Condylar fractures /certified fixed orthodontic courses by Indian dental academy

CONDYLAR FRACRURES

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Introduction
• The topic of mandibular condylar fracture has
generated more discussion and controversy than any
other in the field of maxillofacial trauma.
• Condylar and subcondylar fractures accounting for
between 25% and 35% of all mandibular fractures
• Condyle is a major growth center for the mandible


Anatomy


Melvin Moss - “I know of no other single
anatomical subject concerning which so much
misinformation has been printed, and
then believed.”


Embryology
 Arises from the 1st Pharyngeal Arch--develops around
the ventral cartilage of the 1st branchial arch.
 Begins to develop by the 10th week of gestation
 Two separate blastemas –one for the temporal bone
component and one for the condyle
 Superior to the condylar blastema a band of
mesenchymal cell develops that will eventually
differentiate into the disc
 Temporal condylar mesenchymal cell differentiate into
osteoblasts which lay down membrane bone
 All the components of mature TMJ is formed by14th
week of gestation
 12 – 32 weeks of gestation there is a high degree of
calcification of the condylar head

Relations


Nerve supply


Blood supply


Functions


“The bone fracture at the site of tensile strength since its resistance
to compressive strength is more”
Hodgson ( 1967)


Incidence


Mechanism of Injury


Classification
In 1915 Brophy – location and direction of fracture
– “through the neck; from above and without;
downward and inward; or reversed; from above
and infront; backward and downward”

Thoma – classified
•
•
•
•

Fracture with displacement
Fracture without displacement
Fracture dislocation
Fracture dislocation with complete displacement

Wassmunds Classification – 1934
• Type I – Fracture of condyle with slight displacement of
head with angle of 10-45 degree between head and ramus
– reduces spontaneously
• Type II – Angle of 45 – 90 degree between head and
ramus, tearing of medial portion of capsule
• Type III – Fragments not in contact, head displaced
medially and forward due to lat. Pterygoid pull/spasm,
fragments is within glenoid fossa, capsule is torn and
head is out side the capsule – open reduction advocated
• Type IV –Fractured head articulates on/forward to
articular eminence
• Type V - Vertical/oblique fracture through head of
condyle - rare

McLennan's
Classification
(1952)
A.
B.
C.
D.

No displacement
Deviation
Displacement
Dislocation


Rowe and Killey’s Classification (1968)
• Intracapsular Fractures or High Condylar
i. Fractures involving the articular surface
ii. Fractures above or through the anatomical
neck, which do not involve the articular
surface
• Extracapsular or Low Condylar Fractures
• Fractures associated with injury to the capsule,
ligament and meniscus
• Fractures involving adjacent bone

SPIESSL AND SCHROLL - 1972
• Type I
• Type II
• Type III
• Type IV
• Type V
• Type VI

- Condylar fracture without
angulation and dislocation
- Low condylar fracture with
angulation
- High condylar fracture with
angulation
- Low condylar fracture with
dislocation
- High condylar fracture with
dislocation
- Fracture of condylar head

R.A. Loukotaa et al subclassification (2005)
• Diacapitular fracture (through the head of the
condyle): The fracture line starts in the articular
surface and may extend outside the capsule.
• Fracture of the condylar neck: The fracture line
starts somewhere above line A and in more than
half runs above the line A in the lateral view.
Line A is the perpendicular line through the
sigmoid notch to the tangent of the ramus.
• Fracture of the condylar base: The fracture line
runs behind the mandibular foramen and, in
more than half, below line A

Clinical Signs and Symptoms
•
•
•
•
•
•

Evidence of soft tissue injury - Chin Lacerations
Facial Asymmetry with chin deviation
Noticeable swelling over the affected TMJ
Pain and tenderness over the affected TMJ
Malocclusion
Deviation of the mandible to same side during
opening
• Muscle splinting due to pain with limited opening
• Bleeding from the external auditory canal
• Inability to palpate condylar movement.

Imaging in the Diagnosis of Condylar
Fractures
A. Conventional Radiography
a. P A- View
b. Lateral Oblique
c. Panoramic view
d. Reverse Towne's Projection
e. TMJ views
B. CT
C. MRI

PA skull

Reverse Towne's

Lat. Oblique

Trans-pharyngeal

CT Scan


MRI

Treatment
“Concerning the treatment of condylar fractures, it
seems that the battle will rage forever between the
extremists who urge nonoperative treatment in
practically every case and the other extremists
who advocate open reduction in almost every
case.” - Malkin


Goals of Treatment:
 Relief from pain
 Stable occlusion
 Restoration of inter- incisal opening
 Full range of mandibular movements
 To minimize deviation
 Avoid growth disturbances
 Avoid Ankylosis

M. Todd Brandt et al 2003
• “Under similar indications and conditions,
ORIF is the preferred approach”
• “Adaptation miniplate is least favored and
minidynamic compression plate is most
favored”


Modes of Treatment
1. A period of Maxillo Mandibular Fixation
(MMF) followed by functional therapy
2. Functional therapy without a period of MMF
3. Open reduction with or without internal
fixation.

Edward Ellis III and Gaylord S. Throckmorton 2005

Is a Temporomandibular Articulation
Necessary/Advantageous?

• Is the TMJ a stress-bearing joint?
• Does the TMJ have to be a stress-bearing
joint?
• Does the TMJ guide mandibular movement?
• How does the masticatory system function
when one TMJ is damaged?
• How does the masticatory system function
when both TMJs are damaged?

Is the TMJ a stress-bearing joint?
Does the TMJ have to be a stress-bearing joint?

• Gysi’s “lever” theory – load bearing
• Wilson’s nonlever theory – nonload bearing
• Moss and Moss- Salentijn - TMJ bears at least some
loads that re-establishment of a temporomandibular
articulation may be advantageous
• Patients alter their muscle activity enough to protect the
missing or damaged joint from compressive loads

Does the TMJ guide mandibular movement?
• Aberrations within the TMJ can alter mandibular
movement, which usually manifest as limiting
certain excursions


How does the masticatory system function when one
TMJ is damaged?
• Under normal circumstances, when one bites on the left
molar, the right (contralateral or balancing side) TMJ
bears more load than the left (ipsilateral or working
side)
• If right side TMJ is injured, one way to reduce loading
it would be to selectively increase left masseter activity
Doing so produces greater loading of the left, uninjured
TMJ
• In contrast, when biting on the right (ipsilateral or
working side), alteration of the muscle activity ratio is
not necessary because the normal left-side joint carries
the greater load www.indiandentalacademy.com

How does the masticatory system function when
both TMJs are damaged?
• Bite force for
bilateral fracture
patients is
reduced
• Narrower
chewing cycles,
with significantly
lower adductor
muscle activity

In summary, is a temporomandibular articulation
necessary/advantageous?
• Yes! For the masticatory system to function
efficiently and maximally, a craniomandibular
articulation is necessary. Whether or not this
must be in the form of a ginglymoarthrodial
joint or whether a simple hinge joint is adequate
is unclear. It is also unclear whether open
treatment would provide a more effective
temporomandibular articulation than closed
treatment.

Conservative Management


3 main factors to favor nonsurgical treatment:
1. Nonsurgical treatment gives “satisfactory”
results in the majority of cases
2. There are no large series of patients reported in
the literature who have been followed after
surgical treatment because management of
condylar fractures has historically been with
nonsurgical means
3. Surgery of condylar fractures is difficult
because of the inherent anatomical hazards
(i.e., VII nerve).

Adaptations
3 types of adaptations occurs during non
surgical management:
1) Neuromuscular adaptations
2) Skeletal adaptations
3) Dental adaptations

Neuromuscular Adaptations
• Individuals with bilateral
condylar process fractures
selectively increase the EMG
output in the posterior
temporalis fibers
• Provide a posteriorly directed
vector onto the coronoid
process
• Rotate the anterior portion of
the
mandible
superiorly,
bringing the incisors into
contact

Skeletal Adaptations
•
•

Slowly developing adaptation
Development of a new temporomandibular
articulation.
3 concurrent methods by which a new
temporomandibular articulation occurs:
1. Condylar regeneration
2. Changes in the temporal component of the TMJ
3. Loss of posterior vertical dimension.
• The newly formed temporomandibular articulation
may or may not be another synovial joint.

• Restitutional remodeling a completely new condylar
process of normal
morphology is re-created.
• Functional remodeling the condylar process
looked abnormal even
though it might function
very well.

Dental adaptations
• With closed treatment of condylar process
fractures, extrusion of the incisors and
intrusion of the molars has been
demonstrated.
• Because the ramus moves superiorly to
assist in the re-establishment of a new
temporomandibular articulation

• As early as 1805, Desault wrote: “It is
important to restore contact of the
fragments. Union might fail if the slightest
movement of jaw occurs. If there is no
contact, the callus produced might render
the condyle irregular and deformed, which
will impede function.”
• There is no compelling reason to use MMF
when treating fractures of the condylar
process by closed techniques - Ellis and
Throckmorton 2005

Surgical Management


Contraindications


Anatomic Consideration
The blood supply to the condyle - 3 sources
• A branch of the inferior alveolar artery
• TMJ capsule, with its lush vascular plexus
• Branches of the lateral pterygoid muscle
through its attachment at the pterygoid fovea.
Medullary blood supply from a
branch of the inferior alveolar artery has been
found to be the most important source

Facial Nerve


Approaches
1.
2.
3.
4.
5.
6.
7.
8.

Pre Auricular
Submandibular
Posterior Auricular
Retromandibular
Intra Oral
Combination
Face-Lift
Endoscopic

Incisions

Blair’s Inverted
Hockey Stick
Incision

Thoma’s Angulated
Incision

Dingman’s
Incision

Endaural Incision

Post ramal

Popowich &
Crane Incision

Posterior Auricular
Incision

Submandibular

Intraoral
Incision

Endoscopic


Fixation
Methods
 Miniplates
 Lag Screws
 Pin Fixation
 Interosseous Wire {K-wire}

Wire Osteosysnthesis

Kirschner wire
fixation

Plate & Screw
fixation

Masser technique for
wire osteosynthesis

Axial anchor
screw

Children
 Bony union & remodeling of condylar head in
the glenoid fossa occurs spontaneously in
children.
 This ability to regenerate & remodel declines
after puberty.
 Conservative non immobilization (most cases)
with active function.
 Brief immobilization (7-10 days) - for gross
displacement with malocclusion, followed by
active function & physical therapy to prevent
ankylosis & growth disturbance.

Complications
Early/ Concurrent
• Fracture of the tympanic plate
• Fracture of the glenoid fossa with or without
displacement of the condylar segment into
the middle cranial fossa
• Damage to the Vth and VIIth cranial nerves
• Vascular injury
• Infection

Late
• Malocclusion
• Growth disturbances
• TMJ dysfunction
• Ankylosis
• Delayed union
• Non-union
• Scars


References
1. Rowe and William’s Maxillofacial Injuries Williams L. J., Rowe N. L. (Vol I)
2. Gray’s Anatomy - Williams P. L. (38th Ed.)
3. Textbook of Oral and Maxillofacial Surgery Neelima Malik
4. Oral and Maxillofacial Trauma - Raymond J.
Fonseca (Vol I)
5. Treatment of Mandibular Condylar Process
Fractures: Biological Considerations Edward
Ellis III et al

Condylar fractures /certified fixed orthodontic courses by Indian dental academy

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