 Welcome back to OMFS lecture series. Continuing with condylar fractures, today we shall look into the clinical features, investigations and management of fractures of mandibular condyle. Let's see the clinical features associated with unilateral condyle fracture. Here is often swelling and tenderness over the TMJ area of the affected side. There is hemorrhage from ear on the same side which results from laceration of the anterior wall of external auditory meridus. Here it is important to distinguish bleeding originating in the external auditory canal from the middle ear hemorrhage. In middle ear hemorrhage it indicates a fracture of the pectoral temporal bone and this may be accompanied by cerebrospinal autoria. That means escape of cerebrospinal fluid through the ear. It is known as cerebrospinal autoria. You will also find achemosis 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 and it is known as battle sign. If the condylar head is dislocated medially and after all the edema has subsided due to passage of time a characteristic hollow over the region of the condylar head is observed. So this is characteristic of unilateral condylar fracture. During opening the mandible deviates towards the side of the fracture. That means deviates towards the affected side. There is unilateral posterior crossbite. Displacement of the condyle from the fossa or if the fracture condylar neck is overriding then it causes shortening of the ramus on the same side and produces gagging of occlusion on the same side molars. There is also limited or painful protrusion or excursion. Excursion means while the mandible is being deviated to the opposite side it is painful. In bilateral condylar fractures all the signs and symptoms present in unilateral fractures may be present on both the sides and overall the mandible movement is more restricted than in unilateral fractures. If there is a displacement of the condyle from the glenoid fossa or overriding of the fractured bone ends then an anterior open bite is present. Pain and limitation of opening and restricted protrusion is present in case of bilateral fractures also. Bilateral condylar fractures are frequently associated with fracture of the symphysis and parasymphysis. Also the appearance of an elongated face may be result of bilateral subcondylar fracture. Here is a diagrammatic representation of the characteristic disturbances of occlusion after condylar injury. As you can see in the first diagram this is a post-chromatic effusion or hemarthrosis. Hemarthrosis means collection of blood within the joint space. So this hemarthrosis may distract the joint surfaces causing a posterior open bite on the affected side or the same side with the deviation of the mandibular midline towards the opposite side. So this is characteristic of a contusional injury or where there is bleeding within the joint space without any definite fracture. The second diagram is that of a unilateral fracture with significant dislocation or displacement. This may result in contraction of the fragments under the action of pterigomacetrix link with ipsilateral premature posterior contact. ipsilateral means on the same side. So when there is action of pterigomacetrix link it produces a premature posterior contact on the same side and the deviation of mandibular midline to the affected side. So there is premature contact and shift of midline towards the same side. The third diagram is that of bilateral fracture dislocation. Here the fracture condyles are dislocated medially. In this case medially. This will produce a premature posterior contact on both the sides with no deviation. Here there is no shift in midline but there is premature contact on both the sides with anterior open bite. This is characteristic of bilateral condyler fractures with dislocation. The fourth figure shows bilateral dislocation without fracture. Here the condyles are not fracture but it is dislocated completely. It means the condyler heads are out of glenoid fossa. This is likely to produce an appearance of long face or prognathism. The patient is unable to occlude the posterior teeth. So there is almost complete inability to occlude any teeth and there is appearance of prognathism or pseudo prognathism. So these are the characteristic disturbances of occlusion after condyler injury. Moving on to the investigations associated with condyler injuries. Recent advances in the field of imaging technology have enabled accurate diagnosis and localization of condyler injuries. So you may use conventional radiographic techniques like orthopantamogram, reverse towns view or a transcranial view of TMJ to visualize the injured condyle. You may also use computed tomography and MRI or arthrography. MRI or magnetic resonance imaging is usually performed to study the soft tissues associated with the temporal mandibular joint and arthrography is mainly used to study the joint space. So these are the investigations associated with condyler injuries. The proper management of the fractured mandibular condyle is one of the most controversial topics in maxillofacial trauma. The commonly accepted goal of treatment is the re-establishment of the pre-operative function of the masticatory system. That means it is important to restore the masticatory function as it was before the injury and this involves re-establishment of the pre-op relationship of the fracture segments, the occlusion and maxillofacial symmetry. So even if you perform a perfect radiographic alignment of the fracture segments it is not adequate if you are unable to achieve a fully functioning and pain-free joint. These are the general principles associated with management of condyle or fracture whichever technique you follow whether you do it conservatively or surgically these are the principle goals you need to achieve. Now the treatment is divided into two schools conservative or non-surgical and surgical approaches. Moving on to the conservative management of condyle fractures. Conservative approaches have been practiced by a majority of surgeons and this technique is utilized for all kind of mandibular condyle fractures except those fractures which are an absolute indication for open reduction. Primary goal of conservative and functional treatment is to facilitate active jaw movement as early as possible and also to restore normal occlusion and neuromascular pathways. The conservative management of condyle fractures can be as simple as observation and soft diet or it may include variable periods of immobilization followed by intense physiotherapy but still close supervision is mandatory and at the sign of any occlusion instability deviation with opening or increasing pain both clinical and radiographic revaluation should be performed. Any of these findings like occlusion instability or pain may indicate the conversion of treatment from conservative to surgical immobilization. Immobilization is one of the major components of conservative management of condyle fractures. The period of immobilization is controversial and must be long enough to allow initial union of the fracture segments but short enough to prevent the complications. What are the complications associated with long duration of immobilization? They include muscular atrophy, joint hypomobility and ankylosis. Currently the period of immobilization ranges from 7 to 21 days that is up to 3 weeks. This period may be increased or decreased based on concomitant factors such as the age of the patient, level of fracture, degree of displacement or presence of additional fractures. So this is all about conservative management of condyle fractures. The second approach to manage a fractured condyle is surgical or open reduction. Zide and Kent have proposed a set of both absolute and relative indications for open reduction of the fractured manubular condyle. The absolute indications include displacement of the condyle into the middle cranial fossa, impossibility of obtaining adequate occlusion by close techniques or conservative techniques, lateral extracapsular dislocation of the condyle, any foreign bodies within the TMJ capsule, mechanical obstruction that impedes the function of the TMJ and also open injuries like penetration, laceration or evulsion to the TMJ. All these conditions require immediate treatment and is an absolute indication. The relative indications include bilateral condyle fractures in an edentulous patient where you cannot fabricate a splint because of severe rich atrophy. Unilateral or bilateral fractures where splinting is again not recommended because of any concomitant medical conditions or when physiotherapy is not possible. Bilateral fractures associated with comminuted mid-facial fractures and also bilateral fractures associated with other orthodontic problems. So these are the absolute and relative indications mentioned for opening a manubular condyle but still you need to carefully evaluate the patient on an individual basis and then decide upon the treatment plan. Several surgical approaches to the condyle and the location of the fracture and the degree of displacement decides the selection of approach to access the joint. Subcondylar fractures may be easily accessed via submandibular or recromandibular incisions but the danger of these techniques is the possible damage to the marginal manubular nerve. If the fracture is in the intracapsular or high on the condyle neck then a pre-auricular or end-aural approach is used. It offers better access, more visibility and ease of manipulation. Some surgeons use intra-aural approach to reach the condyle. This approach has the advantage of visualizing the fracture reduction as well as the occlusion simultaneously. But the disadvantage of intra-aural technique is that there is limited access and also it is difficult to place certain fixation devices. Rightedectomy again provides a good access and it is considerably aesthetic also because the scar is placed behind the ear fold. Hemi-coronal approach is used when the condyle fracture is associated with concomitant mid-phase fractures or frontal bone fractures. In such cases, Hemi-coronal approach can be used which gives good access to the condyle. The vital structure at highest risk of damage during a pre-auricular approach to the condyle is the facial nerve. This diagram shows the relationship of facial nerve and its branches to the condyle and auditory canal. Here is the bifurcation of the main concave facial nerve. It is at this point that the facial nerve divides into its five peripheral branches. So this bifurcation is approximately 1.5 to 2.8 centimeter away from the lowest contivity of external auditory canal. This is the external auditory canal and the bifurcation is 1.5 to 2.8 centimeter away from this position, this point. Bifurcation is again 2.4 to 3.5 centimeter away from the post glenoid tubercle. This is the posterior most tubercle at the glenoid fossa and the bifurcation is approximately 2.4 to 3.5 centimeter away. Here is the temporal branch of facial nerve which is again 2 centimeter away from the most anterior concavity of the canal. This is the anterior concavity of the external auditory canal and the temporal nerve or the temporal branches 0.82 3.5 centimeter away from the anterior most concavity. So it is important to keep these measurements in mind to avoid any damage to the nerve while placing an incision or proceeding with dissection. Here is a brief explanation of the pre-auricular approach. First the skin in front of the tragus of the ear is infiltrated with local anesthetic solution to ensure hemostasis. Then the incision is outlined at the junction of the facial skin and the helix of the ear. The incision is usually 3 to 4 centimeter in length and has two limbs, an upper curved limb and an inferior vertical limb anterior to the tragus. Incision is made through the skin and subcutaneous tissues towards the depth of temporalis fascia. It is here that you encounter the superficial temporal vessels and it is retracted anteriorly. This is exposure of the temporalis fascia. At this point you can palpate the zygomatic arch and the lateral pole of mandibular condyle. Here is the arch and here is the condyle. So at this point you can palpate it using finger. Then you make an oblique incision on the surface of temporalis fascia. You place an oblique incision which is parallel to the temporal branch of facial nerve. The incision should be parallel so that it doesn't cut or it doesn't reset the nerve. It doesn't reset the temporal branch. So you place an oblique incision parallel to the temporal branch through the superficial layer of temporalis fascia. And this is all done above the arch. As you can see in the diagram this incision and the dissection following incision is all performed above the level of zygomatic arch. You then insert a periostial elevator beneath the superficial layer of temporalis fascia and the temporalis muscle and strip off the periosteum from the lateral aspect of the arch. You insert an elevator through this incision to reach the zygomatic arch and elevate the periosteum of the arch. The dissection is then carried out inferiorly to expose the capsule of the joint. As you can see in the diagram as the dissection proceeds inferiorly the capsule of the joint is visible which is then incised and the fracture is exposed. So this is in general the principle and the procedure of pre auricular approach to condyle. There are different modifications of pre auricular incision. Pre auricular incision is basically placing an incision within the skin crease in front of the tragus. As you can see in this diagram here the dotted lines represent the classic pre auricular incision. Several authors have given modifications to this incision by exchanging or altering it. For example alkyth and brambly modification is the extension of pre auricular incision anteriorly and superiorly. Few other modifications are inverted hockey stick incision by Blair, vertical angulated incision by Thoma and Dinkman incision. Here is the Popovich incision in which the pre auricular incision is modified into a question mark shape. You have post auricular incision. As you can see in the diagram here the dotted violet lines represent post auricular incision. This is placed behind the ear within the skin crease. You also have end aurial incision. This incision is carried through the skin over the tragal cartilage. It is not placed right in front of the tragus but it is placed within the cartilage of the tragus. In this kind of incision most of vital structures are in the superficial plane and it gives good access to both the joint and the coronoid process. This is another approach to the condyle which is called the rightedectomy or face lift face lift approach. This is an incision that provides the same exposure as the retro mandibular and pre auricular approach. Basically it is a combination of both the retro mandibular and pre auricular approach. The advantage of this incision is that it is placed in a more cosmetically acceptable location. So in this figure you can see all the incisions and all the approaches used to reach the condyle. That is pre auricular incision, the end aurial incision, inverted hockey stick incision, post auricular incision and retro mandibular incision. Here is the hemicoronal or bicaronal incision which is used to gain access to the condyle when it is associated with mid-face or frontal bone fractures. Here the incision is placed in this manner and the dissection is carried out through all the layers of scalp. After gaining a surgical access to the condyle the fractured fragments are reduced in anatomical position and fixed using any of these methods. Transocious wiring. This is used for sub condyle fractures. Here the condyle is approached through submandibular incision and holes are drilled in the fragmented segments. The wire is passed across the segments. It is twisted and tightened. In case of a high condyle fracture, this is a high condyle fracture where a pre auricular incision will be better. Here the fragments are drilled obliquely from the lateral aspect of the fracture that is you know a mandible has both the lateral and middle aspect. So while performing any procedure on the condyle head you take access from the external or the lateral aspect of the mandible. So you drill a hole obliquely here so that you don't injure maxillary artery or other blood vessels in the vicinity. Again transocious wiring is performed and the fragments secured in place. The next technique is the kishner wire or K wire technique in which a vertical passage is first drilled across the two fracture fragments and a K wire is passed in through it. The wire is then secured using transocious wires. The third technique is the intra medullary screw which is placed through submandibular incision. This is a rather inaccurate technique and not used commonly these days. In bone pin technique two pins are inserted on either side of the fracture site and connected by a condyle head and universal joint. This technique is also no longer in use and if at all practiced is very rare. Bone plating is the most popularly used fixation technique. Bone plates provide both stability and frigidity. It also has added advantage of AC application. This is an example of subcondyler fracture which is stabilized using a mini plate. But whereas in case of multiple fracture it is difficult to perform this procedure within the surgical field. Therefore in such cases the ramus is osteotomized in this way. The ramus is osteotomized and the fractured fragments are plated outside the surgical field. That is the fragments are treated like autogenous bone grafts. It is treated totally outside. It is then plated to the main segment again using bone plates. So after fixation the drains are placed. The wound is closed and pressure dressing is applied. The postoperative management includes analgesics, anti-inflammatory, soft diet and intense physiotherapy. Moving on to the complications associated with condyler fractures. There are early and late complications. Complications that occur concurrent or with the treatment of condyler fractures include the following. Fractures of tympanic plate, fracture of the greenoid fossa, with or without displacement of the condyler segment into the middle cranial fossa. Damage to the cranial nerves 5 and 7 that is the trigeminal and the facial nerves and vascular injuries. These are the early complications of condyler fractures. Late complications include malocclusion, growth disturbances, temporomandibular joint dysfunction and ankylosis in children. So with this we have completed the topic on condyler fractures as well as management of mandibular fractures. Thanks for watching.