CONDYLAR FRACRURES
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Introduction • The topic of mandibular condylar fracture has generated more discussion and controversy than any other in the field of maxillofacial trauma. • Condylar and subcondylar fractures accounting for between 25% and 35% of all mandibular fractures • Condyle is a major growth center for the mandible
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Anatomy
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Melvin Moss - “I know of no other single anatomical subject concerning which so much misinformation has been printed, and then believed.�
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Embryology Arises from the 1st Pharyngeal Arch--develops around the ventral cartilage of the 1st branchial arch. Begins to develop by the 10th week of gestation Two separate blastemas –one for the temporal bone component and one for the condyle Superior to the condylar blastema a band of mesenchymal cell develops that will eventually differentiate into the disc Temporal condylar mesenchymal cell differentiate into osteoblasts which lay down membrane bone All the components of mature TMJ is formed by14th week of gestation 12 – 32 weeks of gestation there is a high degree of calcification of the condylar head www.indiandentalacademy.com
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Relations
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Nerve supply
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Blood supply
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Functions
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“The bone fracture at the site of tensile strength since its resistance to compressive strength is more� Hodgson ( 1967)
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Incidence
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Mechanism of Injury
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Classification In 1915 Brophy – location and direction of fracture – “through the neck; from above and without; downward and inward; or reversed; from above and infront; backward and downward”
Thoma – classified • • • •
Fracture with displacement Fracture without displacement Fracture dislocation Fracture dislocation with complete displacement www.indiandentalacademy.com
Wassmunds Classification – 1934 • Type I – Fracture of condyle with slight displacement of head with angle of 10-45 degree between head and ramus – reduces spontaneously • Type II – Angle of 45 – 90 degree between head and ramus, tearing of medial portion of capsule • Type III – Fragments not in contact, head displaced medially and forward due to lat. Pterygoid pull/spasm, fragments is within glenoid fossa, capsule is torn and head is out side the capsule – open reduction advocated • Type IV –Fractured head articulates on/forward to articular eminence • Type V - Vertical/oblique fracture through head of condyle - rare www.indiandentalacademy.com
McLennan's Classification (1952) A. B. C. D.
No displacement Deviation Displacement Dislocation
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Rowe and Killey’s Classification (1968) • Intracapsular Fractures or High Condylar i. Fractures involving the articular surface ii. Fractures above or through the anatomical neck, which do not involve the articular surface • Extracapsular or Low Condylar Fractures • Fractures associated with injury to the capsule, ligament and meniscus • Fractures involving adjacent bone www.indiandentalacademy.com
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SPIESSL AND SCHROLL - 1972 • Type I • Type II • Type III • Type IV • Type V • Type VI
- Condylar fracture without angulation and dislocation - Low condylar fracture with angulation - High condylar fracture with angulation - Low condylar fracture with dislocation - High condylar fracture with dislocation - Fracture of condylar head www.indiandentalacademy.com
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 www.indiandentalacademy.com
Clinical Signs and Symptoms • • • • • •
Evidence of soft tissue injury - Chin Lacerations Facial Asymmetry with chin deviation Noticeable swelling over the affected TMJ Pain and tenderness over the affected TMJ Malocclusion Deviation of the mandible to same side during opening • Muscle splinting due to pain with limited opening • Bleeding from the external auditory canal • Inability to palpate condylar movement. www.indiandentalacademy.com
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Imaging in the Diagnosis of Condylar Fractures A. Conventional Radiography a. P A- View b. Lateral Oblique c. Panoramic view d. Reverse Towne's Projection e. TMJ views B. CT C. MRI www.indiandentalacademy.com
PA skull
Reverse Towne's www.indiandentalacademy.com
Lat. Oblique
Trans-pharyngeal www.indiandentalacademy.com
CT Scan
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MRI
Treatment “Concerning the treatment of condylar fractures, it seems that the battle will rage forever between the extremists who urge nonoperative treatment in practically every case and the other extremists who advocate open reduction in almost every case.� - Malkin
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Goals of Treatment: Relief from pain Stable occlusion Restoration of inter- incisal opening Full range of mandibular movements To minimize deviation Avoid growth disturbances Avoid Ankylosis www.indiandentalacademy.com
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M. Todd Brandt et al 2003 • “Under similar indications and conditions, ORIF is the preferred approach” • “Adaptation miniplate is least favored and minidynamic compression plate is most favored”
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Modes of Treatment 1. A period of Maxillo Mandibular Fixation (MMF) followed by functional therapy 2. Functional therapy without a period of MMF 3. Open reduction with or without internal fixation. www.indiandentalacademy.com
Edward Ellis III and Gaylord S. Throckmorton 2005
Is a Temporomandibular Articulation Necessary/Advantageous?
• Is the TMJ a stress-bearing joint? • Does the TMJ have to be a stress-bearing joint? • Does the TMJ guide mandibular movement? • How does the masticatory system function when one TMJ is damaged? • How does the masticatory system function when both TMJs are damaged? www.indiandentalacademy.com
Is the TMJ a stress-bearing joint? Does the TMJ have to be a stress-bearing joint?
• Gysi’s “lever” theory – load bearing • Wilson’s nonlever theory – nonload bearing • Moss and Moss- Salentijn - TMJ bears at least some loads that re-establishment of a temporomandibular articulation may be advantageous • Patients alter their muscle activity enough to protect the missing or damaged joint from compressive loads www.indiandentalacademy.com
Does the TMJ guide mandibular movement? • Aberrations within the TMJ can alter mandibular movement, which usually manifest as limiting certain excursions
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How does the masticatory system function when one TMJ is damaged? • Under normal circumstances, when one bites on the left molar, the right (contralateral or balancing side) TMJ bears more load than the left (ipsilateral or working side) • If right side TMJ is injured, one way to reduce loading it would be to selectively increase left masseter activity Doing so produces greater loading of the left, uninjured TMJ • In contrast, when biting on the right (ipsilateral or working side), alteration of the muscle activity ratio is not necessary because the normal left-side joint carries the greater load www.indiandentalacademy.com
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How does the masticatory system function when both TMJs are damaged? • Bite force for bilateral fracture patients is reduced • Narrower chewing cycles, with significantly lower adductor muscle activity www.indiandentalacademy.com
In summary, is a temporomandibular articulation necessary/advantageous? • Yes! For the masticatory system to function efficiently and maximally, a craniomandibular articulation is necessary. Whether or not this must be in the form of a ginglymoarthrodial joint or whether a simple hinge joint is adequate is unclear. It is also unclear whether open treatment would provide a more effective temporomandibular articulation than closed treatment. www.indiandentalacademy.com
Conservative Management
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3 main factors to favor nonsurgical treatment: 1. Nonsurgical treatment gives “satisfactory� results in the majority of cases 2. There are no large series of patients reported in the literature who have been followed after surgical treatment because management of condylar fractures has historically been with nonsurgical means 3. Surgery of condylar fractures is difficult because of the inherent anatomical hazards (i.e., VII nerve). www.indiandentalacademy.com
Adaptations 3 types of adaptations occurs during non surgical management: 1) Neuromuscular adaptations 2) Skeletal adaptations 3) Dental adaptations www.indiandentalacademy.com
Neuromuscular Adaptations • Individuals with bilateral condylar process fractures selectively increase the EMG output in the posterior temporalis fibers • Provide a posteriorly directed vector onto the coronoid process • Rotate the anterior portion of the mandible superiorly, bringing the incisors into contact www.indiandentalacademy.com
Skeletal Adaptations • •
Slowly developing adaptation Development of a new temporomandibular articulation. 3 concurrent methods by which a new temporomandibular articulation occurs: 1. Condylar regeneration 2. Changes in the temporal component of the TMJ 3. Loss of posterior vertical dimension. • The newly formed temporomandibular articulation may or may not be another synovial joint. www.indiandentalacademy.com
• Restitutional remodeling a completely new condylar process of normal morphology is re-created. • Functional remodeling the condylar process looked abnormal even though it might function very well. www.indiandentalacademy.com
Dental adaptations • With closed treatment of condylar process fractures, extrusion of the incisors and intrusion of the molars has been demonstrated. • Because the ramus moves superiorly to assist in the re-establishment of a new temporomandibular articulation www.indiandentalacademy.com
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• As early as 1805, Desault wrote: “It is important to restore contact of the fragments. Union might fail if the slightest movement of jaw occurs. If there is no contact, the callus produced might render the condyle irregular and deformed, which will impede function.” • There is no compelling reason to use MMF when treating fractures of the condylar process by closed techniques - Ellis and Throckmorton 2005 www.indiandentalacademy.com
Surgical Management
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Contraindications
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Anatomic Consideration The blood supply to the condyle - 3 sources • A branch of the inferior alveolar artery • TMJ capsule, with its lush vascular plexus • Branches of the lateral pterygoid muscle through its attachment at the pterygoid fovea. Medullary blood supply from a branch of the inferior alveolar artery has been found to be the most important source www.indiandentalacademy.com
Facial Nerve
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Approaches 1. 2. 3. 4. 5. 6. 7. 8.
Pre Auricular Submandibular Posterior Auricular Retromandibular Intra Oral Combination Face-Lift Endoscopic www.indiandentalacademy.com
Incisions
Blair’s Inverted Hockey Stick Incision
Thoma’s Angulated Incision
Dingman’s Incision
Endaural Incision
Post ramal
Popowich & Crane Incision
Posterior Auricular Incision www.indiandentalacademy.com
Submandibular
Intraoral Incision
Endoscopic
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Fixation Methods Miniplates Lag Screws Pin Fixation Interosseous Wire {K-wire} www.indiandentalacademy.com
Wire Osteosysnthesis
Kirschner wire fixation
Plate & Screw www.indiandentalacademy.com fixation
Masser technique for wire osteosynthesis
Axial anchor screw
Children Bony union & remodeling of condylar head in the glenoid fossa occurs spontaneously in children. This ability to regenerate & remodel declines after puberty. Conservative non immobilization (most cases) with active function. Brief immobilization (7-10 days) - for gross displacement with malocclusion, followed by active function & physical therapy to prevent ankylosis & growth disturbance. www.indiandentalacademy.com
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Complications Early/ Concurrent • 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 the Vth and VIIth cranial nerves • Vascular injury • Infection www.indiandentalacademy.com
Late • Malocclusion • Growth disturbances • TMJ dysfunction • Ankylosis • Delayed union • Non-union • Scars
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References 1. Rowe and William’s Maxillofacial Injuries Williams L. J., Rowe N. L. (Vol I) 2. Gray’s Anatomy - Williams P. L. (38th Ed.) 3. Textbook of Oral and Maxillofacial Surgery Neelima Malik 4. Oral and Maxillofacial Trauma - Raymond J. Fonseca (Vol I) 5. Treatment of Mandibular Condylar Process Fractures: Biological Considerations Edward Ellis III et al www.indiandentalacademy.com
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