Bilateral Condylar Fractures Research Articles

Condylar injury: magnetic resonance imaging findings of temporomandibular joint soft-tissue changes

Recent studies have suggested magnetic resonance imaging (MRI) as useful in the evaluation of soft-tissue changes that occur in the temporomandibular joint (TMJ) after acute condylar trauma. The aim of this study was to investigate whether MRI findings of disc displacement, capsular tear and haemarthrosis are linked to the degree of condylar injury. Nineteen patients were assigned a diagnosis of uni- or bilateral condylar fracture ( n = 17), or condylar contusion with a uni- or bilateral diagnosis of TMJ sprain/strain ( n = 2). Condylar injuries were classified as grade I (absence of condylar fracture), grade II (type I, II or III condylar fracture), and grade III (type IV, V or VI condylar fracture). Bilateral sagittal and coronal MR images were obtained immediately after injury to establish the presence or absence of disc displacement, haemarthrosis and capsular tear. The data revealed a significant relationship between the degree of condylar injury and the MRI findings of capsular tear ( P = 0.000) and haemarthrosis ( P = 0.000), and between the MRI diagnoses of capsular tear and haemarthrosis ( P = 0.000). There was good diagnostic agreement between the presence of grade III condylar injury and the MRI diagnoses of capsular tear ( K = 0.62) and haemarthrosis ( K = 0.60). The results suggest that degree of condylar injury is related to MRI findings of capsular tear and haemarthrosis, and that MRI to supplement diagnosis of grade III condylar injury is warranted.

Comparison of Surgical and Nonsurgical Treatment of Bilateral Condylar Fractures Based on Maximal Mouth Opening

This study presents a comparative analysis of the open surgical and nonsurgical treatment of patients with bilateral condylar fractures. Sixty-seven (67) patients were treated, and the completed data on 55 patients were reviewed to compare both therapeutic modalities, which consisted of nonsurgical and surgical treatment in 37 and 18 patients, respectively. In the nonsurgical group, 23 patients (23/37, 62%) had normal mouth opening. Functional success rate was 79% (15/19) and 44% (8/18) in young adult patients (-29yrs) and older patients (30+yrs), respectively, and there was a significant difference of outcome between the two groups. In nonsurgically treated young patients with disorders, bilateral dislocation and existence of concomitant mandibular fractures were commonly observed. In the open surgical group, seven (7/11, 64%) young adult and three (3/7, 43%) older patients gained normal mouth opening, and no significant difference was observed. Additionally, there was no difference between non-surgical and surgical treatment in any category. Patients undergoing rigid fixation benefited from restoring maximum mouth opening, although there was no significant difference between the rigid and non-rigid fixation groups. Based on these findings, nonrigid fixation should be avoided, and rigid fixation might improve outcome in young adult patients with severe fracture pattern, such as bilateral dislocation and concomitant mandibular fracture.

Management of bilateral condylar fractures: Case review

Unilateral mandibular condylar fractures occur approximately three times more frequently than bilateral fractures [1]. Fracture of the mandibular parasymphysis region is usually associated with fracture of contralateral condyle. Unilateral fracture condyle may occur as an isolated case or along with fracture of mandible or other facial bones. Unilateral condylar fractures without displacement, are generally treated conservatively using arch bars and intermaxillary fixation (IMF). It is rare to see bilateral fracture condyle without any other associated fracture. Deranged occlusion, inability to masticate food, difficulty in opening mouth, haemotympanum and pain in preauricular region are some of the complaints of patients. In bilateral subcondylar fractures the dilemma remains whether to manage it conservatively, perform open reduction and bone plating of one side only or perform open reduction and bone plating of bilateral condyles. The age of the patient, the level of fracture, angle of displacement, dislocation of condylar head and presence of other associated fractures influences a surgeon's decision. The growth of the mandible continues throughout childhood and adolescence. So in children, IMF is restricted to fourteen days to facilitate early movement and to prevent ankylosis of temporomandibular joint (TMJ). Four cases of bilateral condylar fractures are being reviewed.

Simultaneous bilateral facial palsy as a result of isolated mandibular fractures

Post-traumatic bilateral facial nerve palsy is usually associated with fracture of the temporal bones in patients who have sustained a significant head injury. Facial nerve injury can also very rarely occur because of isolated mandibular fractures, without associated temporal bone fractures. Here is reported a case of bilateral facial nerve palsy in a patient with mandibular symphysis and bilateral condylar fractures of the mandible without evidence of temporal bone fracture or significant head injury.

O.469 Functional results after endoscope-assisted treatment of bilateral condylar fractures

O.469 Functional results after endoscope-assisted treatment of bilateral condylar fractures

Five-Year Experience with the Transoral Endoscopically Assisted Treatment of Displaced Condylar Mandible Fractures

From April of 1998 to May of 2003, the minimally invasive transoral approach for endoscopically assisted reduction and osteosynthesis of 62 displaced condylar mandible fractures was performed in 58 patients. By means of limited transoral incision, the endoscopically assisted reduction and fixation of condylar fractures was performed using 30- and 45-degree angled endoscopes. Twenty-five fractures were condylar and 37 were subcondylar. The condylar neck of the proximal fragment was displaced medially in 17 fractures and laterally in 45 fractures. Four patients presented bilateral condylar mandible fractures. Using angled endoscopes, good visibility of the fracture site was obtained, which allowed for precise anatomical reduction in all patients. An angulated drill and screwdriver facilitated miniplate fixation by means of the transoral approach. The mean operating time was measured in the last 30 consecutive cases: 1 hour 5 minutes. Postoperatively, all patients showed quick recovery to preinjury occlusion. Normal temporomandibular joint function was noted 6 months after surgery in all patients. The transoral endoscopically assisted treatment using an angulated drill and screwdriver is the method of choice for surgical management of displaced condylar fractures, even in fractures with medial override. Facial nerve injury and visible scars are avoided by using the transoral approach.

3D reconstruction and treatment planning of a facial trauma case

3D RECONSTRUCTION AND TREATMENT PLANNING OF A FACIAL TRAUMA CASE. S. Mardini, M. Noujeim, and A. Hamidaddin, Department of Dental Diagnostic Science, University of Texas Health Science Center at San Antonio. Background. Facial fractures are a common injury in the US. The most common cause is motor vehicle accident. Reconstruction of these multiple facial fractures can pose a difficult task for the surgeon. Visualization of the fractured fragments and adjacent structures is very important for a successful outcome. Computerized tomography (CT), along with new reconstruction software, has allowed for the radiologist to unveil the complexity of the case. Objective. To illustrate the role of the radiologist and the use of multiplanar reconstruction in the diagnosis and the treatment of complex fracture cases. Study design. A case was referred to the Graduate Oral and Maxillofacial Radiology Clinic at the University of Texas Health Science Center at San Antonio. A conventional CT study was reconstructed using 2 multiplanar 3-dimensional reconstruction software (Mimics 8.0 [Materialise Inc, Leuven, Belgium] and Vitrea 2 [Vital Image Inc, Plymouth, Minn]) prior to the reconstruction surgery. Results. These reconstructions revealed lesions of the body of the mandible, TMJs, the zygomaticofrontal, zygomaticotemporal, and zygomaticomaxillary sutures, the floor of the orbits, and the posterior walls of the maxillary sinuses. Conclusions. The reconstructions showed the complexity of the fractures of the mandible and the midface, including bilateral TMJ condylar fractures. Based on these reconstructions, a surgical treatment plan was formed and applied during the reconstructive surgery.

Indications for open reduction and closed reduction treatment

The treatment of condylar fractures is still a highly debated theme. With the advent of stable internal fixation devices, open treatment has become more popular. However, there is still no universal agreement on the indications for open or closed treatment. These seem to vary with every surgeon who treats such injuries. This talk will focus on factors that may be taken into account when one decides how a given condyle fracture is to be treated. The basis of the talk, however, will be that the majority of condylar fractures can be treated satisfactorily by closed techniques. The question is, Which fractures might have better outcomes when treated open? Absolute Indications for Open Treatment 1.Displacement of condyle into the middle cranial fossa (with or without fracture)2.Lateral extracapsular displacement of condyle (with or without fracture)3.Impossibility of obtaining proper occlusion by closed techniques4.Condylar fractures associated with comminuted fractures at or above the LF 1 level Relative Indications for Open Treatment All other condylar fractures may be treated closed or open. The decision to choose one method over another will vary depending upon the experience and philosophy of the surgeon, the expected outcomes from either treatment, and the factors discussed below. I therefore will not list any relative indications because what is a relative indication in my opinion may not be in another’s. I. Loss of Ramus Height. Fractures that are displaced will lead to decreases in the height of the ramus. In most cases this loss of ramus height is acceptable and will be manifest by a small cant in the occlusal plane (if the fracture is unilateral). However, if few posterior teeth are present, control of ramus height by functional (non-surgical) therapy will be difficult and large losses of ramus height may occur. II. Skeletal Maturation of Patient. Skeletally immature individuals possess the unique ability to regenerate the entire condylar process after fracture/dislocation. They also function more symmetrically after non-surgical treatment. On the other hand, skeletally mature individuals have a more limited capacity for condyle regeneration/restitution. Further, most studies indicate more functional disturbances to the masticatory system in later years in such individuals than in those injured when skeletally immature. III. Feasibility of Open Reduction and Internal Fixation. High-level fractures pose a problem in that they do not have adequate bulk to perform stable osteosynthesis. In such cases, one may select non-surgical treatment. Other factors that relate to the choice between surgical and non-surgical treatment are the general health of the patient, the pre-traumatic occlusal relationship, and the desire to avoid intermaxillary fixation/traction. IV. Associated Fractures. When bilateral condylar fractures are present, especially those that are displaced, treatment using closed techniques is extremely difficult, even when a full complement of teeth is present. Treatment will be prolonged and many adaptations, including anterior dental extrusion, will occur out of necessity to maintain the pre-trauma occlusal relationship. Open treatment of at least one fracture seems to improve the occlusal outcomes. V. State of the Dentition. Closed techniques all rely on using the dentition to position the mandible while the new articulation is established. Patients who have an incomplete dentition present a challenge for closed treatment of the condylar fracture, and might necessitate the fabrication of splints to maintain the posterior vertical dimension. Open treatment may be more efficient and may produce improved outcomes in such cases. References Zide MF, Kent JN: Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89, 1983 Konstantinovic VS, Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures: Clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 50:349, 1992 Ellis E: Condylar process fractures of the mandible. Fac Plast Surg 16:193, 2000

Magnetic Resonance Evidence of Joint Effusion of the Temporomandibular Joint After Fractures of the Mandibular Condyle: A Preliminary Report

To investigate the clinical significance of magnetic resonance (MR) evidence of joint effusion of the temporomandibular joint after mandibular condylar fractures, magnetic resonance imaging (MRI) was performed on 18 joints in 15 patients with either unilateral or bilateral mandibular condylar fractures using a 1.5 Tesla MRI scanner (Signa, General Electric, Milwaukee, WI). MR evidence of joint effusion was evaluated and compared with the types and the positions of the fractures. MR evidence of joint effusion was observed in 11 of 18 TMJs, which was 61% of the condylar fractures. It appeared more frequently after fractures with dislocation than those without dislocation (p<0.05). In addition, MR evidence of effusion appeared more frequently in TMJs after high condylar fractures (head to upper neck) than low condylar fractures (lower neck to subcondylar) (p<0.05). These findings indicate that MR evidence of joint effusion may serve as a marker for the detection of severe intra-articular damage to the TMJ after mandibular condyle fractures.

Changes in masticatory patterns after bilateral fracture of the mandibular condylar process

Purpose: Because the morphology of the temporomandibular joint is thought to control movements of the mandible during mastication, bilateral fractures of the condylar process should disrupt masticatory patterns. The purposes of this study were 1) to document changes in masticatory patterns after such fractures, and 2) to determine whether and when normal masticatory patterns are recovered. Patients and Methods: Twenty-two patients (15 men and 7 women) were examined at 6 weeks, 6 months, 1 year, 2 years, and 3 years after bilateral condylar process fractures. Patients were age and sex matched to a control sample. Incisor movements in three dimensions, along with muscle activity from the anterior temporalis, posterior temporalis, and superficial masseter, were recorded at 500 Hz during mastication of a gummy candy. Results: Although the patients showed no reduction of interincisal opening during mastication, the opening was achieved with reduction of anterior translation of the condyles. Patients had significantly narrower chewing cycles, with significantly lower adductor muscular effort during the closing phases of mastication. Differences from controls were no longer detectable 1 year after the fractures. Conclusion: The amount of opening during mastication may appear clinically normal in patients with bilateral condylar process fractures. However, disruption of controlling structures and lateral pterygoid function appears to reduce the amount of anterior translation and lateral excursion during the chewing cycle. Reduced adductor muscle activity during the closing phases may reduce loads on the fractured condylar processes. In general, these patients recover normal masticatory cycles within 1 year.

両側性下顎関節突起骨折の臨床的検討 臨床病態ならびに非観血的治療成績

We investigated clinical characteristics and treatment outcome in 38 patients with bilateral condylar fractures, which accounted for 17.5% of mandibular condylar fractures. Mandibular body fractures were concurrently present in 24 (63.2%) of 38 cases. Condylar fractures occurred most frequently in the upper neck and head of the cundyle; fractures of the condylar head often showed a longitudinal pattern. When bilateral condylar fractures were conservatively treated, the treatment outcome of bilateral condylar fractures combined with mandibular body fractures was slightly better than that of bilateral condylar fractures alone. These results suggest that mandibular body fractures combined with bilateral condylar fractures might play a role in reducing soft tissue injuries due to external force in temporomandibular joint region.

Management of posttraumatic malocclusion caused by condylar process fractures

Purpose: The aim of the study was to evaluate the results of orthognathic surgery in cases with posttraumatic malocclusion as a long-term complication of condylar process fractures. Patients and Methods: 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 or bilateral mandibular ramus osteotomies. In group II, six 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 clinical and radiographic follow-up for at least 1 year. Results: Stable dental and cephalometric results were obtained in all patients except the one 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. Conclusions: Orthognathic surgery is a predictable and stable method for the treatment of posttraumatic malocclusion due to condylar process fractures. Maxillary orthognathic surgery is successful in correcting symmetric anterior open bites due to bilateral condylar process fractures. Because posttraumatic malocclusion is a rare complication after closed treatment of condylar process fractures, and it can be treated satisfactorily using orthognathic surgery, routine open reduction and fixation of condylar process fractures is not indicated to prevent posttraumatic malocclusion.

A pragmatic approach to the management of condylar fractures

A pragmatic approach to the management of condylar fractures: pragmatic in this sense means dealing with a problem by practical methods adapted to the circumstances rather than methods based on theory or ideology. It is an unfortunate fact that despite nearly 100 publications on the subject of condylar fractures in the last 50 years this pragmatic approach remains the only option for the clinician. There is a concerted move by government health departments and corporate bodies who purchase health care towards evidencebased medicine and a consequent responsibility for providers to produce such evidence in support of treatment protocols. The more common the medical problem the more demand there is for evidence-based treatment as we have graphically witnessed in relation to third molar surgery. Regrettably, a review of the recent literature relating to fractures of the condyle suggests we are unlikely to produce evidence-based guidelines for treatment from this symposium, but I do believe we have a chance to develop a realistic protocol for prospective clinical examination of the problem and that would be a major step forward. In Britain our national specialist audit committee embarked on a prospective study of condylar fractures two years ago. The committee was only able to agree on a workable protocol on the basis of a study of isolated unilateral fractures. This was a mnlticentre audit of patients over the age of 12 years. The preliminary results are disturbing in that they reveal that in the UK adult fracture displacements and dislocations are not being optimally managed in 30% of cases. These results are even more disturbing because we already know from countless retrospective studies that unilateral fractures are not the main problem. It is the bilateral condylar fracture particularly in combination with other injuries which is our major clinical concern. In our own unit at East Grinstead one of my registrars, Mr Newman, has just looked at the resnlts of the last 58 bilateral condylar fractures we have treated in all single jaw injuries. Ten per cent of these required osteotomies for consequent malocclusion. Although the six cases treated by open reduction on one or both sides had acceptable function, these are bad results over all for a reputable department which treats over 300 facial bone fractures each year. In a short paper such as this it is impossible to review the whole of the literature. This has in any case been carried out recently in two excellent papers by HAYW~,V & SCOTT in 19939 and H ~ L s in 1994. I have decided to address five questions which I believe are relevant in order to provoke discussion: 1. Should all condylar fractures before puberty be treated conservatively? 2. Is capsular damage and rupture of the articular disk siL, nificanff and can it in practical terms be diagnosed? 3. Do we agree on a case for ORIF in selected condylar fractures? 4. How to address the technical pr0bIcms of ORIF when there are multiple facial injuries? 5. Have we the basis of a protocol for operative intervention?

A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles

The object of the study was to present our experience of the treatment of bilateral condylar fractures between 1979 and 1995 and give the long-term outcome. The subjects were 61 patients, of whom 33 attended for review. There were 41 men and 20 women, age range 12–80 years (although nearly all the patients were between 17 and 32 years old). Thirty-one patients (51%) had bilateral fractures of the mandibular condyles alone, the remainder also having another mandibular fracture, usually at the parasymphysis. Over half the patients had been injured in falls. Only 8 122 fractures (7%) were intracapsular, 59 were of the condylar neck (48%), and the remaining 55 (45%) were subcondylar. Nearly half of the fractures were undisplaced. Thirty-nine patients (21%) were treated with wire intermaxillary fixation for a mean of 37 days, 13 (21%) were managed conservatively, and 9 (15%) with 10 fractured condyles were managed by open reduction and internal fixation (ORIF). The most common complaint after treatment was persistent limitation in mouth opening, which was significantly less in the ORIF group mean (SD)) 44 mm (2 mm) than in the intermaxillary fixation group 28 mm (2 mm), P < 0.01. It is concluded that if either of the condyles is displaced ORIF is the most satisfactory method of treatment.

Adaptations of the masticatory system after bilateral fractures of the mandibular condylar process.

The objective of this investigation was to evaluate the adaptations that occur in the masticatory system after treatment of bilateral fractures of the mandibular condylar process. Twenty-two patients (15 men and seven women) with bilateral condylar process fractures treated by open reduction and rigid internal fixation (n = 6), closed therapy (n = 14), or a combination of these techniques (n = 2) were compared with 22 sex- and age-matched controls. Measures of mandibular range of motion, bite force, muscle activity, estimated joint forces, and skeletal morphology were determined at 6 weeks, 6 months, and 1, 2, and 3 years after treatment in all subjects. Various statistical tests were used for comparing differences between patients and controls. There was no significant difference in the patients' morphologic measures for the open and closed reduction procedures; therefore, all of these patients were tested as a single group. After treatment, patients had significantly increased mandibular plane and gonial angles and decreased facial axis angles. They also showed a significant reduction in posterior facial height and moment arm length for the masseter and pterygoid muscles. Anterior and posterior temporalis muscle direction also was significantly different between patients and controls. Patients had significantly limited mobility during the first year after fracture. Bite forces were lower for patients at all times and tooth positions, with a significant difference at 6 weeks after treatment. Patients had a tendency to use proportionally higher temporalis muscle activity during maximum biting; however, the differences were not statistically significant, probably because of the small sample size. The estimated joint force magnitudes were essentially identical between patients and controls; however, the direction of the patients' joint forces were more posteriorly directed for both incisor and molar bites. The results of this study suggest that early reduction in mandibular range of motion, bite force, and the distribution of masticatory muscle activity assist in preventing overloading of the bilaterally fractured mandibular condylar processes.

Magnetic resonance imaging of the temporomandibular joint after functional treatment of bilateral condylar fractures in adults

The position and functioning of discs in ten adult patients, whose bilateral condylar fractures were treated following a nonsurgical protocol, were investigated by means of magnetic resonance imaging. In seven temporomandibular joints (TMJs), where the condylar fragments were situated in the confines of the glenoid fossa, the discs were not displaced and were functioning normally. In 13 TMJs, where the condylar fragments were medially dislocated out of the fossa, the discs were displaced together with the condylar head, but moved forward together with the condyle during mouth opening. This relationship between disc and condyle appears to play an important role in the reestablishment of function using nonsurgical treatment in patients with condylar fractures.

Wurzburg lag screw plate versus four-hole miniplate for the treatment of condylar process fractures

Purpose : The purpose of this study was to compare the biomechanical stability of rigidly fixed condylar neck fractures using either a conventional four-hole miniplate system or the Wurzburg lag screw plate system. Materials and Methods : Ten identical synthetic mandibles were used for this study. Simulated bilateral condylar neck fractures were fixed with the lag screw plate system on one side and the miniplate system on the other. The mandibles were loaded with an MTS servohydraulic testing machine at a rate of 1 cm/min until failure was reached. Data for resistance to motion and ultimate strength for each fixation device were compared by paired Student t-tests. Results : The mean resistance to motion for the four-hole miniplate was 64.0 kg/mm (SD = 10.1; range = 52–94) and for the lag screw system was 80.2 kg/mm (SD = 24.0; range = 55 to 126). The mean failure strength was 4.0 kg (SD = 0.9) (range = 2.6 to 5.5) for the miniplate system and 5.0 kg (SD = 2.5; range = 3.4 to 7.2) for the lag screw system. The lag screw system was significantly ( P < .05) better than the miniplate for both parameters measured. Conclusion : In laboratory testing using synthetic mandibles, the Wurzburg lag screw-plate fixation system proved superior to a four-hole miniplate system in regard to resistance to motion and failure strength. Clinical trials are necessary to substantiate these laboratory data and determine whether the system can be effectively applied by the surgeon.

Comparison of computed tomography imaging before and after functional treatment of bilateral condylar fractures in adults: Choi BH. Int J Oral Maxillofac Surg 25:30, 1996

Comparison of computed tomography imaging before and after functional treatment of bilateral condylar fractures in adults: Choi BH. Int J Oral Maxillofac Surg 25:30, 1996

Magnetic resonance imaging of the temporomandibular joints after functional treatment of bilateral condylar fractures in adults

Magnetic resonance imaging of the temporomandibular joints after functional treatment of bilateral condylar fractures in adults

Comparison of computed tomography imaging before and after functional treatment of bilateral condylar fractures in adults: Choi BH. Int J Oral Maxillofac Surg 25:30, 1996

Comparison of computed tomography imaging before and after functional treatment of bilateral condylar fractures in adults: Choi BH. Int J Oral Maxillofac Surg 25:30, 1996