Condylar fractures /certified fixed orthodontic courses by Indian dental academy

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Introduction:
 Condylar and Subcondylar fractures constitute
26-40% of all mandible fractures
 Given the unique geometry of the mandible and
the temperomandibular joint, fractures of the
condyle and subcondylar region can result in
marked pain, dysfunction and deformity if not
recognized and treated appropriately.
 These features may be associated with other
injuries that have severe mobility( C- spine
injuries,displacement of the condyle into the
middle cranial fossa, injuries to the external
auditory canal and occlusion of the internal
carotid artery)

DEFINITION:
Fracture is defined as a sudden violent
solution in the continuity of bone which may
be complete or incomplete resulting from
direct or indirect causes.


Anatomy:
Arises from the 1st Pharyngeal Arch-develops around the ventral cartilage of
the 1st branchial arch.
Continues to grow and develop throughout
childhood and adolescence.
Mandible is curved and articulates at both
ends. TMJs are diarthroidal and allow both
rotational and translatory movements.

Nerve supply

Muscle attachment


Blood supply

Classification of Condylar Fractures:
Rowe and Killey’s Classification (1968)
a. 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
surfaces
b. Extracapsular or Low Condylar Fractures
c. Fractures associated with injury to the
capsule, ligament and meniscus
d. Fractures involving adjacent bone

Lindahl's Classification (1977)
a. Fracture Level
i. Condylar Head (Intracapsular)
ii. Condylar Neck
iii. Subcondylar
1. High
2. Low
b. Relation of the condyle to the
Mandible
i. Non Displaced
ii. Deviated or Angulated
iii. Displaced
1. Medial overlap.
2. Lateral overlap

c. Relation of the condyle to
the mandible
i. Non Displaced
ii. Displaced- still related to
the fossa
iii. Dislocation - completely
out of fossa

McLennan's Classification(1952)
A.
B.
C.
D.

No displacement
Deviation
Displacement
Dislocation


CLASSIFICATION OF FRACTURES OF
MANDIBULAR CONDYLE ACCORDING TO
SPIESSL AND SCHROLL
Type I: fracture without displacement
Type II: low fracture with displacement
Type III: high fracture with displacement
Type IV: low fracture with dislocation
Type V: high fracture with dislocation
Type VI: intracapsular fracture (diacapitular)


Etiology
Adult
Represents 20-30% of all mandibular fractures (Ellis et al,
1985)
• Motor Vehicle Accidents
• Assault
• Sports related injuries
• Falls
Children
Higher involvement ranging from 40-60%
(Lehman and Saddawi, 1976)
• Falls
• Motor Vehicle Accidents
• Sports related injuries
• Assaults

Forces resulting in
trauma to the TMJ
A. Moving object
striking a static
individual
B. Moving individual
striking a static
object
C. Combination of
forces


When a blow is given on the face resulting in
fracture of the mandible condyle, the position of
the fractured condyle in relation to the remainder
of the ramal stump will depend on:
1. The direction and degree of force.
2. The precise point of application of force
3. Whether the teeth were in occlusion at the time
of injury
4. Whether the patient is partially or fully
edentulous.


Clinical Signs and Symptoms:
 Evidence of soft tissue injury - Chin Lacerations
 Facial Asymmetry with chin deviation
 Noticable palpable swelling over the affected
TMJ
 Pain and tenderness over the affected TMJ
 Malocclusion
 Deviation of the mandible dental midline
 Muscle splinting due to pain with limited opening
 Bleeding from the external auditory canal
 Inability to palpate condylar movement.

Soft Tissue Injuries:
The soft tissue injuries are characterized by:
 Localized pain at rest exacerbated by function
 Limited range of motion secondary to pain
 If effusion is present - palpable fluctuant swelling
and decreased ability to occlude on ipsilateral
posterior teeth with deviation away from the
affected side


ENT and Neurological Signs
In Displacement of Condvle into the Middle Cranial Fossa
 CSF Otorrhea
 Lacerations of the Extemai Auditory Canal
 Paralysis of the Facial Nerve
 Hearing Deficit
 Hemorrhage from the middle meningeal artery
 Dural Tears
 Subdural and epidural hematoma
 Altered level of consciousness
 Pupillary Dilatation
 Nausea
In Condylar Fractures:
 Laceration of the External Auditory Canal

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
B. CT
C. MRI


Posterior anterior view

Lateral view


Panoramic view

Reverse Towne’s view

CT Scan

Treatment:
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
Modes of Treatment:
1. Conservative treatment I Non-Surgical
2. Surgical treatment by Open Reduction

Conservative Treatment
 Unlike fractures of other bones, the exact anatomic
reapproximation of the fractured segments may not be
absolutely essential.
 There is no correlation between radiographic findings &
either preoperative symptoms or post operative function.
 Complications are uncommon with conservative
treatment.
 Normal occlusion with minimal discomfort:
soft diet and maintain as near normal function as
possible.
 Malocclusion, deviation with function, pain: period of
immobilization (7-21 days) in the form of arch bars or ivy
loops, followed by active mobilization and physical
therapy.
 Period of immobilization depends on age of patient, level
of fracture, & degree of displacement.

Surgical Treatment
1.
2.
3.
4.
5.

Reduction
Fixation
Immobilization
Control of Infection
Rehabilitation


0pen Reduction
Indications for 0pen Reduction of Condylar
Fractures (Zide & Kent -1983)
Absolute Indications
a. Displacement into the middle cranial fossa
b. Impossiblity of obtaining adequate occlusion by
closed reduction
c. Lateral extracapsular displacement of the
condyle
d. Invasion of a foreign body (e.g.: gunshot wound)


Relative Indications
a. Bilateral condylar fracture in edentulous patients
when splinting is impossible
b. Unilateral or bilateral condylar fractures when
splinting is not recommended for medical
reasons or adequate post operative
physiotherapy is impossible
c. Bilateral condylar fractures associated with
comminuted mid-facial fractures.
d. Bilateral condylar fractures associated with
significant pre-injury malocclusion
Perceived Benefits (Muller 1976)
 Early mobilization of the mandible ensures normal
joint function and action.
 Restoration of normal mouth and jaw activity.

Possible Complications (Eckelt 1984)
 Potential visible scarring
 Damage to the facial nerve
 Intra-operative bleeding from the maxillary artery
 Loss of blood supply with avascular necrosis of
the condyle


Posnick's Relative Indications for Open Reduction
1. Lateral displacement of the proximal fracture
segment with cosmetic deformation or a
decrease in range of motion.
2. Presence of foreign body in the joint capsule that
will result in either infection or excessive scarring
if left in place. '
3. Fracture with dislocation into the middle cranial
fossa / temporal fossa with expected clinical
disability.
4. Inability to open/close the mouth because of
mechanical blockage of the fractured segments.
5. Low condylar neck fracture with significant
displacement/dislocation.

6. In addition, if internal fixation is to be placed, it is
assumed that:
a. Fracture is extracapsular and low in the
condylar neck
b. The condylar neck is not split (medial & lateral
pole fractures)
c. Functional disability would be likely without
ORIF
d. Use of ORIF techniques will limit functional
disability more than other options


Approaches:
1.
2.
3.
4.
5.
6.
7.

Pre Auricular
Submandibular
Posterior Auricular
Retromandibular
Intra Oral
Combination
Face-Lift


Incisions

Blair’s Inverted
Hockey Stick
Incision

Thoma’s Angulated
Incision

Dingman’s
Incision

Endaural Incision

Post ramal
Submandibular
Popowich &
Crane Incision

Posterior Auricular
Incision

Incisions

Intraoral Incision


Selection of the Surgical Technique:
The following factors influence the selection of
the method of open reduction
1. Position of the condyle
2. Location of the fracture
3. Character of the patient
4. Amount of edema
5. Location of the incision
6. Type of fixation


Fixation
Methods
 Miniplates
 Lag Screws
 Pin Fixation
 Interosseous Wire


Fixation

Wire Osteosysnthesis

Kirschner wire
fixation

Masser technique for
wire osteosynthesis

Plate & Screw
fixation

Axial anchor
screw

Treatment for Patients upto 12 years of age
 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.

COMPLICATIONS:
-EARLY
Complications that occur concurrent with or early after
treatment of condylar fractures:
1. Fracture of the tympanic plate.
2. Fracture of the glenoid fossa with or without
displacement of the condylar segment into the
middle cranial fossa.
3. Damage to the Vth and VIIth cranial nerves.
4. Vascular injury.
5. Infection.
6. Drug Reaction.


LATE1.
2.
3.
4.
5.
6.
7.

Malocclusion
Growth disturbances
TMJ dysfunction
Ankylosis
Delayed union
Non-union
Scars


References
1. Rowe and William’s Maxillofacillal 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. Oral Radiology – Principles and Interpretation
– White S. C., Pharoah M. J. (4th Ed)

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Condylar fractures /certified fixed orthodontic courses by Indian dental academy

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