Condylar fractures /certified fixed orthodontic courses by Indian dental academy

CONDYLAR FRACTURES

INDIAN DENTAL ACADEMY
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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 phase Less active in latent
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


MAXILLOFACIAL INJURIES
MANDIBULAR FRACTURES
Condylar Fractures
Etiology
Classification
Clinical features
Radiological investigations
Treatment options
Complications

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Etiology
Indirect injury - Chin
Direct injury - Zygoma


GK / MAXFAC
SDM DHARWAD

Mechanism of fractures

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

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


Condylar Fractures
Classification
Anatomical: Intra / extra capsular
Unilateral / bilateral
Radiographic
2 radiographs @ Right angle
OPG, PA mandible
1) Level of #
2) Relationship to mandible

3) Relationship to glenoid fossa

MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Level of #

Head

HEAD (Intra capsular)

Neck
Sub Condylar

NECK
SUB CONDYLAR #

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Relationship to mandible
Undisplaced
Deviated
Displaced

GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Classification
Relationship to glenoid fossa

Undisplaced

Displaced

Dislocated
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SDM DHARWAD

Condylar Fractures
Clinical features
Pain & Tenderness
Painful limitation in mouth opening
Occlusal derangement
Bleeding from ear
GK / MAXFAC
SDM DHARWAD

Condylar Fractures
Clinical features - Unilateral # condyle
Deviation to affected side
Midline shift
Lateral movements limited

GK / MAXFAC
SDM DHARWAD


Condylar Fractures
Clinical features - Bilateral # condyle
Gagging of posterior teeth
Anterior open bite
Lateral movements limited
GK / MAXFAC
SDM DHARWAD


Condylar Fractures
Radiographic investigations
2 radiographs @ right angles
OPG, PA mandible
Optional : Trans Pharyngeal
Trans Cranial
Trans Orbital
C.T coronal views

GK / MAXFAC
SDM DHARWAD

Condylar Fractures

Management (Conservative)
No active treatment
Immobilization (7-10 days)
Active physiotherapy

GK / MAXFAC
SDM DHARWAD

Closed Method
• Range of treatment options available - observation and soft diet,
variable periods of immobilization &/or intense physiotherapy
• Close supervision is mandatory
• Need for immobilization - when malocclusion, deviation with function,
&/or pain is present.
• The period of immobilization - must be long enough to allow initial union
of the fracture segments but short enough to prevent complications
• Active functional therapy allows a return of mandibular range of
motion and functional movements
• Guiding elastics should be used to direct the mandible to its maximal
intercuspation.

Condylar Fractures

Management (Surgical)
Open reduction & fixation
Grossly dislocated #s


GK / MAXFAC
SDM DHARWAD

Indications of Open Method
1.
2.

1.
2.
3.

Relative indications

Bilateral condylar fractures with comminuted midface
fractures in which rigid internal fixation of the midface is
not possible
Situations when intermaxillary fixation is not feasible as
a result of the following:
Medical restrictions
Poorly controlled seizure disorder
Psychiatric disorders
Severe mental retardation
Concomitant injuries such as head injury or chest injury
Displaced fractures where dentures or splints are not
feasible because of severe mandibular atrophy
Bilateral fractures in which it is impossible to determine
what the proper occlusion is

Surgical Approaches
The various incisions to approach the condyle
are :1. Submandibular
2. Preauricular
3. Endaural
4. Retromandibular
5. Intra oral
6. Hemicoronal approach

Surgical Approaches
Submandibular approach
Most suitable for ramus fractures and for low fractures of the
condylar neck
Can be combined with an endaural incision for total joint
reconstruction


Surgical Approaches
Preauricular & Endaural
• appropriate for repositioning and fixing intracapsular and very high
condylar fractures
• Under certain conditions it can also be used, together with a sub
mandibular access, for high temporomandibular joint fractures that
access
are difficult to reduce


Incision

Dissection

Surgical Approaches
Preauricular & Endaural

Dissection above the arch - to sup temp plane
Below the arch – just superficial to tragal cartilage
To the bone – The structures within the flap raised off the arch
contain skin, supf templ vessels and nerves, Facial n braches,
Sup temp fascia & if www.indiandentalacademy.com – temporal fascia
taken more superiorly

Surgical approaches
Retromandibular / Posterior mandible approach
This approach is indicated for low and high condylar
fractures
incision begins 0.5 cm below the lobe of the
ear and continues inferiorly for 3-3.5 cm.


Surgical Approaches
Intra oral approach

Only for low fractures of the TMJ
It was initially proposed by
Steinhauser
• Advantage
No visible scars but this is offset
by the lack of good vision


Methods of Osteosythesis –
Miniplate fixation


Special considerations –
Children
Suggested protocol for treatment of condylar fractures in
children
• Nearly all cases- conservatively treated with immediate
function & analgesics
• In cases with pain & malocclusion – brief period of IMF –
7-10 days followed by active function
• As for adults, close supervision & follow up is mandatory
• Early mobilization & active physical therapy aimed at
increased range of mandibular motion & prevents
ankylosis & growth alteration

Condylar Fractures
Complications
Malocclusion
Damage to teeth
TMJ pain
Ankylosis
Open reduction
Scar
Nerve damage
Intra-operative haemorrhage
Avascular necrosis

GK / MAXFAC
SDM DHARWAD

Complications
EARLY COMPLICATIONS
Complications that occur concurrent with or early after
treatment of condylar fractures include the following
1. Fracture of the tympanic plate - otorrhea
2. Fracture of the glenoid fossa with or without displacement
of the condylar segment into the middle cranial fossa –
nuerological signs
3. Damage to cranial nerves V and VII – traumatic/post op
4. Vascular injury

Complications
LATE COMPLICATIONS

Late complications of condylar fractures commonly
include the following:
1.
2.
3.

Malocclusion
Growth disturbances
Temporomandibular joint dysfunction (Internal
derangement)
4.
Ankylosis

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