Study of the remote results of five cases of unilateral condylar hyperplasia in the adult

Exceptionally bilateral, condylar hyperplasia result in graduated facial asymmetry . The principal treatment is the condylectomy. (Condylar head and a portion of the neck of the condyle are removed.) Sometimes we must complete this condylectomy by mandibular osteotomy or resection of a segment of body of the mandible. The occlusal relationships of the teeth are affected by this process. That's why surgery treatment must be associated with orthodontics and prosthetic preparations. We use in post-operative immediate an intermaxillary fixation and traction by elastics. This allow to have a better congruence between the dental arches, and spare functional troubles.     

Anatomic and physiopathological basis for the surgical treatment of temporomandibular ankylosis

Lack of application of anatomical and physiopathological features leads to incomplete results following wide resection of an ankylosed bone block, the use of an intra-articular interposition with the single objective of interfering with postoperative synostosis, forced mobilization with the open mouth, and complementary surgical acts to improve esthetic results only. These results can be transformed by ensuring good postoperative functional dental occlusion and adequate functioning of the lateral meniscopterygoid-condylar apophysis system, but this is not always possible. When this system (mobilizer of the mandible) is not recoverable, other means of mandibular mobilization must be attempted, particularly a good muscular interposition, mechanotherapy in propulsion and retropulsion, and early sufficient lengthening of the ascending mandibular rami. Early surgery is always beneficial in children as it reduces constraints which limit growth and lowering of the body of the mandible. One of the most important steps in the progress of this surgery is the procedure for lengthening the condylar segment (after freeing or resection of the ankylosed condyle), and the use of a chondrocostal graft. Care must be taken in all cases to restore good occlusal function, the best means of improving articular function and the persistence of a good buccal opening.     

Thin-plate spline analysis of craniofacial morphology in subjects with adenoid or tonsillar hypertrophy

Objective

To compare the skeletal features of subjects with adenoid hypertrophy with those of children with tonsillar hypertrophy using thin-plate spline (TPS) analysis.

Materials and methods

A group of 20 subjects (9 girls and 11 boys; mean age 8.4 ± 0.9 years) with adenoid hypertrophy (AG) was compared with a group of 20 subjects (10 girls and 10 boys; mean age 8.2 ± 1.1 years) with tonsillar hypertrophy (TG). Craniofacial morphology was analyzed on the lateral cephalograms of the subjects in both groups by means of TPS analysis. A cross-sectional comparison was performed on both size and shape differences between the two groups.

Results

AG exhibited statistically significant shape and size differences in craniofacial configuration with respect to TG. Subjects with adenoid hypertrophy showed an upward dislocation of the anterior region of the maxilla, a more downward/backward position of the anterior region of the mandibular body and an upward/backward displacement of the condylar region. Conversely, subjects with tonsillar hypertrophy showed a downward dislocation of the anterior region of the maxilla, a more upward/forward position of the anterior region of the mandibular body and a downward/forward displacement of the condylar region.

Conclusions

Subjects with adenoid hypertrophy exhibited features suggesting a more retrognathic mandible while subjects with tonsillar hypertrophy showed features suggesting a more prognathic mandible.     

Extraoral and intraoral endoscopically assisted management of collum fractures]

AIM OF THE STUDY: Using limited extraoral and transoral incisions for an endoscopically assisted open reduction of condylar mandible fractures, the risk of facial nerve damage and extensive visible scars can be reduced. PATIENTS AND METHODS: The endoscopically assisted treatment of 17 consecutive patients with fractures of the condyle was performed from April 1998 to December 1999. Of the 17 patients, 14 had additional mandibular fractures, and 11 of the condylar fractures were dislocated. Of the 17 patients, 9 were treated by submandibular and 8 by transoral approach. Adequate anatomic reduction was achieved by the submandibular and transoral approaches using an endoscopically assisted technique. APPROACHES: In four patients angulated drills and screwdrivers facilitated the transoral treatment of condylar fractures. Transbuccal stab incisions and the use of trocars were not needed in these four patients. The transoral approach proved to be a reliable surgical approach for fractures of the mandibular condyle even when dislocation with lateral override was present. The extraoral approach was used for severely dislocated fractures such as fractures with medial override or comminution.     

Treatment of displaced mandibular condylar fracture with botulinum toxin A

The aim of this case report is to discuss the effect on condylar reduction of botulinum toxin A treatment used in a child with displaced fracture at condylar neck of mandible.A 3-years old boy was admitted to our clinic for incomplete fracture of mandibular symphysis and displaced condylar fracture at the left side. An asymmetrical occlusal splint with intermaxillary fixation was used instead of open reduction and internal fixation because of incomplete fracture of symphysis and possible complications of condyle surgery. However, it was observed that condylar angulation persisted despite this procedure. Thus, botulinum toxin A was administered to masseter, temporalis and pterygoideus medialis muscles. At the end of first month, it was seen that mandibular condyle was almost completely recovered and that fusion was achieved.In conclusion, Botulinum A toxin injection aiming the suppression of masticatory muscle strength facilitates the reduction in the conservative management of displaced condyle in pediatric patients.     

Condylar metastasis. Review of the literature and report of a case]

BACKGROUND: Metastases in the mandibular condyle are rare. A survey of the literature showed that only 23 of 69 selected cases qualified under the criteria of Meyer and Shklar. REPORT OF A CASE: A 48-year-old white male suffering from a previously operated lung carcinoma was referred due to pain and discomfort in the left TMJ. A solitary condylar metastasis of the mandible was revealed. Because of diffuse tumorous infiltration into periarticular tissue, irradiation treatment was performed. During the long-term follow-up growth of additional skeletal metastases occurred. DISCUSSION: The course of condylar metastases in general is similar to other metastases involving the jaw. Breast cancer as the primary tumor is most frequent, followed by lung cancer. There are no specific clinical or radiological parameters leading to diagnosis. The clinician should take a potential metastasis into account when dealing with TMJ complaints, radiological oddities, and medical history of malignant tumors. For proper treatment planning, diagnosis should be based on histology. Since the diagnosis of metastasis is usually made at an advanced stage of disease, therapy will be mainly intended as palliative.     

Klinische, radiologische und axiographische Untersuchung nach konservativ funktioneller Behandlung diakapitul?rer Kiefergelenkfrakturen

PURPOSE: The different lines of intracapsular fractures of the mandibular condyle were studied and their influence on the prognosis following close treatment was evaluated. METHODS: In 40 patients with 50 intracapsular fractures of the mandibular condyle the following evaluation was carried out after close treatment: clinical, radiological and axiographical follow-up. The examinations were performed between 0.5-5 years following treatment. Three types of intracapsular fractures were distinguished. Type A = fractures through the medial condylar pole, type B = fractures through the lateral condylar pole with loss of vertical height of mandibular ramus, type M = multiple fragments, comminuted fractures. RESULTS: Moderate to serious dysfunction was observed in 33% of the cases. Radiological examination of fracture types B and M revealed a reduction in the height of the mandibular ramus by up to 13% as compared to the contralateral side. Also with regard to deformation of the condylar head these two fracture types resulted in the most prominent pathological findings. Axiography revealed irregular excursions and a clear limitation of condylar movement in comminuted fractures by up to 74% as compared to the non-fractured side. CONCLUSION: The findings emphasize the severity of lesions to the osseo-disko-ligamentous complex of the TMJ caused by intracapsular fractures of the mandibular condyle. The poor functional and radiological results encountered in the fracture types B and M demonstrated the limits of conservative functional treatment. With regard to fracture type B it may be discussed whether surgical therapy would improve the results.     

Condylar retrusion in the algo-dysfunctional syndrome of the mastication apparatus

Although T.M.J. dysfunction-pain syndrome is a multicausal affection, it is obvious that occlusal disturbance is one of the greater etiologic factors. In order to evaluate the role of condylar position in the glenoid fossa, a statistical study has been made on a 16 patients series. These patients presented an uni- or bilateral T.M.J. dysfunction-pain syndrome without arthrosis, ankylosis or traumatologic deformation. The vertical and horizontal relationships of the mandibular condyle to the temporal were quantitatively evaluated from lateral tomographs. Pain and clicking were noted (Y or N) for each of the 32 T.M.J. Condylar position doesn't seem to have any relation with clicking, which is present in cases of meniscus anterior displacement. On the contrary, condylar horizontal retrusion is statistically connected with pain (p less than 0.05) even if one can see condylar retroposition without pain. On the other hand, vertical changes in condylar position cannot be connected with pain. The importance of condylar retrusion in the pain-group can surely be related to inflammatory histologic injuries at the level of the posterior disc attachment. Then, in these cases, the etiologic treatment must be focused on anterior mandibular release by orthodontics, prosthetics or orthognathic surgery.     

Condylar prostheses in head and neck cancer reconstruction.

OBJECTIVE: To discuss the use of condylar prostheses after mandibular resection for tumor. DESIGN: Case series and literature review. SETTING: Tertiary referral center. PATIENTS: Four patients underwent condylar reconstruction with metallic condylar prostheses after hemimandibulectomy for either squamous cell cancer or Ewing sarcoma. MAIN OUTCOME MEASURE: Complications related to the condylar prostheses. RESULTS: Clinical and radiological follow-up in these patients revealed several complications, including exposure or extrusion of the prosthesis and migration of the prosthesis into the epitympanum, resulting in profound sensorineural hearing loss owing to bony destruction of the cochlea. Two of our patients required removal of the mandibular hardware because of the seriousness of the complications, and 1 of the 2 underwent reconstruction of the condyle with a fibular free flap. CONCLUSIONS: Metallic condylar prostheses in the setting of tumor resection and reconstruction involve significant risks. Autogenous materials, such as vascularized bone grafts, should be used whenever possible.     

Neu entwickeltes Kiefergelenkkopfimplantat zur tempor?ren Kondylus-Rekonstruktion in der ablativen Tumorchirurgie

Background Based on own retrospective studies a condylar head add-on system for immediate, temporary reconstruction in patients undergoing ablative surgery requiring the removal of the manibular condyle has been developed in cooperation with the Department of Oral and Maxillofacial Surgery of the University of Tennessee, USA, and the Association for the Study of Internal Fixation (AO/ASIF). Purpose The design of the new condylar head add-on system and its use in an anatomical dissection study on a human cadaver are introduced and discussed. Design and first experiences The condylar replacement is made of commercial pure titanium and is conceived as an add-on system. It consists of a reconstruction plate (2.4 Uni-LOCK-System) und an adaptable condylar head that can be fitted on either side. The offset of the condylar head in a medial direction allows anatomically correct positioning of the implant. The slanted oval head shall provide a large contact area while maintaining function of the mandibular joint. The height-adjustable positioning of the condylar head add-on with four different fixations plates facilitates an intraoperative vertical correction of the condylar head without necessary bending of a new reconstruction plate. A condylar head add-on used on both sides and combined with the frequently used 2.4 Uni-LOCK-plate benefits from reduced storekeeping and turns out to be advantageous from an economic point of view. Perspective An international, prospective multi-center study evaluating the intraoperative applicability of the new condylar head add-on system and its functional as well as aesthetic results during the first two postoperative years has started in September 2006. O. Driemel und E. R. Carlson sind gleichberechtigte Erstautoren.     

Development and clinical application of the total temporomandibular joint (T.M.J.) endoprosthesis

In the course of designing a T.M.J. endoprosthesis we performed biomechanical analysis for testing the stress relationships of the condyle. The photoelastic stress analysis showed that the compressive force in the glenoid fossa varied from 90 to 270 N. The experiments showed also that the selected shape of the prosthetic condyle absorbs the forces of the mandible in a way similar to the natural condylar process. Therefore, we developed a total T.M.J. endoprosthesis. The condyle is made of a Titanium--alloy, the socket of high density polyethylene. From 1978 to 1987 we implanted 25 endoprostheses in 18 patients. The mean age of the patients at the time of the operations was 33 years. Indications for the implantation of total T.M.J. endoprostheses in adults are ankylosis, tumours, multiple fractures and, after all possibilities of conservative treatment have been exhausted, severe deforming arthropathy.     

Mandibular asymmetry in plagiocephaly without synostosis

SUBJECT: The number of plagiocephalies without synostosis (PWS) strongly increased in the last decade. Its impact on the mandible remains badly understood, the more so as there are various forms of PSS. The purpose of this study was to analyze mandible deformation according to the deformation of PWS. MATERIAL AND METHODS: The study was carried out retrospectively starting from three-dimensional scans of children presenting with a PWS. They were classified in 2 groups according to the deformation of the cranium. There were 51 frontal plagiocephalies (PF) and 19 occipital plagiocephalies (PO) for which the cephalic index was calculated. The position of the mandible compared to the base of cranium and its intrinsic asymmetry were analyzed (paired parametric Student test). RESULTS: The mandible was symmetrical in PO whereas it was asymmetrical for PF. This asymmetry was present at the level of the corpus and developed in 2 ways: that is to say asymmetry compensated for that of the base of the cranium (68.6%); or it worsened it (23.5%). The degree of brachycephaly was more important in PO than the PF with a cranial index of 0.93+/-0.07 and 0.85+/-0.07 respectively (P<0.05). In both cases the position of the mandibular condyle followed the asymmetry of the base of cranium and the asymmetry of the temporomandibular joint (TMJ) was secondary with that of the base of cranium. DISCUSSION: In addition to the asymmetry of TMJ position there was an intrinsic mandibular asymmetry in PF which was not found in PO. This asymmetry of the mandible was variable but in most cases it tended to compensate for the asymmetry of the base of the cranium which was more important in PF. The risk to have asymmetry of dental occlusion seems more important in PF than in PO, and an orthodontic follow-up appeared to be justified for these children.     

Condylar resection alone versus alloplastic reconstruction. Comparison of long-term functional and cosmetic results

After condylar resection a decision on whether to proceed immediately to reconstruction has to be decided. In this paper, two patients who had undergone hemimandibulectomy including exarticulation, in one because of an expanded keratocystic odontogenic tumour and in the other because of oral squamous cell carcinoma, are presented. In one patient a metallic condylar reconstruction plate combined with an iliac crest graft was implanted for primary mandibular reconstruction, whereas in the other the part of the mandible that had been removed and the condylar head were not replaced. One patient was followed up for 5 years and the other for 6 years. Functional (max. incisal distance, protrusive and lateral excursions, occlusion and joint noises) and cosmetic results (scarring, facial nerve function), and also quality of life with and without primary mandibular replacement by a metallic condylar reconstruction plate are compared.     

Clinical implications of mandible and neck measurements in non-obese asian snorers: ansan city general population-based study

Objectives

Anthropometric abnormalities of the mandible and neck may contribute to snoring in non-obese Asians. The study evaluated the clinical implications of mandible and neck measurements in non-obese Asian snorers.

Methods

The external mandible and neck measurements (neck circumference, two lengths of neck, mandibular body angle, and lengths of mandibular ramus and body) were compared between snorers and non-snorers in a sample of 2,778 non-obese Koreans (1,389 males, 1,389 females) aged 40 to 69 years (mean, 48.47±7.72 years).

Results

The overall prevalence of snoring was 64.7% (899/1,389) and 48.3% (671/1,389) in non-obese male and female subjects, respectively. In non-obese males, snorers had significantly a greater neck circumference (P<0.0001) and shorter mandibular body length (P=0.0126) than non-snorers. In non-obese females, snorers had significantly greater neck circumferences (P=0.0165), compared with non-snorers. However, there were no statistically significant differences in other variables between non-snorers and snorers.

Conclusion

Anthropometric abnormalities of the mandible and neck, including thick neck circumference in both genders and small mandible size in males, may be relevant contributing factors to snoring in non-obese Asian snorers.     

Infracondylar abscess formation: a rare complication of local anesthesia

INTRODUCTION: Ninety percent of oro-facial infections arise from a dental origin. The remaining 10% are the consequence of oro-pharyngeal, cutaneous or iatrogenic problems, such as in the present case.CASE REPORT: A 24-year-old patient consulted the emergency room because of a left mandibular swelling, accompagnied by trismus. Four days earlier, extraction of the 38 was performed under inferior alveolar nerve block anesthesia. A first drainage by vestibular approach was performed under general anesthesia. Because of the absence of improvement, a CT-scan was performed and an abscess localized at the base of the condyle, surrounding the posterior margin of the mandible, very high above the lingula. Outcome was favourable after a second surgery.DISCUSSION: Formation of an abscess very high above the lingula, around the condylar neck is rarely reported in the literature. In this patient it was certainly a complication resulting from the injection of local anesthesic with a vasoconstrictor. CT-scan should be performed to guide diagnosis in the event of an unusual course after the first surgical procedure and an adequate antibiotic regimen.     

Recurrence factors in the surgical treatment of prognathism of the mandible]

With regard to recurrences following surgery for prognathia of the mandible, the authors draw the distinction between immediate and secondary recurrences caused by errors in surgical indication or technique. They then review late recurrences, which they classify as being alveolar, basal or by forward sliding. They then study the role played in recurrences by growth of the condyle, neuromuscular balance and the hyoid suspensor system. Finally they stress the action of the tongue and the age factor (over 17 years being, in their view, desirable).     

Metallic condylar head prostheses to replace the temporomandibular joint]

BACKGROUND: Up to now the results after condylar reconstruction of the mandible have been regarded as less than satisfactory. PURPOSE: Functional and aesthetic long-term results after condylar head resection in traumatic and tumour cases with or without replacement by a metallic condylar head prosthesis were compared in a retrospective study. PATIENTS AND METHODS: From 1980 to 2001, 23 temporomandibular joints of 19 patients were reconstructed with metallic condylar head prostheses. The resected region, the contralateral joint, facial and masticatory muscles and the dental system were clinically and radiographically monitored for a mean period of 4 years and 9 months. Seven patients who underwent condylar resection without substitution were observed over an average follow-up time of 7 years and 11 months.RESULTS: Patients who underwent condylar resection without substitution reported more trouble with eating and speaking for a long time. TMJ endoprostheses preserved facial symmetry better. Maximum mandibular opening as well as lateral and protrusive excursions were slightly reduced in comparison with both unaffected controls and patients who underwent condylar resection without substitution. In this study bilateral condylar prostheses exhibited the same functional and aesthetic results as unilateral arthroplasty. CONCLUSIONS: Metallic condylar head prostheses originally developed for temporary replacement worked in some cases as long-term joint replacement but were not able to reach the total functional quality of natural temporomandibular joints.     

35 mandibular fracture cases

We present 35 cases of mandibular fracture treated at the Suita Municipal Hospital between 1994 and 2002. Results showed a male predominance by 2 to 1 and the highest occurrence of trauma in the 20-29 year age group (31%). Major causes of fractures were traffic accidents (52%), assaults (31%), and falls (17%). The most common fracture sites were, in descending order, the condyle (33%), parasymphysis (25%), angle (22%), body (10%), and ramus (10%). The cause of fractures in patients less than 30 years old is most likely due to traffic accidents and assaults, while that in patients over 30 years old is due to falls. Traffic accidents and falls significantly induce condylar fractures, while assaults significantly induce other fractures. Patients were treated with open reduction with titanium or biodegradable miniplates and screws (n = 30), maxillomandibular fixation alone (n = 2), conservative therapy (n = 1), or treatment at other hospitals (n = 2). The mean period for maxillomandibular fixation was 42 days. In 22 patients with more than 6 months of follow-up, 6 had complications: 4 had pain, 1 had deviation in mouth opening, 1 suffered from noise, and 1 from facial palsy. Patients with condylar fractures had a significantly high incidence of complications. We think that we should further decrease the period for maxillomandibular fixation, increase the application of biodegradable materials, and use methods for condylar fractures more appropriately.     

A complete intermediate temporomandibular joint prosthesis. Evaluation after 6 years

Since 1983 we have inserted more than 100 temporomandibular joint prostheses. A review after 6 years allows the respective indications to be listed and the complications to be studied in 72 insertions involving 62 cases suitable for analysis. The prosthesis is a total intermediary prosthesis forming an unsealed cupula composed of 2 halves--a mandibular portion and a temporal portion. Insertion of the prosthesis requires preliminary facial nerve dissection then osteotomy of the mandibular condyle and its subsequent drilling to allow the screwing in of the prosthesis. The prosthesis was used in traumatology, in condylar and high sub-condylar fractures, in the event of failure of functional treatment, in malformation syndromes, in tumors and, finally, in degenerative pathology. 13 prostheses were removed. A study of the probable causes of complications shows a predominance of technical problems related to inaccurate positioning of the prosthesis, in that it was not placed in the axis of the condyle, or that inadequate bicortical support was present. In our opinion, these complications do not question the conception of the prosthesis but rather indicate that it is necessary to perfect the insertion technique while taking advantage of improvements in the prosthesis which are currently under study.     

Temporary intraoperative external fixation in mandibular reconstruction

OBJECTIVES: To describe the use of a temporary intraoperative external fixation device to assist in the optimal bony reconstruction of the mandible in the setting of vascularized bone grafts. STUDY DESIGN: A retrospective review of six patients who underwent composite resection of the mandible and subsequent reconstruction with osteocutaneous free tissue transfer in a tertiary care center. METHODS: Six cases of mandibular reconstruction using an intraoperative external fixation system to assist the positioning of vascularized bone grafts are presented. All patients had composite resection of the mandible and subsequent reconstruction with either a scapula or fibula osteocutaneous flap. Follow-up ranged from 2 to 16 months. RESULTS: Successful reconstruction as defined by acceptable contour, occlusion, and condylar position was achieved in all cases. Complications were limited to a postoperative cerebrovascular accident requiring anticoagulation and subsequent neck hematoma. CONCLUSIONS: Use of intraoperative external fixation maintains the proper alignment of mandibular segments without the use of a bridging reconstruction plate. This technique is particularly valuable with tumors involving the outer cortex of the mandible.