Current Concepts in the Mandibular Condyle Fracture Management Part I_ Overview of Condylar Fracture
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Go to: Go to: Arch Plast Surg. 2012 Jul; 39(4): 291–300. Published online 2012 Jul 13. doi: 10.5999/aps.2012.39.4.291 PMCID: PMC3408272 Current Concepts in the Mandibular Condyle Fracture Management Part I: Overview of Condylar Fracture KangYoung Choi , JungDug Yang , HoYun Chung , and ByungChae Cho Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, Daegu, Korea. Corresponding author. Correspondence: KangYoung Choi. Department of Plastic and Reconstructive Surgery, Kyungpook National University School of Medicine, 130 Dongdukro, Junggu, Daegu 700721, Korea. Tel: +82534205685, Fax: +82534253879, Email: [email protected] Received 2012 Jun 24; Revised 2012 Jun 25; Accepted 2012 Jun 26. Copyright © 2012 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/licenses/bync/3.0/ ), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract The incidence of condylar fractures is high, but the management of fractures of the mandibular condyle continues to be controversial. Historically, maxillomandibular fixation, external fixation, and surgical splints with internal fixation systems were the techniques commonly used in the treatment of the fractured mandible. Condylar fractures can be extracapsular or intracapsular, undisplaced, deviated, displaced, or dislocated. Treatment depends on the age of the patient, the coexistence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and dental occlusion, and the surgeonnds on the age of the patient, the coexistence of othefrom which it is difficult to recover aesthetically and functionally;an appropriate treatment is required to reconstruct the shape and achieve the function ofthe uninjured status. To do this, accurate diagnosis, appropriate reduction and rigid fixation, and complication prevention are required. In particular, as mandibular condyle fracture may cause longterm complications such as malocclusion, particularly open bite, reduced posterior facial height, and facial asymmetry in addition to chronic pain and mobility limitation, great caution should be taken. Accordingly, the authors review a general overview of condyle fracture. Keywords: Mandibular condyle, Mandibular fractures, Temporomandibular joint INTRODUCTION Among facial bone fractures, the mandible fracture has a highest incidence next to nasal bone fracture and condyle fracture most frequently occurs in mandible fracture [1 ]. Condyle fracture accounts for approximately 30% and 37% of mandible fracture in dentulous mandible patients and edentulous mandible patients, respectively. The reason for a high incidence of mandibular condyle fracture is attributable to the binding of the mandibular ramus with high stiffness and mandibular condyle head with low stiffness [2 ]. This is generally caused by indirect force that is delivered to the mandibular condyle head. The most common external causative factor is physical trauma, and car accident, violence, industrial hazard, fall, sports, and gunshot wound are also included in the external causative factors. Internal causative factors include osteomyelitis, benign or malignant tumor, and muscular spasm during electric shock treatment. As mandibular fracture may cause disorders that is hard to be recover aesthetic and functionally, an appropriate treatment is required to reconstruct the shape and function of uninjured status. To do this, accurate diagnosis, appropriate reduction and rigid fixation, and complication prevention are required. In particular, as mandibular
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Transcript of Current Concepts in the Mandibular Condyle Fracture Management Part I_ Overview of Condylar Fracture
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4/15/2015 CurrentConceptsintheMandibularCondyleFractureManagementPartI:OverviewofCondylarFracture
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ArchPlastSurg.2012Jul39(4):291300.Publishedonline2012Jul13.doi:10.5999/aps.2012.39.4.291
PMCID:PMC3408272
CurrentConceptsintheMandibularCondyleFractureManagementPartI:OverviewofCondylarFractureKangYoungChoi, JungDugYang,HoYunChung,andByungChaeCho
DepartmentofPlasticandReconstructiveSurgery,KyungpookNationalUniversitySchoolofMedicine,Daegu,Korea.Correspondingauthor.
Correspondence:KangYoungChoi.DepartmentofPlasticandReconstructiveSurgery,KyungpookNationalUniversitySchoolofMedicine,130Dongdukro,Junggu,Daegu700721,Korea.Tel:+82534205685,Fax:+82534253879,Email:[email protected]
Received2012Jun24Revised2012Jun25Accepted2012Jun26.
Copyright2012TheKoreanSocietyofPlasticandReconstructiveSurgeons
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNonCommercialLicense(http://creativecommons.org/licenses/bync/3.0/),whichpermitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
ThisarticlehasbeencitedbyotherarticlesinPMC.
Abstract
Theincidenceofcondylarfracturesishigh,butthemanagementoffracturesofthemandibularcondylecontinuestobecontroversial.Historically,maxillomandibularfixation,externalfixation,andsurgicalsplintswithinternalfixationsystemswerethetechniquescommonlyusedinthetreatmentofthefracturedmandible.Condylarfracturescanbeextracapsularorintracapsular,undisplaced,deviated,displaced,ordislocated.Treatmentdependsontheageofthepatient,thecoexistenceofothermandibularormaxillaryfractures,whetherthecondylarfractureisunilateralorbilateral,thelevelanddisplacementofthefracture,thestateofdentitionanddentalocclusion,andthesurgeonndsontheageofthepatient,thecoexistenceofothefromwhichitisdifficulttorecoveraestheticallyandfunctionallyanappropriatetreatmentisrequiredtoreconstructtheshapeandachievethefunctionoftheuninjuredstatus.Todothis,accuratediagnosis,appropriatereductionandrigidfixation,andcomplicationpreventionarerequired.Inparticular,asmandibularcondylefracturemaycauselongtermcomplicationssuchasmalocclusion,particularlyopenbite,reducedposteriorfacialheight,andfacialasymmetryinadditiontochronicpainandmobilitylimitation,greatcautionshouldbetaken.Accordingly,theauthorsreviewageneraloverviewofcondylefracture.
Keywords:Mandibularcondyle,Mandibularfractures,Temporomandibularjoint
INTRODUCTION
Amongfacialbonefractures,themandiblefracturehasahighestincidencenexttonasalbonefractureandcondylefracturemostfrequentlyoccursinmandiblefracture[1].Condylefractureaccountsforapproximately30%and37%ofmandiblefractureindentulousmandiblepatientsandedentulousmandiblepatients,respectively.Thereasonforahighincidenceofmandibularcondylefractureisattributabletothebindingofthemandibularramuswithhighstiffnessandmandibularcondyleheadwithlowstiffness[2].Thisisgenerallycausedbyindirectforcethatisdeliveredtothemandibularcondylehead.Themostcommonexternalcausativefactorisphysicaltrauma,andcaraccident,violence,industrialhazard,fall,sports,andgunshotwoundarealsoincludedintheexternalcausativefactors.Internalcausativefactorsincludeosteomyelitis,benignormalignanttumor,andmuscularspasmduringelectricshocktreatment.
Asmandibularfracturemaycausedisordersthatishardtoberecoveraestheticandfunctionally,anappropriatetreatmentisrequiredtoreconstructtheshapeandfunctionofuninjuredstatus.Todothis,accuratediagnosis,appropriatereductionandrigidfixation,andcomplicationpreventionarerequired.Inparticular,asmandibular
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condylefracturemaycauselongtermcomplicationssuchasmandibulargrowthandfunctionaldisorders,andchronictemporomandibularjoint(TMJ)complication,amorecautionshouldbegiven.Accordingly,theauthorsreviewthegeneraloverviewoncondylefracturehere.
ANATOMYANDPHYSIOLOGYOFMANDIBLE
Themandible
Themandible,whichisthehardestmonostoticboneamongfacialbones,isaUshapedlongbone(Fig.1).Itconsistsofareaswithandwithoutteeth,andbindstothebilateraltemporalbonesattheleftandrightTMJ.Attheearlystageofdevelopment,itdevelopslaterallyandfusesatthemidline1to2yearsafterbirth,formingacompletestructurelikethemaxilla.Nameofeachareahassomevariationdependingontheliteratures.However,themostclinicallyusefulclassificationofeachareadividesthemandibleintothesymphysisandparasymphysis,body,angleandramus,condylarprocess,coronoidprocess,andalveolarprocess.Thesymphysisandparasymphysisreferstoanareabetweenbothcanine.Thebodyreferstoanareafromthecaninetothesecondmolar.Theangleandramusreferstotheareanexttothirdmolarexceptforthecoronoidandcondylarprocess.Themandibularcondyleconsistsofthecondylarprocessandheadofthemandible.Thecondylarprocessandheadsubunitreferstoasuperiorareaoftheextensionlineconnectingthemasseterictuberosityfromthedeepestareaofthesigmoidnotch.Thecondylarprocessandheadsubunitconsistsofthehead,neck,andsubcondylararea.Thesearethreeheightlevellinesthatdividethesubunit,anddefinetheboundary.Thethreeheightlevellinesconsistofanextensionlinethatisparalleltotheposteriorborderofthemandible,anextensionlinethatparallellyheadsfortheperpendicularfromthedeepestareaofthesigmoidnotch,andanextensionlinethatisinferiortothecondylarheadlateralpole.Thecondylarheadreferstoanareathatissuperiortotheextensionlinethatisinferiortothecondylarheadlateralpole.Thecondylarneckreferstoanareabetweentheextensionlinethatisinferiortothecondylarheadlateralpoleandtheextensionlinethatparallellyheadsfortheperpendicularfromthedeepestareaofthesigmoidnotch.Thesubcondylarareareferstoanareathatisinferiortotheextensionlinethatparallellyheadsfortheperpendicularfromthedeepestareaofthesigmoidnotch.Meanwhile,thecondylarneckisdividedintothehighlevelandlowlevel,andthereferencelinedividingthemisanextensionlinethatispositionedinthemiddleofthesigmoidnotchlineandthelateralpolelineofthehead(Fig.1).
Fig.1Theanatomyofmandibulararea
Theelevatedareaofthemidlineofthemandibleisdefinedasmentalprotuberance.Thementaltubercleexistsinferiortotheleftandrightelevatedareasandthementalforamenbywhichimportantfacialnervesandbloodvesselspassexistslaterallysuperiortotheaforementionednodulearea.Internally,apairofthementalspinesexistsinferiorlytothemidline,fromwhichthegenioglossusandstylohyoidmuscleoriginate.Themylohyoidlinethatreachesthemandibularramusposterosuperiorlyexistsatthelateralsideofthementalspine.Themylohyoidmuscleoriginatesfromthemylohyoidline.Thenerverootispositionedbelowthemylohyoidmuscle,andcontrolsit.Themandibularangleandramusisarectangularbonypartthatexistssuperoposteriorlytothemandibularbody.Mandibularanglesizevariesdependingonageandindividuals.Itisapproximately140inchildrenand110to120inadults.Thetuberositasmassetericaandtuberositaspterygoideaexistatthelateralsideandinternalsideofmandibularangle,respectively.Theyareinsertionpartsofthemassetermuscleandmedialpterygoidmuscle,respectively.
Temporomandibularjoint
Themandibularcondyleformsarticulationwiththemandibularfossaofthetemporalbone,whichiscalledtemporomandibularjoint.Thearticulationdisc,whichisafibroustissue,existsbetweentheTMJ,andactsasabuffer.Assynovialfluidthathaslubricationfunctioninsidethejointcapsuleexistsaroundthejoint.Itminimizesfrictionduringjointmotion,andenablesthesmoothmovementofthejoint.Thearticulationdiscgenerallyhasanovalshape.However,asitsshapeisdeterminedbytheshapeofthecondyleheadandmandibularfossa,itssizeandshapemayvary.Thearticulationdisciscomposedoffibroustissueswithoutnerveorbloodvessel,anddiscthicknessis1mmforthecenter,3mmfortheposterioraspect,and2mmfortheanterioraspect.Thus,ithasashapethatisthethinnestinthecenterandthethickestintheposterioraspect.Forthenormaljoint,themandibular
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Occlusion
Mandibularmovement
condyleispositionedatthecenterwhichisthethinnest.Thus,discinjuryoccursatthecenterduetoagingorchronicphysicalstimuli.Thediscisattachedtothecondyleheadviathebilateralarticulardiscligaments,whichpreventsthedeviationofthediscfromthecondyleheadduringmandibularmovement.ThejointcapsulethatsurroundstheTMJproducesthesynovialfluidinternally,andtheproducedsynovialfluidactsasalubricantduringmandibularmovement,andsuppliesnutrientstoanareawithoutbloodvessels.Inaddition,asthejointcapsulehassubstantialwrinkles,itchangesthecontactareaduringmandibularmovement,protectingthejoint.Thetemporomandibularligamentwithatriangularshapeexistsatthelateralsideofthearticularcapsule,anditpreventsexcessivemovementthatisbeyondthenormalrangeofthemandibleduringmadibularmovement.Thetemporomandibularligamentisrigidlyfixedbythetemporalboneandmandible,whichprovidesthestabilityofTMJmovement.Unlikehingetypedjointsofthefourextremities,theTMJhascharacteristicsofthesimultaneousmovementofthebilateraljointsduringmandibularmovementsuchastalkingoreating.TheleftandrightTMJcannotmoveindependently,andiscloselyassociatedwithdentalocclusion(Fig.2).
Fig.2Theanatomyoftemporomandibularjoint
Occlusionandmandibularmovement
Occlusionisintercuspationbetweentheteeth.Itisdividedintostaticocclusionwithoutjawmovementandfunctionalordynamicocclusionwithjawmovement.Staticocclusionmayvarydependingoncondylelocation,amongwhichmaximumintercuspaloccclusionorintercuspalocclusionpositionreferstoasitethatcontacttheteethmostfrequently.Thisisknownascentricocclusion(CO).COisarelationshipbetweentheteethregardlessofcondyleposition.AsCOmaybechangedbyprosthodontictreatmentorjawsurgery,condylelocationthatisalwaysconstantandreproducibleisrequired.Thisisbecausethecondylelocationthatactsasareferenceforprosthodontictreatmentorjawsurgeryisrequired.ProcedureswherethestabilityofcondylepositionisnotmaintainedeventuallycauseTMJdiseaseormalocclusion.Basedontheaforementionedconcept,occlusionatcondylepositionthatisstableandreproduciblewithoutintercupationisdefinedascentricrelation(CR),andcalledcentricrelationocclusion(CRO).IfCROissameasCO,itisconsideredasidealocclusion.CondylepositioninCRhasbeencontroversialoveralongperiodoftime.Currently,mostanteriorsuperiorpositionreportedbyCelenzaandNasedkin[3]isconsideredtheclosestposition(Fig.3).
Fig.3Theidealcondylepositionstate
Thisstaticocclusionoccursforashorttimeinadailyliving.Inmostcases,functionalocclusionwithjawmovementoccurs.Duringjawmovementanteriormovement,occlusalcontactoccursattheanteriorteethanddisclusionoccursattheremainingteeth.Duringlateralmovement,occlusionoccursattheworkingsidedcanineorcaninepremolargroupteeth,anddisclusionoccursattheremainingteeth.Thisiscalledguidance(Fig.4).Theanteriorregionisfarawayfromforcepointsothatitistolerabletolateralforceduringanteriormovement.Meanwhile,thecaninehasalongrootandthealveolarboneishardsothatitistolerabletolateralforceduringlateralmovement.Ifteethotherthantheguidanceteethcontactduringtheaforementionedmovement,theyarerelativelymorevulnerabletolateralforce.Itcausesperiodontalligamentinjury,whichisvulnerabletoperiodontitis.Eventually,teethsupportingbecomesweakduetoabsorptionbytheadjacentalveolarbone.Theteethbecomeexfoliated.Thisstatusreferstotraumafromocclusion(TFO).
Fig.4Thesequenceoffunctionalocclusion
MandibularmovementoccursbytheinvolvementoftheTMJasaposteriorguidance,andteethasananteriorguidance.TheTMJasaginglymoarthroidaljointhasamovementof25to30mmbytheupperjointspace.Themouthopeningasahingejointhasrotationmovement.Beyondthat,themouthopeningasslidingjointhasamovementinadditiontorotationmovement(Fig.5).Inaddition,thebodilylateralmovementofthe
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mandibleoccursduringlateralexcursions,whichreferstobennettmovement(Fig.6).Ifnobennettmovementoccurduetointerferencecausedbychangesincondylepositionduringfractureorjawsurgerythoughocclusionisnormal,mandibularmovementdisorderoccurs.Ifthedisorderispersistentforalongtime,TMJdiseaseocclusioninstabilityrelapsemaybecaused.
Fig.5Movementofthemandibularcondyle
Fig.6Movementofthemandibularcondyle
CLASSIFICATIONOFMANDIBULARCONDYLEFRACTURE
CondylefracturecanbeclassifiedasfollowsaccordingtoLindahlclassification.Itisclassifiedintocondyleheadfracture,condyleneckfracture,andsubcondylefractureaccordingtofactureposition.Condyleheadfractureisalsocalledintracapsularfractureasthejointcapsuleexistsuntilthecondyleneck.condyleneckfracture,whichoccursattheinferiorattachareaofthejointcapsule,referstoanareathatbecomesnarrowfromthecondylehead.Itisanextracapsularfractureasitisnotincludedinthejointcapsule,andexistsattheinferiorattachareaofthelateralpterygoid.Subcondylefracture,whichexistsinferiorlytothecondyleneck,referstoanareabetweenthemandibularsigmoidnotchandmandibularposterioraspect.Accordingtothedegreeoffracturefragmentdisplacement,condylefractureisclassifiedintonondisplacedfracturethathasfracturewithnodisplacementofthefracturesite,deviatedfracturewherefracturefragmentsaredisplacedbutsomeofthemcontactthemandibularjoint,displacedfracturewherefracturefragmentisseparatedfromthemandibularbodyanddisplaced,butexistsintheTMJ,anddislocationwherethecondyleheadisdeviatedfromtheTMJ(Fig.7).Thedisplacementoffracturefragmentisobservedincondylefracture.Itputmainlyintractionbythemassetermuscle,lateralpterygoidmuscle,andtemporalismuscle.Themostcommonlyobservedtypeisthedisplacementofthecondyleheadtotheanteromedialside,whichisshowninafracturethatoccursinferiorlytothelateralpterygoidmuscle(Fig.7).
Fig.7TheclassificationofmandibularcondylefractureaccordingtoLindahlclassification
TREATMENTOFMANDIBULARCONDYLEFRACTURE
Closedreductionandfunctionaltherapy
Forclosedreduction,intermaxillaryfixationisconductedusingarchbarandwire,followedbymaintainingofthefixationofthemaxillaandmandiblefor2to4weeks.Afterachievingstableunionofthefactoredsite,awireforintermaxillaryfixationisremoved.Then,normalocclusionisinducedafterfixationusingrubber,andsoftdietismaintainedfor2weeks.Functionaltherapythatconsistsofpassivemandibularmovementexerciseandmouthopeningexerciseisconductedandthenclinicaloutcomesareobserved.
Openreductionandinternalfixation
Therearevariousoperationmethodsofopenreductionformadibularcondylefracturedependingonfracturesiteanddegreeofbonefragmentdisplacement.Ingeneral,theyincludepreauricularapproach,postauricularapproach,submandibularapproch,Risdonapproach,combinedapproach,andretromandibularapproach.Treatmenttypeshouldbeselectedconsideringpatient'sage,preference,fracturetype,fractureofothersites,andteethstatus.
COMPLICATIONOFMANDIBULARCONDYLEFRACTURE
Nonunionandmalunion
Nonunionisassociatedwithfracturefragmentstability,repeatedtrauma,infection,inappropriatereduction,multiplefractures,mandibularatrophy,andpatientcompliance[4].Infectionofthefracturesitemorefacilitatesfibroblastgrowththantheactivitiesofosteoblastsorosteoclasts.Thismakesfibroustissuesdominantinthebone
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Temporomandibularjointderangement
Traumaticarthritisoftemporomandibularjoint
Ankylosisoftemporomandibularjoint
healingarea,andcausesfibrousbinding,whichresultsinnonunion[5].Inthecaseofexcessiveexposureoftheperiosteum,delayedfracturetreatmentisshown,particularly,incomminutedfractureandedentulousfracture.Iffracturedfragmentsareinappropriatelyassigned,andteethalignmentisinappropriatelypositioned.Inaseverecase,nonunionmayoccur.Malocclusioniscausedbyfacialasymmetry.Ifthishappens,correctionshouldbeperformedviaorthognathicsurgeryandbonetransplantation.
Malocclusion
Malocclusionisassociatedwithpatient'steethstatus,fracturetype,displacementofthebonesegments,incompletereductionofbonefragments,inappropriatefixationandfixationtime,delayedtreatment,andpatientcompliance[68].Formalocclusionthatoccursafterthecompletionofboneunion,occulsaladjustmentisrequiredorevenreoperationandorthodonticsurgeryisrequiredinaseverecase.Openreductionshouldbeconductedinanearlyphaseafterinjurytopreventmalocclusionaftermandibularcondylartrauma.Furthermore,accuratereductionandfixationduringthesurgeryandregularfollowupafterthesurgeryarerequiredtopreventpostoperativemalocclusion(Fig.8).
Fig.8A21yearoldwomanwithiatrogeniccondylefractureduringfacialbonecontouringsurgery
Temporomandibularjointdysfunction
Ifthefunctionaldisordersofthecondyledisccomplexoccurwithchangesintheshapeofthediscduetotrauma,thisiscalledtemporomandibularjointderangement.Thefunctionaldisordersofthecondyledisccomplexoccurscausediscdisplacement.Thisdisplacementisthemostimportantcharacteristicsoftemporomandibularjointderangement,whichoccurswithmajorsymptomssuchasjointsound,abnormalmovementofthecondylehead,impingementofcondylehead,mandibularmovementlimitationandjointpain.Fortemporomandibularjointderangement,changesindiscshapeandthefunctionaldisordersofthecondyledisccomplexareminimizedandpreventedbytheearlyreductionandrigidfixationofthedisplacedbonefragmentsadjacenttothejoint(Fig.9).
Fig.9A24yearoldwomanwithiatrogeniccondylefractureduringorthognaticsurgery
Traumaticarthritisreferstoanarthritisthatoccurssecondarilyafterthedeformityofthejointduetothedirectinjurytothearticularcartilageorfracturecausedbytrauma.Traumaticarthritisgenerallyoccursafterfractureinvadingthearticularsurface,butalsooccursbyrepeatedmildtraumaorjointinjurycausedbychronicload.Inparticular,forintracapsularfractureamongmandibularcondylefractures,articularsurfaceinjuryoccursatthetimeoftraumaonset,andtraumaticarthritisisfurtherexpectedtooccurduetochronicandrepeatedjointmovement.Clinicalsymptomsthatmayoccurinanearlyphaseincludejointsoundandpainduringjointmovement.Asbonyarthritisprogresses,progressedclinicalfindingssuchasjointsoundincrease,locksensation,pain,andmouthopeninglimitationareobserved[9].
AnkylosisoftemporomandibularjointreferstoamovementdisorderoftheTMJcausedbythegrowthoffibroustissuesorbonetissuesintheTMJstructureduetovariousfactors.Itcausesseverefunctionalandstructuralabnormalitiesinpatients.Ankylosisoftemporomandibularjointismainlydividedintotwotypes.Oneistrueankylosisoftemporomandibularjointwherejointankylosisisattributabletothejointitself.Theotherispseudoankylosisoftemporomandibularjointwherecausativefactorsareattributabletoothersexceptforthejoint.Inaddition,ankylosisoftemporomandibularjointisclassifiedintocompleteandpartialtypes,andunilateralandbilateraltypesaccordingtotheintensityandpositionofankylosisoftemporomandibularjoint,respectively.Ankylosisoftemporomandibularjointfrequentlyoccursbytrauma.Itoccursinallagebrackets,butmainlyoccursinpatientsagedlessthan10years.Ithasclinicalsymptomssuchaspoornutritionalstatusduetomouthopeningormasticatorydisorders,severeinjuryofteethandperiodontaltissuesduetoinappropriateoralhygiene,facialasymmetryoftheadjacentTMJ,dislocationofmandibleattheinjuredsite,thetoothmalalignement
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oftheinjuredsite,neuromuscularocclusion,shortnessofmandibluarramus,deepantegonialnotch,lossanddecreaseofthejointcapsule,andincreasedfracturedensityofthejointarea[10].Ifbilateralankylosisoftemporomandibularjointoccursatgrowthstage,aestheticdisordersuchasmicrognathiaandfacialasymmetrymayoccurduetodecreasedmandibulargrowth(Fig.10).
Fig.10An18yearoldmanwithmandibularankylosisatrightsideduetopreviousfacialtrauma
Growthdisorderandfacialasymmetry
Ithasbeenknownthatdecreasedmandibulargrowthoccursin20%to25%ofpatientswithmandibularcondylefracture.Thisgrowthdisorderhasbeenreportedtobeattributabletodirectcondylegrowthdisorderandseverefunctionaldisordercausedbytheadjacentmuscularstiffness,injuryofsofttissues,andscar.Inparticular,asmandibularcondyle,whichisasecondarygrowthpointthatisaffectedbyexternalfactorssuchasperimandibulargrowthandbiodynamicforce,hasspecialanatomicalstructuresandmanyfunctions,mandibularcondylefracturemaycausethegrowthdisorderoffracturesite.Inaddition,condylegrowthisprogressedoverthelongestperiodamongotherpartsofthecraniofacial,atwhichmandibularasymmetryoccursduetolateralgrowth,traumaticandneuronaldisorders.Asthemandiblesupportsthesofttissuesofthelowerface,changesinitspositionorshapeareimportantforfacialasymmetry.
Condyleresorption
Condylarresorption,aTMJ'snonfunctionalremodeling,isalsoknownascondylardissolution.Itisdefinedasastatuswherecondyleshapechangeandsizedecreasegraduallyoccur[11].Despitethesuccessfulreductionofcondylefracture,excessivedissectionandinjuryoftheadjacentbloodvesselsduringthesurgerymaycausecondyleheadresorptionoveralongperiod.Asaresult,patientsmaycomplainoftheinstabilityofocclusionandskeleton,TMJdysfunction,andpain,andfacialasymmetry,anterioropenbite,andmandibularsetbackmayoccur[12].Forexample,Nam'smethod,whereosteotomyisconducedoncondylefractureatsubcondyleleveltopulloutthefragment,andthenputitbacktoitsoriginalpositionafterreduction,waspreviouslyusedasasurgerymethodforcondylefracture.However,duetoresorptioncausedbypoorcondylarvascularization,itisnolongerused.
Nerveinjury
Variousopenreductionapproacheshavebeenusedtotreatmadibularfracture.Nerveinjurymayoccurduringflapelevation,fracturereduction,andinsertionofametalplate[13,14].Axonotmesis,whichisamainnerveinjury,causessensorylossfor4weeksormore.Ittakesapproximately4weekstorecoverfromneuropraxia.Inparticular,aprecautionshouldbegivennottocausetheinjuryoffacialnervetemporalbranchduringpreauricularapproach.Ifnerveinjuryisobservedafterthesurgery,steroidshouldbeimmediatelyadministeredtopreventtissueswelling,therebyshorteningrecoverytimeandpreventingpermanentinjury.
Infection
Infectionshouldbepreventedbytheaccuratereductionofthedisplacedbonefragmentsattheearlystageofmandibularfracture.Afterthesurgery,pulpvitalitytestofthefracturelineoradjacentteeth,andtheperiodontalstatusshouldbecarefullyfollowedup.Inaddition,anearlytreatmentisrequiredtominimizecomplicationscausedbyinfection.Manystudiesreportedthatinfectionoccurredin7%ofpatientswithmandibularfracture[15].Inaddition,somestudiesreportedpreoperativeinfection,mostofwhichareassociatedwithdelayedearlytreatmentandtheteethpositionedonthefractureline.Postoperativeinfectionmayoccurbyvariousfactors.Inparticular,bonesegmentinstability,patient'ssystemicstatus,fracturedegreeforeignmaterials,openwindow,andpreoperativeandpostoperativeoralhygienewithariskofcontaminationinthefracturesiteareimportantcausativefactors.Thus,infectionshouldbepreventedbytheaccuratereductionofthedisplacedbonefragmentsattheearlystageofmandibularfracture.Afterthesurgery,pulpvitalitytestofthefracturelineoradjacentteeth,andthe
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periodontalstatusshouldbecarefullyfolloweduptominimizecomplicationcausedbyinfection.
CONCLUSIONS
Thetreatmentofmandibularcondylefracturesdependsonthebiologiccharacterandadaptivecapabilityofthemasticatorysystem.Thesewilldifferwidelyamongpatients,anditisthelackofsoundbiologyandadaptationthatcanleadtoanunfavorableoutcome.Thereforewemustunderstandthefunctionalmechanismofthemandible.Furthermore,thesuccessfultreatmentofmandibularfracturesmaybeaccomplishedbyavarietyoftechniqueswhenoneadherestosoundsurgicalprinciplesrelatedtothediagnosis,stablefixation,andrehabilitationofthepatient.Therecoveryofpatient'spreinjuryocclusionandfunctionistheultimategoalwhentreatingfracturesofthemandible.Toobtainthisultimategoal,accuratediagnosis,appropriatereductionandrigidfixation,andcomplicationpreventionarerequired.
FootnotesThisarticlewasinvitedaspartofapanelpresentation,whichwasoneofthemosthighlyratedsessionsbyparticipants,atthe69thCongressoftheKoreanSocietyofPlasticandReconstructiveSurgeonsonNovember11,2011inSeoul,Korea.
Nopotentialconflictofinterestrelevanttothisarticlewasreported.
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4/15/2015 CurrentConceptsintheMandibularCondyleFractureManagementPartI:OverviewofCondylarFracture
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3408272/ 8/8
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