Non surgical management of condylar fracture in a 12 year old patient

Introduction

Condylar fractures account for 28.2% -62% of all mandibular fractures. Pediatric condylar process fractures have gained attention in the literature, not only because of the high incidence of these traumatic injuries, but also for the possible longterm adverse effects.¹

Falls, fractures caused by sporting activities, motor vehicle accident, work-related fractures and personal violence are the main causes for these fractures. The most common etiology behind trauma in children are falls fromsports, bicycle and on steps.²

The clinical presentation can be either straight forward or less obvious. Trauma to the chin, which is the main cause, usually results in soft tissue injury (abrasion, laceration and hematoma) over the area of direct blow. There are often more chances of missed diagnosis of fracture in the condylar region, as the soft tissue injury is given more importance and it diverts the attention of both clinician and parent. Moreover, because of its closed nature, these fractures are not evident.³

Panoramic radiographs and CT scans detect the location, presence and absence of associated injuries and also the direction of displacement and the presence of condylar fractures.

Condylar fracture can result in pain, muscle spasm with restricted mandibular movement and deviation of the mandible, facial asymmetry, malocclusion, and if left untreated, result in pathological changes in the TMJ, osteonecrosis and ultimately ankylosis.⁴ Therefore, diagnosis, prompt and appropriate treatment, and follow-up over a longer period in the developing mandible is essential.

Diagnosis and management of condylar fracture has created more controversy and differences of opinion than any other fracture. In this report, the treatment of fracture of the neck of the condyle in a growing patient, has been discussed.

Case description and results

A twelve year old male child reported to the department of pediatric and preventive dentistry, Government Dental College And Research Institute, Bangalore with a history of self fall from bicycle 4 days back. His medical report revealed thatafter the fall he had lost consciousness, had ottorrrhea and vomiting. He was admitted at NIMHANS, Bangalore for observation and no fracture of the skull bones was detected and subsequently discharged. Extraoral evaluation, revealed a laceration ofthe chin associated with restriction in mandibular movement.(fig.1) Diffuse swelling was present from left preauricular region to right submandibular region. (Fig.2) On palpation child reported pain in the left auricular area. On intraoral examinationthere was anElli’s class II fracture of 31 and 32 without any derangement of occlusion. (Fig.3 & 4) These signs and symptoms pointed towards left condylar fracture. The orthopantamograph revealed a well defined oblique fracture line from the mesial slope to the distal slope of the left condyle, confirming the diagnosis.(Fig. 5)

Considering the patient’s age, the fracture being undisplaced, and the capacity for bone remodeling, functional (closed) treatment was chosen. Intermaxillary fixation using arch bars was done for two weeks and removed(delete). (Fig.6) After 2 weeks, a postoperative OPG taken showed a completely healed fracture. (Fig.7) The patient and patient’s attendant were trained to perform masticatory muscle exercises.

Discussion

Mandibular condylar neck is a comparatively weak part of the facial skeleton and is the most frequent location where fractures usually occur. When present , it can be either isolated or combined with other fractures.5 The signs which points towards the fracture can be preauricular edema on the affected side, palpation pain, jaw deviation in the mouthopening, midline deviation, muscle spasms, movement restriction, external auditory canal bleeding, trismus, altered occlusion, masticatory difficulty, protrusion, short-blunt injury or hematoma and ecchymosis in the region of mentum and compromised retrusion and laterality are the most prominent signs and symptoms of trauma associated with a mandibular condyle fracture.⁶

Condylar fractures should be addressed at the earliest to restore optimal function. Disturbance during the growth of cartilage will leads to alteration in mandibular development. It is important to restore mandibular movements at the earliest to avoid the development of facial asymmetry and to achieve potential mandibular growth, in children with unilateral condylar fracture. Surgery is not recommended in majority of pediatric patients with condylar fractures. Restoring a normal joint occlusion, symmetry and most importantly the function ,are the main focus of the treatment.⁷

In children, many fractures heals with little or no intervention. Inter-maxillary fixation with arch bars can only safely be used in patients older than 11 whose permanent dentition has been able to form adequate roots.⁸ In the present case, the child was 12 years and all the permanent teeth were erupted. So arch bars were placed from premolar to premolar for IMF in both maxillary and mandibular arches. A surgical treatment is advisable for dislocated fractures or seriously displaced fractures (for example, >55° of angulation), whereas conservative management should be considered for fractures without displacement or with reduced ramus height. The self-reconstructive ability of the condylar process and the adaptive capacity of the masticatory system make closed approach of the condylar process fracture possible.⁹

Because children have a high bone remodeling and osteogenic potential, which is achieved within three weeks, these fractures rarely do not osteointegrate. This favorsa higher rate ofsuccess of the conservative treatment for condylar process fracture in pediatric patients. Management is mainly by the use of maxillo-mandibular blockade for two weeks, when allowed, associated with liquid diet, and later with functional exercise.5 Nonsurgical management has advantage for its reduced percentage ofmorbidity, easier implementation, prevention of surgical complications, the decreased chances of ankylosis and vascular necrosis, in comparison with the open reduction with internal fixation.¹⁰

Conclusion

Condylar process fracture is one which is usually missed duringdiagnosis and it should be identified mainly on the basis of clinical signs and symptoms. With prompt diagnosis, most of the condylar fractures will often require only non invasive treatment and canbe effectively managed conservatively without any surgery