BECKING AG, ZIJDERVELD SA, TUINZING DB. Management Of Posttraumatic Malocclusion Caused By Condylar Process Fracture. J Oral Moxillofac Surg 56: 1370-l 374, 1998.

PRESENTED BY – DR. SHEETAL KAPSE

GUIDED BY – DR. RAJASEKHAR G.

AUTHORS

1. BECKING AG - Oral and Maxillofacial Surgeon.

2. ZIJDERVELD SA -Oral and Maxillofacial Surgeon.

3. TUINZING DB -Professor, Oral and Maxillofacial Surgery.

Departmcnt of Oral and Maxillofacia1 Surgery, Free University Hospital, Amsterdam, The Netherlands.

CONTENTS

IntroductionAim Materials and methodsResults & DiscussionCross referencesConclusionPros and Cons of studyReferences

Introduction

Condylar fracture is one of the most common fractures in the mandibular region, with an incidence ranging from 29 to 52%.

The great majority of condylar process fractures arc probably treated with closed reduction. The occurrence of posttraumatic malocclusion is reported to be 4.4%

Conventional therapy, tooth grinding, extraction of interfering teeth, prosthodontics, orthodontics, orthognathic surgery, or combinations of these.

Introduction

Posttraumatic malocclusion with asymmetry due to unilateral condylar process fractures are corrected with an osteotomy on the affected side, or sometimes on both sides.

A symmetric anterior open bite due to bilateral condylar process fractures presents a surgical dilemma. It can be corrected with either an osteotomy of both affected sides of the mandible or an osteotomy the maxilla.

Rubens BC, Stoelinga PJW, Weaver TJ, et ai: Management of malunited mandibular condylar fractures. Int J Oral Maxillofac Surg 19:22,1990

Ellis E III: Biological considerations concerning treatment of fractures of the mandibular condyle. International conference on management of fractures of the mandibular condyle, Groningen, The Netherlands, 1997

Aim

1) To evaluate the treatment of asymmetric malocclusion

due to unilateral condylar process fractures

2) To evaluate the treatment of symmetric posttraumatic

malocclusion with anterior open bite due to bilateral

condylar process fractures.

Materials and methods

A retrospective study on 21 patients with posttraumatic malocculsions attributable to condylar process fractures was performed.

In group I, 15 patients were treated for asymmetric malocclusion with unilateral (13) or bilateral mandibular ramus osteotomies (2).

In group II, 6 patients were treated for anterior open bit with either a Le Fort I osteotomy (n = 5) or a bilateral ramus osteotomy (n = 1).

All patients had closed treatment, including 1 to 3 weeks of maxillomandibular fixation, followed by elastic bands for regaining preinjury occlusion and functional therapy.

All patients had clinical and radiographic follow-up for at least 1 year.

Group I

32 year-old man with an asymmetric malocclusion due to a right-sided condylar process fracture 2 years after initial treatment of’ 3 weeks of maxillomandibular fixation and subsequent use of elastic bands and functional therapy. A, Intraoral view before orthographic surgery; 6, Preoperative panoramic radiograph; C, Clinical situation 1 year after a sagittal spit osteotomy on the right side; D, Postoperative panoramic radiograph.

Group II

Twenty-two-year-old woman with an anterior open bite as the result of bilateral condylar process fractures 18 months after initial treatment with 3 weeks of maxillomandibular fixation, class 2 elastic band traction, and functional therapy. A, Preoperative anterior open bite; B, Panoramic radiograph of the bilateral condylar process fractures and a median symphyseal fracture before treatment; C , Preoperative lateral cephalogram; D, Lateral cephalogram 1 year after orthognathic surgery; E, Dental situation 1 year after orthognathic surgery.

Results

All patients had a follow-up period after orthognathic surgery of at least 1 year, with a mean of 3.6 years.

Models and serial cephalograms were used to identify occlusal changes & skeletal relapse.

Stable dental and cephalometric results were obtained in all patients except the 1 in group II who was treated with bilateral sagittal split osteotomies.

In two cases, both in the asymmetric group, minor occlusal interferences had to be treated by equilibration in the early postoperative period.

Discussion

According to the literature, the treatment of choice in restoring preinjury occlusion in patients with posttraumatic malocclusion is an osteotomy on the affected jaw, sometimes even at the fractured side.

In cases with asymmetric posttraumatic malocclusion due to a condylar process fracture, the only. Surgical option is an osteotomy at the affected side of the mandible, because facial symmetry needs to be corrected.

A posttraumatic anterior open bite due to bilateralcondylar process fractures presents a philosophical dilemma. The open bite can be considered either an entirely posttraumatic situation or an acquired dentofacial deformity.

Discussion

The first statement dictates restoration of ramus heigth; the latter advocates closure of the anterior open bite with (bi)maxillary surgery.

Dorsal impaction of the maxilla and subsequent autorotation of the mandible is reported to prevent relapse.

Ramus osteotomies with counterclockwise rotation of the distal fragment exceeding 40 are unsuitable because of reported relapse.

Cross references

Arguments in favourof mandibular ramus osteotomies

1. Correction of the lower jaw will not lead to alterations in the inclination of the upper anterior teeth so that presurgical or postsurgical orthodontics will therefore seldom be necessary.

2. If correction is carried out in the affected lower jaw, the resulting situation will be identical to the original skeletal relation.

3. Reconstruction of the affected jaw will be more acceptable to patients.

Arguments in favour of the Le Fort I osteotomy:

1. In time, because of neuromuscular adaptation, a posttraumatic situation might be considered as a dentofacial deformity. Autorotation of the mandible after dorsal impaction of the maxilla might result in less relapse when there is a considerable anterior open bite rather than closure of an open bite by ramus osteotomies and counterclockwise rotation of the distal fragment of the mandible.

2. No technical difficulties will be encountered in surgery of the maxilla with respect to the earlier condylar process fracture. On the contrary, managing the proximal fragment in ramus osteotomies after a condylar process fracture can be difficult, especially if the condylar process was grossly dislocated at the time of the initial treatment.

3. A higher prevalence of temporomandibular joint problems are reported to occur after mandibular ramus surgery than after Le Fort I osteotomies used to close an anterior open bite.

The non-surgical treatment of mandibular condylar fractures, may occasionally result in articular imbalance and temporomandibular joint dysfunction.

This may be attributed to condylar head displacement and resorption, resulting in a shortened vertical ramus and lost posterior vertical facial height.

Restoring the vertical ramus height is essential in the treatment of such dysfunction, and may be accomplished by unilateral, or bilateral ramus osteotomies.

Four examples of patients treated with mandibular ramus osteotomies to restore vertical ramus height, with subsequent improvement in occlusal balance and function are presented.

The use of the sagittal split mandibular osteotomy and the external vertical ramus osteotomy, stabilized with small osseous plates, and monocortical screws, is discussed.

Pros Cons Prospective study

Long term follow up

Logical

Less sample size

Relapse

Children

Pros and Cons of study

Conclusion

The supratemporalis approach provides excellent exposure of the surgical field with minimal complications.

Compared with the traditional approach, the supratemporalis approach effectively prevents injury to the facial nerve.

Therefore, the authors suggest this surgical method as a routine approach to treat intracapsular condylar fractures.

References

1. Rubens BC, Stoelinga PJW, Weaver TJ, et ai: Management of malunited mandibular condylar fractures. Int J Oral Maxillofac Surg 19:22,1990

2. Ellis E III: Biological considerations concerning treatment of fractures of the mandibular condyle. International conference on management of fractures of the mandibular condyle, Groningen, The Netherlands, 1997

3. B. C. Rubens, P. J. W Stoelinga, T. J. Weaver and P. A. Blijdorp: Management Of maiunited mandibular condylar fractures. Int. J. Oral MaxiIlofae. Surg. 1990; 19: 22-25.

4. N. Zachariades, M. Mezitis, A. Michelis. Posttraumatic osteotomies of the jaws. lnt. J. Oral Maxillofac. Surg. 1993," 22." 328-331.