Condylar Fracture & Its Management

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GOOD MORNING

CONDYLAR FRACTURE & ITS MANAGEMENT (cont.) DR.SHADAB ALI BAIG MDS II

Topic covered • • • • • • • • • • • •

Introduction Incidence Etiology Surgical anatomy Classification Clinical signs & symptoms Imaging Management Complications Flow chart Conclusion References

INDEX • Controversies between 1. Open vs closed approach 2. ORIF vs Endoscopic-assisted surgery 3. Endoscopic-assisted surgery : Extraoral vs Intraoral

• Conclusion • References

Controversies In the area of mandibular condyle fracture, there is controversy not only with regard to indication for open reduction versus closed reduction but also how to approach when there is an indication to do so.

Controversies To compare between ORIF and Closed reduction techniques • To compare between extra oral approach and Endoscopic assisted repair . • To compare between an Endoscopic assisted Extra oral & Trans oral approach for open reduction for condylar mandibular fracture.

ORIF vs CLOSED TECHNIQUE • A study was performed to evaluate and compare the results of open and closed treatment of intra capsular condylar fractures of mandible. • 14 displaced condylar fractures, which were treated ORIF were examined clinically, radiological & axiographically & were compared to a group of 29 similar condylar fractures which had been treated with closed techniques.

ORIF vs CLOSED TECHNIQUE (cont.) • Closed treatment avoids potential complications such as facial nerve damage and loss of osteosynthesis material. • But complaints such as • extensive condylar deformity • Height reduction of the mandibular ramus • Disc displacement • Dysfunctional complaint such as Limitation of mandibular mobility, Crepitation, Lateral deviation during mouth opening. has been described.

CLINICAL DYSFUNCTION INDEX

ORIF vs CLOSED TECHNIQUE (cont.) • The risk associated with ORIF can be reduced by using • • • • •

A nerve stimulator Modified auricular approach Cautious retraction Meticulous hemostasis Use of resorbable slender osteosynthesis Plates.

ORIF vs ENDOSCOPIC ASSISTED SURGERY Treatment of subcondylar fracture has been traditionally between open or closed techniques but recently Endoscopic fracture repair has been described as a minimally invasive approach for open reduction with potential for decreased patient morbidity

ORIF vs Endoscopic assisted surgery (cont.) • Endoscopic assisted surgical • A 15-20 mm modified Risdon incision was used to gain access to the lateral ramus. • A subperiostal dissection was performed blindly to create an ‘optical cavity’ on the lateral aspect of the ramus • A modified retractor with a curved end was placed through the incision & below the periosteum to engage the sigmoid notch

Lateral view of mandibular condyle region to demonstrate the use of angled elevator for the reduction of condylar fracture

ORIF vs Endoscopic assisted surgery (cont.) • A 4-mm, 30 degree Hopkins endoscope was used for retraction & visualization on a video monitor system. • Following irrigation & the use of suction elevators the sigmoid notch , inf border, post border and the fracture site is to be identified endoscopically. • Reduction was achieved using DCP with screws placed via preauricular stab incision

Intraoperative Endoscopic view of the reduction of the fragment using reduction forceps and an angled elevator

ORIF vs Endoscopic assisted surgery (cont.) • Following reduction and stabilization, the MMF is released and the occlusion is reevaluated. • Post op MMF is not used • Incision is closed in layers. • Follow up

ORIF vs Endoscopic assisted surgery (cont.) • The current limitations of ORIF includes • poor access & visualization • Difficult dissection that may necessitate 2 incisions • Facial nerve deficit • Delayed functional rehabilitation becoz of wide reflection of periosteum & muscle • And scar(s)

ORIF vs Endoscopic assisted surgery • In comparison to ORIF , the endoscopically assisted reduction technique -• Allows direct visualization of the fracture site via an illuminated & magnified field of view for fracture reduction • Stabilizes through a conservative incision with an acceptable cosmetic result • Remains extracapsular with out effect on articular cartilage or synovial fluid • The additional morbidity of a preauricular incision & extended periods of MMF are avoided, with accelerated functional recovery.

ENDOSCOPY-ASSISTED OPEN TREATMENT:- EXTRAORAL vs INTRAORAL • In case of moderately displaced , a transoral approach is used to avoid damage of the facial nerve & visible scars. • Surgical approach:The periosteum of the ascending ramus was elevated down to the mandibular angle & the inferiorly inserting fibers of the temporalis muscle was stripped off the muscular process to create the optical cavity.

ENDOSCOPY-ASSISTED OPEN TREATMENT:- EXTRAORAL vs INTRAORAL (cont.)

• The endoscope was inserted subperiosteally without incision of the masseter muscle & advanced cranially towards the # site untill the # gap is visible in the endoscope • Angulated drills& screw drivers were used to avoid transbuccal stab incision

Intra operative view of angulated drill and screw driver for the drilling & insertion of screws

ENDOSCOPY-ASSISTED OPEN TREATMENT:- EXTRAORAL vs INTRAORAL (cont.)

• The transoral approach is less time consuming than extra oral approach & intraoral scars are invisible & no facial nerve damage is expected. Suitable for dislocation with lateral override but not for severe dislocation & comminuted #s.

CONCLUSION • The principal factors that determines the treatment decision are the • Level of fracture • Degree of displacement • Age of patient • Availability of advanced surgical equipment • Surgical skill of the operator • Patients consent.

REFERENCES • Michael Miloro , DMD, MD , Omaha, Neb. Endoscopic-assisted repair of subcondylar fractures. Oral Surg Oral Med Oral Path.2003;96:387-391. • M. Hlawitschka, R Loukota, U ECKELT: Functional & radiological results of open & closed treatment of intracapsular condylar fracture of the mandible. Int J. Oral & Maxillofac surg. 2005;34: 597-604. • Edward EllisIII,DDS,MS-Treatment of mandibular condylar process fractures; Biological consideration. Int J. Oral & Maxillofac surg. 2005,63:115-134. • R Schon, R Gutwald- Endoscopy- assisted open treatment of condylar fractureof the mandible:- Extraoral vs Intraoral approach. Amer J. Oral & Maxillofac surg. 2002;31:237-243. • Pedro M, Villarreal MD, PhD, FEBOMS-Mandibular condyle fracture: determinates of treatment & outcome. Amer J. Oral & Maxillofac surg. • Takashi Honda, M.D,- Endoscope-assisted facial fracture repair. World J Surg. 2001;25:1075-1083.

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