Condylar fractures 2 /certified fixed orthodontic courses by Indian dental academy

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Condylar Fractures

INDIAN DENTAL ACADEMY
Leader in continuing dental education


Contents
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Introduction
Embryology & Surgical anatomy
Mechanism of injury & biomechanical considerations
Classification of Condylar fractures
Clinical features - examination
Radiologic imaging modalities
Treatment considerations
The controversies in treatment
Special considerations
Complications
Summary & conclusion
References

Introduction
Fracture of the condyle can sometimes be the consequence of
an indirect blow…. the head of the condyle is forced against
the prominent margins of the glenoid cavity; and sometimes
from a direct blow …..and impinges upon this part of the
bone…… it is usually observed to occur in the narrow
section which supports the condyle, and below the insertion
of the external pterygoid


Introduction
“Concerning the treatment of condylar fractures, it seems
that the battle will rage forever between the extremists
who urge nonoperative treament & other extremists who
advocate open reduction in almost every case”


Definition
“A structural break in the normal continuity of bone”
Bailey & Lowe
• Fractures of the mandible - 40 and 62% of all facial
fractures
• Mandibular fractures are multiple > 50% of the cases
• Falls - Subcondylar fractures in 36.3% cases

• Most common combinations are angle and opposite body,
bilateral body, bilateral angle, and condyle and
opposite body


Incidence

- Luyk NH - 1992


Incidence
Oikarinen & Malmstrom- Percentage occurrence
of fracture based on site of occurrence -1969
1.3%
33.4%

17.4%
33.6%

Force Required
Line of force through the
symphysis and TMJ
• A single subcondylar fracture at
193 kg(425 lb)

• A bilateral subcondylar fracture at
250 kg (550 lb)
• symphyseal fractures – b/w 250 and
408 kg (900 lb)

Embryology of Mandibular
Condyle
• Condylar secondary cartilage -10th week i.u - primordium of
the future condyle
• Important growth center for the ramus and the body of
mandible
• Much cartilage is replaced with bone – endochondral
• But its upper end “persists into adulthood, acting as both as
growth cartilage and articular cartilage”
• Changes in mandibular position and form are related to the
direction and amount of Condylar growth

Embryology of Mandibular
Condyle
• Growth rate increases at puberty , peaks b/w 12-14 years &
ceases at about 20 years of age
• The subarticular appositional proliferation of cartilage endochondral bone, on whose outer surface a cortex of
bone
intramembranous bone is laid (functional matrix)
• Bone resorbtion subjacent to the condylar head accounts for
the narrowed condylar neck.
• The attachment of the lateral pterygoid muscle to this neck,
and the growth and action of the tongue and the masticatory
muscles are functional forces implicated in this phase of
mandibular growth.

Surgical Anatomy


Differences in Adult and
Pediatric Condyles
Parameter

Child

Adult

1 Cortical bone

Thin

Thick

2 Condylar neck

Broad

Thin

3 Articular surface

Thin

Thick

4 Capsule

Highly vascular

Less vascular

5 Periosteum

Highly active – in osteogenic Less active in latent
phase
stage

6 Intracapsular
hemarthrosis.

fracture

& Very common

7 Remodelling capacity following
Present
trauma
Likely
8 Disturbance in growth

Rare
Absent
N.A

Differences in Adult and
Pediatric Condyles


Mechanism of fractures
W should we know this?
hy
• Simplifies diagnosis
• Helps surgeon to look for parts of the mandible most likely to
fracture
• About two thirds of all temporomandibular joint fractures' are
associated with other fractures of the mandible
• Condylar fractures are mainly due to an indirect injury
• They seldom arise from direct trauma, unless accompanied
by a zygomatic arch fracture.


Factors influencing the fracture sites
Occlusion
whether mouth was open or closed at impact
Direction of the impact
Amount of force applied


A few com on injury patterns
m
 A direct blow to the TMJ region – fracture of condyle
 A blow to the mandibular body in a horizontal direction – ipsilateral
body & contralateral condyle fracture
 A force on the parasymphysis region can cause ipsilateral or
bilateral condylar fracture as well as localized parasymphysis
fracture
 An axially directed force to the parasymphysis – bilateral Condylar
fracture with symphyseal or parasymphyseal fracture
It can further be associated with fracture of the glenoid fossa with
penetration into the middle cranial fossa or fracture of the
tymphanic plate causing damage to the external acoustic meatus

General nature of injury Rowe & Williams
Three main groups
1. Contusion of the soft tissues of
the joint
2. Dislocation of the condylar head
from the glenoid fossa

3. F
racture of the condyle
Combination of the above can
also be seen and should be
ruled out before further treatment
options are being considered


Mechanism of injury
According to Lindahl, the forces causing damage to
the joint are of three main types

1. Kinetic energy imparted by a moving object through the
tissues of a static individual. Ex by a fist, cricket bat or ball


Mechanism of injury
2. Kinetic energy derived from the moving individual striking a
static object
ex a child slipping and striking the pavement or a fall during
an epileptic fit or parade ground fracture


Mechanism of injury
3. Kinetic energy, which is the sum of, forces due to
combination of factors 1 and 2
Ex RTA where a person in a moving car strikes his chin across
the dashboard


Classification of condylar
fractures
Rowe & Killey’s classification (1968)
1.Intracapsular fracture - high condylar fracture
Involving the articular surface

Fracture through the neck
2.Extracapsular fracture - low condylar fracture
3.W injury to the capsule, ligament and meniscus
ith
4.Involving the adjacent bone


fractures
MacLennan Classification: 1952 –Clinical Classification
Type I: No displacement
Type II: Fracture deviation – simple angulation of the fracture segments
without overlap or separation. Ex. Green stick fracture in children
Type III: Fracture displacement –when there is overlap of fracture
fragments. This overlap may be in an anterior, posterior, lateral or medial.
Medial is commonest.
Type IV: Fracture dislocation – here the condylar head is completely
dislocated out of the articular fossa and out of the capsular confines. Again
dislocation can be medial or lateral and rarely anterior or posterior.
Type V : High condylar fracture with luxation
Type VI : Head fracture or intracapsular fracture


fractures

Condylar neck fractures classification - Spiessl & Schroll
Type I

Condylar neck fracture without serious dislocation

Type II

Deep-seated Condylar neck fracture with
dislocation

Type III

High Condylar neck fracture with dislocation

Type IV

Deep-seated Condylar neck fracture with luxation

Type V

High Condylar neck fracture with luxation

Type VI

Head or intracapsular fracture

fractures
Lindhal’s classification:- Comprehensive classification (1977)
Lindahl proposed a classification based on several factors namely
1. The anatomic location of the fracture
2. The relation of the condylar segment to the mandibular
segment
3. The relation of the condylar head to the articular fossa
1. Depending on fracture level
i.
ii.
iii.

Condylar head #
Condylar neck #
Subcondylar #

fractures
2. The relation of the condylar segment to the mandibular segment

i. Undisplaced (fissure fracture) (B)
ii. Deviated – simple angulation of the condylar process in i.r.t
distal mandibular segment without overlap.(C)
iii. Displaced with medial overlap (D)
iv. Displaced with lateral overlap (E)
v. Antero-posterior overlap – possible but are seldom seen. (F)
vi. Without contact between fragments (G)

fractures
3. The relation of the condylar head to the articular fossa

i. No displacement- condylar head appears in normal prelation
with fossa
ii. Displacement – condylar head is in fossa but there is alteration
of joint space. Joint space is increased
iii. Dislocation. – The condylar process is completely out of the
fossa.

Clinical examinationExtra oral
Inspection
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Swelling
Preauricular depression
ecchymosis
lacerations
facial asymmetry
pain on jaw mobilization
deviation on opening
Ear bleed
CSF otorrhea
Battle sign

Clinical examinationExtra oral
Palpation

Position : The clinician begins the examination from
behind the seated or supine patient

• Inability to open jaws
• tenderness associated with
crepitation
• a limited range of motion
• a significant deviation on opening –
(same side)
• otoscopic evaluation
• firm posterior pressure on the chin
will cause pain in the preauricular
region

Clinical examination –
Intra oral

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malocclusion
fracture of the dentition
▲ or ▼ in inter-incisal opening
Premature occlusal contacts
Anterior open bite
Posterior gagging of occlusion

Clinical examination –

Summary
Clinical signs to look for and to rule out - Fonseca
1.

Evidence of trauma – facial contusions, abrasions, laceration of
the chin, and /or ecchymosis or hematoma in the TMJ region
2. Bleeding from the external auditory canal
3. A noticeable or palpable swelling over the TMJ
4. Facial asymmetry as a result odf edema or ramal shortening
5. Pain and tenderness
6. Crepitation
7. Malocclusion
8. Deviation of the mandible
9. Muscle spasm (“splinting”) with associated pain and limited
mouth opening
10. Dentoalveolar injuries

Radiologic Diagnosis
Available Options

1. Plain radiographs
View in two dimensions
orthopantomogram view
posterior-anterior view

2. Computed tomography
To be able to exclude head or intracapsular fractures and particularly
if surgical treatment is planned, it is imperative that the fracture line be
demonstrated in a coronal CT scan

3. Magnetic resonance imaging
Disk position can be shown by means of MRI
4. Ultasonography
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Limited use – only can tell presence of fracture in TMJ region
•
Can be used to check position of condyle following surgery

Plain Radiographs
• At least two views at right angles to each other are
necessary – OPG & Reverse Towne’s view
• In the multiple-trauma patient for whom OPG not
possible, lateral oblique views may be substituted
• Other radiographic views that may be useful depending
on the circumstances are
posteroanterior mandibular
mandibular occlusal
periapical
Limitation
Intracapsular fractures of the condylar head are often
difficult to visualize accurately on plain films

Orthopantomograph & Lateral
oblique views

Anteroposterior plane
Centered on condyles
Open mouth – if poss

R www.indiandentalacademy.com

L

Computed tomography
Indications

for CT scans

1. Significant displacement or dislocation
2. Limited range of motion with a suspicion
of mechanical obstruction caused by
the position of the condylar segment

3. Alteration of the surrounding osseous
anatomy by other processes, such as
previous internal derangement or TMJ
surgery, to the degree that a
pretreatment baseline is necessary

4. Inability to position the multi- trauma
patient for conventional radiographs

Thank you

Thank you

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Condylar fractures 2 /certified fixed orthodontic courses by Indian dental academy

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