Condyle Fractures.pptx

Various approaches, pediatric and adult condylar fractures, open and closed reductions.

1. MANDIBULAR CONDYLAR FRACTURES Animation source: www.wikimedia.org Presenter – Dr. Harjeet Yadav PG III, Dept. of OMFS Moderator – Dr. Ajay Das Reader, Dept. of OMFS

2. Animation source: www.wikimedia.org This seminar deals with the etiology, classification, clinical features, diagnosis, and contemporary management of mandibular condylar fractures. Along with the regular management strategies, treatment protocols for geriatric and pediatric patients have also been discussed. The indications and contraindications of closed as well as open reduction and fixation of condylar fractures are analyzed in detail. CONTENTS

3. The topic of mandibular condylar fracture has generated more discussion and controversy than any other in the field of maxillofacial trauma. Direct or indirect trauma can lead to fracture of the condyle. T he degree of displacement of fractured condyle depends on the direction and magnitude of force. In spite of a common occurrence, the management of condylar fractures has been controversial as there is no established consensus. Traditionally closed reduction has been the treatment of choice for condylar fractures and have been treated by various forms of intermaxillary fixation. With the improvement in radiographic imaging and biomaterials used in the fixation, surgical management has gradually found acceptance as it restores early function. INTRODUCTION

4. Image source: www.researchgate.net Elliptical Shape Condyle is a knuckle like structure. It is a strong upward projection from the postero -superior part of the ramus. The condyle has a backward angulation of 15–33° to the frontal plane and is elliptical in shape. The mesio -lateral width is 15–20 mm and the antero-posterior width is 8–10 mm.  The condyle articulates with the mandibular fossa in the temporal bone, as part of the TMJ. ANATOMY OF CONDYLE

5. The main source of arterial supply to the condyle is inferior alveolar artery. Other sources include: superficial temporal artery, posterior tympanic artery, posterior deep temporal artery and transverse facial artery. Venous drainage is by the corresponding tributaries. Nerve supply is from auriculotemporal, masseteric and deep temporal nerves.  Lateral pterygoid muscle is attached at the pterygoid fovea which is helpful in protrusive and lateral excursive movements. Image source: www.aofoundation.org

6. Rounded Bird-beak Diamond Crooked-finger DIFFERENT SHAPES OF CONDYLAR HEADS ON OPG Image source: www.banglajo.info

7. Image source: www.zipfslaw.org ANATOMIC VARIATIONS AT DIFFERENT AGES N P a r a me t e r Child Ad u lt 1 Corti ca l bone Thin Thi c k 2 Con d y lar n ec k B ro a d Thin 3 A r ti c ular surf a c e Thin Thi c k 4 C a psule Hi g h l y v a s c ular L e ss v a s c ular 5 P e riosteum Hi g h l y a c tive oste o g e nic ph a se L e ss a c tive in lat e nt st a ge 6 I nt r a c a psul a r fr ac tu r e & h e ma r throsi s . V e r y c ommon R a re 7 R e modelling ca p a c i t y f ollowing tr a uma Pr e s e nt Abs e nt 8 Disturb a n c e in g r o wth L ike l y N.A

8. Image source: Ellis surgical approaches to the facial skeleton SURGICAL ANATOMY

9. The bifurcation of Facial nerve lies 1.5–2 cm away from the bony external auditory canal. The temporal branch of the facial nerve lies 8–35 mm from the bony external auditory canal. The marginal mandibular branch of the facial nerve lies 1.2 cm away from the inferior border. Complication : Injury to extracranial branches of facial nerve may lead to paralysis or severe weakness of muscles of facial expression. Image source: Ellis surgical approaches to the facial skeleton

10. The Maxillary artery can be injured during procedures in the subcondylar portion of the mandible. The mean distance of the branching point of the maxillary artery to the tip of the condyle is 22.4 mm. Maxillary artery Maxillary artery: anatomical landmarks and relationship with the mandibular subcondyle , Hakan Orbay et al, PMID: 18090748 Image source: www.researchgate.net Complication : Injury to the maxillary artery may lead to profuse bleeding.

11. The Auriculotemporal nerve p a s s e s post e rior to the n e c k of the c on d y l e. The average vertical distance between the superior condyle and the auriculotemporal nerve is 7.06 mm Auriculotemporal nerve The distribution of the auriculotemporal nerve around the temporomandibular joint, B L Schmidt et al, PMID: 9720090 Image source: www.springer.com Complication : Injury to auriculotemporal nerve may lead to Frey’s syndrome. Frey’s syndrome

12. There is a risk of damage to the Transverse facial artery during condylar surgeries. It is located about 1.9 cm below the condylar process and runs about 1.25 mm lateral to the head of mandibular condyle. Transverse facial artery The transverse facial artery and the mandibular condylar process: An anatomic and radiologic study, P Nicol et al, PMID: 30965155 Image source: www.wesnorman.com Complication : Injury to the transverse facial artery may lead to impaired blood supply to the TMJ .

13. The mean distance between the Middle meningeal artery and the apex of the condyle is 18.8 mm. Middle meningeal artery Proximity of the middle meningeal artery and maxillary artery to the mandibular head and mandibular neck as revealed by three-dimensional time-of-flight magnetic resonance angiography, Daphne Schönegg , PMID: 34024006 Image source: www.worldofmedicalsaviours.com Complication : Injury to middle meningeal artery may lead to epidural hematoma.

14. The mean distance between medial margin of mandibular condyle to Internal carotid artery is 11.2 mm ±0.6. Surgical importance of distance from mandibular condyle to carotid canal and foramen spinosum: an anatomical study, November 2019, International Journal of Research in Medical Sciences 7(12):4733, DOI:10.18203/2320-6012.ijrms20195547 Internal carotid artery Complication : Injury to internal carotid artery may lead to thrombosis and neurological deficit.

15. The Masseteric nerve is about 16 mm superior to the lowest point on the mandibular notch. Masseteric nerve Topographical Landmarks for the Identification of Branches of Mandibular Nerve and Its Surgical Implications: A Cadaveric Study, Ariyanachi Kaliappan et al, PMID: 34984156 Image source: www.pocketdentistry.com Complication : Injury to masseteric nerve may lead to weakness in masseter muscle and sensory deficit to the TMJ.

16. The location of Superficial temporal artery bifurcation is about 9.5 ± 5.3 mm anterior to the posterior margin of the condyle. Superficial temporal artery The Anatomy of the Superficial Temporal Artery in Adult Koreans Using 3-Dimensional Computed Tomographic Angiogram: Clinical Research, Byung Soo Kim et al, PMID: 24167792 Image source: www.musculoskeletalkey.com Complication : Injury to superficial temporal artery may lead to profuse bleeding.

17. Road traffic accidents 45% Fall injury 40% Interpersonal violence 8% Sports injury 3% Crushing trauma 2% Gun shot <1% Pathological process <1% ETIOLOGY

18. INCIDENCE About 30% of all mandibular fractures. Male predilection – About 80% cases. Image source: www.researchgate.net 28%

19. BLOW FALL RTA Kinetic energy imported to the static individual by a moving object. Lindahl (1977) proposed 3 mechanisms of injury to the condyle MECHANISM OF INJURY Kinetic energy derived from the movement of individual and extended upon a static object. Kinetic energy which is summation of forces derived from a combination of 1. & 2 1 2 3

20. BONE BIOMECHANICS Mandible functions as a class III lever system, where the muscle force is between the TMJ & the occlusal load. Sources: www.oralmaxsurgeryatlas.theclinics.com www.springer.com

21. BIOMECHANICS OF INJURY (HUNTING BOW CONCEPT) The Mandible resembles a Hunting bow which is weak at the ends and strong in the midline. Its ends (the condyles) are enclosed by the glenoid fossa. So any blow to the midline (symphysis region) of the mandible can cause bilateral condylar fracture and any blow to the parasymphysis region may cause a contralateral condylar fracture. This is based on the impact of the force. Condyle Tension Rotational movement permitted Tension Condyle Symphysis Blow Image s ource : www.researchgate.net T T T C C C

22. V A RI A T I ONS IN S T AND A RD F RA C TU R E P A T T E R N S Five g en e r a l r e aso n s: M a g nitude of the impact Di re c t i on of the i m pa c t Pos i t i on of t h e m a ndi b le C o n d i ti o n of the d e nt i ti o n Shape of the o b j e ct d e l i v e r i ng the i m pact Image s ource : www.zerodonto.com

23. Unilateral subcondylar fractures 425 lbs / 193 kgs Bilateral subcondylar fractures 550 lbs / 220 kgs Symphyseal fractures 924 lbs / 419 kgs Lateral impact for body fractures 300 to 700 lbs / 136 to 317 kgs Biomechanics of cranio-maxillofacial trauma – Biju Pappachan & Mohan Alexander 2012 June PMID 23730074 FORCE REQUIRED TO FRACTURE A MANDIBLE

24. A. Facial nerve injuries B. C-spine injuries C. Displacement of the condyle into the middle cranial fossa D. Injuries to the external auditory canal E. Blunt internal carotid artery injury F. Injury to inferior alveolar nerve EARLY COMPLICATIONS ASSOCIATED WITH CONDYLAR FRACTURES A. B. C. D. E. F. The relationship between the carotid canal and mandibular condyle: an anatomical study with application to surgical approaches to the skull base via the infratemporal fossa, Fernando Alonso et al, doi:10.2399/ana.16.03 GLENOID FOSSA CAROTID CANAL

25. LATE COMPLICATIONS ASSOCIATED WITH CONDYLAR FRACTURES A. Malocclusion B. Growth disturbances C. Temporomandibular joint dysfunction syndrome D. Ankylosis E. Condylar resorption A. B. C. D. E. Image s ource : www.zerodonto.com www.mayoclinic.org www.banglajol.info

26. COMPLICATION ASSOCIATED WITH CONDYLAR FRACTURES Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

27.   CLASSIFICATION OF CONDYLAR FRACTURES Unilateral or bilateral condylar fractures Wassmund's classification (1934) MacLennan’s Clinical classification (1952) Rowe and Killey's classification (1968) Spiessel and Schroll’s classification (1972) Lindahl’s classification (1977) Loukota’s classification (2005)

28. TYPE I The angle between the head and the long axis of the ramus is 10 to 45 degrees. TYPE II The angle between the head and the long axis of the ramus is 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 to traction of lateral pterygoid muscle, confined to within the glenoid fossa. TYPE IV The 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. WASSMUND’S CLASSIFICATION (1934) Image source: www.oralmaxsurgeryatlas.theclinics.com

29. TYPE I Non-displaced TYPE II Deviation TYPE III Displacement TYPE IV Dislocation MACLENNAN’S CLINICAL CLASSIFICATION (1952) Image source: www.oralmaxsurgeryatlas.theclinics.com

30. A. Simple fractures of condyle B. Compound fractures of condyle C. Comminuted fracture associated with zygomatic arch fracture.

31. Type I Non-displaced fracture Type II Low neck fracture with displacement Type III High neck fracture with displacement Type IV Low neck fracture with dislocation Type V High neck fracture with dislocation Type VI Head fracture SPIESSEL AND SCHROLL’S CLASSIFICATION (1972) TYPE I TYPE II TYPE III TYPE IV TYPE V TYPE VI Image source: www.oralmaxsurgeryatlas.theclinics.com

32. LINDAHL’S CLASSIFICATION (1977) I. Anatomic location of the fracture: Condylar head Condylar neck Subcondylar II. Relationship of condylar fragment to mandible: Non-displaced Deviated Displacement with medial or lateral overlap Displacement with anterior or posterior overlap III. Relationship of condylar head and fossa: Non-displaced Displacement Dislocation IV. Injury to meniscus: It may be torn, ruptured or herniated in forward/backward direction. Image source: www.researchgate.net

33. LOUKOTA’S CLASSIFICATION Diacapitular fracture Condylar neck fracture Condylar basis fracture Image source: www.researchgate.net

34. CLINICAL EXAMINATION Condylar fractures are diagnosed with the help of both clinical and radiological assessment. These fractures are most commonly missed on clinical examination. Extracapsular condylar fractures are frequent and may be associated with displacement of the condylar head. The condylar head may be in contact with the ramus or may be displaced laterally or medially.

35. Unilateral condylar fractures : Facial asymmetry. Swelling and pain over the TMJ. Hemorrhage from the external ear (due to laceration of external acoustic meatus by the violent impact of condyle). Proper examination with an auriscope is essential to differentiate bleeding from external auditory canal and middle ear. Temporal bone fracture may be accompanied by CSF leak which is termed as otorrhea. Hematoma surrounding the fractured condyle. Hematoma in the mastoid region called the Battle’s sign. INSPECTION Image source: www.tuyenlab.com www.ihealthblogger.com Auriscope

36. If the condylar head is displaced medially, characteristic hollow in the region of condylar head can be observed once the edema subsides. Ear bleed will persist if the head of the condyle is impacted in the glenoid fossa. Deviation of mandible towards the side of fracture. Decreased range of movements. Gagging of occlusion on the ipsilateral side. L o c k e d mandible – due t o e nt r y into the middle cr a nial f ossa. Deviation of mandible and ipsilateral open bite Image source: www.sciencedirect.com

37. Bilateral condylar fractures : Overall mandibular movements are usually more restricted. If the condyle is displaced bilaterally, shortening of ramus occurs resulting in derangement of occlusion. Overriding of the fractured segments result in anterior open bite. Associated fracture of symphysis or para-symphysis can also be present; thus careful examination is mandatory ( Contre -coupe injury). Ps e udo Class I I a pp e a r a n c e. Anterior open bite Image source: www.archwired.com www.semanticscholar.org

38. PALPATION The condyles are palpated by standing behind the patient. The little fingers are placed inside the external auditory canal and the patient is asked to open and close their mouth. By this method the position and movement of the condyles are determined. Tenderness over the condylar area w ith associa te d cre pita t io n . Displacement of the condylar head within the external auditory meatus. Paresthesia of the lips. Image source: www.pocketdentistry.com

39. RADIOGRAPHIC ASSESSMENT PA Skull View Or Reverse Towne’s View Lateral Oblique View Orthopantomography (OPG) Computed Tomography (CT Scan) Cone Beam Computed Tomography (CBCT) Multidetector Computed Tomography (MDCT)

40. PA Skull View or Reverse Towne’s View Image source: www.radiopaedia.org

41. Lateral Oblique View Image source: www.sciencephoto.com

42. Orthopantomography (OPG) Image source: www.radiopaedia.org

43. Computed Tomography Scan Image source: www.radiopaedia.org www.researchgate,net Gold standard for the diagnosis of mandibular condylar fractures. Coronal section of CT scan showing a right condylar neck fracture with medial dislocation of the condyle . CT scan 3D reconstruction image of skull showing a right condylar neck fracture. Axial section of CT scan showing a left condylar neck fracture with lateral dislocation of the condyle .

44. Cone Beam Computed Tomography Image source: www.semanticscholar.org Coronal section of CBCT scan showing a left condylar neck fracture with medial dislocation of the condyle . Multidetector Computed Tomograpy (MDCT) provides similar information as CBCT scan, but additionally allows some visualization of the soft tissues. But the patients are exposed to higher radiation doses than CBCT scans.

45. MANAGEMENT OF CONDYLAR FRACTURES This is achieved by proper repositioning and immobilization of the fractured fragments. Restoration of form. Obt a in st a ble o c c lusion. Restore int e rin c isal op e n i ng. Establish a f ull r a n g e of mandibular e x c ursive movem e nts. Minim i z e d e viation of the mandible. Produ c e a p a i n - fr e e a rti c ular a pp a r a tus at r e st a nd during fu n c tion. Avoid int e rn a l der a n g e m e nt of the TMJ on the injur e d and the c ontr a lat e r a l sid e . Avoid the lon g - t e rm c o m pli ca tion of gro w th disturb a n ces . GOALS OF THERAPY

46. FACTORS TAKEN INTO CONSIDERATION FOR TREATMENT • Location of the fracture. • Amount of vertical reduction in height of the ramus. • Degree of angulation. • Relation of condylar head to the glenoid fossa. • Fragmentation pattern (simple versus complex). • Association with other mandibular injuries. • Dental occlusion/status of dentition. • Association with other facial bone injuries. • Association with systemic injuries. • Association with the condition of the patient (comorbidity factors). • Foreign body in temporomandibular joint (TMJ).

47. Conservative treatment TREATMENT OPTIONS FOR MANDIBULAR CONDYLAR FRACTURES Surgical treatment Image source: www.aofoundation.org

48. CONSERVATIVE TREATMENT In closed reduction, achievement of good occlusal relationship acts as the guidance for proper reduction. The upper and lower jaws are fixed together in occlusal relationship by means of intermaxillary fixation or maxillomandibular fixation, done using wires or splints. Various modalities of intermaxillary fixation used commonly for condylar fracture are: Wiring: Ivy loop wiring Continuous ivy loop wiring Gilmer wiring Image source: www.achievers.in www.springer.com

49. Arch bars: Erich’s arch bar Bone supported arch bar Custom made arch bar 1. 2. Image source: www.joms.org www.omfsfoam.com

50. Splints: Cap splint in pediatric patients Gunning splints in edentulous patients Image source: www.jaypeedigital.com www.ijds.in 1. 2.

51. 1. Minimally displaced fractures (Not more than 30°). 2. Pediatric fractures. 3. Presence of systemic comorbidities which may be an absolute contraindication for surgery. 4. Condylar head fractures where there is an increased risk of injury to the joint and the adjoining structures. 5. Minimal pain complaints and no occlusal discrepancies with acceptable range of movements. INDICATIONS FOR CONSERVATIVE TREATMENT

52. ADVANTAGES DISADVANTAGES Non-invasive, simple and easy. Immobilization might not be adequate which delays healing. Especially in subcondylar fractures where control over proximal segments is not established. Unfavorable muscle pull can cause displacement of fragments. Does not require exposure to general anesthesia. Increases patient morbidity. Economical. Not safe in epileptic patients. Less chances of infection. Not tolerated by alcoholic patients. ADVANTAGES AND DISADVANTAGES OF CONSERVATIVE TREATMENT

53. 1. Severe displacement of the condyle. 2. Mal-united fractures. 3. Bilateral condylar fractures with severe displacement or dislocation affecting the occlusion. 4. Associated fractures of the mandible. 5. Multi-fragmented fractures of the condylar head. 6. Inability to bring the teeth into occlusion for closed reduction. INDICATIONS FOR SURGICAL TREATMENT

54. ABSOLUTE INDICATIONS RELATIVE INDICATIONS Displacement of condyle into the middle cranial fossa . Bilateral condylar fractures in an edentulous patient when a splint is unavailable or when splinting is impossible because of alveolar ridge atrophy. Impossibility of restoring occlusion. Unilateral or bilateral condylar fractures when splinting is not recommended for medical reasons. Invasion of foreign body. Bilateral condylar fractures associated with comminuted midfacial fractures. Lateral extracapsular displacement. Bilateral condylar fractures and associated gnathologic problems, such as retrognathia or prognathism. ZIDE AND KENT’S CRITERIA FOR OPEN REDUCTION

55. CLOSED REDUCTION OPEN REDUCTION 1. Undisplaced or displaced condylar or comminuted fracture (in growing children) where form and function can be restored. 1. Dislocated condyle and mechanical interferences with the mandibular function. 2. No medical contraindications for MMF. 2. Loss of antero-posterior and vertical dimension that cannot be managed by closed reduction (example: panfacial and edentulous fractures). 3. Medical and anaesthetic contraindications for open reduction. 3. Compound fractures. 4. Displacement of condyle into middle cranial fossa. 5. Patient or surgeon preference for early or immediate mobilization of function. AAOMS 2017 INDICATIONS FOR CLOSED AND OPEN REDUCTION

56. ADVANTAGES AND DISADVANTAGES OF SURGICAL TREATMENT ADVANTAGES DISADVANTAGES Dir e c t visuali z a tion of the f r a g ments for c o r r e c t r e du c tion a nd fi xa tion e n a bling p rop e r bo n e h ea ling. Potential visible s ca r r ing due to skin in c isions. E a r l y mobili z a tion of the m a ndible e nsur e s nor m a l joint fun c tion a nd ac tion. D a m a g e to the n e rv e s, p a rti c ul a r l y f a c ial n e rve. R e stor a tion of norm a l oral and j a w a c tivi t y. I nt r a op e r a tive ble e di n g f rom the m a x illary a rte r y inju r y. L oss of blood supp l y wi t h a v a s c ul a r n e c rosis of the c on d y le.

57.  SURGICAL APPROACHES TO CONDYLAR FRACTURES 1. Preauricular approach and its modifications 2. Post-auricular approach and its modifications 3. Endaural approach and its modifications 4. Submandibular approach (Risdon) 5. Retromandibular approach (Hind’s / Post-ramal / Trans-parotid) 6. Rhytidectomy approach (Face-Lift) 7. Coronal approach 8. Intraoral approach Image source: www.intechopen.com

58. APPROACH IS BASED ON THE LEVEL OF FRACTURE The surgical approach to the condyle for open reduction and fixation is also dictated by the surgeon’s experience and skill level, the degree of fracture displacement or dislocation, the patient’s desires, and the complication risk, among other factors. Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

59. SUBMANDIBULAR APPROACH Image source: www.aofoundation.org Oral and maxillofacial surgery for clinicians – AOMSI

60. RETROMANDIBULAR APPROACH Image source: www.pocketdentistry.com Oral and maxillofacial surgery for clinicians – AOMSI Two main variations: Transparotid approach Retroparotid approach

61. POSTAURICULAR APPROACH Image source: Ellis Surgical approaches to the facial skeleton

62. INTRAORAL ENDOSCOPIC APPROACH Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

63. Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

64. PREAURICULAR APPROACH Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

65. 2. Dissection Locating temporalis fascia Image source: www.aofoundation.org 1. Skin incision 3. Incising temporalis fascia 4. Dissection of the joint capsule

66. AL-KAYAT & BRAMLEY ( MODIFIED PRE-AURICULAR APPROACH) Image source: www.wbidajournal.org www.joms.org

67. CORONAL APPROACH Image source: www.njms.in www.aofoundation.org Anterior branch of Superficial temporal artery Superficial temporal artery

68. Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI OTHER INCISIONS DINGMAN BLAIR AL-KAYAT & BRAMLEY POPWICH ENDAURAL POSTAURICULAR RHYTIDECTOMY RETROAURICULAR LIMB OF RHYTIDECTOMY THOMA

69. REDUCTION Reduction is the procedure done for restoring the functional alignment of the fractured bone fragments. Reduction is one of the most difficult steps in mandibular condylar fracture surgery, and a key factor governing the postoperative outcome. It is done to bring the fractured fragments together close to their previous anatomical position so that healing is proper and rapid. Once access is gained to the surgical site, reduction is done with the help of repositioning forceps, repositioning pins, screws, bone clamps, wires or towel clips. Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

70. M E T HO D S TO RED U CE O F C OND Y LA R F R A CT URE S ELEVATOR FORCEPS REDUCTION PINS SHARP RETRACTORS

71. FIXATION Fixation is the surgical procedure that is done to stabilize and join the ends of fractured bones by mechanical devices such as metal plates, pins, rods, wires, or screws. Wires Screws Plates Image source: www.plasticsurgerykey.com www.ijoms.com

72. IDEAL LINES OF OSTEOSYNTHESIS Zone of tension : lies along the anterior border of the condyle and the sigmoid notch Zone of compression : lies along the posterior border of the ramus Image source: www.sciencedirect.com TENSION __________________________ COMPRESSION ---------------------------------------

73. FIXATION USING WIRES P e rth e s a nd Wa ssmund fi r st mentioned the use of wi r e s f or fi x ing a TMJ f r ac t u re in 1924 a nd 1 927 r e sp ec tiv e l y. It provides non-rigid fixation. It requires other forms of fixation to maintain stability; like splints and IMF. It is low cost.

74. DIFFERENT FIXATION OPTIONS IN PLATING SYSTEM Image source: www.joms.com PLLA – Poly-L-Lactide (Biodegradable plates) * * *

75. In a single miniplate the fracture must be stabilized using two screws on each side of the fracture line. The drawback of this plating has showed the greatest peak displacement of fracture. SINGLE PLATE Image source: www.springer.com www.aofoundation.org

76. Application of two plates at the anterior and posterior aspects of the condylar neck helps in resisting the torsional force that may not be opposed with a single plate. TWO PLATE Image source: www.aofoundation.org

77. These includes single L plate, Y plate, triangular plate, trapezoidal plate, and delta plate. Among all plates geometric plates provide the better stability and outcome, because it fulfills the criteria of functionally stable osteosynthesis in the fracture segments. GEOMETRIC PLATE Image source: www.e-asp.org www.joms.org www.orthopaper.com Oral and maxillofacial surgery for clinicians – AOMSI

78. LAMBDA PLATE DELTA PLATE Image s ource : Oral and maxillofacial surgery for clinicians – AOMSI

79. DISADVANTAGES OF PLATING SYSTEM The whole joint must be op e n e d in most hi g h f r ac tur e s. I f the osteo s y nthe s is mat e ri a l is to be r e moved a ft e r the f r ac tu r e h a s h ea led, t h e n a s ec ond op e r a tion on the joi n t re g ion is r e quir e d. The s ec ond operation c a n e v e ntua ll y b e more d a ng e rous f o r the f ac ial n e rve b e ca u s e of the s c a r r i ng f rom the f irst oper a tion.

80. They prevents the need for re-operation and has shown good results in the treatment of condylar fractures. They are not very stable when compared to titanium plates in the treatment of condylar fractures. RESORBABLE PLATES Image source: www.oooojournal.net www.bjoms.com Three-dimensional fixation of fracture of the mandibular condyle with a resorbable three-dimensional osteosynthesis mesh.

81. Lag screw technique compresses the fracture fragments together. G ood clinical results can be obtained especially in diacapitular fractures. LAG SCREW Image source: www.oooojournal.net www.aofoundation.org www.pocketdentistry.com

82. Kirschner wires or K-wires are sharpened, smooth  stainless steel  pins. Introduced in 1909 by  Martin Kirschner , the wires are now widely used in  orthopedics  They come in different sizes and are used to hold bone fragments together. The pins are often driven into the bone through the skin (percutaneous pin fixation) using a power or hand drill. KIRSCHNER WIRE / K WIRE AND BIORESORBABLE PINS Image source: Indian Dental Academy R a sse d e s c rib e d a n ost e o s y nthesis method f o r f i x ing intr a ca psul a r f r a c t ur e s usi ng bio re sorb a ble pins. K WIRE BIORESORBABLE PINS

83. The condyle is explanted from the glenotemporal fossa, reduced and fixed in desired position. The drawback of this type of fixation is that it will lead to avascular necrosis related to detachment of soft tissue  EXTRA CORPOREAL REDUCTION AND FIXATION Image source: www.researchgate.net

84. MANAGEMENT OF PEDIATRIC CONDYLAR FRACTURES Cap splints for pediatric patients Cons er vativ e - F un c tio n al t r e a t me nt: No ac tive fi x a tion but e a r l y g e ntle mobili z a tion if the p a ti e nt, with or wit h out a ssistan c e , c a n obtain a n orm a l oc c lusion. I nt e rm a x illary fi x a tion f o r 10 d a y s, then g e ntle m o bili z a tion a nd f u n c tion. The incr e a s e d v a s c ula r i t y , c ombi n e d with thinn e r c o r ti ca l bon e , mak e s the c hild ' s c on d y l e more susc e pt i ble to " burst" t y p e fr ac tu r e s, le a vi n g multiple small hi g h l y oste o g e nic f r a g ments within the jo i nt sp ace , whi c h m a y i n c r e a s e the risk f or joint a n k y losi s . The p r i n c i p le b e hi n d t h e t r e a t m e nt is the re po s itioni n g o f large to o t h - b e a r i n g f r ag m e nt and m obiliz a tion of the m andi b le a t as e a r ly a sta g e as p ossible i n o r d e r to avoid a r th r o d e si s . Bone awl

85. Current Concepts in the Mandibular Condyle / Fracture Management Part II: Open Reduction Versus Closed Reduction Kang-Young Choi et al, Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, Daegu, Korea

86. MANAGEMENT OF GERIATRIC CONDYLAR FRACTURES Ed e ntulous p a ti e nts a re tr e a ted with a Gunni n g s plint or the p a ti e n t ' s own d e ntur e s to r e c r ea te the v e rti ca l h e i ght of the mandible. I f th e se splints a re not fi r m e n ou g h, th e n c ir c um-mandibular wiring is us e d. Intermediate splint is made with self cure acrylic resin in the articulator A modified maxillary Gunning splint using the patient's preexisting dentures Gunning Splint Image source: www.researchgate.net www.jaypeedigital.com

87. CIRCUM-MANDIBULAR WIRING Image source: www.jaypeedigital.com

88. CONCLUSION The most dif f icult probl e m a rising a fter a n y c ond y l a r f r a c ture is the risk of a n k y losis. Th e se c omplic a tions s e ldom a rise tod a y if the mandible is mobil i z e d ea rly a nd if the p a ti e nt ful l y c oop e r a tes. L o ng - te r m ac tive p a ti e n t c o - op e r a tion is r e quired for upto 6 months. Perhaps the collective experience of many surgeons who treat these fractures can best be characterized as follows: Intracapsular fractures are best treated closed . Fractures in children are best treated closed except when the fracture itself anatomically prohibits jaw function. Most fractures in adults can be treated closed. When open reduction is indicated, the procedure must be performed well , with an appreciation for the patient's occlusal relationships, and it must be supported by an appropriate physical therapy and follow-up regimen.

89. REFERENCES Oral and maxillofacial trauma – Fonseca, vol.1 Maxillofacial trauma & Esthetic facial reconstruction – Peterward Booth Maxillofacial Injuries – Rowe & Williams, vol 1 Principles of oral maxillofacial and reconstructive surgery – Peterson’s, vol 1 Oral and maxillofacial surgery for clinicians – AOMSI