Assessment of patients treated for intracapsular fractures of the mandibular condyle by closed techniques.

PURPOSE: The goals to study different lines of intracapsular fractures of the mandibular condyle and to evaluate their influence on the prognosis after closed treatment. PATIENTS AND METHODS: Clinical, radiologic, and axiographic follow-up of 40 patients with 50 intracapsular fractures of the mandibular condyle was carried out after closed treatment. The examinations were performed an average of 22 weeks after treatment. Three types of intracapsular fractures were distinguished: type A, or fractures through the medial condylar pole; type B, or fractures through the lateral condylar pole with loss of vertical height of mandibular ramus, and type M, multiple fragments, comminuted fractures. RESULTS: Moderate to serious dysfunction was observed in 33% of the cases. Radiologic examination of fracture types B and M revealed a reduction in the height of the mandibular ramus of up to 13% compared with the contralateral side. These 2 fracture types also resulted in the most prominent deformations of the condylar head. Axiography revealed irregular excursions and a limitation of condylar movement in comminuted fractures of up to 74% compared with the nonfractured side. CONCLUSION: Lesions to the osseodiscoligamentous complex of the temporomandibular joint caused by intracapsular fractures of the mandibular condyle can be severe. The poor functional and radiologic results encountered in the fracture types B and M showed the limitations of closed functional treatment.     

Articular soft tissue injuries associated with mandibular condyle fractures and the effects on oral function

The majority of studies debating the optimization of treatment for condylar mandibular fractures focus on the bony aspect first. However, fractures of the mandibular condyle may go together with soft tissue injury of the temporomandibular joint. An electronic literature search for this topic was undertaken. Assessment of quality was carried out using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Sixteen articles were included in this review. The reviewed literature showed that intracapsular fractures and dislocated condylar fractures result in more severe injuries. Serious injury to the disc and capsule of the temporomandibular joint is a contributing factor towards development of complications after closed treatment. The results of this review give an overview of the published studies focusing on articular soft tissue injuries caused by condylar mandibular fractures. Additionally, an overview of the magnetic resonance imaging (MRI) settings used to detect these injuries is provided. Until now, the relation between soft tissue injuries and type of condylar trauma and their influence on clinical outcome has been insufficiently investigated. Before considering reduction of soft tissues next to reduction of the fracture, more research is needed into the impact of soft tissue injuries on oral functioning, in which a uniform classification is used.     

Frey's syndrome after condylar fracture: case report

Frey's syndrome is the occurrence of hyperesthesia, flushing and warmth or sweating over the distribution of the auriculotemporal nerve and/or greater auricular nerve while eating foods that produce a strong salivary stimulus. Frey's syndrome is also known as auriculotemporal syndrome and gustatory sweating. We present a case of Frey's syndrome after a condylar fracture and its treatment by internal rigid fixation. A review of the literature is provided along with mention of a simple test (Minor's test) that can help in the diagnosis of this syndrome.     

Congenital Frey's syndrome associated with nontraumatic bilateral trifid mandibular condyle

Congenital Frey's syndrome and bilateral trifid mandibular condyle are two different entities. The occurrence of both together is rare and has not been reported in the literature. This article describes the case of a 17-year-old male patient who complained of bilateral warmness, flushing and sweating in the preauricular area after eating spicy and sour foods since childhood. He had no complaint related to the functions of the temporomandibular joint and had no history of facial trauma. The patient was treated with injections of botulinum toxin A and the signs and symptoms of Frey's syndrome improved significantly.     

Conventional radiographic and computed tomographic findings in cases of fracture of the mandibular condylar process

A total of 40 patients with 46 fractures of the mandibular condylar process were examined an average of 47 months after the injury. The conventional radiologic examination consisted of panoramic radiography and lateral transcranial view of the fracture in the mouth-open and mouth-closed positions. Sixteen patients with 21 fractures of the condylar process were examined additionally by computed tomography (CT) because of temporomandibular joint problems in the sagittal and coronal projection. Computed tomography revealed bony changes in the fractured mandibular condyle and its position in the mandibular fossa more exactly than conventional radiographic examinations. Furthermore, the results showed that disturbances in the position and function of the articular disc may be more common than was earlier anticipated, suggesting the more frequent use of CT examinations to evaluate temporomandibular joint changes after condylar process fractures.     

The anatomical relationship between the position of the auriculotemporal nerve and mandibular condyle

Head, neck, face, and ear pains are commonly associated with disorders of the temporomandibular joint (TMJ). Several theories have been proposed regarding the functional relationship of the TMJ and the associated structures, and how they might contribute to certain painful conditions. This study was conducted to determine the anatomic relationship of the auriculotemporal nerve to the middle meningeal artery and the mandibular condyle. Forty human cadaver temporomandibular joints were dissected to locate the precise position of the auriculotemporal nerve to the mandibular condyle. The study findings revealed a significant variation in the relationship of the auriculotemporal nerve to the middle meningeal artery. The auriculotemporal nerve was found to be between 10-13 mm inferior to the superior surface of the condyle and 1-2 mm posterior to the neck of the condyle. The nerve was not found to be in a position that would likely create an entrapment with adjacent tissues. These findings may assist the clinician to locate the most appropriate injection site for an auriculotemporal nerve block.     

Temporomandibular joint prosthesis as treatment option for mandibular condyle fractures: a systematic review and meta-analysis

The aim of this study was to perform a systematic review of the literature on the temporomandibular joint (TMJ) prosthesis as a treatment option after mandibular condyle fracture. Three databases were searched (PubMed, Embase, Cochrane Library) and 2670 unique papers were identified. A total of 337 studies were included (121 case reports, 89 case series, and 127 cohort/clinical studies). In total 14,396 patients and 21,560 prostheses were described. Of the 127 cohort or clinical studies, 100 (79%) reported inclusion criteria, 54 (43%) reported exclusion criteria, and 96 (76%) reported the inclusion period. The base population from which patients were recruited was reported in 57 studies (45%). The reason for TMJ prosthesis implantation was reported for 4177 patients (29.0%). A history of condylar fracture was present in 83 patients (2.0%); a history of mandibular trauma was present in 580 patients (13.9%). The meta-analysis showed a pooled prevalence of condylar fracture of 1.6% (95% confidence interval 0.9–2.4%) and a pooled prevalence of trauma or condylar fracture of 11.3% (95% confidence interval 7.1–16.0%). Heterogeneity was highly significant (P < 0.001). The TMJ prosthesis appears to be reserved for patients with persistent pain, bony or fibrous ankylosis, or osteomyelitis after primary closed or open treatment of fractures of the mandibular condyle.     

Functional and radiological results of open and closed treatment of intracapsular (diacapitular) condylar fractures of the mandible

The study was performed to evaluate and compare the results of open and closed treatments of diacapitular fractures of the mandible. Following open reduction and internal fixation (ORIF) 14 patients with 15 displaced condylar fractures, which had caused a shortening of the mandibular ramus, were examined clinically (Helkimo index), radiologically (Orthopantomogram, Clementschitsch [reversed Towne's] view, Submentovertex view) and axiographically (CARDIAX). These findings were compared to a group of 29 patients with 34 similar condylar fractures which had been treated using closed techniques. Following ORIF patients showed better radiological results with regard to the mandibular ramus height, resorption and pathological changes to the condyle, compared to the patient group after closed functional treatment. In both groups some signs of dysfunction persisted, although there were slightly better results in the ORIF group. In 30% of the closed treatment group, lateral deviation during mouth opening, crepitus and occlusal disturbances were noted. No cases of occlusal disturbance were observed in the ORIF group. The axiographic examinations revealed a significant limitation of movement of the fractured condyle in both groups. However, after open treatment, the temporomandibular joint displayed significantly less irregularities in the condylar paths. In cases of complex reconstruction of the mandibular condyle, ORIF appears to improve the function of fractured condyles, when combined with a postoperative therapeutic exercise regime.     

The long-term effect of oromaxillofacial trauma on the function of the temporomandibular joint

Thirty patients with temporomandibular disorders (TMD) after trauma to the orofacial region were followed for 6 months. They were assessed at 10 days, 1 month, and 6 months. It was found that patients with combined fractures of the mandible and condyle showed more effects on function of the temporomandibular joint after 1 month than patients with condylar fracture only. This difference was not so apparent after 6 months. Patients with trauma but no fracture showed similar effects to those with non-condylar fractures. There was a tendency for arthrogenous patients to develop myogenous problems with time. A group of patients with TMD but no trauma, showed more favourable long-term response to conservative treatment. Long-term follow-up of these patients for TMD problems is recommended.     

下颌骨创伤致慢性颞下颌关节创伤性关节炎相关因素的初步分析

目的 初步探讨下颌骨骨折后颞下颌关节发生慢性创伤性关节炎的相关因素。方法 对下颌骨骨折后37例颞下颌关节慢性创伤性关节炎病例(A组)和83例无关节症状病例(B组)的临床资料进行比较分析。结果 A组较B组女性及成人比例多；颌间结扎时间长，开口练习执行情况差；髁突骨折病例多，经保守治疗的髁突脱位骨折病例多。结论 下颌骨骨折引起的颞下颌关节慢性创伤性关节炎易发于颌间结扎时间长、未能进行完善开口练习的患者，且成年及女性患者多见；髁突骨折是引起该病的主要创伤类型，其中保守治疗的髁突脱位骨折患者更易发生慢性创伤性关节炎；下颌骨其它部位骨折者也可引起慢性创伤性关节炎，应引起临床工作者重视。     

Magnetic resonance evidence of joint effusion of the temporomandibular joint after fractures of the mandibular condyle: a preliminary report

To investigate the clinical significance of magnetic resonance (MR) evidence of joint effusion of the temporomandibular joint after mandibular condylar fractures, magnetic resonance imaging (MRI) was performed on 18 joints in 15 patients with either unilateral or bilateral mandibular condylar fractures using a 1.5 Tesla MRI scanner (Signa, General Electric, Milwaukee, WI). MR evidence of joint effusion was evaluated and compared with the types and the positions of the fractures. MR evidence of joint effusion was observed in 11 of 18 TMJs, which was 61% of the condylar fractures. It appeared more frequently after fractures with dislocation than those without dislocation (p < 0.05). In addition, MR evidence of effusion appeared more frequently in TMJs after high condylar fractures (head to upper neck) than low condylar fractures (lower neck to subcondylar) (p < 0.05). These findings indicate that MR evidence of joint effusion may serve as a marker for the detection of severe intra-articular damage to the TMJ after mandibular condyle fractures.     

穿腮腺手术径路治疗下颌骨髁突骨折的临床效果评价

目的评价穿腮腺手术径路治疗下颌骨髁突骨折的临床效果。 方法对31例（共36侧）下颌骨髁突骨折的患者,穿腮腺入路行下颌骨髁突骨折切开复位钛钉钛板坚固内固定术、髁突骨折碎片取出术并髁突成形术。术后观察面型、张口度、咬合关系、面神经损伤、有无唾液腺瘘及复查颌面部CT观察骨折段的复位情况等。 结果24例（共29侧）行下颌骨髁突骨折切开复位钛钉钛板坚固内固定术,7例（共7侧）髁突骨折碎片取出术并髁突成形术,术后随访6 ~ 18个月（平均11.3个月）;通过穿腮腺手术径路骨折断端复位准确、固定良好、咬合功能恢复正常、面部外形均满意;4例患者早期出现Ⅰ~Ⅱ度张口受限,经过张闭口训练后恢复正常;5例患者出现面神经暂时性麻痹,8周后均恢复正常;1例患者出现唾液腺瘘,经过加压包2周后扎后创口愈合;4例患者出现创伤性关节紊乱症,有关节弹响、疼痛等。 结论穿腮腺手术径路治疗下颌骨髁突骨折安全有效,手术并发症少,值得临床推广应用。     

Surgical complications of mandibular condylar fractures

The purpose of this study was to retrospectively evaluate the complications of 58 patients who underwent surgery for mandibular condylar process fractures. Data were collected from patients during a 10-year period (1999-2009). The data recorded included demographic data, etiology, diagnosis, type of condylar fracture, surgical approaches, and postoperative complications. A total of 58 underwent surgery for reduction of the condylar fractures. There were 22 patients with bilateral condyle fractures and 36 patients with unilateral condyle fractures, accounting for 65 surgeries. In 8 fractures, a preauricular approach was performed to access the fractures condyle, whereas the retromandibular approach was performed in 57 fractures. There were 2 temporary facial palsies, 1 permanent facial palsy, and 1 sialocele. There were no cases of hypertrophic scar, Frey syndrome, or salivary fistula. In conclusion, permanent deformities after surgical complications were unusual, and the results are acceptably safe.     

Endoscopically assisted reconstruction of the mandibular condyle with a costochondral graft through a modified preauricular approach

We describe our experience with reconstruction of the mandibular condyle with a costrochondral graft (CCG). We retrospectively evaluated 122 patients with diagnoses including osteoarthrosis, ankylosis, tumours, idiopathic condylar resorption, comminuted condylar fracture, and chronic osteomyelitis of the temporomandibular joint (TMJ). We used a modified preauricular approach and an endoscopically assisted technique. The grafts were followed-up by computed tomograms (CTs) and magnetic resonance (MR) examinations. All patients had successful reconstruction of the mandibular condyle with a CCG. No patient had permanent weakness of the facial nerve or any other severe complication. With its wide range of indications, the endoscopically assisted reconstruction of the mandibular condyle with a CCG through a modified preauricular approach can produce good aesthetic and functional results while reducing operating time and tissue damage.     

下颌升支垂直截骨内固定术治疗髁突高位骨折

目的:比较手术和非手术方法治疗单侧下颌骨髁突高位骨折的临床效果。方法:19例髁突高位骨折患者,其中10例行下颌升支截骨内固定术+颌间牵引术(手术组),其余9例单纯行颌间牵引术(非手术组),随访0.5～1年。结果:手术组和非手术组之间比较,开口度及前伸运动度均无显著性差异(P>0.05);侧方运动度手术组优于非手术组,有显著性差异(P<0.01)。非手术治疗的患者,下颌骨平面不对称,X线片显示髁突的解剖位置欠佳。手术患者,下颌下区存在线形疤痕,但下颌骨平面对称,X线片显示患侧髁突与健侧形态相似。19例中无1例出现明显的颞下颌关节紊乱综合征。结论:采用下颌升支垂直截骨内固定术+颌间牵引术治疗下颌骨髁突高位复杂骨折,兼顾美观和功能,手术简便,不失为一种理想的治疗方法。     

无髁突骨折颞下颌关节急性创伤后的变化:影像学和手术所见

目的:通过CT、MRI及手术探查观察无髁突骨折颞下颌关节急性创伤后的变化,为该疾患的早期诊治提供依据。方法:上海交通大学医学院附属第九人民医院口腔颌面外科关节组2009—2010年收治的无髁突骨折颞下颌关节急性创伤患者7例11侧关节纳入研究。所有患者伤前均无关节症状,但在伤后出现长时间的关节区疼痛和开口受限,其中6例合并面部骨折,曾在其他医院或由其他医师手术治疗。所有患者均进行了关节区的MRI检查,对受伤后即刻和再次就诊的CT进行比较。所有病例进行了手术探查,术中所见进一步证实影像学的变化。结果:CT显示,87.5%(7/8)的髁突在受伤即刻表面骨质"完好",而伤后1个月至1a出现骨质破坏。伤后1个月至1a的MRI检查显示,所有11侧关节均出现盘前移位,90.9%(10/11)的髁突伴骨质破坏。手术探查显示,2侧关节出现骨性黏连,3侧关节髁突表面骨质破坏与关节窝纤维性黏连,5侧关节髁突表面软骨变性伴黏连,1侧关节髁突表面软骨无明显破坏,关节盘前移位但形态尚可。结论:无髁突骨折的颞下颌关节急性创伤如伴关节盘前移位,可导致骨关节病和(或)关节强直。     

Atypical Frey syndrome as a complication of Obwegeser osteotomy

A patient with Frey syndrome on the left cheek area as a complication of an Obwegeser osteotomy is reported. Flushing, sweating of skin, and hypoesthesia of buccal mucosae were present 6 months after surgery. An injury to the auriculotemporal nerve during desperiostization of the posterior border of the mandibular ramus is believed to be the principal cause. The physiopathologic mechanism is thought to occur in relation to aberrant regeneration of the postganglionic secretomotor parasympathetic nerve fibers carried in this nerve. These regenerated fibers erroneously reach the sweat glands of the cheek skin through anastomosis with the buccal nerve and temporofacial ramus of the facial nerve. Direct injury of the buccal nerve may be another cause, because of its close anatomic course with the external pterygoid muscle and the mandibular ramus. An extensive literature review revealed no cases of this syndrome as a complication of Obwegeser osteotomy.     

Retromandibular approach to condyle fractures: two case reports

Retromandibular approach was first described in 1967 for vertical subcondylar osteotomy and later became popular for surgical treatment of temporomandibular joint dysfunction and low condyle fractures. The trajectory of the incision, parallel to the posterior border of the mandibular ramus, allows a good approach with easy separation of the buccal and marginal mandibular branches of the facial nerve, when they are present in the surgical field. When open reduction and internal rigid fixation with plates and screws are indicated for condylar fractures, retromandibular approach offers an excellent esthetic result with low morbidity. Two clinical cases are presented, in which the surgical treatment was carried out for condylar fractures, and clearly illustrate the proposed approach.     

髁突骨折分型及手术治疗50例临床分析

目的 研究出现移位和功能障碍的下颌髁突骨折的分型和疗效.方法 2007年7月至2010年7月,收治有骨折移位和功能障碍的下颌髁状突骨折的患者50例(69侧),依据骨折线的水平分为髁突囊内,髁突颈部和髁突下骨折,采用不同手术方法和固定方法进行治疗.术后3天、1个月、3个月、6个月、1年进行临床随访,从临床和影像学两方面评估术后恢复情况.囊内骨折根据杨驰教授的骨折线分类方法,将骨折分为分为A、B、C、M四型,回顾性分析不同类型手术的特点.结果 50例患者中获得3个月以上随访的48例(66侧),术后平均随访10.45个月,随访期末平均开口度33.89 mm(31.5~43.7 mm),8侧出现暂时性额纹消失,3个月后7侧恢复.术后总体满意度97.92%(47/48),仅1例骨折患者因1年后伴有颞区皮肤麻木和额纹消失不满意,其余无严重并发症出现.结论 对于发生移位和功能障碍的下颌骨髁突骨折分型的不同采取不同的手术方法可达到良好的治疗效果,但对术者的手术技巧和经验要求较高.     

Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and teeth-supporting structures, and fractures of the mandibular body.

In 123 individuals, 138 fractures of the mandibular condyle were classified with respect to fracture level, dislocation at the fracture level, and condylar head relation to the articular fossa. The age of the patient and the location of the most distal occlusal contact were recorded as well as teeth injuries and concomitant fractures of the mandibular body. The position of the most distal occlusal contact did not influence the dislocation of the condylar fragment. Teeth injuries such as fractures and luxation were found to be associated with condylar head or neck fractures, whereas the concomitant fractures of the mandibular body were mostly seen with the subcondylar fractures. Teeth injuries as well as concomitant fractures of the mandibular body were found more frequently in patients with bilateral than unilateral condylar fractures. Fractures of teeth in the molar and bicuspid regions were most frequent on the condylar fracture side, while the concomitant fractures of the mandibular body were located to the contralateral side. Medial angulation of the condylar fragment with lateral override at the fracture level was the typical fracture in adults, and angulation without override the characteristic fracture in growing individuals. Medical override occurred both in children and in adults and seemed to be the result of more severe trauma to the chin.