Учебники / Color atlas of temporomandibular joint surgery Quinn
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Color Atlas of Temporomandibular joint Surgery |
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A B
A, Open reduction of grossly displaced condylar fracture. Note that the condyle is at a right angle to the distal mandibular segment. The proximal fragment must be retrieved with care to prevent damage to the internal maxillary artery during repositioning. B, Figure-of-eight wiring technique to stabilize the fracture segments.
F I G S . |
6 . 4 0 , 6 . 4 1 |
Rigid fixation of condylar fracture. Note the presence of at least two screws in the distal and proximal fragments. (Fonseca RJ, Walker
RV: Oral and maxillofacial trauma, ed 2, Philadelphia, 1997, WB
Saunders.)
Rigid fixation (with a four-hole plate) of a condylar neck fracture. Note the wire at the posterior-inferior aspect of the fracture, which is used temporarily to align the fracture segments while the rigid fixation is applied. The wire may then be removed.
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Open reduction with plole fixation of displaced condylar fractures.
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The next step is the selection of a method of fixation to maintain the fracture segments in the reduced position. Some surgeons choose not to apply any fixation after reduction of the condyle. This is not advisable because the same muscular pull that caused the initial displacement or dislocation could again cause displacement of the reduced fragment.
Historically a wide variety of fixation techniques have been employed, including suture ligatures, external fixation, K wires, osteosynthesis wires, axial anchor screws, and rigid plates and screws. Because of advances in biomaterials, downsizing of hardware, and the availability of instrumentation in most operating rooms, rigid fixation with plates and screws is the most common technique. These plates afford stability in three dimensions, and placement can be accomplished through any of the surgical approaches. Percutaneous trocars have been developed to facilitate accurate screw placement in areas where access is difficult.
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A B
A, Coronal CT depicting a fragment from a previously undetected condylar fracture on the medial surface of the right condylar neck. The patient had been experiencing joint pain and a decreased range of motion. The fragment was not discernible by Panorex x-ray imaging; it appeared only by CT scanning. B, Open arthroplasty technique with distraction of condyle out of the fossa with a Wilkes' retractor to retrieve the displaced fragment.
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Fractured condyle that had been completely displaced from the glenoid fossa. Note level of fracture at the thinnest portion of the condylar neck.
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A
B
A, Coronal CT scan showing fragmentation of the condyle. B, Surgical specimen of irreparable condylar
fragments (as depicted in Fig. 6-48, A).
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A B
c |
D |
A, Right symphyseal fracture in combination with left subcondylar fracture. B, Transcranial view of condylar fracture. C, Posterior mandibular incision for rigid fixation of condylar-ramus fracture. D, Lateral skull film showing rigid fixation in place and intermaxillary fixation.
Continued
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F I G . 6 . 4 6 , C O N T ' D |
E F
G
E, Palienl 6 weeks after open reduction of condylar-ramus fracture showing excellent cosmesis with posterior mandibular approach. Preoperative (F) and postoperative (G) Panorex x-ray images showing rigid fixation and intermaxillary fixation for combination body-condylar fracture. This allows for rigid fixation of the fractures with early mobilization.
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A
Extraoral technique for complicated condylar fracture reduction with completely avulsed condylar segments in complex fracture patterns or fractures that are difficult to visualize. The rigid plate is placed on the proximal Iragment and reinserted into the wound through a posterior mandibular incision.
B
A , This fractured condyle was so grossly displaced from the fossa that it was almost completely severed from its soft tissue attachments. The superior screws were placed out of the body, and then the entire complex was inserted into its proper position from the posterior mandibular incision. This allowed better control over the final reduction and easier placement of the inferior screws. B, Postreduction anteroposterior skull film depicting proper positioning of condylar fragment.
Chapter Six Trauma
A
Various alternative techniques (or condylar fracture reduction: A, K-wire placed from inferior approach through body of posterior ramus for reduction of nondisplaced condylar fracture. B, Lag-screw-washer technique as advocated by Krenkel. (Fonseca RJ, Walker RV: Oral and maxillofacial trauma, ed 2, Philadelphia, 1997, WB Saunders.)
1 6 1
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B
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Example of the lag-screw technique for reducing condylar fractures as described by Krenkle. Note the bony channel that is drilled to allow perpendicular access to the plane of the fracture for screw placement.
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Color Atlas of Temporomandibular Joint Surgery
A
B
A, Bicoronal approach for midface and condylar trauma. The standard endaural-rhytideclomal incision can simply be extended from a bicoronal incision. B, Access to the temporomandibular joint in conjunction with a bicoronal incision. The subcondylar fracture plate is evident in the lower right. The plate in the middle portion of the photograph is on the zygomatic process of the maxilla.
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A B
c |
D |
A, B Inlracapsulor-displaced fracture segment in conjunction with ZMC fracture approached by bicoronal incision. C, D, Wilkes' retractor used in bicoronal approach to remove irreparable segment
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CONDYLAR FRACTURES IN CHILDREN
Condylar fractures in children involve mechanisms similar to those of adult injury. However, the incidence of condylar fracture among children is higher, reportedly between 4 0 % and 6 0 % . Falls from heights and bicycles are the most common causes of condylar fracture in children, with an incidence of between 3 0 % and 5 0 % of cases. Motor vehicle accidents are second in frequency ( 2 6 % to 3 4 % ) , followed by sports-related injuries (15% ) and assault ( 3 % ) . In most series, boys are affected more than girls by a ratio of 2 to 1. Carroll et al. also noted a seasonal variation in the number of fractures sustained by children; not surprisingly, the increase occurred during the summer months, when children are more active outdoors.