Fractures of the mandibular condyle (2023)

paraphernalia

Procedural history

Fractures of the mandibular condyle account for 25% to 35% of all fractures of the mandible. The classification and treatment of condyle fractures is a controversial issue in maxillofacial trauma. This is due to the anatomical complexity of the condyle, the wide insertions, and its contribution to the temporomandibular joint. The Lindahl classification of mandibular condyle fractures is a complex but commonly used system. It is based on the level of the fracture, the amount of displacement, and the relationship of the condylar head to the fossa.Figure 67-1). Lindahl classified fractures based on fracture levels: condylar head fracture, condylar neck fracture, and subcondylar fracture.Figure 67-2). A condyle head fracture is located within the joint capsule; a fracture of the neck of the condyle is inferior to the joint capsule and inferior to the insertion of the lateral pterygoid muscle. A subcondyle fracture is inferior to the condyle between the sigmoid notch and the posterior aspect of the mandible. Spiessl identified six types of fractures (1 to 6) that described displacement of the fracture fragments and displacement of the condylar head from the fossa. The classifications are: nondisplaced fracture, displaced inferior condyle neck fracture, displaced superior condyle neck fracture, dislocated inferior condyle neck fracture, dislocated superior condyle neck fracture, and intracapsular fracture.

Neff et al also classified condylar head fractures into three types. In this classification, type A passes through the medial part of the condylar head; type B is on the lateral part of the condylar head; and type C is close to the insertion of the lateral capsule. Bhagol et al developed a classification system for subcondylar fractures based on ramus height shortening and the degree of fracture displacement. It recommended that Class I (minimum displacement) be treated conservatively. Class II (moderately displaced) can be treated conservatively or surgically, although functional results in this group were slightly better than the surgically treated group. Class III (severely displaced) fractures are treated surgically. Loukota et al recently developed a subclassification of subcondylar fractures into high condylar neck, low condylar base, and dicapitular fractures. Ellis et al further simplified condylar fractures into three groups: condylar head, neck, and base fractures.

The management of condylar fractures is controversial and includes observation, closed treatment, and open reduction with or without endoscopic visualization using transfacial or intraoral approaches.Figure 67-3). Studies published in the last decade are more favorable to open surgical treatment. Isolated intracapsular fracture is treated only with physical therapy. Although these fractures can cause significant anatomic and radiological changes in the appearance of the condyle itself, most patients do well if adequately rehabilitated.Figure 67-4). Singh et al recently published the largest blinded randomized controlled trial comparing (open) surgical techniques with closed treatment; concluded that both treatment options yield acceptable results (Figure 67-5). However, the surgically treated group was superior in all objective and subjective functional parameters, except occlusion.Figure 67-6). A recent meta-analysis, containing 20 studies, including four randomized clinical trials, found that surgical treatment was as good as or better than conservative treatment.Figure 67-7).

The surgical approach to the condyle for open reduction and fixation is dictated by the level of the fracture, the experience and skill level of the surgeon, the degree of displacement or displacement of the fracture, the wishes of the patient, and the risk of complications, among others. other factors. . The retromandibular approach is the most versatile approach for the head, neck, and condylar ramus. There are two variations of this technique: transparotid and retroparotid. The transparotid technique described by Hinds with the Ellis modification provides the shortest distance with the fastest access from the skin to the mandible. Branches of the facial nerve are often found; however, complications with facial nerve weakness or injury rarely occur. The retroparotid technique requires a longer incision and is 2 cm posterior to the ramus, allowing the dissection to proceed deep into the parotid gland and facial nerve. The disadvantage of this approach is the dissection and the working distance between the incision and the condyle.

Wire fixation, intramedullary pins, miniplates, and compressive rigid plates have been used to stabilize these fractures. However, a single rigid miniplate or two semirigid plates are the current treatment of choice.Figure 67-8).

Procedural history

Fractures of the mandibular condyle account for 25% to 35% of all fractures of the mandible. The classification and treatment of condyle fractures is a controversial issue in maxillofacial trauma. This is due to the anatomical complexity of the condyle, the wide insertions, and its contribution to the temporomandibular joint. The Lindahl classification of mandibular condyle fractures is a complex but commonly used system. It is based on the level of the fracture, the amount of displacement, and the relationship of the condylar head to the fossa.Figure 67-1). Lindahl classified fractures based on fracture levels: condylar head fracture, condylar neck fracture, and subcondylar fracture.Figure 67-2). A condyle head fracture is located within the joint capsule; a fracture of the neck of the condyle is inferior to the joint capsule and inferior to the insertion of the lateral pterygoid muscle. A subcondyle fracture is inferior to the condyle between the sigmoid notch and the posterior aspect of the mandible. Spiessl identified six types of fractures (1 to 6) that described displacement of the fracture fragments and displacement of the condylar head from the fossa. The classifications are: nondisplaced fracture, displaced inferior condyle neck fracture, displaced superior condyle neck fracture, dislocated inferior condyle neck fracture, dislocated superior condyle neck fracture, and intracapsular fracture.

Neff et al also classified condylar head fractures into three types. In this classification, type A passes through the medial part of the condylar head; type B is on the lateral part of the condylar head; and type C is close to the insertion of the lateral capsule. Bhagol et al developed a classification system for subcondylar fractures based on ramus height shortening and the degree of fracture displacement. It recommended that Class I (minimum displacement) be treated conservatively. Class II (moderately displaced) can be treated conservatively or surgically, although functional results in this group were slightly better than the surgically treated group. Class III (severely displaced) fractures are treated surgically. Loukota et al recently developed a subclassification of subcondylar fractures into high condylar neck, low condylar base, and dicapitular fractures. Ellis et al further simplified condylar fractures into three groups: condylar head, neck, and base fractures.

The management of condylar fractures is controversial and includes observation, closed treatment, and open reduction with or without endoscopic visualization using transfacial or intraoral approaches.Figure 67-3). Studies published in the last decade are more favorable to open surgical treatment. Isolated intracapsular fracture is treated only with physical therapy. Although these fractures can cause significant anatomic and radiological changes in the appearance of the condyle itself, most patients do well if adequately rehabilitated.Figure 67-4). Singh et al recently published the largest blinded randomized controlled trial comparing (open) surgical techniques with closed treatment; concluded that both treatment options yield acceptable results (Figure 67-5). However, the surgically treated group was superior in all objective and subjective functional parameters, except occlusion.Figure 67-6). A recent meta-analysis, containing 20 studies, including four randomized clinical trials, found that surgical treatment was as good as or better than conservative treatment.Figure 67-7).