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| IMC Wiki | Classification and diagnosis of condylar process fractures

Classification and diagnosis of condylar process fractures

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Definition

Fractures of the condylar (articular) process include superior, medial and inferior fractures and fractures of the condylar head.
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Classification

A wide range of systems of classifications are currently in use internationally, making comparison between treatment outcomes difficult (Eckelt 2000). In the Germanophone world, as well as fractures of the condylar head, the term 'Kollumfraktur' (condylar neck fracture) is used, and is in turn divided into superior and inferior and occasionally medial condylar neck fractures, depending on the level of the fracture gap. The term 'Gelenkfortsatzbasisfraktur' (fracture of the base of the articular process) is also frequently used as a synonym for inferior condylar neck fractures. Rasse et al. (1993) note that fractures of the condylar head are frequently both intracapsular and extracapsular.

In the Anglophone world, fractures of the articular process are divided into condylar and subcondylar fractures. Laskin (1991) regards only intracapsular fractures as condylar fractures. Subcondylar fractures are defined as extracapsular fractures which run through the anatomical neck of the articular process or diagonally downwards and backwards from the mandibular notch towards the posterior edge of the ramus (Eckelt 2000).
In the Germanophone world, depending on the displacement of the fragments, a distinction is made between a 'Dislokation' and a 'Luxation' (Eckelt 2000).
Dislokation
Displacement of the fragments
Luxation
Displacement of the complementary joint components.
Luxationsfraktur
Protrusion of the condylar head from the mandibular fossa

In the Anglophone world, by contrast, a distinction is drawn between deviation, displacement and dislocation. Deviation represents a simple kink in the condylar process fragment, where there is still osseous contact between the displaced fragments. Where this contact is entirely absent, this is referred to as displacement. Dislocation refers to the complete luxation of the condylar head (Eckelt 2000).

Classification by Spiessl and Schroll

In the German speaking world, the system of classification devised by Spiessl and Schroll (1972) has become the established standard. It considers both dislocation/luxation of the minor fragment and the level of the fracture.

Spiessl and Schroll (1972) differentiate between 6 different types of fracture:

Type 1: fracture with no dislocation
Type 2: inferior condylar neck fracture with dislocation
Type 3: superior condylar neck fracture with dislocation
Type 4: inferior condylar neck fracture with luxation
Type 5: superior condylar neck fracture with luxation
Type 6: intracapsular fractures

From a treatment point of view, further differentiation of the degree of dislocation is useful. While severely dislocated fractures (no osseous contact between fragments, significant contraction of the fragments) and luxated fractures (with luxation > 30°) are increasingly treated surgically, slightly dislocated fractures are frequently treated using a conservative approach.

Treatment objectives

The objective of treatment is to restore the function of the mandible, with correct occlusion, articulation and joint function. In the acute phase, pain relief remains a primary concern.
  • Restoration of mandibular form and function
  • Prevention of growth disorders in adolescents and children
  • Prevention of acute and/or chronic disorders of the temporomandibular joint (osteoarthritis, disc dislocation)
  • Prevention of infection
  • Prevention of ankylosis

Diagnosis

Clinical diagnosis

The clinical signs of fracture of the condylar process are directly dependent on the level of the fracture and the degree of dislocation of the fragments. A significant factor is the relative position of the fracture gap and the insertion of the lateral pterygoid muscle.

Fracture gap above the insertion of the lateral pterygoid muscle
  • Tenderness to pressure in the area of the joint
  • Pain on compression
  • Restricted mouth opening with associated pain
  • Malocclusion as a result of intracapsular oedema, with deviation to the uninjured side
  • No loss of function of the lateral pterygoid muscle
Fracture gap below the insertion of the lateral pterygoid muscle
  • Loss of function of the lateral pterygoid muscle during mouth opening
  • The lower jaw deviates toward the injured side during protrusion.
  • It is not possible to move the lower jaw toward the uninjured side.
  • Movement of the condylar head during mouth opening does not occur where there is dislocation of the lesser fragment. This can be demonstrated by inserting the little finger into the external auditory canal.
Luxation fractures
  • If the condylar head has luxated out of the socket, this can be palpated by inserting the little finger into the external auditory canal.
  • In the case of a unilateral luxation fracture, a lateral open bite on the uninjured side is observed.
    #pic#
  • In the case of bilateral fractures, anterior open bite with retrodisplacement of the mandible is observed.
    #pic# #pic#

Examination

Examination of the auditory canal and the joint area

Symptoms:
  • Swelling of the temporomandibular joint
  • Swelling of the cheek
  • Possible bleeding from the ear

Palpation

  • Pain on palpation of the temporomandibular joint and the ear

Functional examination

  • Facial nerve
  • Mouth opening
  • Deviation from the midline?
  • Forward and lateral displacement
  • Premature contact in the molar region?
  • Where required, analysis with the aid of diagnostic instruments and production of a model
  • Pain on compression of the temporomandibular joint, which is triggered by exerting pressure on the chin with the mouth slightly open.
    #pic# #pic#

Radiological diagnosis

The temporomandibular joint should always be imaged in two planes. Established views for basic diagnosis are:
  • OPG
  • Posteroanterior X-ray

Further examinations

  • Specific X-ray examinations
  • Computed tomography (CT) for fractures with multiple segments or significant dislocation of the condylar head
    A coronal CT is recommended prior to any planned surgery (Schimming et al. 1999).
  • Magnetic resonance imaging (MRI) may be required where destruction of soft tissues of the temporomandibular joint (e.g. capsule, disc) is suspected)


sources

  • Eckelt U (2000), Fractures of the mandibular condyle, MundKieferGesichtschir 4 Suppl 1:S110-7
  • Laskin DM (1991), Establishing new Standards, J Oral Maxillofac Surg 49:1141
  • Rasse M, Koch A, Traxler H, Mallek R (1993), Der Frakturverlauf von diakapitulären Frakturen der Mandibula - eine klinische Studie mit anatomischer Korrelation, Z Stomatol 90:119-125
  • Schimming R, Eckelt U, Kittner T (1999), The value of coronal computer tomograms in fractures of the mandibular condylar process, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:632-9
  • Spiessl B, Schroll K (1972), Gesichtsschädel, in: Nigst H (Hrsg) Spezielle Frakturen- und Luxationslehre, Bd l. Thieme, Stuttgart New York, S 1