HEAD
AND
NECK SURGERY
Therapeutic Outcomes in the Treatment of Unilateral Glenoid Fossa Fractures Using Intermaxillary Elastic Traction Shi-Jun Kuang, MD, You-Hua Zheng, MD, and Zhi-Guang Zhang, MS Introduction: This study aimed to evaluate the therapeutic outcomes of intermaxillary elastic traction in the treatment of unilateral glenoid fossa fractures. Methods: Five patients with traumatic unilateral glenoid fossa fractures were treated with intermaxillary elastic traction at the Sun Yat-Sen University Hospital of Stomatology during a 5-year period from 2006 to 2011. Pantomography and Schu¨ller position radiographs were obtained at days 7, 28, and 90 to monitor glenoid fossa fracture healing. Removal of the intermaxillary elastic traction and the arch bar splint occurred at day 90, and the patients were advised to initiate mouth-opening exercises. Results: Schu¨ller position radiographs revealed a 100% reduction rate of the glenoid fossa fracture for all patients; morphologies of the glenoid fossa and mandibular condyle were normal. Follow-up ranged from 6 months to 2 years. The occlusal relationship (degree of mouth opening) was excellent in all cases. Patient recoveries were uneventful; no complications occurred such as pain, snapping, or limitations of mouth opening. Average mouth opening was measured at 3.6 cm at the last follow-up. Conclusions: Intermaxillary elastic traction is an effective, simple, and feasible method in the treatment of a glenoid fossa fracture. Accurate reduction and stable fixation may be achieved without significant complications. Key Words: intermaxillary elastic traction, temporomandibular joint, glenoid fossa fracture, arch bar splint (Ann Plast Surg 2014;73: 295Y298)
(1) adding rubber occlusal pads (5-8 mm of appropriate thickness) to both sides of the molar area, (2) producing a strong and continuous negative pressure within the joint cavity based on the ‘‘lever principle’’ (2 equal forces acting in opposite directions), and (3) drawing the fractured segment of the glenoid fossa projecting into the cranium using a ‘‘suction effect’’ for reduction. Our group used the principle of leverage to apply downward traction on the mandibular condyle, thereby, creating negative pressure within the joint cavity which resulted in reduction of the glenoid fossa fragments via suction.10Y14 Fixation serves as the basis of fracture healing, and because no fixation was applied after reduction of the bone fragment of the glenoid fossa, early removal of the intermaxillary elastic traction inevitably resulted in secondary displacement of the glenoid fossa of incomplete bony healing due to the massive pressure conducted by the condyloid process. Therefore, the duration of intermaxillary traction in this current 3-month study was longer than the treatment period of common mandibular fracture to prevent malunion of the glenoid fossa fracture. The primary focus in the treatment of glenoid fossa fractures is to effectively restore the anatomical morphology and recover the occlusal function. To date, there have been no clinical reports regarding this treatment approach for glenoid fossa fractures in China. Therefore, we present an initial attempt to report our findings in a retrospective study in the treatment of 5 patients while using the intermaxillary elastic traction.
METHODS AND MATERIALS
A
ccording to several studies, there has been much debate and controversy regarding surgical and nonsurgical treatment protocols for glenoid fossa fractures.1Y4 Glenoid fossa fractures most commonly result from traumatic facial blows to the chin resulting from motor vehicle crashes, assaults, or contrecoup injuries.1,5 Contrecoup injuries to the chin often result in symphysis or condylar neck fractures. In contrast, glenoid fossa fractures are generally caused by a direct force and are rarely seen in clinical practice.1Y5 However, when a glenoid fossa fracture is clinically encountered, oftentimes the mandible is displaced superiorly into the middle cranial fossa.5Y9 The condyloid process, articular disc, and glenoid fossa are all important components and structures of the temporomandibular joint (TMJ) which is located at the base of the skull. They are located in a closed and confined space because of the presence of a joint capsule. Fractures to these delicate structures and bones may occur because of a forceful blow or traumatic event. Because of the relative infrequency of glenoid fossa fractures,5 our team developed a surgical treatment protocol which consisted of Received May 29, 2012, and accepted for publication, after revision, October 18, 2012. From the Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, People’s Republic of China. Conflicts of interest and sources of funding: Guangdong Provincial Science & Technology Research Grants, China (No.2009B030801200). Reprints: Zhi-Guang Zhang, MS, Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Institute of Stomatology, Sun Yat-Sen University, 56 Ling Yuan Road West, Guangzhou, Guangdong 510055, People’s Republic of China. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7303-0295 DOI: 10.1097/SAP.0b013e31827a2ebd
Annals of Plastic Surgery
Five patients, consisting of 3 males and 2 females with radiographically confirmed glenoid fossa fractures, were treated at the Sun Yat-Sen University Hospital of Stomatology between September 2006 and August 2011. The patient’s ages ranged from 21 to 32 years with an average age of 26 years. After obtaining institutional review board approval, our group devised the following clinical criteria for this study. Inclusion criteria consisted of (1) front teeth in a state of open bite (with mild to moderate limitation of mouth opening), (2) x-ray imaging confirming a glenoid fossa fracture, (3) free movement of the bone fragment into the cranium, and (4) time from the date of injury to admission less than 3 days; exclusion criteria were (1) fractures of the mandible, maxilla, or skull; (2) evidence of traumatic brain injury; or (3) a comatose patient. All 5 patients were confirmed to have unilateral glenoid fossa fractures; 2 with left-sided involvement and 3 with right-sided involvement. Violent traumatic blows to the head (consisting of traumatic impacts to the chin including falls and physical assault) were determined to be the cause of injury in all 5 cases. The time from the date of injury to admission ranged from 1 to 3 days. All patients had occlusal relationship disorders; the front teeth were in a state of open bite and there was mild to moderate limitation of mouth opening. There were no fractures of the mandible and maxilla including the condyloid process. There was no fluid outflow from the nose (rhinorrhea) or external ear canal (otorrhea). Brain computed tomography (CT) showed no evidence of significant brain injury. Our group opted to use a stainless steel arch bar splint (Hangzhou Aosu Medical Device Co, Ltd, China). Pantomography and Schu¨ller radiography (a conventional radiographic projection) were used to evaluate and delineate the temporal bone and its adjoining structures. To obtain Schu¨ller radiographs, the patients were
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traction and the arch bar splint were both removed on day 90. After removal, patients were advised to initiate mouth-opening exercises (as part of an oral rehabilitation regimen) and cautioned to abstain from excessive strength or extreme mouth opening during these exercises. Follow-up visits were carried out once every 6 months, and imaging studies, if necessary, were performed based on clinical examination findings.
RESULTS
FIGURE 1. Arch bar and occlusal pad placement.
positioned in the ventral decubitus position with the head turned laterally on the side to be examined. This positioning exposed the lining of the external auditory canal, the glenoid fossa, the anterior wall of the sigmoid sinus, and the upper border of the petrous bone. Excellent imaging of the glenoid fossa and articular tubercle, condyle, and associated joint space surrounding the TMJ was afforded. For intermaxillary elastic traction, the patient was placed in a supine position on a conventional dental treatment chair. Two arch bar splints (equidistance in length between the ipsilateral and contralateral second molars) were selected (Fig. 1). Ligation wires (0.4 mm) were applied in a manner to go through each tooth in the mandible and maxilla, and the arch bar splints were ligated to the upper and lower dental arches, respectively. Rubber occlusal pads (5Y8 mm in thickness) were placed between the first (or second) molars bilaterally then suspended on the arch bar splints in the mandible and maxilla to achieve intermaxillary elastic traction (Fig. 1). After the procedure, patients were maintained on a semiliquid (or soft) diet along with traditional Chinese medicine decoction (consisting of plant- and animal-based supplements which facilitate calcium carbonate supplementation and improved circulation) to enhance fracture healing. Patients were seen twice a week at clinic to adjust wire looseness and replace and adjust the direction of rubber bands if needed. This was done to achieve gradual reduction of the glenoid fossa fracture. Pantomography and Schu¨ller position radiographs were obtained at days 7, 28, and 90 to monitor the state of fracture reduction, fixation, and the occlusal relationship. The end point was determined to be conclusive radiographic evidence of a completely healed fracture. As bone healing typically requires a 3-month period, a 90-day traction period was carried out to ensure complete healing. Thus, the intermaxillary elastic
All 5 patients underwent intermaxillary elastic traction. Successful reduction of the glenoid fossa fractures were demonstrated by postoperative Schu¨ller position radiographs for all patients. The morphologies of the glenoid fossa, mandibular condyle, and occlusal relationship were all normal and unremarkable. After completion of mouth opening and oral rehabilitation exercises, the degree and morphology of mouth opening returned to normal. A considerable improvement in mastication was seen, as patients were now tolerating soft foods. All 5 cases resulted in no complications. Furthermore, patients were neurologically intact as no brain injuries were identified during the period of treatment. Schu¨ller position radiograph for a typical patient before receiving treatment (Fig. 2A) shows a right-sided glenoid fossa fracture and the right condyloid process embedded in the fracture gap. Six months after receiving treatment, reduction of the right-sided glenoid fossa fracture can be seen (Fig. 2B) as well as the descended condyloid process. The outlines of the glenoid fossa and condyloid process are clearly visible and the anterior joint space can be seen. Computed tomographic CT imaging (Fig. 3) of the patient before (Fig. 3A) and after (Fig. 3B) treatment can be seen, which illustrate the excellent healing of the glenoid fossa after reduction. Furthermore, CT imaging obtained at days 7 (Fig. 4A), 28 (Fig. 4B), and 90 (Fig. 4C) revealed excellent fracture healing of the glenoid fossa. At follow-up (6 months to 2 years), no ankylosis, joint snapping, occlusal disorder, or facial deformities were observed for all 5 patients. Average mouth-opening height was measured to be 3.6 cm at the last follow-up. The results were satisfactory with a total efficiency of 100%.
DISCUSSION Because of the prominent location of the mandible, fractures in different parts of the mandible are easily caused by external forces.12 A normal TMJ has an excellent positional relationship between the glenoid fossa, articular disc, and condyloid process. Surfaces of the glenoid fossa and the condyloid process are covered by cartilage and a fibrous articular disc with tremendous elasticity and are padded between the condyloid process and glenoid fossa.4 When a relatively
FIGURE 2. A, Schu¨ller position radiograph for a typical patient before receiving treatment, showing a right-sided glenoid fossa fracture and the right condyloid process embedded in the fracture gap. B, Schu¨ller position radiograph 6 months after receiving treatment; reduction of the right-sided glenoid fossa fracture can be seen as well as the descended condyloid process. The outlines of the glenoid fossa and condyloid process are clearly visible and the anterior joint space is seen. 296
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Annals of Plastic Surgery
& Volume 73, Number 3, September 2014
Treatment of Glenoid Fossa Fractures
FIGURE 3. A, Computed tomography showing right glenoid fossa fracture before initiating treatment. B, Computed tomography showing reduced and healed right glenoid fossa fracture 3 months after treatment.
mild contrecoup force acting on the chin is encountered, this energy can be conducted and transferred through the mandibular ramus to the condyloid process. Because structures of the TMJ mentioned previously are relatively good in absorbing energy, this unique ability to dissipate the force may not result in a glenoid fossa fracture, thereby acting as a protective mechanism.6 Even when relatively severe contrecoup forces acting on the chin occur, fractures of the neck of the condyloid process (or intracapsular fracture) can absorb the excessive energy, thereby preventing a glenoid fossa facture. Thus, a glenoid fossa fracture is rarely seen in clinical practice. However, because of the very weak bone quality and delicate nature of the glenoid fossa at its apex, when the energy from a blow cannot be completely absorbed by the structures previously mentioned, or fracture of the condyloid process does not occur in time, as a result, the glenoid fossa will move into the cranium.5Y9 At this point, the condyloid process loses the support from the glenoid fossa and sinks into the fractured cavity, which is clinically seen as an anterior open bite of patients. No condyloid process fractures were observed in these 5 patients; consequently, glenoid fossa fractures resulted. Additionally, the bone fragment of the glenoid fossa fracture moved into the cranium and resulted in an anterior open bite state. Therapies and treatments of fractures are to perform a compressive fixation to the fracture site after accurate reduction. This shortens the distance between fractures maximally to provide the best condition for direct fracture healing. Because the TMJ is located in the base of the skull, anatomical reduction and fixation of the glenoid fossa fracture prove to be difficult from a conventional surgical approach.1Y4 Intermaxillary elastic traction is an effective traditional technique used in treating fractures of the mandible and maxilla. In this study, 5 to 8 mm rubber occlusal pads were placed at the bilateral molar areas for intermaxillary elastic traction, and continuous elastic
traction was applied through the rubber band suspended to the arch bar splints on the mandible and maxilla, and continuous negative pressure was produced in the joint cavity based on the principle of lever. Reduction of the glenoid fossa was carried out by drawing the bone fragment protruding into the cranium using the suction effect. Because no fixation was carried out for the bone fragment after glenoid fossa reduction, early removal of the intermaxillary elastic traction may result in secondary replacement of the glenoid fossa without complete bone healing due to the excessive pressure exerted by the condyloid process. Therefore, the duration of intermaxillary traction (3 months) was longer than that of conventional treatment methods for mandibular fractures in an effort to avoid poor fracture healing of the glenoid fossa. Because preoperative measurement of mouth opening may inadvertently cause displacement of bone fragments, which certainly presents an increased difficulty in fracture reduction, no preoperative measurements were conducted. In contrast, postoperative mouth opening measurements were more readily obtainable and average mouth opening were measured to be 3.6 cm. Patients resumed a solid diet after 6 months to prevent repeated displacement of bone fragments after reduction. Fracture healing can be divided into the following 3 stages: (1) period of hematoma organization requiring approximately 3 weeks for connective fibrous growth, (2) period of bone callus formation requiring approximately 3 months for satisfying clinical criteria of fracture healing, and (3) period of bone callus remodeling requiring approximately 2 years for recanalization of bone marrow cavity and recovery of original condition. Therefore, our group used a conservative and cautious treatment approach by instituting a 3-month period of opening limitation. In 1 case, the intermaxillary traction had to be removed 1 month after traction. In this patient, Schu¨ller position radiograph was taken
FIGURE 4. A, Day-7 CT image showing right glenoid fossa fracture already reduced. B, Day-28 CT image showing no observed significant dislocation at the reduced right glenoid fossa fracture site. C, Day-90 CT image showing a well-healed right glenoid fossa fracture. * 2013 Lippincott Williams & Wilkins
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1 week later and the result showed secondary displacement of the fragment. Intermaxillary traction was performed again for this patient. Prolonged continuous intermaxillary elastic traction can achieve accurate reduction of the glenoid fossa, as well as avoid harmful interference from the condyloid process and enhance absolute fixation stability of the glenoid fossa fracture for direct bone healing. Intermaxillary elastic traction was applied for the treatment of glenoid fossa fracture to achieve reliable reduction and stable fixation. Using this technique yielded several advantages which included mild pain, lack of surgical trauma, decreased medical costs, ease of application, and excellent clinical outcomes. In contrast, a disadvantage to using this technique requires the patient to have a sufficient number of healthy molars as fulcrums and teeth with excellent periodontal condition for continuous elastic retraction. Moreover, this process requires a longer time for the limitation of mouth opening compared to the traditional intermaxillary traction. This results in several limitations to the patient such as inconvenience in eating, speaking, and maintaining oral hygiene during the course of treatment. Because of this, this technique is not suitable for children and patients with missing teeth. In conclusion, because the TMJ is delicately structured (with the glenoid fossa located at the cranial base), it is impossible to manage glenoid fossa fractures at the cranial base with traditional open reduction internal fixation approaches. Therefore, a more conservative treatment strategy should be initially attempted. Thus, our investigative team advocates that this technique should be initially attempted in the treatment protocol for managing patients with glenoid fossa fractures who have considerable oral and dental conditions because it not only can achieve excellent fracture reduction and fixation but also can recover the facial feature and occlusal relationship. This study demonstrated excellent clinical results and outcomes for patients undergoing intermaxillary elastic traction. Furthermore, we strongly encourage the use of this technique and hope it is widely adopted by other institutions and readily applied within clinical practice for the treatment of glenoid fossa fractures. Subsequent investigations may be required to further
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evaluate the use of this treatment strategy on a potentially larger cohort of patients. REFERENCES 1. Klatt J, Pohlenz P, Blessmann M, et al. Clinical follow-up examination of surgically treated fractures of the condylar process using the transparotid approach. J Oral Maxillofac Surg. 2010;68:611Y617. 2. Carneiro S, Vasconcelos B, Caldas A Jr, et al. Treatment of condylar fractures: a retrospective cohort study. Med Oral Patol Oral Cir Bucal. 2008;13:589Y594. 3. Nicholson I, Wyatt J, Radke H, et al. Treatment of caudal mandibular fracture and temporomandibular joint fracture-luxation using a bi-gnathic encircling and retaining device. Vet Comp Orthop Traumatol. 2010;23:102Y108. 4. Kyzas PA, Saeed A, Tabbenor O. The treatment of mandibular condyle fractures: a meta-analysis. J Craniomaxillofac Surg. 2012;40:438Y452. 5. Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 1: patterns of distribution of types and causes of fractures in 348 patients. Br J Oral Maxillofac Surg. 2000;38:417Y421. 6. Engevall S, Fischer K. Dislocation of the mandibular condyle into the middle cranial fossa: review of the literature and report of a case. J Oral Maxillofac Surg. 1992;50:524Y527. 7. Magge SN, Chen HI, Heuer GG, et al. Dislocation of the mandible into the middle cranial fossa. Case report. J Neurosurg. 2007;107:75Y78. 8. Barron RP, Kainulainen VT, Gusenbauer AW, et al. Fracture of glenoid fossa and traumatic dislocation of mandibular condyle into middle cranial fossa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93:640Y642. 9. Melugin MB, Indresano AT, Clemens SP. Glenoid fossa fracture and condylar penetration into the middle cranial fossa: report of a case and review of the literature. J Oral Maxillofac Surg. 1997;55:1342Y1347. 10. Xu Y, Zhang ZG, Zheng YH. Measurement and analysis of the intra-articular pressure in temporomandibular joint with sudden-onset, severe closed lock. Hua Xi Kou Qiang Yi Xue Za Zhi. 2005;23:41Y42. Chinese. 11. Zhang ZG. Intra-articular pressure measurement in TMJ of the patients with TMD and arthroscopic surgery. Zhonghua Kou Qiang Yi Xue Za Zhi. 2004; 39:168Y170. Chinese. 12. Tanaka E, van Eijden T. Biomechanical behavior of the temporomandibular joint disc. Crit Rev Oral Biol Med. 2003;14:138Y150. 13. Topouzelis N, Palaska KP. A review of the clinical applications of elastic tractions in orthodontics. World J Orthod. 2009;10:e12Ye18. 14. Stewart CM, Chaconas SJ, Caputo AA. Effects of intermaxillary elastic traction on orthodontic tooth movement. J Oral Rehabil. 1978;5:159Y166.
* 2013 Lippincott Williams & Wilkins
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AND
NECK SURGERY
Therapeutic Outcomes in the Treatment of Unilateral Glenoid Fossa Fractures Using Intermaxillary Elastic Traction Shi-Jun Kuang, MD, You-Hua Zheng, MD, and Zhi-Guang Zhang, MS Introduction: This study aimed to evaluate the therapeutic outcomes of intermaxillary elastic traction in the treatment of unilateral glenoid fossa fractures. Methods: Five patients with traumatic unilateral glenoid fossa fractures were treated with intermaxillary elastic traction at the Sun Yat-Sen University Hospital of Stomatology during a 5-year period from 2006 to 2011. Pantomography and Schu¨ller position radiographs were obtained at days 7, 28, and 90 to monitor glenoid fossa fracture healing. Removal of the intermaxillary elastic traction and the arch bar splint occurred at day 90, and the patients were advised to initiate mouth-opening exercises. Results: Schu¨ller position radiographs revealed a 100% reduction rate of the glenoid fossa fracture for all patients; morphologies of the glenoid fossa and mandibular condyle were normal. Follow-up ranged from 6 months to 2 years. The occlusal relationship (degree of mouth opening) was excellent in all cases. Patient recoveries were uneventful; no complications occurred such as pain, snapping, or limitations of mouth opening. Average mouth opening was measured at 3.6 cm at the last follow-up. Conclusions: Intermaxillary elastic traction is an effective, simple, and feasible method in the treatment of a glenoid fossa fracture. Accurate reduction and stable fixation may be achieved without significant complications. Key Words: intermaxillary elastic traction, temporomandibular joint, glenoid fossa fracture, arch bar splint (Ann Plast Surg 2014;73: 295Y298)
(1) adding rubber occlusal pads (5-8 mm of appropriate thickness) to both sides of the molar area, (2) producing a strong and continuous negative pressure within the joint cavity based on the ‘‘lever principle’’ (2 equal forces acting in opposite directions), and (3) drawing the fractured segment of the glenoid fossa projecting into the cranium using a ‘‘suction effect’’ for reduction. Our group used the principle of leverage to apply downward traction on the mandibular condyle, thereby, creating negative pressure within the joint cavity which resulted in reduction of the glenoid fossa fragments via suction.10Y14 Fixation serves as the basis of fracture healing, and because no fixation was applied after reduction of the bone fragment of the glenoid fossa, early removal of the intermaxillary elastic traction inevitably resulted in secondary displacement of the glenoid fossa of incomplete bony healing due to the massive pressure conducted by the condyloid process. Therefore, the duration of intermaxillary traction in this current 3-month study was longer than the treatment period of common mandibular fracture to prevent malunion of the glenoid fossa fracture. The primary focus in the treatment of glenoid fossa fractures is to effectively restore the anatomical morphology and recover the occlusal function. To date, there have been no clinical reports regarding this treatment approach for glenoid fossa fractures in China. Therefore, we present an initial attempt to report our findings in a retrospective study in the treatment of 5 patients while using the intermaxillary elastic traction.
METHODS AND MATERIALS
A
ccording to several studies, there has been much debate and controversy regarding surgical and nonsurgical treatment protocols for glenoid fossa fractures.1Y4 Glenoid fossa fractures most commonly result from traumatic facial blows to the chin resulting from motor vehicle crashes, assaults, or contrecoup injuries.1,5 Contrecoup injuries to the chin often result in symphysis or condylar neck fractures. In contrast, glenoid fossa fractures are generally caused by a direct force and are rarely seen in clinical practice.1Y5 However, when a glenoid fossa fracture is clinically encountered, oftentimes the mandible is displaced superiorly into the middle cranial fossa.5Y9 The condyloid process, articular disc, and glenoid fossa are all important components and structures of the temporomandibular joint (TMJ) which is located at the base of the skull. They are located in a closed and confined space because of the presence of a joint capsule. Fractures to these delicate structures and bones may occur because of a forceful blow or traumatic event. Because of the relative infrequency of glenoid fossa fractures,5 our team developed a surgical treatment protocol which consisted of Received May 29, 2012, and accepted for publication, after revision, October 18, 2012. From the Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, People’s Republic of China. Conflicts of interest and sources of funding: Guangdong Provincial Science & Technology Research Grants, China (No.2009B030801200). Reprints: Zhi-Guang Zhang, MS, Department of Oral and Maxillofacial Surgery, Guanghua School of Stomatology, Hospital of Stomatology, Institute of Stomatology, Sun Yat-Sen University, 56 Ling Yuan Road West, Guangzhou, Guangdong 510055, People’s Republic of China. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7303-0295 DOI: 10.1097/SAP.0b013e31827a2ebd
Annals of Plastic Surgery
Five patients, consisting of 3 males and 2 females with radiographically confirmed glenoid fossa fractures, were treated at the Sun Yat-Sen University Hospital of Stomatology between September 2006 and August 2011. The patient’s ages ranged from 21 to 32 years with an average age of 26 years. After obtaining institutional review board approval, our group devised the following clinical criteria for this study. Inclusion criteria consisted of (1) front teeth in a state of open bite (with mild to moderate limitation of mouth opening), (2) x-ray imaging confirming a glenoid fossa fracture, (3) free movement of the bone fragment into the cranium, and (4) time from the date of injury to admission less than 3 days; exclusion criteria were (1) fractures of the mandible, maxilla, or skull; (2) evidence of traumatic brain injury; or (3) a comatose patient. All 5 patients were confirmed to have unilateral glenoid fossa fractures; 2 with left-sided involvement and 3 with right-sided involvement. Violent traumatic blows to the head (consisting of traumatic impacts to the chin including falls and physical assault) were determined to be the cause of injury in all 5 cases. The time from the date of injury to admission ranged from 1 to 3 days. All patients had occlusal relationship disorders; the front teeth were in a state of open bite and there was mild to moderate limitation of mouth opening. There were no fractures of the mandible and maxilla including the condyloid process. There was no fluid outflow from the nose (rhinorrhea) or external ear canal (otorrhea). Brain computed tomography (CT) showed no evidence of significant brain injury. Our group opted to use a stainless steel arch bar splint (Hangzhou Aosu Medical Device Co, Ltd, China). Pantomography and Schu¨ller radiography (a conventional radiographic projection) were used to evaluate and delineate the temporal bone and its adjoining structures. To obtain Schu¨ller radiographs, the patients were
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& Volume 73, Number 3, September 2014
traction and the arch bar splint were both removed on day 90. After removal, patients were advised to initiate mouth-opening exercises (as part of an oral rehabilitation regimen) and cautioned to abstain from excessive strength or extreme mouth opening during these exercises. Follow-up visits were carried out once every 6 months, and imaging studies, if necessary, were performed based on clinical examination findings.
RESULTS
FIGURE 1. Arch bar and occlusal pad placement.
positioned in the ventral decubitus position with the head turned laterally on the side to be examined. This positioning exposed the lining of the external auditory canal, the glenoid fossa, the anterior wall of the sigmoid sinus, and the upper border of the petrous bone. Excellent imaging of the glenoid fossa and articular tubercle, condyle, and associated joint space surrounding the TMJ was afforded. For intermaxillary elastic traction, the patient was placed in a supine position on a conventional dental treatment chair. Two arch bar splints (equidistance in length between the ipsilateral and contralateral second molars) were selected (Fig. 1). Ligation wires (0.4 mm) were applied in a manner to go through each tooth in the mandible and maxilla, and the arch bar splints were ligated to the upper and lower dental arches, respectively. Rubber occlusal pads (5Y8 mm in thickness) were placed between the first (or second) molars bilaterally then suspended on the arch bar splints in the mandible and maxilla to achieve intermaxillary elastic traction (Fig. 1). After the procedure, patients were maintained on a semiliquid (or soft) diet along with traditional Chinese medicine decoction (consisting of plant- and animal-based supplements which facilitate calcium carbonate supplementation and improved circulation) to enhance fracture healing. Patients were seen twice a week at clinic to adjust wire looseness and replace and adjust the direction of rubber bands if needed. This was done to achieve gradual reduction of the glenoid fossa fracture. Pantomography and Schu¨ller position radiographs were obtained at days 7, 28, and 90 to monitor the state of fracture reduction, fixation, and the occlusal relationship. The end point was determined to be conclusive radiographic evidence of a completely healed fracture. As bone healing typically requires a 3-month period, a 90-day traction period was carried out to ensure complete healing. Thus, the intermaxillary elastic
All 5 patients underwent intermaxillary elastic traction. Successful reduction of the glenoid fossa fractures were demonstrated by postoperative Schu¨ller position radiographs for all patients. The morphologies of the glenoid fossa, mandibular condyle, and occlusal relationship were all normal and unremarkable. After completion of mouth opening and oral rehabilitation exercises, the degree and morphology of mouth opening returned to normal. A considerable improvement in mastication was seen, as patients were now tolerating soft foods. All 5 cases resulted in no complications. Furthermore, patients were neurologically intact as no brain injuries were identified during the period of treatment. Schu¨ller position radiograph for a typical patient before receiving treatment (Fig. 2A) shows a right-sided glenoid fossa fracture and the right condyloid process embedded in the fracture gap. Six months after receiving treatment, reduction of the right-sided glenoid fossa fracture can be seen (Fig. 2B) as well as the descended condyloid process. The outlines of the glenoid fossa and condyloid process are clearly visible and the anterior joint space can be seen. Computed tomographic CT imaging (Fig. 3) of the patient before (Fig. 3A) and after (Fig. 3B) treatment can be seen, which illustrate the excellent healing of the glenoid fossa after reduction. Furthermore, CT imaging obtained at days 7 (Fig. 4A), 28 (Fig. 4B), and 90 (Fig. 4C) revealed excellent fracture healing of the glenoid fossa. At follow-up (6 months to 2 years), no ankylosis, joint snapping, occlusal disorder, or facial deformities were observed for all 5 patients. Average mouth-opening height was measured to be 3.6 cm at the last follow-up. The results were satisfactory with a total efficiency of 100%.
DISCUSSION Because of the prominent location of the mandible, fractures in different parts of the mandible are easily caused by external forces.12 A normal TMJ has an excellent positional relationship between the glenoid fossa, articular disc, and condyloid process. Surfaces of the glenoid fossa and the condyloid process are covered by cartilage and a fibrous articular disc with tremendous elasticity and are padded between the condyloid process and glenoid fossa.4 When a relatively
FIGURE 2. A, Schu¨ller position radiograph for a typical patient before receiving treatment, showing a right-sided glenoid fossa fracture and the right condyloid process embedded in the fracture gap. B, Schu¨ller position radiograph 6 months after receiving treatment; reduction of the right-sided glenoid fossa fracture can be seen as well as the descended condyloid process. The outlines of the glenoid fossa and condyloid process are clearly visible and the anterior joint space is seen. 296
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Annals of Plastic Surgery
& Volume 73, Number 3, September 2014
Treatment of Glenoid Fossa Fractures
FIGURE 3. A, Computed tomography showing right glenoid fossa fracture before initiating treatment. B, Computed tomography showing reduced and healed right glenoid fossa fracture 3 months after treatment.
mild contrecoup force acting on the chin is encountered, this energy can be conducted and transferred through the mandibular ramus to the condyloid process. Because structures of the TMJ mentioned previously are relatively good in absorbing energy, this unique ability to dissipate the force may not result in a glenoid fossa fracture, thereby acting as a protective mechanism.6 Even when relatively severe contrecoup forces acting on the chin occur, fractures of the neck of the condyloid process (or intracapsular fracture) can absorb the excessive energy, thereby preventing a glenoid fossa facture. Thus, a glenoid fossa fracture is rarely seen in clinical practice. However, because of the very weak bone quality and delicate nature of the glenoid fossa at its apex, when the energy from a blow cannot be completely absorbed by the structures previously mentioned, or fracture of the condyloid process does not occur in time, as a result, the glenoid fossa will move into the cranium.5Y9 At this point, the condyloid process loses the support from the glenoid fossa and sinks into the fractured cavity, which is clinically seen as an anterior open bite of patients. No condyloid process fractures were observed in these 5 patients; consequently, glenoid fossa fractures resulted. Additionally, the bone fragment of the glenoid fossa fracture moved into the cranium and resulted in an anterior open bite state. Therapies and treatments of fractures are to perform a compressive fixation to the fracture site after accurate reduction. This shortens the distance between fractures maximally to provide the best condition for direct fracture healing. Because the TMJ is located in the base of the skull, anatomical reduction and fixation of the glenoid fossa fracture prove to be difficult from a conventional surgical approach.1Y4 Intermaxillary elastic traction is an effective traditional technique used in treating fractures of the mandible and maxilla. In this study, 5 to 8 mm rubber occlusal pads were placed at the bilateral molar areas for intermaxillary elastic traction, and continuous elastic
traction was applied through the rubber band suspended to the arch bar splints on the mandible and maxilla, and continuous negative pressure was produced in the joint cavity based on the principle of lever. Reduction of the glenoid fossa was carried out by drawing the bone fragment protruding into the cranium using the suction effect. Because no fixation was carried out for the bone fragment after glenoid fossa reduction, early removal of the intermaxillary elastic traction may result in secondary replacement of the glenoid fossa without complete bone healing due to the excessive pressure exerted by the condyloid process. Therefore, the duration of intermaxillary traction (3 months) was longer than that of conventional treatment methods for mandibular fractures in an effort to avoid poor fracture healing of the glenoid fossa. Because preoperative measurement of mouth opening may inadvertently cause displacement of bone fragments, which certainly presents an increased difficulty in fracture reduction, no preoperative measurements were conducted. In contrast, postoperative mouth opening measurements were more readily obtainable and average mouth opening were measured to be 3.6 cm. Patients resumed a solid diet after 6 months to prevent repeated displacement of bone fragments after reduction. Fracture healing can be divided into the following 3 stages: (1) period of hematoma organization requiring approximately 3 weeks for connective fibrous growth, (2) period of bone callus formation requiring approximately 3 months for satisfying clinical criteria of fracture healing, and (3) period of bone callus remodeling requiring approximately 2 years for recanalization of bone marrow cavity and recovery of original condition. Therefore, our group used a conservative and cautious treatment approach by instituting a 3-month period of opening limitation. In 1 case, the intermaxillary traction had to be removed 1 month after traction. In this patient, Schu¨ller position radiograph was taken
FIGURE 4. A, Day-7 CT image showing right glenoid fossa fracture already reduced. B, Day-28 CT image showing no observed significant dislocation at the reduced right glenoid fossa fracture site. C, Day-90 CT image showing a well-healed right glenoid fossa fracture. * 2013 Lippincott Williams & Wilkins
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1 week later and the result showed secondary displacement of the fragment. Intermaxillary traction was performed again for this patient. Prolonged continuous intermaxillary elastic traction can achieve accurate reduction of the glenoid fossa, as well as avoid harmful interference from the condyloid process and enhance absolute fixation stability of the glenoid fossa fracture for direct bone healing. Intermaxillary elastic traction was applied for the treatment of glenoid fossa fracture to achieve reliable reduction and stable fixation. Using this technique yielded several advantages which included mild pain, lack of surgical trauma, decreased medical costs, ease of application, and excellent clinical outcomes. In contrast, a disadvantage to using this technique requires the patient to have a sufficient number of healthy molars as fulcrums and teeth with excellent periodontal condition for continuous elastic retraction. Moreover, this process requires a longer time for the limitation of mouth opening compared to the traditional intermaxillary traction. This results in several limitations to the patient such as inconvenience in eating, speaking, and maintaining oral hygiene during the course of treatment. Because of this, this technique is not suitable for children and patients with missing teeth. In conclusion, because the TMJ is delicately structured (with the glenoid fossa located at the cranial base), it is impossible to manage glenoid fossa fractures at the cranial base with traditional open reduction internal fixation approaches. Therefore, a more conservative treatment strategy should be initially attempted. Thus, our investigative team advocates that this technique should be initially attempted in the treatment protocol for managing patients with glenoid fossa fractures who have considerable oral and dental conditions because it not only can achieve excellent fracture reduction and fixation but also can recover the facial feature and occlusal relationship. This study demonstrated excellent clinical results and outcomes for patients undergoing intermaxillary elastic traction. Furthermore, we strongly encourage the use of this technique and hope it is widely adopted by other institutions and readily applied within clinical practice for the treatment of glenoid fossa fractures. Subsequent investigations may be required to further
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evaluate the use of this treatment strategy on a potentially larger cohort of patients. REFERENCES 1. Klatt J, Pohlenz P, Blessmann M, et al. Clinical follow-up examination of surgically treated fractures of the condylar process using the transparotid approach. J Oral Maxillofac Surg. 2010;68:611Y617. 2. Carneiro S, Vasconcelos B, Caldas A Jr, et al. Treatment of condylar fractures: a retrospective cohort study. Med Oral Patol Oral Cir Bucal. 2008;13:589Y594. 3. Nicholson I, Wyatt J, Radke H, et al. Treatment of caudal mandibular fracture and temporomandibular joint fracture-luxation using a bi-gnathic encircling and retaining device. Vet Comp Orthop Traumatol. 2010;23:102Y108. 4. Kyzas PA, Saeed A, Tabbenor O. The treatment of mandibular condyle fractures: a meta-analysis. J Craniomaxillofac Surg. 2012;40:438Y452. 5. Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 1: patterns of distribution of types and causes of fractures in 348 patients. Br J Oral Maxillofac Surg. 2000;38:417Y421. 6. Engevall S, Fischer K. Dislocation of the mandibular condyle into the middle cranial fossa: review of the literature and report of a case. J Oral Maxillofac Surg. 1992;50:524Y527. 7. Magge SN, Chen HI, Heuer GG, et al. Dislocation of the mandible into the middle cranial fossa. Case report. J Neurosurg. 2007;107:75Y78. 8. Barron RP, Kainulainen VT, Gusenbauer AW, et al. Fracture of glenoid fossa and traumatic dislocation of mandibular condyle into middle cranial fossa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93:640Y642. 9. Melugin MB, Indresano AT, Clemens SP. Glenoid fossa fracture and condylar penetration into the middle cranial fossa: report of a case and review of the literature. J Oral Maxillofac Surg. 1997;55:1342Y1347. 10. Xu Y, Zhang ZG, Zheng YH. Measurement and analysis of the intra-articular pressure in temporomandibular joint with sudden-onset, severe closed lock. Hua Xi Kou Qiang Yi Xue Za Zhi. 2005;23:41Y42. Chinese. 11. Zhang ZG. Intra-articular pressure measurement in TMJ of the patients with TMD and arthroscopic surgery. Zhonghua Kou Qiang Yi Xue Za Zhi. 2004; 39:168Y170. Chinese. 12. Tanaka E, van Eijden T. Biomechanical behavior of the temporomandibular joint disc. Crit Rev Oral Biol Med. 2003;14:138Y150. 13. Topouzelis N, Palaska KP. A review of the clinical applications of elastic tractions in orthodontics. World J Orthod. 2009;10:e12Ye18. 14. Stewart CM, Chaconas SJ, Caputo AA. Effects of intermaxillary elastic traction on orthodontic tooth movement. J Oral Rehabil. 1978;5:159Y166.
* 2013 Lippincott Williams & Wilkins
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