Dr. SUBHABRATA GHOSH - 52.172.27.147:8080

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE.

“THE TEMPOROMANDIBULAR JOINT ARTICULAR DISC

POSITION AFTER OPEN AND CLOSED TREATMENT OF

MANDIBULAR CONDYLAR FRACTURES: A COMPARATIVE

STUDY.”

By

Dr. SUBHABRATA GHOSH

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

In partial fulfillment of the requirements for the degree of

MASTER OF DENTAL SURGERY in the speciality of

ORAL AND MAXILLOFACIAL SURGERY

Under the Guidance of

Dr. UMASHANKARA K. V. M. D. S. Professor

Department of Oral, Maxillofacial and Reconstructive Surgery

BAPUJI DENTAL COLLEGE AND HOSPITAL

DAVANGERE 577004, KARNATAKA, INDIA.

2016 - 2019

I

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “THE

TEMPOROMANDIBULAR JOINT ARTICULAR DISC POSITION

AFTER OPEN AND CLOSED TREATMENT OF MANDIBULAR

CONDYLAR FRACTURES: A COMPARATIVE STUDY.”

is a bonafide and genuine research work carried out by me under the guidance of Dr.

UMASHANKARA K. V.MDS Professor, Department of Oral and Maxillofacial

Surgery, Bapuji Dental College and Hospital, Davangere

Date: / / 2018 Signature of the Candidate

Place: DAVANGERE Dr. SUBHABRATA GHOSH

II

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “THE



CONDYLAR FRACTURES: A COMPARATIVE STUDY.” is a

bonafide research work done by Dr. SUBHABRATA GHOSH, in partial fulfillment

of the requirement for the degree of M.D.S in ORAL AND MAXILLOFACIAL

SURGERY.

Signature of the Guide

Dr. UMASHANKARA K. V. M.D.S, Professor

DATE: / / 2018 Department of Oral and Maxillofacial Surgery,

Bapuji Dental College and Hospital,

PLACE: DAVANGERE Davangere.

III

ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD

OF THE INSTITUTION

This is to certify that the dissertation entitled “THE



CONDYLAR FRACTURES: A COMPARATIVE STUDY.” is a

bonafide research work done by Dr. SUBHABRATA GHOSH under the guidance

of Dr. UMASHANKARA K. V.MDS Professor, Department of Oral and Maxillofacial

Surgery, Bapuji Dental College and Hospital, Davangere

Dr. KIRTHI KUMAR RAIM.D.S Dr.K. SADASHIVA SHETTYM.D.S

Professor & Head, Principal,

Department of Oral, Maxillofacial & Bapuji Dental College & Hospital,

Reconstructive Surgery, Davangere – 577 004.

Bapuji Dental College & Hospital,

Davangere – 577 004.

DATE: / / 2018 DATE: / / 2018

PLACE: DAVANGERE PLACE: DAVANGERE

IV

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this dissertation

/ thesis in print or electronic format for academic / research purpose.

DATE: / / 2018 Signature of the Candidate

PLACE: DAVANGERE Dr. SUBHABRATA GHOSH

© Rajiv Gandhi University of Health Sciences, Karnataka

V

ACKNOWLEDGEMENT

“Arise! Awake! And stop not, till the Goal is reached…...”

-Swami Vivekananda

I take this opportunity to thank the almighty God for a smooth sailing life He

blessed me with. But for his blessings, nothing would have been possible.

I take this opportunity to extend my sincere thanks and indebtedness to all

those people and dignitaries who helped me to complete this work.

“A true teacher would never tell you what to do. But he would give you the

knowledge with which you could decide what would be best for you to do.”

-Christopher Pike

An institution is always known for its infrastructure. It is my greatest fortune

to express my heartful thanks to Dr. K. SADASHIVA SHETTY, Principal, Bapuji

Dental College and Hospital, Davangere, for being an inspiration to work hard, and

also by providing with all the essential logistics which the institution has to offer

thereby giving me an opportunity to utilize the necessary facilities in this institution

for the study.

One such truly inspiring and encouraging teacher is our beloved Professor and Head

of the Department, Dr. Kirthi Kumar Rai. He is an excellence personified with the

highest of ideals and the deepest of convictions, which have been truly inspirational

for me and will continue to be in my future too. He is an amalgamation of academic

excellence with fine surgical skills. The care he takes while explaining his students is

unparalleled. He not only teaches his students, but makes sure that they understand

VI

and implement the same. His constant words of encouragement and time to time

evaluation help us understand much better. He aided me developing natural curiosity

as a student and building self-trust as a surgeon. He has taught me more than I credit

him for. I am in debt to him for my lifetime, for the knowledge I gained as a post-

graduate student under sir. I would like to express my deepest consecration and

gratefulness to towards him.

A teacher affects eternity; one can never tell where his influence stops …

It is a great honor to express my respect and gratitude to my guide

Dr. Umashankara K. V. Professor, Department of Oral Maxillofacial and

Reconstructive Surgery, Bapuji Dental College and Hospital, Davangere. His

immense knowledge and untiring pursuit of academic excellence and simplicity to

approach have been a constant source of encouragement throughout my post-

graduation course. It is indeed a privilege to have had the opportunity of being his

student. I am indeed deeply indebted for his kindness, courtesy, untiring patience and

meticulous care in correcting my mistakes during the course of this study. His

expertise and enthusiasm for the subject have made him a role model for me to

follow. I sincerely thank him for teaching me to think and reason while learning, and

for inculcating in me the scientific temperament that is essential for research.

“I am indebted to my father for living, but to my teacher for living well.”

-Alexander the Great

I wish to express my sincere appreciation and heartfelt gratitude to,

Dr. Umashankara K.V., Dr. Shivakumar H. R., Dr. Amarnath P. Upasi, Dr.

VII

Geetha N.T., Dr. Nanda Kishore D., Dr. Vinayak G. Naik, Dr. Amith H., Dr.

Fatima Hasina, Dr. Kavya Priya T., Dr. Sunil Byadagi, Dr. Prabhu B.G., for their

guidance throughout my postgraduate course.

Learning without thought is labor lost; thought without learning is perilous …

“Everyone needs a house to live in, but a supportive family is what builds a home”

- Anthony Liccione

My parents deserve special mention for their constant support and prayers. My

Father, Mr. Dipankar Ghosh., My Mother and Mrs. Sujata Ghosh for all trust they

had in me and the innumerable sacrifices, patience, love and understanding, to make

me what I am today. I place at your holy feet, all I am and I have earned today. You

are the wind beneath my wings.

I would like to thank my best friends Dr. Madhura Chitale, Dr. Sucharita

Vishwakarma, Dr. Poorva Attarde and Dr. Archie Khera for their everlasting love

and care. It is their energy that keeps me moving.

I will be failing in my duty, if I don’t thank my patients without whom my work

would not have been possible.

I sincerely thank the Nursing Staff and the Non-Teaching Staff of our

department for their valuable help and cooperation throughout the course.

My heart fills with fond gratitude as I reminisce the cherishable moments of

benevolence and selfless co-operation I received from My Seniors- Dr. Vinitha, Dr.

Jeevan, Dr. Shreepriya, Dr.Vibha; My Batchmates- Dr. Samyak, Dr. Nirdhum, Dr.

Anurag, My Juniors- Dr. Parvathi, Dr. Vani, Dr. Sulagna, Dr. Avijit, Dr. Sampada,

Dr. Madhuri.

VIII

I am thankful to Dr. Arun & Mr. Nagraj, Bio-Statisticians, for their services

in carrying out the statistical analysis.

Date: / / 2018 Signature of the candidate

Place: DAVANGERE Dr. SUBHABRATA GHOSH

IX

LIST OF ABBREVIATIONS USED

CT Computed Tomography

CDC/TMD Clinical Diagnostic Criteria for Temporomandibular

Disorders

cm Centimetre

IMF Inter Maxillary Fixation

MFIQ Mandibular Function Impairment Questionnaire

MIO Maximal Interincisal Opening

mm Millimetre

MMF Maxillo-Mandibular Fixation

MMO Maximal Mouth Opening

MR Magnetic Resonance

MRI Magnetic Resonance Imaging

OPG Orthopantomogram

ORIF Open Reduction and Internal Fixation

SFMC Sagittal Fracture Of The Mandibular Condyle

T Tesla

TMJ

Temporo Mandibular Joint

3D 3 Dimensional

X

LIST OF TABLES

SL. NO. TITLE PAGE NO.

TABLE 1 Spiessl & Schroll’s Classification Of Condylar Fracture

38

TABLE 2 Demographic Distribution Of Patients

38

TABLE 3 Preoperative Disc Condition And Its Correlation With

Type Of Condylar Fracture 38

TABLE 4 Post-Operative Condition Of Disc In Condylar Fractures

Treated By Open And Closed Reduction 39

TABLE 5 Post-Operative Assessment Of Functional Parameters At

Six Months Post Op. 39

TABLE 6

Correlation Of Correction Of Occlusion With Post-

Operative Position Of Disc In Patients Treated By Open

Reduction.

40

TABLE 7

Correlation Of Correction Of Occlusion With Post-

Operative Position Of Disc In Patients Treated By Closed

Reduction

40

TABLE 8

Correlation Of Correction Of Deviation On Mouth

Opening With Post-Operative Position Of Disc In

Patients Treated By Open Reduction

41

TABLE 9

Correlation Of Correction Of Deviation On Mouth

Opening With Post-Operative Position Of Disc In

Patients Treated By Closed Reduction

41

XI

LIST OF FIGURES

SL. NO TITLE PAGE NO.

PHOTOGRAPH 1 Phillips Achiever MRI Machine (Field

Density 1.5 Tesla)

71

PHOTOGRAPH 2 Head Rest For TMJ MRI 71

PHOTOGRAPH 3 Flex-M Surface Coils For TMJ MRI 71

PHOTOGRAPH 4

Preoperative Sagittal Section Of MRI

Scan Showing Displacement Of

Articular Disc In Anterior Direction

72

PHOTOGRAPH 5

Closed Reduction Of Condylar

Fracture By Placing Erich Arch Bar

And IMF

72

PHOTOGRAPH 6 Open Reduction And Internal

Fixation Of Condylar Fracture

72

PHOTOGRAPH 7 Case 1: Left Condylar Fracture Treated By

Open Reduction And Internal Fixation

showing

“Excellent” Post-Operative Outcome with

Articular Disc In Normal Position In All

Three Sections at six months post op

73

PHOTOGRAPH 8 73

PHOTOGRAPH 9 73


Open Reduction And Internal Fixation

showing “Good” Post-Operative Outcome

with Articular Disc In Normal Position In

Two Sections at six months post op

74

PHOTOGRAPH 11 74

PHOTOGRAPH 12 74


Closed Reduction showing

“Poor” Post-Operative Outcome with

Articular Disc Displacement In All Three

Sections at six months post op

75

PHOTOGRAPH 14 75

PHOTOGRAPH 15 75

XII

PHOTOGRAPH 16 Evaluation Of Maximal Inter-Incisal

Opening By Using Vernier Calipers 6

Months After Completion Of Treatment

76

PHOTOGRAPH 17 Evaluation Of Occlusion By Checking

Adequate Intercuspationof Teeth At 6


76

PHOTOGRAPH 18 Evaluation Of Deviation On Mouth At 6


76

XIV

ABSTRACT

Background and Objective: There are several literatures focusing on the hard tissue

reduction of the condylar fractures, while the soft tissue management remains

neglected. But, a good post treatment outcome requires correction of the inter-

articular disc and associated soft tissues of the TMJ along with proper anatomical

reduction of the bony component of the condyle. This study aims to assess whether a

mere hard tissue reduction is sufficient to restore the normal TMJ anatomy or not by

evaluating the post-treatment articular disc position and functional outcomes in

mandibular condylar fractures treated by open and closed method.

Methodology: A study consisting of 24 patients with unilateral condylar fracture

were included and were treated by either open or closed reduction (12 in each group).

MRI scans were taken prior to the treatment and six months after the surgery. Disc

displacement was assessed in the pre and post- operative MRI scans. At six months

after completion of treatment, functional parameters like maximal inter-incisal

opening, occlusion and deviation on mouth opening were assessed and they were

correlated with the post- operative position of disc.

Results: 18/24 patients had displacement of articular disc with most of the condylar

fractures being those where the fractured fragment was displaced. 9 out of 12 patients

treated by open reduction were successfully treated for disc displacement while in

closed reduction, the number was only 6 out of 12. The patients treated by open

reduction had a better success rate in correcting pre-operative malocclusion and

deviation on mouth opening. It was also observed that irrespective of the mode of

treatment, patients who had a successfully reduced articular disc had a better success

rate for correction of pre-operative maloclussion and deviation on mouth opening.

XV

Conclusion: In this study the data suggested that open reduction and internal fixation

of condylar fractures was more efficient than closed reduction in treating a displaced

articular disc.

Key Words: Condylar fracture; Articular disc; Magnetic Resonance Imaging

Introduction

1

“THE TEMPOROMANDIBULAR JOINT ARTICULAR DISC

POSITION AFTER OPEN AND CLOSED TREATMENT OF

MANDIBULAR CONDYLAR FRACTURES: A COMPARATIVE

STUDY.”

INTRODUCTION

The mandibular condyle is the place of least resistance and thus has high

susceptibility of fracture resulting from both direct and indirect trauma1. Condylar

fractures account for 17.5%-52% of all mandibular fractures and till date its ideal

treatment remains a controversy2. There are two principal therapeutic approaches to

treat these fractures, surgical or open and closed reduction. Closed reduction is

adopted most frequently since it permits adequate functional stimulation of condylar

growth in growing subjects and bone remodeling in all subjects. It is indicated in

almost all pediatric condylar fractures and in intra-capsular and extra-capsular

fractures that do not include serious condylar dislocation in adults. In contrast, open

reduction and internal fixation is indicated primarily for adults with displaced

fractures or with dislocation of condylar head3. There are several literatures focusing

on the hard tissue reduction of the condylar fractures, while the soft tissue

management remains neglected. But, a good post treatment outcome requires

correction of the intra-articular disc and associated soft tissues of the TMJ along with

proper anatomical reduction of the bony component of the condyle1. In this field,

Magnetic resonance Imaging (MRI) has stood out as the preferred method for

observing the disc and ligaments of the TMJ, and thus is capable of providing

information concerning the condylar disc apparatus4. An ideal treatment of condylar

fracture should achieve normal and pain free mouth opening, sufficient masticatory

Introduction

2

strength and restore pre-trauma occlusion and articulation5. This requires a thorough

knowledge about the soft tissue changes taking place in TMJ of a patient with

condylar fracture pre and post operatively for patients treated by either open or closed

reduction. Therefore this study aims to assess whether a mere hard tissue reduction is

sufficient to restore the normal TMJ anatomy or not by evaluating the post-treatment

articular disc position and functional outcomes in mandibular condylar fractures

treated by open and closed method and compares the data to see which of the two

methods of treatment is a better procedure for a hard and soft tissue reduction of

condylar fractures, so that a protocol can be made in which simultaneous correction

and restoration of hard and soft tissues can be established while treating cases of

condylar fractures, thus improving post treatment functional outcomes and achieving

a near normal morpho-functional state of the condyle.

Aims and Objectives

3

AIMS AND OBJECTIVES

Aim:

• To compare the post-treatment disc position in condylar fractures which are

managed by open or closed method.

Objectives:

• To record post-treatment position of disc in each type of condylar fracture and

compare the disc displacement.

• To assess the post-treatment disc position in condylar fractures which are managed

by open or closed method.

• To assess and compare post-treatment functional outcome with respect to disc

displacement.

Review of Literature

4

REVIEW OF LITERATURE

Catzberg R. W. and his associates evaluated the normal tempromandibular

joint using magnetic resonance imaging with a surface coil in 5 subjects and

compared with the abnormal joints in 37 patients. 3mm thick sagittal, coronal and

axial images were obtained with a 1.5 T MR system and 6.5cm diameter surface coil

using both partial saturation and spin echo sequences. A comparison with

arthrography, computed tomography, and surgical finding demonstrated that MR

imaging with the surface coil provided an accurate depiction about meniscal position,

morphology, and histology. Thus it was concluded that MR Imaging with surface coil

assessed the normal and abnormal TMJs accurately and its non-invasive

characteristics warrant priority for further examination of MR as a useful modality in

the diagnosis of TMJ pain and dysfunction6.

A prospective study was conducted with the aim of evaluating the damage to

the intra-capsular soft tissues in acute traumatic injuries of the temporomandibular

joint. 12 joints in 10 patients (7-males and 3-females;age range: 7-65 years; mean

age:30 years) with condylar and sub-condylar fractures of the TMJ were studied. All

patients underwent MRI examination preoperatively and after open reduction. All

patients had facial asymmetry, diffuse swelling of the pre-auricular region, limitation

of mouth opening (range: 10-32mm) and malocclusion. The fracture site evaluated by

plain radiography, tomography and CT scan was the condylar neck in 5 joints, sub--

condylar area in 5 joints and the condylar head in 2 joints. These were dislocated from

the mandibular fossa. As the control for MRI diagnosis, 30 right TMJ’s in 30

asymptomatic volunteers were used, having been previously used for the diagnosis of


5

TMJ disorders. Only unilateral joints (right side) were chosen for the purpose of

lightening the psychological and physical burden of the volunteers at the time of

MRI. It was noted that the joint capsule and the retro-discal tissue were both swollen

and showed increased signal intensity. Tears were recognized in the capsule of the 8

joints and in the retro-discal tissue of 6 joints. All discs were displaced in an antero-

medial direction along with the fractured condylar segments, but tear (rupture) was

not recognized. In all cases, high signal intensity was seen in the joint spaces and

hemarthrosis was recognized in 6 joints during open reduction surgery. The study

concluded that the damage to the intra-capsular soft tissues, excluding bony

structures, was most remarkable in the mobile tissues, such as the joint capsule and

the retro-discal tissue, with almost no signs of injury to the disc. This finding suggests

that, in the case of delayed open reduction, contracture caused by secondary fibrous

changes at the site of injury, may preclude reduction of a displaced condylar fragment

and disc. From this point of view, open reduction should be performed at the earliest

time permitted by the local and systemic condition of the patient7.

A prospective study was conducted to investigate the position and functioning

of discs in 10 adult patients whose bilateral condylar fractures were treated by a non-

surgical protocol by means of MRI. Pre-treatment CT images were obtained for all

patients. IN 13 TMJs the condylar fragments were medially dislocated out of the

glenoid fossa while in the rest 7 the fragments were inside the fossa. All patients

underwent non-surgical treatment, which consisted of tight IMF with elastic bands

for10 days, followed by active jaw exercises. Mandibular manipulation was

performed on each of the patients at weekly intervals for 4 weeks. All patients

underwent MRI 6 months after treatment and the images were evaluated relative to


6

disc position and functioning for the determination of TMJ function, the interincisal

distance at maximum mouth opening was recorded. In 7 TMJs the condylar fragment

and the disc were inside glenoid fossa and were functioning normally while in 13

TMJs the condylar fragment along with the disc lay below the summit of the articular

eminence. These findings indicated that the discs moved with the fractured condyles

as the disc is firmly and independently attached to the condyle by the discal ligament.

The study concluded that the condylar head remains in the intermediate zone of the

disc, even though the condyle is dislocated out of the fossa. This relation plays an

important role in the re-establishment of function when patients with condylar

fractures are treated conservatively. The authors recommended functional treatment in

cases were the condylar fragments were situated in the confines of the glenoid fossa

or are medially dislocated out of the fossa if it is possible to obtain good occlusion by

closed reduction8.

A prospective study was done to determine the frequency of occlusal and TMJ

disorders in a representative group of adult patients with non-surgically treated

unilateral condylar fractures upto 1 year after injury and to correlated this findings

with radiological characteristic of the fracture on admission. 80 patients with

unilateral condylar fractures were included in the study who were treated with inter-

maxillary fixation. The patients were interviewed about subjective complaints and

were clinically examined by the same examiner. The examinations included palpation

of the main masticatory muscles, TMJ’s and registration of joint sounds. Ranges of

mandibular excursion and functional asymmetry, such as mandibular deviation on

maximal mouth opening and on protrusion were recorded. Differences between lateral

excursions towards the fracture and non-fractured sides were calculated and distances


7

between retruded and intercuspal contact positions, lateral deviation during this side

and contact relationships between upper and lower teeth during lateral excursion were

recorded. A patient was defined as having occlusal disorders if severe occlusal

interferences or deviation of 5mm or more on mouth opening or protrusion were

objectively verified at the latest examination and he/she complained about subjective

symptoms like TMJ pain, altered occlusion or ability to bite only unilaterally.

Panoramic views and Towne’s views were always taken on admission. Reduction of

mandibular ramus height and angulation between proximal and distal fragments in the

lateral projection were measured from panoramic views and angulation between

fragments in the oblique frontal projection from Towne’s view. At the 1 year

examination, a panoramic view and lateral trans-cranial radiograph of both the TMJ’s

were recorded with the mouth open and closed. Reduction of ramus height, position

of condylar head in relation to glenoid fossa and signs of remodelling or degenerative

joint disease, such as flattening or sclerotic changes were recorded. Translational

movements of condyles on mouth opening were estimated from later trans-cranial

views and were compared between the fractured and non-fractured sides. It was seen

that during follow up, mandibular deviations on opening towards the fractured side

was more pronounced in cases with marked reduction of ramus height and condylar

dislocation. This restriction of translational movement of the fractured joint was also

seen radiologically in 1/3rd

of cases while in 2/3rd

of the fractured condyles,

malpositioning was observed when compared with the healthy side. In patients having

subjective symptoms such as TMJ pain, altered occlusion or ability to bite only

unilaterally and objectively verified occlusal interferences, a marked reduction of

ramus height on the fractured side was observed and in such cases non operative

treatment of condylar fractures may be compromised9.


8

A prospective study was conducted to visualize the disc by MRI scans and to

investigate the relationship between disc position and TMJ dysfunction after

conservative and after operative treatment of mandibular condylar fractures. 30

patients with healed condylar fractures were included in the study. 10 patients were

conservatively treated while in 20 patients the fractures were treated surgically. All

patients were assessed using MRI of both TMJs to evaluate the disc position and

morphology, radiographs to evaluate the alignment of bony fragments after

consolidation and clinical examnation including stomatognathic functional status and

mechanical axiography. MRI scans showed disc displacement in 30 percent of the

conservative cases and 10 percent in the surgery group . In 7 patients treated

conservatively compared to 2 treated surgically the disc underwent a visible re-

modeling, which resulted in deformation, or partial or even total loss of the disc . In 8

patients from the conservative treatment group the MRI scans showed that the

condylar process healed in a dislocated position with severe disfigurement of the

condylar head. The functional analysis of the stomatognathic system showed nearly

normal mandibular mobility in both groups. The study concluded that anatomical

reduction of a low displaced or dislocated condylar fracture by surgical approach may

benefit for functional recovery of TMJ10

.

A comparative study of the mandibular and condylar mobility after open or

closed treatment for fractures of the mandibular condylar process was done. 74

patients were treated by closed reduction while 62 patients were treated by open

reduction. Radiographs were traced and digitized to assess condylar displacement and

mobility. Measurements of voluntary mandibular range of motion were obtained

using a magnetic jaw tracking device (sirognathograph), while motion of the fractured


9

and non-fractured condyles in the sagittal plane was measured using tomograms taken

at each post-surgical trial period in both open and closed mouth positions on a Quint

Sectrograph-200. The patients underwent testing of mandibular and condyle mobility

at 6 weeks, 6 months, and 1, 2 and 3 years post-surgery. It was seen in this study that

patients treated by open reduction had significantly greater initial displacement of

their condylar processes than patients treated by closed reduction. At 6 weeks patients

treated by closed reduction had significantly greater measures of mandibular mobility

than those in patients treated by open reduction, however this difference in mobility

reduced between the two groups after the 6 week period. At the 6 weeks period,

patients treated by open reduction had significantly greater vertical mobility of the

condyle on the fractured side than the patients treated by closed reduction despite

having reduced mouth opening and this feature was appreciated even after the 6

weeks period. In patients treated by closed reduction, several measures of condylar

displacement correlated with measures of mandibular mobility indicating a direct

dependence of mandibular mobility on condylar displacement. Thus the authors came

to a conclusion that despite having more preoperative condylar displacements,

patients treated for fractures of the mandibular condylar process by open reduction

had greater postoperative condylar mobility than patients treated by closed reduction.

Therefore open reduction may produce better functional benefits to patients with

severely displaced condylar process fractures11

.

A prospective study was conducted to compare the Occlusal relationships after

open or closed treatment for fractures of the mandibular condylar process. 137

patients with unilateral fractures of the mandibular condylar process were included in

the study. Patients were given the choice to choose their mode of treatment where in


10

closed treatment maxillo-mandibular fixation was done using wires and in open

surgery the fractured fragments were rigidly stabilized using internal bone plate or

screw fixation. A pre-treatment panaromic radiograph was used to classify the level of

condylar process fractures into the head, neck, and sub-condylar. To quantify the pre-

treatment displacement of the fracture condylar processes, coronal displacement was

evaluated using a pre-treatment Town’s view radiograph while the sagittal

displacement was evaluated using a pre-treatment panaromic radiograph.

Standardized frontal and right and left lateral photographs of patients occlusal were

obtained at 6weeks, 6months, 1, 2, and 3 years after treatment. One surgeon and

orthodontist independently examined each set of photograph and evaluated the

occlusion as good or poor or undecided. It was seen in the study that though the initial

displacement of the fractures were greater in the patients treated by open reduction,

the patients treated by closed reduction had a comparatively greater percentage of post

treatment malocclusion at all but the 6 month period. The authors suggested that the

reason why there were no significant differences between the open and closed

treatment groups at 6 months is probably due to 2 factors, attrition in the patient

sample sizes after the 6 week time and improvement in occlusion in some patient

from 6 weeks to 6 months. They also found that the presence of other fracture of the

mandible did not seem to increase the number of malocclusions in their study

samples. It was reasoned that the better post treatment occlusion for ORIF cases is

because it returns the condylar process to its pre traumatic position, or close to that

position, restoring skeletal continuity, re-establishing normal mandibular position and

bringing the teeth into their proper relation ship though risks of surgical morbidity

always remains. Thus, the authors concluded that more consistent occlusal results can


11

be expected when fractures of the mandibular condylar process are treated by open

reduction12

.

MRI examination of the TMJ after surgical treatment of condylar fractures

Choi B. H.5 and his associates conducted a study to evaluate the position of discs in

20 adult patients whose unilateral condylar fractures were treated by open reduction

with the help of magnetic resonance imaging. Pre-treatment CT scan and post

treatment MRI was done for all the patients. Surgical indications were based on both

clinical examination that found shortening of ramus associated with molar prematurity

and on radiologic findings that showed a condylar neck fractures with displacement or

dislocation. All fractures were classified according Spiessl and Schroll into I-VI. 2

fractures were classified as type II, 8 as type III, 3 as type IV and 7 as type V. Both

the condylar fracture and the additional fracture were treated during the same session.

All patients underwent open reduction and rigid fixation using plates and screws. The

immediate postoperative position of the condylar fragments was assessed by an

orthopantomogram and Towne’s radiograph. All subjects underwent MRI 1 to 3

months after surgery and these images were evaluated for disc position. All patients

were followed up at monthly intervals for 6 months. During the follow up period,

interincisal distance at maximal mouth opening was measured, and the deviation from

the midline during mouth opening was recorded. MRI clearly showed the disc and its

relationship to the condyle, although titanium plates and screws made artifacts on the

condylar neck areas. Immediate postoperative radiographs showed excellent reduction

of the fractures in al patients, whereas MRI showed that repositioning of dislocated

condyle did not always lead to anatomical restoration of the joint structures. In 4 of

the 20 cases the disc was anteriorly displaced in both open and closed mouth positions


12

while in the remaining 16 the disc was normally positioned. The study concluded that

the disc has to be inspected during surgery when the joint capsule is opened at the

time of open reduction of high condylar fractures. Once the displaced disc is detected,

simultaneous discal repositioning should be considered.

A comparative study was done between two groups of patients with similar

condylar fractures which were treated non-surgically and by open reduction and rigid

internal fixation and the post treatment results were evaluated. In this study the group

of patients treated surgically consisted of 20 patients, while the non-surgical treatment

group consisted of 19 patients. The clinical diagnosis was supported by radiological

analysis of the mandible with an orthopantomogram, antero-posterior X-rays and a

CT scan. Surgical access was obtained either with a submandibular, pre-auricular or a

variant of retromandibular approach and MMF was performed for 3-5 days followed

by light functional therapy for 1-2 months, while the functional treatment consist of

individual occlusion restoration with MMF for 5-7 days, achievement of lateral

protrusion on the contralateral side with horizontal light training elastics and

nocturnal vertical traction to maintain the midline for 40-60 days and a lateral

propulsion splint for a further 40-50 days in cases of less favorable progress.

Comparison of the two groups was based on pre and post treatment X-rays and

clinical data. In both groups fracture level and degree of dislocation, mandibular

deviation and movements, articular noise and pain and TMJ anatomic alterations were

assessed3.

A prospective study was conducted to evaluate the clinical significance of

magnetic resonance imaging in investigating the occurrence of joint effusion of the


13

TMJ after mandibular condylar fractures. 18 joints in 15 consecutive patients with

condylar fractures whose joints were evaluated by MRI before treatment were

included in the study. Radiographic examination included a panoramic transcranial

view and tomography to determine the position of mandibular fractures. Computed

tomography was also done for 5 patients. The types of condylar fractures in relation to

the mandible were classified according to MacLennan’s classification. The treatment

protocol for the condylar fractures depended on the position and the types of the

fracture. In cases with fractures in the upper region of the condyle, closed reduction

was performed. 10 patients were treated with closed reduction that included

intermaxillary fixation for 10 days. In cases with fractures in the lower region of the

condyle, in those with severely displaced condylar fractures, a retromandibular

approach to perform open reduction with dual mini titanium plate fixation was used.

In all patients, MRI examination was completed for diagnostic purposes before any

treatment procedure began. MRI revealed evidence of joint effusion in 11 of 18

TMJ’s, which was 61% of the condylar fractures. It appeared more frequently after

fractures with dislocation than those without dislocation. In addition, evidence of

effusion appeared more frequently after higher condylar fractures than lower ones. It

was concluded that these findings indicated that magnetic resonance evidence of joint

effusion may serve as al marker for the detection of severe intra-articular damage to

the TMJ after mandibular condyle fractures13

.

A prospective randomized multicentre study was done to compare operative

and conservative treatment of displaced condylar fractures of the mandible. A total of

66 patients with 79 fractures of the mandibular condylar process were included in the

study. The patients were divided into two treatment groups to be treated by operative


14

or conservative treatment and the type of treatment was chosen by opening a sealed

envelope which had been prepared by the study coordination centre. A classification

of the location of the fractures was performed according to Louka et al. (2005) on the

basis of the panoramic view and posterior-anterior cranial radiograph and a computed

tomogram was permitted in the study as an alternative. In order to measure the degree

of displacement of the fracture, the angle between the vertical axis of the displaced

condylar fragment and the axis of the original position of the condylar fragment as

mirrored from the contralateral side in the frontal plane was measured. The vertical

height of the ascending ramus from the condylar surface to the level of the lower

border of the horizontal ramus was measured on both sides. In conservative treatment

group, therapy consisted of short term elastic maxillomandibular immobilization

applied to arch bars for 10 days which was occasionally prolonged in cases with

complications like occlusal problems. In the operative group, the decision about the

type of operation was made by the surgeon depending on the position of the fracture

and degree of displacement. The patients were followed up after the first 6 weeks and

after 6 months. The treatment result was assessed by evaluating the range of motion

of the injured joint together with the contralateral joint as given by maximal

interincisal distance and by extension of lateral excursion and of protrusion. The

function of the TMJ was assessed by deviation or deflection during mouth opening

along with the Mandibular Function Impairment Questionnaire (MFIQ). Assessment

of pain and discomfort was done using a visual analogue scale while malocclusion

was assessed by an examiner and as described by the patient. It was seen that correct

anatomical position of the fragments was achieved significantly more often in the

operative group than in the closed treatment group. Mouth opening, lateral excursion

and protrusion were all more in operative group in contrast to the closed treatment


15

group. The visual analogue scoring revealed significantly less pain in the operative

group and the conservative treatment group and the MFIQ also recorded a less pain

and discomfort in the open treatment group. Thus the study concluded that though

both the treatment options for condylar fractures of the mandible yielded acceptable

results, operative treatment was superior in all objective and subjective functional

parameters14

.

A comparison of MRI, radiographic and clinical findings of the position of the

TMJ articular disc following open treatment of condylar neck fractures

A prospective study was conducted to examine the position and function of the

articular disc after open treatment of condylar fractures by comparing magnetic

resonance images and radiographs with clinical data. 28 patients with 33 fractures of

the condylar neck that required open reduction and internal fixation were included in

the study. The fractures were classified as dislocated or displaced and were treated by

osteosynthesis. The criteria for open treatment were fracture types II – V, with an

angulation of the proximal fragment of more than 30º or a reduction in the height of

the ramus of more than 5mm or both. During post-operative follow-up, all patients

were assessed in a standard seating position for mouth opening, protrusion and lateral

excursion left and right. The radiological investigations comprised reverse Townes’

view and panoramic radiographs together with MRI which was taken using an 0.5

tesla device. MR images were individually planned by the position of the articular

process in the sagittal axis and vertical to the diagonal axis of the condyle. In MR

examinations, with the mouth open and closed, the position of the articular disc was

viewed bilaterally relative to the joint cavity and to the articular prominence was also

assessed. Conventional radiographs were used to assess the position of the fragment


16

and arthritic changes. The clinical examination showed mouth opening of at least 30

mm in all patients. In 4 patients, there was a limitation of protrusion to less than 5 mm

and in 3 there was a limitation to less than 5mm of the lateral excursion. After MR

scanning, the function of the disc was shown to be normal in 8 patients. In all patients,

the disc was in the antero-central section of the condylar fossa and was only slightly

displaced medially in one. The damage visible on the MRI increased from displaced

to dislocated fractures. There was an increase in anterior dislocation with decreased

reduction of the disc and restricted mobility of the condyle. The radiograph findings

showed that 3 of 33 fractures treated openly had healed in slightly displaced positions,

each one being a Type IV fracture. Thus the authors came to a conclusion that the

MRI, radiographic and clinical findings did not correlate, and damage to the TMJ

could be seen more clearly on MRI than on clinical or radiographic examinations.

Damage to the soft tissues seen on MRI after treatment was more pronounced in

dislocated than in displaced fractures4.

A prospective study was conducted with the aim of investigating whether the

MRI findings of disc displacement, capsular tear and hemarthrosis are linked to the

degree of condylar injury. The study group of condylar trauma patients comprised of

9 females and 10 males CT diagnosis of condylar fracture type was made according to

the diagnostic criteria published by SPIESSL & SCHROLL. Clinical diagnosis of

trauma related TMJ sprain/strain was made according to the Clinical Diagnostic

Criteria for Temporomandibular Disorders(CDC/TMD).Condylar injuries were

classified as grade I (absence of condylar fractures, grade II (Type I, II or III condylar

fractures ) and grade III(type IV, V or VI condylar fractures). MRI was carried out

with a 1.5T MR scanner and parcoronal and para sagittal 3mm slices of each TMJ


17

were obtained . Sequential bilateral T1 & T2 weighed images were made at closed

mouth positions. T1 weighted images were selected for analysis of disc condyle

relationship that depicted the disc, condyle, articular eminence, & glenoid fossa. On

the T1 and T2 weighted images TMJ capsular tear was defined by the presence of a

dotted high signal area. On the T2 weighted images, hemorrhagic joint effusion was

identified as an area of high signal intensity in the region of joint space. The data

revealed a significance relation between the degree of condylar injury and the MRI

findings of capsular tear and hemarthrosis and between the MRI diagnosis of capsular

tear and hemarthrosis. There was good diagnosis agreement between the presence of

grade III condylar injury and the MRI diagnosis of capsular tear and hemarthrosis.

Thus the study concluded that the degree of condylar injury is related to MRI findings

of capsular tear and hemarrthrosis15

.

A prospective study was conducted with the aim of using MR imaging to

assess and compare TMJ soft tissue changes after dislocated and non-dislocated

condylar fractures.81 patients with 120 fractured condyle of mandible were included

in the study and MR imaging examinations were performed for all subjects with in 1

month after the injuries before management. On the basis of the position of the

fractured condyles, 118condylar fractures were divided into 2 groups; group 1,

fractures with dislocation{108TMJ, group 2,fractures with out dislocation (10 TMJ’s).

MR imaging examinations of the TMJ’s were performed on 1.5T dual TMJ array coil

MRI machine. The location of the normal TMJ disc was defined by the posterior band

of the disc at the superior (12 O’ clock) position relative to the top of the condyle in

the glenoid fossa in the closed mouth position. Joint effusion was identified as an area

of high signal intensity in the joint space at least in two consecutive sections. The


18

absence of a biconcave shape of the disc was depicted as a disc deformity. 3 blinded

radiologist visually and independently inspected all of the MR imaging studies of 118

TMJ’s. MR imaging demonstrated that 97.2% of patients in group 1 and 30% of

patients in group 2 had disc displacement most of which were in anteroinferior

direction, abnormal signal intensities of retrodiscal tissues were appreciated in 87.3%

of patients in group 1 and 50% of patients in group 2 , joint effusion was seen in 88%

of patients in group 1 and 60% in group 2, abnormal inferoposterior attachments of

discs were seen in 88.9% of the patients in group 1 and 70% of patients in group 2

and damaged joint capsules were seen in 87% of the patients in group 1 and 70% of

patients in group 2. Thus the study concluded most dislocated condylar fracture were

characterized with anteroinferior discs displacement along with the fractured

fragments and MR imaging could provide additional information of TMJ soft tissue

injuries after condylar fractures16

.

Saponaro A.1 and his associates evaluated the morphostructural and functional

modifications of the temporomandibular joint and onset of parotid complications in

patients with extracapsular monocondylar fractures treated by reduction with the

application of a titanium microplate via a transparotid approach. The study was

comprised of 20 patients who had undergone the reduction of Spiessl and Scroll type

III or V mandibular condyle fractures and 12 months later were examined by means

of MRI of the TMJ and parotid gland on the treated side. All the patients were treated

via the transparotid approach and the fractures were reduced and stabilized by means

of a titanium plate. At 12 months after surgery, the patients underwent MRI of the

TMJ and parotid gland by the use of coronal T2 weighed turbo spin echo sequences,

as well as para-sagittal T1 weighed turbo spin echo and T2 weighed fast field echo


19

sequences. The assessment of signal intensity, morphology and position of the disc at

various oral apertures, the morphology and signal intensity of the treated condyle, the

signal intensity of the retrodiscal tissue, the presence of articular effusion, plate

integrity, the presence of altered parotid signals and the lengths of the treated and

contralateral mandibular branches were made. It was found that 5 out 20 patients had

anteriorly dislocated inter articular disc that was irreducible at the various degress of

oral aperture, 1 case of disc fibromyxoid degeneration and 1 case parotid fistula. Thus

the authors came to a conclusion that MRI allowed the complications due to the

trauma and/or treatment to be identified and made it possible to compare the condyles

and joint function.

A prospective study was conducted to detect changes in 3D mandibular

motion after 2 types of condylar fracture therapies. 21 patients treated for unilateral

fractures of the mandibular condyle were analysed. In 9 patients the condylar

fractures were treated by open reduction , rigid internal fixation and functional

treatment while in 12 patients closed reduction and functional treatment was done.

The criteria for treatment selection were mainly based on the kind of fracture and the

present and amount of condylar displacement/ dislocation, clinical considerations,

dental occlusion and patients preference. Fractures were classified according to

radiological findings as per SPIESSSL & SCHROLL classification. All surgically

treated patients underwent postsurgical functional therapy for approximately 40- 60

days and the closed treatment was based on functional therapy. The patients were

assessed between 6 and 66 months after the end of therapy. For free mandibular

border movements were recorded using and optoelectronic 3 Dimensional motion

analyser and the data was compared to those collected in 25 healthy subjects. It was


20

seen that no differences were found among the groups for maximum mouth opening,

protrusion and in lateral excursion. During opening, the patients had a larger maximal

deviation to the fractured side than the controls with a larger coronal plane angle. In

the closed treatment patients a longer follow up was related to increase maximum

mouth opening, sagittal plane angle and reduced lateral mandibular deviation during

mouth opening. Thus the study concluded that mandibular condylar fracture can

recover goof function and some kinematic variables of mandibular motion were more

similar to normal in the open treatment patients than in the close treatment patients17

.

Amit Nandan Dhar Dwivedi18

and coworkers conducted a study to evaluate

the role of magnetic resonance imaging (MRI) in cases of acute condylar injury and

assessed soft tissue damage such as disc displacement, capsular tear and hemarthrosis

within the temporomandibular joint. This prospective study was conducted in 15

patients who presented with unilateral or bilateral condylar fracture or contusion with

a unilateral or bilateral diagnosis of TMJ sprain/strain. Patients with trauma of less

than 7 days previously with a unilateral or bilateral condylar fracture or contusion

with a diagnosis of TMJ strain/sprain were included in the present study. The

diagnosis of condylar fracture was made by clinical examination and by radiographs,

which included orthopantamograms of the mandible, a reverse Towne’s view of the

skull and a CT scan of the condylar region. MRI scans were performed only after

clinical and plain radiographs confirmed the presence of condylar injury. MRI images

were obtained and interpreted by 2 experienced radiologists who were blinded to each

other’s findings. In case of differences, a common consensus was taken. Condylar

injuries were classified using the classification of Spiessl and Schroll and further

classified depending on the severity of injury as grade1(absence of condylar fracture),

grade II (typeI, II| or III condylar fracture), or grade III(type IV, V or VI condylar


21

fracture). The patients clinical details, including the presence/absence of jaw

deviation, inter-incisal opening, occlusion and the presence/absence of any TMJ

pain/noise were recorded. All patients were treated by closed reduction of the condyle

fracture and intermaxillary fixation for 14 to 21 days. Patients were recalled at 1week,

3-week, 2month and 3-month intervals and the clinical examination and

measurements at follow-up were compared with the pretreatment records. It was seen

that of all 17 TMJ cases (2 bilateral,13-unilateral), 2 condylar fractures were of the

high variety and 13 were of the low variety. MRI diagnosis of disc displacement was

established in 8 of 17 TMJ cases. There was a significant association between degrees

of condylar injury and the MRI diagnosis of displaced disc and hemarthrosis.

However, an MRI finding of capsular tear was not significantly associated with the

degree of condylar injury. It was concluded that soft tissue changes of the TMJ can be

predicted accurately by MRI and are in direct proportion to the severity of the

condylar injury of the mandible. Among the soft tissue changes, disc displacement

and hemarthrosis seem to affect the outcome of functional treatment.

D. H. Duan19

and his associates performed a retrospective study to evaluate

the potential influence of the sagittal fracture pattern and articular disc displacement

on the development of temporo-mandibular joint ankylosis. 33 sagittal fractures of

mandibular condyles were treated conservatively and were divided onto non-

ankylosis and ankylosis groups based on the prognosis. In order to interprete the

displacement of fractured fragment CT Scans were done and the sagittal mandibular

condylar fractures were classified into type I II and III. To evaluate the disc position

relative to joint fossa, sagittal section of MRI images were evaluated. In this study,

the SFMCs were associated with a high rate of disc displacement, It was seen that in


22

the non ankylosis group type I SFMCs no disc displacement was seen while 9 out of

14 cases of SFMCs showed disc displacement. All the cases in the ankylosis group

were type III SFMCs showing disc displacement. These findings indicated that the

position of the articular disc was highly associated with the position of the fractured

fragments. Several factors were thought to contribute to this post traumatic TMJ

ankylosis; firstly, an intact disc may act as a physical impediment to transarticular

bony fusion. Secondly, the type of fracture may determine the prognosis of condylar

fracture. Thirdly, the age of the patient at the time of injury is a key factor. Finally,

the absence of mouth opening exercise accelerates transarticular bony fusion. In this

study, the SFMCs associated with TMJ ankylosis were Type III SFMCs, in which the

lateral poles of the condyle are dislocated out of the joint fossa, resulting in

mechanical locking and mandibular hypomobility, with subsequently accelerated TMJ

ankylosis. Apart from the influence of the fractured type the position of articular discs

play a more critical role. In this study, SFMCs that progressed to ankylosis

demonstrated fibrous adhesion or partial bony fusion between the lateral pole of the

condyle and the lateral rim of the joint fossa without the barrier of the articular disc as

validated by MRI. In cases showing good prognosis without surgery, the lateral poles

were completely or incompletely covered by discs. The possible reason for this

phenomenon was that the absence of the articular disc between the lateral pole of the

condyle and the lateral rim of the joint fossa played a key role in TMJ ankylosis,

owing to the transarticular bony fusion triggered by the post traumatic response. In

conclusion, the results of this study confirmed that the displacement of the fractured

fragments entailed the displacement of the articular discs in SFMCs. In addition, Type

III SFMCs with severe displacement of the articular disc were associated with a high

risk of TMJ ankylosis and were a potential indication for surgery.


23

A prospective study was conducted to evaluate the soft tissue of the TMJ with MRI

after intracapsular condylar fracture. 18 patients with unilateral or bilateral

intracapsular condylar fractures that had been confirmed on computed tomography

were examined by MRI. The fractures were classified based on the location of

fracture line. Type A was a fracture with displacement of the medial parts of the

condyle but maintaining vertical mandibular dimensions, type B affected the lateral

condyle with reduction in mandible height and type M included high extracapsular

fracture dislocations. The TMJ were examined using a 1.5T MR machine with mouth

both open and closed using dual coil. The normal disc position was defined using the

location of the posterior band of the disc at the superior (12o’clock) position relative

to the top of the condyle in the glenoid fossa while in closed mouth position. On the

T1 and T2 weighed images, capsular tears in TMJ and tears in the retrodiscal tissue

were defined by the presence of a dotted high signal area. The joint effusions were

defined by dotted, high signal area on diffusion weighed image while hemarthrosis

was defined by the presence of a dotted, high signal area on the T1 and diffusion

weighed images. The 18 patients had 19 joints with intracapsular condylar fractures

out of which 4 were classified as type A, 14 as type B and 1 as type M. Disc

displacement was seen in 15 out of 19 joints and the fractured condyle was also

displaced in an anteroinferior direction. Capsular tears were seem in 9 cases which

were on the lateral side of joint capsule and 3 on the medial side. A diagnosis of

retrodiscal tissue was established in 16 out of 19 TMJs while hemarthrosis was seen

in 16 out of 19 fractures. Thus the authors concluded on the notion that MRI is useful

for diagnosis and for estimation the amount of damage to the TMJ and is helpful in

planning treatment20

.


24

A retrospective study was done to evaluate the displacement of the disc of the TMJ

in different types of condylar fracture. The records of 160 patients (222 joints) with

condylar fractures who had preoperative CT scans and MRI were reviewed. The CT

scans were reviewed to classify the types of condylar fractures while the MRI scans

were assessed to check whether there is displacement of the disc or not. The condylar

fractures were classified into intracapsular condylar fractures, fractures of the

condylar neck and subcondylar fractures. Intracapsular condylar fractures were further

classified into subtypes A, B, C and M. The position of the disc was assessed on the

parasagittal MRI. For all the fractures of the condylar neck or subcondylar region, the

position of the disc was assessed depending on whether the fracture was displaced or

not. Displacement of the disc was assessed by the relation between the posterior band

of the disc and the top of the condyle (12o’clock), or the lateral aspect of the condyle

in the closed mouth position. The postoperative position of the disc was assessed

based on a criteria which included three sagittal planes lateral, central and medial.

Patients whose discs were in the normal position in all three planes were assessed as

excellent, those with discs in a normal position in two planes were good and the

remainder were poor. Cases regarded as excellent or good were considered to be

successful. There were 160 intracapsular condylar fractures, 4o fractures are condylar

neck and 22 subcondylar fractures out of which discs were displaced in 153 intra

capsular condylar fractures 17 fractures of condylar neck, and 8 subcondylar

fractures. Thus the study concluded that intracapsular condylar fractures were more

likely to have displaced discs than the other types2.


25

A retrospective study was conducted to analyse the outcome result of surgical and

non -surgical treatment of mandibular condyle fractures. 27 patients with isolated

condylar fractures and condylar fracture associated with other additional fractures

were included in the study. Out of 27 patients, 16 had undergone non- surgical

management which included closed reduction with maxillo-mandibular fixation

ranging from 2-4 weeks followed by physiotherapy. The other 11 patients were

treated surgically by means of open reduction and rigid internal fixation.

Postoperative follow up period ranged from 3-18 months. Various complications

associated with respect to mouth opening, deviation of the mandible, pain in the TMJ

, malocclusion, reduced ramal height and pain on lateral excursion. It was seen that in

non-surgical group, 9 patients had loss of vertical ramus height and 6 patients had

reduced mouth opening of below 35 mm. In open reduction group temporary facial

nerve weakness was seen in two patients and one patient developed post-operative

infection. No differences were found in mastication, or maximum interincisal opening

between the two groups. The ORIF group was associated with perceptible scars, and

the closed reduction group with chronic pain. Mandibular deviation towards the

fracture side and pain on lateral excursion was more common in patients treated by

closed reduction. The study concluded that open reduction is indicated in cases of

dislocated condylar fractures with ramus shortening and occlusal disharmony and

closed reduction in cases of undisplaced condylar fractures without occlusal

disharmony21

.

A prospective study was conducted to study the incidence etiology and various

types of mandibular condylar and sub condylar fractures indications and techniques

for closed and open treatment of condylar and subcondylar fractures .43 cases of


26

condylar and subcondylar fractures were included in the study which were treated by

open or closed reduction according to clinical and radiological criteria. Among 43

cases, 13 cases were unilateral condylar fracture, 11 cases were bilateral condylar

fractures, 16 cases unilateral subcondylar fractures and 5 cases bilateral subcondylar

fractures.26 cases underwent ORIF and 17 cases underwent closed reduction.

Occlusion was normal in all ORIF cases. In ORIF group complications such as

temopary facial nerve palsy, severe painful mouth opening , hematoma , infection ,

loosening and displacement of screw was recorded. In closed reduction group ,

malocclusion and shortening of vertical height of mandible were the chief

complications .the study concluded that the mode of treatment for condylar fractures

should be selected considering patient’s age, fracture type , patient systemic status ,

other associated fractures, possibility of occlusal restoration by intermaxillary fixation

and existence of foreign materials22

.

In this prospective study, Bo-Lei-Cai et al.23

proposed a modified open reduction

technique and evaluated its functional and the radiographic outcomes. 34 adult

patients with intra-capsular fractures were included who underwent pre and post-

operative computed tomography to evaluate the condylar morphology and magnetic

resonance imaging to evaluate the position of the articular disc. Intra-operatively the

fractured fragments were reduced with 12 mm bicortical screws, the abnormal

adhesion around the discs were carefully released, sparing the anterior attachment

with pterygoid muscles, the disc was placed in its anatomical positon and was tightly

anchored to a anchoring screw which were placed at posterior lateral third of the

condylar neck to counteract the force from lateral pterygoid muscle. At 6 months

follow-up, no malocclusion was found and the maximal inter-incisal opening


27

significantly expanded to 3.56 ± 0.13 cm. post-operative CT and MRIs showed that

all the fragments were properly reduced and the condyles were in the normal position,

post-operative disc displacement was seen in 4 cases and condylar morphological

abnormalities were noticed in 3 cases. Thus, the authors concluded that their modified

open reduction internal fixation technique achieved inspiring outcomes on the

treatment of all types of intra-capsular condylar fractures and manifested promising

prospect in their treatment.

A retrospective study was done to evaluate the clinical and radiological outcomes

of the isolated functional treatment in the case of condylar process fracture with

articular impact in adults in comparison with surgical treatment. 83 patients with

either unilateral or bilateral mandibular high condylar fractures were included in the

study. The maximal mouth opening excursion and projection of the affected condyle,

temporo-mandibular joint dysfunction and pain were noted at one, three, six months

and one year after the trauma. Radiological examinations were done to classify the

fractures, to measure the height of the ascending ramus and to analyse the chin

position and horizontal correction of the occlusal plane at the end of the follow up,

and condylar remodelling was assessed. Functional treatment advocated active re-

education with projection and lateral excursion movements while in surgical approach

a submandibular trans-masseteric approach or a pre-auricular approach were

performed. The clinical data showed non operative patients had more maximal mouth

opening in the 1st six months after the treatment and lateral excursion was more severe

for non-operated patients. Significant increase in post-operative ramus height was also

appreciated. The authors did not operate Type A fractures because in these cases there

was a preservation of the vertical dimension and occlusion. In the present study,


28

mouth opening was significantly higher in non-operated patients until 6 months after

traumatism and became non-significant one year after. MMO was higher than an

average 40 mm at the end for both groups, demonstrating that conservative

management including early functional treatment could result in restoring TMJ

function. Initial lower MMO for operated patients could be explained by more

displaced fractures in this group. Better mouth opening recovery for non -operated

patients could be due to earlier re-education of non-operated patients. Difference in

ramus height was initially significantly different between operated and non-operated

patients. After surgery, both groups did not show any difference. As expected, ORIF

allowed for the restoration of ramus height. This result induced bias between the two

groups because initial fractures in operated group were more displaced which

probably caused more occlusal trouble and TMJ damages. In some cases it was

observed that there was a good fracture reduction and functional treatment

completion, but with inadequate functional results. In these particular cases, the

authors desired to look for damage of TMJ’s elements (disc, capsule) with MRI. The

authors concluded that a properly followed functional treatment of the condylar

process mandibular fractures with articular impacts provides satisfactory clinical

results. Early mobilization is essential and when fractures are too displaced or

dislocated, surgical treatment is necessary to restore the ramus height24

.

A cross sectional study was performed to evaluate the outcomes of the treatment of

condylar fractures using the Mandibular Functional Impairment Questionnaire

(MFIQ) and the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD)

and to compare the outcomes of open and closed treatment. 74 patients with condylar

fractures were included in the study and were followed up for a least of 1 year. The


29

Mandibular Functional Impairment Questionnaire was used to measure a patients

subjective perception of mandible functioning. The diagnostic criteria for

temporomandibular disorders consist of two axes, one for clinical examination,

evaluation and diagnosis and the second for psychosocial background of the patient.

In choosing the treatment protocol, closed treatment was divided into expectative and

conservative treatment. An expectative treatment policy was applied if the patient

could bring their teeth into an almost normal occlusion or had normal mandibular

excursions while conservative treatment was given in case of a persistent or

developing malocclusion with an open bite of more than 2 mm. in case of severe

malocclusion, uncontrolled pain or poor patient compliance, open treatment was

considered. It was seen that the mean MFIQ score was 10.70 in the open group and

4.96 in the closed group, an outcome favoring the later. 85.7 % of patients in the open

group had a stable occlusion and in the closed group, the expectative group had a 70.8

% stable occlusion while the conservative group had a 91.7 % of stable occlusion.

With regard to maximal mouth opening, in the open treatment group 28.6 % had a

deviation of more than 2 mm while in closed treatment group 48.8 % demonstrated

the deviation. The study concluded that closed treatment of unilateral condylar

fractures appears to be a safe and appropriate treatment modality while the open

treatment should be reserved for limited indications25

.

Methodology

30

METHODOLOGY

Source of data

A prospective study was conducted in the Department of Oral Maxillofacial and

Reconstructive Surgery, Bapuji Dental College and Hospital, Davangere, 24 cases

having mandibular unilateral condylar fracture were obtained from the Out-Patient

Department irrespective of their gender.

Inclusion Criteria :

1. The patient should be between the age of 18yrs and 60yrs.

2. The patient has to have a unilateral or bilateral mandibular condylar fracture.

3. The patient having extra-capsular condylar fracture.

4. The patient may have other associated maxillofacial fractures with condylar

fracture.

Exclusion Criteria :

1. Patients who give a history of cardiac pacemakers or any electronic device in

their body.

2. Patients with any ferromagnetic substance (e.g. stainless steel plating) or any

other materials in their body.

3. Patients with Intra-capsular condylar fractures.

4. Patients who give a history of a metallic foreign body (metal sliver) in their eye, or who

have an aneurysm clip in their brain.

5. Patients with severe claustrophobia.

Methodology

31

6. Pregnant & lactating women.

7. Patients who give a history of previous temporomandibular joint problems.

8. Patients with a history of diseases of bones or joints.

Twenty-four patients who satisfied the inclusion and exclusion criteria were

included in the study. All the patients were explained about the procedures involved

and those willing to be a part of the study were enrolled and a written consent was

obtained. A case proforma was made. A detailed case history was taken and a

thorough clinical examination of all the patients was carried out, which included

extra oral and intra oral examinations.

Clinical diagnosis was confirmed radiographically using orthopantomogram

(OPG) and Reverse Town’s view X-ray of skull. Classification of the condylar

fractures were done according to the clinical grading given by Spiessl & Schroll in

1972. Patients with intra-capsular condylar fractures were excluded from this study.

An MRI of both the TMJs were taken before starting the treatment using a Phillips

Achiever (field density 1.5 tesla). Each joint was examined in an open and closed

mouth position using surface coils. T1 and T2 weighed spin-echo sequences were

made in coronal and sagittal planes. The slice thickness were 3.0/0.3mm at a

resolution of 205x256pixels.

The position of the disc was assessed in sagittal plane. In MRI examinations,

with the mouth open and closed, the position of the articular disc was viewed relative

Methodology

32

to the joint surfaces of the condylar process and of the temporal bone. The position of

the articular disc relative to the joint cavity and to the articular prominence was

assessed. Assessment of all the patients were done by a single radiologist who was

unaware of the treatment protocols.

For all the condylar fractures, the position of the disc was assessed depending

on whether the fracture was displaced or not. To define the diagnostic reference,

displacement of the disc was assessed by the relationship between posterior band of

the disc and the top of the condyle (12 o’clock), or the lateral aspect of the condyle in

closed mouth position.

The cases which can be treated by open or closed method of reduction were

included for the study. The criteria by Klotch and Lundy9 and Choi et al

10 were

followed to decide whether to treat the condylar fracture by open or closed method.

Open reduction and internal fixation included direct reduction of the fractured

condyle in its correct anatomical position via pre-auricular approach and fixation of

the same using miniplates, followed by an intermaxillary fixation for a short period

(7-10 days). On the other hand closed reduction of any condylar fracture included an

intermaxillary fixation using arch bars for a period of 4 to 6 weeks depending on the

patient’s age, type of condylar fracture and physical status of the patient.

A post treatment MRI scan was taken after 6 months from completion of the

treatment. If the disc was inside the glenoid fossa, displacement of the disc was

assessed by relation between posterior band of the disc and the top of the condyle (12

o’clock), or the lateral aspect of the condyle in closed mouth position. The position of

the disc was assessed based on the following criteria, which included three sagittal

Methodology

33

planes (lateral, central and medial). The cases where the post treatment disc position

was excellent or good were considered to be successfully treated when considering

the articular disc displacement.

The patients were recalled 6 months after completion of treatment to assess

their post-operative occlusion, mouth opening and mandibular deviation on mouth

opening. The patient’s mouth opening was assessed by measuring the inter-incisal

distance with Verniere calipers on maximum mouth opening. The patient was asked

to occlude his teeth and it was checked whether there was adequate inter-cuspation

amongst his teeth or not. The patient was asked to open his mouth slowly and it was

assessed whether there was a deviation on mouth opening to any side or not.

The data obtained was used for correlating the disc positions and functional

outcomes between condylar fractures treated by open and closed method.

Sample size estimation

34

Sample Size Estimation:

To calculate sample size proportion of disc displacement between open and closed

groups were considered. Using following formula.

Where:

α is Type I error

β is Type II error, meaning 1−β is power

p expected proportion (pA = 40% and pB = 20%).

Calculated sample size is 24, minimum twelve in each group.

Statistical analysis:

The data will be evaluated using chi square tes

Results

35

RESULTS

The study consisted of two groups of patients, with each group having 12

patients with unilateral condylar fracture, who were treated by open and closed

modes of treatment respectively.

The study had patients whose age ranged from 18 years to 56 years. 14 of

them were in the age group of 18-32 years, while there were 5 patients each in

the age groups of 33-46 years and 47-60 years (TABLE 2, GRAPH 1).

Out of the total of 24 patients in this study, 18 were males and 6 were females

(TABLE 2, GRAPH 2).

CLASSIFICATION OF CONDYLAR FRACTURES

The condylar fractures were classified according to the SPIESSEL AND SCHROLL

classification (TABLE 1). Here, 9 out of 24 patients had type II condylar fractures, 7

out of 24 had type III condylar fractures, 6 out of 24 had type IV condylar fractures

and there was 1 patient each in type I and type V of condylar fractures. Patients with

type VI condylar fractures were excluded from this study (TABLE 2, GRAPH 3).

PREOPERATIVE MRI EVALUATION OF TMJ

18 out of 24 TMJs showed a displaced articular disc in the MRI scans, while 6 out of

24 TMJs had no displacement of articular disc post condylar fracture. It was seen that

out of the 18 TMJs which had a disc displacement, 9 had a type II condylar fracture, 7

had a type III condylar fracture while 2 patients had type IV condylar fracture. On the

other hand, out of the 6 TMJs where there was no disc displacement, 4 were of type

IV condylar fractures and the rest were of type I and type V having 1 patient in each

group (TABLE 3, GRAPH 4).

Results

36

POST OPERATIVE MRI EVALUATION OF THE TMJ

Patients whose discs were in the normal position in all three planes were assessed as

excellent, those with discs in position in two planes were assessed good and the

remainder were assessed poor. Out of the 12 patients who were treated by open

reduction, in 8 of them the post operative position of the disc was excellent, in 1 of

the patients the post operative position of the disc was good, while in the rest of the 3

patients, the position of the disc was poor in both open and closed mouth positions

(TABLE 4, GRAPH 5,6).

In the group of patients treated by closed reduction, in 6 out of 12 patients post

operative position of the disc was excellent while in the rest 6 patients, the position of

the disc was poor (TABLE 4, GRAPH 5,6).

So, in terms of treating disc displacement, the open reduction of condylar fractures

successfully treated 9 out of 12 TMJs, while the closed reduction of condylar fractures

successfully treated 6 out of 12 TMJS. While comparing the efficacy of open and

closed methods in treating disc displacements in condylar fractures, in condylar

fractures treated by open reduction, there were more number of TMJs which were

treated successfully (9 out of 12) in contrast to condylar fractures treated by closed

reduction(6 out of 12) and it was statistically significant (p= 0.012).

POST OPERATIVE ASSESSMENT OF FUNCTIONAL PARAMETERS

The change in mouth opening after the treatment was complete was noted at 6 months

post op. In all the patients there was an increase in maximal interincisal opening post

operatively. In the patients treated by open reduction a mean increase in mouth

opening of 12.5 cm was seen. While in patients treated by closed reduction, a mean

increase in mouth opening of 12.83 cm was seen (TABLE 5, GRAPH 7).

Results

37

All the patients in the study had unsatisfactory occlusion pre operatively. Open

reduction of the condylar fractures was successful to correct the malocclusion in 9 out

of 12 patients, while closed reduction was able to correct the malocclusion in 4 out of

12 patients (TABLE 5, GRAPH 8).

Deviation on mouth opening towards the direction of the fractured condyle was seen

in all the patients in this study preoperatively. Post-operative evaluation revealed that

in 8 out of 12 patients treated by open reduction, the deviation on mouth opening was

corrected while in 5 out of 12 patients treated by closed reduction, the deviation on

mouth opening was corrected (TABLE 5, GRAPH 9).

Tables

TABLES

TABLE 1: SPIESSL & SCHROLL’S CLASSIFICATION OF CONDYLAR

FRACTURE

TYPE I FRACTURES WITHOUT DISPLACEMENT

TYPE II LOW FRACTURES WITH DISPLCEMENT

TYPE III HIGH FRACTURES WITH DISPLACEMENT

TYPE IV LOW FRACTURED WITH DISLOCATION

TYPE V HIGH FRACTURES WITH DISLOCATION

TYPE VI INTRACAPSULAR FRACTURES

TABLE 2: DEMOGRAPHIC DISTRIBUTION OF PATIENTS

GROUPS SUBGROUPS NUMBER OF

PATIENTS

AGE 18-32YEARS 14

33-46 YEARS 5

46-60 YEARS 5

GENDER MALE 18

FEMALE 6

TYPE OF CONDYLAR

FRACTURES

TYPE I 1

TYPE II 9

TYPE III 7

TYPE IV 6

TYPE V 1

TYPE VI EXCLUDED

TABLE 3: PREOPERATIVE DISC CONDITION AND ITS CORRELATION

WITH TYPE OF CONDYLAR FRACTURE

PREOPERATIVE

DISC CONDITION

(OPEN & CLOSED

MOUTH)

NUMBER OF

PATIENTS

TYPE OF

CONDYLAR

FRACTURE

NUMBER OF

PATIENTS

DISC DISPLACED 18 TYPE I 0

TYPE II 9

TYPE III 7

TYPE IV 2

TYPE V 0

DISC UNDISPLACED 6 TYPE I 1

TYPE II 0

TYPE III 0

TYPE IV 4

TYPE V 1

Tables

TABLE 4: POST OPERATIVE CONDITION OF DISC IN CONDYLAR

FRACTURES TREATED BY OPEN AND CLOSED REDUCTION

POST

OPERATIVE

DISC

ASSESSMEN

T

OPEN

REDUCTIO

N (OPEN

MOUTH)

CLOSED

REDUCTIO

N (OPEN

MOUTH)

OPEN

REDUCTIO

N (CLOSED

MOUTH)

CLOSED

REDUCTIO

N (CLOSED

MOUTH)

EXCELLENT 8 6 8 6

GOOD 1 0 1 0

POOR 3 6 3 6

*p=0.012 *p=0.012

Chi-square test

*p value significant if p≤0.05

TABLE 5: POST OPERATIVE ASSESSMENT OF FUNCTIONAL

PARAMETERS AT SIX MONTHS POST OP.

POST OPERATIVE

PARAMETERS

ASSESED

SUBGROUPS OPEN

REDUCTION

CLOSED

REDUCTION

MAXIMAL

INTERINCISAL

OPENING

0-5mm 0 1

6-10mm 5 2

11-15mm 5 6

16mm-20mm 2 3

CORRECTION OF

OCCLUSION

SUCCESSFUL 9 4

UNSUCCESSFUL 3 8

CORRECTION OF

DEVIATION ON

MOUTH OPENING

SUCCESSFUL 8 5

UNSUCCESSFUL 4 7

Tables

TABLE 6: CORRELATION OF CORRECTION OF OCCLUSION WITH

POST OPERATIVE POSITION OF DISC IN PATIENTS TREATED BY OPEN

REDUCTION

FUNCTIONAL

PARAMETERS

TREATMENT OF DISC

DISPLACEMENT

SUCCESFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESFUL

CORRECTION OF

OCCLUSION

SUCCESSFUL

8 1

CORRECTION OF

OCCLUSION

UNSUCCESSFUL

1 2

TABLE 7: CORRELATION OF CORRECTION OF OCCLUSION WITH

POST OPERATIVE POSITION OF DISC IN PATIENTS TREATED BY

CLOSED REDUCTION

FUNCTIONAL

PARAMETERS

TREATMENT OF DISC

DISPLACEMENT

SUCCESFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESFUL

CORRECTION OF

OCCLUSION

SUCCESSFUL

4 0

CORRECTION OF

OCCLUSION

UNSUCCESSFUL

2 6

Tables

TABLE 8: CORRELATION OF CORRECTION OF DEVIATION ON MOUTH

OPENING WITH POST OPERATIVE POSITION OF DISC IN PATIENTS

TREATED BY OPEN REDUCTION

FUNCTIONAL

PARAMETERS

TREATMENT OF DISC

DISPLACEMENT

SUCCESFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESFUL

CORRECTION OF

DEVIATION ON

MOUTH OPENING

SUCCESSFUL

8 0

CORRECTION OF

DEVIATION ON

MOUTH OPENING

UNSUCCESSFUL

1 3

TABLE 9: CORRELATION OF CORRECTION OF DEVIATION ON MOUTH

OPENING WITH POST OPERATIVE POSITION OF DISC IN PATIENTS

TREATED BY CLOSED REDUCTION

FUNCTIONAL

PARAMETERS

TREATMENT OF DISC

DISPLACEMENT

SUCCESFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESFUL

CORRECTION OF

DEVIATION ON

MOUTH OPENING

SUCCESSFUL

4 1

CORRECTION OF

DEVIATION ON

MOUTH OPENING

UNSUCCESSFUL

2 5

Graphs

GRAPHS

GRAPH 1: AGE WISE DISTRIBUTION OF PATIENTS

GRAPH 2: GENDER WISE DISTRIBUTION OF PATIENTS

AGE WISE DISTRIBUTION

18-32 years

33-46 years

46-60 years

GENDER WISE DISTRIBUTION OF

PATIENTS

MALE

FEMALE

Graphs

GRAPH 3: DISTRIBUTION OF PATIENTS ON THE BASIS OF TYPE OF

CONDYLAR FRACTURE

GRAPH 4: PRE-OPERATIVE POSITION OF ARTICULAR DISC IN

PATIENTS

1

9

7 6

1 0

1

2

3

4

5

6

7

8

9

10

TYPE I TYPE II TYPE III TYPE IV TYPE V

TYPES OF CONDYLAR FRACTURE

18

6

PRE-OP POSITION OF ARTICULAR DISC

DISC DISPLACED

DISC UNDISPLACED

Graphs

GRAPH 5: CORRELATION BETWEEN PRE-OPERATIVE POSITION OF

ARTICULAR DISC AND TYPE OF CONDYLAR FRACTURE

DISC DISPLACED DISC UNDISPLACED

TYPE I 0 1

TYPE II 9 0

TYPE III 7 0

TYPE IV 2 4

TYPE V 0 1

0

1

9

0

7

0

2

4

0

1

0

1

2

3

4

5

6

7

8

9

10

Graphs

GRAPH 6: POST OPERATIVE CONDITION OF DISC IN CONDYLAR

FRACTURES TREATED BY OPEN AND CLOSED METHOD (OPEN &

CLOSED MOUTH)

GRAPH 7: ASSESSMENT OF MAXIMAL INTERINCISAL OPENING AT

SIX MONTH POST OP

8

6

8

6

1

0

1

0

3

6

3

6

0

2

4

6

8

10

12

14

OPEN

REDUCTION

(OPEN MOUTH)

CLOSED

REDUCTION

(OPEN MOUTH)

OPEN

REDUCTION

(CLOSED

MOUTH)

CLOSED

REDUCTION

(CLOSED

MOUTH)

POOR

GOOD

EXCELLENT

0

5 5

2

1

2

6

3

0

1

2

3

4

5

6

7

0-5 mm 6-10 mm 11-15 mm 16-20 mm

OPEN

REDUCTION

CLOSED

REDUCTION

Graphs

GRAPH 8: CORRELATION OF CORRECTION OF OCCLUSION WITH

POST OPERATIVE POSITION OF DISC IN PATIENTS TREATED BY OPEN

REDUCTION

GRAPH 9: CORRELATION OF CORRECTION OF OCCLUSION WITH

POST OPERATIVE POSITION OF DISC IN PATIENTS TREATED BY

CLOSED REDUCTION

8

1

1

2

0

1

2

3

4

5

6

7

8

9

10

TREATMENT OF DISC

DISPLACEMENT

SUCCESSFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESSFUL

CORRECTION OF

OCCLUSION

UNSUCCESSFUL

COREECTION OF

OCCLUSION

SUCCESSFUL

4

2

6

0

1

2

3

4

5

6

7

TREATMENT OF DISC

DISPLACEMENT

SUCCESSFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESSFUL

CORRECTION OF

OCCLUSION

UNSUCCESSFUL

COREECTION OF

OCCLUSION

SUCCESSFUL

Graphs

GRAPH 10: CORRELATION OF CORRECTION OF DEVIATION ON

MOUTH OPENING WITH POST OPERATIVE POSITION OF DISC IN

PATIENTS TREATED BY OPEN REDUCTION

GRAPH 11: CORRELATION OF CORRECTION OF DEVIATION ON

MOUTH OPENING WITH POST OPERATIVE POSITION OF DISC IN

PATIENTS TREATED BY CLOSED REDUCTION

8

1

2

0

1

2

3

4

5

6

7

8

9

TREATMENT OF DISC

DISPLACEMENT

SUCCESSFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESSFUL

CORRECTION OF

DEVIATION ON

MOUTH

OPENNING

UNSUCCESSFUL

COREECTION OF

DEVIATION ON

MOUTH

OPENNING

SUCCESSFUL

4

1

2

5

0

1

2

3

4

5

6

7

TREATMENT OF DISC

DISPLACEMENT

SUCCESSFUL

TREATMENT OF DISC

DISPLACEMENT

UNSUCCESSFUL

CORRECTION OF

DEVIATION ON

MOUTH

OPENNING

UNSUCCESSFUL

COREECTION OF

DEVIATION ON

MOUTH

OPENNING

SUCCESSFUL

Discussion

DISCUSSION

The management of condylar fractures of the mandible is a matter of controversy till

date where the efficacy of open and closed methods of treating the fracture is still

being debated10

. The importance of an effective treatment of any fracture in this

region increases because of the fact that this region is associated with the only mobile

joint of the face, the TMJ. Literature holds proof of the fact that condylar fracture may

result in severe changes in the soft tissue structures of the joint like the articular disc,

joint capsule and retrodiscal tissues16

. Thus, the treatment should aim at achieving a

morpho-functional recovery of the involved structures which can be achieved by

either conservative or surgical therapy1,2

. Displacement of the disc is the most

common form of internal derangement affecting the TMJ5. It is reported to occur in

21% to 33% of healthy population, while its incidence increases to 78% in cases of

condylar fractures1. Trauma of the TMJ, resulting in displacement of the disc, a tear

of retrodiscal tissue and a tear of lateral capsule are often reported with the

displacement of disc being the most crucial one as it is associated with a high risk of

causing internal derangement, osteoarthritis and even fibrous or bony ankylosis2. It is

therefore important to examine the articular disc pre and postoperatively among

different types of condylar fractures.

Here, we have studied the incidence of disc displacement amongst various

types of condylar fractures of the mandible and have compared the efficacy of open

and closed modes of treatment in restoration of the articular disc postoperatively.

Various classification systems exist in categorizing condylar fracture of the mandible,

but the one given by SPISSEL & SCHROLL (TABLE 1) was chosen for this study

because it gives an idea about the level of the fracture and the displacement of the

fracture segment, both of which are seen to influence the fate of the articular disc,

Discussion

post condylar fracture16

. The intracapsular condylar fractures (type VI) were excluded

from this study because of the higher incidence of disc displacements associated with

this type of condylar fractures, because of the fact that these condylar fractures are

seldom treated by open method and thus can result in a bias while comparing the

efficacy of the two treatment modalities. Even if an intracapsular condylar fracture is

treated by open reduction, it involves damaging the capsule of the TMJ which itself

can result in an anterior displacement of the articular disc requiring a separate surgical

procedure for repositioning of the disc.

The introduction of MRI in the diagnosis of TMJ dysfunction has contributed

significantly to the understanding of the importance of the topographic relationship

between the disc and the condyle10

. MRI scans has been proved as the preferred

method for displaying the disc and ligaments of the TMJ. It gives a clear picture about

the damage to the soft tissue of the TMJ in a more sensitive way than the clinical

examination, normal radiographs and CT-scans4. Thus, in this study MRI examination

of fractured condyles were done, pre and postoperatively.

In this study, 75% (18/24) of the patients had suffered an articular disc

displacement pre operatively (TABLE 3), which is in accordance with the findings of

Yu et al2. It has been seen that the incidence of disc displacement in extracapsular

condylar fractures varies from one study to another, which may be due to the varying

diagnostic criterias used across the studies to evaluate the displacement of the disc24

.

It was seen that out the 18 cases where the disc was displaced, the majority were type

II and type III fractures (type II-9, type III-7) (TABLE 3). Both these types of

fractures are associated with displacement of the fractured fragment and substantiates

the fact that displaced fractures of the mandibular condyle are associated with more

articular disc displacements2. In all the cases with articular disc displacement it was

Discussion

appreciated that the disc has moved in an antero-medial direction, and lies in close

relation to the displaced condylar head16

. In a normal TMJ the articular disc is

attached to the ligament of the lateral pterygoid muscle anteriorly and retrodiscal

ligament posteriorly which counterbalances the force acting on the disc. In case of a

condylar fracture, in most of the cases there is disruption of the retrodiscal tissues

which results in an unopposed contraction force of the lateral pterygoid acting on the

articular disc, which results in the disc displacement in the direction of the vector. It is

seen sometimes that the rupture of the capsule of the TMJ was also responsible for

disc displacement in few cases. The disc is found to be firmly attached to the medial

and lateral pole of the condyle, which is the reason why the disc is always in close

proximity to the condylar head thus resulting in more disc displacments in displaced

condylar fractures10

.

The patients were treated either by open or closed reduction as per Klotch and

Lundy’s criteria such as angulation between the fractured fragments in excess of 30

degrees ,fracture gap between the bone ends exceeding 4 or 5 mm, lateral override

and lack of contact of the fractured fragments are the ones to be considered before

justifying open reduction. An MRI scan was done 6 months after the completion of

either of the treatment methods. It was seen that in cases treated by open reduction,

there were more number of cases (9 out of 12) where the treatment of disc

displacements were successful with the post-operative condition being either

“excellent” or “good”. In contrary, patients in the closed group had fewer successful

treatments of the displaced discs with only 50% of the cases having discs in “poor”

condition post operatively (TABLE 4). It was noted that position of the disc,

(displaced or undisplaced) remained constant when the mouth was open or closed

which was in agreement to the study by Choi8 and is mainly because of the tight

Discussion

attachment of the disc to the condylar head. This study showed that for open method

of treatment, 25% of the patients had a disc displacement remaining after the

treatment was complete which was similar as the study by Saponaro A et al1. This

may be a consequence of direct damage to the articular disc or the rupture of articular

capsule. It was noted that all these patients had high level extracapsular condylar

fractures and it might be that the surgical procedure have resulted in damaging the

TMJ capsule which itself is one of the etiology for disc displacemnt5. In comparison,

the effectiveness of conservative treatment in treating articular disc displacement was

much lower as seen by Oezmen et al10

and Choi5. The open reduction proved to have

a statistically significant better efficacy in treating articular disc displacements in

condylar fractures which substantiated the fact that a better anatomical restoration of

the TMJ after surgical therapy was essential for spontaneous disc repositioning5,10

.

Despite the high success rate, there were a few cases in this study treated by open

reduction (especially high condylar fractures), which had a persisting disc

displacement post operatively, for such cases it is suggested that disc has to be

inspected during surgery when the joint capsule is opened at the time of open

reduction of condylar fractures5. Alternatively, along with open reduction, the

displaced articular disc can be replaced in its anatomic position and rigidly fixed

using an anchoring screw as described by Bo-Lei Cai23

.

In this study, at 6 months post op, three functional parameters (MIO, occlusion and

deviation on mouth opening) were evaluated. The mean MIO of patients treated by

open reduction was less when compared to patients treated by closed reduction

(TABLE 5). This can be attributed to the more amount of preoperative displacement

of the fractured fragment in patients taken up for open reduction and post operative

pain24

. It has been observed that the MIO increases gradually with time and returns

Discussion

back to near normal irrespective of the post operative position of the disc, which can

be explained by the fact that the contralateral joint compensates for the mobility

restriction of the affected side by increased non rotational movements10

.

When post operative occlusion was compared between the two methods of

treatment, it was seen that open reduction was more successful in correcting

preoperative malocclusions (9 out of 12)(TABLE 5) which is in accordance with

results of Worsaae and thorn. This can be attributed to the fact that, open reduction

and internal fixation returns the condylar process to its pre-traumatic position, or close

to that position, restoring skeletal continuity, re-establishing normal mandibular

positioning and bringing the teeth into their proper relationship12

. Several studies

evaluating clinical signs and symptoms and disc position in patients with anterior disc

displacement have reported that patient’s clinical signs and symptoms tended to be

resolved, although the disc displacement was not resolved5.

In this study, we correlated the post-operative position of the disc with the

success in treating the post-operative occlusion for both open and closed fractures. It

was observed that for both open and closed fracture reductions, when the disc was

restored to its normal position post-operatively, the success rate of treatment of

malocclusion increased (TABLE 6 & TABLE 7). Though the sample size is small, but

this gives a definitive predilection of a positive effect of restoration of articular disc in

restoring post-operative malocclusion.

While comparing the postoperative deviation on mouth opening, between the

two modalities of treating condylar fractures, it was appreciated that open reduction

had a better success rate in correcting deviation on mouth opening (8 out of 12) than

closed reduction (5 out of 12) which was similar to the results as obtained by

Rozeboom A. V. J. et al25

. This can be attributed as a manifestation of compensatory

Discussion

movements of the contralateral joint due to shortening of ramus height on the affected

side in patients treated by closed reduction17

.

For deviation on mouth opening also, we compared the post-operative disc

position with the success rate of correction of deviation on mouth opening after

completion of the treatment. The data showed a trend towards favorable effects of

successful correction of disc displacement on correction of deviation on mouth

opening for both the open and closed methods of treatment. Though deviation on

mouth opening is a complex interplay of several factors, and its etiology cannot be

narrowed down to a single independent factor, this observation throws light on the

positive influence of a successfully treated disc displacement on reducing deviation

on mouth opening in patients with condylar fractures.

Conclusion

CONCLUSION

This study concludes that:

A condylar fracture disrupts both the hard and soft tissue architecture of the

TMJ. Thus, a mere anatomical reduction of the fractured fragments is not enough and

a sound restoration of the TMJ function is necessary, leading to normal and pain free

mouth opening, satisfactory masticatory strength along with restored pre traumatic

occlusion and articulation. Out of the several confounding factors playing a role in

sound functioning of the TMJ, the articular disc is the most important one. Earlier

studies have substantiated that the articular disc gets displaced in antero-medial

direction in a condylar fracture. Apart from that, in this study it was evident that open

reduction and internal fixation of the fractured condyle, along with anatomical

reduction of the fractured fragments is more successful to return the displaced disc in

its normal anatomical position than closed reduction modality of treatment. But, in

case of high condylar fractures which are displaced, an additional surgical procedure

may be required to anchor the disc in its normal anatomical position. This study

definitely throws light on the fact that the disc does have a beneficial influence on

functional parameters like post-operative occlusion and deviation on mouth opening.

Though the sample of this study was small, but definitive trends towards the influence

of articular disc on post-operative morpho-function improvement is evident and

further studies in this aspect is required to get more affirmative results.

Summary

SUMMARY

To sumarise, preoperative MRI scans substantiated the fact that displaced fractures of

the mandibular condyle have higher risks of having disc displacements, because of the

tight adherence of the disc to the medial and lateral pole of the condylar head. The

disc displacements took place mostly in the antero-medial direction beacause of the

unopposed action of the lateral pterygoid muscle in that direction.

Although the series was small, it is evident from this study that open reduction

and internal fixation is better than closed reduction while treating condylar fractures

of mandibule in turn treating articular disc displacement. But, in certain cases,

especially high level condylar fractures, it is necessary to inspect the disc during

surgery when the joint capsule is opened to detect the displaced disc along with its

simultaneous repositioning.

Functional parameters at the end of 6 months indicated that open reduction

and internal fixation of condylar fracture had better results in correcting pre-operative

malocclusion and deviation on mouth opening than closed reduction. Comparison of

postoperative position of articular disc with functional parameters revealed that a

successful disc reduction played a pivotal role in correction of malocclusion and

deviation in mouth opening after treatment.

This study shows better efficiency of open reduction and internal fixation in

hard and soft tissue reduction of condylar fractures of the mandible as noted by

various other authors. But the fact that there is an association between post-operative

occlusion and deviation in mouth opening and post-operative correction of disc

displacement, generates interest and needs further studies to be conducted with larger

sample sizes in order to get a definitive result.

Bibiliography

BIBLIOGRAPHY

1. Saponaro A, Stecco A, Brucoli M, Armienti F, Stellin L, Favano

F, Benech A, Carriero A Magnetic resonance imaging in

the postsurgical evaluation of patients with mandibular condyle

fractures treated using the transparotid approach: our experience. J Oral

Maxillofac Surg. 2009 Sep;67(9):1815-20.

2. Zheng J, Zhang S, Yang C, Abdelrehem A, He D, Chiu H Assessment of

magnetic resonance images of displacement of the disc of the

temporomandibular joint in different types of condylar fracture. Br J Oral

Maxillofac Surg. 2016 Jan;54(1):74-9.

3. De Riu G, Gamba U, Anghinoni M, Sesenna E A comparison of open and

closed treatment of condylar fractures: a change in philosophy. Int J Oral

Maxillofac Surg. 2001 Oct;30(5):384-9.

4. Schneider A, Zahnert D, Klengel S, Loukota R, Eckelt U A comparison

of MRI, radiographic and clinical findings of the position of the TMJ articular

disc following open treatment of condylar neck fractures Br J Oral Maxillofac

Surg. 2007 Oct;45(7):534-7.

5. Choi BH, Yi CK, Yoo JH MRI examination of the TMJ after surgical

treatment of condylar fractures Int J Oral Maxillofac Surg. 2001

Aug;30(4):296-9

6. Katzberg RW, Bessette RW, Tallents RH, Plewes DB, Manzione

JV, Schenck JF, Foster T, Hart HR Normal and abnormal

Bibiliography

temporomandibular joint: MR imaging with surface coil. Radiology. 1986

Jan;158(1):183-9

7. Takaku S, Yoshida M, Sano T, Toyoda T Magnetic resonance images in patients

with acute traumatic injury of the temporomandibular joint: a preliminary report. J

Craniomaxillofac Surg. 1996 Jun;24(3):173-7.

8. Choi BH Magnetic resonance imaging of the temporomandibular joint after

functional treatment of bilateral condylar fractures in adults. Int J Oral

Maxillofac Surg. 1997 Oct;26(5):344-7

9. Silvennoinen U, Raustia AM, Lindqvist C, Oikarinen K Occlusal and

temporomandibular joint disorders in patients with unilateral condylar

fracture. A prospective one-year study. Int J Oral Maxillofac Surg. 1998

Aug;27(4):280-5

10. Oezmen Y, Mischkowski RA, Lenzen J, Fischbach R MRI examination of

the TMJ and functional results after conservative and surgical

treatment of mandibular condyle fractures. Int J Oral Maxillofac Surg. 1998

Feb;27(1):33-7

11. Palmieri C, Ellis E 3rd, Throckmorton G Mandibular motion after closed

and open treatment of unilateral mandibular condylar processfractures. J Oral

Maxillofac Surg. 1999 Jul;57(7):764-75; discussion 775-6

12. Ellis E 3rd, Simon P, Throckmorton GS Occlusal results after open or closed

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Surg. 2000 Mar;58(3):260-8.

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13. Takahashi T, Ohtani M, Sano T, Ohnuki T, Kondoh T, Fukuda M

Magnetic resonance evidence of joint effusion of the temporomandibular joint

after fractures of the mandibular condyle: a preliminary report. Cranio. 2004

Apr;22(2):124-31

14. Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota

R, Rasse M, Schubert J, Terheyden H Open versus closed treatment of

fractures of the mandibular condylar process-a prospective randomized multi-

centre study J Craniomaxillofac Surg. 2006 Jul;34(5):306-14.

15. Gerhard S, Ennemoser T, Rudisch A, Emshoff R

Condylar injury: magnetic resonance imaging findings of temporomandibular

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Epub 2007 Jan 16.

16. P. Wang, J. Yang and Q. Yu MR Imaging Assessment of Temporomandibular

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Fractures American Journal of Neuroradiology January 2009, 30 (1) 59-63;

17. Sforza C, Ugolini A, Sozzi D, Galante D, Mapelli A, Bozzetti A Three-

dimensional mandibular motion after closed and open reduction of unilateral

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Jun;39(4):249-55.

18. Dwivedi AN, Tripathi R, Gupta PK, Tripathi S, Garg S Magnetic

resonance imaging evaluation of temporomandibular joint and associated soft

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19. Duan DH, Zhang Y A clinical investigation on disc displacement in sagittal

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20. Yu YH, Wang MH, Zhang SY, Fang YM, Zhu XH, Pan LL, Yang C

Magnetic resonance imaging assessment of temporomandibular joint soft

tissue injuries of intracapsular condylar fracture. Br J Oral Maxillofac

Surg. 2013 Mar;51(2):133-7.

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Fractures? J Oral Maxillofac Surg. 2018 May;76(5):1026-1035.

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H, ed.: SpezielleFrakturen und Luxationslehre Bd. I/I. Stuttgart: Thieme.

1972.

Annexures

61

ANNEXURE I

CONSENT FORM

BAPUJI DENTAL COLLEGE AND HOSPITAL, DAVANGERE

DEPARTMENT OF ORAL, MAXILLOFACIAL AND

RECONSTRUCTIVE SURGERY

“THE TEMPOROMANDIBULAR JOINT ARTICULAR DISC POSITION


CONDYLAR FRACTURES: A COMPARATIVE STUDY.”

Name of the investigator: Guided by:

Dr. Subhabrata Ghosh Dr. Umashankara K. V.

Post Graduate Student Professor

INFORMED CONSENT

I have been informed about the objectives of this study along with

its advantages and disadvantages. It has been assured to me that the

details obtained during the course of the study will be kept confidential.

Hence, I volunteer myself to participate in the study.

Name of the Patient:

Date :

Signature:

Annexures

62

PATIENT INFORMATION FORM

I, Dr. Subhabrata Ghosh, post graduate student in the Department of Oral,

Maxillofacial and Reconstructive surgery, Bapuji Dental College and Hospital,

Davangere am conducting a study on “THE TEMPOROMANDIBULAR JOINT

ARTICULAR DISC POSITION AFTER OPEN AND CLOSED TREATMENT

OF MANDIBULAR CONDYLAR FRACTURES: A COMPARATIVE

STUDY.”. You will be given complete information about the research. I assure you

that the details obtained during the course of study will be kept confidential and will

not be revealed to anyone. You are free to decide anytime you want to participate in

the study or not after going through the information given to you. The research

process involves pre and post treatment MRI scan and pretreatment radiological

examination (OPG and P-A view skull). If you have any questions you are always

free to ask. You will not be compensated by any means for participation in this study.

If you are not interested to participate or if you feel uncomfortable, you can withdraw

or refuse for the same at any time.

NAME AND ADDRESS OF THE INVESTIGATOR:

Dr. SUBHABRATA GHOSH

Post graduate student,

Room no 2,

Department of Oral, Maxillofacial and Reconstructive Surgery,

Bapuji Dental College and Hospital,

Davangere.

Mobile number: 8904645595

If you experience any grievances while participating in the study, feel free to call any

of the following numbers:

Dr K. Sadashiva Shetty: 08192-220575

(Member Secretary, Institutional Review Board)

Dr Raison Thomas: 9886279018

(Member, Institutional Review Board)

Annexures

63

ANEXURE II

ETHICAL APPROVAL LETTER

Annexures

64

ANNEXURE III

CASE PROFORMA

TITLE: “THE TEMPOROMANDIBULAR JOINT ARTICULAR DISC POSITION

AFTER OPEN AND CLOSED TREATMENT OF MANDIBULAR CONDYLAR

FRACTURES: A COMPARATIVE STUDY”

PATIENT DETAILS:

PATIENT NAME: OPD NO:

AGE: (in years) IP NO:

SEX: DATE OF

ADMISSION:

ADDRESS:

OCCUPATION:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PREGNANCY:

DRUG HISTORY:

Annexures

65

PAST DENTAL HISTORY:

FAMILY HISTORY:

PERSONAL HISTORY:

HABITS IF ANY:

GENERAL PHYSICAL EXAMINATION:

SYSTEMIC EVALUATION:

CVS:

CNS:

RS:

GIT:

CLINICAL EXAMINATION:

EXTRA ORAL EXAMINATION:

Annexures

66

INTRA ORAL EXAMINATIONS:

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:

BLOOD INVESTIGATIONS:

URINE EXAMINATION:

RADIOGRAPHS:

RADIOGRAPHIC FINDINGS(PRE-OPERATIVE):

1)TYPE OF CONDYLAR FRACTURE:

A) UNILATERAL BILATERAL

B) SIDE AFFECTED (IF THE FRACTURE IS UNILATERAL):

LEFT RIGHT

C)OTHER ASSOCIATED FRACTURES IN MAXILLO-FACIAL AREA (IF ANY):

Annexures

67

CLASSIFICATION OF CONDYLAR FRACTURE (CLASSIFICATION BY SPIESSL

& SCHROLL):

TYPE I TYPE II TYPE III TYPE IV TYPE V

TYPE VI

MRI FINDINGS (PRE-OPERATIVE):

WHEN MOUTH IS OPEN:

DISC IS PRESENT INSIDE THE GLENOID FOSSA: YES/NO

IF YES:

1)DISC DISPLACEMENT

PRESENT ABSENT

MODE OF TREATMENT PROCEDURE SELECTED:

OPEN/SURGICAL REDUCTION CLOSED REDUCTION

MRI FINDINGS (6 MONTHS POST OPERATIVE)

WHEN MOUTH IS OPEN:


IF YES:

1)DISC DISPLACEMENT

PRESENT ABSENT

2)THE POSITION OF DISC WITH RESPECT TO SAGITAL VIEW:

LATERAL PLANE: DISPLACED/NOT DISPLACED

MEDIAL PLANE: DISPLACED/NOT DISPLACED

Annexures

68

CENTRAL PLANE: DISPLACED/NOT DISPLACED

WHEN MOUTH IS CLOSED:


IF YES:

1)DISC DISPLACEMENT

PRESENT ABSENT

2)THE POSITION OF DISC WITH RESPECT TO SAGITAL VIEW:

LATERAL PLANE: DISPLACED/NOT DISPLACED

MEDIAL PLANE: DISPLACED/NOT DISPLACED

CENTRAL PLANE: DISPLACED/NOT DISPLACED

FINAL INTERPRETATION:

THE POSITION OF THE DISC:

EXCELLENT GOOD POOR

POST OPERATIVE FOLLOW-UP (AFTER 6 MONTHS):

MOUTH OPENING: (in mm)

OCCLUSION:

SATISFACTORY UNSATISFACTORY

DEVIATION ON MOUTH OPENNING:

DEVIATION: YES/NO

IF YES : RIGHT/LEFT

Annexures

69

ANNEXURE IV:

MASTER CHART (OPEN REDUCTION)

Sl.n

o Name Age Sex

Classification

of condylar

fracture

Disc assessment

Preoperative

disc

assessment

Open mouth Closed mouth

Disc position

Final

interpretation

Disc position

Final

interpretation

lateral central medial lateral central medial

1. PRAKASH 44 M TYPE II YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

2. VANI 30 F TYPE II YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

DISPL

ACED GOOD

NOT

DISPL

ACED

NOT

DISPL

ACD

DISPL

ACED GOOD

3. RAMESH 25 M TYPE IV NO

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

4. MUSTAFA 30 M TYPE III YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

5. SOMASHEKH

ARAIYA 52 M TYPE II YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

6. VINAYAKA 24 M TYPE IV NO

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

7. KARTHIK 18 M TYPE II YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR

8. SUSHEELAM

MA 54 F TYPE III YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR

9. SUCHETAN

SAGAR 25 M TYPE IV NO

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

10. HONAMMA 44 F TYPE II YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

11. MANJUNATH 30 M TYPE III YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T

12. GUDDAPPA 25 M TYPE III YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR

Annexures

70

MASTER CHART (CLOSED REDUCTION)

Sl.n

o Name Age Sex

Classification

of condylar

fracture

Disc assessment Functional Assessment

Preoperative

disc

assessment

Open mouth Closed mouth

Disc position

Final

interpretation

Disc position

Final

interpretation

Pre operative Post operative increase in

mouth

opening lateral central medial lateral central medial mouth

opening occlusion deviation

mouth

opening occlusion deviation

1. ADARSH 18 M TYPE III YES

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR 27mm

UNSATISF

ACTORY PRESENT 45mm

SATISFA

CTORY PRESENT 18mm

2. REKHA 26 F TYPE I NO

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T 38mm

UNSATISF

ACTORY PRESENT 55mm

UNSATI

SFACTO

RY

PRESENT 17mm

3. CHIKKAKEN

CHAPPA 35 M TYPE II YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR 23mm

UNSATISF

ACTORY PRESENT 28mm

UNSATI

SFACTO

RY

PRESENT 5mm

4. MANJUNATH 30 M TYPE IV NO

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T 20mm

UNSATISF

ACTORY PRESENT 45mm

UNSATI

SFACTO

RY

ABSENT 15mm

5. NILAKANTA

PPA 52 M TYPE II YES

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

DISPL

ACED

DISPL

ACD

DISPL

ACED POOR 20mm

UNSATISF

ATORY PRESENT 27mm

SATISFA

CTORY ABSENT 7mm

6. DURGESH 24 M TYPE II YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T 22mm

UNSATISF

ACTORY PRESENT 40mm

SATISFA

CTORY ABSENT 18mm

7. SURESH 19 M TYPE II YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR 28mm

UNSATISF

ACTORY PRESENT 35mm

SATISFA

CTORY PRESENT 7mm

8. NAGAMMA 54 F TYPE III YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR 21mm

UNSATISF

ACTORY PRESENT 35mm

UNSATI

SFACTO

RY

PRESENT 14mm

9. PRAKASHA 25 M TYPE IV YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T 26mm

UNSATISF

ACTORY PRESENT 30mm

UNSATI

SFACTO

RY

ABSENT 14mm

10. NEMYA 42 M TYPE IV YES

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T 23mm

UNSATISF

ACTORY PRESENT 35mm

UNSATI

SFACTO

RY

ABSENT 12mm

11. REVANA

SIDDESHA 45 M TYPE V NO

NOT

DISP

LACE

D

NOT

DISPL

ACED

NOT

DISPL

ACED

EXCELLEN

T

NOT

DISPL

ACED

NOT

DISPL

ACD

NOT

DISPL

ACED

EXCELLEN

T 22mm

UNSATISF

ACTORY PRESENT 34mm

UNSATI

SFACTO

RY

PRESENT 12mm

12. SRI BAI 60 F TYPE III YES

NOT

DISP

LACE

D

DISPL

ACED

DISPL

ACED POOR

NOT

DISPL

ACED

DISPL

ACED

DISPL

ACED POOR 20mm

UNSATISF

ACTORY PRESENT 25mm

UNSATI

SFACTO

RY

PRESENT 15mm

Photographs

71

PHOTOGRAPH 1:

PHILLIPS ACHIEVER MRI MACHINE (FIELD DENSITY 1.5 TESLA)

PHOTOGRAPH 2:

HEAD REST FOR TMJ MRI

PHOTOGRAPH 3:

FLEX-M SURFACE COILS FOR TMJ

MRI

Photographs

72

PHOTOGRAPH 4: PREOPERATIVE SAGITTAL SECTION OF MRI

SCAN SHOWING DISPLACEMENT OF ARTICULAR DISC IN

ANTERIOR DIRECTION

PHOTOGRAPH 5: CLOSED

REDUCTION OF CONDYLAR

FRACTURE BY PLACING ERICH

ARCH BAR AND IMF

PHOTOGRAH 6: OPEN

REDUCTION AND INTERNAL

FIXATION OF CONDYLAR

FRACTURE

Photographs

73

PHOTOGRAPH 7: MEDIAL

SAGITTAL SECTION OF MRI

SHOWING ARTIULAR DISC

IN NORMAL POSITION

PHOTOGRAPH 8: CENTRAL



IN NORMAL POSITION

PHOTOGRAPH 9: LATERAL



IN NORMAL POSITION

CASE 1: LEFT CONDYLAR FRACTURE TREATED BY OPEN RUDCTION AND INTERNAL FIXATION

“EXCELLENT” POST OPERATIVE OUTCOME: ARTICULAR DISC IN NORMAL POSITION IN ALL THREE SECTIONS

POST OPERATIVE MRI SCANS AT SIX MONTHS AFTER TREATMENT COMPLETION

Photographs

74


CASE 2: LEFT CONDYLAR FRACTURE TREATED BY OPEN RUDCTION AND INTERNAL FIXATION

“GOOD” POST OPERATIVE OUTCOME: ARTICULAR DISC IN NORMAL POSITION IN TWO SECTIONS




IN NORMAL POSITION




IN NORMAL POSITION



SHOWING DISPLACED

ARTICULAR DISC

Photographs

75


CASE 3: LEFT CONDYLAR FRACTURE TREATED BY CLOSED REDUCTION

“POOR” POST OPERATIVE OUTCOME: ARTICULAR DISC DISPLACED IN ALL THREE SECTIONS



SHOWING DISPLACED

ARTICULAR DISC



SHOWING DISPLACED

ARTICULAR DISC



SHOWING DISPLACED

ARTICULAR DISC

Photographs

76

POST OPERATIVE EVALUATION OF FUNCTIONAL PARAMETERS

PHOTOGRAPH 16:

EVALUATION OF MAXIMAL INTER-

INCISAL OPENING BY USING

VERNIER CALIPERS 6 MONTHS

AFTER COMPLETION OF

TREATMENT

PHOTOGRAPH 17:

EVALUATION OF OCCLUSION BY

CHECKING ADEQUATE

INTERCUSPATIONOF TEETH AT 6

MONTHS AFTER COMPLETION OF

TREATMENT

PHOTOGRAPH 18:

EVALUATION OF DEVIATION ON

MOUTH AT 6 MONTHS AFTER

COMPLETION OF TREATMENT

Dr. SUBHABRATA GHOSH - 52.172.27.147:8080

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