Condylar fractures

condylar fractures of the mandible and its management

1. Condylar fractures -Zeeshan Arif

2. Introduction Condylar and subcondylar fractures constitute 26-40% of all mandible fractures Given the unique geometry of the mandible and temporomandibular joints (TMJs), these fractures can result in marked pain, dysfunction, and deformity if not recognized and treated appropriately.

3. Development Meckel’s cartilage. Intramembranous ossification Bone formation : secretion of bone matrix directly within the connective tissue; without any intermediate cartilage formation. Condensation of mesenchyme just lateral to the Meckel’s cartilage. Cartilage then disappears as the bony mandible develops.

4. Anatomy Condyle : knuckle like It is a strong upward projection from the posterosuperior part of the ramus. Upper end : Head TMJ Pterygoid fovea

5. Surgical anatomy Elliptical in shape, long axis angled backwards between 15-33 to frontal plane. Long axis of 2 condyles meet at basion on anterior ligament of foramen magnum forming an angle 0f 145-160 degrees.

6. Mediolateral width: 15-20 mm Anteroposterior width: 8 - 10mm Lateral pole: roughened, bluntly pointed. Medial pole: rounded, extends from plane of ramus

7. Blood supply Superficial temporal artery Transverse facial artery Posterior tympanic artery Posterior deep temporal artery

8. Facial nerve Auriculotemporal nerve Nerve supply

9. Muscle attachments Lateral pterygoid muscle Protrusion & lateral excursive movements

10. Etiology Assault RTA Sport injuries Falls Work-related incidents

11. Associated injuries Facial nerve injuries C-spine injuries Displacement of the mandibular condyle into the middle cranial fossa Injuries to the external auditory canal

12. Mechanism of injury

13. Classification of Condylar Fractures Unilateral or bilateral condylar fractures Rowe and Killey’s classification a. Simple fractures of condyle b. Compound fractures of condyle c. Comminuted fracture associated with zygomatic arch fractures

14. Rowe and 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 surfaces b. Extracapsular or low condylar or subcondylar fractures : c . Fractures associated with injury to the capsule, ligaments and meniscus . d . Fractures involving the adjacent bone —e.g. fracture of the roof of the glenoid fossa or the tympanic plate of the external auditory meatus

15. Clinical classification by MacLennan (1952) a. No displacement b. Deviation - Simple angulation exists between the condylar neck and the ramus. c. Displacement - Overlap occurs between the condylar process and the ramus. d. Dislocation - Disruption takes place between the condylar head and the glenoid fossa.

16. Wassmund’s 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.

17. 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 Lindahl classification (1977)

18. Spiessel and Schroll classification (1972) i . Nondisplaced fracture ii. Low neck fracture with displacement iii. High neck fracture with displacement iv. Low neck fracture with dislocation v. High neck fracture with dislocation vi Head fracture

19. Neff and Rasse’s modification (2006) Type A(VI A): Displacement of medial condylar pole with preservation of the vertical dimension Type B (VI B): The lateral condylar pole is involved with loss of the vertical dimension Type C (V): dislocation of the entire condylar head Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11

20. R.A loukotaa et al subclassification (2005) 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

21. Diagnosis History Clinical examination Radiographic examination

22. History How did the patient sustain the injury? -Area of impact -Direction of impact -degree of force

23. Unilateral condylar fracture Inspection Swelling over the TMJ area. Heamorrhage from ear on that side. - bleeding from external auditory canal - middle ear haemorrhage Haematoma on the involved side Ecchymosis of skin just below the mastoid process Characteristic hollow over the region of condylar head.

24. B. Palpation : Tenderness over the condylar area. Mandibular movements: - Protrusion - Lateral excursion Determine the displacement of the condylar head.

25. Intra – orally : Mandible deviates on opening towards the side of fracture. Painful protrusion or lateral excursion to the opposite side. Premature contact of the molar teeth on the side of fracture.

26. Bilateral condylar fractures Inspection & palpation are same as unilateral Overall mandibular movement is usually more restricted than in case of unilateral. Mandible may not be deviated. The midlines are often coincident, and premature contact is present bilaterally on the posterior dentition with an anterior open bite.

27. Signs & symptoms : Evidence of facial trauma especially in the area of mandible & symphysis. Localised pain & swelling in the region of TMJ. Limitation in mouth opening. Deviation, upon opening to the involved side. Posterior open bite on the contralateral side Shift of occlusion towards the ipsilateral side with possible crossbite . Blood in the external auditory canal.

28. Pain on palapation Lack of condylar movement on palpation Difficulty in lateral excursion as well as protrusion Occurrence of anterior open bite with bilateral subcondylar fractures. Persistent cerebrospinal fluid leak through the ear: associated fracture of the middle cranial fossa .

29. Radiographic imaging OPG Bilateral lateral oblique. Towne view. Reverse Towne view. Computed Tomography. TMJ views CBCT

30. OPG PA view

31. Towne view

32. Indications for CT scans 1 . Significant displacement or dislocation, particularly if open reduction is contemplated 2. Limited range of motion with a suspicion of mechanical obstruction caused by the position of the condylar segment 3. Alteration of the surrounding osseous anatomy by other processes, such as previous internal derangement or temporomandibular joint surgery.

33. 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

34. 2 schools of thought: Conservative-functional therapy Surgical treatment

35. Indications : Non displaced or incomplete fractures Condylar neck fractures with little or no displacement Fractures occuring in children (10-12 yrs ) Isolated Intracapsular fractures Medical illness or injury that inhibits the ability to receive extended GA

36. Conservative 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

37. Conservative-functional 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 Range of motion Elastic MMF for 2-3 weeks When occlusion is found to be altered P resence of pain or swelling

38. Elastic band – Class II light elastics Review after 1 week 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 week Occlusion maintainable: halt elastics Occlusion difficult obtain: continue elastics (as long as 3 months)

39. 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

40. 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 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 Growth and functional disorders of the TMJ may occur in 20% to 25% of pediatric patients aged 7 to 10 years Closed reduction

41. Open reduction 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 Relative 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.

42. Open reduction Advantage direct approach to the facture site. prevent complications such as respiration disorder, pronunciation disorder, and severe nutritional imbalance by shortening intermaxillary fixation period via rigid fixation . Disadvatage injury of nerves or blood vessels during operation, and postoperative complications including infection. permanent scar

43. Surgical approaches All open approaches have three common aspects to their success 1- the ramus must be distracted 2- the proximal condyle must be controlled and manipulated 3- the fracture must be anatomically reduced

44. Submandibular approach/ Ridsons appraoch Indications - axial anchor screw fixation Advantages – ability to distract the mandibular ramus direct access of the gonial angle Disadvantages - limited surgical site exposure difficult to reduce medially displaced condyle Plate and screw fixation restricted without a transfacial trocar

45. Pertinent anatomy Marginal mandibular branch of the facial nerve Facial artery and vein

46. Incision

47. Dissection Through the platysma From the platysma to the pterygomassetric sling Division of the pterygomassetric sling

48. Osteosynthesis axial anchor screw Visibility and reduction – sigmoid notch retractor and condylar neck retractor is used to reflect the soft tissues Direct fixation- a groove is made in the lateral cortex ( 1cm anterior to the posterior border) and 1.5 to 2cm inferior to the fracture line

49. Indirect fixation- indicated when the proximal condylar fragment is difficult to reduce The screw is locked to the groove with the help of a 2 hole mini plate

50. Closure Pterygomassetric sling- masseter and the medial pterygoid is sutured Platysma – resorbale sutures are used in a running fashion Subcutaneous tissue – resorbable sutures are used Skin- non resorbale sutures are used

51. Retromandibular approach Indications large fractures which requires plates and screws Advantages short distance between incision and fracture site Better access to the fracture site No need for a transfacial trocar Scar is less noticeable than that of a submandibular incision Effective in patients with oedema Access for an osteotomy if required to reach the condyle Disadvantage - scar is more visible than that of a preauricular incision

52. Pertinent anatomy Facial nerve Retromandibular vein

53. Incision 0.5 cm below the ear lobe Carry inferiorly for 3 to 3.5 cm Placed posterior to the posterior border of the mandible

54. Dissection Dissection of the platysma and substance of the parotid Dissection to the pterygomassetric sling Avoid injury to the facial nerve and the retromandibular vein Division of the pterygomassetic sling

55. Osteosynthesis

56. Closure Pterygomassetric sling- masseter and the medial pterygoid is sutured together using interrupted resorbable sutures Parotid capsule, platysma and the superficial muscular layer is sutured using a horizontal mattress resorbale sutures Subcutaneous tissue Skin

57. Rhytidectomy approach This approach provides the same exposure as the retromandibular accesses. The only difference is that the skin incision is placed in a more cosmetically acceptable location. It exposes the entire ramus from behind the posterior border. It therefore may be useful for procedures involving the condylar neck/head, or the ramus itself. This approach is drained with closed suction drainage

58. Transmassetric-anteroparotid approach Indications high and low subcondylar and ramus fractures Advantages – Q uick and direct access to the fractured site Access to the gonial angle Ramus can be distracted Disadvantages Visible scar Potential damage to the facial nerve

59. Pertinent anatomy Marginal mandibular and the buccal branches of the facial nerve Layers of the parotid- massetric region- skin, subcutaneous fat, parotid- massetric fascia,superficial and the deep bellies of the masseter and lastly the periostium of the mandible

60. Incision Line through bottom of ear lobe till the gonial angle in the posterior border 2 nd line from gonial angle (same length) in the inferior border Incision in the intersection 3rd

61. Dissection Dissection to the pterygomassetric sling Division of the massetric sling Exposure of the mandible and fracture

62. Osteosynthesis Plates and screws are placed under direct visualization A trocar may be required in cases of high subcondylar fracture

63. Closure No closure of the periostium or the masseter muscle sling is necessary The paritomassetric fascia is sutured in running fashion to avoid any salivary fistula Subcutaneous tissue Skin

64. Preauricular approach Indications W henever wire fixation of a high anteromedially displaced proximal fragment Advantages P rovides access to the posterior most segment of the jaw Disadvantages N ot ideal for plate and screw fixation No access to the angle of the mandible to distract the ramus inferiorly Limited ramus exposure makes the plate placement difficult

65. Incision In the skin fold in the entire length of the ear Superiorly to the top of the helix Incise to the depth of the superficial layer of the temporalis fascia

66. It provides an easier approach to high condylar fracture such as intercapsular fracture E asy reduction of the injured soft tissues of the TMJ R eduction via a direct inspection of the appropriate relationship among the condyle, disc, and joint. As the amount of mandibular ramus exposure is very limited, rigid fixation using mini-plate is hard to be conducted if fracture site is positioned inferiorly to the mandibular condyle neck.

67. Intraoral approach Indications L ow subcondyar fractures, Axial anchor screws or mini plates can be used Adantages N o visible scar No damage to the facial nerve Disadvantages - Intraoral approach without endoscope- very limited access, poorest access among all the approaches Endoscope assisted intraoral approach- steep learning curve, difficulty in reducing the fracture segments

68. Pertinent anatomy This is an anatomically safe approach with minimal risks

69. Incision

70. Dissection

71. Osteosynthesis Miniplate and screw fixation Preauricular transcutaneous trocar insertion- drill and screw driver is inserted through a trocar incision Screws and plates inserted via the intraoral incision

72. Axial anchor screw The screw is positioned just superior and parallel to the occlusal plane, superior to the mandibular foramen The groove is placed in the medial cortical plate, 1.5 to 2cm anterior to the fracture line 2mm drill is used to drill a pilot hole-1.5 mm drill penetrates beyond the fracture line upto 1 to 2mm Titanium screws are used for fixation

73. Endoscopic assisted osteosynthesis Advantages- access high condylar fractures, better visualization, lesser complications Instruments required- angled drills, a 30 degree angled 4mm endoscope, screwdrivers, illuminating hooks and retractors

74. Fixation of fracture

75. Transosseous wiring Occasionally used in low subcondylar fractures extending through the sigmoid notch Access is possible through a submandibular approach Higher level fractures are approached through the pre auricular incision Damage to the maxillary artery Fracture segments are not stable because of the pull from the lateral pterygoid muscle

76. Bone pins Archer (1975) described the insertion of pins into the condylar head and neck which were connected with an external bar This technique is rarely indicated

77. Glenoid fossa- condyle suture Wassmund (1935) described drilling a small hole through the lateral edge of the glenoid fossa and the related edge of the condylar articulating surface. A chromic catgut suture was looped through it and tied Disadvantage – resorb prematurely, loosen

78. Kirschner wire A k-wire may be drilled vertically through the main mandibular fragment from the angle, avoiding the inferior alveolar bundle, so that it enters the fracture interface Brown and obeid modified this technique in 1984, in which they used two interosseous wires to fix the k wire

79. Intramedullary screws Petzel (1982) described the use of an intramedullary screw fixing the fracture segments, through a submandibular approach kitayama (1989) described the same through an intraoral approach This technique requires special instrumentation(tapping drills), a variety of length of screws of correct diameter and specialised forceps

80. Bone plating This the method of choice as it gives higher stability and is relatively easy to apply Robinson and yoon (1960) described the use of a 2-hole plate Koberg and momma (1978) advocated the use of a 4-hole plate, which has become standard

81. Axial anchor screw Generally approached by the submandibular or intraoral incision This restores the vertical ramus height and may be more effective than mini plates

82. Paediatric Condylar Fractures Most common pediatric mandibular fracture. Prior to age 6, most fractures are intracapsular , whereas after that age they occur most frequently in the neck of the mandible. When normal occlusion is present, fractures of the condylar region are treated conservatively with close observation, soft diet, and pain medication. When there is malocclusion, a short course of maxillary–mandibular fixation is warranted. Limiting fixation to 7 to 10 days helps limit the chance of joint ankylosis , although postoperative physiotherapy may still be beneficial.

83. Choice of technique is largely dependent on the age of the child and, more importantly, the quality and quantity of dentition. When possible, intradental wires with arch bars maybe placed. If not possible, intermaxillary fixation using 1-point circumandibular wiring should be used Due to the possibility of injuring nonerupted teeth, intermaxillary fixation screws should not be placed. It is important to discuss chin deviation during chewing and the possibility of long-term growth abnormalities of the jaw with patients’ parents.

84. 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 opg CT scan No radiographic evidence of condylar # 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

85. Open vs closed reduction

86. Ellis III E, Throckmorton GS. Facial Symmetry After Closed and Open Treatment of Fractures of the Mandibular Condylar Process. J Oral Maxillofac Surg 2000; 58:719-728 Ellis and Throckmorton conducted a study with open or closed treatment for fractures of the mandibular condylar process, in 146 patients, 81 treated by closed and 65 by open methods. The patients whose condylar process fractures were treated by closed methods had significantly shorter posterior facial and ramus heights on the side of injury, and more tilting of the occlusal and bigonial planes toward the fractured side, than patients whose fractures were treated by open methods. The patients treated by closed methods developed asymmetries characterized by shortening of the face on the side of injury.

87. Santler G, Kärcher H, Ruda C, Köle E. Fractures of the condylarprocess : surgical versus nonsurgical treatment. J Oral Maxillofac Surg 1999; 234 patients with fractures of the mandibular condylar process were treated by open or closed methods. In the follow-up study, 150 patients with a mean follow-up time of 2.5 years were analyzed using radiologic and objective and subjective clinical examinations. No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve disorders were observed The only significant difference was in subjective discomfort. Surgically treated patients showed significantly more weather sensitivity and pain on maximum mouth opening. Because of these disadvantages, open surgery is only indicated in patients with severely dislocated condylar process fractures.

88. Marker P, Nielsen A, Lehmann Bastian H. Fractures of the mandibular condyle. Part 2: results of treatment of 348 patients. British Journal of Oral and Maxillofacial Surgery 2000 The ability to open the mouth, deviation and occlusion were recorded in closed reduction cases After one year 45 of the 348 patients (13%) had minor physical complaints such as reduced ability to open the mouth, deviation, or dysfunction. Ten of them (3%) had pain in the joint or muscles or both. Eight patients (2%) had malocclusion They concluded that closed treatment of condylar fractures is non-traumatic, safe, and reliable and in only a few cases may cause disturbances of function and malocclusion

89. 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 facial nerve Vascular injury Late complications: Malocclusion Growth disturbance Temporomandibular joint dysfunction Ankylosis Asymmetry Frey’s syndrome

90. Conclusion Intracapsular fractures are best treated closed. Fractures in children are best treated closed except when the fracture itself anatomically prohibits jaw function. Physical therapy 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 must be supported by an appropriate physical therapy and follow-up regimen  

91. References Oral & maxillofacial trauma-Fonseca & walker Oral & maxillofacial trauma-Rowe & Williams vol 2 Principles of Oral & maxillofacial surgery-Peterson Maxillofacial trauma & facial reconstruction-Peter Ward Booth Classification of condylar process fractures; M. Schneider, U. Eckelt ; Journal of the Canadian Dental Association December 2006, Vol. 68, No. 11 Ellis III E, Throckmorton GS. Facial Symmetry After Closed and Open Treatment of Fractures of the Mandibular Condylar Process.Journal Of Oral Maxillofacial Surgery 2000;58 : 719 -728 Santler G , Kärcher H, Ruda C, Köle E. Fractures of the condylarprocess : surgical versus nonsurgical treatment. J Oral MaxillofacialSurg1999 Marker P, Nielsen A, Lehmann Bastian H. Fractures of the mandibular condyle. Part 2: results of treatment of 348 patients.British Journal of Oral and Maxillofacial Surgery 2000