CONDYLE FRACTURE CONDYLE FRACTURE

Dr V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY SURGEON

REG NO: 4118- TAMILNADU- INDIA( ASIA)

ETIOLOGY - MECHANISM OF INJURY 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 CLINICAL CLASSIFICATION Spiessl & Schroll 1972Spiessl & 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 CLINICAL FEATURES OF SUBCONDYLAR FRACTURESFRACTURES

* 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 SCHOOL OF THOUGHTS IN MANAGEMENTMANAGEMENT

CONSERVATIVE - FUNCTIONAL -

SURGICAL

DIAGNOSTIC AIDS AND ITS DIAGNOSTIC AIDS AND ITS ROLED IN TREATMENT PLANROLED 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 ABSOLUTE AND RELATIVE INDICATION OF OPEN REDUCTION(ZIDE AND KENT)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 RELATIVE INDICATIONS (ZIDE AND KENT)(ZIDE AND KENT)

* Edentulous jaws

* Uncontrolled seizure disorders

* Status asthmaticus.

* Psycologic compromise

ROLE OF FUNCTIONAL SCHOOL OF THOUGHT IN MANAGEMENT

WHEN - WHY - HOW?

OPEN REDUCTIONOPEN REDUCTION APPROACHES AND ADVANTAGES 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 REDUCTIONOPEN REDUCTION APPROACHES AND ADVANTAGES 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 OPEN REDUCTION APPROACHES & ADVANTAGES APPROACHES & ADVANTAGES

BICORONAL APPROACH

RIGID INTERNAL FIXATION RIGID INTERNAL FIXATION DIVICES & ADVANTAGESDIVICES & ADVANTAGES

COMPRESSION PLATE OSTEOSYNTHESIS

3 DIMENSIONAL PLATING 3 DIMENSIONAL PLATING

COMPRESSION PLATE OSTEOSYNTHESIS

TRANSOSSEOUS WIRING

PETZED LAG SCREWS PETZED LAG SCREWS OSTEOSYNTHESIS OSTEOSYNTHESIS

INTRA MEDUALLARY SCREWS

KRISCHNER WIRE

CLOSED REDUCTION & MAXILLO CLOSED REDUCTION & MAXILLO MANDIBULAR FIXATIONMANDIBULAR FIXATION

DISADVANTAGESDISADVANTAGES- 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 CLOSED REDUCTION & MAXILLO MANDIBULAR FIXATIONMANDIBULAR FIXATION

ADVANTAGESADVANTAGES- 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 RETROSPECTIVE STUDY 6 YEARS (1996 - 2002)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 COMPLICATION CONSERVATIVE VS OPEN REDUCTIONCONSERVATIVE 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 Have we reached to a reached to a conclusion?conclusion?