Journal of Shanghai Jiao Tong University (Medical Science) >

2022 , Vol. 42 >Issue 6: 695 - 701

DOI: https://doi.org/10.3969/j.issn.1674-8115.2022.06.001

Oral surgery

Diagnosis and treatment protocol of mandibular condylar fracture: experience from the TMJ Center of Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine

  • Dongmei HE ,
  • Chi YANG
Expand
  • Department of Oral Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology, Shanghai 200011, China
YANG Chi, E-mail: yangchi63@hotmail.com.

Received date: 2022-03-02

  Accepted date: 2022-05-30

  Online published: 2022-08-19

Supported by

National Natural Science Foundation of China(32071313);Science Research Project of Science and Technology Commission of Shanghai Municipality(20Y11903900)

Fold

Abstract

Mandibular condylar fracture is common in clinic. Improper treatment will cause sequelae such as malocclusion, ankylosis and limited mandibular development. This paper combines the literature review and the diagnosis and treatment experience of the team to provide reference for clinicians. Imaging diagnosis, especially coronal CT reconstruction, is the basis for classification and treatment of condylar fracture. According to the fracture location, it is divided into condylar (intracapsular) fracture, condylar neck fracture and subcondylar fracture. And intracapsular fracture can be further divided into four types: A, B, C and M. The treatment of condylar fracture includes non-surgical treatment and surgical treatment. For non-surgical treatment, intermaxillary elastic traction is recommended for malocclusion correction. The absolute indication of surgical treatment is the ramus stump dislocated out of the fossa. The relative indications include the stump of the mandibular ramus contacting the articular fossa, severe displacement or dislocation of the condylar neck and subcondylar fracture. The key points of successful operation include adequate exposure, anatomic reduction and stable fixation, protection of lateral pterygoid muscle attachment and articular cartilage, and reposition of the temporomandibular joint disc. For the condylar fracture combined with mandibular fracture, lingual fissure of the mandible should be closed during reduction and fixation for restoring the mandibular width and condylar position in the fossa. When the condylar fracture is combined with midface fracture, the condylar fracture and occlusal relationship should be restored first, and then the maxillary fracture should be fixed according to the lower dentition. The children under 6 years old have the stronge ability of condylar remodeling, so non-surgical treatment is commonly used. The healing and remodeling ability of condyle gradually decreases with age. The condyles of the teenagers over 12 years old are close to those of the adults, so the indications of surgical treatment for condyle fracture refer to the adults.

Key words： mandibular condyle; mandibular fracture; diagnosis; treatment

Cite this article

Dongmei HE , Chi YANG . Diagnosis and treatment protocol of mandibular condylar fracture: experience from the TMJ Center of Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2022 , 42(6) : 695 -701 . DOI: 10.3969/j.issn.1674-8115.2022.06.001

References

1 MCLEOD N M, KEENAN M. Towards a consensus for classification of mandibular condyle fractures[J]. J Craniomaxillofac Surg, 2021, 49(4): 251-255.
2 Consensus conference on open or closed management of condylar fractures. 12th ICOMS. Budapest, 1995[J]. Int J Oral Maxillofac Surg, 1998, 27(4): 243-267.
3 BOS R R, WARD BOOTH R P, DE BONT L G. Mandibular condyle fractures: a consensus[J]. Br J Oral Maxillofac Surg, 1999, 37(2): 87-89.
4 张益. 中国颌面外科高年资医师髁突骨折治疗观点一致性的调查[J]. 中华口腔医学杂志, 2010, 45(4): 196-202.
4 ZHANG Y. Condylar fracture and temporomandibular joint ankylosis[J]. Chin J Stomatol, 2010, 45(4): 196-202.
5 NEFF A, CHOSSEGROS C, BLANC J L, et al. Position paper from the IBRA symposium on surgery of the head: the 2nd international symposium for condylar fracture osteosynthesis, Marseille, France 2012[J]. J Craniomaxillofac Surg, 2014, 42(7): 1234-1249.
6 黄国伟, 郑吉驷, 张善勇, 等. 曲面体层X线、CT和MRI在髁突骨折诊断中的应用比较[J]. 中华口腔医学杂志, 2014, 49(7): 434-439.
6 HUANG G W, ZHENG J S, ZHANG S Y, et al. The value of paronamic radiograph, CT and MRI for the diagnosis of condylar fracture[J]. Chin J Stomatol, 2014, 49(7): 434-439.
7 姜滨, 陈敏洁, 张善勇, 等. 全景片诊断髁突骨折的应用价值[J]. 中国口腔颌面外科杂志, 2009, 7(5): 397-400.
7 JIANG B, CHEN M J, ZHANG S Y, et al. The value of panoramic films in diagnosis of condylar fractures[J]. China J Oral Maxillofac Surg, 2009, 7(5): 397-400.
8 何冬梅, 杨驰, 姜滨, 等. 下颌骨髁突囊内骨折不同治疗方法的冠状CT评价[J]. 中国口腔颌面外科杂志, 2009, 7(6): 509-514.
8 HE D M, YANG C, JIANG B. Evaluation of the treatment for intracapsular condyle fracture of the mandible by coronal CT[J]. China J Oral Maxillofac Surg, 2009, 7(6): 509-514.
9 SCHIMMING R, ECKELT U, KITTNER T. The value of coronal computer tomograms in fractures of the mandibular condylar process[J]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1999, 87(5): 632-639.
10 YANG X J, YAO Z D, HE D M, et al. Does soft tissue injury affect intracapsular condylar fracture healing?[J]. J Oral Maxillofac Surg, 2015, 73(11): 2169-2180.
11 ZHENG J S, ZHANG S Y, YANG C, et al. Assessment of magnetic resonance images of displacement of the disc of the temporomandibular joint in different types of condylar fracture[J]. Br J Oral Maxillofac Surg, 2016, 54(1): 74-79.
12 LINDAHL L. Condylar fractures of the mandible. Ⅰ. Classification and relation to age, occlusion, and concomitant injuries of teeth and teeth-supporting structures, and fractures of the mandibular body[J]. Int J Oral Surg, 1977, 6(1): 12-21.
13 LOUKOTA R A, ECKELT U, DE BONT L, et al. Subclassification of fractures of the condylar process of the mandible[J]. Br J Oral Maxillofac Surg, 2005, 43(1): 72-73.
14 HLAWITSCHKA M, ECKELT U. Assessment of patients treated for intracapsular fractures of the mandibular condyle by closed techniques[J]. J Oral Maxillofac Surg, 2002, 60(7): 784-792.
15 NEFF A, CORNELIUS C P, RASSE M, et al. The comprehensive AOCMF classification system: condylar process fractures—level 3 tutorial[J]. Craniomaxillofac Trauma Reconstr, 2014, 7(Suppl 1): S044-S058.
16 HE D M, YANG C, CHEN M J, et al. Intracapsular condylar fracture of the mandible: our classification and open treatment experience[J]. J Oral Maxillofac Surg, 2009, 67(8): 1672-1679.
17 YING B B, ZHANG Q Q, ZHU S S, et al. Outcomes of treatment for intracapsular fractures of the mandibular condyle: recommendation for a new classification[J]. Br J Oral Maxillofac Surg, 2018, 56(2): 139-143.
18 ASSAEL L A. Open versus closed reduction of adult mandibular condyle fractures: an alternative interpretation of the evidence[J]. J Oral Maxillofac Surg, 2003, 61(11): 1333-1339.
19 WANG B L, HE D M, YANG C, et al. Factors affecting the outcomes of non-surgical treatment for intracapsular condylar fractures[J]. Int J Clin Exp Med, 2016, 9(6): 10847-10855.
20 ELLIS E, THROCKMORTON G S. Treatment of mandibular condylar process fractures: biological considerations[J]. J Oral Maxillofac Surg, 2005, 63(1): 115-134.
21 ELLIS E III. Complications of mandibular condyle fractures[J]. Int J Oral Maxillofac Surg, 1998, 27(4): 255-257.
22 ELLIS E III, SIMON P, THROCKMORTON G S. Occlusal results after open or closed treatment of fractures of the mandibular condylar process[J]. J Oral Maxillofac Surg, 2000, 58(3): 260-268.
23 HE D M, CAI Y H, YANG C. Analysis of temporomandibular joint ankylosis caused by condylar fracture in adults[J]. J Oral Maxillofac Surg, 2014, 72(4): 763.e1-763.e9.
24 HE D M, ELLIS E III, ZHANG Y. Etiology of temporomandibular joint ankylosis secondary to condylar fractures: the role of concomitant mandibular fractures[J]. J Oral Maxillofac Surg, 2008, 66(1): 77-84.
25 SCHNEIDER M, ERASMUS F, GERLACH K L, et al. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level[J]. J Oral Maxillofac Surg, 2008, 66(12): 2537-2544.
26 ANDERSSON J, HALLMER F, ERIKSSON L. Unilateral mandibular condylar fractures: a 31-year follow-up of non-surgical treatment[J]. Int J Oral Maxillofac Surg, 2007, 36(4): 310-314.
27 AL-MORAISSI E A, ELLIS E III. Surgical treatment of adult mandibular condylar fractures provides better outcomes than closed treatment: a systematic review and meta-analysis[J]. J Oral Maxillofac Surg, 2015, 73(3): 482-493.
28 ZHANG X, LI K, HAN C, et al. Prognosis of diacapitular condylar fractures: a multivariate analysis[J]. Br J Oral Maxillofac Surg, 2019, 57(10): 1019-1024.
29 CHANG S P, YANG Y, SHI L Q, et al. Modification of the measurement of the major variables in mandibular condylar fractures: angulation of sidewards displacement and shortening of the height of the ramus[J]. Br J Oral Maxillofac Surg, 2018, 56(2): 113-119.
30 LI J, YANG H B, HAN L. Open versus closed treatment for unilateral mandibular extra-capsular condylar fractures: a meta-analysis[J]. J Craniomaxillofac Surg, 2019, 47(7): 1110-1119.
31 ELLIS E III, THROCKMORTON G S, PALMIERI C. Open treatment of condylar process fractures: assessment of adequacy of repositioning and maintenance of stability[J]. J Oral Maxillofac Surg, 2000, 58(1): 27-34.
32 HE D M, YANG C, CHEN M J, et al. Modified preauricular approach and rigid internal fixation for intracapsular condyle fracture of the mandible[J]. J Oral Maxillofac Surg, 2010, 68(7): 1578-1584.
33 SCH?N R, FAKLER O, GELLRICH N C, et al. Five-year experience with the transoral endoscopically assisted treatment of displaced condylar mandible fractures[J]. Plast Reconstr Surg, 2005, 116(1): 44-50.
34 BU L T, CHEN Q, HUANG K, et al. Evaluation of internal fixation techniques for condylar head fractures: a finite element analysis and comparison[J]. Oral Surg Oral Med Oral Pathol Oral Radiol, 2022, 133(5): e96-e104.
35 冯智强, 杨驰, 何冬梅, 等. 339例下颌骨髁突骨折回顾分析[J]. 中国口腔颌面外科杂志, 2009, 7(3): 209-212.
35 FENG Z Q, YANG C, HE D M, et al. Fractures of the mandibular condyle: a retrospective study of 339 cases[J]. China J Oral Maxillofac Surg, 2009, 7(3): 209-212.
36 何冬梅, 杨驰. 单(双)侧髁突骨折与合并颌骨骨折的治疗原则[J]. 中华口腔医学杂志, 2009, 44(12): 725-727.
36 HE D M, YANG C. Treatment differences between unilateral and bilateral condylar fractures of the mandible and combined maxillary fractures[J]. Chin J Stomatol, 2009, 44(12): 725-727.
37 冯智强, 何冬梅, 杨驰. 儿童髁突骨折诊断和治疗的现状与展望[J]. 口腔颌面外科杂志, 2008, 18(6): 439-442.
37 FENG Z Q, HE D M, YANG C. Current status and prospects on the diagnosis and treatment of mandibular condyle fractures in children[J]. J Oral Maxillofac Surg, 2008, 18(6): 439-442.
38 胡敏, 王燕一, 张立海, 等. 手术与非手术治疗儿童下颌骨髁状突骨折的疗效比较[J]. 中国修复重建外科杂志, 2010, 24(12): 1440-1443.
38 HU M, WANG Y Y, ZHANG L H, et al. Comparative effectiveness of surgical and non-surgical treatment for pediatric mandibular condylar fractures[J]. Chin J Repara Reconstr Surg, 2010, 24(12): 1440-1443.
39 韩晶, 李智, 周海华, 等. 儿童髁突骨折治疗方法的临床评价与分析[J]. 中华口腔医学杂志, 2014, 49(8): 486-490.
39 HAN J, LI Z, ZHOU H H, et al. Clinical evaluation of open and close treatment in pediatric condylar fractures[J]. Chin J Stomatol, 2014, 49(8): 486-490.
40 王航, 周伟, 安金刚, 等. 儿童髁突骨折临床特点及保守治疗的疗效观察[J]. 现代口腔医学杂志, 2020, 34(4): 227-231.
40 WANG H, ZHOU W, AN J G, et al. Clinical characteristics of pediatric mandibular condylar fractures and the outcomes of closed treatment[J]. J Modern Stomatol, 2020, 34(4): 227-231.
41 ZHOU H H, LV K, YANG R T, et al. Abduction of the condyle head leads to condylar resorption: a radiologic study in children with intracapsular fractures[J]. Int J Pediatr Otorhinolaryngol, 2019, 123: 168-174.
42 朱妍菲, 唐艳梅, 孙蕙珺, 等. 144例儿童髁突骨折闭合性治疗回顾分析[J]. 中国口腔颌面外科杂志, 2017, 15(4): 329-333.
42 ZHU Y F, TANG Y M, SUN H J, et al. Nonsurgical management of condylar fractures in children: a retrospective study of 144 cases[J]. China J Oral Maxillofac Surg, 2017, 15(4): 329-333.
43 唐艳梅, 徐兵, 聂萍, 等. 正畸辅助儿童髁突囊内骨折外脱位伴下颌后缩的闭合性治疗[J]. 中国口腔颌面外科杂志, 2015, 13(6): 550-553.
43 TANG Y M, XU B, NIE P, et al. Closed treatment of pediatric dislocated intracapsular condylar fractures with mandibular retrusion using orthodontic appliance[J]. China J Oral Maxillofac Surg, 2015, 13(6): 550-553.
44 朱妍菲, 唐艳梅, 孙蕙珺, 等. 2～15岁单侧髁突骨折患者保守治疗后颌骨对称性的三维评价[J]. 中华口腔医学杂志, 2018, 53(5): 318-323.
44 ZHU Y F, TANG Y M, SUN H J, et al. Facial symmetry after conservative treatment of unilateral condylar fracture in children: a three-dimensional study[J]. Chin J Stomatol, 2018, 53(5): 318-323.
45 杜常欣, 徐兵, 朱妍菲, 等. 65例儿童髁突囊内骨折保守治疗临床预后的Helkimo指数评价[J]. 中国口腔颌面外科杂志, 2020, 18(5): 421-426.
45 DU C X, XU B, ZHU Y F, et al. Evaluation of clinical prognosis of condylar intracapsular fractures in 65 children with conservative treatment using Helkimo index[J]. China J Oral Maxillofac Surg, 2020, 18(5): 421-426.
46 WALKER R V. Condylar fractures: nonsurgical management[J]. J Oral Maxillofac Surg, 1994, 52(11): 1185-1188.
47 LI L Z, FENG Z Q, MA R, et al. The comparative study of mandibular ramus growth with different treatment methods for intracapsular condylar fracture[J]. J Craniofac Surg, 2013, 24(2): 657-670.
48 FENG Z Q, LI L Z, HE D M, et al. Role of retention of the condylar cartilage in open treatment of intracapsular condylar fractures in growing goats: three-dimensional computed tomographic analysis[J]. Br J Oral Maxillofac Surg, 2012, 50(6): 523-527.
Options
Outlines

/

〈 〉