Dr Bhavik Miyani, Resident Doctor in Department of Oral & Maxillofacial Surgery, NPDCH, SPU, Visnagar.

1. Presented By :
Dr. Bhavik Miyani
PG 3rd Year.
Guided By:
Department of OMFS,
NPDCH, SPU,
Visnagar
A Case of Trauma # 5

2. CONTENTS
 Case report
 Case summary
 Discussion
 Conclusion
 References
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3. CASE REPORT
NAME :- Subhadraben Senma
AGE/SEX :- 42 Years/Female
OCCUPATION :- Housewife
ADDRESS :- Kansa
OPD NO. :- 12680-I
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4. CHIEF COMPLAINT
• Patient complaint of pain in bilaterally ear region,
& also complaint of bleeding from mouth.
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5. HISTORY OF PRESENT ILLNESS
 Patient was relatively asymptomatic before 4 days.
 Then on 7 th Feb. 2020 around 5:40 pm ,she met with a road traffic accident
while she was travelling with her husband on bike, she fell down due to bike
collision with cart which was coming from opposite side.
 H/o bleeding from mouth for a while.
 No H/O unconsciousness after trauma.
 No H/O – Epistaxis, Bleeding from ear, Vomiting.
 Then she shifted to Nootan general hospital, (Emergency Room)with above
mentioned chief complaint.
5

6.  PAST MEDICAL HISTORY :-
- No H/O previous hospitalization
- No H/O any systemic diseases like Hypertension,
Diabetes Mellitus, Hepatitis
 PAST DENTAL HISTORY :-
- No relevant past dental history
 DRUG HISTORY :-
- No relevant drug allergy
 FAMILY HISTORY :-
- No relevant family history
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7. PERSONAL HISTORY :-
- Habits :-No any harmful habit.
- Diet :- Vegetarian
- Marital status :- Married
- Brushing :- Once a day with toothbrush
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8. • Conscious
• Cooperative
• Well Oriented to time, place and person
• Built :-Well built
• Nourishment :- Well nourished
• Gait :- Normal
 Vital signs :-
Temperature: Afebrile
Blood pressure: 136/88 mmHg
Pulse rate: 84 beats/min
Respiratory rate: 17 cycles/min
GENERAL EXAMINATION
8

9. • Face :- Facial asymmetry due to swelling present over right and left
side on TMJ region.
• Skin and soft tissue :- CLW (1*1 cm)present irt with lower chin region.
• Lips :- Incompetent
• Jaw movement :- Restricted due to pain.
• TMJ :- Tenderness on both TMJ region.
• Mouth Opening :- 38 mm.
1. EXTRA- ORAL EXAMINATION
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10. EXTRA- ORAL EXAMINATION
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11.  Present teeth- 11-18,21-28,31-38,41-47.
 Root Stump irt with :16,17,18,27,28,35,36,37,45.
 Occlusion was disturbed bilaterally. (Anterior open bite)
On palpation:
- Step deformity was palpated (31-32) & (45-46).
- Segmental mobility irt with (31-45) mandibular anterior
segment.
2. INTRA-ORAL EXAMINATION
Hard Tissue Examination
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12. Soft Tissue Examination
- Buccal Mucosa – NAD
- Labial Mucosa – Laceration present on lower labial mucosa.
- Palate - NAD
- Gingiva – Laceration is present in 31,32 & 45,46 tooth region.
- Floor of the mouth- Sublingual hematoma present.
(Coleman’s Sign +ve)
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13. INTRA- ORAL EXAMINATION
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14. PROVISIONAL DIAGNOSIS
1. Mandibular Right Parasymphysis Fracture.
2. Bilateral Condylar Fracture.
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15. (1) Pre- operative blood profile
(2) ECG
(3) Chest X-Ray
(4) OPG
(5) CT Scan of Facial bone
INVESTIGATIONS
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16. PRE-OPERATIVE PROFILE
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17. Chest X- RAY
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18. OPG is showing fracture line starting from crest
of alveolar ridge between 33 and 34 tooth and passing
inferior and backward direction involving inferior border
of mandible suggestive of Parasymphysis fracture. There
is also presence of fracture line passing from
48 inferior and backward direction involving basal bone
suggestive of simple fracture.
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OPG

19. 19
TMJ VIEW

20. 20
CT SCAN

21. FINAL DIAGNOSIS
1. Mandibular Right Parasymphysis Fracture.
2. Medially Displaced Bilateral Condylar Fracture.
3. Right Coronoid Fracture.
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22. TREATMENT PLAN
1. Intermaxillary Fixation
2. Open Reduction Internal Fixation
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23. 23
CASE SUMMARY
A 42 years old female patient named Subhadraben Senma
came to ER with complaint of pain in both ear region and bleeding from
mouth. Patient gave history of RTA while she was travelling with her
husband on bike, she fallen down from bike due to bike collision with
cart which was coming from opposite side on 7th Feb. 2020 around 5:40
pm at Kansa. There was H/O- Bleeding from mouth for a while and No
H/O- Unconsciousness, Vomiting, Epistaxis and bleeding from ear. Then
she shifted to NGH where primary treatment given.

24. 24
On taking Patient’s past medical, dental, family and drug
history, all were insignificant. On taking patient’s general examination,
patient was conscious, co-operative and well oriented to time, place
and person. Patient was well built and well nourished with all vital signs
were within normal limit at time of examination in our department.
Patient’s GCS score was E4V5M6 = 15/15 on time of examination in our
department. On taking patient’s local extraoral examination, facial
asymmetry was present due to swelling on bilateral TMJ region. Also
tenderness present on both TMJ region. Jaw movement was restricted
and mouth opening was 38 mm interincisally.

25. 25
On taking patient’s local intraoral examination, there were all the
teeth present except 48. Occlusion was disturbed (Anterior openbite). Step
deformity was palpated (31-32) & (45-46). Segmental mobility irt with (31-45)
mandibular anterior segment. There was gingival laceration present in 31,32
and 45,46 tooth region. Coleman’s sign positive. Based on all positive clinical
finding we have made our provisional diagnosis as Bilateral Condylar Fracture
and mandibular right parasymphysis fracture. We have advised various
investigations and came to our final diagnosis as Medially displaced bilateral
condylar fracture along with right coronoid process fracture and mandibular
right parasymphysis fracture. Treatment plan decided to do IMF F/B ORIF.

26. INTERMAXILLARY FIXATION
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27. 27
OPEN REDUCTION INTERNAL FIXATION

28. 28

29. 29

30. 30

31. 31

32. 32
POST OPERATIVE OPG

33. 33
POST OPERATIVE CT SCAN

34. 34
DISCUSSION
• Condylar and subcondylar fractures
constitute 26-40% of all mandible
fractures.
• Given the unique geometry of the
mandible and temporomandibular
joints (TMJs), these fractures can
result in marked pain, dysfunction,
and deformity if not recognized
and treated appropriately.
INTRODUCTION

35. TREATMENT
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Aims of treatment:
1. Relief from pain
2. Stable occlusion
3. Restoration of inter- incisal opening
4. Full range of mandibular movements
5. Tominimize deviation
6. Avoid growth disturbances
7. Avoid Ankylosis

36. 2 schools of thought:
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1. Conservative-functional therapy
2. Surgical treatment

37. Conservative therapy
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• Involves no surgical intervention of the fracture site
instead it reduces the fracture taking occlusion as a key
factor.
• Immobilization usually involves fixation with arch bars,
eyelet wires or splints.
• Period of immobilization varies from 7-17 days.

38. Indications
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1. Non displaced or incomplete fractures.
2. Condylar neck fractures with little or no displacement.
3. Fractures occuring in children (10-12 yrs).
4. Isolated Intracapsular fractures.
5. Medical illness or injury that inhibits the ability to receive
extended GA.

39. Conservative-functional management
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• Exercise
• Increasing mouth opening
• Push the jaws laterally
• Diet: Soft diet
• Analgesics
• Anti-inflammatory
• Soft diet and mouth exercises-
• Teeth into normal occlusion
• Adequate Range of motion
• Elastic MMF for 2-3 weeks
• When occlusion is found to be altered
• Presence of pain or swelling

40. Functional exercise:
• > 40 mm interincisal distance (adult)
• > 10 mm lateral excursion
• > 12 mm protrusion
Types of exercise:
• Maximal mouth opening
• Right lateral excursion
• Left lateral excursion
• Protrusive action
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Department of OMFS, NPDCH, SPU.

41. OPEN REDUCTION
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ABSOLUTE
INDICATIONS
• Fracture dislocation of condyle into middle cranial fossa.
• Foreign body into joint capsule.
• Lateral dislocation of condyle.
• Inability to achieve occlusion by closed reduction due to the interlocking of the
fractured condylar segments.
RELATIVE
INDICATIONS
• Bilateral / unilateral condylar fractures where in IMF is not recommended due to
systemic conditions.
• Bilateral condylar fractures in edentulous patients where splinting is not
recommended.
• Bilateral condylar fractures with comminuted midface fractures.
• Bilateral condylar fractures in patients with orthognathic problems such as
retrognathia or prognathia.

42. Department of OMFS, NPDCH, SPU.
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43. Department of OMFS, NPDCH, SPU.
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44. Transmasseteric Anterior Parotid Approach for Treatment of
Mandibular Subcondylar Fractures
Yemei Qian, MD, Weihong Wang, MD,y Biao Xu, MD, ZhiRong Zou, MD,y Chun Yang, MD,z and Shenjie Shao, MD
Abstract: This study demonstrated the application of transmasseteric anterior parotid
approach for open reduction of mandibular subcondylar fractures depending on the basis
of the anatomical study of the temporomandibular joint and parotid gland area. The
anatomical study was performed on 5 Chinese adult cadavers fixed by 10% formalin. The
temporomandibular joints and parotid regions were studied. In the clinical study, 26
patients with mandibular subcondylar fractures were recruited between July 2014 and
December 2017. All 26 patients with mandibular subcondylar fractures received satisfactory
occlusions and normal mouth opening: no postoperative facial paralysis occurred in these
patients. It is crucial to know the anatomy of both temporomandibular joint and parotid
region for reducing significantly the surgical trauma and complications. Transmasseteric
anterior parotid approach is a feasible approach for the surgical treatment of the
mandibular subcondylar fractures. This method can provide adequate exposure, minimal
facial nerve injury, open reduction easily, and inconspicuous scarring.
Department of OMFS, NPDCH, SPU.
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45. Paediatric Condylar Fractures
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• Most common pediatric mandibular fracture.
• Prior to age 6, most fractures are intracapsular, whereas after that age they occur
most frequently in the neck of the mandible.
• When normal occlusion is present, fractures of the condylar region are treated
conservatively with close observation, soft diet, and pain medication.
• When there is malocclusion, a short course of maxillary–mandibular fixation is
warranted.
• Limiting fixation to 7 to 10 days helps limit the chance of joint ankylosis, although
postoperative physiotherapy may still be beneficial.

46. • Choice of technique is largely dependent on the age of the child and,
more importantly, the quality and quantity of dentition.
• When possible, intradental wires with arch bars maybe placed.
• If not possible, intermaxillary fixation using 1-point circumandibular wiring
should be used
• Due to the possibility of injuring nonerupted teeth, intermaxillary fixation
screws should not be placed.
• It is important to discuss chin deviation during chewing and the possibility of
long- term growth abnormalities of the jaw with patients’ parents.
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47. CONDYLAR TRAUMA?
Clinical Sign
Malocclusion
Deviation
Range of motion
Negative clinical exam
(-)Malocclusion
Minimal pain
Normal range of motion
No deviation on opening
Observation
Radiographs
Lateral oblique
OPG
CT scan
No radiographic
evidence of condylar#
hemathrosis
Jointeffusion
(+) Condylar fracture
Normal occlusion Malocclusion
ORIF?
RMO
Pain
Deviation
Conservative IMF (7-21 days)
ORIF Other # ?
IMF (7-21 days)
Yes
89Follow up
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YesNo
No
No
Reduction/fixation of other #
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48. 48
• Intracapsular fractures are best treated by closed reduction.
• Fractures in children are best treated closed except when the
fracture itself anatomically prohibits jaw function.
• Physical therapy is integral to good patient care and is the primary
factor influencing successful outcomes, whether the patient is
treated open or closed.
• When open reduction is indicated, the procedure must be
performed well, with an appreciation for the patient's occlusal
relationships, and must be supported by an appropriate physical
therapy and follow-up regimen.
CONCLUSION

49. REFERENCES
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1. Oral & maxillofacial trauma-Fonseca & walker.
2. Oral & maxillofacial trauma-Rowe & Williams Vol 2.
3. Principles of Oral & maxillofacial surgery-Peterson.
4. Transmasseteric anterior parotid approach for treatment of mandibular
subcondylar fractures: Yemei qian, MD, weihong wang, md,y biao xu, MD, zhirong zou, md,y
chun yang, md,z and shenjie shao, MD.
5. Transmasseteric anterior parotid approach for condylar fractures: experience
of 129 cases: Vinod Narayanan, Ashok Ramadorai, Poornima Ravi, Natarajan Nirvikalpa.
6. Preauricular transmasseteric anteroparotid approach for extracorporeal
fixation of mandibular condyle fractures: Rajasekhar Gali, Sathya Kumar Devireddy,
Kishore Kumar Rayadurgam Venkata, Sridhar Reddy Kanubaddy, Chaithanyaa Nemaly, Mallikarjuna
Dasari
Department of OMFS, NPDCH, SPU.