Condylar fractures surgical approaches /certified fixed orthodontic courses by Indian dental academy

Surgical
Approaches
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Surgical Approaches
The various incisions to approach the condyle
are :1.
Submandibular
2.
Preauricular
3.
Endaural
4.
Retromandibular
5.
Intra oral
6.
Hemicoronal approach

Surgical Approaches
Submandibular approach
Most suitable for ramus fractures and for low fractures of the
condylar neck
Can be combined with an endaural incision for total joint
reconstruction


Surgical Approaches
Preauricular & Endaural




appropriate for repositioning and fixing intracapsular and very high
condylar fractures
Under certain conditions it can also be used, together with a sub
mandibular access, for high temporomandibular joint fractures that
access
are difficult to reduce

Incision


Dissection

Surgical Approaches
Preauricular & Endaural

Dissection above the arch - to sup temp plane
Below the arch – just superficial to tragal cartilage
To the bone – The structures within the flap raised off the arch
contain skin, supf templ vessels and nerves, Facial n braches,
Sup temp fascia & if taken more superiorly – temporal fascia

Surgical approaches
Retromandibular / Posterior mandible approach
This approach is indicated for low and high condylar
fractures
incision begins 0.5 cm below the lobe of the
ear and continues inferiorly for 3-3.5 cm.


Surgical Approaches
Intra oral approach

Only for low fractures of the TMJ
It was initially proposed by
Steinhauser
• Advantage
No visible scars but this is offset
by the lack of good vision


Treatment
options
1.

NoNsurgical/coNservative/closed
Soft diet
Intermaxillary fixation
Post treatment jaw exercise
Physiotherapy

2.

surgical/ opeN

Open reduction- hooks, forceps..
Osteosymthesis- wires, Lag screw, Miniplates, pin
fixation..

Treatment Modalities
Surgical approach

Conservative-functional
approach

Open reduction of
fracture segment with
osteosynthesis
The main objective is to
perform a repositioning
of the fractured condyle
as near to its anatomical
position as possible


to produce an acceptable
functional
psuedoarthrosis by re-educating
the
neuromuscular
pathways
“The main aim
encourage
movement of the
early as possible”

is to
active
jaw as

Methods of Reduction


Methods of Osteosythesis


Methods of Osteosythesis –
Miniplate fixation


Wiring
First - Perthes and Wassmund - Wires in 1924 and 1927

A. Silverman(1925)

B. Thoma(1942)


K Wire

K wire fixation -- Stephenson

Lag Screw

Lag Screw fixation - Eckelt

Controversies in
Treatment


Controversies in Treatment
“There has been too much discussion in the literature

relative to the treatment of condylar fracture. Two
schools of thought..”
“ The debate continues about the best way to manage
condylar process fractures; Is open reduction a
superior method of treatment compared with closed
reduction?”


The limitations that existed in the early days

Rudimentary radiographic techniques

hazards of anasthesia

vulnerability to infection - preantibiotic era

lack of rigid fixation
The advances in the modern era

Better diagnosis & management for facial injuries

Safer intra & post operative anesthetic management

Decreased risk of infections

More precise methods of fixation

Landmark Studies
Edward Ellis III & Gaylord Thockmorton-JOMS 2005
“Treatment of condylar process fractures”

Summary of current treatment options1.
2.
3.

A period of MMF followed by functional therapy
Functional therapy without MMF
Open reduction & Internal fixation


Goals of treatment


Goals of treatment
1.
2.
3.
4.
5.
6.
7.

Obtain stable & functional occlusion
Restore maximal interincisal opening
Establish a full range of mandibular
excursive movements
Minimize deviation of the mandible
Produce a pain-free articular apparatus at
rest and during function
Avoid internal derangement of the TMJ on
the injured or the contralateral side
Avoid the long-term complications of
growth disturbance

Indications of Open Method
- Zide & Kent, Raveh et al

Absolute indications

1. Limitation of function secondary to the following:
Fracture into middle cranial fossa
Foreign body within the joint capsule
Lateral extracapsular dislocation of condylar
head
2. Other fracture dislocations in which a mechanical stop
is present on opening which is confirmed
radiographically
3. Inability to bring the teeth into occlusion for closed
reduction
4. Open injury (penetrating, avulsive, lacerating) to the

Indications of Open Method
Relative indications

1.

2.

1.
2.
3.

Bilateral condylar fractures with comminuted midface
fractures in which rigid internal fixation of the midface is
not possible
Situations when intermaxillary fixation is not feasible as
a result of the following:
Medical restrictions
Poorly controlled seizure disorder
Psychiatric disorders
Severe mental retardation
Concomitant injuries such as head injury or chest injury
Displaced fractures where dentures or splints are not
feasible because of severe mandibular atrophy
Bilateral fractures in which it is impossible to determine
what the proper occlusion is

Closed Method


Range of treatment options available - observation and soft diet,
variable periods of immobilization &/or intense physiotherapy



Close supervision is mandatory



Need for immobilization - when malocclusion, deviation with function,
&/or pain is present.



The period of immobilization - must be long enough to allow initial union
of the fracture segments but short enough to prevent complications



Active functional therapy allows a return of mandibular range of
motion and functional movements



Guiding elastics should be used to direct the mandible to its maximal
intercuspation.

Special considerations


Special considerations –
Children
•Condylar fractures are relatively common
•Green stick fractures are more common
Mandibular fracture
incidence in children




Hall et al – 20.7% (<14 yrs)
Kaban et al – 32% (< 16 yrs)
Carroll et al – 26.5%


Condylar fractures in
children
Amaratunga - Hall ~ 40-60%
Etiology
Falls (30-50%)
Vehicle accidents (26-34%)
Sports related injury (15%)
Assault (3%)

Special considerations –
Children
Suggested protocol for treatment of condylar fractures in
children
 Nearly all cases- conservatively treated with immediate
function & analgesics
 In cases with pain & malocclusion – brief period of IMF –
7-10 days followed by active function
 As for adults, close supervision & follow up is mandatory
 Early mobilization & active physical therapy aimed at
increased range of mandibular motion & prevents
ankylosis & growth alteration

Complications
EARLY COMPLICATIONS
Complications that occur concurrent with or early after
treatment of condylar fractures include the following
1. Fracture of the tympanic plate - otorrhea
2. Fracture of the glenoid fossa with or without displacement
of the condylar segment into the middle cranial fossa –
nuerological signs
3. Damage to cranial nerves V and VII – traumatic/post op
4. Vascular injury

Complications
LATE COMPLICATIONS

Late complications of condylar fractures commonly
include the following:
1.
2.
3.

Malocclusion
Growth disturbances
Temporomandibular joint dysfunction (Internal
derangement)
4.
Ankylosis

Thank you
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Condylar fractures surgical approaches /certified fixed orthodontic courses by Indian dental academy

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