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Condylar fracture by Dr. Amit T. Suryawanshi

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Condylar fracture by Dr. Amit T. Suryawanshi

  1. 1. 1 Condylar Fracture A Dr. Amit T. Suryawanshi Literature Click here www.faceart-clinic.com Dr. Amit T. Suryawanshi (MDS) Facial Cosmetic Surgeon Oral & Maxillofacial Surgeon Dental Surgeon & Implantologist Hair Transplant Surgeon (Germany) Consulting Surgeon in Kolhapur, Sangli, Pune & Mumbai (India) & founder of Face Art International Super speciality at Kolhapur Cell Phone no. +91 9405622455 Clinic Landline - +91 7758976097 Email– amitsuryawanshi999@gmail.com
  2. 2. 2 Annual Global Road Crash Statistics -  Nearly 1.3 million people die in road crashes each year, on average 3,287 deaths a day.  An additional 20-50 million are injured or disabled.  More than half of all road traffic deaths occur among young adults ages 15-44.  Road traffic crashes rank as the 9th leading cause of death and account for 2.2% of all deaths globally.  Road crashes are the leading cause of death among young people ages 15-29, and the second leading cause of death worldwide among young people ages 5-14.  Each year nearly 400,000 people under 25 die on the world's roads, on average over 1,000 a day.  Over 90% of all road fatalities occur in low and middle-income countries, which have less than half of the world's vehicles.  Road crashes cost USD $518 billion globally, costing individual countries from 1-2% of their annual GDP.  Road crashes cost low and middle-income countries USD $65 billion annually, exceeding the total amount received in developmental assistance.  Unless action is taken, road traffic injuries are predicted to become the fifth leading cause of death by 2030. In the present time, when human beings have to race against time to live a comfortable life, we need to overlook the danger that may follow and still we are more subjected to trauma.
  3. 3. 3 Also, when the rule of survival of fittest exists, first flights and assaults becomes a feature of everyday life. Chin, being the most prominent part of the face, has to bear with blows, resulting in fracture of the mandible. Automobile, sports and industrial accidents also contribute towards fracture of mandible. The condylar process, forms an important component of the temporomandibular joint and takes part in proper functioning of the T.M.J. Also proper occlusion and facial appearances depends upon the integrity of the condylar process. The oldest study of the condylar fracture was made by Desault in 1805, who recognized the importance of restoring the contact with the fragment and stated that the union might fail to take place, if slightest movement of the jaw occurred. The term condylar fracture can be applied to fracture of the condylar process which occurs between the sigmoid notch and up to the including articular surface of the condyle. Condylar fracture may be either unilateral or bilateral and occurs as a result of indirect blow, i.e. when a blow is sustained centrally upon the point of the chin, the forces of the impact is transmitted upwards and backwards along the length of the bone, to the point where the mandible articulates with the skill. Condylar fractures are more common due to the frail neck of the condyle which snaps when a blow is received on the chin and directed along the ramous of the mandible. If the degree of the violence sustained is sufficiently serve, the condylar and may be driven through the roof of the glenoid surface into the middle fossa of the skull. Fortunately, this does not happen often, since the neck of the condyle which is very slender, fractures and prevents further damage. Hence it can be called as safely mechanism. Regarding the treatment of the condylar fracture opinion is divided, some authors advocate open reduction while others advocate conservative treatment. Also, they differ on the length of time, the joint should be immobilized. But all authors agree that the treatment must include restoration of functional occlusion of the teeth, acceptable appearance of the face, and normal working of the jaws. They achieve these objective, certain basic orthopaedic principles should be followed. This includes adequate immobilization of the fragments in proper positioning for sufficient time to allow the fracture to heal. Whatever method may be used in the treatment of condylar fractures, the surgeon must air at achieving the best result. It must be properly treated, the complication, like arthritis, asymmetry, clicking, limitation of jaw movement, open bite and ankylosis and myo-facial
  4. 4. 4 pain dysfunction syndrome may supervene. Utmost care must be taken while treating children to avoid injury to the condylar growth. If the growth centre is affected, it will cause disfigurement of the face and malocclusion and can lead to emotional disturbance in the child as age advances. Timely treatment is of utmost importance.
  5. 5. 5 Click here www.faceart-clinic.com SURGICAL ANATOMY OF TEMPOROMANDIBULAR JOINT
  6. 6. 6 The mandible is the largest, strongest, single, horseshoe shaped bone of the facial skeleton, it houses the mandibular teeth. The body of the mandible lies horizontal with its convex portion facing anteriorly. Attached to the curve body of the mandible are two broad rami, which project upwards and have two processes, the coronoid and condylar process. The TMJ is ginglymoarthrodial joint that allows the mandibular condyle to move freely in both rotation and translation, with respect to the glenoid fossa. The joint contain superior and inferior joint spaces separated by the meniscus. The articular surfaces of the condylar head and glenoid fossa are covered by dense fibrocartilage. A synovial lining is found within both the upper and the lower joint cavities. Synovial villi is present anterior and posterior to the meniscus extending from the disk to the temporal bone superiorly and the condylar head inferiorly. The meniscus is a biconcave disk consisting of dense, fibrous tissue. It is situated within the joint space and separates that area in superior and inferior joint space, thereby allowing translation and rotation, respectively. The central portion of the disk is avascular and relatively thin. Anteriorly the disk thickens and attaches superiorly to the articular eminence and superior belly of the lateral pterygoid muscle. Inferiorly the anterior aspect of the disk attaches to the condylar neck just superior to the insertion of the inferior belly of the lateral pterygoid muscle. This area is highly vascular, with the auriculotemporal, masseteric, and deep temporal vessels supplying the lateral pterygoid muscle and joint. Posteriorly the disk attaches via the bilaminar zone, which is composed of two layers of fibrous tissue with intervening loose areolar tissue. This area too is highly vascular and richly innervated. The superior layer of fibers attaches to the tympanic plate of the temporal bone, and the inferior layer runs from the posterior aspect of the disk to the posterior condylar neck. Medially and
  7. 7. 7 laterally the disk is tightly attached to the medial and lateral poles of the condylar head, allowing the disk to move with the condylar head during translation. This relationship becomes displaced medially, carrying the disk with it. The entire joint is surrounded by a fibrous capsule. It attaches superiorly at the margins of the glenoid fossa and inferiorly at the condylar neck. The capsule is thickened laterally, forming the temporomandibular ligament. This increased thickness resists lateral displacement of a fractured condylar segment from the glenoid fossa. Medially the capsule is relatively thin, making displacement in medial direction much more likely. Two additional ligaments serve to support the TMJ, the sphenomandibular and stylomandibular ligaments.
  8. 8. 8 Anatomy of the Temporomandibular joint.
  9. 9. 9 The sphenomandibular ligament inserts superiorly on the spine of the sphenoid bone and courses inferolaterally to insert in the medial aspect of the ramus at the lingual. The stylomandibular ligament passes from the styloid process to the angle of the mandible. These ligaments act in a manner similar to collateral ligaments in other joints: the contralateral TMJ ligaments acting like medial collateral ligaments aiding in the prevention of lateral dislocation of the joint. Overlying the joint, capsule, laterally is the parotidomasseteric fascia, which is tightly adherent to the inferior aspect of the zygomatic arch. The superficial investing fascia lies superficial to this. Within the superficial fascia lie the temporal and zygomatic branches of the facial nerve. The TMJ lies in a region rich in neural and vascular structures. For two reasons, it is important to understand the relationship of the structures to the joint. Second, overzealous ligation of vessels and stripping of the fracture segments lead to unnecessary compromise of the vascular supply to the condyle and other joint structures. Avascular necrosis of the condyle is an uncommon but serious complication of fracture treatment. Special care must be exercised to prevent damaging the neural structures surrounding the TMJ, particularly the branches of the facial nerve. Sensory deficits, although annoying to the patients, are usually tolerable, whereas facial paresis may result in devastating cosmetic, functional, and psychologic consequences. The primary blood supply to the mandibular condyle derives from branches of the superficial temporal artery, the transverse facial artery, the posterior tympanic artery, and the posterior deep temporal artery. The superficial temporal artery is one of the terminal branches of the external carotid artery that runs deep to the paroid gland, emerging behind the neck of the condyle. From there, it crosses the root of the zygomatic process of the temporal bone to ascend to the temporal region of the scalp. The transverse facial artery departs from the superficial temporal artery at its base and travels across the face on the superficial aspect of the masseter muscle approximately 1.5 cm inferior to the zygomatic arch. The posterior deep temporal and posterior tympanic arteries are branches of the maxillary artery that leave this vessel to enter the anterior and medial aspects of the joint, respectively. Variable degrees of damage to these vessels are inevitable, secondary to the nature of the injury, but as mentioned earlier, additional damage should be prevented or, at least, minimized when the surgeon approaches the condyle.
  10. 10. 10 Arterial supply of Temporomandibular joint Relation of the facial nerve with the condyle
  11. 11. 11 The neural structures of primary import are the sensory auriculotemporal nerve and the motor branches of facial nerve. The auriculotemporal nerve, a branch of the trigeminal nerve, passes posterior to the neck of the condyle and crosses the zygomatic arch to ascend to the scalp just anterior to the ear and posterior to the superficial temporal artery. This nerve supplies sensory fibers to the posterior aspect of the TMJ. The surgeon must be mindful of the facial nerve’s intimate involvement with the TMJ, especially when performing surgical approaches to the joint. The temporal and zygomatic branches are at increased risk during the preauricular approach, as is the marginal mandibular branch during the submandibular approach. The intraoral approach to the joint has minimal risk to the branches of the facial nerve as one of its major advantages. In 1979 Al-Kayat and Bramley studied anatomic dissection of 56 cadaveric facial halves with the intent of identifying the branches of the facial nerve and determining the distances between these branches and readily identifiable landmarks of external auditory canal and the postglenoid tubercle .Their aim was to determine areas of increased risk during surgical dissection in the region of the TMJ. They found that the temporofacial division and the most posterior significant twig of the temporal branch lie within a zone 0.8 to 3.5 cm (average 2.0 cm) anterior to the greatest anterior concavity of the external auditory canal. They also reported that the point of division of the main trunk into temporofacial and cervicofacial branches lies within a zone 1.5 to 2.8 cm (average 2.3) below the lowest concavity of the external auditory canal and within 2.4 to 3.5 cm (average 3.0 cm) inferoposteriorly to the postglenoid tubercle. In 1962 Dingman and Grabb, in a similar manner, studied 100 cadaveric facial halves with the aim of determining the course of the marginal mandibular branch of the facial nerve. They found that posterior to the facial artery, the marginal mandibular branch of the facial nerve was observed to run above the inferior border of the mandible in 81% of cases. In the remaining 19%, the nerve coursed in the arc with the lowest point being within 1 cm of the inferior border. Anterior to the artery, the nerve ran above the inferior border in 100% of cases. They also observed that contrary to the majority of anatomy texts, the marginal mandibular branch of the facial nerve is composed of several branches in the majority of cases. In only 21%of cases was a solitary branches in 9%, and four branches in 3% of cases studied. These measurements should serve as useful guides for the surgeon performing surgical dissection in the region of the TMJ.
  12. 12. 12 Alkayat-Bramly study showing the relation of the facial nerve with the TMJ
  13. 13. 13 INCIDENCE & ETIOLOGY
  14. 14. 14 The incidence of fracture involving the mandibular condyle varies throughout the literature and is influenced by factors such as age, geographic location, and socioeconomic level of the study population. Early reports revealed an incidence as low as 8% of mandibular fractures, with later reports claiming an incidence as high as 76%. In any event fracture involving the condylar process are by no means uncommon and probably make up between one quarter and one third of all mandibular fractures. Injury to the condyle may be caused by a variety of mechanisms, which also vary according to the characteristics of the group studied. In adults motor vehicle accidents account for the majority of condylar fractures, and interpersonal violence, work-related incidents, sporting accidents, and falls play important but lesser roles. In children falls and bicycle accidents also contributing significantly. Different still are the elderly, in whom falls again constitute the primary factor, followed by assault and automobile accidents. Other less obvious causes of injury to the TMJ include orotracheal intubation, whiplash injury, childbirth, and weight lifting. Lindahl divided traumatic forces causing condylar injury into three categories. The first is energy imparted on a static individual by a moving object. This type of injury is typified by a blow to the face by a fist, a baseball bat, or another object. The second type of force is that of a moving individual striking a static object, such as a child falling and striking the chin against the pavement. This mechanism is also seen in the classically described “parade ground fracture.” The third classification is energy developed by a combination of the first two mechanisms. This type of force is typical of that generated during an automobile accident in which the individual is moving forward and the instrument console is moving in the opposite direction following impact. This type of force is usually the greatest and produces the most severe injury patterns. A belief exists that the presence or absence of the dentition and the status of the mandible (i.e., open versus closed) at the moment of impact also influence the type and severity of fracture. He correlated this finding with the relatively high incidences of condylar fractures in automobile accidents, presumably because the mouth is open because of screaming or fear at the time of impact. In 1977 Lindahl, however, noted in his study that no correlation existed between the presence of, or status of, the dentition and the type of fracture observed, stating that all fracture types
  15. 15. 15 were seen regardless of the occlusion. Furthermore, he found no influence on the degree of the fracture by the most distal occlusal contact. In any event, the type of fracture produced following an injury depends in part on the age of the patient and in part on the direction and magnitude of the force. Certain mechanism however, consistently reproduce specific fracture pattern. Therefore knowledge of the mechanisms of injury may yield clues to guide the clinician during the initial examination of the patient. For example, a direct blow to the TMJ region may result in a fracture of that condyle. But this fracture is fairly uncommon owing to the protection afforded to the condyle by the lateral rim of the glenoid fossa. More commonly a blow directed horizontally to the mandibular body, such as that provided by a fist, results in a fracture of the ipsilateral mandibular body and also the contralateral condyle. A force applied to the parasymphyseal region may cause an ipsilateral condylar fracture. When a force is directed axially to the chin region, such as when the chin strikes the ground after a fall or dashboard during an automobile accident, force is transmitted along the mandibular body to the condyles. This typically results in a symphyseal or parasymphyseal fracture combined with unilateral or bilateral fracture of the condyles. As the condyles are driven superiorly and posteriorly into the glenoid fossa, there may be concomitant fracture of the glenoid fossa with penetration into the middle cranial fossa, or fracture of the tympanic plate and damage to the external auditory canal. In children bone has greater elasticity and therefore a blow to the chin may result in bilateral “greenstick” fractures of the condyles. The mechanism of injury thus alerts the clinician to heighten his or her degree of suspension and provides useful insight into the type of injury to be expected. Click here www.faceart-clinic.com
  16. 16. 16
  17. 17. 17
  18. 18. 18 SOFT TISSUE INJURIES
  19. 19. 19 An extensive review of soft tissue injuries involving the TMJ is presented by Goldman. He reviewed a large number of studies related to TMJ dysfunction and found that trauma was a primary causative factor in the majority of instances. He described a division of trauma into two groups: macrotrauma and microtrauma. Macrotrauma includes bruxism or a direct blow to the jaw, whereas microtrauma includes less conspicuous injuries, such as nail biting, yawning, violin playing, scuba diving, and whiplash injury. Depending on the magnitude, direction, and duration of the insult, damage may include mild inflammatory changes, such as synovitis, capsulitis, and inflammation of the surrounding muscles and ligaments. Prolonged abnormal loading of the joint perpetuates the inflammatory process and leads to chondromalacia, internal derangements, alteration of disk and articular cartilage morphology, and eventually degenerative changes. The majority of soft tissue injuries to the TMJ may be successfully treated with conservative measures, such as jaw rest, soft diet, analgesic, and nonsteroidal anti-inflammatory agents. Additional measures including behaviour modification, psychotherapy, bite splints, and occlusal adjustment may also be of benefit in selected circumstances.
  20. 20. 20 CLASSIFICATION
  21. 21. 21 Fracture of the condylar process of the mandible presents a special problem which has to be treated with care. In order to plan a treatment of the condylar fracture it is important to classify and group a particular type of fracture to facilitate proper study of the case before deciding on the method of reduction and fixation. The classification of the condylar fractures can be carried out taking some important landmarks into consideration or according to the displacement of the fractured part of the condyle. Rowe and Killey (1968) taking into consideration the anatomy and clinical findings, classified the fractures in the following way: A) ANATOMICAL CLASSIFICATION B) CLINICAL CLASSIFICATION ANATOMICAL CLASSIFICATION: SIMPLE: 1) Intra capsular 2) Extra capsular 3) Fracture associated with injury to the capsule, ligament and meniscus. 4) Fracture involving the adjacent bone e.g. roof of the glenoid fossa and tympanic plate.
  22. 22. 22 COMPOUND: Are those fractures which compounds to the external meatus, middle ear and to nasopharynx through the eustachian tube. Penetrating injury of the joint from a sharp weapon or a gunshot may also compound to the external environment or to oral cavity. CLINICAL CLASSIFICATION MacLennan System. In an attempt to establish a more clinically useful classification scheme, MacLennan in 1952 proposed a system based primarily on relationship of the proximal and distal fracture segments to each other. His system consists of four divisions as follows. 1. Type I fracture, non-displaced. 2. Type II fracture, fracture deviation. This type consists of a simple angulation of the fracture segments without overlap or separation. This type includes the greenstick fracture commonly seen in children. 3. Type III fracture, fracture displacement. This group of fractures is characterized by overlap of the proximal and distal fracture segments. The overlap may be anterior, posterior, lateral, or medial. However, as mentioned previously, medial displacement is seen most commonly because of the anteromedial pull of the lateral pterygoid muscle. 4. Type IV fracture, fracture dislocation. Here the condylar head is completely outside the glenoid fossa and therefore outside the capsular confines. Again the dislocation may be medial or lateral and rarely anterior or posterior. Lindahl System. In 1977 Lindahl proposed a system that classified condylar fractures based on factors, including (1) anatomic location of the fracture, (2) the relationship of condylar segment to the mandibular segment, and (3) relationship of the condylar head to the glenoid fossa. His system necessitates that radiographs be obtained at-least two views at right angle to each other. The classification is as follows: 1. Level of condylar fracture a) Condylar head. Although the exact anatomic confines are somewhat nebulous, the condylar head is usually defined as the portion of the condyle superior to the narrow constriction of the condylar neck. Grays anatomy defines the condylar head as extending a short distance down the anterior aspect of the process, covering the entirety of the superior portion, and extending at-least 5mm down the posterior aspect. Although different to define precisely radiographically, it is relatively easy to identify the constriction of the condylar neck. They may be further classified as vertical fractures, compression fractures, and comminuted fractures. b) Condylar neck. The condylar neck is the thin constricted area located immediately below the condylar head. It is fairly easy to identify this area radiographically. The
  23. 23. 23 condylar neck anatomically is the region where the caudal portion of the joint capsule attaches. These fractures are therefore extracapsular, c) Subcondylar. This region is located below the condylar neck and extends from the deepest point of the sigmoid notch anteriorly to the deepest point along the concave posterior aspect of the mandibular ramus. Depending on the location of the fracture, these fractures are sometimes described as “high” or “low” subcondylar fractures, perhaps to make reference to the more difficult surgical approach to the low subcondylar fracture. 2. Relationship of the condylar segment to the mandibular fragment a) Non-displaced. b) Deviated. This involves only an angulation of the condylar fragment in relation to the distal mandibular segment. The fractured ends remain in contact, with no separation or overlap. c) Displacement with medial or lateral overlap. The fractured end of the proximal condylar segment lies either medial or lateral to the proximal end of the distal mandibular segment. Secondary to the pull of the lateral pterygoid muscle, the medially displaced condylar fragment is the more common variety. d) Displacement with anterior or posterior overlap; these types are uncommon. e) No contact between the fracture segments. 3. Relationship between the condylar head and the glenoid fossa a) Non-displaced. The condylar head is in normal relation to the glenoid fossa. b) Displacement. The condylar head remains within the fossa, but there is alteration in the joint space. c) Dislocation, the condylar head lies completely outside the confines of the fossa. For this displacement to occur, there must be rupture of the capsule. The lateral capsule is usually quite thick and strong, whereas the medial joint capsule is thin and weak. Therefore the usual location of a dislocation condylar segment, because of the lateral pterygoid pull, is anteromedial. Richardson and Cohen (1953) classified the condylar fracture in the following manner:- A) Fracture of the condylar head: 1. Incomplete fracture with no displacement. 2. Incomplete fracture with dislocation of a segment. 3. Complete communited fracture with little displacement. 4. Complete communited fracture with dislocation. B) Fracture of the neck of the condyle: 1. Green Stick fracture. 2. Slight displacement with good alignment.
  24. 24. 24 3. Gross displacement with overriding of the fragments. 4. Displacement with rotation of the condyle. 5. Complete fracture with dislocation of the codylar head. C) Subcondylar fractures: This fracture may be green stick, impacted, overriding or displaced. D) Injury to the meniscus: It may be torn, ruptured or herniated in forward or backward position. Garry presented his own classification: a) Undisplaced condylar fractures. b) Displaced condylar fracture, displacement may take place anteriorly, medially or inferiorly. c) Condylar fracture dislocation. The dislocation may take place in any direction, but chiefly the condyle herniates through the joint capsule in anteromedial direction.
  25. 25. 25 Lindahl’s classifications
  26. 26. 26 Thoma (1945) classified fractures in a simple way, taking into consideration the direction of displacement. A) Codylar fractures: 1. Without displacement of condyle: a) Green stick. b) Intracapsular. c) Extracapsular. 2. With displacement of condyle: a) Lateral b) Medial c) Forward d) Backward 3. With overriding of fragments 4. With dislocation in lateral or medial direction: a) Intracapsular b) Complete fracture dislocation(40-90 degrees) c) Complete dislodgement of the condyle d) Dislocation of the fractured part of the head of the condyle. 5. With dislocation in a forward directions: a) Anteriorly from the articular eminence. b) Posteriorly from the articular eminence. 6. With dislocation and displacement of the meniscus 7. With comminution 8. Old fracture with deformities: a) Pseudoarthrosis b) Ankylosis B) Sub-condylar fracture: i) Without displacement of the fragment ii) With displacement of the fragment Fracture line either extending through head or base of the condyle or neck has been called condylar fracture by Thoma, whereas in sub-condylar fracture, the line runs transversely over ascending ramus. Roentgenographic studies were considered for classification of condylar fractures by Blevins and Groves (1961). They believed that incorrect plane of roentgen may mislead the diagnosis.
  27. 27. 27 They classified the condylar fractures as follows: CLASS I:- Medial displacement. a) Anterior position b) Posterior position CLASS II:- Lateral displacement a) Anterior position b) Posterior position CLASS III:- Medial override a) Anterior position b) Posterior position CLASS IV:- lateral override a) Anterior position b) Posterior position CLASS V:- Green Stick fracture. Many other workers like Berger (1924), Blair and Ivy (1936), Walker (1942) have also classified condylar fractures in different ways. ARCHERS CLASSIFICATION OF FRACTURES Single fractures: Bone is fractured only in one place, usually unilateral. Rarely seen in mandibular fracture, when seen it may pass through the neck of the condyle. Multiple fractures: Bone is fractured in two or more places. Bilateral are more than other types of fractures occurring in mandible and maxilla. If the fracture occurs through the neck of the condyle on one side, there is usually a fracture through the mental foramen on the contralateral side. If it occurs through the mental foramen on one side, it may occur through the angle formed by the ramus and body on the other side, or through the neck of the condyle. Multiple fractures may also be unilateral, the bone being fractured into several segments on side only. Simple fractures: More commonly found as fracture of the ramus of the mandible or at the angle formed by the ramus and the body of the mandible. In these type of fractures, the fractured bone is not in contact with the secretions of the oral cavity and the fractured bone
  28. 28. 28 does not communicate with the external surface os the face through a laceration in the investing soft tissues. Compound fractures: Where the fractured parts of the bone communicates with the oral cavity or external surface of the face through a laceration in the oral mucosa or in the skin. The fractures generally occur anterior to the angle. Communicated fractures: In this type of fractures, either the bone is shattered or broken up into pieces of fragments. Complicated fractures: In this type of fracture both maxilla and mandible are involved or in which the maxilla or the mandible is edentulous. There might be marked displacement of the compound communited osseous fragments of either or both the maxilla and mandible, with extensive trauma of the investing and covering soft tissues. There may be an associated fracture of the skull.
  29. 29. 29 CLINICAL EXAMINATION
  30. 30. 30 As with examination of any other area or system, clinical examination of the patient suspected of having a fracture of the mandibular condyle should proceed in a systematic and orderly manner. An overall examination of the patient with traumatic injury should precede evaluation of the maxillofacial region. After the patient’s condition has been deemed stable, and other more serious injuries have been addressed, attention can be directed to the suspected maxillofacial fracture. The patient with fracture of the mandibular condyle usually has a suggestive history and, in addition, one or more of the following findings: 1) GENERAL EXAMINATION AT ARRIVAL: Gain information quickly from the patient, or accompanying person regarding mechanism of injury, any obvious deformities signs of injury or illness. PRIMARY SURVEY: Assessment of patency of airway(breathing)circulation, or any active profuse bleeding or history of excessive blood loss. SECONDARY SURVEY: Vital signs:- - Radical pulse rate and character should be determined. - Respiratory rate and character of respiratory should be noted. - Blood pressure should be measured by auscultation and palpation. HEAD TO TOE SURVEY: - Check scalp for cuts, bruises, swelling and other signs of injury. Examine skull for deformities, depressions and signs of injury including facial bones, eyelids and orbit. - Determine pupil size, their equality and reactivity.
  31. 31. 31 - Look for blood, clear fluid, or blood contamination fluid from the ears and nose. - Examine mouth for obstruction. - Examine the patient for any injuries to the neck, chest or abdomen and upper and lower extremities. It is always better to explain and warn the patient when there is a possibility of pain during examination at all times go gain the patient’s co-operation. 2)LOCAL EXAMINATION: SIGNS AND SYSTOMS: 1. Evidence of trauma, which may include facial contusions, abrasions, laceration of the chin, and ecchymosis and/or hematoma in the TMJ region .these injuries should alert the clinician not only to possible fractures in the area of direct injury but also to indirect injury to the ipsilateral and the contralateral TMJ. 2. Bleeding from the external auditory canal. This finding may indicate fracture of the anterior tympanic plate from a posteriorly displaced condyle. 3. A noticeable or palpable swelling over the TMJ may be 4. a laterally dislocated condylar head that is directly visible under the skin. 5. Facial asymmetry may be the result of soft tissue edema or may be a result of foreshortening of the ramus caused by overlap of the proximal and distal fracture segments. 6. Pain and tenderness to palpation over the affected TMJ. There may also be notable pain on attempted manipulation of the jaw by the patient or the clinician. 7. Crepitation over the affected joint secondary to friction of the irregular fracture ends sliding over one another during manipulation. 8. Malocclusion may be a useful clue to the type of injury sustained. A unilateral condylar fracture usually results in ipsilateral premature contact of the posterior dentition secondary to foreshortening of the ramus on the side. This foreshortening
  32. 32. 32 may also result in a contralateral posterior open bite because of the canting of the mandible. Bilateral condylar fractures may result in a marked anterior open bite and retrognathia. The medial pterygoid and masseter muscles exert a superior and posterior pull on the distal mandiblular segment, causing it to telescope past the condylar segments. This telescoping results in premature contact in the posterior occlusion with rotation of the mandible around this point and anterior open bite. Gagging on the posterior teeth may also occasionally be seen because of the posteriorly positioned mandibular segment. 9. Deviation of the mandible midline may be seen both at rest and with attempted excursion of the mandible. At rest, because of shortening of the ipsilateral ramus , the mandible may deviate toward the fractured side. In a unilateral fracture, with attempted opening of the mouth, the lateral pterygoid on the fracture side is unable to effect pull on the mandible, and the unaffected contralateral muscle function normally. This inequality of function causes an exaggeration of the deviation toward the fractured side. Similar deviation is seen with protrusive movements. Attempts to move the mandible laterally away from the fractured side are met with great difficulty because of the ineffective lateral pterygoid muscle. Bilateral condylar fractures may result in little deviation of the midline because both condyles are involved. As, mentioned, an anterior open bite will be seen with retrognathia in addition to severely limited range of motion. 10. Muscle spasm(“splinting”)with associated pain and limited opening. 11. Dentoalveolar injuries. Any one or combination of these findings should raise the clinician’s index of suspicion as to the possibility of unilateral or bilateral condylar fractures in addition to other maxillofacial injuries. INSPECTION Inspection of fracture site may reveal oedema, ecchymosis and deformity in the region of fracture. Soft tissue injuries in the joint region should be examined for perforation in the joint region. The presence of blood in the external auditory canal may indicate perforation injury of the joint, presence of cerebrospinal fluid may give to suspicious involvement of middle cranial fossa
  33. 33. 33 The facial asymmetry, or any obvious bulge or depression in the preauricular area may indicate the displacement of a fragment or a fracture dislocation. A shift in the midline of the teeth may be apparent, or a lateral displacement of chin in the edentulous patient with unilateral condylar fracture may be observed. Abnormal movements of the jaw can occur during opening and closing movements of the jaw. An intraoral inspection within a few hours of injury will reveal the presence of blood stained saliva. The buccal and lingual sulci is examined to note any breach in continuity of mucosa and the existence of ecchymosis or sublingual haematoma. The alignment and the occlussal plane should be noted for the presence of any step deformity, suggestive of a fracture of the underlying bone. PALPATION: Palpation should be started from the temporomandibular joint region and should proceed along the entire length of the mandibular posterior and inferior border noting any tenderness or breach in the continuity. By means of palpation we can determine the pain due to pressure at the joint or the protrusion of the displaced or dislocated fragment. Crepitations may be noted during jaw movements due to rubbing of the fracture ends together. In all cases of suspected condylar fractures it is helpful to place the little finger into the external auditory meatus, in order to detect any movement or lack of movement of the condylar head, when the mandible is moved. The buccal and the lingual sulcus should be palpated intraorally, for presence of any tenderness and alterations in the contour, the mandible should then be grasped on either side of the suspected fracture and a gentle attempt should be made to elicit any abnormal mobility. Clinically it will be noted that there is asymmetry of the face on the involved side due to, shifting of the mandible posteriorly and laterally towards the affected side. Premature occlusion on the involved side is caused by upward pull of the elevator muscle of the mandible. This result in a class I lever with the fulcrum on the molar teeth on the involved side. An open bite deformity anteriorly on the opposite side of the mandible is noted. Tenderness on palpation over the TMJ and in the external auditory canal is a common
  34. 34. 34 finding. Moderate to severe oedema, ecchymosis and occasionally haemorrhage may be noted in the external auditory canal. If both the mandibular condyles are fractured the patient will have an anterior open bite deformity with occlusion only on the posterior teeth. Anterior open bite deformity is caused by upward displacement of ramus and telescoping of the fractured segments, due to contractions of the strong elevator muscles of the mandible. In bilateral condylar fractures which occur below the attachment of the lateral pterygoid muscles, the patient is unable to protrude the mandible. In unilateral fractures at the same level, the patient is unable to form lateral motions to the opposite side. Lateral movements of the mandible can be made only towards the affected side, because the lateral pterygoid muscle on the unaffected side shifts the mandible medially and forward, while the muscle is completely out of function on the affected side. The patient usually will have dysfunction and pain on attempting the opening movement of the jaw. If the posterior fragment have been displaced posteriorly, the mandible may shift forward as the segment of the ramus distal to the fracture rides upward and glides forward on contact with the condyle fragment. This may produce an open bite with protrusive relationship of the mandible. Fractures above the level of the lateral pterygoid muscle insertion do not exhibit displacement, because of the absence of contracting muscle attached to the proximal segment. The patient may complain of severe pain in the TMJ, and it will be noted that the teeth are shifted and do not come into occlusion on the affected side because of the haemorrhage and oedema in the joint which forces the condyle downwards. It may be several weeks before the teeth come into their normal occlusal relationship. In this type of fractures, especially in children the parents should be warned about the possibility of the development of ankylosis, if proper treatment is not initiated. In some cases, even though ankylosis does not occur the head of the condyle may be damaged, thus affecting the growth, with subsequent mal- development.
  35. 35. 35 RADIOLOGICAL EXAMINATION
  36. 36. 36 When a patient has a history of trauma and a clinical examination suggestive of condylar fracture, a radiographic evaluation is mandatory. Maxillofacial radiographic technique mandates that at least two radiographs be obtained at right angle to each other to adequately evaluate the TMJ region. In most centres the mandible series consists of a posteroanterior skull view, two lateral oblique, and a Towne’s view to evaluate the mandible. If available a panoramic radiograph may added to this series. Interestingly, Charya et al compared the sensitivity of the “standard” mandibular series with the panoramic radiograph in detecting mandibular fracture. They found that the panoramic film had a higher accuracy in detecting all types of mandibular fracture (92% versus 66%) except those in ramus region, where two studies are of equal value. They cite a decreased cost and low radiation exposure as advantage of the panoramic film compared with the mandible series. The panoramic radiograph, however, necessitates that the patient be able to stand erect and immobile for an adequate period of time. Problems with the mandibular series include the increased radiation exposure, increased cost, and decreased detail secondary to superimposition of other maxillofacial bony structures. In midfacial injury, however, the panoramic film is of little value, and the maxillofacial series becomes necessary. With the advent of newer imaging techniques,(i.e., computed tomography “CT” and magnetic resonance imaging “MRI”, the standard radiographic survey has largely been supplanted in the diagnosis of maxillofacial trauma. Computed tomography scans yield excellent bony detail of the facial skeleton in multiple views and, with adjustment of the contrast of the machine, give adequate soft tissue detail. An additional advantage is less dependence on patient cooperation, which is useful in the severely injured or uncooperative patient. The disadvantages of CT include radiation exposure, the notably higher cost, and the limited availability in some centers. Magnetic resonance imaging yields excellent soft detail but less bony resolution compared with CT. It may be useful as an adjunctive study, if notable soft tissue injury of the joint is suspected. It has the additional advantages of no ionizing radiation exposure and the ability to obtain images in any desired plane of view by reconstructing the imaging data. Disadvantage include the notably higher cost compared with standard plain films and CT and the increased time required individual images. In summary in the acutely injured patient, the standard mandibular series suffices as a screening survey. If further diagnostic information is required, such as in dislocation condylar
  37. 37. 37 fractures, suspected intracranial penetration, notable soft tissue injury, and midfacial trauma, additional studies including CT and MRI may be indicated. Following are the type of radiographs that are helpful in diagnosis of condylar fracture. I) POSTERO - ANTERIOR PROJECTIONS FOR MANDIBULAR RADIOGRAPHY: a) POSTERO-ANTERIOR VIEW OF THE MANDIBLE: This view has been long remained the standard type for the mandible, the entire outline of the mandible is visible in this view. With standard P.A. view it is not possible to define the condylar head the glenoid fossa because of superior position of the zygomatic bone and the mastoid shadow, hence only fractures of the sudcondylar region are seen in this view. For this purpose a modification has been suggested. In standard P.A. projection the ‘X’ Ray beam passes parallel to the orbitomeatal plans which is oriented parallel to the horizontal plane, whereas the modified view the beam passes at 10 degrees to the horizontal plane. The P.A. view only shows the extent of lateral or medial displacement of the fractured condyle. b) THE REVERSE TOWNE’S PROJECTIONS: This view gives a clear idea of medial or lateral displacement of the condyle and its relation to the ramus of the mandible. Also the fractures of the condyle neck are appreciated in this view. The Reverse Towne’s projection is obtained with the orbitomeatal plane oriented at 25 to 30 degrees towards the horizontal. The ‘X’ Ray beam is passes from behind, through the occipital protuberance. c) ORTHOPANTOMOGRAPHY: In recent years OPG is fast replacing over views as a standard projection. It provides the best visualisation of the entire mandible. Its added advantage over other P.A. views is that the condyle and the glenoid fossa are well defined. It gives
  38. 38. 38 an idea of the extent of anterior displacement of the fractured condyle. Fractures of the condylar head are seen well in the OPG. Horwitz et al suggested the use of Computerised Tomography to determine the exact location of the fracture line in condylar fracture. They claim that a coronal computerised tomographic view defines the head, neck as well as subcondylar regions extremely as well as, the relation of the fractured condyle to the ramus. II) THE ANTERO-POSTERIOR PROJECTIONS: a) TRANS ORBITAL VIEW: This determines an excellent localised view of the condylar neck and the subcondylar region. The condylar head may be obscured, however, with this view it is difficult to judge the relation of the condylar fragment to the ramus . The ‘X’ Ray film is placed behind the patients head and the ‘X’ Ray beam passes from the orbit on the same side at 10 degrees to the sagittal plane to the film. b) TOWNE’S VIEW: It is also known as 30 degree fronto-occipital projections. The patient seats with his back to the film. The orbitomeatal plane is oriented parallel to the floor the beam passes at 30 degrees towards the floor from above the nasion. If the patient opens his mouth the condylar head outline can be traced. III) LATERAL PROJECTIONS a) THE LATERAL OBLIQUE VIEW: The outline of the mandible may be visualised from the first premolar to the condyle, it is advisable to specify the area of fracture to the radiologist. If taken meticulously, may provide a good view of the condylar neck subcondylar area and the relations of the condyle to the antero-posterior direction. Overlapping of the condyle by the shadows of the cervical vertebrae and radiolucency of the pharyngeal air spaces is disadvantages.
  39. 39. 39 b) TRANSCRANIAL VIEW: Provides an excellent view of the intracapsular fractures of the condylar head if any and the relation of the condylar head to the glenoid fossa. The diagnosis of fracture of the condyle is usually made on clinical examination and confirmed by roentgenographic findings.
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  41. 41. 41 PHYSIOLOGICAL & HISTOLOGICAL CONSIDERATION OF FRACTURE HEALING
  42. 42. 42 The two remarkable properties that distinguish the bone tissue from other structural tissues are: - The property of altering its local mechanical characteristics is response to changes in functional demand. - The capacity to heal itself through a repair process that results in no scar formation, a capacity to heal itself through actual regeneration. A fracture disrupts the continuity of a bone, disturbing its mechanical as well as the biological function. Starting from this initial state, fracture healing is intended to restore the original structure, and thus the function. The pattern of healing is governed, to a fair extended, by the amount of motion in the fracture gap. An essential prerequisite for a rapid and undisturbed healing process is a well functioning blood supply in the fracture region. Mechanical conditions immediately after fracture are as follows: - The fragment and mobility is only limited by soft tissue envelope. The muscles in the fracture region are contracted, possibly are reflex reaction. These muscle contractions cause an initial, though incomplete, attempt to immobilize the injured area. In addition, the sensation of pain prevents large scale active movements. - The initial biological situation is characterised in the first instance by disturbed circulation. Soft tissue injuries are partially detached from bone cortex, are interrupted at the fragment ends, and are closed by blood clotting. During the first hours after trauma, the area of closed vessels increases in size. Border zones at the fragment ends are thus left without blood supply. The pattern of non-perfused regions depends on the possibility of anastomoses to occur in the bone. It may happen that entire fragments, or fragment ends with sharp points, have no circulation. A more or less extensive hematoma will be produced between the fragment ends by the bleeding from interrupted vessels. - Bone heals by primary or secondary intention
  43. 43. 43 BONE HEALING BY PRIMARY INTENTION: This occurs when the fractures bones are in excellent anatomic position and the fractured fragments are rigidly fixed, thereby preventing the interfragmentary movement due to muscle activity. Primary bone healing occurs in two different ways: a) Contact healing b) Gap healing a)Contact healing: The contact healing takes place by haversian remodelling or intracortical remodelling. It is the mechanism the replaces compact cortical bone step by step, by new bone of the same structure. In this process, a group of osteoclasts “drills” a tunnel with a diameter of about 0.2mm in the longitudinal axis of the bone. These osteoclasts are followed by vessels and mesenchymal cells, and somewhat farther back by a front of osteoblasts. These osteoblasts are arranged in a funnel shaped. In longitudinal section their arrangement appears V-shaped and in cross-sections, round. New osteoid is deposited in this canal, which then matures into lamellar bone. The process of haversian remodelling can take place directly through the fracture zone if the fragment ends are in close and stable contact. This type of healing occurs in fractures treated with compression osteosynthesis as claimed by the ASIF School. The fractured bone is thus replaced by the new lamellar bone, which in its structure corresponds to a certain extent of the original bone. However, Hutzencheuter et al have shown that even through compression osteosynthesis was used, a very small gap (0.01 osteons) allowed intolerable interfragmentary strain to develop, resulting in resorption of the bone ends. This resorption results in a gap in which interfragmentary strain is dissipated and in which healing occurs. Luhr et al mentioned that dissipation of interfragmentary strain is not due to resorption of bone ends, but, due to mechanical deformation of the bone at the fracture site. b)Gap healing: Healing of fractures takes place when rigid fixation is used and very small defects of 3 to 4 osteons exists. A fracture scarcely can be realigned in such a way that contact is produced everywhere. When the plate is applied the interfragmentary compression is not always homogenously distributed, thus minute gaps may be maintained. Lamellar bone starts
  44. 44. 44 depositing into these gaps, and is comparable to the filling of bone defects. By means of haversian remodelling, such filled defects are then restructured to result into osteons arranged in the longitudinal axis of the bone. Callus formation is not seen. BONE HEALING BY SECONDARY INTENTION: Initially the mobility of the fragment ends is still too extreme to permit calcification in the interfragmentary spaces. The continuous motion even results in resorption of the fragments ends, which becomes rounded. Initially, the interfragmentary region is filled by a hematoma. This is gradually replaced by granulation tissue, which further differentiates into connective tissue and, in the region between the fragments, into fibrocartilage. The whole shape of the callus cuff is thus performed soft tissue. At a distance from the fracture, this callus slowly begins its transformation into fibrous bone, also designated as desmal ossification. The formation of connective tissue and fibrocartilage already begins about a decrease in the mobility of the fragments, which allows mineralization of the callus. This is to increase in the cross section of the bone, and thus to a longer lever arm to counteract the displacing forces. Thus the demands for the strength of the repair tissues may be reduced. The interfragmentary fibrocartilage contributes to a damping of motion. The cartilaginous component acts as a kind of hydraulic pressure pad, such that the fibers absorb tensile forces. The resulting inhibition of movement permits calcification process in the interfragmentary region as well. The intercellular substance of the cartilage gradually incorporates mineral and can be replaced by bone, designated as ‘chondral ossification’. The narrowing of the interfragmentary space causes a further reduction of the mobility until final bony bridging has occurred. Osteoclastic resorption balanced with osteoblastic bone formation then gradually changes the cancellous callus structure back into a cortical tubular bone. As the new cortices become more compact, the cross-section of the bone is reduced to normal dimensions and a new medullary cavity is formed. The great majority of fractures are allowed to heal by secondary intention. The jaws are immobilized by wiring the teeth together. Even it transosseous wiring is done, a semirigid fixation is at best achieved, some interfragmentary movement occurs with muscle activity even though the jaw is rendered non-functional. Function in the fractured part also plays an important role in the healing process. Sample evidence shows that a functional limb heals faster and better than the immobilized limb.
  45. 45. 45 Rigid internal fixation when used, drastically the healing period restores early function to the joint. Ideal conditions for the healing of fractured bones involve rigid fixation and compression of the fragment without immobilization of the injured part.
  46. 46. 46 STABLE OSTEOSYNTHESIS THEORETICAL & TECHNICAL CONSIDERATION
  47. 47. 47 BIOMECHANICAL FUNDAMENTALS: During the past decade the operative treatment of the mandibular fractures has been influenced and modified by a variety of experimental studies. In the search for a simple osteosynthesis, that would guarantee fracture healing without intermaxillary fixation and without compression, the monocorticle plate osteosynthesis of Michelet et al (1973) was modified and developed into a practical method. The biomechanical principles of this method are based on the mathematical and experimental studies carried out in strausbourg at Ecole National Supereieure Des Arts et Industries. The research goal was to develop a true tension banding system for the mandible along an ideal osteosynthesis line and an osteosynthesis material with favourable mechanical properties. ANATOMICAL AND BIOMECHANICS OF THE MANDIBLE: The parabola shaped body of the mandible consists of outer and inner cortical layers with a simple spongiosa. The outer cortex is particularly strong. The trajectories of the mandible shows that the mandible is strengthened in response to the forces of the muscles of mastication by development of massive compact, as well as by trajectories of the spongiosa. The masticatory forces are led up towards the condyle of the crest of the mandibular neck, which is prominent on the inner side of the ramus and runs from the end of the alveolar process diagonally towards the head of the mandible. On an average the outer cortex is 5mm thick in subcondylar fractures the main forces acting on the condylar fragment is the lateral pterygoid muscle, which is responsible for the displacement. The outer cortex provides osteosynthesis screws with good anchorage by virtue of its compact structure. The same principle can be utilized to achieve stable osteosynthesis in case of subcondylar fracture using a 3 or 4 hole bone plate with monocortical screws engaging the outer cortex. As soon as the fractured fragments are stabilised by using
  48. 48. 48 monocortical miniplate system the distraction at the fractured site is prevented. It is possible to place this miniplates in the centre of the condylar region on the lateral aspect, so that the fracture is stabilised well without any distraction of fragments on the medial or lateral aspects, due to the tortional forces (this eliminates the need of any additional tension banding as described for the body of the mandible). TECHNICAL ASPECTS OF FRACTURED FIXATION: The screws, plates and instruments should be of the same material, since variation in metal ions can lead to an oxidation – reduction phenomenon with detrimental tissue effects. The following points must be observed strictly during plate fixation: 1) Drilling must be precise and must be monoaxial, otherwise, an unfavourable cortical bur hole results. 2) The screws must be self tapping, the drill must be of the width of the screw core. 3) The screw thread must be relatively narrow so that considerable contact is made between the thread and the bone. The distance between the turns of the thread is more than 1mm. CONSIDERATION IN IMPLANT DESIGN Compression of the fragment ends is an important mechanism for stabilization in bones that are functionally loaded with high mechanical forces. Specially designed screw holes in the plate facilitate compression. In screw design, various engineering and biomechanical aspects come into consideration. For technical applications in thin sheets, the screw thread gets its grip on outer surface of the material. In thick layers, the thread design may take different strengths of the materials into consideration and allow a larger volume for the weaker material. This design characteristic with asymmetric threads is widely used in screws for bone fixation, and it makes a good compromise in both thin and thick bones. Besides the screw design, the mechanical properties of the bone structure determine the initial holding force. The approximate force may be estimated from the radiological bone density.
  49. 49. 49 The plate dimension is to be adapted to their planned field of use, where they should provide sufficient stability. The bone plates used are 1mm thick a width of 6mm. The screw holes are neutral with a diameter of 2.6mm and a bevel of 30 degrees. The counter sinking of the screw hole ensures a snug fit between screw and plate causing compression between the plate and bone, thus increases its stability. The comparatively high elasticity of the material tolerates easy deformation in all 3 planes so that exact adaptation to the bony surface is possible. COMPARISION OF METALS FOR THE PLATE Selection of an implant material for craniomaxillofacial use involves two important considerations. a) Whether physical properties of the implant material allows its adaptation and the application for functional load. b) Whether biocompatibility of the material, in its loaded or unloaded clinical adaptation, will be tolerated by the host tissues. In assessing the performance of a permanent implant, the effect of the body tissues on functional properties of the implant i.e. ‘biofunctionally’ and the cellular effect on near and distant tissue i.e. ‘biocompatibility’ must be examined simultaneously. After implantation of a solid alloplast during normal would healing, fibrous encapsulation will depend upon the mechanical, chemical and physical chemistry of the implant interface as well as the stability of the implant at the site during functional loading. These range from inertness to reactivity in the chemical sense, from stiffness to softness in the mechanical sense and from solid to porous in regard to physical properties. The desirable properties of an implantable alloy include primarily corrosion resistance, malleability and strength. The use of metal is not an absolute requirement in the jaws, since the mechanical demands could be met by other materials as well. But the ductility of the metals (as opposed to polymers and composites) is a feature that allows for intra-operative contouring of the implant according to the clinical need. The design, processing and handling of metallic implants significantly influence the in vivo corrosion and stress corrosion behaviour. Metallurgical analysis had shown that fatigue seems to be major cause of failure of an implant. Fatigue occurs when corrosion weakens an
  50. 50. 50 area of the implant that is subject to functional stress. Defects which lower the corrosion resistance include high inclusion content, cracks due to cold rolling, pitting of the surface, poorly sunk holes and molybdenum content below 2% as ASTM specification. When a alloy has a low corrosion rate in an oxidizing environment, it is said to be passive. This state is due to the formation of a surface film, which can be explained on the basis of oxide film theory or adsorption theory of passivity. The metals commonly used for fixation of maxillofacial fractures include stainless steel (Champy, AO), Cobalt alloys (Luhr) and titanium (Wurtzberg. Steinhauser ). Vitallium: It was first used in orthopaedic surgery in 1932 by Venables but its reference in jaw surgery was made by Winter in 1945. A Cobalt-Chromium alloy has two to three times more tensile strength, 50% greater yield strength and twice the hardness of titanium or steel Vitallium has remarkable resistance to corrosion as well as excellent stability properties. Vitallium is also a better metal for screws than titanium having a higher torque strength. When metal is bent, there is an increase in its tensile strength and hardness and this is similar for all three metals. However, there is an increase in yield strength which is slight for titanium but 50% for steel and doubling for Vitallium. Therefore smaller plates can be made without a compromise in strength. Titanium: First discovered in 1971, it was in 1930s that its ductility and usefulness as an implant was realised. Alloying of titanium to vanadium and aluminium increases its strength. The weight of titanium is 60% that of steel, is readily machined and manufactured into a variety of shapes and forms. Titanium is highly flexible as the modulus of elasticity is half that of stainless steel or Vitallium. It has excellent ductility and tensile strength fatigue limit equal or greater than that of steel or Vitallium. High corrosion resistance is one of its exceptional properties due to formation of titanium dioxide layer spontaneously with exposure to air, preventing further oxidation. Despite this corrosion resistance, titanium can still be found in the adjacent soft and hard tissues although in minute quantities, as compared to Ni-Cr and Co-Cr alloy implants. Its great limitation is its cost.
  51. 51. 51 Leinbenger system is used as titanium plates for fracture reduction. Stainless Steel: It is presently the most widely used surgical implant alloy. The primary constitutions of 316 L are chromium, nickel, manganese, molybdenum and carbon which are essential trace elements that exist in body fluids under physiologic regulation and with precise function. 316 L falls within the austenitic range. It is biologically well tolerated, has a yield strength that is less then Vitallium and titanium but sufficient enough to withstand the bending and tortional forces of 60-100 DaN. The stainless steel plates are adaptable and can be miniaturized but its resistance to corrosion is much less than that of the other metallic implants. However, the corrosion reaction is usually localized and rarely requires its removal. Maxillofacial implants are not loaded heavily and therefore corrosion due to fretting between screws and plates is minimal. Being cheaper than other metals, financial considerations dictate the choice of surgical stainless steel as implant material for screws and plates. Click here www.faceart-clinic.com
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  55. 55. 55 TREATMENT Click here www.faceart-clinic.com
  56. 56. 56 GENERAL PRINCIPLES The proper management of the fractured mandibular condyle is one of the most controversial topics – if not the most controversial – in maxillofacial trauma. This controversy is reflected in wide variety of opinions and proposed treatment modalities offered in the literature. The commonly accepted and generally agreed on goal of treatment is the reestablishment of the preoperative function of the masticatory system. This restoration typically involves the reestablishment of the preoperative relationship of the fracture segments, the occlusion, and maxillofacial symmetry. Unlike fractures of other bones, however, the exact anatomic re- approximation of the fracture segments may not be absolutely essential. This fact is certainly demonstrated in children in whom a conservatively treated displaced or dislocated condylar fracture can heal with a perfectly functional and often morphologically reconstituted condylar process despite lack of exact reduction at the time of injury. This is no doubt related to the remarkable remodelling capacity of bone in children. A similar tendency exists in older patients, although it is much less pronounced. Therefore a perfect radiographic alignment of fracture segments should be considered inadequate if the restoration of a fully functioning, relatively pain-free joint is not simultaneously achieved. Historically, early management of condylar fractures consisted of various methods and lengths of time of immobilization of the joint. This situation was based on the relatively good results obtained and a degree of caution regarding the complications of surgical exposure of the temporomandibular region. The initial methods of internal fixation also probably had little advantage to offer over conservative methods. As surgical techniques were improved and rigid fixation developed, a number of surgeons became comfortable with open approaches to the joint. From this development evolved an expanding set of indications. However, controversy followed closely and stimulated a great deal of debate, which still permeates the current literature.
  57. 57. 57 Treatment is generally divided into two schools: conservative, or nonsurgical, and surgical approaches. We discuss the advantages, disadvantages, and indications for each of these treatment options and surgical access to the TMJ. CONSERVATIVE TREATMENT As mentioned previously, the goal of management in general is restoration of proper form and function. The surgeon should use the simplest technique that allows this goal to be met while minimizing complications. The vast majority of data available support the belief that fractures of the mandibular condyle can be successfully treated, with the establishment of a functionally acceptable joint, through conservative means. A number of investigators have published follow-up data on condylar fractures treated conservatively, and the overwhelming opinion is that this method of treatment is preferred in nearly all cases. In 1947 the Chalmers J. Lyons group published their data on 140 cases of condylar fractures, with an average follow-up of 5 years (range 8 months to 19 years). They found functional disturbance of any kind in only seven cases (5.8%). All these disturbances were deemed mild, did not interfere with adequate function, and included limitation of motion in lateral excursion, deviation in opening, interocclusal mal-relationship, and mild joint noise during function. In 1952 MacLennan followed 180 cases for 14 to 37 months. He reported an overall complication rate of approximately 20%, including 29 patients with deviation on opening and 7 with visible deformity. In 1953 Kromer reported on 154 cases of condylar fractures with an unspecified follow-up interval and found only 14 cases with persistent functional disability (9.1%). In his series, there was one case of ankylosis in a 12 year old boy as a result of a bomb blast, with major damage and foreign body penetration of the TMJ. In 1961 Blevins and Gores compiled data on 90 cases through clinical and survey follow-up. A 14% complication rate was found. Finally, in 1989 Dahlstrom et al studied 36 patients with a follow-up of 15 years. In 14 children there was good masticatory function, no disturbance in the growth of the maxillofacial region, and no evidence of earlier fracture. In the adults examined, there was markedly less restitution of the condyle, with major signs of masticatory dysfunction. This dysfunction, however, was not bothersome to the patients.
  58. 58. 58 Teenagers in their series lay somewhere intermediate to the adult and children. Again there were few subjective symptoms. Taken together the average complication rate over all these studies was approximately 15%. These authors and others derived several conclusions, including: 1) there is no correlation between radiographic findings and either preoperative symptoms or postoperative function, 2) complications are uncommon with conservative therapy, and 3) the majority of evidence is in favour of conservative treatment. There are also animal data to support the effectiveness of conservative therapy in the management of condylar fractures. Surgically induced condylar “fractures” were studied, and a remarkable degree of regenerative capacity in the components of the injured joint was found. A workable, usable mandibular articulation resulted regardless of whether the condylar was left remaining at a right angle to the ramus, was pushed medially or anteriorly, or was reduced and maintained by transosseous wiring. Each mandible produced a morphologically identifiable condyle in the upright position. There was little sacrifice of mandibular growth or symmetry. In another study, comparison was made between three different treatment groups, which included reduction with wire fixation and immobilization, closed reduction with immobilization, and no treatment. No difference was found between the three groups with respect to time of healing. The conservative management of condylar fractures may be as simple as observation and soft diet or may encompass variable periods of immobilization followed by intense physiotherapy. If the patient is able to establish and maintain a normal occlusion with a minimal amount of discomfort, no active treatment may be needed. The patient should be encouraged to adhere to a soft diet and maintain as nearly normal function as possible. Close supervision is mandatory – and at the first sign of occlusal instability, deviation with opening, or increasing pain – both clinical and radiographic re-evaluation should be performed. Any one of these findings may signal the conversion of a non-displaced fracture to a displaced one requiring active treatment. Only responsible patients who are committed to a period of close follow-up should be considered for the “observation only” treatment regimen. In general some degree of malocclusion, deviation with function, and/or pain is present when some form of immobilization is required. Immobilization usually involves intermaxillary fixation with arch bars, eyelet wires, or splints. The period of immobilization is controversial and must be long enough to allow initial union of the fracture segments but
  59. 59. 59 short enough to prevent complications, such as muscular atrophy, joint hypomobility, and ankylosis. In the past, periods of as long as 8 weeks were used but have since shown to be unnecessarily long. Currently the period of immobilization ranges from 7 to 21 days. This period may be increased or decreased based on concomitant factors, such as age of the patient, level of the fracture, degree of displacement, and presence of additional fractures. Children require special consideration, which is discussed in a subsequent section. Probably more important than the length of immobilization is management following the release of postimmobilization treatment. This therapy allows a return of mandibular range of motion and functional movements that were hindered by the injury and assists the neuromuscular system in adapting to alterations in occlusion, joint position, or morphology. Following the release of intermaxillary fixation, there is usually some degree of deviation, and guiding elastics should be used to direct the mandible to its maximal intercuspation. The patient is encouraged to function as normally as possible and is also instructed in range of motion exercises. The guiding elastic are placed lightly during the day to promote increased mobility and more tightly at night to maintain the occlusion. As the functional capabilities of the patient improve with time, the period of elastic guidance is decreased. It may be necessary for the patient to wear the elastics only at night while sleeping. Once the occlusion remains stable and there is minimal pain with function, the elastics may be discontinued, and the arch bars removed. Until the mid 1980s, there is a large body of evidence to support closed reduction techniques for treatment of condylar fractures. However, with the improvement in internal rigid fixation coupled with a better understanding of the surgical anatomy and access to the TMJ, there has been a resurgence in the literature advocating open reduction techniques, citing earlier return of joint function and improved range of motion with less dietary disturbance as benefits over closed reduction techniques.
  60. 60. 60 Management with closed reduction Erich arch bar Ivy Loops
  61. 61. 61 Gunning splint MMF screws
  62. 62. 62 OPEN REDUCTION OF CONDYLAR FRACTURE The vast majority of available of available data support closed reduction as the treatment of choice for condylar fracture. In an attempt to avert the complications associated with closed reduction, many surgical approaches and methods of reduction and fixation have been advocated. Surgeons supporting these methods have supplied few long term follow-up data, however, to establish these methods as being superior to closed reduction. The complication rates that have been reported are often higher than those attained with closed reduction. Surgical reduction also introduces new complications not seen with closed techniques, including damage to the facial nerve and unaesthetic scar formation. Konstantinovic and Dimitrijevic compared 26 surgically and 54 conservatively treated unilateral condylar fractures with regard to clinical function and radiographic reduction of the fracture segments. After 1 year, there was no significant difference clinically between the groups with regard to maximum opening (surgical mean, 39mm; conservative mean, 39 mm)and lateral or protrusive movements. No complications were seen in the conservative group, and a 15.4% rate of complications was found in the surgically treated group. Takenoshita et al also compared functional recovery after closed and open repair, with a 2- year follow-up. They found that at 1 month following the release of intermaxillary fixation, there was no difference in the maximum opening more quickly than did those treated surgically. At the conclusion of the study, the average opening was comparable with the conservatively treated group (50mm) and the opening of the surgically treated group (39mm). All patients attained good occlusion with minimal pain during function. No cases of infection or ankylosis were found. Work by Ellis has indicated that open techniques for condylar reduction and fixation produce more reliable occlusal results when treated open rather than closed. In a study of 137 patients with unilateral condylar injuries, 77 patients were treated closed and 65 patients were treated open. Patients treated by closed reduction techniques had a notably greater percentage of malocclusion compared with open reduction despite the fact that the severity of the initial injuries was greater than in the group treated by open reduction. Throckmorton and Ellis showed that patients treated with open reduction achieve normal incisal opening and excursive movements sooner than patients treated with closed reduction. In a study of 130
  63. 63. 63 patients, 74 were treated closed and 62 were treated open with 52 control subjects. Normal values of interincisal opening were seen in all subjects after 3 years. However, the rate of recovery is significantly faster in the group treated with open reduction versus closed reduction (0.43mm/month and 0.15mm/month, respectively). The most common reason that closed reduction techniques are favoured is related to prevention of postsurgical complications. The most common complications from open reduction of condylar fractures are facial nerve palsy and unsightly facial scarring. However, in a study by Ellis evaluating the complication rate in 178 patients, 93 were treated by open techniques. At 6 weeks postoperatively, 17.2% of patients had some degree of facial weakness; the majority of these had resolved by 6 months. Surgical scarring was also judged as wide or hypertrophic in 7.5% of cases. Their conclusion was that surgical complications of open treatment of condylar fractures that lead to permanent dysfunction or deformity are uncommon. Ellis demonstrates further support for open reduction to re-establish anatomic orientation of the condylar process. In a study of 146 patients, 81 were treated by closed techniques and 65 treated by open techniques. Towne’s and panoramic radiographs taken at serial intervals were used to qualify the degree of displacement. Of the condylar process and ramal height post treatment. Patients treated by closed reduction had significantly shorter posterior facial height on the side of injury, leading to a greater degree of facial asymmetry than in the group treated by open reduction. Re-establishment of preoperative occlusion is the gold standard in any fracture reduction method. Ellis et al showed that patients treated with open reduction versus closed reduction had consistently better occlusal results. Despite a current body of evidence to support open techniques for all condylar fractures, there does seem to be a specific group of individuals who will benefit from surgical intervention. Zide and Kent, Raveh et al, and others have proposed a set of both absolute and relative indications for open reduction of the fractured mandibular condyle. They stress, however, the need for careful evaluation of each case on an individual basis. The current indications for open reduction are as follows: Absolute Indications 1. Displacement of the condyle into the middle cranial fossa
  64. 64. 64 2. Impossibility of obtaining adequate occlusion by closed techniques 3. Lateral extracapsular dislocation of the condyle 4. Foreign bodies within the capsule of the TMJ 5. Mechanical obstruction impeding the function of the TMJ 6. Open injury (penetrating, lacerating, and avulsive) to the TMJ that requires immediate treatment. Relative Indications 1. Bilateral condylar fractures in an edentulous patient when splints are unavailable or impossible because of severe ridge atrophy 2. Unilateral or bilateral condylar fractures when splinting is not recommended because of concomitant medical conditions or when physiotherapy is not possible 3. Bilateral fractures associated with comminuted midfacial fractures 4. Bilateral fractures associated with other gnathologic problems Displacement of the condyle into the middle cranial fossa severely limits the mandibular range of motion and may cause intracranial damage. Most authors think that the condylar segment should be surgically addressed. Some, however, advocate leaving the segment intracranially and achieving a functional joint via condylotomy. This procedure will be discussed later in the section on complications. The inability to obtain adequate occlusion may be secondary to mechanical obstruction caused by severely displaced fracture segments. In addition, delay in repair may allow soft tissue in growth into the fracture, inhibiting reduction of the segments and resulting in persistent malocclusion. Severe displacement or dislocation fractures may also be impossible to adequately reduce manually with closed techniques, necessitating open reduction. Lateral displacement of the condylar segment impedes proper function by creating a mechanical stop. Invasion of the TMJ by a foreign body (e.g., a gunshot wound) usually causes comminution of the bony segments. These fragments may interfere mechanically with proper joint function, act interfere mechanically with proper joint function, act as a nidus for infection, and increase the risk of ankylosis. It is generally recommended that surgical removal of foreign bodies be delayed foe 7 to 10 days to allow edema to subside and some fibrosis to occurs around the foreign body. This fibrosis may aid in localization and removal of the fragments.
  65. 65. 65 Relative indications include edentulous patients with bilateral fractures in whom splints are not available or are not usable, as in the patients have no reference point with which to establish the proper condyle-fossa relationship; therefore direct visualization may aid in attaining adequate reduction. Bilateral fractures with concomitant fractures pose a similar problem in that no stable reference point exists for reconstructing the midfacial complex. The mandible is repaired first with the use of open reduction and internal fixation to provide a stable platform on which the remaining midfacial fractures are repaired. The presence of other important medical conditions may make it impossible to use intermaxillary fixation or to perform physiotherapy. Some of these conditions include uncontrolled seizure disorders, psychiatric problems, alcoholism, mental retardation, and neurologic injury. Some believe that severe chronic obstructive pulmonary disease and other respiratory conditions are also relative indications for open reduction because of the increased upper airway resistance that results from intermaxillary fixation. Once the decision is made to use an open technique, the next step in treatment planning is to select a surgical approach. Over the years, many approaches to the TMJ have been developed, including horizontal incisions over the zygomatic arch and intraoral, preauricular, endaural, postauriclar, submadibular, retromandibular, and rhytidectomy approaches. Each has its own advantages, disadvantages, and complications. Many of these approaches have fallen from use, and only the preauricular, submandibular, and retromandibular incisions with various modifications, and occasionally the intraoral route, are routinely employed in most centers. The location of the fracture and the degree of displacement are the prime determinants in the selection of the approach used to access the joint. If the fracture is intracapsular or high on the condylar neck, the preauriclar or endural approach is preferred. Either one offers better access, greater visibility of the fracture site, ease of manipulation of the soft tissue within the joint, and relative ease of placement of fixation devices. The major disadvantages of these approaches include the possibility of damage to the facial nerve and the presence of a facial scar. Fractures located lower on the condylar neck and subcondylar fractures may be more easily accessed via a submandibular approach. The danger of this technique is possible damage to the marginal mandibular nerve, with subsequent weakness of the depressor muscles of the lower lip. In some cases, a combination of these approaches must be used to gain adequate access to reduce and fixate the fracture segments. Several authors have advocated an intraoral approach to fractures of the condyle. This approach offers the
  66. 66. 66 advantages of visualization of the fracture reduction and the occlusion simultaneously, minimal risk of damage to the facial nerve, and the prevention of an unaesthetic facial scar. The disadvantage include more limited access, especially in high subcondylar and condylar neck fractures, and difficulty in placing certain fixation devices. PREAURICULAR APPROACH. This preauricular incision has been widely used for approaching the ear and the TMJ. Historically an early description was provided by Blair, who used an inverted L incision, beginning within the temporal hairline and progressing inferiorly just anterior to the anterior auricle. Since then many modifications of the basic incision have been made. Dingman and Grabb modified the incision by making the angle between the vertical and the superior portions of the incision more obtuse and rounding the angle of intersection. Others, including Lempert and Shambaugh, modified the incision by carrying it to varying degrees behind the tragus and into the external auditory canal, creating the endural incision. When the preauricular approach is performed, a cotton pledget moistened with mineral oil is placed into the external auditory canal to prevent debris and hemorrhage from accumulating and possibly damaging the tympanic membrane. Next, anesthetic solution is infiltrated into the preauricular skin and the joint capsule to aid in hemostasis. The incision is begun within the hairline of the temporal skin approximately 1.5 to 2.0cm anterosuperiorly to the superior attachment of the helix. The incision is made through the skin, passing in a gentle curve to the superior attachment of the helix, where it is continued inferiorly within the skin crease just anterior to the auricle. The incision is continued in this crease to the junction of the inferior helix and the skin of the cheek. Care should be exercised in the lower extent of the incision so as not to penetrate too deeply, as the main trunk of the facial nerve passes within several centimetres of the earlobe before it enters the posterior aspect of the paroid gland. In the area superior to the zygomatic arch, incision is deepened to the level of the temporal fascia. Immediately over the zygomatic arch, the incision is carried to the periosteum over the bone. Below the arch, the incision follows just superficial to the tragal cartilage. Any vessels encountered during the dissection should be clamped, transacted, and ligated to allow adequate access.
  67. 67. 67 The temporal fascia is then incised several millimetres anterior to the initial incision. The dissection is carried anteriorly and inferiorly between the temporal fascia and the muscle fibres of the temporal muscle. This plane is continued inferiorly to the level of the decussation of the temporal fascia into the superficial and deep layers. At this point, the dissection is continued to the superior edge of the zygomatic arch within the fatty tissue pocket between the two layers of the temporal fascia. Thus in the superior region of the dissection, a flap is created consisting of the skin, subcutaneous tissue containing the superficial temporal vessels and branches of the facial nerve, the superficial layer of the temporal fascia, and more superiorly the temporal fascia. The branches of the facial nerve are well protected within this soft tissue flap. When the zygomatic arch has been reached, an elevator is used to reflect the periosteum from the lateral aspect of the arch. Reflection can be carried anteriorly as far as the glenoid tubercle. This reflection should be done carefully, as the periosteum, temporal fascia, and subcutaneous tissue coalesce to form a single layer in this region, and the temporal branch of the facial nerve lies within this tissue as it passes over the arch toward the scalp. Below the arch, the dissection is continued beneath the parotidomasseteric fascia, which is a continuation of the temporal fascia from above. The flap is lifted anteriorly, as a single unit, thus exposing the joint capsule and temporomandible ligament. The dissection is carried inferiorly as needed until the fracture site is carried inferiorly as needed until the fracture site is adequately exposed. Inferiorly the parotid gland is reflected anteriorly with the skin fascial flap, protecting the gland and facial nerve. The endural approach is similar but differs in that the initial incision is made to pass along and just inside the lateral aspect of the tragus. The remainder of the skin incision is the same. The dissection in the area of the tragus is carried to the root of the zygomatic arch in a plane just above the perichondrium of the tragal cartilage. Once the dissection reaches the level of the arch, it is similar to the preauricular approach. This incision has the added advantage of a less conspicuous scar compared with the preauricular incision. SUBMANDIBULAR APPROACH. The submandibular, or Risdom, incision is the approach of choice for low subcondylar fractures. It allows good exposure to the level of the neck and coronoid notch. The incision has been modified by Blair to expose the parotid gland for procedures on the same. There is a
  68. 68. 68 reduced risk of injury to the temporal and zygomatic branches of the facial nerve but an increased risk of damaging the marginal mandibular branch. The incision is made within the relaxed skin tension lines approximately 2cm inferior to the inferior border of the mandible in the region of the angle. The Blair modification places the incision slightly posterior to this point and curves slightly superiorly behind the angle. The incision is made through the skin and sudcutaneous tissue. Depending on the location of the incision, the posterior fibres of the platysma muscle may be identified. Near the posterior aspect of the incision, the strenocleidomastoid muscle is visible with its fibres running in a posterosuperior to anteroinferior direction. A nerve stimulator may be useful in locating the marginal nerve, the cervical nerve, and possibly the main trunk of the facial nerve as the dissection proceeds. The platysma muscle is divided, and the dissection is continued bluntly in a superior and medial direction. At this point, the angle of the mandible should lie fairly close to the surface. External jugular, retromandibular, and facial vessels may be encountered during this approach and may require ligation. Once the inferior border of the mandible is reached in the region of the angle, the fascia of the pterygomasseteric sling is sharply incised. A periosteal elevator is used to reflect the periosteum over the lateral aspect of the angle and ramus, extending superiorly to the sigmoid notch. This length of reflection should allow adequate exposure of most subcondylar and some low-neck fractures. If additional access is necessary, the tissue at the posterior aspect of the incision may be further released, allowing the pored gland with its contained facial nerve to be further retracted anteriorly. Greater care must be exercised during any dissection in the deeper tissue just inferior to the auricle, as this is the location of the main trunk of the facial nerve as it courses from the styloid foramen to the posterior aspect of the parotid gland. RETROMANDIBULAR APPROACH. From its original description by Blair for access to an ankylosed TMJ, the retromandibular approach to the TMJ is becoming increasing popular. It is a versatile approach to fractures of the body, angle, and subcondylar fractures to the level of the coronoid notch. This approach also allows distraction of the angle of the mandible, allowing fracture reduction and fixation. With the use of transfacial trocars this approach may also be used to rigidity fixate high level condylar fractures. As compared with the sudmandibular
  69. 69. 69 approach, the retromandibular approach is associated with significantly less injury to the marginal mandibular branch, temporal, and zygomatic branches of the facial nerve. The incision is placed in the resting tension lines in the lateral neck. The incision is typically 2 to 3 cm in length and placed 1 cm inferior and posterior to the angle of the mandible. The incision is placed through skin and subcutaneous tissue. The posterior aspect of the playsma may be identified and carefully divided. Through the subplatysmal plane, the superficial layer of the deep cervical fascia is encountered. Peripheral nerve testing should be employed to identify the cervical and marginal mandibular branch of the facial nerve. The cervical branch runs vertically, usually out of the surgical field. However, the marginal mandibular branch may run transversely across the surgical field and limit exposure of the mandible. If the marginal branch is encountered, it should be dissected free from the adjacent soft tissue to facilitate its retraction. Further blunt dissection reveals the sternocleidomastoid muscle posteriorly and the capsule of the submandibular gland anteriorly. The tail of the parotid gland may be encountered in this time. Dissection into the parotid capsule should be avoided to prevent inadvertent injury to the facial nerve. The retromandibular space is then entered with blunt dissection. This space lies at the midpoint between the anterior surface of the sternocleidomastoid muscle and the posterior aspect of the submandibular gland. The angle of the mandible should be palpable at this point. The external jugular vein, posterior facial artery, retromandibular veins, and facial artery may be encountered and require ligation. Once the retromandibular space is entered, the dissection is carried superiorly to encounter the angle of the mandible. The pterygo-masseteric sling is encountered and sharply incised along the aponeurosis to expose the lateral border of the mandible. The overlying soft tissue including the paroid gland is then retracted to facilitate further fracture exposure. The main advantages of this technique are the ease and rapidity with which the dissection can be performed. Compared with the submandibular incision, the retromandibular incision is placed closely to the angle of the mandible. Therefore the extent of soft tissue dissection required to expose the mandible is limited. The posterior position of this approach is associated with a reduced risk of facial nerve injury. RHYTIDECTOMY (FACE-LIFT). The rhytidectomy or face-lift approach to the mandible ramus and condylar region is a variant of the retromandibular approach. The main difference is the placement of the incision. The approach can provide greater exposure to high–level condylar fractures, providing
  70. 70. 70 excellent cosmesis. However, it requires additional time for closure. The initial incision is placed through skin and subcutaneous tissue. A skin flap is then raised superficial to the superficial musculo-aponeurotic sheath (SMAS). The dissection is extended toward the angle of the mandible with tenotomy scissors to create a widely undermined subcutaneous pocket that extends 2cm anterior to the posterior border of the mandible. The plane superficial to the SMAS is relatively avascular without major anatomic structures. Just below the SMAS lies the greater auricular nerve (C2-C3). Once the skin flap is raised and retracted, the underlying lateral surface of the mandible can be visualized. The remainder of the dissection is identical to the retromandibular approach. POSTAURICUALR APPROACH. Although rarely used this approach does have certain advantages. The postauricular approach provides excellent exposure to the entire TMJ. The ability to camouflage the scar in a postauricular fashion is beneficial, especially in patients who have a tendency to form hypertrophic scars. The main disadvantage of this procedure is auricular stenosis. The postauricular approach is contraindicated in the presence of joint infection or chronic otitis externa. The incision is placed 3 to 4 mm posterior to the auricular flexure and extended toward the mastoid fascia. Superior to the mastoid fascia, the incision exposes the superior and posterior circumference of the external auditory canal. Blunt dissection below the external auditory canal creates a plane running anteriorly to separate the pinna. A blade is then used to transect the external auditory canal and retract the ear anteriorly. Dissection is then carried through the superficial layer of the temporalis fascia to the root of the zygoma. Once the joint surgery is completed, the ear canal is reapproximated by closure of the overlying skin flap only. INTRAORAL APPROACH. Steinhauser first described an intraoral approach to the fractured condyle in 1964. Others, including Niederdellmann, Jeter et al, and Lachner et al, also advocate the use of this approach. Lachner initially described the technique for the treatment of low subcondylar fractures but later expanded its use to all extracapsular fractures. An incision is made along the anterior border of the ascending ramus, extending anteriorly along the external oblique and ending in the vestibule adjacent to the second molar. A full-thickness mucoperiosteal flap including the masseter muscle is reflected, exposing the
  71. 71. 71 lateral aspect of the mandible to the posterior border. The subperiosteal dissection is continued superiorly to the level of the sigmoid notch. A retractor can be placed in the sigmoid notch to aid in access. The proximal condylar fragment is then identified and reduced. It may be necessary to distract the mandible inferiorly to locate a medially displaced condyle. The periosteum of the condylar segment is stripped, with care taken to elevate only enough periosteum to allow placement of fixation plates or wires. This minimal stripping prevents unnecessary compromise of the vascular supply to the condyle. Intermaxillary fixation is then applied with the condyle reduction into its proper position. One advantage of this technique is that the condylar segment can be directly visualized during the application of the intermaxillary fixation. Proper reduction is confirmed by inspection and palpation of the posterior border with an instrument. There are circumstances in which none of the mentioned surgical approaches are sufficient to gain exposure to the mandible condyle. For example, one circumstance is a fracture-dislocated mandibular condyle displaced into the middle cranial fossa. There are only approximately 30 reported cases in the literature of this unusual event. To facilitate fracture reduction, a combined hemicoronal or bicoronal incision allows exposure for reduction and fixation. A multidisciplinary approach with neurosurgical consultation allows for transcranial repair of the glenoid fossa and dural perforations concomitantly with condyle fracture reduction and fixation.
  72. 72. 72
  73. 73. 73 Surgical approaches to the Condyle Pre auricular incision Modifications of pre auricular incision
  74. 74. 74 Endaural approach
  75. 75. 75 Al-kayat Bramley incision
  76. 76. 76 Submandibular incision Post ramal incision

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