mandibular fragments. Type IV Fracture dislocation, where the head of the condyle is completely disrupted from the articular fossa .

Rowe & Killey 's classification(1968):

Rowe & Killey 's classification(1968) Intracapsular Fractures or High Condylar i . Fractures involving the articular surface ii. 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

Spissel and Schroll classification (1972):

Spissel and Schroll classification (1972) Non-displaced fracture Low-neck fracture with displacement, mostly with contact between fragments High-neck fracture with displacement, mostly without contact between fragments Low-neck fracture with dislocation High-neck fracture with dislocation Intracapsular fracture of condylar head Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11

Neff & Rasse’s Modification(2006):

Neff & Rasse’s Modification(2006) Type M: communited #; loss of vertical dimensions ( Eckelt & Hlawitschaka ) Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11

Lindahl classification(1977):

Lindahl classification(1977) Anatomic location of the fracture Condylar head Condylar neck Subcondylar Relationship of condylar fragment to mandible Nondisplaced Deviated Displacement with medial or lateral overlap Displacement with anterior or posterior overlap No contact between fractured segments Relationship of condylar head & fossa Nondisplaced Displacement Dislocation

Helmut Schüle classification(1986):

Helmut Schüle classification(1986) Contusion of the TMJ Fractures of the condylar process without displacement of the fragments Fractures of the condyle Transcapitular . Subcapitular . Fractures of the condylar neck Basal fracture of the condylar process. Fractures of the condylar process with displacement of the fragments. Displacement of the small fragments Ventrally Dorsally Medially Laterally Torsion of fragments

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Sprains of the TMJ Dislocation ( subluxation ) of the TMJ. Dislocation of the condylar head ( condyle ). Anteriorly Posteriorly Cranially (central dislocation) Medially Laterally Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11

R.A. Loukotaa et al subclassification (2005):

R.A. Loukotaa et al subclassification (2005) Diacapitular fracture (through the head of the condyle ): The fracture line starts in the articular surface and may extend outside the capsule. Fracture of the condylar neck: The fracture line starts somewhere above line A and in more than half runs above the line A in the lateral view. Line A is the perpendicular line through the sigmoid notch to the tangent of the ramus . Fracture of the condylar base: The fracture line runs behind the mandibular foramen and, in more than half, below line A Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11

Diagnosis:

Diagnosis History Clinical examination Radiological examination

Signs and symptoms:

Signs and symptoms Evidence 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.

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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

Radiologic evaluation:

Radiologic evaluation A. Conventional Radiography a. P A- View b. Lateral Oblique c. Towne's Projection d. Panoramic view e. TMJ views B. CT C. MRI

Definitive treatment :

Definitive treatment Aims for surgery: Relief from pain Stable occlusion Restoration of inter- incisal opening Full range of mandibular movements To minimize deviation Avoid growth disturbances Avoid Ankylosis

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2 schools of thought: Conservative-functional therapy Surgical treatment

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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 7-17 days

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Conservative management Exercise Increasing mouth opening Push the jaws laterally Diet: Soft diet Analgesics Anti-inflammatory Soft diet and mouth exercises- Teeth into normal occlusion Adequate ROM Elastic MMF for 2-3 weeks When occlusion is found to be altered Patient was unable to bring their teeth into normal occlusion presence of pain or swelling

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Physiotherapy Elastic band – Class II light elastics Review after 6 days Normal occlusion: Remove when brushing and replace immediately Unable to achieve normal occlusion: to be worn 24 hrs/day till next review Review after next 6 days Occlusion maintainable: halt elastics Occlusion difficult obtain: continue elastics

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Functional exercise: > 40 mm interincisal distance (adult) > 10 mm lateral excursion > 12 mm protrusion Types of exercise: Maximal mouth opening Right lateral excursion Left lateral excursion Protrusive action

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Indications: Condylar neck # with little or no displacement # occuring in child (10-12 yrs) Intracapsular #

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Recently thermoforming plates is used for the same Fixation strength is less than wiring so contraindicated in bilateral fractures Advantage: Smooth surface Transparent Closed treatment of condylar fractures by intermaxillary fixation with thermoforming plates; Haruhiko Terai et al, British Journal, 2004, Pg. 61-63

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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:

Open reduction

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New indications have slowly evolved with improvement in the surgical techniques . Zide’s 1989 indications Absolute indications: Fracture in to middle cranial fossa Foreign body in to joint capsule Lateral extracapsular deviation Inability to open mouth or achieve occlusion after 1 week Open fracture with potential for fibrosis Possible indications: Bilateral / unilateral fracture with crushed midface Comminuted symphysis and condyle fracture with tooth loss Displaced fracture with open bite or retrusion in mentally retarded or medically compromised patients. Displaced condyle in edentulous or partially edentulous mandible with posterior bite collapse.

Surgical approaches:

Surgical approaches

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Blair’s Inverted Hockey Stick Incision Thoma’s Angulated Incision Dingman’s Incision Popowich & Crane Incision Preauricular Incision

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Preauricular Incision

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End aural Incision

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Post auricular Incision

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Submandibular Incision

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Transparotid Incision

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Retroparotid Incision

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Rhytidectomy Incision

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Intraoral Incision e e

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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 artery Submandibular (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

Reduction of fracture:

Reduction of fracture

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Fixation of fracture

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Fixation of medially displaced fracture

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Eckelt technique of lag screw osteosynthesis

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CONDYLAR TRAUMA? Clinical Sign Malocclusion Deviation Range of motion Negative clinical exam (-) Malocclusion Minimal pain Normal range of motion No deviation on opening Observation Radiographs Lateral obliques Panorex CT scan No radiographic evidence of condylar # R/O hemathrosis Joint effusion (+) Condylr fractre Normal occlusion Malocclusion ORIF? ROM Pain Deviation Conservative IMF (7-21 days) ORIF Other # ? IMF (7-21 days) Reduction/fixation of other # Follow up Yes Yes No No No Yes

Current concepts:

Current concepts

Open vs closed reduction:

Open vs closed reduction Ellis 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

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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

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Mini- retromandibular approach to condylar fractures ; Federico BIGLIOLI, Giacomo COLLETTI; Journal of Cranio -Maxillofacial Surgery (2008) 36, 378e383 No visible scar Less complication rate

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Intraoral approach for treatment of displaced Condylar fractures: case report; valfrido pereira-filho et al; craniomaxillofacial trauma & reconstruction/volume 4, number 2 2011

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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

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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

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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

Complications:

Complications Early complications: Fracture of the tympanic plate Fracture of the glenoid fossa with or without displacement of the condylar segment into the middle cranial fossa Damage to cranial nerves V & VII Vascular injury Late complications: Malocclusion Growth disturbance Temporomandibular joint dysfunction Ankylosis Asymmetry Frey’s syndrome

Conclusion:

Conclusion Fractures 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.

References:

References Oral & maxillofacial trauma-Fonseca & walker vol 2 Oral & maxillofacial surgery-Fonseca vol 3 Oral & maxillofacial trauma-Rowe & Williams vol 2 Principles of Oral & maxillofacial surgery-Peterson Fractures of middle third of face- Killey & Kay Oral & maxillofacial surgery- Fragiskos Maxillofacial trauma & facial reconstruction-Peter Ward Booth Oral & maxillofacial surgery-Peter Ward Booth: vol 2 Chen Lee et al; Applications of the Endoscope in Facial fracture Management, seminars in plastics surgery/volume 22, number 1 2008 Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11 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

PowerPoint Presentation:

Closed treatment of condylar fractures by intermaxillary fixation with thermoforming plates; Haruhiko Terai et al, British Journal, 2004, Pg. 61-63 The risks & benefits of surgery for temporomandibular joint internal derangements; Simon Weinberg et al 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 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 Intraoral approach for treatment of displaced Condylar fractures: case report; valfrido pereira-filho et al; craniomaxillofacial trauma & reconstruction/volume 4, number 2 2011 Mini- retromandibular approach to condylar fractures; Federico BIGLIOLI, Giacomo COLLETTI; Journal of Cranio -Maxillofacial Surgery (2008) 36, 378e383 Renato VALIATI, 2008, The treatment of condylar fractures: to open or not to open? A critical review of this controversy 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