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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 405-409

An unusual traumatic superolateral dislocation of mandibular condyle with right parasymphysis mandibular fracture: A report of rarity


Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission10-Oct-2019
Date of Decision30-Oct-2019
Date of Acceptance30-Nov-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Akhil Sharma
Department of Oral and Maxillofacial Surgery, SPDC, Wardh, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_151_19

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  Abstract 


We describe what is to our knowledge that anteromedial fracture dislocation of the mandibular condyle is common, but a superolateral dislocation of the mandibular condyle is quite rare, this type of dislocation is often misdiagnosed or completely overlooked and hence inadequately addressed. We report a case of a 35-year-old male patient in which there was a sagittal fracture of the right condyle and the lateral fragment was hooked on the zygomatic arch with contralateral superolateral dislocation of the left condyle and right parasymphysis fracture following a road traffic accident. The present report exhibits an atypical case and highlights its management.

Keywords: Condyle, dislocation, fracture, superolateral, trauma


How to cite this article:
Sharma A, Jadhav A, Bhola N, Patil C, Trivedi R. An unusual traumatic superolateral dislocation of mandibular condyle with right parasymphysis mandibular fracture: A report of rarity. J Datta Meghe Inst Med Sci Univ 2019;14:405-9

How to cite this URL:
Sharma A, Jadhav A, Bhola N, Patil C, Trivedi R. An unusual traumatic superolateral dislocation of mandibular condyle with right parasymphysis mandibular fracture: A report of rarity. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 13];14:405-9. Available from: http://www.journaldmims.com/text.asp?2019/14/4/405/289835




  Introduction Top


Anteromedial dislocation of the mandibular condyle is a common injury, and this is mainly the result of the forces caused by the action of the lateral pterygoid muscle. However, posterior, superior, or lateral dislocations are rare.[1] We treated a patient who had a superolateral dislocation with a sagittal fracture of the mandibular condyle of the right side and associated with right mandibular parasymphysis fracture. This case report highlights the importance of paying particular attention to such associated condylar morbidity in patients with a mandible fracture.


  Case Report Top


A 35-year-old male patient was involved in a motorcycle crash and sustained a direct blow to his jaw on November 19, 2018. A patient gives a history of two episodes of vomiting. Vomitus was mainly having gastric content and bleeding from both the ears. Routine hematological investigations were within normal limits. Chest X-ray was also normal. He was alert, and condylar movement could not be elicited. He was alert and condylar movement could not be elicited with restricted inter incisal mouth opening (approximately 5mm). In addition, a single, tender, bony hard tender swelling in the preauricular region bilaterally was found. Gross occlusal discrepancy with anterior open bite and posterior gagging of occlusion associated with remarkable crossbite was present. Facial palsy was noted over the left side [Figure 1]. Radiologic examination including panoramic radiograph and computed tomography (CT) scans confirmed the right mandibular parasymphysis with condylar heads were displaced laterally away from the glenoid fossa with superolateral dislocation of condyle (Type IIB) hooked above the zygomatic arch on the left side [Figure 2] with a sagittal fracture of the mandibular condyle of the right side and associated with right mandibular parasymphysis fracture [Figure 3]. The patient was then given muscle relaxants before an indirect reduction under general anesthesia. Direct reduction through a preauricular incision was planned in case this failed.
Figure 1: Pre-op frontal photograph demonstrating left side facial nerve weakness

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Figure 2: Pre-op CT coronal view depicting type IIB superiolateral dislocation of left condyle

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Figure 3: Pre-op CT 3D reconstruction view showing bilateral condyle dislocation

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After nasoendotracheal intubation under general anesthesia, the displaced condyles were successfully returned to the glenoid fossa by manual reduction with the application of external force. After repositioning the condyles into the normal position, the parasymphyseal fracture was reduced and fixed using 2.5 mm and 2.0 mm A-O reconstruction plates (Synthes, Oberdorf, Switzerland) through intraoral approach [Figure 4], and a full range of mandibular movement was regained intraoperatively with diminished bilateral preauricular prominences. Intermaxillary elastics have applied the keep the jaw immobilized, and the patient was extubated and discharged 3 days later. The elastics were kept on for 3 weeks.
Figure 4: Post-op CT 3D reconstruction view showing condyle sited in glenoid fossa

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The postoperative clinical course was uneventful. Intermaxillary fixation was removed after 3 weeks of surgery, and the patient was instructed to commence postoperative rehabilitation exercises. The postoperative interincisal distance was about 38 mm [Figure 5] and more than 8-mm bilateral lateral excursion was maintained with a relatively good occlusion and no painful movement of the mouth. The patient was discharged with almost normal mandibular movement and facial contour of the patient after reduction of the mandibular condyle was satisfactory. The patient was advised for active jaw physiotherapy and was followed up.
Figure 5: Post-op interincisal mouth opening

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  Discussion Top


Biomechanics of traumatic injuries to slender condylar neck is such that whenever a high impact force is exerted over the condylar region, the condylar neck fractures before condyles dislocates or displaces into the middle cranial fossa. Superolateral dislocation of mandibular condyle (SLDMC) has commonly been reported in the younger age group with male predominance and the most common etiology was road traffic accidents followed by fall.[2] We believed that believe that four factors determine the type of dislocation: The anatomy of the condylar head, capsule of the temporomandibular joint (TMJ), pterygoid and masseter muscles, and elasticity of the anterior mandible. Medial pulling of the pterygoid muscles during impact on the face may partly contribute to the rarity of condylar lateral displacement.[3]

Allen and Young[1] classified lateral dislocations of the mandibular condyle into Type I (lateral subluxation) and Type II (complete dislocation), in which the condyle is forced laterally and then superiorly. Satoh et al.,[4] further subclassified Type II dislocations into Type IIA (where the condyle is not hooked above the zygomatic arch); Type IIB (where the condyle is hooked above the zygomatic arch); and Type IIC (where the condyle is lodged inside the zygomatic arch, which is fractured). Our patient fits the criteria of Type IIB. Tauro et al.[5] proposed a change in existing classification for SLDMC in which Type II is complete dislocation with an associated fracture of the anterior mandible, and Type III is complete dislocation without an associated fracture of the anterior mandible.

In a partially open mouth position, the pterygomasseteric sling will provide a minimal splinting effect, which facilitates lateral dislocation of the condyle. We postulated either in our case that during this fall, the patient was frightened and suddenly opened his jaw to scream or from fright. The force of the impact displaced the condyles anterior to the articular eminence, rupturing the capsular and ligamentous attachments to the condylar head, and drove the condyles upward anterior to the eminence, lateral to the zygomatic arches, and lateral to the temporalis muscle and fascia into the temporal fossa.

Tauro et al.[5] suggested that more than one impact is necessary for a superolateral dislocation to occur, as the first impact would fracture the anterior mandible, and the subsequent impact would force the condyle out of the glenoid fossa superolateral. Worthington[6] suggested a mechanism for such a dislocation, stating that two obstacles need to be overcome to achieve such a condition. First, the soft-tissue attachments around the condyle must rupture. Second, the transverse dimension of the condylar head (from lateral pole to medial pole) must exceed the lateral dimensions of the space between the zygomatic arch and the medial bony wall of the temporal fossa. In order for the condylar head to pass this obstacle, it is necessary for at least one of the following three things to happen: the zygomatic arch may fracture, affording more room for the condyle to pass; the condylar head may fracture, decreasing the bulk; the condyle head may rotate about a vertical axis, which would be likely to occur only in association with a mandibular fracture disposed to facilitate rotation of the ramus. Rattan[7] also stressed that, for cases with lateral dislocation of the mandibular condyle, the impact would be always toward the side of the chin and there would be an associated fracture in the symphyseal or body region, usually on the contralateral side.

Due to its rarity, these types of dislocation may be misdiagnosed as condylar fractures or completely overlooked. Worthington[6] described the diagnostic features of this type of dislocation as follows: malocclusion persisting after the jaw fracture was reduced, the persistence of an open bite, persistent restriction of mandibular movement, an apparent loss of ramus height with an elevation of the ramus fragment, and facial asymmetry. The diagnosis can be proved by radiography and CT scans, in particular by three-dimensional CT. Three-dimensional CT scans can demonstrate the dislocated condyle, dislocation type, and whether or not there is a fracture. It is very effective and useful in the diagnosis of this type of dislocation. Besides, magnetic resonance imaging (MRI) is the method of choice for diagnosing TMJ disc position. If necessary, MRI and MR arthrography can be used preoperatively for identifying both soft tissue and joint space abnormalities of the TMJ.[8] Routine postoperative MRI is recommended to describe the internal disk structure as well as to detect any deformity of the disks.[9] If internal derangements of the joint exist, arthroscopy seems to be a safe, minimally invasive, and effective tool for diagnosis and treatment, with reduced pain and increased mandibular range of motion.[10] However, open arthrotomy is required if there is anterior disc displacement after reduction, extensive intra-articular fibrosis, and failed arthroscopy.[11]

One of the most critical factors determining the success of the treatment is the time between injury and reduction. Delay in the reduction induces fibrosis of the glenoid fossa, resulting in imperfect or unsuccessful reduction. The presence of the fibrous tissue may make closed reduction impossible. If diagnosis and treatment in this type of dislocation is delayed, lateral dislocation has a high incidence of unsatisfactory results and imperfect reduction.[12]

The goal of treatment of any dislocation is the return of the condyle to its original physiologic position, and the first choice of treatment for SLDMC should be closed/manual reduction because it is simplest, least traumatic, and safest.[13] Owing to the difficulty of the procedure and patient comfort, this is best done under general anesthesia. Attempts to reduce manually by grasping each side of the mandible by placing one's thumbs over the posterior teeth and remaining fingers on the inferior border of the mandible may be tried first. Failure to reduce the dislocation means alternatives have to be considered. Nonsurgical methods such as traction wire placed at the angle of the mandible[12] or mouth props – functioning as fulcrum placed in the molar region[3] have been previously used. The following factors may be useful to predict the difficulty of closed reduction: (1) the delay before definitive treatment. If the delay is more than 2 weeks, a satisfactory result with closed reduction is less likely, (2) the type of dislocation. Cases in which the condyle is lodged within the zygomatic arch (Type IIC) or the condyle is hooked above the zygomatic arch (Type IIB) are more likely to require open reduction than the other types (Type I and Type IIA), (3) the presence of an associated mandibular fracture, and (4) the age of the patient. Those cases not responding to closed reduction will require open reduction.

It is advisable to record the facial nerve condition of the patient before performing the open reduction because the extrapetrosal peripheral segment of the facial nerve is so near the mandibular ramus, the nerve may be affected by injuries involving fractures of the ramus (especially of the condylar process) or by injuries causing severe dislocation without actual fracture of the ramus.

Those cases not responding to open reduction methods eventually require a condylectomy.[14],[15],[16],[17],[18],[19],[20],[21],[22] Postoperative mandibulomaxillary fixation (MMF) is necessary irrespective of the type of reduction method used The duration of MMF will vary depending on the delay in treatment and the presence of associated fractures of the mandible. The duration of MMF, this varied from 1 week to 5 weeks. The reduced condyle tends to return to the preoperative position. Besides, immobilization facilitates the healing of the presumably damaged ligaments. The patient should receive mouth-opening training to prevent fibrosis from developing.

The prognosis of treatment depends on regular follow-up and rigorous physiotherapy exercises in the post-MMF period. Early treatment and a successful reduction will usually provide adequate mouth opening, as well as a lateral excursion.


  Conclusion Top


SLDMC is easily diagnosed based on clinical findings and the use of CT scans. The reduction should be attempted as soon as the diagnosis is made, and the importance of a long follow-up and physiotherapy should not be underestimated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Allen FJ, Young AH. Lateral displacement of the intact mandibular condyle. A report of five cases. Br J Oral Surg 1969;7:24-30.  Back to cited text no. 1
    
2.
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Hsieh CH, Chen CT, Tsai HH, Lai JP. Lateral dislocation of bilateral intact mandibular condyles with symphysis fracture: A case report. J Trauma 2007;62:1518-21.  Back to cited text no. 3
    
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Tauro D, Lakshmi S, Mishra M. Superolateral dislocation of the mandibular condyle: Report of a case with review of literature and a proposed modification in the classification. Craniomaxillofac Trauma Reconstr 2010;3:119-23.  Back to cited text no. 5
    
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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