Condylar fracture.pptx

Presentation on mandibular condyle fracture and its maanagement by Dr.G.Kathirvel M.D.S (OMFS)

1. Condy l ar fractures G.Kathirve l PG - OMFS

2. Contents : Introduction Surgica l anatomy Biomechanics C l assification C l inica l features Radiographic features Management Closed treatment Open reduction Surgical approaches to condylar fractures Comp l ications

3. Introduction: Condylar fractures account for 17.5% to 52 %. It differ significantly from other fractures of the mandible owing to the functional derangement that may affect occlusion, mastication and speech However, functional derangements unique to condylar fractures are very frequent sequelae of these injuries This is due to the unique functional anatomy of the mandibular condyles, the specific challenges of surgical treatment of these fractures and the various patient-specific factors affecting the outcomes of condylar fractures. Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition ; 2011; PEOPLE’S MEDICAL PUBLISHING HOUSE—USA

4. Anatomy: The mandibular condyle forms a part of the temporomandibular joint which is unique and TMJ made of the following structures: • Condyle of the mandible • Squamous portion of the temporal bone • Articular disc (contained within the TMJ) • Ligaments Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

5. Condyle The condylar head is ovoid in shape measuring approximately 15–20 mm mediolaterally and 8–10 mm anteroposteriorly A rticulates with the glenoid fossa present in the squamous portion of the temporal bone t o form the temporomandibular joint. Squamous portion of the temporal bone is as thin as 2 mm as a result; the condylar processes maybe driven into the middle cranial fossa following trauma. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

6. Articular Disc The squamous portion of the temporal bone and the condyle is separated by a dense f i brous connective tissue called the articular disc. The disc is f i rmly anchored to the condyle by the medial and lateral collateral ligaments and it merges with the capsule in the periphery. The joint space is divided into superior and inferior compartments by the disc. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

7. Capsule and Ligaments The capsule surrounds the TMJ and is reinforced by the medial and lateral ligaments which connect the mandible to the temporal bone. The synovial membrane lines the capsule. This membrane produces synovial fuid which aids in the lubrication and nourishment of the joint. The lateral ligament also known as temporomandibular ligament has a horizontal and an oblique component which stabilizes the joint. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

8. Capsule and Ligaments The strength of the lateral ligament may be partly responsible for the fracture at the neck of condyle just below the insertion of the ligament. The medial and lateral discal ligaments which are present inside the capsule are also called collateral ligaments . These ligaments connect the disc to the poles of the condyle. Accessory ligaments: The stylomandibular and sphenomandibular ligaments are accessory and are not directly attached to any part of the joint. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

9. The stylomandibular ligament Runs from the styloid process to the angle of the mandible It separates the parotid and submandibular salivary glands B ecomes taut when the mandible is protruded The sphenomandibular ligament Runs from the spine of the sphenoid bone to the lingula of mandible The inferior alveolar nerve descends between the sphenomandibular ligament and the ramus of the mandible to gain access to the mandibular foramen B ecomes taut when the mandible is protruded Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

10. Muscles : Lateral pterygoid Superior head is attached to the joint capsu l e Inferior head to pterygoid fovea at the condylar neck and is responsible for the displacement of the condylar fractures. Change in the direction of resultant forces post fracture will alter the function of the mandible during various excursion movements. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

11. Vascularisation : Condyle receives blood supply from three sources 1. Medullary bone supplied by inferior alveolar artery 2. Overlying periosteum of the condyle 3. Attachment of lateral pterygoid muscle This may explain the reason for the fractured condyle to remains viable even after stripping of the periosteum during the surgical procedure as the lateral pterygoid muscle remains attached to the fractured fragment. The venous drainage starts in the retrodiscal plexus which drains into the superfcial temporal and maxillary veins that join to form the retromandibular vein, which in turn drains into the external jugular vein Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

12. Nerve i nnervation Both the sensory and motor innervation The sensory nerves are auriculotemporal and masseteric Auriculotemporal nerve crosses the condyle medial to it and lies in contact with the condylar neck and capsule. It is encountered in the preauricular incision Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

13. Facial Nerve It is the key nerve that transverses the face and it is liable for the motor function of the muscles of facial expression. This nerve transverses the temporoparietal fascia and f i nally divides into fve terminal branches in the parotid gland. Hence all the extraoral approaches for the condylar fractures are designed keeping the facial nerve in mind. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

14. Surgica l anatomy: The preauricular incision Al- Kayat and Bramley found the nerve was at an average distance of 20 mm with a range of 8–35 mm from the anterior margin of the auditory canal. This is the reason the preauricular incision is given in the skin crease near the tragus or placed endurally . Transparotid approach. The neck of the condyle can be exposed via the transparotid approach. In this approach the condyle is reached through the space between the temporozygomatic and buccocervical trunks of the nerve. This results in a direct and safe approach to the neck of the condyle.

15. Surgica l anatomy: The marginal mandibular nerve The marginal mandibular nerve is encountered in the submandibular or periangular approach. This branch may further subdivide into two or more branches. As a rule, the submandibular incision is given 2 cm below the lower border of the mandible to prevent paresis of the lower lip. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

16. BIOMECHANICS

17. LINDAHL (1977)

18. HUNTING BOW CONCEPT

19. C l assification

20. 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. 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 .

21. Condylar fractures i. Without displacement of condyle • Greenstick fracture • Intracapsular • Extracapsular   ii. With displacement of condyle • Lateral • Medial • Forward • Backward iii. With overriding of fragments iv. With dislocation in lateral or medial direction • Intracapsular • Complete fracture dislocation • Complete dislodgement of the condyle • Dislocation of the fractured part of the head of the condyle v. With dislocation in forward direction • Anteriorly from the articular eminence • Posteriorly from the articular eminence • With dislocation and displacement of the meniscus • With comminution • Old fracture with deformities — Pseudoarthrosis — Ankylosis Thoma (1945)

22. B. Subcondylar fractures   i . Without displacement of fragment ii. With displacement of fragment By Thoma Fracture line either extending through head or base of the condyle or neck has been called condylar fracture , whereas in subcondylar fracture, the line runs transversely over ascending ramus .

23. Mac Lennan classification (1952) a. No Displacement - A crack fracture is seen without alteration of the normal relationship of TM Joint b. Deviation - simple angulation of the condylar process to the ramus c. Displacement - Overlap occurs between the condylar process and the ramus and fractured fragment lies lateral to the ramus. d. Dislocation - condylar head is completely disrupted from the glenoid fossa and gets pulled anteriorly and medially by the lateral pterygoid muscle

24. Rowe & Killey 's classification(1968) a. Intracapsular Fractures or High Condylar Fractures i . Fractures involving the articular surface ii. Fractures above or through the anatomical neck, which do not involve the articular surface b. Extracapsular or Low Condylar or Sub condylar Fractures Fracture line runs obliquly from the lowest point of curvature of the sigmoid notch downward and backward below the neck to the upper posterior limit of the ramus. c. Fractures associated with injury to the capsule, ligament and meniscus d. Fractures involving adjacent bone - Roof of the glenoid fossa or tympanic plate of the external auditory meatus .

25. Spissel and Schroll classification (1972) Type 1 : Non-displaced fracture Type 2 : Low-neck fracture with displacement, mostly with contact between fragments Type 3 : High-neck fracture with displacement, mostly without contact between fragments Type 4 : Low-neck fracture with dislocation Type 5 : High-neck fracture with dislocation Type 6 : 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

26. Lindahl classification(1977) a. Anatomic location of the fracture i ) Condylar head ii) Condylar neck iii) Subcondylar

27. b. Relationship of condylar fragment to mandible i ) Undisplaced ii) Deviated iii) Displacement with medial or lateral overlap iv) Displacement with anterior or posterior overlap v) No contact between fractured segments

28. c. Relationship of condylar head & fossa Nondisplaced Displacement Dislocation

29. 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

30. Neff & Rasse’s Modification(2006) Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11 Type A: continuous bony contact within the articular fossa, with a component of the condylar head remaining and the fracture supported without loss of ramus height Type B: loss of support within the articulating fossa and subsequent loss of mandibular ramus height. Type C: the uppermost portion of the fracture is below the level of the lateral ligament, resulting in a loss of ramus height.

31. He et al classification of Dicapitular fracture (2009) A - Fracture line through the lateral third portion of the condylar head with reduction of the ramus height B - Fracture line through the central third portion of the condylar head without reduction of the ramus height C - Fracture line through the medial third portion of the condylar head without reduction of the ramus height M - A comminuted fracture with multiple fragments (usually more than three) of the condylar head He D, Yang C, Chen M, Jiang B, Wang B. Intracapsular condylar fracture of the mandible: our classification and open treatment experience . J Oral Maxillofac Surg 2009;67(8):1672–1679

32. Jing et al classification of diacapitular fractures (2011) M - Fractures involving the medial section of the condylar head C - Fractures involving the central section of the condylar head L - Fractures involving the lateral section of the condylar head Jing J, Han Y, Song Y,Wan Y. Surgical treatment on displaced and dislocated sagittal fractures of the mandibular condyle. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(6): 693–699

33. AO CM F Classification ( 2014 ) Condylar Head fracture Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

34. Neck and Base fractures Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

35. Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

36. Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

37. Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

38. Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

39. Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

40. Distortion of condylar head articular congruency Andreas Neff; The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

41. Clinical Features

42. Clinical Features Condylar fractures infrequently occurred in isolation and are generally associated with fractures of other sites of the facial bones. Signs and symptoms: • Pain and swelling over the preauricular region • Ecchymosis over the mastoid region • CSF otorrhea • Hollowness over the condylar region • Restricted incisal opening • Locked mandible Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

43. Unilateral c ondylar Fractures : • Premature occlusion on the ipsilateral side • Open bite due to the loss of vertical height on the contralateral side. • Affected side deviates on opening and is common because of the interruption of the action of the lateral pterygoid muscle. • Limited laterotrusive movements away from the fractured side but may be maintained towards the fracture. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

44. Bilateral c ondylar Fractures : • Bilateral loss of vertical height results in anterior open bite with posterior gagging • Restricted mouth opening • In bilateral condylar fractures with an associated mandibular symphysis fracture, facial widening may result with posterior buccal cross-bites and anterior open bite. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

45. Radiographic eva l uation : Towne’s radiograph C oronal displacement is evaluated with Towne’s radiograph OPG S agittal displacement , the loss of ramus heigh is evaluated with a panoramic radiograph The measurement technique is as follows : • Line drawn between gonial angles across Panorex • Perpendicular lines to most superior aspect of condylar heads • The difference between the nonfractured and fractured side equals the change in ramus height. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

46. Computed tomography A nterior posterior dimension (sagittal position) M edial lateral dimension (coronal position) MRI MRI are essential to evaluate the disc injuries specially in dislocation and intracapsular condylar fractures; however MRI are not taken as a routine practise Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

47. Management

48. CONSERVATIVE TREATMENT Closed treatment is treatment of condylar fractures by means other than surgical exploration, reduction, and fixation of the fracture line (i.e., not involving an open surgical exposure of the fracture). Traditionally, this has been achieved by arch bars, splints fitted over the remaining dentition, IMF, screws, or bonded brackets. Once reduction of the occlusion has been achieved, a period of immobilization may be required to encourage bony healing. Early mobilization is advised to minimize the risk of fibrous and bony TMJ ankylosis . Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

49. INDICATIONS FOR CLOSED TREATMENT Nonsurgical treatment may be the appropriate management strategy in cases of • C ondylar neck fractures in children <12 years of age. • H igh condylar neck fractures without displacement. • I ntracapsular (diacapitular) condylar fractures without loss of ramus height. • P oor anesthetic risk. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

50. INDICATIONS FOR OPEN TREATMENT

51. APPROACHES

52. Emam HA, Jatana CA, Ness GM. Matching surgical approach to condylar fracture type. Atlas Oral Maxillofac Surg Clin North Am 2017;25:55-61

53. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

54. Submandibular Approach. This is also known as the Risdon approach Advantages : These include the ability to distract the mandibular ramus and direct access of the gonial angle. Disadvantages : These include limited surgical site exposure (the incision is distant from the fracture) D ifficult to reduce medially displaced condyles P late and screw fixation restricted without a transfacial trocar. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

55. Surgical Technique Incision.  These are 1.5 to 2 cm below the inferior border of the mandible in or parallel to a skin crease. In patients with ramus height shortening, place the incision 1.5 to 2 cm below where the anticipated reduced mandible would be. The initial incision is placed to the depth of the platysma , with extensive undermining in all directions. Dissection.  Through the platysma. Undermine and sharply dissect, being careful to stay superficial to the superficial layer of the deep cervical fascia. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

56. Make a small incision through the superficial layer of the deep cervical fascia at the level of the skin incision (1.5 to 2 cm inferior to the mandible). The facial artery and vein may be retracted anteriorly or divided and ligated if necessary. Continue the dissection superiorly until the pterygomasseteric sling is encountered. Division of the pterygomasseteric sling. Sharply incise the pterygomasseteric sling with a scalpel along the inferior border of the mandible. Use a periosteal elevator to expose the ramus up to the level of the TMJ capsule and coronoid process. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

57. Retromandibular Approach Advantages. S hort distance between the incision and the fracture site B est access to the fracture site N o need for a transfacial trocar F acial scar is less noticeable than with a submandibular incision E ffective in patients with edema A ccess for an osteotomy if required to reach the condyle. Disadvantages. The facial scar is more noticeable than with a preauricular incision. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

58. Retromandibular – Trans-parotid Approach

59. Retromandibular- Retro-parotid- Approach

60. Technique A preauricular incision is made that extends downwards in a curvilinear fashion in the cervicomastoid skin crease, though any variation in this incision. The great auricular nerve is preserved and the flap raised in the subdermal fat plane, superficial to the superficial musculoaponeurotic layer to allow access to the masseter adjacent to the anteroinferior edge of the parotid gland, just below the parotid duct. The area next to the anterior edge of the parotid gland is usually relatively free of branches of the facial nerve, making this an ideal point to dissect down to the fracture

61. Technique If a buccal branch crosses the field it is easily retracted up or down. The masseter is split in the direction of its fibres . The periosteum overlying the lateral aspect of the ramus in the region of the condylar neck is incised and the fracture site is exposed.

62. Periangular transmasseteric approach 4 cm long curvilinear incision, 5 mm below and along the angle of the mandible After skin incision, dissection was continued in the subcutaneous plane, upward and superficial to the platysma till the zygomatic arch. The thin platysma muscle is held with tissue holding forceps and incised obliquely to expose the masseteric fascia overlying the masseter belly

63. Periangular transmasseteric approach The area adjacent to the anterior edge of the parotid gland is relatively free of the branches of the facial nerve and hence ideal for further dissection. The parotid tissue was retracted posteriorly with retractors positioned horizontally, and the belly of masseter muscle was incised parallel to the fibers of the branches of the facial nerve to expose the periosteum. The periosteum was incised and the direction of retractor changed vertically to retract masseter in an upward pull manner to expose the fractured segment

64. Pre-Auricular Approach

65. TRANSORAL APPROACH Indications: F ractures that involve the low condylar region. Technique: An incision is made over the anterior border of the vertical ramus, extending into the lower buccal sulcus. The temporalis muscle is stripped from the anterior ascending ramus, and the masseter is stripped by subperiosteal dissection. A transbuccal trocar is introduced and drilling occurs transbuccally the plate is introduced transorally .

66. TRANSORAL APPROACH A dvantage : A voiding facial scarring and risk of injury to the facial nerve. D isadvantage : limited access, which makes fragment control difficult and the procedure surgically more challenging. It may not be possible to align the posterior border perfectly and slight errors of reduction are inevitable .

67. TECHNIQUES OF REDUCTION The use of the curved elevator, Howarth’s elevator, and the tracheostomy hook have all been advocated. Kocher’s bone-holding forceps may be used to grasp and reduce fragments but can crush and split the condylar head and therefore must be used with caution. In cases of severe and difficult reduction, the lateral pterygoid insertion may be cut to give greater mobility and reducibility, but preservation of the periosteal attachment to the condylar head is mandatory to preserve a blood supply to the proximal fragment. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

68. Manual digital traction: Thumb is placed on the lower teeth and fngers support the lower border. Mandible is pulled in inferior and anterior direction. Bite block: A bite block is placed on the same side of the condylar fracture in the molar region. This will result in inferior distraction of the mandible with rotation. Transosseous wire: A transosseous wire can be passed along the posteroinferior border of the mandible. A traction is applied on this wire in an inferior and anterior direction. For easy manipulation, a plate with a single screw is f i xed on the proxima l fragment. This will help in easy lateralization of the distal fragment and prevent the fragment from slipping back as the lower end of the plate acts as a rest on the proximal segment. Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

69. FIXATION Miniplate Osteosynthesis : Meyer’s line of osteosynthesis In the case of low condylar fracture, two plates may be required to achieve stability. The posterior plate should parallel the posterior ascending ramus, and the anterior plate parallel to sigmoid notch. High condylar fractures may accommodate only one plate due to bony limitations 3-D plate s Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

70. Lag Screw Osteosynthesis Lag screw osteosynthesis was first described in condylar fractures by Wackerbauer in 1962. The Eckelt screw is one of the most popular lag screws Advantage R apid application of rigid fixation and close approximation of the fractured parts because of the large amount of compression generated. Bioresorbable Plates Vikas Dhupar ; Fracture of the Mandibular Condyle; Oral and Maxillofacial Surgery for the Clinician; Springer; 2021

71. Comp l ications

72. Malocclusion. This is often implied secondary to improper treatment, such as inadequate use of occlusal guidance or closed reduction when open reduction is indicated. Patients presenting with displaced fractures, ramus shortening, and early objective malocclusion will often have persistent centric relation discrepancies when treated in a closed fashion. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

73. Mandibular Hypomobility. This is related to delayed physiotherapy of the joint and has been shown to increase the longer the patient is subjected to MMF. Children are more susceptible to hypomobility, as are those subjected to high-energy injuries with capsular disruption. Ankylosis. In children, ankylosis is related to severe meniscal disruption with inappropriate physiotherapy. In adults, ankylosis usually results from a widened mandible, which leads to superior lateral displacement of the condyle. This may be mitigated by proper reduction of the fractures restricting mandibular widening. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

74. Asymmetry. In children, approximately 25% of condylar fractures will produce some facial asymmetry, whether it is hypoplasia or hyperplasia. In adults, deviation on opening has been noted in up to 50% of individuals following fracture of the condyle. Dysfunction or Degeneration. All injured joints are more susceptible to arthritis, and the TMJ is no different. Risk factors include increased age, displaced condyle, longer periods of MMF and hypomobility secondary to capsular or meniscal injuries. Condylar Resorption. A voidable by limiting the total denudation of the blood supply and proper anatomic reduction. However, difficult cases may demand replacement of the condylar head as a free bone graft. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

75. Iatrogenic Injury. Following surgical repair of condylar f ractures , up to 15% of patients may experience transient facial nerve weakness; however, permanent injury is rare. Chronic Pain. This occurs more commonly when condylar fractures are treated with closed reduction. Raymond.J Fonseca; O ral & maxillofacial trauma ; fourth edition ; 2013, Saunders, Elsevier Inc

76. Nerve injury During preauricular approach, a precaution should be given not to cause the injury of facial nerve temporal branch Nerve injury may occur during flap elevation, fracture reduction and insertion of a metal plate. If nerve injury is observed after the surgery, steroid should be immediately administered to prevent tissue swelling, thereby shortening recovery time and preventing permanent injury.

77. Sialocele: C ollection of saliva beneath the skin and subcutaneous tissue associated with injury to glandular parenchyma or ductal system. Clinical features : S alivary extravasations into the tissues causing swelling over or adjacent to parotid gland (sialocele) E xpanding neck mass C utaneous fistula formation. Following transparotid approach closure includes formal closure of the masseter and the parotid fascia - reduces the swelling and the possibility of a sialocele

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