Condylar fracture

CONDYLAR FRACTURES

Dr V.RAMKUMAR

CONSULTANT DENTAL &FACIOMAXILLARY SURGEON

REG NO: 4118- TAMILNADU-INDIA(ASIA)

ETIOLOGY - MECHANISM OF INJURY

LINDAHL (1977) PROPOSED 3 MECHANISMS OF INJURY TO THE CONDYLE.1. Kinetic energy imported to the static individual by a moving

object.2. Kinetic energy derived from the movement of the individual and

expended upon a static object.3. Kinetic energy which is a summation of forces derived from a

combination of 1 & 2.

CLINICAL CLASSIFICATION Spiessl & Schroll 1972

Type I - No displacement

Type II - Fracture deviation

Type III - Fracture displacement

Type IV - Fracture dislocation

COMPREHENSIVE CLASSIFICATION (LINDAHL

1977)

FRACTURE LEVEL

Condylar head or intracapsular fracture

Condylar neck fracture

Subcondylar fracture

RELATIONSHIP OF CONDYLAR FRAGMENT TO MANDIBLE

Undispladed fracture

Deviated – simple angulation

Displaced: - medial or lateral overlap. - anterior or posterior overlap

No contact between fragments

RELATIONSHIP OF CONDYLAR HEAD TO FOSSA

> No displacement

> Displacement

> Dislocation

CLINICAL FEATURES OF SUBCONDYLAR FRACTURES

* Contusion, abrations, laceration of chin, ecchymosis and hematoma in the temperomandibular joint region

* Laceration or bleeding of external auditory canal.

* Swelling over TMJ - secondary to hematoma, edema, in indicating laterally dislocated condylar head.

* Facial asymmetry - secondary to foreshortening of mandibular ranus.

* Pain and tenderness spontaneously or in response to pressure.

* Deviation of mandibular midline towards the fracture side.

.

SCHOOL OF THOUGHTS IN MANAGEMENT

CONSERVATIVE - FUNCTIONAL -

SURGICAL

DIAGNOSTIC AIDS AND ITS ROLED IN TREATMENT PLAN

* CONVENTIONAL RADIOGRAPHY (in common use)

- Orthopantomogram

- Lateral oblique view mandible

- Reverse towens view mandible

- P.A. view skull

- Trans cranial views of TMJ

* CONVENTIONAL TOMOGRAPHY

- Coronal or saggital plane may provides useful information - Three dimensional CT scans indicates shift of the

condyle either anteriorly or medially deciding the treatment plan.

* ARTHROGRAPHY- Evaluates soft tissue components especially disk

position, function and shape during capsular damage

ABSOLUTE AND RELATIVE INDICATION OF OPEN REDUCTION(ZIDE AND KENT)

ABSOLUTE INDICATIONS:* To restore vertical and anterioposterior facial dimention

* When stability of occlusion is limited (less than 3 teeth per quadrant, gross, periodontal diseases, skeletal abnormality)

* When rigid internal fixation is used to address other facial fractures affecting the occlusion

* when manipulation and closed treatment cannot re-establish the pre tramatic occlusion

* Invation of the foreign body

* Post pubertal patients

* Dislocation of condyle into middle cranial fossa

RELATIVE INDICATIONS (ZIDE AND KENT)

* Edentulous jaws

* Uncontrolled seizure disorders

* Status asthmaticus.

* Psycologic compromise

ROLE OF FUNCTIONAL SCHOOL OF THOUGHT IN

MANAGEMENT

WHEN - WHY - HOW?

OPEN REDUCTION APPROACHES AND ADVANTAGES

PRE AURICULAR APPROACH

* An incision of the Alkayat & Bramley type for high condylar and neck fractures.

* Condyle can be exposed for almost half of its depth in addition to lateral aspects

* Branches of facial nerve are avoided

* Postoperative scar hidden

OPEN REDUCTION APPROACHES AND ADVANTAGES

RETROMANDIBULAR APPROACH

* A Risdon type submandibular incision gives good access of low sub condylar fractures. (Basal # dislocation)

* Osteosynthesis with wire ligature or mini plates may be accomplished

OPEN REDUCTION APPROACHES & ADVANTAGES

BICORONAL APPROACH

RIGID INTERNAL FIXATION DIVICES & ADVANTAGES

COMPRESSION PLATE OSTEOSYNTHESIS

3 DIMENSIONAL PLATING

COMPRESSION PLATE OSTEOSYNTHESIS

TRANSOSSEOUS WIRING

PETZED LAG SCREWS OSTEOSYNTHESIS

INTRA MEDUALLARY SCREWS

KRISCHNER WIRE

CLOSED REDUCTION & MAXILLO MANDIBULAR FIXATION

DISADVANTAGES- FAILURE OF INDIRECT REDUCTION.

* When Condyle has incompletely penetrated the capsule assumes a cuff-life position around the neck of the condyle interfering with repositioning.

* Connection between the peripheral mandibular fragment and dislocated small fragment is torn so that force is not transmitted to the fragment.

* The rate of dyfunction like malocclusion, reduced mouth opening, deviation, impaired masticatory function, pain over affected joint.

CLOSED REDUCTION & MAXILLO MANDIBULAR FIXATION

ADVANTAGES- The Risks associated with surgical intervention are

compensated.

- Economic point of view hospitalization can be dispensed with, were two periods of hospitalization are necessary for surgical treatment.

RETROSPECTIVE STUDY 6 YEARS (1996 - 2002)

- Total number of # in 6 years - 435 cases

- Condylar fractures 72

Types of Condylar fractures - undisplaced = 34

- displaced = 24

- deviated = 8

- dislocated = 6

Type of treatment - Conservative = 59

- Functional = 7

- Surgical = 6

0

10

20

30

40

50

60

70

Conservative Functional Surgical

No

. of

con

dy

lar

fra

ctu

res

COMPLICATION CONSERVATIVE VS OPEN REDUCTION

- Conservative method - necrosis of high condylar segment

- occlusal derangement

- Open reduction - Plate infection

(Warranted plate removal)

- Transient facial nerve palsy

(zygomatico temporal)

- Complication % of Open Reduction - 15%

- Complication % of Conservative Management - 6%

Have we reached to a conclusion?