condylar fracture & its management
TRANSCRIPT
![Page 1: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/1.jpg)
• GOOD MORNING
![Page 2: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/2.jpg)
CONDYLAR FRACTURE & ITS MANAGEMENT (cont.)
DR.SHADAB ALI BAIG
MDS II
![Page 3: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/3.jpg)
Topic covered
• Introduction• Incidence • Etiology • Surgical anatomy• Classification• Clinical signs & symptoms • Imaging • Management• Complications • Flow chart • Conclusion • References
![Page 4: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/4.jpg)
INDEX
• Controversies between 1. Open vs closed approach2. ORIF vs Endoscopic-assisted surgery3. Endoscopic-assisted surgery :
Extraoral vs Intraoral
• Conclusion• References
![Page 5: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/5.jpg)
Controversies
In the area of mandibular condyle fracture, there is controversy not only with regard to indication for open reduction versus closed reduction but also how to approach when there is an indication to do so.
![Page 6: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/6.jpg)
Controversies
To compare between ORIF and Closed reduction techniques
• To compare between extra oral approach and Endoscopic assisted repair .
• To compare between an Endoscopic assisted Extra oral & Trans oral approach for open reduction for condylar mandibular fracture.
![Page 7: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/7.jpg)
ORIF vs CLOSED TECHNIQUE
• A study was performed to evaluate and compare the results of open and closed treatment of intra capsular condylar fractures of mandible.
• 14 displaced condylar fractures, which were treated ORIF were examined clinically, radiological & axiographically & were compared to a group of 29 similar condylar fractures which had been treated with closed techniques.
![Page 8: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/8.jpg)
![Page 9: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/9.jpg)
ORIF vs CLOSED TECHNIQUE (cont.)
• Closed treatment avoids potential complications such as facial nerve damage and loss of osteosynthesis material.
• But complaints such as • extensive condylar deformity • Height reduction of the mandibular ramus• Disc displacement• Dysfunctional complaint such as Limitation of
mandibular mobility, Crepitation, Lateral deviation during mouth opening.
has been described.
![Page 10: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/10.jpg)
CLINICAL DYSFUNCTION INDEX
![Page 11: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/11.jpg)
ORIF vs CLOSED TECHNIQUE (cont.)
• The risk associated with ORIF can be reduced by using
• A nerve stimulator• Modified auricular approach• Cautious retraction• Meticulous hemostasis• Use of resorbable slender osteosynthesis
Plates.
![Page 12: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/12.jpg)
ORIF vs ENDOSCOPIC ASSISTED SURGERY
Treatment of subcondylar fracture has been traditionally between open or closed techniques but recently Endoscopic fracture repair has been described as a minimally invasive approach for open reduction with potential for decreased patient morbidity
![Page 13: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/13.jpg)
ORIF vs Endoscopic assisted surgery (cont.)
• Endoscopic assisted surgical • A 15-20 mm modified Risdon incision was
used to gain access to the lateral ramus.• A subperiostal dissection was performed
blindly to create an ‘optical cavity’ on the lateral aspect of the ramus
• A modified retractor with a curved end was placed through the incision & below the periosteum to engage the sigmoid notch
![Page 14: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/14.jpg)
Lateral view of mandibular condyle region to demonstrate the use of angled elevator for the reduction of condylar fracture
![Page 15: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/15.jpg)
ORIF vs Endoscopic assisted surgery (cont.)
• A 4-mm, 30 degree Hopkins endoscope was used for retraction & visualization on a video monitor system.
• Following irrigation & the use of suction elevators the sigmoid notch , inf border, post border and the fracture site is to be identified endoscopically.
• Reduction was achieved using DCP with screws placed via preauricular stab incision
![Page 16: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/16.jpg)
Intraoperative Endoscopic view of the reduction of the fragment using reduction forceps and an angled elevator
![Page 17: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/17.jpg)
ORIF vs Endoscopic assisted surgery (cont.)
• Following reduction and stabilization, the MMF is released and the occlusion is reevaluated.
• Post op MMF is not used
• Incision is closed in layers.
• Follow up
![Page 18: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/18.jpg)
![Page 19: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/19.jpg)
ORIF vs Endoscopic assisted surgery (cont.)
• The current limitations of ORIF includes
• poor access & visualization
• Difficult dissection that may necessitate 2 incisions
• Facial nerve deficit
• Delayed functional rehabilitation becoz of wide reflection of periosteum & muscle
• And scar(s)
![Page 20: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/20.jpg)
ORIF vs Endoscopic assisted surgery
• In comparison to ORIF , the endoscopically assisted reduction technique --
• Allows direct visualization of the fracture site via an illuminated & magnified field of view for fracture reduction
• Stabilizes through a conservative incision with an acceptable cosmetic result
• Remains extracapsular with out effect on articular cartilage or synovial fluid
• The additional morbidity of a preauricular incision & extended periods of MMF are avoided, with accelerated functional recovery.
![Page 21: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/21.jpg)
ENDOSCOPY-ASSISTED OPEN TREATMENT:- EXTRAORAL vs
INTRAORAL• In case of moderately displaced , a transoral
approach is used to avoid damage of the facial nerve & visible scars.
• Surgical approach:-The periosteum of the ascending ramus was
elevated down to the mandibular angle & the inferiorly inserting fibers of the temporalis muscle was stripped off the muscular process to create the optical cavity.
![Page 22: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/22.jpg)
ENDOSCOPY-ASSISTED OPEN TREATMENT:- EXTRAORAL vs
INTRAORAL (cont.)• The endoscope was inserted
subperiosteally without incision of the masseter muscle & advanced cranially towards the # site untill the # gap is visible in the endoscope
• Angulated drills& screw drivers were used to avoid transbuccal stab incision
![Page 23: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/23.jpg)
Intra operative view of angulated drill and screw driver for the drilling & insertion of screws
![Page 24: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/24.jpg)
ENDOSCOPY-ASSISTED OPEN TREATMENT:- EXTRAORAL vs
INTRAORAL (cont.)• The transoral approach is less time
consuming than extra oral approach & intraoral scars are invisible & no facial nerve damage is expected. Suitable for dislocation with lateral override but not for severe dislocation & comminuted #s.
![Page 25: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/25.jpg)
CONCLUSION
• The principal factors that determines the treatment decision are the
• Level of fracture• Degree of displacement• Age of patient• Availability of advanced surgical equipment• Surgical skill of the operator• Patients consent.
![Page 26: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/26.jpg)
REFERENCES• Michael Miloro , DMD, MD , Omaha, Neb. Endoscopic-
assisted repair of subcondylar fractures. Oral Surg Oral Med Oral Path.2003;96:387-391.
• M. Hlawitschka, R Loukota, U ECKELT: Functional & radiological results of open & closed treatment of intracapsular condylar fracture of the mandible. Int J. Oral & Maxillofac surg. 2005;34: 597-604.
• Edward EllisIII,DDS,MS-Treatment of mandibular condylar process fractures; Biological consideration. Int J. Oral & Maxillofac surg. 2005,63:115-134.
• R Schon, R Gutwald- Endoscopy- assisted open treatment of condylar fractureof the mandible:- Extraoral vs Intraoral approach. Amer J. Oral & Maxillofac surg. 2002;31:237-243.
• Pedro M, Villarreal MD, PhD, FEBOMS-Mandibular condyle fracture: determinates of treatment & outcome. Amer J. Oral & Maxillofac surg.
• Takashi Honda, M.D,- Endoscope-assisted facial fracture repair. World J Surg. 2001;25:1075-1083.
![Page 27: Condylar Fracture & Its Management](https://reader033.vdocuments.site/reader033/viewer/2022061117/5467e54baf795969338b5a5f/html5/thumbnails/27.jpg)
THANK YOU