CONDYLAR FRACTURES
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Surgical Anatomy
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Differences in Adult and Pediatric Condyles
Parameter
Child
Adult
1 Cortical bone
Thin
Thick
2 Condylar neck
Broad
Thin
3 Articular surface
Thin
Thick
4 Capsule
Highly vascular
Less vascular
5 Periosteum
Highly active – in osteogenic phase Less active in latent stage
6 Intracapsular hemarthrosis.
fracture
& Very common
7 Remodelling capacity following Present trauma www.indiandentalacademy.com Likely 8 Disturbance in growth
Rare Absent N.A
Differences in Adult and Pediatric Condyles
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Indirect injury - Chin Direct injury - Zygoma
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GK / MAXFAC SDM DHARWAD
Mechanism of fractures
A few common injury patterns
A direct blow to the TMJ region – fracture of condyle A blow to the mandibular body in a horizontal direction – ipsilateral body & contralateral condyle fracture A force on the parasymphysis region can cause ipsilateral or bilateral condylar fracture as well as localized parasymphysis fracture An axially directed force to the parasymphysis – bilateral Condylar fracture with symphyseal or parasymphyseal fracture It can further be associated with fracture of the glenoid fossa with penetration into the middle cranial fossa or fracture of the tymphanic plate causing damage to the external acoustic meatus www.indiandentalacademy.com
Mechanism of injury  According to Lindahl, the forces causing damage to the joint are of three main types  1. Kinetic energy imparted by a moving object through the tissues of a static individual. Ex by a fist, cricket bat or ball
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Mechanism of injury 2. Kinetic energy derived from the moving individual striking a static object ex a child slipping and striking the pavement or a fall during an epileptic fit or parade ground fracture
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Mechanism of injury 3. Kinetic energy, which is the sum of, forces due to combination of factors 1 and 2 Ex RTA where a person in a moving car strikes his chin across the dashboard
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Anatomical: Intra / extra capsular Unilateral / bilateral Radiographic 2 radiographs @ Right angle OPG, PA mandible 1) Level of # 2) Relationship to mandible www.indiandentalacademy.com
3) Relationship to glenoid fossa
MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Level of #
Head
HEAD (Intra capsular)
Neck Sub Condylar
NECK SUB CONDYLAR # www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Relationship to mandible Undisplaced Deviated Displaced
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Classification Relationship to glenoid fossa
Undisplaced
Displaced www.indiandentalacademy.com
Dislocated GK / MAXFAC SDM DHARWAD
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Clinical features Pain & Tenderness Painful limitation in mouth opening Occlusal derangement Bleeding from ear www.indiandentalacademy.com GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Clinical features - Unilateral # condyle Deviation to affected side Midline shift Lateral movements limited
GK / MAXFAC SDM DHARWAD
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Clinical features - Bilateral # condyle Gagging of posterior teeth Anterior open bite Lateral movements limited GK / MAXFAC SDM DHARWAD
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Radiographic investigations 2 radiographs @ right angles OPG, PA mandible Optional : Trans Pharyngeal Trans Cranial Trans Orbital C.T coronal views www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
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MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures
Management (Conservative) No active treatment Immobilization (7-10 days) Active physiotherapy www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
Closed Method • Range of treatment options available - observation and soft diet, variable periods of immobilization &/or intense physiotherapy • Close supervision is mandatory • Need for immobilization - when malocclusion, deviation with function, &/or pain is present. • The period of immobilization - must be long enough to allow initial union of the fracture segments but short enough to prevent complications • Active functional therapy allows a return of mandibular range of motion and functional movements • Guiding elastics should be used to direct the mandible to its maximal intercuspation. www.indiandentalacademy.com
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures
Management (Surgical) Open reduction & fixation Grossly dislocated #s
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GK / MAXFAC SDM DHARWAD
Indications of Open Method 1. 2.
1. 2. 3.
Relative indications
Bilateral condylar fractures with comminuted midface fractures in which rigid internal fixation of the midface is not possible Situations when intermaxillary fixation is not feasible as a result of the following: Medical restrictions Poorly controlled seizure disorder Psychiatric disorders Severe mental retardation Concomitant injuries such as head injury or chest injury Displaced fractures where dentures or splints are not feasible because of severe mandibular atrophy Bilateral fractures in which it is impossible to determine what the proper occlusion is www.indiandentalacademy.com
Surgical Approaches The various incisions to approach the condyle are :1. Submandibular 2. Preauricular 3. Endaural 4. Retromandibular 5. Intra oral 6. Hemicoronal approach www.indiandentalacademy.com
Surgical Approaches Submandibular approach
Most suitable for ramus fractures and for low fractures of the condylar neck Can be combined with an endaural incision for total joint reconstruction
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Surgical Approaches Preauricular & Endaural
• appropriate for repositioning and fixing intracapsular and very high condylar fractures • Under certain conditions it can also be used, together with a sub mandibular access, access for high temporomandibular joint fractures that are difficult to reduce
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Incision
Dissection
Surgical Approaches Preauricular & Endaural
Dissection above the arch - to sup temp plane Below the arch – just superficial to tragal cartilage To the bone – The structures within the flap raised off the arch contain skin, supf templ vessels and nerves, Facial n braches, Sup temp fascia & ifwww.indiandentalacademy.com taken more superiorly – temporal fascia
Surgical approaches Retromandibular / Posterior mandible approach This approach is indicated for low and high condylar fractures incision begins 0.5 cm below the lobe of the ear and continues inferiorly for 3-3.5 cm.
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Surgical Approaches Intra oral approach
Only for low fractures of the TMJ It was initially proposed by Steinhauser • Advantage No visible scars but this is offset by the lack of good vision
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Methods of Osteosythesis – Miniplate fixation
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Special considerations – Children Suggested protocol for treatment of condylar fractures in children • Nearly all cases- conservatively treated with immediate function & analgesics • In cases with pain & malocclusion – brief period of IMF – 7-10 days followed by active function • As for adults, close supervision & follow up is mandatory • Early mobilization & active physical therapy aimed at increased range of mandibular motion & prevents www.indiandentalacademy.com ankylosis & growth alteration
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Etiology Classification Clinical features Radiological investigations Treatment options Complications www.indiandentalacademy.com
GK / MAXFAC SDM DHARWAD
MAXILLOFACIAL INJURIES MANDIBULAR FRACTURES Condylar Fractures Complications Malocclusion Damage to teeth TMJ pain Ankylosis Open reduction Scar Nerve damage Intra-operative haemorrhage www.indiandentalacademy.com Avascular necrosis
GK / MAXFAC SDM DHARWAD
Complications EARLY COMPLICATIONS Complications that occur concurrent with or early after treatment of condylar fractures include the following 1. Fracture of the tympanic plate - otorrhea 2. Fracture of the glenoid fossa with or without displacement of the condylar segment into the middle cranial fossa – nuerological signs 3. Damage to cranial nerves V and VII – traumatic/post op 4. Vascular injury www.indiandentalacademy.com
Complications LATE COMPLICATIONS
Late complications of condylar fractures commonly include the following: 1. 2. 3.
Malocclusion Growth disturbances Temporomandibular joint dysfunction (Internal derangement) 4. Ankylosis www.indiandentalacademy.com
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