presentation kcd

Condylar fractures and their management

most common fractures of the mandible.

Involve TMJ eitherdirectly or indirectly

Represent 20-30% of all mandibular fractures

CLASSIFICATION• 1.Unilateral or Bilateral condylar fractures• 2.Rowe and Killeys classification(1968)• a)Intracapsular or high condylar #• b)Extracapsular or low condylar#or

subcondylar #• c)fractures associated with injury to

capsule,ligaments and meniscus• d)fractures involving the adjacent bone

e.g # of roof of glenoid fossa or the tympanic plate of external auditory meatus

• 3.Clinical classification by MacLennan(1952

• a)No displacement• b)Displacement• c)Deviation• d)Dislocation

WASSMUNDS CLASSIFICATION

A. TYPE I• Fracture of neck of the condyle with slight

displacement of head.• 10-45 degree variation between head and axis

of ramus.• Tend to reduce spontaneously.B.TYPE II• 45-90 degree angulation between head and

ramus.• Tearing of medial portion of joint capsule.

C. TYPE III• Fragments not in contact.• Condylar head displaced medially

and forward.• Fragments confined within glenoid

fossa.• Capsule torn and head is outside the

capsule.

D. TYPE IV• Fractured head articulates on or

forward to articular eminence.E. TYPE V• Vertical or oblique fracture through

head of condyle.

• COMPREHENSIVE CLASSIFICATION• Lindhal (1977)• A) Fracture level• i)condylar head• Intracapsular • Vertical ,compression, comminuted

ii) Condylar neckiii) Subcondylarb) Relationship of condylar fragment to mandiblei) Undisplacedii) deviatediii) displaced with medial overlap of condylar fragmentiv) displaced with lateral ovelap of the condylar fragmentv) Anteroposterior overridevi) no contact

• Relationship of condylar head to fossa• i)No displacement• Joint space appears normal• ii)Displacement• Joint space increased• D)injury to meniscus• Torn,ruptured or herniated in forward or

backward direction

• 7.Thoma classification (1945)

• Spiessl and schroll classification

• 5 types

• AETIOLOGY1) Assault• Interpersonal violence or fist fight2)Road Traffic Accident3)Sports injuries4)Falls on the chin5)war injuries

• MECHANISM• i)Degree of force• K=1/2 mvv• ii)Direction of impact• Above,below,front ,side• iii)The precise point of application of force• chin• Lateral side of face• iv)open or closed mouth• v)partially or fully edentulous patients

• DIAGNOSIS1) Examination• Inspection• Palpation• Auscultation

2)Radiographs OPG PA VIEW

OPG

• Clinical features• Unilateral condylar fracture• Limitation in mouth opening• Swelling over TMJ area• Bleeding from the ear• i)laceration of anterior wall of EAM ii)fractur of petrous temporal boneBattles signGagging of occlusion on Ipsilateral side(ramus

shortening

Deviation on opening towards the side of fracturePainful limitation of protrusion and lateral excursion to the opposite sideBilateral condylar fracturesAnterior open bite(bilateral displaced fractures of condylar necks)Pain an d L.M.O With restricted protrusion and lateral excursion fracture of symphasis and parasymphasis frequent.

TREATMENT OF CONDYLAR FRACTURES

• No clear guidelines exist.• Three treatment options• 1)functional• 2)indirect immobilization• 3)osteosynthesis• CONSERVATIVE-FUNCTIONAL TREATMENT• Condylar neck fracture with little or no dislocation• ALL intracapsular # and all # in growing children.• CHILDREN• UNDER 10 YEARS• DISREGARD MALOCCLUSION• DO FUNCTIONAL TREATMENT• MMF INDICATED FOR 7-10 DAYS for pain control only.

Treatment• ADOLESCENTS AGED 10-17 YEARS• If occlusion undisturbed= FUNCTIONAL TREATMENT• If malocclusion present=MMF for 2-3 weeks.• ARGUMENT FOR ORIF?Whether indicated for major

displacement of condyle.• FUNCTIONALTREATMENT• SEMI SOLID DIET• ANALGESICS• MUSCLE TRAINING JAW EXERCISES• ELASTIC TRACTIONS

MMF

ADULTSINTRACAPSULAR UnilateralOcclusion undisturbed=conservative treatment(dietary advice,appropriate analgesics)Slight malocclusion with effusion in tmj=MMF for 2-3 weeks.BilateralIf there is slightly deranged occlusion=MMF for 3-4 weeks.

CONDYLAR NECK #UNILATERALUndisplaced # and occlusion undisturbed=no active treatment necessarySUBCONDYLAR #ORIFHIGH CONDYLAR FRACTUREExtensive displacementand malocclusion=MMF FOR 3-4 WEEKS.BILATERALFUNCTIONALTREATMENT C/IOPERATIVE REDUCATION OF ATLEAST ONE OF THE # IS DESIRABLE TO RESTORE RAMUS HEIGHT.BILATERAL HIGH CONDYLARNECK #OPEN REDUCTION DIFFICULT=MMF FOR 6 WEEKS.

METHODS OF FIXATION OF CONDYLAR #• 1)TRANSOSSEOUS WIRING• 2)BONE PLATING WITH

MINIPLATING SYSTEM• TWO STANDARD MINIPLATES

SHOULD ALWAYS BE INSERTED• 3)LAG SCREW OSTEOSYNTHESIS

• SUBMANDIBULARAPPROACH

• Ramus #• Low fractures of condylar

neck• Retromandibularapproach

/postramal incision• Subcondylar/low condylar

#• PREAURICULAR

APPROACH• High condylar #

• THANK YOU• Dr. Qiam-ud-din• Dr. Umer Khitab• Dr. Muslim khan• Dr. Attaurahman• Dr. Murad• TMOS Oral Surgery