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PATTERNS AND CAUSES OF CONDYLAR FRACTURES " A STUDY.

Byline: JAMEEL KIFAYATULLAH FARRUKH JEHAN FAHAD ASLAM and TANVEER HUSSAIN BANGASH

ABSTRACT

Mandibular condyle is one of the most common site of injury of the facial skeleton. It is also the most commonly missed and least diagnosed fracture in the head and neck region. The condyle forms the very corner stone of mandibular form and function. Therefore alterations in the anatomic relationship and subsequently the function of this portion of the mandible due to its fracture may significantly change occlusion and range of motion.

The objective of this study was to evaluate the patterns and causes of condylar fractures in pa- tients seen in Maxillofacial Unit of Khyber College of Dentistry Peshawar.

Detailed history clinical and radiographic examination of 76 patients were performed. Data for causes and patterns of condylar fracture were collected. Data analysis was done on SPSS 16.0.

Out of 76 patients with condylar fractures58 (76.%) were males and 18 (2.7%) were females. The mean age was 171years with maximum number of patients belonged to the first decade of life (42.1%) followed by second decade (26.%). Most common cause of condylar fracture was Road traffic accidents (44.7%) followed by fall (40.8%) and assault (6.6%). Extracapsular fracture was found in 46.1% patients followed by subcondylar fracture in 9.5% patients and intracapsular condylar frac- tures in 1.2% patients. Condylar fracture in isolation was found in 17.1% patients while condylar fracture in combination with other facial bones was found in 82.9% patients.

Key Words: Mandibular condyle fractures facial bones road traffic accidents.

INTRODUCTION

Maxillofacial trauma affects a significant percent- age of trauma patients.1 Traumatic injury is identified as a leading cause of reduced productivity accounting for the loss of more working years than heart disease and cancer combined.2

Mandible performs an important role in mastica- tion phonetic and deglutition. It articulates at both ends with the skull by temporomandibular joint (TMJ) which is a diarthrodial joint and allows both rotational and translational movements.4 The mandible is the most commonly fractured bone of the face5 and frac- ture of the condyle process is one of the most common fractures of the mandible.6 The incidence of condylar fracture varies from 25-6 %.7 Unilateral fractures are three times more common than bilateral one.8 In adults

Road Traffic Accident (RTA) is most common cause for symphysis and condylar fracture of mandible. Other causes comprise fall and aggression. Falls are the most frequent cause of condylar fracture in children.11 Aetiology varies country wise and they can usually be attributed to cultural social environmental and economical factors.12 The prevalence of different types of condylar frac- tures is subcondylar (7.5%) intracapsular fractures (5.6%) and condylar neck fractures (26.9%).114 In children the three types of condylar fractures include intracapsular crush fractures of the condylar head and high condylar fractures through the neck above the sigmoid notch. They are most common till six years of age. The third type which is most common is a lower subcondylar fracture associated with green stick frac- ture and is usually seen in children above six years of age.

The diagnosis of condylar fracture is based on clini- cal features and appropriate radiological investigations. The clinical features include; pain and swelling in the preauricular region trismus malocclusion in the guise of premature occlusal contact on the fractured side with a slight posterior open bite on the non-fractured side an anterior open bite if there is fracture displacement of both condyles deviation on mandibular opening to the fractured side. Definitive diagnosis of condylar fractures is only possible with properradiological in- vestigations.16

The radiographs used most commonly for diagnosis of condylar fractures are orthopantogram (OPG) and posteroanterior (PA) radiogram.17 The more advanced imaging techniques such as CT- scans CBCT and MRI are usually reserved for complex injuries of the condyle where surgical intervention is likely to be considered.

Conservative management is the main stay of treatment in the vast majority of condylar fractures management.19 Closed reduction is the technique most frequently employed to treat this type of fracture inspite of all adversity of maxillomandibular fixation (MMF).

Numerous methods of open reduction and plate fixation fortreatment of condylar fracture have been developed over the years to avoid MMF.21

The condylar fracture is documented to be a leading cause of TMJ related complications such as malocclusion limitation of function disc adhesion and perforation disc derangement osteoarthritis chronic pain mandibular growth alterations and ankylosis.

In children the intracapsular compression fracture of the condyle usually leads to masticatory disability and temporomandibular joint ankylosis.

The objective of this study was to evaluate the pat- terns and causes of condylar fractures in patients seen in maxillofacial unit of Khyber College of Dentistry Peshawar.

METHODOLOGY

This descriptive cross-sectional study was done in the department of Oral and Maxillofacial Surgery Khyber College of Dentistry Peshawar from March 2012 to June 2014. Sample size of 76 patients was calculated through computer based software named Sample Size determination in health studies by WHO by Consecutive (non probability) sampling technique. (Expected Prevalence of extracapsular (condylar neck) fractures = 26.9%4 Expected error = 10% Level of confidence =95%). The inclusion criteria consisted of; (1) The patient presenting with fracture condyles due to blunt trauma including RTA fall assault sports in isolation or in combination with other maxillofacial injuries. (2) All age groups. () Both genders. The exclu- sion criteria comprised of condylar fractures resulting from penetrating trauma incidents including fire arm injuries and sharp blast injuries because these inju- ries are entirely different from blunt trauma and the fracture line is distorted in these conditions. The data were collected from patients who reported to the Maxillofacial Unit of Khyber College of Dentist- ry Peshawar with radiographically proved condylar fractures. Study protocol and use of data for research was explained to the patients and informed consent was obtained. Approval of ethical committee was tak- en. All the necessary information about the variables of the study (level/type site and fracture event) were collected by taking detailed history from the patients. Extra oral and intraoral examination was performed. In extra oral examination facial asymmetry swelling and tenderness in the pre auricular region chin abra- sion or laceration bleeding from the ears crackling sound upon palpation in auditory canals was noted. In intraoral examination occlusion (contact of upper and lower teeth) was assessed by asking the patient to close the jaws premature contact of the teeth (gag- ging) and open bite (no contact of teeth) was noted.

Any midline shift of the lower anterior teeth was also noted. The definitive diagnosis of the patterns (type/ level site fracture event) was confirmed through Or- thopantomogram (OPG) and Posteroanterior View Face (PA-Face). CT scan was done in selected cases in case of intracapsular fractures. The data were collected on specially designed proforma and were analyzed using SPSS version 16.0.

RESULTS

Out of 76 patients with condylar fractures 58 (76.%) were males and 18 (2.7%) were females. The male to female ratio was :1. The mean age was 171 years with maximum number of patients presenting in the first decade of life (42.1%) followed by second decade of life (26.%). The detail of age distribution is given in the Table 1. Most common cause of condylar fracture was Road traffic accidents (44.7%) followed by fall (40.8%) and assault (6.6%). The detail of etiology of condylar fracture is given in Fig 5.

On extraoral examination facial asymmetry was noted in 44 (57.9%) patients. Tenderness in preauricular area was noted in 6 (82.9%) patients. Chin abrasion was present in 45(59.2%) patients. Bleeding from the ear was noted in only 5(6.6%) patients. Crepitation in pre-auricular area was found in 16 patients (21.1%) (Table 2). On intraoral examination occlusion was dis- turbed in 82.9% patients. Anterior open bite was found in 47.4% patients. Posterior open bite was observed in 46.1% patients. Midline shift was found in 44.7% patients (Table ).

Extracapsular fracture was found in 46.1% patients followed by subcondylar fracture in 9.5% patients and intracapsular condylar fractures in 1.2% patients. The detail is given in Table 4. Unilateral condylar fracture was seen in 68.4% cases while bilateral condylar frac- ture was seen in 1.6% cases (Table 5).

TABLE 1: AGE DISTRIBUTION OF PATIENTS

Age###Frequency###Percentage

###1-10###32###42.1

###11-20###20###26.3

###21-30###16###21.1

###31-40###06###7.9

###41-50###01###1.3

###51.60###01###1.3

###Total###76###100

TABLE 2: EXTRAORAL CLINICAL FEATURES

Clinical###Total No. of###Affected###Percent-

features###patients###patients###age

Facial###76###44###57.9

asymmetry###

Tender-###76###63###82.9

ness

Chin###76###45###59.2

abrasio

Bleeding###76###05###6.6

from ear

Crepita-###76###16###21.4

tion

TABLE 3: INTRAORAL FEATURES

Clinical###Total No.###Affected###Percent-

features###of###patients###age

###patients

Disturbed###76###63###82.9

Anterior###76###36###47.4

ope bite

Posterior###76###35###46.1

open bite

Midline###76###34###44.7

shhift

TABLE 4: LEVEL OF MANDIBULAR CONDYLE FRACTURES

Level of###No of patients###Percentage

fracture###(n)

Extracapsular###35###46.1

fracture###

Subcondylar###30###39.5

Intracapsular###10###13.2

(condylar hear)

Extracapsular###1###1.3

and subcondy-###

lar fracture

Total###76###100.0

TABLE 5: SITE OF MANDIBULAR CONDYLAR FRACTURE

Site of###No of patients###Percent-

fracture###(n)###age

Unilateral fracture###52###68.4

Bilateral###24###31.6

Total###76###100.0

TABLE 6: FRACTURE EVENT

Site of###No of patients###Percent

fracture###(n)###age

Isolated condylar###13###17.1

fracture

In combbinaton###63###82.9

with other facial

ones

Total###76###100.0

TABLE 7: CO-EXISTING FRACTURE OF FACIAL BONES

Level of###No of patients###Percent

fracture###(n)###age

Mandible fracture###43###68.25

Midfacial and man-###13###20.6

dible fracture

Midface fracture###7###11.11

Total###63###100.0

Condylar fracture in isolation was found in 17.1% patients while condylar fracture in combination with other facial bones was found in 82.9% patients (Table 6).

Condylar fracture in combination with mandibu- lar fractures was found in 68.25% patients. Condylar fracture in association with mandible and midfacial fractures was found in 20.6% patients. Condylar frac- tures co-existing with midface fractures were found in 11.11% patients (Table 7).

DISCUSSION Mandibular condylar fractures are the most common fracture of facial bones.24 The increased incidence of condylar fractures in the current in males may be explained by the fact that males are more frequent drivers and also tend to practice more physical contacts and sports. In our setup social economic and emotional conflicts in males further increases the incidence of condylar fractures. Also boys are more boisterous than girls and spend more time outdoors. Sawazaki25 in his study also reported that males were more commonly affected than females with male to female ratio of :1.5.

In the present study the mean age of condylar fracture was 171 years. The reason explained for this is that the child is more enthusiastic to learn new skills and also more involved in outdoor activities. Also this age group is the most active careless and playing period of life therefore making them prone to injuries. Zachariades et al11 and Murad et al26 reported that children have high proportion of condylar fracture. While Sawazaki5 reported that greater prevalence of condylar fracture was found in patients aged 10-0 years.

In this study the most common cause of condylar fracture was Road traffic accident which accounted for 44.7% followed by fall 40.8%. This is because of careless driving ignorance of traffic rules no vehicle safety laws overloading of vehicles poor road infrastructure by Villareal ondylar fracture was associated with poor vehicle maintenance lack of enforcement of traffic rules poor educational status of the drivers inadequate trauma care lack of legislation and political will in our part of the world. Marker et al27 in his study of 48 patients with condylar fracture found RTA as the main cause followed by falls. While in another study by Zachariades etal11 RTA is the most common cause of condylar fracture which accounted for 57.8% of condylar fracture.

In this study neck fracture was found in 46.1% cases followed by subcondylar fracture which is 9.5% while intracapsular fracture was found in 1.2% cases. The reason is that condylar neck constitutes the weakest region in the entire mandible and is therefore more susceptible to fracture. Also as the mandible grows and develops to structurally resemble that of adult by age 7 or 8 years most fractures are extracapsular involving the condylar neck so in the neck portion it become thin and more fragile and prone to fracture whereas in children younger than 2 years of age the short stout and very vascular nature of condylar head combined with its thin cortex makes this region prone to intracapsular crush fractures. An increased percentage of condylar neck fracture (46.1%) were seen in this study because maximum number of children were in mandibular growth phase. Thoren et al28 in his study reported intracapsular fracture to be 14%.

In Lindhl studies29 condylar neck fractures presented with 19.6% cases while subcondylar fracture presented in 70.7% cases.

In our study unilateral condylar fracture was seen in 68.4% cases while bilateral condylar fracture was seen in 1.6% cases. Unilateral condylar fractures are more common as compared to bilateral condylar fractures in a study by Silvennoinen et al0 Murad et al26 Smetset al1 and Khan2 68.5% unilateral con- dylar fractures were noted while bilateral condylar fractures reported were 1.5% cases. This study is consistent with the other national and international studies when as far as the site distributionof condylar fracture is concerned.

In this study condylar fracture in isolation was found in 17.1% while condylar fracture co-existing with other facial bones is 82.9%. Condyle fracture in combination with other mandibular fracture was found in 68.25% in association with midfacial and other mandibular regions was 20.6% while condylar fracture co-existing with midface fractures was found in 11.11%. The reason of this high association with other injuries is due to elevated frequency of high energy impacts in RTA and falls. Also one of the reason may be that mandible is a U shaped bone which tends to fracture at more than one points due to an impact. In a study other parts of fractured mandible in 54.8% cases while condylar fracture co-existing with midface fracture was found to be 8.%. This finding correlates well with the finding of the present study.

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Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2014
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