CONDYLAR FRACTURE: CONDYLAR FRACTURE Presented by : Dr Amit Agnihotri M.D.S. Dept of Oral & Maxillofacial Surgery Fracture of the condylar process: Fracture of the condylar process Most frequent direction of displacement is medially and forward under the influence of lateral pterygoid muscle. 2 Condylar fractures: 3 Condylar fractures The most common mandibular fracture Unilateral or bilateral Intracapsular or extracapsular Antero-medial displacement is common but it may remain angulated with the ramus Dislocation of the glenoid fossa and fracture of petrous temporal bone which is very rare Classification : Classification May be : 1. unilateral or bilateral 2. intracapsular or extracapsular Intracapsular – involve the joint compartment Extracapsular – condylar neck fracture 4 Categories of condylar injuries: Categories of condylar injuries 1 - Contusion - injuries to the soft tissue 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 subcondylar 5 Slide 6: intracapsular extracapsular 6 Relationship to mandible: Relationship to mandible 7 undisplaced - hairline fracture Deviated displaced (medial overlap) Relationship to mandible: Relationship to mandible 8 displaced (lateral overlap) antero -posterior over-ride no contact Relation of condyle to glenoid fossa: Relation of condyle to glenoid fossa 9 undisplaced displaced - condylar head still related to glenoid fossa dislocation - condylar head completely out of glenoid fossa. Condylar head usually lies anteromedial Relation of condyle to glenoid fossa Sign and symptoms: 10 Sign and symptoms Swelling, pain, tenderness and restriction of movement Deviation of mandible towards the side of fracture Gagging of occlussion (premature contact on the posterior teeth) with bilateral condylar displaced or over-riding fractures Displacement of mandible toward the affected side Anterior open bite Laceration Retroauricular ecchymosis Cerebrospinal leak and otorrhea in association with skull base fracture Condylar fractures Slide 11: The external auditory meatus should be inspected for discharges of blood or CSF. In association with a fracture of the condyle, the sharp end of the condylar neck can can penetrate the anterior wall of the external auditory meatus. 11 Slide 12: 12 Slide 13: Facial asymmetry with deviation of occlusion may be seen. 13 Slide 14: Acute malocclusion following fracture of condyle . Unilateral condylar fracture results in ipsilateral premature contact of posterior dentition secondary to foreshortening of ramus on that side. 14 Slide 15: Haematoma surrounding a fractured condyle may track downwards and backwards below the external auditory canal gives rise to ecchymosis of the skin just below the mastoid process on the same side. 15 Slide 16: 16 Pseudoprognathism Inability to occlude teeth Elongated face Pain and limitation of opening and restricted protrusion and lateral excursions The mandible deviates on opening to the side of the fracture and there is usually painful limitation of protrusion and lateral excursion to the opposite side Slide 17: If condylar head is impacted through glenoid fossa, the mandible will be locked Tenderness over the condylar area. On inspection there may be swelling over the temporomandibular joint area and Condyles palpable anterior to articular eminence with preauricular hollow. 17 X rays needed for diagnosis; : X rays needed for diagnosis; Lateral oblique To show angle of mandible, the ramus, the condylar neck and the condylar head on one side. Orthopantomogram This represents the best single over all view of the mandible and are especially valuable for demonstrating fractures in the condylar region. PA of mandible Shows whole mandible, including ascending ramus on each side without superimposition of mastoid processes. 18 Slide 19: AP 30 0 (townes view) To show posterior fossa of skull, zygtomatic arches, ascending rami of mandible, mandibular condyles and condylar necks. Reverse Townes view Gives good representation of proximal and distal fragments in a medio-lateral plane. Shows the condylar heard much better than PA view of mandible Tomography Can be helpful, in cases where conventional radiographs have not been definitive or possible, 19 Radiographs : 20 Radiographs Sequlae of TMJ injury: 21 Sequlae of TMJ injury Artheritic changes Haemartherosis, fibrosis and aknylosis Meniscal damage and detachment TMD Staph infection with condylar backward displacement and external auditory meatus injury Meningitis with petrous temporal bone fracture and intracranial involvement Condylar fractures Slide 22: Management of condylar fracture: Conservative Open reduction 22 Treatment of condylar fractures is usually conservative;: Treatment of condylar fractures is usually conservative; 1- Minimal Displacement - no active treatment. A normal occlusion is maintained which allows bony union to occur. In fracture dislocation a functional pseudoarthrosis may be produced. 2 - Persistent Malocclusion Or Severe Pain - a short period of intermaxillary fixation (7 - 10 days) until oedema and muscle spasm disappear 3 - Bilateral Fractures - a longer period of intermaxillary fixation ( 3 - 4 weeks) with posterior distraction blocks, e.g. gutta percha, acrylic wedges. Elastic traction may be necessary to close anterior open bite. 23 Open reduction: Open reduction Absolute indications – Displacement of condyle into middle cranial fossa Impossibility of restoring occlusion Lateral extracapsular displacement Invasion by foreign body, e.g. missile. Slide 25: Relative indications – When intermaxillary fixation is contraindicated for medical reasons Bilateral fracture with associated mid-face fracture Bilateral fracture with severe open bite deformity. Slide 26: Surgical Approaches for Condyle Fractures Slide 27: Submandibular (Risdon’s ) approach Postramal (Hinds) approach Postauricular approach Endaural approach ( Lamport’s s endaural approach) Preauricular approach Conventional Preauricular incision Modification of Basic Preauricular incisions Dingman’s Thoma’s Alkyat & Bramleys incision modification of conventional Preauricular incision Popwichs modification of Alkyat & Bramleys Slide 28: Through soft tissue laceration or scars Closed Condylotomy Horizontal Incision along the lower border of the malar arch Intra-oral Temporal Hemicoronal approach Coronal or Bicoronal approach Submandibular (Risdon’s) approach : Submandibular (Risdon’s) approach Advantages Useful for faracture of the condyle neck, 2. Minimal scarring. Disadvantage Procedures involving the articular portion of the head and the meniscus can not be performed by this approach. POSTRAMAL (Hind) APPROACH : POSTRAMAL (Hind) APPROACH Advantages Excellent cosmesis. 2. Excellent visibility and accessibility. Disadvantages : Close proximity of the posterior facial vein and the trunk of the facial nerve. Proximity of the posterior border of the parotid gland. In analysis, this is the ideal approach to the condyle neck and upper ramus. When properly performed, this procedure assures excellent exposure cosmesis and a gratifying procedure. POSTAURICULAR APPROACH : POSTAURICULAR APPROACH Advantages Uniform predictability of anatomic exposure & Avoidance of a salivary fistula or formation of a sialocele . Negligible intraoperative and post surgical hemorrhage. No paresis of the facial nerve (either temporary or permanent. A lesser degree and duration of post surgical edema. No distortion of anatomic landmarks ( pinna , stenosis of the external auditory canal and so forth.) or permanent loss of hair. Aesthetics uniformly secured, Shortened operative dissection time Ease and safety of surgical approach in patients who have had previous procedure in this region that increase the difficulty of dissection and potential nerve damage. Slide 32: Disadvantages Infection involving the external auditory canal or cartilaginous frame work or both. Paresthesis (temporary or permanent ) of the external pinna . Deformity of the auricle. In analysis, it must be stated that it is difficult to justify a procedure that carries the potential for serious complications without a corresponding increase in access or visibility. In the selection of any surgical technique, the welfare of the patient should be of utmost concern. Therefore the technique selected must afford adequate visibility and accessibility but should also possess a minimum potential for serious complications. ENDAURAL APPROACH : ENDAURAL APPROACH Advantages 1. Excellent cosmesis. 2. Excellent lateral and posterior exposure with intermediate anterior exposure. Disadvantages : 1. Limited access. 2. Possibility of meatal stenosis or chondritis. CONVENTIONAL PREAURICULAR INCISION: CONVENTIONAL PREAURICULAR INCISION Advantage Inconspicious location of the incision. Disadvantages The dissection follows a route through an area which in rich is nerve and vascular supply. The blood supply to the joint is prolific, coming from temporal, middle meningeal, anterior tympanic, and ascending pharyangal arteries, with the large vessel entering the posterior aspect of the joint. In analysis, it appears that little is to be gained by a deep and tedious approach to the capsule of the condyle. The advantage of this procedure is that considerably more exposure of the capsule is attained by this dissection because the glenoid pole of the parotid gland is reflected forward to expose the joint. This advantage is outweighed by the aforementioned disadvantages Slide 37: Blair Incision In 1913 advocated a curved or inverted “L” incision, commencing from within the temporal hair line and curving downward in close proximity to the anterior auricle. Many modifications of the Blair incision and other preauricular incisions have been reported Slide 38: Dingman Used a modification of the Blair incision involving an obtuse angulated vertical incision with the angle rounded. The vertical component was just anterior to the traqus , with the angle rounded at the anterior attachment of the pinna and the superior leg progressing obiliquely anteriorly at the pinna of the ear for the short distance. Slide 39: Thoma’s angulated incision (in 1958): Recommended an “angulated vertical incision” which is carried out across the zygomatic arch in the fold, directly in the front of the ear, extending down slightly above the ear lobe, to avoid the main trunk of facial nerve. Slide 40: ALKAYAT AND BRAMLEY’S APPROACH (1979) Slide 41: Popwich’s modification (1982) Advantage of Popwich’s modification: 1. Reduction in incidence of facial nerve palsy 2. provision of donor site for temporalis muscle 3. Deceased haemorrhage (dissection through avascular zone) 4. Improved visibility and easier identification of fascial planes. 5. Reduction in postoperative edema and discomfort. Potential complication of muscle herniation and fibrosis avoided 7. Good cosmetic results. 8. Reduction in total operating time 9. Avoidance of auricotemporal nerve anesthesia / parasthesia . Intra-oral: Intra-oral Advantages Avoidance of a skin incision and the safety of the procedure. This approach has been advocated for condylectomy. Disadvantages : Limitation of visibility and accessibility. Only a small number of procedure can be accomplished. Bicoronal approach: Bicoronal approach INDICATIONS 01. Frontal sinus 02. Facial esthetic surgery 03. Nasal root 04. Temporomandibular joint disorders 05. Naso-ethmoidal complex06. Tumor extirpation 07. Superior orbital rim 08. Zygomatic complex fractures 09. Zygomatic arch 10.Calvarial bone graft 11. Infratemporal fossa 12. Congenital deformities 13. Lateral orbital rim 14. Lateral skull base Hemi-coronal Approach : Hemi-coronal Approach The hemicoronal incision provides wide surgical exposure to the zygoma and frontal bone. Indications for this approach include superior orbital rim fractures and comminuted fractures of the ZMC, including the zygomatic arch.