CONDYLAR FRACTURES AND ITS MANAGEMENT.pptx

complete description on condylar fractures and management

1. CONDYLAR FRACTURES PRESENTED BY- DR YASH ANANDPARA III MDS DEPT. OF OMFS

2. CONTENTS INTRODUCTION SURGICAL ANATOMY MECHANISM OF INJURY ETIOLOGY BIOMECHANICS CLASSIFICATION OF CONDYLAR FRACTURES RADIOGRAPHIC EVALUATION CLINICAL FEATURES ADAPTATION OF FRACTURES MANAGEMENT PEDIATRIC CONDYLAR FRACTURES COMPLICATIONS CONCLUSION REFERENCES 2

3. INTRODUCTION Most common of all mandibular fractures after symphysis and parasymphysis fractures 17.5 % to 52% - mandibular fractures Difficult to diagnose clinically and radiologically 3

4. SURGICAL ANATOMY 4

5. BLOOD SUPPLY 5

6. NERVE SUPPLY A MODIFIED PRE-AURICULAR APPROACH TO THE TEMPOROMANDIBULAR JOINT AND MALAR ARCH ADIL AL-KAYAT, B.D.S., M.MED.SCI., F.D.S.R.C.S., 1 and PAUL BRAMLEY, M.B., CH.B., B.D.S., F.D.S.R.C.S. 2 6

7. MUSCLE AND LIGAMENT ATTACHMENTS 7

8. 8 ANATOMY OF CONDYLE Condylar process- 3 subregions Head Neck Subcondylar area

9. ETIOLOGY Direct or indirect trauma Interpersonal violence- frequent cause, Sports injury, Falls and road traffic accident 9

10. According to Silvennoinen et al. Intracapsular fractures – 14% Condylar neck - 24% Subcondylar - 62% Associated with severe displacement – 16% Highest incidence -20 to 39 years of age 10

11. 11 Renato Sawazaki, DDS, MS, PhD,*Sergio Monteiro Lima Júnior, DDS,† Luciana Asprino, DDS, MS, PhD,‡ Roger Willian Fernandes Moreira, DDS, MS, PhD,§ and Márcio de Moraes, DDS, MS, PhD Purpose: to retrospectively evaluate the epidemiologic prevalence, type, and treatment modalities of condylar fractures of the mandible Patients and Methods: 8-year period (1999 to 2007). Results: 209 unilateral fractures 54 bilateral fractures male/female ratio of 3.05:1 mean age of 28.4 years, for a total of 317 condylar fractures. The most common cause of condylar fractures was road traffic accidents (57.8%). Of the 317 fractures, 300 simple fractures, 249 fractures were not displaced .

12. BIOMECHANISM OF CONDYLE FRACTRUE Treatment of Mandibular Condylar Process Fractures: Biological Considerations Edward Ellis III, DDS, MS* and Gaylord S. Throckmorton, PhD† 12

13. HUNTING BOW CONCEPT 13

14. MECHANISM OF INJURY What sort of forces cause damage to the joint? LINDAHL (1977) – condylar injuries into 3 groups 14

15. 15

16. : RTA 16

17. 17 CLASSIFICATION OF CONDYLAR FRACTURES WASSMUND CLASSIFICATION(1927) MAC LENNAN CLASSIFICATION (1952) DINGMAN AND NATVIG CLASSIFICATION (1964) ROWE AND KILLEYS CLASSIFICATION(1968) SPIESSEL AND SCHROLL CLASSIFICATION(1972) COMPREHENSIVE CLASSIFICATION- LINDHAL(1977) ELLIS AND COWORKERS (1999) LOUKOTA ET AL- ADOPTED BY STRASBOURG OSTEOSYNTHESIS RESEARCH GROUP (2005) AO CLASSIFICATION (2010) NEFF & COWOKERS (2014)

18. 18 WASSMUND CLASSIFICATION [1927] BASE # NECK # HEAD #

19. MAC LENNAN (1952) M ore simple and practical classification. Class I: no deviation (bending) Class II: deviation (bending) at the fracture level Class III: displacement (condylar head remains within fossa) Class IV: dislocation (condylar head outside of fossa) 19

20. 20 Type I: condylar neck fracture without deviation/ displacement Type II : low condylar neck fracture with deviation/ displacement Type III: high condylar neck fracture with deviation/ displacement IIIa : ventral IIIb : medial IIIc : lateral IIId : dorsal Type IV: low condylar neck fracture with dislocation Type V: high condylar neck fracture with dislocation Type VI : intracapsular fracture of the condylar head SPIESSL AND SCHROLL CLASSIFICATION

21. COMPREHENSIVE CLASSIFICATION Proposed by LINDAHL (1977) RELATIONSHIP OF CONDYLAR FRAGMENT TO MANDIBLE b. RELATIONSHIP OF CONDYLAR HEAD TO GLENOID FOSSA FRACTURE LEVEL 21

22. AO Foundation in 2010 expanded on Ellis classification with the determination of “high-neck” and “low-neck” fractures in the online AO Surgery : 22

23. 23 RADIOGRAPHIC EVALUATION Townes radiograph Orthopantomogram Lateral oblique of mandible PA view CT, MRI

24. Townes radiograph ORTHOPANTOMOGRAM PA view 24

25. Measuring the ramus height. 25

26. Coronal CT scan - Demonstrate the fracture line MRI – disc position can be shown Arthrography Transcranial view of TMJ 26

27. SKELETAL DENTAL NEUROMUSCULAR Following condylar fracture of the mandible, patients adapt to the injury by compensation mechanism which is divided as follows: ADAPTATION TO FRACTURE 27

28. CLINICAL FEATURES 28

29. CONDYLAR FRACTURES : UNILATERAL UNILATERAL FRACTURE WITH DISLOCATION OR DISPLACEMENT 29

30. CONDYLAR FRACTURES: BILATERAL 30

31. INTRACAPSULAR FRACTURES : Fracture line run above attachment point of lateral pterygoid Tenderness in auricular region Painful limitation of mouth opening Occlusal derangement No functional loss Fracture line below the attachment of lateral pterygoid Functional loss of the muscle during opening of mouth Lateral deviation of mandible to injured side 31

32. MANAGEMENT OF CONDYLAR FRACTURES CONSERVATIVE FUNCTIONAL SURGICAL 32

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34. CONSERVATIVE TREATMENT Achieved by - 1.Wiring Ivy loop wiring Gilmer wiring Continuos ivy loop wiring 2. Arch bars- Erich arch bar 3. Splints Cap splints in pediatric patients Gunning splints in edentulous patients 34

35. UNILATERAL INTRACAPSULAR FRACTURES Occlusion- undisturbed Treated conservatively without immobilization of mandible Malocclusion noted , when there is associated effusion in the joint - IMF – 2-3 weeks BILATERAL INTRACAPSULAR FRACTURES Occlusion – slightly deranged Degree of displacement of 2 condyles may not be same Immobilization – 3-4 weeks Thought this would predispose to chronic limitation of movement Post reduction physiotherapy is effective 35 ADULTS

36. Undisplaced fracture occlusion will be undisturbed no active treatment Dislocation will often induce malocclusion due to shortening of ramus and premature contact of molar teeth on that side Low condylar neck fractures best treated by open reduction High condylar neck fracture with extensive dislocation and malocclusion IMF 3 – 4 weeks Relapse may take place when fixation is removed, corrected by combination of occlusal grinding and spontaneous adaptation UNILATERAL CONDYLAR NECK FRACTURES 36

37. Bilateral condylar neck fracture Considerable displacement of one side or the other Inherently unstable and functional treatment is contraindicated Application of IMF will establish occlusion, it well not reliably reduce fracture on both sides Operative reduction of at least one of the fractures to restore ramus height is desirable Operative reduction is difficult, IMF – 6 weeks If strong arch bars or even cap splints are applied this will allow use of intermittent intermaxillary elastics at night This technique may encourage better functional remodelling 37

38. CLOSED FUNCTIONAL TREATMENT when a full range of jaw movements is attained, normal jaw growth is hindered Application of elastics- guide occlusion, degree of remodelling and articulation to its new position Intermittent maxillomandibular elastic traction Wooden spatulas – 40 mm of interincisal opening 3 months of rehabilitation 38

39. PHYSICAL THERAPY Manual therapy techniques Joint distraction for general mobility Anterior glide to restore translation during mandibular depression greater than 20 -25 mm Protrusion , lateral or medial glides to restore lateral deviation required for chewing Tongue depressor- facilitate straight opening and symmetrical lateral deviation Muscle strengthening – progressive diet instruction, encouraging to chew on both sides 39

40. CLOSED REDUCTION Advantages Relatively safe procedure No injuries to vital structures Hospitalization may not be required Disadvantage Long period of intermaxillary fixation Growth disturbances can occur in children Success depends on patients cooperation Long-term follow Contraindicated in medically compromised Challenge in partially or totally edentulous patients 40

41. INDICATIONS FOR NON SURGICAL TREATMENT Nondisplaced or incomplete fractures Isolated intracapsular fractures without loss of ramus height Condylar neck fractures in children ( < 12 yrs ) Reproducible occlusion Medical illness or injury that inhibits ability to receive extended general anesthesia 41

42. 42 SURGICAL APPROACHES Preauricular Submandibular Retromandibular Rhytidectomy Intraoral Endoscopic Inviscision

43. ABSOLUTE Displacement into middle cranial fossa or external auditory meatus Inability to obtain adequate occlusion by non surgical treatment Invasion of foreign body Lateral extracapsular displacement RELATIVE Bilateral fractures in edentulous jaws Gross condylar displacement > 45 degrees Anatomic reduction of ramus height > 2mm Unstable occlusion condylar fractures with an unstable base (associated with midface fractures) IMF contraindicated for medical reasons Condylar fractures in which active physiotherapy is impossible 43 INDICATIAONS FOR OPEN REDUCTION AND INTERNAL FIXATION ZIDE AND KENT – 1983

44. 44 INCISIONS

45. PREAURICULAR APPROACH 45

46. In some cases, to maximize the exposure to the TMJ, preauricular incision is modified to a question mark pattern presented by Al-Kayat and Bramley Al-Kayat bramley incision Endural incision 46

47. SUBMANDIBULAR APPROACH Also known as RIDSON APPROACH Incision -1.2 -2cm below lower border of the mandible 47

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49. The Periangular Approach to the Posterior Mandible: A Novel Approach and Technique Neel Patel, MD, DMD and Robert Cronyn, DDS, JD The Journal of Craniofacial Surgery Volume 29, Number 8, November 2018 Abstract : There exist 2 classic extraoral approaches to the posterior aspect of the mandible, namely the submandibular or Risdon approach, and the retromandibular approach. The authors wish to propose a more conservative, technically easier, and less time-consuming approach to the posterior mandible, with less risk of damage to the branches of the facial nerve, as well as other structures such as the facial vessels and the parotid gland CONCLUSION The periangular approach to the posterior mandible offers a technically simpler and less time-consuming method for exposure of the mandibular body, angle, and ramus. Most importantly, it presents a significantly decreased risk for facial nerve injury, preservation of facial vasculature, as well as avoidance of other vital structures such as the major salivary glands. Peri-angular Pterygomasseteric Transectioning Approach (IPPTA) 49

50. RETROMANDIBULAR APPROACH 50

51. RHYTIDECTOMY APPROACH 51

52. INTRAORAL APPROACH 52

53. APPROACH ADVANTAGE DISADVANTAGE PREAURICULAR ENDURAL Exposure of lateral and anterior part of condyle cosmetic Injury to facial nerve Injury to auriculotemporal nerve Hemorrhage Parotid fistula SUBMANDIBULAR (RIDSON) Adequate access to condylar neck and sub condyle Injury to marginal mandibular nerve RETROMANDIBULAR Adequate access to condylar neck and sub condyle Less risk of injury to marginal mandibular nerve Scar Parotid fistula RHYTIDECTOMY Enough access to condylar process Good cosmetic result Injury to facial nerve POST AURICULAR Esthetic Minimal risk for facial nerve Infection Hematoma Cartilage necrosis INTRAORAL No visible scar Adequate access to condylar neck Injury to buccal, IAN Damage to maxillary artery Injury to lingual vessels 53

54. ENDOSCOPE ASSISTED APPROACH Alternative technique Advantages Avoidance of facial scars Minimizes the risk of facial nerve injury More time consuming, with a steep learning curve , 54

55. SURGICAL TECHNIQUE Surgical technique 55

56. 2013- 2015 Patients were treated with endoscopic-assisted ORIF evaluated for functional outcomes that included occlusion, maximal interincisal opening, and deviation of mouth and complications such as facial nerve pareses, postsurgical infection, and morbidity 15 Patients 4 left side 11 right side Mean age- 28.2 years Mean mouth opening at end of 1 week, 6 weeks and 6 months Transient facial paralysis- 1 patient Extraoral draining sinus – 1 patient Conclusion : Difficulty increases with the level of fracture and the endoscope could be better used in subcondylar and lowsubcondylar fractures. 56

57. INVISCISION 57

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62. 62 OPEN REDUCTION AND INTERNAL FIXATION

63. 63 BENEFITS OF ORIF Direct visualization of fracture fragments for accurate fixation and reduction Early mobilization of mandible Early restoration of normal jaw activity COMPLICATIONS OF ORIF Poor esthetic result from skin incision Neural damage , especially to facial nerve Intraoperative bleeding from maxillary artery loss of blood supply to condylar head, leading to necrosis

64. TYPE OF DISLOCATION ACUTE CHRONIC RECURRENT Reduction Manual Reduction Indirect Reduction Direct Reduction 64

65. METHODS OF REDUCTION MANUAL DIGITAL TRACTION BITE BLOCK TRANSOSSEOUS WIRE TOWEL CLIP 65

66. 66

67. METHODS OF IMMOBILIZATION HISTORIC METHODS Transosseous wire fixation External fixation Kirschner wire fixation CURRENT METHODS Miniplate osteosynthesis Dynamic compression plating Lag screw osteosynthesis Pin fixation Bioresorbable plates and pins 67

68. Bone pins ARCHER (1975) Insertion of pins into condylar head and neck which were connected with an external bar and universal joints Rarely indicated THOMA (1945) Similar technique but placed pins in condylar neck and zygomatic bone 68

69. Transosseous wire fixation 69

70. Kirschner wire fixation Drilled vertically from angle region and inserted into the reduced condyle Avoids Inferior alveolar bundle Modified by Brown and Obeid (1984) Kirschner wire inserted into proximal condylar fragment Groove is cut in main distal mandibular fragment for its base Base of the pin secured by two interosseous wires 70

71. Lag screw osteosynthesis Direct fixation using lag screw 71

72. BONE PLATING Robinson & yoon (1960) Koberg & Momma (1978) 72

73. 73 MINIPLATE OSTEOSYNTHESIS

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75. 75 CONCLUSION Trapezoidal condylar plates (TCP s ) were able to stabilise sub-condylar fractures in the experiments described and to fulfil the biomechanically required principles of functionally stable osteosynthesis. The primary stability achieved by TCP s s was superior to that obtained by single plating techniques, by axial lag-screw osteosynthesis, and by rectangular plates in the sagittal plane. Material and methods: In order to apply the principles of functionally stable osteosynthesis to the mandibular condyle, i.e. to put the plate as close as possible to the tensile strain lines occurring during function, two new 4- and 9-hole 3-D trapezoidal plates were designed. Tests were conducted on fresh human mandibles before and after osteosynthesis of a standardised unilateral sub-condylar ‘fracture’, and a static biting exercise between the ipsilateral first molars was reproduced on a test bench. The resulting condylar fragment displacement in the sagittal plane was measured and the alterations of the condylar tensile strain lines induced by the osteosynthesis were investigated by using photoelastic strain tests.

76. 76 The aim of this study was to present A-shape plate dedicated to rigid fixation of mandible condyle neck fracture Material and methods: A-shape condylar plate (ACP) design is prepared of 1.0 mm thick titanium alloy (grade 5) sheet: posterior and anterior bars are reinforced by widening to 2.5 mm and anatomically curved along the compression and traction lines in ramus and condylar neck. Superior three-hole-group has triangular organization and located on the level of condylar head. Conclusion: Application of proposed A-shape condylar plate would be possible in all levels of neck fractures and can be use for stabilization additionally existed coronoid process fracture.

77. INTRACAPSULAR FRACTURES Chin impact Disperses force on condyles Crush type injuries to articular disc HIGH CONDYLAR FRACTURES No articular involvement Located superior to sigmoid notch Medially dislocate the mandible Good regenerative potential and union Conservative management SUBCONDYLAR FRACTURES Located caudally Greenstick fractures Donot require open surgical intervention Management of Pediatric Mandible Fractures Erik M. Wolfswinkel, BS , William M. Weathers, MD , John O. Wirthlin, DDS, MSD , Laura A. Monson, MD , Larry H. Hollier Jr, MD * , David Y. Khechoyan, MD PEDIATRIC CONDYLAR FRACTURES 77

78. 78 Face to cranium – 1: 8 Marked growth in facial skeleton in relation to rest of the head as child ages Vertical growth of mandible achieved by Bony remodelling by development of alveolar process Eruption of dentition Resistant to traumatic forces due to Poor pneumatization High elasticity High ration of cancellous to cortical bone Thick surrounding soft tissue and adipose coverings Management of Pediatric Mandible Fractures Erik M. Wolfswinkel , BS , William M. Weathers, MD , John O. Wirthlin , DDS, MSD , Laura A. Monson, MD , Larry H. Hollier Jr , MD * , David Y. Khechoyan , MD PEDIATRIC CONDYLAR FRACTURES

79. 79 Ages 0 to 2 condylar neck - short and thick and engages a shallow glenoid fossa Extensive vascular channels Unlike older age groups, the short stocky nature of the condylar neck makes it relatively resistant to fracture, whereas the regenerative capacity is significant Ages 3 to 12 A glenoid fossa begins to develop Although unlike adults, there still remains an enormous potential for regeneration and remodeling in this age group PEDIATRIC CONDYLAR FRACTURES

80. Adequate range of motion and occlusion < 2 years of age- considered edentulous Immobilization- acrylic splint with circumandibular wiring 2-5 years- teeth can be used for fixation 6- 12 years- primary roots are being resorbed Combinations of MMFs used to immobilize jaw Anchors – primary molars and incisors MMF – 7 to 14 days to reduce pain and to correct minor maloclusion Management of Pediatric Mandible Fractures Erik M. Wolfswinkel , BS , William M. Weathers, MD , John O. Wirthlin , DDS, MSD , Laura A. Monson, MD , Larry H. Hollier Jr , MD *, David Y. Khechoyan , MD PEDIATRIC CONDYLAR FRACTURES 80

81. Aggressive physiotherapy with early range of motion of tmj – mainstay of treatment Younger children- lollipop Older children- stacked popsicle sticks, to increase incisor opening Restricted growth on injured side- results in ipsilateral chin deviation and facial asymmetry Seen in cases of communited intracapsular fractures PEDIATRIC CONDYLAR FRACTURES 81

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83. EDENTULOUS PATIENTS Patients own dentures to recreate the vertical height of mandible Gunning splints If these splints are not enough, zygomaticomaxillary suspension or circumfrential wiring is used 83

84. 84 COMMON Joint mobility disorders Occlusal discrepancies Ipsilateral asymmetry on the side of trauma Ankylosis [0.2% -0.4%] Alteration of facial growth Infection Fixation failure Malunion RARE Articular head necrosis which is related with surgical method SURGICAL Transient or permanent facial palsy Marginal mandibular nerve palsy Ear lobe hypoesthesia Post surgical scarring EAC stenosis Auriculotemporal nerve syndrome or Frey’s syndrome Formation of sialocele or salivary fistulas Masseter myotonia COMPLICATIONS