Condylar fracture.pptx

Condylar fractures
G.Kathirvel
PG - OMFS

Contents:
• Introduction
• Surgical anatomy
• Biomechanics
• Classification
• Clinical features
• Radiographic features
• Management
• Closed treatment
• Open reduction
• Surgical approaches to condylar fractures
• Complications

Introduction:
• Condylar fractures account for 17.5% to 52 %.
• It differ significantly from other fractures of the mandible owing to the functional
derangement that may affect occlusion, mastication and speech
• However, functional derangements unique to condylar fractures are very frequent sequelae
of these injuries
• This is due to the unique functional anatomy of the mandibular condyles, the specific
challenges of surgical treatment of these fractures and the various patient-specific factors
affecting the outcomes of condylar fractures.
Peterson’s Principles of Oral and Maxillofacial Surgery - Third Edition; 2011; PEOPLE’S MEDICAL PUBLISHING HOUSE—USA

Anatomy:
The mandibular condyle forms a part of the temporomandibular joint which is
unique and TMJ made of the following structures:
• Condyle of the mandible
• Squamous portion of the temporal bone
• Articular disc (contained within the TMJ)
• Ligaments
Vikas Dhupar; Fracture of the Mandibular Condyle; Oral and Maxillofacial
Surgery for the Clinician; Springer; 2021

Condyle
• The condylar head is ovoid in shape measuring approximately 15–
20 mm mediolaterally and 8–10 mm anteroposteriorly
• Articulates with the glenoid fossa present in the squamous portion
of the temporal bone to form the temporomandibular joint.
• Squamous portion of the temporal bone is as thin as 2 mm as a
result; the condylar processes maybe driven into the middle
cranial fossa following trauma.

Articular Disc
• The squamous portion of the temporal bone and the
condyle is separated by a dense fibrous connective tissue
called the articular disc.
• The disc is firmly anchored to the condyle by the medial
and lateral collateral ligaments and it merges with the
capsule in the periphery.
• The joint space is divided into superior and inferior
compartments by the disc.

Capsule and Ligaments
• The capsule surrounds the TMJ and is reinforced by
the medial and lateral ligaments which connect the
mandible to the temporal bone.
• The synovial membrane lines the capsule.
• This membrane produces synovial fuid which aids in
the lubrication and nourishment of the joint.
• The lateral ligament also known as temporomandibular
ligament has a horizontal and an oblique component
which stabilizes the joint.

Capsule and Ligaments
• The strength of the lateral ligament may be partly responsible
for the fracture at the neck of condyle just below the insertion
of the ligament.
• The medial and lateral discal ligaments which are present
inside the capsule are also called collateral ligaments.
• These ligaments connect the disc to the poles of the condyle.
Accessory ligaments:
• The stylomandibular and sphenomandibular ligaments are
accessory and are not directly attached to any part of the joint.

The stylomandibular ligament
• Runs from the styloid process to the angle of the
mandible
• It separates the parotid and submandibular salivary
glands
• Becomes taut when the mandible is protruded
The sphenomandibular ligament
• Runs from the spine of the sphenoid bone to the lingula
of mandible
• The inferior alveolar nerve descends between the
sphenomandibular ligament and the ramus of the
mandible to gain access to the mandibular foramen
• Becomes taut when the mandible is protruded

Muscles:
Lateral pterygoid
• Superior head is attached to the joint capsule
• Inferior head to pterygoid fovea at the condylar neck and
is responsible for the displacement of the condylar
fractures.
• Change in the direction of resultant forces post fracture
will alter the function of the mandible during various
excursion movements.

Vascularisation:
Condyle receives blood supply from three sources
1. Medullary bone supplied by inferior alveolar artery
2. Overlying periosteum of the condyle
3. Attachment of lateral pterygoid muscle
This may explain the reason for the fractured condyle to remains viable even after
stripping of the periosteum during the surgical procedure as the lateral pterygoid
muscle remains attached to the fractured fragment.
The venous drainage starts in the retrodiscal plexus which drains into the superfcial
temporal and maxillary veins that join to form the retromandibular vein, which in turn
drains into the external jugular vein

Nerve innervation
• Both the sensory and motor innervation
• The sensory nerves are auriculotemporal and masseteric
• Auriculotemporal nerve crosses the condyle medial
to it and lies in contact with the condylar neck
and capsule.
• It is encountered in the preauricular incision

Facial Nerve
• It is the key nerve that transverses the face and it is liable for the motor function of
the muscles of facial expression.
• This nerve transverses the temporoparietal fascia and finally divides into fve terminal
branches in the parotid gland.
• Hence all the extraoral approaches for the condylar fractures are designed keeping
the facial nerve in mind.

Surgical anatomy:
The preauricular incision
• Al-Kayat and Bramley found the nerve was at an
average distance of 20 mm with a range of 8–35 mm
from the anterior margin of the auditory canal.
• This is the reason the preauricular incision is given in
the skin crease near the tragus or placed endurally.
Transparotid approach.
• The neck of the condyle can be exposed via the
transparotid approach.
• In this approach the condyle is reached through the
space between the temporozygomatic and buccocervical
trunks of the nerve.
• This results in a direct and safe approach to the neck of
the condyle.

Surgical anatomy:
The marginal mandibular nerve
• The marginal mandibular nerve is encountered in
the submandibular or periangular approach.
• This branch may further subdivide into two or
more branches.
• As a rule, the submandibular incision is given
2 cm below the lower border of the mandible to
prevent paresis of the lower lip.

Wassmund classification(1934)
Type I- The angle between the head and the long axis of the ramus :10 to
45 degrees.
Type II- angle of 45 to 90 degrees, resulting in tearing of the medial
portion of the capsule.
Type III- the fragments are not in contact, and the head is displaced
mesially and forward owing to traction of the lateral pterygoid muscle.
Type IV- fractures where the condylar head articulates in an anterior
position to the articular eminence.
Type V- vertical or oblique fractures through the head of the condyle.

A.Condylar fractures
i. Without displacement of condyle
• Greenstick fracture
• Intracapsular
• Extracapsular
ii. With displacement of condyle
• Lateral
• Medial
• Forward
• Backward
iii. With overriding of fragments
iv. With dislocation in lateral or medial direction
• Intracapsular
• Complete fracture dislocation
• Complete dislodgement of the condyle
• Dislocation of the fractured part of the head of the condyle
v. With dislocation in forward direction
• Anteriorly from the articular eminence
• Posteriorly from the articular eminence
• With dislocation and displacement of the meniscus
• With comminution
• Old fracture with deformities
— Pseudoarthrosis
— Ankylosis
Thoma (1945)

B. Subcondylar fractures
i. Without displacement of fragment
ii. With displacement of fragment
By Thoma
Fracture line either extending through head or base of the condyle or neck
has been called condylar fracture , whereas in subcondylar fracture, the line
runs transversely over ascending ramus.

Mac Lennan classification (1952)
a. No Displacement - A crack fracture is seen without alteration of the normal relationship of
TM Joint
b. Deviation - simple angulation of the condylar process to the ramus
c. Displacement - Overlap occurs between the condylar process and the ramus and fractured
fragment lies lateral to the ramus.
d. Dislocation - condylar head is completely disrupted from the glenoid fossa and gets pulled
anteriorly and medially by the lateral pterygoid muscle

Rowe & Killey 's classification(1968)
a. Intracapsular Fractures or High Condylar Fractures
i. Fractures involving the articular surface
ii. Fractures above or through the anatomical neck,
which do not involve the articular surface
b. Extracapsular or Low Condylar or Sub condylar Fractures
Fracture line runs obliquly from the lowest point of curvature of the sigmoid notch
downward and backward below the neck to the upper posterior limit of the ramus.
c. Fractures associated with injury to the capsule, ligament and meniscus
d. Fractures involving adjacent bone - Roof of the glenoid fossa or tympanic plate of
the external auditory meatus.

Spissel and Schroll classification (1972)
Type 1 : Non-displaced fracture
Type 2 : Low-neck fracture with displacement,
mostly with contact between fragments
Type 3 : High-neck fracture with displacement,
mostly without contact between fragments
Type 4 : Low-neck fracture with dislocation
Type 5 : High-neck fracture with dislocation
Type 6 : Intracapsular fracture of condylar head
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian Dental Association December
2006, Vol. 68, No. 11

Lindahl classification(1977)
a. Anatomic location of the fracture
i) Condylar head
ii) Condylar neck
iii) Subcondylar

b. Relationship of condylar fragment to mandible
i) Undisplaced
ii) Deviated
iii) Displacement with medial or lateral overlap
iv) Displacement with anterior or posterior overlap
v) No contact between fractured segments

c. Relationship of condylar head & fossa
Nondisplaced
Displacement
Dislocation

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

Neff & Rasse’s Modification(2006)
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian Dental Association December
2006, Vol. 68, No. 11
Type A: continuous bony contact within the
articular fossa, with a component of the
condylar head remaining and the fracture
supported without loss of ramus height
Type B: loss of support within the articulating
fossa and subsequent loss of mandibular ramus
height.
Type C: the uppermost portion of the fracture
is below the level of the lateral ligament,
resulting in a loss of ramus height.

He et al classification of Dicapitular fracture
(2009)
A - Fracture line through the lateral third portion of the
condylar head with reduction of the ramus height
B - Fracture line through the central third portion of the
condylar head without reduction of the ramus height
C - Fracture line through the medial third portion of the
condylar head without reduction of the ramus height
M - A comminuted fracture with multiple fragments (usually
more than three) of the condylar head
He D, Yang C, Chen M, Jiang B, Wang B. Intracapsular condylar fracture of the mandible: our classification and open
treatment experience. J Oral Maxillofac Surg 2009;67(8):1672–1679

Jing et al classification of diacapitular fractures (2011)
M - Fractures involving the medial
section of the condylar head
C - Fractures involving the central
L - Fractures involving the lateral
Jing J, Han Y, Song Y,Wan Y. Surgical treatment on displaced and dislocated sagittal fractures of the mandibular condyle.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(6): 693–699

AOCMF Classification (2014 )
Condylar Head fracture
Andreas Neff; The Comprehensive AOCMF Classification System:
Condylar Process Fractures - Level 3 Tutorial; Craniomaxillofacial Trauma and Reconstruction Vol. 7 Suppl. 1/2014

Neck and Base fractures

Distortion of condylar head articular congruency

Clinical Features
Condylar fractures infrequently occurred in isolation and are generally associated
with fractures of other sites of the facial bones.
Signs and symptoms:
• Pain and swelling over the preauricular region
• Ecchymosis over the mastoid region
• CSF otorrhea
• Hollowness over the condylar region
• Restricted incisal opening
• Locked mandible
Raymond.J Fonseca; Oral & maxillofacial trauma; fourth edition; 2013, Saunders, Elsevier Inc

Unilateral condylar Fractures:
• Premature occlusion on the ipsilateral side
• Open bite due to the loss of vertical height on the
contralateral side.
• Affected side deviates on opening and is common because
of the interruption of the action of the lateral pterygoid
muscle.
• Limited laterotrusive movements away from the fractured
side but may be maintained towards the fracture.

Bilateral condylar Fractures:
• Bilateral loss of vertical height results in anterior open bite
with posterior gagging
• Restricted mouth opening
• In bilateral condylar fractures with an associated
mandibular symphysis fracture, facial widening may result
with posterior buccal cross-bites and anterior open bite.

Radiographic evaluation:
Towne’s radiograph
Coronal displacement is evaluated with Towne’s radiograph
OPG
Sagittal displacement, the loss of ramus heigh is evaluated
with a panoramic radiograph
The measurement technique is as follows :
• Line drawn between gonial angles across Panorex
• Perpendicular lines to most superior aspect of condylar
heads
• The difference between the nonfractured and fractured side
equals the change in ramus height.

Computed tomography
Anterior posterior dimension (sagittal position)
Medial lateral dimension (coronal position)
MRI
MRI are essential to evaluate the disc injuries specially in dislocation and
intracapsular condylar fractures; however MRI are not taken as a routine practise

CONSERVATIVE TREATMENT
• Closed treatment is treatment of condylar fractures by means other than surgical
exploration, reduction, and fixation of the fracture line (i.e., not involving an open
surgical exposure of the fracture).
• Traditionally, this has been achieved by arch bars, splints fitted over the remaining
dentition, IMF, screws, or bonded brackets.
• Once reduction of the occlusion has been achieved, a period of immobilization may
be required to encourage bony healing.
• Early mobilization is advised to minimize the risk of fibrous and bony TMJ
ankylosis.

INDICATIONS FOR CLOSED TREATMENT
Nonsurgical treatment may be the appropriate management strategy in cases of
• Condylar neck fractures in children <12 years of age.
• High condylar neck fractures without displacement.
• Intracapsular (diacapitular) condylar fractures without loss of ramus height.
• Poor anesthetic risk.

INDICATIONS FOR OPEN TREATMENT

Emam HA, Jatana CA, Ness GM. Matching surgical approach to condylar fracture type.
Atlas Oral Maxillofac Surg Clin North Am 2017;25:55-61

Submandibular Approach.
This is also known as the Risdon approach
Advantages:
These include the ability to distract the mandibular ramus
and direct access of the gonial angle.
Disadvantages:
• These include limited surgical site exposure (the
incision is distant from the fracture)
• Difficult to reduce medially displaced condyles
• Plate and screw fixation restricted without a
transfacial trocar.

Surgical Technique
Incision.
• These are 1.5 to 2 cm below the inferior border of the mandible
in or parallel to a skin crease.
• In patients with ramus height shortening, place the incision 1.5 to
2 cm below where the anticipated reduced mandible would be.
• The initial incision is placed to the depth of the platysma, with
extensive undermining in all directions.
Dissection.
• Through the platysma. Undermine and sharply dissect, being
careful to stay superficial to the superficial layer of the deep
cervical fascia.

• Make a small incision through the superficial layer of the deep
cervical fascia at the level of the skin incision (1.5 to 2 cm
inferior to the mandible).
• The facial artery and vein may be retracted anteriorly or
divided and ligated if necessary.
• Continue the dissection superiorly until the pterygomasseteric sling is encountered.
• Division of the pterygomasseteric sling. Sharply incise the pterygomasseteric sling with
a scalpel along the inferior border of the mandible.
• Use a periosteal elevator to expose the ramus up to the level of the TMJ capsule and
coronoid process.

Retromandibular Approach
Advantages.
• Short distance between the incision and the fracture site
• Best access to the fracture site
• No need for a transfacial trocar
• Facial scar is less noticeable than with a submandibular incision
• Effective in patients with edema
• Access for an osteotomy if required to reach the condyle.
Disadvantages.
The facial scar is more noticeable than with a preauricular incision.

Retromandibular – Trans-parotid Approach

Retromandibular- Retro-parotid- Approach

Technique
• A preauricular incision is made that extends downwards in a curvilinear
fashion in the cervicomastoid skin crease, though any variation in this
incision.
• The great auricular nerve is preserved and the flap raised in the subdermal fat
plane, superficial to the superficial musculoaponeurotic layer to allow access
to the masseter adjacent to the anteroinferior edge of the parotid gland, just
below the parotid duct.
• The area next to the anterior edge of the parotid gland is usually relatively free
of branches of the facial nerve, making this an ideal point to dissect down to
the fracture

Technique
• If a buccal branch crosses the field it is easily retracted up or down.
• The masseter is split in the direction of its fibres.
• The periosteum overlying the lateral aspect of the ramus in the
region of the condylar neck is incised and the fracture site is
exposed.

Periangular transmasseteric approach
• 4 cm long curvilinear incision, 5 mm below and along the angle of
the mandible
• After skin incision, dissection was continued in the subcutaneous
plane, upward and superficial to the platysma till the zygomatic
arch.
• The thin platysma muscle is held with tissue holding forceps and
incised obliquely to expose the masseteric fascia overlying the
masseter belly

Periangular transmasseteric approach
• The area adjacent to the anterior edge of the parotid gland is relatively
free of the branches of the facial nerve and hence ideal for further
dissection.
• The parotid tissue was retracted posteriorly with retractors positioned
horizontally, and the belly of masseter muscle was incised parallel to
the fibers of the branches of the facial nerve to expose the periosteum.
• The periosteum was incised and the direction of retractor changed
vertically to retract masseter in an upward pull manner to expose the
fractured segment

TRANSORAL APPROACH
Indications:
Fractures that involve the low condylar region.
Technique:
• An incision is made over the anterior border of the vertical
ramus, extending into the lower buccal sulcus.
• The temporalis muscle is stripped from the anterior ascending
ramus, and the masseter is stripped by subperiosteal dissection.
• A transbuccal trocar is introduced and drilling occurs
transbuccally
• the plate is introduced transorally.

TRANSORAL APPROACH
Advantage:
Avoiding facial scarring and risk of injury to the facial nerve.
Disadvantage:
• limited access, which makes fragment control difficult and the
procedure surgically more challenging.
• It may not be possible to align the posterior border perfectly
and slight errors of reduction are inevitable.

TECHNIQUES OF REDUCTION
The use of the curved elevator, Howarth’s elevator, and the
tracheostomy hook have all been advocated.
Kocher’s bone-holding forceps may be used to grasp and
reduce fragments but can crush and split the condylar head
and therefore must be used with caution.
In cases of severe and difficult reduction, the lateral
pterygoid insertion may be cut to give greater mobility and
reducibility, but preservation of the periosteal attachment to
the condylar head is mandatory to preserve a blood supply to
the proximal fragment.

Manual digital traction: Thumb is placed on the lower
teeth and fngers support the lower border. Mandible is
pulled in inferior and anterior direction.
Bite block: A bite block is placed on the same side of the
condylar fracture in the molar region. This will result in
inferior distraction of the mandible with rotation.
Transosseous wire: A transosseous wire can be passed
along the posteroinferior border of the mandible. A traction is
applied on this wire in an inferior and anterior direction.
For easy manipulation, a plate with a single screw is fixed on
the proximal fragment. This will help in easy lateralization of
the distal fragment and prevent the fragment from slipping
back as the lower end of the plate acts as a rest on the proximal
segment.

FIXATION
Miniplate Osteosynthesis:
Meyer’s line of osteosynthesis
In the case of low condylar fracture, two plates may be
required to achieve stability.
The posterior plate should parallel the posterior ascending
ramus, and the anterior plate parallel to sigmoid notch.
High condylar fractures may accommodate only one plate
due to bony limitations
3-D plates

Lag Screw Osteosynthesis
Lag screw osteosynthesis was first described in condylar fractures
by Wackerbauer in 1962.
The Eckelt screw is one of the most popular lag screws
Advantage
Rapid application of rigid fixation and close approximation of the
fractured parts because of the large amount of compression
generated.
Bioresorbable Plates

Malocclusion.
• This is often implied secondary to improper treatment, such as inadequate use of
occlusal guidance or closed reduction when open reduction is indicated.
• Patients presenting with displaced fractures, ramus shortening, and early
objective malocclusion will often have persistent centric relation discrepancies
when treated in a closed fashion.

Mandibular Hypomobility.
• This is related to delayed physiotherapy of the joint and has been shown to
increase the longer the patient is subjected to MMF.
• Children are more susceptible to hypomobility, as are those subjected to high-
energy injuries with capsular disruption.
Ankylosis.
• In children, ankylosis is related to severe meniscal disruption with inappropriate
physiotherapy.
• In adults, ankylosis usually results from a widened mandible, which leads to
superior lateral displacement of the condyle.
• This may be mitigated by proper reduction of the fractures restricting mandibular
widening.

Asymmetry.
• In children, approximately 25% of condylar fractures will produce some facial
asymmetry, whether it is hypoplasia or hyperplasia.
• In adults, deviation on opening has been noted in up to 50% of individuals following
fracture of the condyle.
Dysfunction or Degeneration.
• All injured joints are more susceptible to arthritis, and the TMJ is no different.
• Risk factors include increased age, displaced condyle, longer periods of MMF and
hypomobility secondary to capsular or meniscal injuries.
Condylar Resorption.
• Avoidable by limiting the total denudation of the blood supply and proper anatomic
reduction.
• However, difficult cases may demand replacement of the condylar head as a free bone
graft.

Iatrogenic Injury.
• Following surgical repair of condylar fractures, up to 15% of patients may
experience transient facial nerve weakness; however, permanent injury is
rare.
Chronic Pain.
• This occurs more commonly when condylar fractures are treated with
closed reduction.

Nerve injury
• During preauricular approach, a precaution should be given not to cause the injury of facial
nerve temporal branch
• Nerve injury may occur during flap elevation, fracture reduction and insertion of a metal
plate.
• If nerve injury is observed after the surgery, steroid should be immediately administered to
prevent tissue swelling, thereby shortening recovery time and preventing permanent injury.

Sialocele:
• Collection of saliva beneath the skin and subcutaneous tissue
associated with injury to glandular parenchyma or ductal system.
Clinical features:
• Salivary extravasations into the tissues causing swelling over or
adjacent to parotid gland (sialocele)
• Expanding neck mass
• Cutaneous fistula formation.
• Following transparotid approach closure includes formal closure of the
masseter and the parotid fascia - reduces the swelling and the
possibility of a sialocele

Condylar fracture.pptx

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