• 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.
THANK YOU