Académique Documents
Professionnel Documents
Culture Documents
Introduction
Incidence
Anatomy
Etiology
Classification of Fracture
Clinical Examination
Conclusion
Reference
Introduction
Condylar fractures are the most common overall fractures of the mandible. Condylar
fractures account for 25% to 35% of all mandibular fractures. Fracture of the neck of
the condyle can be regarded as a safety mechanism which protects the patient from
the serious consequence of middle fossa fracture. Fractures involving the mandibular
condyle are the only facial bone fractures which involve a synovial joint.
Fracture of condyle may be consequence of an indirect blow and direct blow. Indirect
blow as when the external force, being applied in an anteroposterior direction and
from below upwards upon the chin, the head of the condyle is forced against the
prominent margins of the glenoid cavity. From a direct blow as when moving object
strikes the region of the joint forcibly and impinges upon this part of the bone.
Incidence
The relative weakness of the mandible in the region of the neck would appear to make
it the most vulnerable part of the whole jaw.
Incidence of condylar fractures may be as high as 35.6%. (Rowe & Killey, 1968)
Tasanen et. al. 1975 -> 32.4%
Ekholm 1961 -> 27.7%
Schuchardt et.al. 1966 -> 25%.
Fonseca (1974) pointed out a relatively high incidence of condylar fractures in road
traffic accidents, speculating that the mouth is likely to be open, either to scream or in
fright at the moment of impact, and contrasted this with the low incidence in boxing
where the boxer uses a mouth protector and has a tendency to keep the teeth clenched
into the soft mouthpiece.
Anatomy
Anatomy of condyle is important to predict and manage the effect of trauma.
Muscles Several muscles act upon the mandibular condyle, ramus and boyd.
Lateral pterygoid muscle act upon the condyle. Lateral pterygoid muscle is often
described as having a superior and inferior portion. The superior lateral pterygoid
muscle originates from the inflatemporal surface of the greater wing of the sphenoid
and inserts on the temporomandibular joint capsule and disk and the neck ofthe
mandibular condyle.
structures. The superior portion of the lateral pterygoid muscle functions when the
mandible is elevated against resistance. The inferior portion of the lateral pterygoid
muscles originates from the lateral surface of the lateral pterygoid plate and inserts on
the condylar neck. These muscles function during protrusion and lateral excursive
movements of the mandible.
Blood Vessels The temporomandibular joint itself is relatively a vascular the soft
tissue surrounding the mandibular condyle and subcondylar region is highly vascular.
End branches of the external carotid artery travel on both the medial (maxillary
artery) and lateral (superficial temporal artery) aspects of the condylar head and neck.
The external carotid artery bifurcates in the parotid gland region, developing into the
maxillary and superficial temporal arteries.
Superficial Temporal Artery This artery in the pre-auricular region runs in the
temporoparietal fascia just beneath the subcutaneous fat layer. This artery crosses
lateral to the zygomatic arch and forms a single branch, the transverse facial artery.
After crossing over the zygomatic arch the superficial temporal artery divides into the
frontal and parietal branches.
Maxillary Artery The maxillary artery is the largest terminal branch of the external
carotid artery. It originates from the external carotid medial to the condylar neck at
the level of the sigmoid notch. It first travels through the parotid gland posterior and
medial to the condylar neck and then runs along the inferior portion of the lateral
pterygoid muscle. The first portion of the maxillary artery, termed the mandibular
portion, travels through the infratemporal fossa in close proximity to the medial
aspect of the mandibular condyle and neck. In this region the maxillary artery divided
into several branches, including the deep auricular, anterior tympanic, middle
meningeal, accessory meningeal and inferior alveolar arteries. The second portion of
the maxillary artery also partitions into several branches.
detaches from the maxillary artery and travels through the sigmoid notch before
entering the medial surface of the masseter muscle.
Retromandibular Vein The superficial temporal vein and the maxillary vein unite,
forming the retromandibular vein, within the body of the parotid gland medial to the
mandibular condyle neck. This vein descends through the parotid gland superficial to
the external carotid artery and deep to the facial nerve. It travels just posterior to the
ramus of the mandible and divides into an anterior and a posterior portion. The
anterior portion joins the facial vein and then empties into the internal jugular. The
posterior portion joints the posterior auricular vein and then empties into the external
jugular vein.
Nerves
Facial Nerve The facial nerve emerges from the brain-stem and enters the internal
auditory meatus. It travels through the petrous portion of the temporal bone in the
facial canal and exits the skull base at the stylomastoid foramen. The main trunk of
the facial nerve is 2 cm deep to the skin surface at the middle of the anterior border of
the mastoid process. The posterior auricular nerve and branches to the posterior
digastric and stylohyoid muscle arise from the facial nerve as it exits the skull base.
The nerve then courses forward toward the parotid gland. It crosses over the styloid
process, retromandibular vein and external carotid artery before entering the parotid
gland and dividing into the temporal facial and cervical facial branches. The mean
distance from the lowest portion of the bony external auditory canal to the bifurcation
of the facial nerve was 2.3 cm and that from the post glenoid tubercle was 3 cm. At
kayat and branmley also found that distances from the most anterior portion of the
bony external auditory canal to where the upper trunk crossed the zygomatic arch
ranged from 0.8 cm 3.5 cm. This defined the 8 mm 'safe zone' for preauricular
incisions. In the body of the parotid gland the temporal facial and cervical facial
branches further divide into the nerve's terminal branches (temporal, zygomatic,
buccal, mandibular and cervical). The temporal branch travels in, or just deep to, the
temporal parietal fascia. It innervates the frontalis, corrugator and orbicularis oculi
muscles.
Trigeminal Nerve The third division of the trigeminal nerve exists the skull base
through the foramen ovale. At this point the nerve is 4 cm from the skin surface and
just anterior and deep to the condyle neck. The motor root of the third division of
trigeminal nerve supplies motor innervation of the muscle of mastication.
The
auricular temporal nerve (branch of the third division of trigeminal nerve) courses
laterally behind the condyle neck and supplies sensation to skin in the temporal and
pre-auricular region, the external auditory meatus and the tympanic membrane. The
lingual nerve (next branch) travels in an anterior direction deep to the lateral
pterygoid muscle. The nerve continues laterally, emerges from under the lateral
pterygoid and runs between the mandibular ramus and medial pterygoid muscle. The
inferior alveolar nerve is initially deep to the lateral pterygoid muscle. It emerges
below the inferior surface of the muscle, crosses the spheno-mandibular ligament and
enters the mandibular foramen.
Etiology
A etiological factors leading to condylar fractures may be grouped as
1)
2)
Mechanism of Injury
Lindanl (1977) divided trauma causing condylar injury into three groups.
1)
2)
Kinetic energy derived from the movement of the individual and expended
upon a static object. This type of injury is more often seen in an epileptic
patients or soldiers who fall on the face during parade.
3)
The position of the fractured condyle in relation to the other fractured segment
will depend on certain factors :
1)
2)
3)
4)
2)
a)
b)
c)
3)
a)
ii)
b)
c)
d)
Fractures involving the adjacent bone eg. fracture of the roof of the glenoid
fossa or the tympanic plate of the external auditory meatus.
4)
a)
b)
Deviation : Simple angulation exists between the condylar neck and the ramus.
c)
Displacement : Overlap occurs between the condylar process and the ramus.
The obliquely fractured condylar fragment lies lateral to the ramus.
d)
Dislocation : Disruption takes place between the condylar head and the
glenoid fossa. The condylar fragment gets pulled anteriorly and medially by
the lateral pterygoid muscle.
5)
a)
Type I : Fracture of the neck of the condyle with slight displacement of the
head. The angle between the head and axis of the ramus varies from 10-45.
These type of fractures tend to reduce spontaneously.
b)
Type II : An angle of 45-90 is seen between the head and the ramus. There is
tearing of the medial portion of the joint capsule.
c)
Type III : The fragments are not in contact. Head is displaced medially and
forward due to the pull of lateral pterygoid muscle and spasm. The fragment
is generally confined within the area of the glenoid fossa. The capsule is turn
and head is outside the capsule open reduction is advocated.
d)
e)
Type V Vertical or oblique fracture through the head of the condyle (rare).
6)
Comprehensive Classification
Proposed by Lindhal (1977), which required radiographs in two planes at right
angles to each other.
a)
i)
comminuted
ii)
iii)
Sub condylar
b)
i)
ii)
iii)
iv)
v)
vi)
c)
i)
ii)
iii)
d)
7)
A)
Condylar fracture
1.
Greenstick fracture
Intracapsular
Extra capsular
2.
Lateral
Medial
Forward
Backward
3.
4.
Intracapsular
5.
With comminution
B)
1.
2.
C)
1.
2.
3.
4.
5.
6.
Head fracture
Clinical Examination
Condylar fracture are the most common overall fractures of the mandible and are the
ones most commonly missed on clinical examination.
They may be unilateral or bilateral and they may be intra capsular or extra capsular.
The most common displacement is anteromedial owing to the direction of pull of the
lateral pterygoid muscle, which is attached to the anteromedial aspect of the condylar
head and to the meniscus of the tempromandibular joint.
Unilateral Condylar Fractures
Sign and Symptoms
There may be haemorrhage from the ear on that side results from laceration of
the anterior wall of the external auditory meatus.
Ecchymosis of the skin just below the mastoid process on the same side. This
particular physical sign also occurs with fractures of the base of the skull when
it is known as 'Battle's sign'.
If the condylar head is dislocated medially and all oedema has subsided due to
passage of time, a characteristic hollow over the region of the condylar head is
observed.
Paraesthesia of the lower lip in the absence of a fracture of the body or angle
of mandible on that side.
The signs and symptoms for unilateral fracture may be present on both sides.
There is pain and limitation of opening and restricted protrusion and lateral
excursions.
1.
2.
3.
Open reduction
The objective of surgical treatment is achieved by exposure of the condylar fragment,
reduction to the normal relationship and fiaxation in that position.
Zide and Kent (1983) have outlined the indications for open reduction.
Zide and Kent's indication of open reduction
1.
Absolute Indications
2.
Relative indications
Surgical Approaches
There are three principal approaches to a fractured condyle.
1.
Preauricular approach
2.
Submandibular approach
3.
Intraoral approach
1.
2.
3.
Intra oral approach An incision is made from high on the anterior border
of the ramus downwards to the retromolar region. The tendinous attachment
of the temporalis is exposed. Medial dissection is carried out to identify the
inferior alveolar nerve at the mandibular foramen. With intra and extra oral
Bone pins Archer (1975) describes the insertion of pins into the condylar
2.
head and neck which are connected with an external bar and universal joints.
Plating A small monocortical non-compression bone plate may be used for
3.
4.
lateral edge of the glenoid fossa and the related edge of the condylar
articulating surface. A chronic catgut suture can be looped through and tied.
It may, however, resorb or loosen prematurely with unpredictable results, as
reported by Herfert (1961).
Kirschner wire A Kirschner wire may be drilled vertically through the main
5.
mandibular fragment from the angle, avoiding the inferior alveolar bundle, so
that it enters the fracture interface and can be further inserted into the condyle
which has previously been reduced. Petzel (1982) describes a technique using
self tapping intramedullary screw pins inserted from a submandibular incision.
The lower end is secured to a countersunk nut which, when tightened, exerts a
degree of compression at the fracture site.
Surgical Technique (Endoural modification of preauricular approach)
Scalp is shaved and head prepared and draped for sterile surgery.
To get a correct relationship between the fractured segments one must do IMF
prior to the surgery.
Once the fractured segments are reduced four miniature holes are made using
a drill to stabilize the attained result.
Patients should be informed not to perform any physical jaw exercise in the
immediate postoperative period.
Mouth
opening,
overbite,
overjet,
mandibular
mobility
and
2.
3.
4.
5.
The degree of
fixation required for a period of 3-4 weeks for stable union. Physiotherapy
after intermaxillary fixation prevents any restriction of the mouth opening.
6.
1.
2.
Site and type of fracture Intracapsular fractures are associated with high risk
of ankylosis. Laskin considers that the most important feature in a fracture
encouraging ankylosis is close contact between the glenoid fossa and the
condylar stump and that this is more likely to occur with intracapsular
fractures than with extra capsular fractures.
3.
4.
Damage to meniscus Laskin has suggested that the position and state of the
meniscus may be the key factor in determining whether post traumatic
ankylosis will develop. The meniscus acts as a barrier between the glenoid
fossa and the condylar head. Therefore bony union does not occur in a
condylar fracture wherein the meniscus is intact, but If meniscus is damaged
or misplaced then ankylosis may occur.
Conclusion
Condylar fractures are most common fractures of the mandible. Because of relative
weakness of mandible in this region, neck of mandible is the most vulnerable part of
the whole jaw.
It is unfortunate that there are still no clear guide lines for the treatment of mandibular
condylar fracture. Fractures can be treated by conservative treatment using closed
reduction and by surgical treatment using open reduction. Treatment type should be
selected considering patient's age, fracture type.
References
S.M. Balaji