CONDYLAR FRACTURES

Presented by
Neelofar
IInd YR MDS
Moderator
Dr Varsha upadya
INDEX
▪ Introduction
▪ Anatomy of TMJ
▪ Etiology
▪ Mechanisms of injury
▪ Classification
▪ Clinical signs and symptoms
▪ Imaging
▪ Treatment
▪ Recent advances
▪ Conclusion
▪ Reference
 INTRODUCTION
▪ Fractures of mandibular condyle are common and account for
9-45% of all mandibular fractures.
▪ The complexity of TMJ region, as well as its anatomic
proximity to other craniofacial structures, makes diagnosis and
treatment especially challenging.
▪ Interestingly, only few areas of oral & maxillofacial surgery
have evoked as much controversy and debate as management of
injury to the TMJ.
SURGICAL ANATOMY
RELATIONS
BLOOD SUPPLY
▪ Superficial temporal artery
▪ Transverse facial artery
▪ Posterior tympanic artery
▪ Posterior deep temporal artery

NERVE SUPPLY
▪ Facial nerve
▪ Auriculotemporal nerve
DIFFERENCE IN ADULT AND PEDIATRIC
CONDYLE
 ETIOLOGY
Ellis et al - In a large retrospective
study of 2137 patients with
mandibular fractures

▪ 43% -Vehicular accidents

▪ 34% -Assaults
▪ 7% -Work related
▪ 7% -Result of a fall
▪ 4% -Sporting accidents
Remainder - Miscellaneous causes
 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. Eg by a fist, cricket bat or ball
2. Kinetic energy derived from the moving individual striking a static object
3. Kinetic energy, which is the sum of, forces due to combination of factors 1 and 2
 Classification of
Condylar Fractures

10
 WASSMUND’S
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 confined to within the glenoid fossa.

• 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.
Thoma (1948) – classified
▪ Fracture with displacement
▪ Fracture without displacement
▪ Fracture with dislocation
▪ Fracture dislocation with complete displacement
Clinical classification by MacLennan (1952)

Class I: no deviation (bending)

Class II: deviation (bending) at the fracture level
Class III: displacement (condylar head remains within
fossa)
Class IV: dislocation (condylar head outside of fossa)
 Rowe and Killey’s classification (1968)

•Intracapsular Fractures or High Condylar

•Extracapsular or Low Condylar Fractures

•Fractures associated with injury to the capsule, ligament

and meniscus

•Fractures involving adjacent bone

Spiessel and Schroll
classification (1972)

i. Nondisplaced fracture
ii. Low neck fracture with
displacement
iii. High neck fracture with
displacement
iv. Low neck fracture with
dislocation
v. High neck fracture with
dislocation
vi Head fracture

1
LINDAHL CLASSIFICATION (1977)

Anatomic location of the fracture

• Condylar head
• Condylar neck
• Subcondylar

Relationship of condylar fragment to

mandible
• Nondisplaced
• Deviated
• Displacement with medial or
lateral overlap
• Displacement with anterior or
posterior overlap
• No contact between fractured
segments

Relationship of condylar head & fossa

• Nondisplaced
• Displacement
• Dislocation
NEFF AND RASSE’S
MODIFICATION (2006)
• Type A: Displacement of
medial condylar pole with
preservation of the vertical
dimension

• Type B : The lateral condylar

pole is involved with loss of
the vertical dimension

• Type C : dislocation of the

entire condylar head

Classification of condylar process fractures; M. Schneider, U. Eckelt;

Journal of the Canadian Dental Association December 2006,
Vol. 68, No. 11
R.A. LOUKOTAA ET AL
SUBCLASSIFICATION
(2005)

Diacapitular fracture (through the head
of the condyle)

Fracture of the condylar neck:



Fracture of the condylar base


AO Classification

The condylar process and head is a subunit of the mandible and

is defined by an oblique line running backward from the sigmoid
notch to the upper masseteric tuberosity. The condylar process is
differed into three subregions:
•Head
•Neck
•Subcondylar (caudal) area
Treatment implications
Clinical features
UNILATERAL CONDYLAR
FRACTURE
A. Inspection
• Swelling over the TMJ area.
• facial asymmetry
• CSF otorrhea may be present
• Heamorrhage
• Haematoma on the involved side
• Ecchymosis of skin just below the mastoid process( battle ‘s
sign)
• Characteristic hollow over the region of condylar head.
• Deviation of chin to the affected side
• Soft tissue trauma over the anterior mandible or prearicular
region
23
B. Palpation :
• Tenderness over the
condylar area.
• Mandibular movements:
- Protrusion
- Lateral excursion will be
limited
• Inability to palpate condylar
movement.
 Intra – orally :
• Mandible deviates on
opening towards the side of
fracture.
• Painful protrusion or lateral
excursion to the opposite
side.
• Premature contact of the
molar teeth on the side of
fracture.
 BILATERAL CONDYLAR
• FRACTURES
Inspection & palpation are same
as unilateral
• Overall mandibular movement is
usually more restricted than in case
of unilateral.
• Mandible deviation may or may not
be present
• The midlines are often coincident,
and premature contact is present
bilaterally on the posterior
dentition with an anterior open
bite and retruded appearance of
mandible
• widening of the mandible and
subsequent malocclusion
 RADIOGRAPH
IC IMAGING
• OPG
• Bilateral lateral oblique.
• Towne view.
• Reverse Towne view.
• Tmj views
• Computed Tomography.
• CBCT
• MRI
Orthopantomogram and lateral oblique View of
mandible
REVERSE TOWNE’S VIEW

•Mainly indicated for Condylar

neck fractures.

•To visualise medial & lateral

displacement of the condyles.
PA VIEW TOWNE’S
VIEW

6
TYPES OF TMJ VIEWS
▪ TRANSPHARYNGEAL VIEW
▪ TRANSORBITAL VIEW
▪ TRANSCRANIAL VIEW
 CBCT

▪ CBCT is more sensitive and accurate in imaging the mandible

▪ Fractures that are not evident in conventional CT can be identified using CBCT
•Computed tomography (CT) –
• Ideal for visualizing
mandibular fracture
• Axial and coronal views
• 3d reconstruction of the face
gives a better image of the
fracture

•TMJ including tomograms –

detecting condylar fracture and
anterior post displacement of
condylar head.
MAGNETIC RESONANCE IMAGING
(MRI) –

6
MANAGEMENT
Treatment Goals

▪ No pain and minimum interincisal distance of 40 mm on opening the mouth.

▪ On excursions movements are good.
▪ Restore pre-injury occlusion.
▪ Good stable temporomandibular joints.
▪ Good symmetry of face and jaw.
 MANAGEMENT
Non-operative:
• Observation, physiotherapy, etc.
Operative:
• Closed procedures:
• MMF (arch bars or screws—elastic or wire)

• Open reduction and internal fixation (ORIF)

–– Approach is determined by:
(i) Surgeon preference
(ii) Fracture location
(iii) Type of fixation
Factors Taken into Consideration for Treatment

• Location of the fracture

• Amount of vertical reduction in height of the ramus
• Degree of angulation
• Relation of condylar head to the glenoid fossa
• Fragmentation pattern (simple versus complex)
• Association with other mandibular injuries
• Dental occlusion/status of dentition
• Association with other facial bone injuries
• Association with systemic injuries
• Association with the condition of the patient
(comorbidity factors)
• Foreign body in temporomandibular joint (TMJ)
 Indication for Open and
Absolute
Closed Reduction
• Condyle displaced into middle cranial fossa
• Presence of foreign body
• Extracapsular displacement of condyle laterally
• Malocclusion not amenable to closed reduction (e.g., functional reduction of ramus height)

Strong evidence for open reduction

• Bilaterally fractured condyles
• Condyle displacement grossly >45° (severely displaced)
• Anatomic reduction of ramus height ≥ 2 mm
• Condylar fractures with an unstable base (associated midface fractures)
• Unstable occlusion generally seen in periodontal disease, less than three teeth per quadrant
• Condylar fractures for which adequate physiotherapy is impossible
Mixed evidence for open reduction
• Moderate condylar displacement, 10–45°

When to treat with closed reduction

• Nondisplaced or incomplete fractures
• Isolated intracapsular fractures
• Condylar fractures in children (except for absolute indications)
• Reproducible occlusion without dropback or with dropback that returns to midline on
release of posterior force
• Medical illness or injury that inhibits ability to receive extended general anaesthesia
 CLOSED REDUCTION
Closed reduction may involve the following:

1)Maxillomandibular fixation (MMF):

▪ Children under 10 years of age-7-10 days
• Adolescents-10-17 years-2-3 weeks
• Adults – U\L intracapsular-2-3 weeks
U\L condylar neck- 3-4 weeks
B\L intracapsular-3-4 weeks
B\L condylar neck-6 weeks
2) Functional treatment-At times only, functional
treatment may be followed. This treatment relies
on guiding elastics and active movements
OPEN REDUCTION AND FIXATION
Surgical approaches to the condylar fracture are entirely dependent on the
following factors

1. Location of the injury

2. Type of osteosynthesis
Incisions used to approach the fractures are divided as
▪ 1. Intraoral
▪ 2. Retromandibular
▪ 3. Submandibular/ periangular
▪ 4. Preauricular/ retroauricular
 SUBMANDIBULAR/PERIANGULAR/RISDON’S

Incision for submandibular/periangular approach. Area exposed marked green in the mandible
RETROMANDIBULAR
TRANSPAROTID APPROACH
RETROPAROTID APPROACH
PREAURICULAR APPROACH
RETROAURICULAR APPROACH
INTRAORAL APPROACH
REDUCTION

Can be achieved as follows :

1. Manual digital traction: Thumb is placed on the lower teeth and fingers support
the lower border. Mandible is pulled in inferior and anterior direction.
2. 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.
3. 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.
 FIXATION TECHNIQUES

At the time of surgery fixation, technique is selected based on the following parameters:
▪ 1. Fracture morphology
▪ 2. Amount of bone available
▪ 3. Surgeon preference

Several osteosynthesis techniques are available for fixation like the mini plates, stainless
steel wire, standard lag screws, resorbable screws and plates , resorbable pins, and
cannulated lag screws
 TRANSOSSEOUS WIRING

• Occasionally used in low

subcondylar fractures extending
through the sigmoid notch
• Access is possible through a
submandibular approach
BONE PINS
GLENOID FOSSA-CONDYLE
SUTURE
▪ Wassmund (1935) described drilling a small hole through the
lateral edge of the glenoid fossa and the related edge of the
condylar articulating surface.

▪ A chromic cat-gut suture was looped through and tied.

▪ It may, however, resorb and loosen prematurely with

unpredictable results as reported by Herfert ( 1961).
 KIRSCHNER WIRE

• A k-wire may be drilled vertically

through the main mandibular
fragment from the angle, avoiding
the inferior alveolar bundle, so that
it enters the fracture interface
• Brown and obeid modified this
technique in 1984, in which they
used two interosseous wires to fix
the k wire
INTRAMEDULLARY SCREWS
FUNCTIONAL EXERCISE:
REHABILITATION

Targets
1. Maximal mouth opening > 40 mm
2. Lateral excursive movement > 10 mm
3. Protrusive movement > 10 mm
4. Full range of movements which are pain free
5. Close supervision by the surgeon
 RECENT ADVANCES

• Improvements in imaging (CT scan/MRI)

• Surgical approaches better understood, and their application is based on the site of condylar
fracture.
• Importance of anatomic reduction which leads to early full range of function.
• Improvement in open or assisted internal fixation techniques.
• Ability to approach and manage intracapsular fractures.
• Need to manage soft tissue injury as and when need.
• There is an improvements and wide choice of fixation materials including resorbable
materials.
• Early and effective postoperative rehabilitation
 ENDOSCOPIC ASSISTED
OSTEOSYNTHESIS
Advantages-
• access high condylar fractures,
• better visualization,
• lesser complications
• Instruments required- angled
drills, a 30 degree angled 4mm
endoscope, screwdrivers,
illuminating hooks and retractors
COMPLICATIONS OF CONDYLAR
FRACTURES
1.Malocclusion
2. Mandibular hypomobility
3. Ankylosis
4. Asymmetry.
5. Dysfunctional degeneration
6. Condylar resorption
7. Hardware failure
8. Infection
9. Chronic pain seen in closed reduction.
10. Neurosensory disturbances
CONCLUSION
 REFERENCES
▪ Oral & maxillofacial trauma-Fonseca & walker
▪ AOMSI -Oral and Maxillofacial Surgery for the Clinician
▪ Text book of Oral surgery – kruger
▪ Killley and kay
▪ Oral & maxillofacial trauma-Rowe & Williams-vol 2
▪ Principles of Oral & maxillofacial surgery-Peterson
▪ Maxillofacial trauma & facial reconstruction-Peter Ward Booth
▪ Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the
CanadianDental Association December 2006, Vol. 68, No. 11
▪ Condylar Fractures Raja Sawhney, MD, MFAa , Ryan Brown, MDb , Yadranko Ducic,
MD, FRCS(C)
▪ Handschel J, Rüggeberg T, Depprich R, Schwarz F, Meyer U, Kübler NR,
Naujoks C. Comparison of various approaches for the treatment of fractures
of the mandibular condylar process. Journal of Cranio-Maxillofacial Surgery.
2012 Dec 1;40(8):e397-401.
▪ Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in
the pathogenesis of traumatic temporomandibular joint ankylosis.
Head & face medicine. 2014 Dec;10(1):1-2.