Mandible Condyle Fracture Consolidation by Neurophysiological Alignment of the Segments, Four Months after Unsuccessful Surgery. Case report

Fractures of the mandibular condyle are one of the most commonly occurring mandibular fractures. Management of these fractures has always been a controversial issue. One of the complications of mandibular condyle fracture is nonunion.

This case report documents a 57-year-old male patient with a complication nonunion of the left mandibular condyle 4 months after surgery and the resolution of this case with a neurophysiological alignment of the segments, without a new surgery or internal fixation.

1 AA 57 year-old male patient was referred to the clinic by his dentist. His principal complaints were lack of strength when chewing, difficulty in opening the mouth, cervical pain, pain in the TMJs and ringing in the left ear.

Past history revealed that the patient fell in the bathroom 4 months before the consultation, hitting his jaw and fracturing his mandible. He was subsequently surgically treated for fracture of the symphysis and the left mandibular condyle.

Extra oral examination did not reveal any obvious swelling. 1 BAfter performing all the clinical evaluations a panoramic radiograph was solicited where the nonunion of the left condyle was noticed.

Dental abnormalities included missing 14, 36 and 46 and a posterior open bite on the left side.

Panoramic radiograph of the patient on the day of consultation showing a nonunion of the left condyle.

Asymmetric mandibular condyles. Radiopaque image compatible with osteosynthesis wire in the lower region of condylar apophysis on the left side with bone fragment displacement.

In the region of the chin on the right, horizontal radiopaque images compatible with osteosynthesis devices for contention of the fracture of the anterior mentonian symphysis.

2 condilo inicial Magnification of the left mandibular condyle on the panoramic radiograph.

3 LAMINOGRAFIA INICIAL

TMJ laminography of the patient on the day of consultation showing the nonunion fracture of the left mandibular condyle 4 months after surgery.

A  CT was solicited to get a more accurate diagnosis.

4 CORTES DE TOMOGRAFIA INICIAISCT sagital slices confirming the total nonunion of the mandibular condyle fracture four months after surgery.        

4AA CORTES DE TOMOGRAFIA INICIAIS   CT frontal slices confirming the total nonunion of the mandibular condyle fracture four months after surgery.               5 3D da fratura  3D reconstruction showing the total  nonunion of the mandibular condyle fracture four months after surgery .        6 3D transparencia da fraturaAnother 3D reconstruction showing the total  nonunion of the mandibular condyle fracture four months after surgery .        7 A ELETROMIOGRAFI inicial  Surface electromyographic record before electronic deprogramming on the first consultation: elevated activity of the right masseter, right trapezius and right digastric at rest. All this masticatory muscles lowered after electronic deprogramming.7 B ELETROMIOGRAFIA após demaDecreased masticatory muscle activity at rest after  electronic deprogramming.7 Cc ELETROMIOGRAFIA comparativas ante e apos desprogramação Comparative rest electromyography records before and after electronic deprogramming.

Based on the case history it´s clinical and radiographic features, this case was diagnosed as nonunion fracture of the left mandibular condyle . Nonunion is a complication in mandibular fractures. The causative factors include delay in treatment, infection, inadequate immobilization, and improper internal fixation; concomitant infection may be present.

Other suspected contributory factors include failure to provide antibiotics, delay in treatment, teeth in the fracture line, alcohol and drug abuse, inexperience of the surgeon, and lack of patient compliance.

Generally treatment of nonunion consists of standard techniques of debridement, antibiotic therapy and further immobilization.1 A

We referred the patient back to the surgeon where a new surgery was proposed.

THE PATIENT ABSOLUTELY REFUSED TO HAVE A NEW SURGERY

Considering the categorical decision of not performing a new surgery the patient returned to the clinic and a conservative approach to treatment was proposed. The patient was informed about possible limitations due to his age.

Analyzing the alternatives  he accepted the clinic’s proposal.

8 REGISTRO INICIALUltra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles to record the rest position of the mandible.

That tridimentional mandible rest position was recorded in the form of a bite occlusal registration, which was later used to fabricate a Intraoral device. This is a removable mandibular appliance that in this case must be worn during day and night by the patient. This intraoral appliance, tested electromiographically and magne­tographically, support this neurophysiological position.

9 0clusão com o DIO

The patient was asked to wear the intraoral appliance full time. The dynamic evaluations improved and the patient felt no more pain, and no difficulty to chew.

During the treatment  new intraoral device in neurophysiological position was constructed.10  0clusão com o 2 DIOA second panoramic radiograph was solicited after three months. The new panoramic radiograph showed the improvement of the condyle position and finally, four months after this control a third panoramic radiograph was solicited where we can see the union of the fracture. 11 comparação de panorâmicas Comparative image of the left mandibular condyle of the first panoramic radiograph of the patient on the day of consultation (4A), second panoramic radiograph three months after (4B) and third panoramic radiograph (4C) four months after the second control showing the improvement of condyle position and the union bone.

LOOK THE UPRIGHTING OF THE WIRE FROM THE SURGERY.

11Aa comparação de panorâmicas E OCLUSÃO Comparative image of the left mandibular condyle of the first panoramic radiograph of the patient on the day of consultation (4A), second panoramic radiograph three months after (4B) and third panoramic radiograph (4C) four months after the second control showing the improvement of condyle position and the union bone.

The frontal images of the habitual occlusion on the consultation day, four and seven months after initiating the treatment are also posted.

11AB comparação de panorâmicas com inversãoLOOK THE UPRIGHTING OF THE WIRE FROM THE SURGERY.

COLOR INVERSION of the comparative image of the left mandibular condyle of the first panoramic radiograph of the patient on the day of consultation (4A), second panoramic radiograph three months after (4B) and third panoramic radiograph (4C) four months after the second control showing the improvement of condyle position and the union bone.12 CORTES DE TOMOGRAFIA FINAIS A new CT was solicited and clearly showed the union of the fracture, without submitting the patient to a new surgery and   without using any maxillomandibular fixation (MMF)  15 3D comparativas3D reconstruction showing the nonunion of the left mandibular condyle after four months surgery and the later union of the mandibular condyle after neurophysiological treatment.

Fractures where the muscles tend to draw fragments together are more favorable than those fractures where the muscles tend to draw fragments apart.

The displacement of fracture fragments is observed in mandibular condyle fractures. The most commonly observed type is the displacement of the condyle head to the anteromedial side because of lateral pterygoid muscle action.

The ability to place the mandible in a spatial relationship by measuring the masticatory muscles at their rest length can be an important auxiliary tool to assist in the recuperation of condylar fractures.

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Osteonecrosis of the Mandibular Head: recovery of condylar bone marrow alteration

I had been showing clinical cases in the page lidiayavich.com  and in several groups. Some of them with rehabilitation and with tridimensional orthodontics, always after treating the TMJ.

In this post I’m not going to show all the sequence of the patient. I have  the intention to show the improvement of the signal of the MEDULLAR OF THE CONDYLE that had presented osteonecrosis.

Anamnesis and clinical inspection are a fundamental part in the  diagnosis of the patient that presents TMJ pathology.

Images are primordial when we study any sinovial joint, unfortunately I see patients with valuable information in their images that were told that those are just occasional findings.

MRI (magnetic resonance imaging) can give a lot of information and not only the disk position information. Logically is necessary to know what to do with that information.

Osteonecrosis of the mandibular head corresponds to a death of the osseous tissue, also called avascular necrosis.

 Alteration in the bone marrow of the mandibular condyle is a possible cause of TMJ pain.

01

MRI: T 1 closed sagittal rightTMJ before treatment.

Avascular necrosis in the acute phase can be diagnosed only through MRI imaging or biopsy.

The differential diagnosis of altered signal intensity in the mandibular condyle starts with an awareness of its normal signal characteristics.

This condyle has also a severe irregularity on the superior pole, with loss of substance, but in this post I want to analyze the bone marrow signal. Of course, in a diagnosis we need to consider all the information.

-1

MRI: T1 closed sagittal rightTMJ before treatment.

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced, which may be caused by several conditions, like joint or bone injury, pressure inside the bone, medical conditions, among others.

A condyle affected by avascular necrosis displays low signal intensity on T1 weighted images as a result of edematous changes in the cancellous bone.

2

MRI: T2 closed sagital rightTMJ before treatment.

The differential diagnosis of effusions in the TMJ has a broad-spectrum as of joint effusions in other skeletal regions.

A MRI (magnetic resonance imaging) can give a lot of information and not only the disk position. In this case THE PATIENT HAS NO DISK.

2AA

The same sagittal slice of the condyle in T1 and T2. Image A shows osteonecrosis of the head of the mandible and image C shows the articular effusion.

The patient complained from severe pain in the TMJ, headache, and pain on the back of the neck.

The patient had a major trauma history in the jaw in adolescence. She had rheumatic fever in childhood.

 We referred her to a rheumatologist, and in that moment she did not present positive results for inflammatory systemic disease.

Her muscles were electronically deprogrammed and a DIO (Intraoral Device) was constructed in a neurophysiological position. In other publications we mentioned the computarized kinesiographic used methods.

2A

Comparing T1  images: A (before the treatment) and B (after the treatment): we can see the improvement and recovery of the the medullar signal. Improvement of the superior cortical of the mandibular head. 

The differential diagnosis and the systemic condition of the patient must be taken in account for the prognosis of the case.

2B Comparing T2  images: C (before the treatment) and D (after the treatment).It is clear in the first one (C) the inflammatory signal and in the other (D) the remission of the effusion.

Sem Título-1

Comparing T1 images (A and B) we can see the improvement and recovery of the  medullar signal and the superior cortical of the mandibular head. In T2 weightened images (C and D) it  is clear (in C) the inflammatory signal and in the other (in D) the remission of the effusion.

Sem Título-6

One year after the second image, a new control was solicited, and the results were even better.

In this case  I decided  NOT TO GO forward to a second phase.  Diagnosis is essential for each case.  Dentistry need to understand like Medicine do, that we have limitations and if a patient needs to live with an orthotic  it is not the end of the world.

We have patients that are going to live with insulin all their life, or with other medicines that are saving their lives or just improving their life quality.
Therefore, diagnosis is essential and for that all the tools that can help to get there are welcome.