Management of Various Mandibular Condyle Fractures 1
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MANAGEMENT OF VARIOUS MANDIBULAR CONDYLE
FRACTURES
Masykur Rahmat
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• Mandibular condyle
eliptical shape mediolateral (13-25 mm) anteroposte. (6 – 16 mm) Various dimensions between
individuals & between the right and left sides in an individual.
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PROBLEMATIKA FRAKTUR KONDILUS 1.Insidensi tertinggi karena sering terjadi fraktur indirect2.Sering tidak terdiagnosis3.Dampaknya langsung mengenai gigi geligi4.Komplikasi : open bite, deviasi artikulasi, problem TMJ, trismus, mal oklusi.5.Bila tidak tertangani dapat menimbulkan ankylosis terutama pada anak
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INSIDENSI
-Fraktur mandibula : 65-70% Fraktur Oral Maksilofasial (OMF)-Fraktur mandibula saja : 50 %Fraktur Kondilus :
-Banyak penulis melaporkan sekitar 26 – 57 % dari fraktur mandibula- Male : Female = 3 : 1- 66 % px dengan fraktur kondilus juga menderita fraktur korpus/angulus mandibula- 84 % adalah unilatral
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Silvennoinen :-14% intrakapsuler-24% condylar neck-62% subcondylar
Insidensi tertinggi terjadi pada umur 20 – 39 th
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ETIOLOGI :
-Kecelakaan lalu lintas (mobil, motor dan sepeda)-Perkelahian-Kecelakaan kerja-Kekerasan rumah tangga-Trauma olah raga
Etiologi dan Insidensi berbeda tergantung waktu, lokasi dan lama studi
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KLASIFIKASI
Syarat ideal :
-Menjelaskan posisi anatomis fraktur secara mudah dan jelas-Menjelaskan derajat dislokasi dan displacement fraktur-Dapat membantu operator menentukan rencana dan prognosis perawatan
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Rowe dan Killey (1955) :
-Fraktur intrakapsular-Fraktur ekstrakapsular-Fraktur dengan lesi pada diskus dan struktur TMJ
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Digman dan Natvig (1964) :
-Fraktur kondilus tinggi : garis fraktur terdapat diatas atau satu level dengan lokasi insersi dari M.pterygoid lateralis-Fraktur kondilus intermediate : garis fraktur terdapat dibawah lokasi insersi M.pterygoid lateralis-Fraktur kondilus tinggi : garis fraktur terdapat dibawah sigmoid notch dan berjalan menuju ramus mandibula
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Lindahl ( 1977 ) :
1.Ketinggian fraktur :-kepala kondilus-leher kondilus-subkondilus
2.Deviasi dan displacement :- Deviasi dengan overlapping ke medial- Deviasi ke lateral- Displacement tanpa overlapping- Fraktur fissural tanpa deviasi
3.Relasi antara kepala kondilus dan fossa :- Tanpa dislokasi- Dislokasi minimal/ moderat / parah
4.Arah garis fraktur :- horisontal/vertikal/kompresi
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Spiessl dan Schroll (1972) :
A.Fraktur tanpa dislokasiB.Fraktur leher kondilus rendah dengan displacementC.Fraktur leher kondilus tinggi dengan displacementD.Fraktur leher kondilus dengan dislokasiE.Fraktur leher kondilus tinggi dengan dislokasiF.Fraktur kapitulum /intrakapsular
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Schwenzer dan Ehrenfeld :
1.Berdasarkan ketinggian : ( Kapitulum , kondilus dan subkondilus)2.Berdasarkan derajat dislokasi :
- D1 : tanpa dislokasi- D2 : dislokasi dengan kontak antar fragmen- D3 : dislokasi tanpa kontak antar fragmen, akan tetapi
terdapat overlapping tulang (dislocation ad latum cum contractione)
- D4 : dislokasi tanpa kontak antar fragmen same sekali3.Berdasarkan derajat luksasi :
- L1 : tanpa luksasi(hubungan kondilus-fossa normal)- L2 : subluksasi (kontak antara kapitulum dan fossa tidak
fisiologis)- L3 : luksasi total
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DIAGNOSIS :
-Tanda-tanda klinis : sakit pada daerah sendi rahang, sakit jika bagian dagu ditekan, pembengkakan, open bite anterior, kontak prematur posterior, sakit saat membuka mulut, perdarahan dari telinga, deviasi artikulasi, open bite posterior unilatral,
! Hati- hati : CSF Leaking
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PEMERIKSAAN RADIOGRAFIS :
-OPG- Mandibula PA- Waters position- MSCT Scan – Rekonstruksi 3 D-MRI
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Mandibula PA Waters / Sinus Maksilaris Oksipito Mental
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SEJARAH PERAWATAN FRAKTUR KONDILUS
-Perthes (1924) : Bedah kondilus pertama-Wassmund (1927) : Pertama kali Osteosintesis kondilus
Saat itu seringkali infeksi dan nekrosis (Antibiotika ?) Terapi konservatif lebih dianjurkan jaringan ikat diantara fragmen tulang remodelling kondilus dan adanya organ organ yang sangat rawan disekitar condylus
MILESTONE : Fleming (1941) Penilisin
-AO (Arbeitsgemeinschaft für Osteosynthesefrage) 1960 : Miniplat-Robinson, Yoon , Snell dan Doot (1960) : Miniplat pada fraktur kondilus-Petzel, Eckelt, Gerber : Lag screw-Rasse (1993) : Plat terdegradasi -- > ????
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Terapi Konservatif (fungsional) Vs Terapi Operatif
Fakta : 40 % reposisi belum dapat tercapai sempurna
Tujuan terapi fraktur kondilus :
-Pergerakan mandibula tanpa rasa sakit kesemua arah-Oklusi dan artikulasi yang baik-Simetri mandibula dan wajah-Buka mulut tanpa rasa sakit (Interinsisal 40 mm)-Keadaan TMJ stabil
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TERAPI KONSERVATIF :
-Tidak ada resiko kerusakan syaraf, perdarahan dan infeksi-Waktu perawatan lama-Oral hygiene jelek-Penurunan berat badan-Tidak dapat melakukan reposisi sempurna
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TERAPI OPERATIF :
-Resiko kerusakan syaraf, perdarahan dan infeksi-Waktu perawatan singkat-Comfort pasien-Reposisi sempurna / direct vision-Teknik tinggi
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Terapi Fraktur Kondilus
Tertutup / Closed reduction Open reduction
Pasif Aktif
-Analgetik-Diet Lunak-Fisioterapi
-Traksi Elastik/IMW-Alat Ortho-Fisioterapi
-ORIF-Fisioterapi
Joos U, Kleinheinz J. Therapy of condylar neck fractures. Int J Oral Maxillofac Surg.1998, 247
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Anak- anak hingga 12 tahun
Displacement minimal / tidak ada
Perawatan pasif closed
Re Evaluasi
Displacement / dislokasi
Perawatan aktif closed
Re Evaluasi Open reduction
Fisioterapi Fisioterapi
Kontrol rutin dan berkala
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TERAPI KONSERVATIF -FUNGSIONAL INDIKASI :- Fraktur condylar neck pada anak < 12 th-Fraktur high condylar tanpa dislokasi-Fraktur intra kapsuler-Resiko anastesi yang jelek
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Hypomochlion ( baji ):
-Dipasang pada gigi posterior-Mengurangi pemendekan sendi rahang-Bahan resin komposit-Diharapkan terjadi kompensasi dentoalveolar
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TERAPI OPERATIF
Indikasi :Absolute :-Displacment kemedial-Tidak terjadi oklusi bila dirawat dengan konservatif-Invasi adannya benda asing-Dislokasi ke latral ekstrakapsuler
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Relative : :-Fraktur bilateral pada edentulous-Kontra indikasi IMW karena alasan medik-Fraktur condyle bilateral yang berhubungan dengan pan facial fraktur
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Akses Operasi : -Intraoral (Endoskopi)-Ekstraoral
Akses Tahun Penulis
Preaurikular 1925,1934 Lindemann, Nieden
Preaurikular /retrotrageal 1944 Dingmann
Endaural/transtrageal 1954,1956 Rongetti, Davidson
Aurikular (hingga temporal) 1992 Rasse
Retroaurikular 1920,1931 Bockenheimer, Axhausen
Intraoral 1964 Steinhauser
Submandibular Risdon
Retromandibular
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BAHAN OSTEOSINTESIS :
-Miniplate titanium 2.0 (1 atau 2 plate), Straight 4-5 hole-Miniplate bahan terdegradasi-Lag Screw
Delta Plate TCP Plate
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FIKSASI DAN OSTEOSINTESIS EKSTRAKORPORAL
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KESIMPULAN :
-Penentuan Diagnosis secara tepat -Prinsip terapi trauma (ABCDE), Primary survey, secondary survey-Penentuan Indikasi secara tepat (Konservatif atau Operatif ??)-Informed consent !!-Kontrol rutin jangka panjang, Rö OPG
KOMPETENSI : Sp BEDAH MULUT DAN MAKSILOFASIAL
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TIPS :
-Teknik operasi, anatomi (N.VII)-Alat dan Instrument yang baik-Bahan Osteosintesis -Ahli anestesi berpengalaman
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GOOD RESULT COMES FROM GOOD EXPERIENCE
GOOD EXPERIENCE COMES FROM BAD RESULT
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