Management of posttraumatic malocclusion caused by condylar process fracture

1. BECKING AG, ZIJDERVELD SA, TUINZING DB.
Management Of Posttraumatic Malocclusion Caused By
Condylar Process Fracture. J Oral Moxillofac Surg 56:
1370-l 374, 1998.
PRESENTED BY –
DR. SHEETAL KAPSE
GUIDED BY –
DR. RAJASEKHAR G.

2. 1. BECKING AG - Oral and Maxillofacial Surgeon.
2. ZIJDERVELD SA -Oral and Maxillofacial Surgeon.
3. TUINZING DB -Professor, Oral and Maxillofacial Surgery.
 Departmcnt of Oral and Maxillofacia1 Surgery, Free University
Hospital, Amsterdam, The Netherlands.

3.  Introduction
 Aim
 Materials and methods
 Results & Discussion
 Cross references
 Conclusion
 Pros and Cons of study
 References

4.  Condylar fracture is one of the most common fractures in the
mandibular region, with an incidence ranging from 29 to 52%.
 The great majority of condylar process fractures arc probably treated
with closed reduction. The occurrence of posttraumatic malocclusion
is reported to be 4.4%
 Conventional therapy, tooth grinding, extraction of interfering teeth,
prosthodontics, orthodontics, orthognathic surgery, or combinations
of these.

5.  Posttraumatic malocclusion with asymmetry due to unilateral condylar
process fractures are corrected with an osteotomy on the affected side,
or sometimes on both sides.
 A symmetric anterior open bite due to bilateral condylar process
fractures presents a surgical dilemma. It can be corrected with either an
osteotomy of both affected sides of the mandible or an osteotomy the
maxilla.
Rubens BC, Stoelinga PJW, Weaver TJ, et ai: Management of malunited mandibular condylar fractures. Int J Oral
Maxillofac Surg 19:22,1990
Ellis E III: Biological considerations concerning treatment of fractures of the mandibular condyle. International
conference on management of fractures of the mandibular condyle, Groningen, The Netherlands, 1997

6. 1) To evaluate the treatment of asymmetric malocclusion due to
unilateral condylar process fractures
2) To evaluate the treatment of symmetric posttraumatic
malocclusion with anterior open bite due to bilateral condylar
process fractures.

7.  A retrospective study on 21 patients with posttraumatic malocculsions
attributable to condylar process fractures was performed.
 In group I, 15 patients were treated for asymmetric malocclusion with
unilateral (13) or bilateral mandibular ramus osteotomies (2).
 In group II, 6 patients were treated for anterior open bit with either a Le Fort
I osteotomy (n = 5) or a bilateral ramus osteotomy (n = 1).
 All patients had closed treatment, including 1 to 3 weeks of maxillomandibular
fixation, followed by elastic bands for regaining preinjury occlusion and
functional therapy.
 All patients had clinical and radiographic follow-up for at least 1 year.

8. 32 year-old man with an asymmetric malocclusion
due to a right-sided condylar process fracture 2 years
after initial treatment of’ 3 weeks of
maxillomandibular fixation and subsequent use of
elastic bands and functional therapy. A, Intraoral
view before orthographic surgery; 6, Preoperative
panoramic radiograph; C, Clinical situation 1 year
after a sagittal spit osteotomy on the right
side; D, Postoperative panoramic radiograph.

9. Twenty-two-year-old woman with an anterior open bite as the
result of bilateral condylar process fractures 18 months after initial
treatment with 3 weeks of maxillomandibular fixation, class 2
elastic band traction, and functional therapy. A, Preoperative
anterior open bite; B, Panoramic radiograph of the bilateral
condylar process fractures and a median symphyseal fracture
before treatment; C , Preoperative lateral cephalogram; D, Lateral
cephalogram 1 year after orthognathic surgery; E, Dental situation 1
year after orthognathic surgery.

10. All patients had a follow-up period after orthognathic surgery of at
least 1 year, with a mean of 3.6 years.
Models and serial cephalograms were used to identify occlusal changes
& skeletal relapse.
Stable dental and cephalometric results were obtained in all patients
except the 1 in group II who was treated with bilateral sagittal split
osteotomies.
In two cases, both in the asymmetric group, minor occlusal
interferences had to be treated by equilibration in the early
postoperative period.

11.  According to the literature, the treatment of choice in restoring
preinjury occlusion in patients with posttraumatic malocclusion is an
osteotomy on the affected jaw, sometimes even at the fractured side.
 In cases with asymmetric posttraumatic malocclusion due to a condylar
process fracture, the only. Surgical option is an osteotomy at the
affected side of the mandible, because facial symmetry needs to be
corrected.
 A posttraumatic anterior open bite due to bilateralcondylar process
fractures presents a philosophical dilemma. The open bite can be
considered either an entirely posttraumatic situation or an acquired
dentofacial deformity.

12.  The first statement dictates restoration of ramus heigth; the latter
advocates closure of the anterior open bite with (bi)maxillary surgery.
 Dorsal impaction of the maxilla and subsequent autorotation of the
mandible is reported to prevent relapse.
 Ramus osteotomies with counterclockwise rotation of the distal
fragment exceeding 40 are unsuitable because of reported relapse.

14. 1. Correction of the lower jaw will not lead to alterations in the
inclination of the upper anterior teeth so that presurgical or
postsurgical orthodontics will therefore seldom be necessary.
2. If correction is carried out in the affected lower jaw, the resulting
situation will be identical to the original skeletal relation.
3. Reconstruction of the affected jaw will be more acceptable to patients.

15. 1. In time, because of neuromuscular adaptation, a posttraumatic
situation might be considered as a dentofacial deformity.
Autorotation of the mandible after dorsal impaction of the maxilla
might result in less relapse when there is a considerable anterior open
bite rather than closure of an open bite by ramus osteotomies and
counterclockwise rotation of the distal fragment of the mandible.
2. No technical difficulties will be encountered in surgery of the maxilla
with respect to the earlier condylar process fracture. On the contrary,
managing the proximal fragment in ramus osteotomies after a
condylar process fracture can be difficult, especially if the condylar
process was grossly dislocated at the time of the initial treatment.

16. 3. A higher prevalence of temporomandibular joint problems are
reported to occur after mandibular ramus surgery than after Le Fort I
osteotomies used to close an anterior open bite.

17.  The non-surgical treatment of mandibular condylar fractures, may occasionally
result in articular imbalance and temporomandibular joint dysfunction.
 This may be attributed to condylar head displacement and resorption, resulting in a
shortened vertical ramus and lost posterior vertical facial height.
 Restoring the vertical ramus height is essential in the treatment of such dysfunction,
and may be accomplished by unilateral, or bilateral ramus osteotomies.
 Four examples of patients treated with mandibular ramus osteotomies to restore
vertical ramus height, with subsequent improvement in occlusal balance and
function are presented.
 The use of the sagittal split mandibular osteotomy and the external vertical ramus
osteotomy, stabilized with small osseous plates, and monocortical screws, is
discussed.

20.  Prospective study
 Long term follow up
 Logical
 Less sample size
 Relapse
 Children

21.  The supratemporalis approach provides excellent exposure of the
surgical field with minimal complications.
 Compared with the traditional approach, the supratemporalis
approach effectively prevents injury to the facial nerve.
 Therefore, the authors suggest this surgical method as a routine
approach to treat intracapsular condylar fractures.

22. 1. Rubens BC, Stoelinga PJW, Weaver TJ, et ai: Management of malunited mandibular condylar
fractures. Int J Oral Maxillofac Surg 19:22,1990
2. Ellis E III: Biological considerations concerning treatment of fractures of the mandibular condyle.
International conference on management of fractures of the mandibular condyle, Groningen, The
Netherlands, 1997
3. B. C. Rubens, P. J. W Stoelinga, T. J. Weaver and P. A. Blijdorp: Management Of maiunited
mandibular condylar fractures. Int. J. Oral MaxiIlofae. Surg. 1990; 19: 22-25.
4. N. Zachariades, M. Mezitis, A. Michelis. Posttraumatic osteotomies of the jaws. lnt. J. Oral Maxillofac.
Surg. 1993," 22." 328-331.