Controversies in the management of Condylar Fractures

Dr jameel kifayatullahTMO oral surgery

Khyber college of dentistry

Controversial fractures

• The most controversial fractures regarding diagnosis and management(Villareal 2004).

• The major controversy is to open? or not to open

Reasons for controversy

• There are many different methods to treat this injury.

• Poor quality of the available data and the lack of other important information.

• No definitive study performed that has shown superiority of open v/s closed reduction.

• Basic mechanisms of repair of the condyle after injury have not been fully appreciated.

CLOSED PROCEDURE

Closed procedure

• Traditionally all of the condylar fractures were managed closed with maxillo mandibular fixation.

• Conservative approach should be regarded as the first choice of treatment for condylar fracture.(villareal 2004,smete 2003)

• As long as there is contact b/w the proximal and distal fragments= union with acceptable results(Maclennan,villarel etal)

• Closed reduction provides good results(Zide and Kent 1983)

• Conservative methods technically simpler,offer reduced overall morbidity with satisfactory functional results with infrequent ankylosis and avascular necrosis.

• Little justification for surgically exposing the area provided the vertical height and occlusion are maintained.

MacLennan and Simpson(1965)

• After reviewing large series of condylar fractures concluded that a good result was

achieved by closed conservative management in 93 % cases.

Complications of Closed technique

• True anatomic reduction not achieved.RESULTS are malocclusion,facial

asymmetry,decreased mouth opening. dahlstron etal studyDecreased translation,deviation to the fractures side

of greater than 5mm with opening,abnormal condylar head and shortened condylar/ramus height on plain films.

Worsae and Thorn(1994)

• In the group treated closed there were higher rate of facial asymmetry impaired masticatory function post operative joint pain

Marker and Nielson(2000)

• patients had minor complaints of slight limitations of M.O Or deviation with opening.

• complaints of joint pain on the side of fracture.

• malocclusion related to initial injury.

Yang and Chen(2002)

• Of the 96 patients 30 were managed closed.• Of the closed group 21% patients showed

facial asymmetry with chin deviation to the fractured side.

Haug And Foss( 2000)

• Malocclusion• Chronic pain• Limited mobility• AsymmetryOccasionally associated with closed

reduction.

Takenoshita(1989) Zhang and Obeid(1991)

• Closed treatment for more displaced fractures is more prone to produce suboptimal results

• Deviation on M.O• Loss of ramus height• malocclusion

Kent etal (1990)

• Late arthritic changes may occur 10-50 years later in cases treated by closed reduction.

Silvennoinen etal

• 30% of their condylar process fractures had persistent deviation on opening.

• Loss of posterior vertical dimension has been demonstrated within 6 weeks after closed treatment of condylar process fractures.

• The combination of a damaged condylar process and immobilization may cause a cicatricial reduction in condylar translation,resulting in deviation toward the side of fracture on opening or in protrusion.

• Immobilization of a damaged joint leads to degeneration of the articular surfaces and development of fibrous adhesions,limiting mobility.

Adaptations

• 3 main types of adaptation to restore TMJ articulation to facilitate masticatory function: 1)NM adaptation

2)skeletal adaptation 3)dental adaptation

NM Adaptation

nm adaptations are short term adaptations that assist in positioning the mandible until a new skeletal articulation has been reestablished.

NM adaptations• Bilateral condylar fracture=posterior

collapse=premature contact of terminal molars creating an anterior open bite.

• NM adaptation that occur are in the muscles of mastication eg temporalis = increased activity in temporalis=posteriorly directed vector onto the coronoid process=rotate the anterior portion of mandible superiorly bringing incisors into contact.

Skeletal Adaptation

• Development of a new tm articulation after condylar process fracture.

• Begins immediately after injury and continues for many months afterwards.

• 3 methods:1)condylar regeneration 2)changes in the temporal component of tmj and superior

movement of ramus

3)loss of posterior vertical dimension(within 6 weeks after closed treatment)

Dental Adaptations

• With closed treatment of condylar process fractures there is extrusion of incisors and intrusion of molars.

Open techniques

Introduced in mid 1940 s.1980 s miniplate fixation introducedOpen reduction aims at anatomical repositioning

and rigid fixation of the fragments,occlusal stability,rapid return to function,maintenance of vertical ramus dimension,no airway compromise and less long term TMJD(Hovinga etal 1999;Ellis etal 2000)

Open Reduction

• Open reduction of the condylar process eliminates the need for extensive remodelling.

• ORIF of the fractured condylar process obviate the necessity for these NM,skeletal and dental adaptations.

Open reduction

• Surgical treatment to reapproximate the fractures segments has been advocated to avoid the complications of

• Open bite• Retrognathia• Pain• Reduced lateral and protrusive mobility• Deviation on opening (jeter etal 1988,Lachner etal 1991)

Haug and Assael 2001

List of indications for open treatment • Patient preference• Inability to establish normal occlusion with

a closed procedure• Situation in which the stabilty of occlusion

was limited

palmieri 1999, Ellis and throckmorton 2004)

• Surgically treated condylar fracture give better results in terms of occlusion,masticatory function,mouth opening and bone morphology.

Surgical Approaches

Surgical Approaches

Open treatment methods

Open Treatment Methods

Open treatment methods

Complications of open treatment

• Difficulty of surgical access• Extraoral scars• Lesion of facial nerve• Plate fracture• Aseptic necrosis of the condylar segmentSecondary to loss of periosteal blood supply during

dissection for exposure.• Haemorrhage(intraoperative bleeding from

maxillary artery injury)

– Berger(1943) warned that ORIF of condylar process fractures using wires could cause infection and necrosis of the condylar fragment.

James R Hayward(1993)Advocated the factors affecting decision of closed

versus open reduction of condylar fractures:• Age of patient• Level of fracture• Degree of displacement• Direction of displacement• Medical status of the patient• Concomitant injuries• Presence of dentition• Status of existing dentition• Ease in establishing adequate occlusion

Guidelines• Fractures in growing

children(intracapsular+extracapsular) must be with closed treatment(consensus).

• No consensus as regards the treatement of condylar fracturs in adults.

• Open v/s closed treatment is judged individually.• In adults the type of treatment must mainly be

chosen on case to case basis and the personal experience of each professional.

• Intracapsular fracture in adults also managed closed.• Conservative treatment required when the patients

past medical history doesn’t allow the administration of G.A.

Intracapsular fracture

Zide and kent (1983)

• Outlined indications for open reduction as follows:ABSOLUTE INDICATIONS (a) displacement of condyle into middle cranial fossa(b) Impossibility of obtaining adequate occlusion by

closed treatement(c) Lateral extracapsular displacement of condyle(d) Invasion by foreign body e.g missile

RELATIVE INDICATIONS(a)When IMF is C/I for medical reasons( e.g

alcoholism,seizure disorder,asthma,mental retardation)

(b)bilateral condylar fractures associated with comminuted midface fractures.

(c) Bilateral condylar fractures associated with gnathologic problems (e.g retrognathia,open bite).

• Medial or lateral override (ORIF)

• Surgery should be performed in the adult whenever the vascular supply of the displaced part of the condyle is compromised as in cases of severely displaced condyles(i.e displacement greater than 45 degree in either the coronal or sagittal plane.

• ORIF should be contemplated for the edentulous or the mandible with lack of posterior support,and those with skeletal abnormalities(such as open bite and prognathism) that compromise occlusal stability.

• To avoid/shorten duration of MMF.

Bilateral condylar neck fractures

• Operative reduction of atleast one of the condyles to restore ramus height desirable.

• Bilateral high condylar neck fracture= operative reduction likely to be difficult=go for MMF for upto 6 weeks.

• When there is bilateral condylar neck fracture associated with major mid facial fracture =go for operative reduction of both sides.

• Displaced subcondylar fractures in adults esp bilateral =ORIF.

Thank you