Condylar injury: magnetic resonance imaging findings of temporomandibular joint soft-tissue changes

Temporomandibular joint degenerative changes following mandibular fracture: a computed tomography-based study on the role of condylar involvement

OBJECTIVES

This study assessed the incidence of postfracture radiological temporomandibular joint (TMJ) degeneration in patients with different types of mandibular fractures, focusing on the impact of condylar fractures.

METHODS

This retrospective review included patients diagnosed as having mandibular fractures from 2016 to 2020 who had undergone initial computed tomography (CT) and a follow-up CT scan at least 1-month postfracture. Patient demographics, fracture details, treatment methods, and radiological signs of TMJ degeneration on CT were analyzed to identify risk factors for postfracture TMJ degeneration, with a focus on condylar head fracture and non-head (condylar neck or base) fractures.

RESULTS

The study included 85 patients (mean age: 38.95 ± 17.64 years). The per-patient analysis indicated that the incidence of new radiologic TMJ degeneration on CT was significantly the highest (p < 0.001) in patients with condylar head fractures (90.91%), followed by those with non-head condylar fractures (57.14%), and those without condylar involvement (24.49%). The per-joint analysis indicated nearly inevitable degeneration (93.94%) in 33 TMJs with ipsilateral condylar head fractures. For the remaining 137 TMJs, multivariate logistic regression revealed that other patterns (ipsilateral non-head, contralateral, or both) of condylar fractures (odds ratio (OR) = 3.811, p = 0.007) and the need for open reduction and internal fixation (OR = 5.804, p = 0.005) significantly increased the risk of TMJ degeneration.

CONCLUSIONS

Ipsilateral non-head condylar fractures and contralateral condylar fractures are associated with a high risk of postfracture TMJ degeneration. Indirect trauma plays a vital role in postfracture TMJ degeneration.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute soft tissue injury to the temporomandibular joint and posttraumatic assessment after mandibular condyle fractures: a longitudinal prospective MRI study

OBJECTIVE

Evaluation of acute soft tissue injury of the temporomandibular joint (TMJ) with type I-VI fractures immediately after trauma and investigation of the longitudinal evolution including response to conservative treatment using MRI.

METHODS

The joints of 24 patients with 33 condylar fractures (15 unilateral, nine bilateral) were imaged on a 1 Tesla MR system within the first 24 h post-trauma. 12 of these patients with 16 condylar fractures (eight unilateral, four bilateral) were clinically re-evaluated using MRI after 3 months of closed treatment. The position, morphology, and signal intensities of the disc, capsule, retrodiscal tissue, and osseous structures were documented.

RESULTS

In the acute phase, disc displacements (DDs) were diagnosed in 8 out of 33 joints with fracture, including posterior DDs in two joints and tears of the inferior retrodiscal lamina in 11 joints. The follow-up MRI in 12 patients revealed new DD in four joints on the fractured side (FS) including a posterior DD and an increased degree of displacement, and new DDs in two joints in the non-fractured side (NFS).

CONCLUSION

Preexisting and traumatic DD and soft tissue injuries are frequent findings in patients with condylar fracture. Independent of the degree of trauma, condylar fractures may determine the subsequent development of DD on both FS and NFS. Early MR imaging may help initiate well-directed specific measures for better outcomes in the acutely injured TMJ.

Preauricular Swelling Mimicking a Tumour: Dissolution of Mandibular Capitulum Following Trauma in a 15-Year Old Child

AIM

The report is about diagnosis, therapy, and follow-up of a 15-year old boy, who experienced facial swelling and impaired mouth opening after a sport accident.

CASE REPORT

Diagnosis of mandibular damage was delayed due to inadequate clinical investigation and radiography after trauma and only became clear after a parotid swelling occurred sometime later resulting from the dissolution of the upper part of the articular process. Follow-up control over a period of three years showed a partial restoration of the articular process but some inhibition of mouth opening combined with slight deviation of the mandible to the affected side remained over the years.

CONCLUSION

This report reminds us that parotid swelling can be the result of mandibular trauma without a recent history of physical injury to this region. Therefore, the basic standards of radiologic diagnosis should be maintained and the limited restoring capacity of the condylar process in adolescence should be acknowledged.

Abduction of the condyle head leads to condylar resorption: A radiologic study in children with intracapsular fractures

OBJECTIVE

This study aimed to explore and make an understanding of absorption existed in children with intracapsular fractures.

METHODS

The sample was composed of all children (less than 12 years) who presented with intracapsular fractures within a 5-year period (January 2011 to April 2016). Data about age, gender, date of injury, dates of admission and discharge, transfer and/or referral by other clinics or local facilities, mechanism of trauma, location and pattern of fracture, associated injuries, centimeter of mouth opening, treatment methods, image date of pre- and post-treatment (including time of review), position of condylar head in pre-treatment or post-treatment, and absorption of condylar head in pre-treatment or post-treatment were recorded and analyzed. Data analysis included the Chi-Square test, the Fisher exact test, and the t-test. Logistic regression analysis was utilized to control the confounding variables. Probabilities of p less than 0.05 were considered statistically significantly different.

RESULTS

In the 5 years records retrieved during this study, 93 children patients sustained a total of 140 condylar head fractures. Statistical analysis revealed that abduction of condylar process in post-treatment was highly related to the condylar absorption. Patients associated with other mandibular fractures were highly related to abduction of condylar process. Patients with condylar head fractures, the closer to the medial of the condylar process, the higher the risk of abduction of the condyle. No matter what kind of treatment method is used, it is very difficult to reverse the abduction of condylar process in children patients with intracapsular fractures efficaciously.

CONCLUSION

Abduction of condylar process in post-treatment was highly related to the condylar absorption. Patients associated with other mandibular fractures were highly related to abduction of condylar process. Children patients who presented with condylar head fractures, the closer to the medial of the condylar process the higher the risk of abduction of the condyle. Neither surgery nor conservative treatment can recover the abduction of condylar process efficaciously.

Articular soft tissue injuries associated with mandibular condyle fractures and the effects on oral function

The majority of studies debating the optimization of treatment for condylar mandibular fractures focus on the bony aspect first. However, fractures of the mandibular condyle may go together with soft tissue injury of the temporomandibular joint. An electronic literature search for this topic was undertaken. Assessment of quality was carried out using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Sixteen articles were included in this review. The reviewed literature showed that intracapsular fractures and dislocated condylar fractures result in more severe injuries. Serious injury to the disc and capsule of the temporomandibular joint is a contributing factor towards development of complications after closed treatment. The results of this review give an overview of the published studies focusing on articular soft tissue injuries caused by condylar mandibular fractures. Additionally, an overview of the magnetic resonance imaging (MRI) settings used to detect these injuries is provided. Until now, the relation between soft tissue injuries and type of condylar trauma and their influence on clinical outcome has been insufficiently investigated. Before considering reduction of soft tissues next to reduction of the fracture, more research is needed into the impact of soft tissue injuries on oral functioning, in which a uniform classification is used.

Changes of disc status in adult patients with condylar head fracture who did or did not undergo disc anchoring operation

PURPOSE

Views on treatment procedures for condylar head fractures (CHFs) are far from reaching a consensus. The aim of this study was to evaluate the changes in disc status for anteromedial disc displacement with anchorage (AMDDwA) and without anchorage (AMDDwoA - just suturing to the adjacent TMJ soft tissue) in adult CHFs, to get a better understanding of this very complex process and to show that rigid disc anchorage is an essential technique for the treatment of CHF during the open reduction and internal fixation (ORIF).

PATIENTS AND METHODS

144 temporomandibular joints (TMJ) in 95 patients were included in this retrospective study, and were divided into an AMDDwA group (50 TMJs in 38 patients) and an AMDDwoA group (94 TMJs in 57 patients) based on the different surgical procedures. The joints were quantitatively and qualitatively assessed for disc length and disc morphology preoperatively and at follow-up visits. Other variables, such as disc position, joint effusion, retrodiscal tear and lateral capsular tear, were also evaluated. Paired t-tests, Wilcoxon signed rank tests, independent t-tests and χ² tests were used to assess intragroup and intergroup differences.

RESULTS

The results showed that discs became shorter, moved further forward and distorted more seriously in the AMDDwoA group. In contrast, discs became longer, maintained a normal disc-condyle relationship in the AMDDwA group. Joint effusion, retrodiscal tear, and lateral capsular tear healed well in both groups.

CONCLUSION

Taking these findings together suggests that the rigid disc anchorage is an alternative technique for the treatment of CHF.

Intraoperative arthroscopy of the TMJ during surgical management of condylar head fractures: A preliminary report

PURPOSE

The purpose of this preliminary study was to evaluate intraarticular soft tissues of the temporomandibular joint (TMJ) using intraoperative arthroscopy during open reduction and internal fixation (ORIF) of condylar head fractures (CHF).

MATERIALS AND METHODS

26 patients (29 joints) were diagnosed in period of 5 years (2011-2015) with CHF, 5 patients had concomitant mandibular fracture. Fractures were diagnosed on basis of conventional orthopantomogram (OPG) and computed tomography (CT).

RESULTS

Intraoperative arthroscopy revealed hyperemia and hypervascularity in all 29 joints, anterior disc dislocation in 26 joints, cartilage erosion in 21 joints and hemorrhagic clots were present in 10 joints. Major hemarthrosis or tear of the posterior band, as often described in MRI, could not be shown in our patients. Data from the study further the understanding of intraarticular pathology of the TMJ after acute trauma in a group with CHF.

CONCLUSION

Intraoperative arthroscopy is useful for direct evaluation and accurate diagnosis of the extent of soft tissue damage to TMJ in CHF. Larger and more long-term studies including comparison to MRI findings should be helpful to refine the treatment and postoperative management of patients after CHF.

Physiotherapy Maneuver Is Critical to Recover Mouth Opening After Pediatric Trauma

PURPOSE

A restricted mouth opening (MO) is predominantly a complication of maxillofacial trauma in pediatric patients and develops in 4 to 26.2% of cases. The purpose of the present study was to quantitatively investigate the influence of patient demographic data, fracture characteristics, and regular vigorous physiotherapy, with either voluntary or forcible MO exercises, on the recovery of a post-traumatic restricted MO in pediatric patients.

PATIENTS AND METHODS

A prospective cohort study was performed of pediatric patients with maxillofacial injuries who had been referred to Al-Zahraa and El-Fayoum Hospitals from 2013 to 2015. The predictive variables were patient demographic data, fracture characteristics, and regular vigorous physiotherapy. The patients were treated with a closed technique. The MO measurements were the clinical outcome variables and were recorded at the first week and then monthly for 12 months. Regular vigorous physiotherapy was performed until the patients had returned to their preoperative MO. The data were tabulated and statistically analyzed.

RESULTS

Eighty-six patients were enrolled in the present study. Males predominated. Falls were the most common cause of fracture. Condylar fractures had the greatest incidence. A restricted MO occurred in 81 patients. The results showed no interaction between MO recovery and age, gender, etiology, or fracture site. After physiotherapy, the patients had returned to their preoperative MO at the fourth month, with the measurements fixed at normal values at the sixth month. The recovery rate was nonlinear, with faster improvement in the months closest to the injury.

CONCLUSION

Physiotherapy is more critical in the recovery of the MO and prevention of bony ankylosis than patient data or fracture characteristics in pediatric trauma. We highly advocate the performance of voluntary mouth exercises, even in the absence of fracture. Forcible MO exercises are mandatory to recover a restricted MO. These exercises should be performed under close supervision of the patient's surgeon with the parents motivated to cooperate for at least 6 months.

Characteristics of temporomandibular joint structures after mandibular condyle fractures revealed by magnetic resonance imaging

Background

This study aimed to evaluate the structural changes of temporomandibular joint immediately after condylar fractures with magnetic resonance imaging (MRI).

Method

We evaluated 34 subjects of condylar fractures with MRI. The position, shape, and signal intensity of the condyle, disc, and retrodiscal tissue were analyzed with MR images.

Results

Immediately after trauma, the disc was displaced with the fractured segment in almost all cases. And, the changes of signal intensity at the retrodiscal tissue were found but less related to the degree of fracture displacement. And, the high signals were observed almost at all fractured joint spaces and even at some contralateral joints.

Conclusions

The displaced disc as well as the increased signal intensity of the joint space, condylar head, and retrodiscal tissue demands more attention to prevent the possible sequela of joint.

Temporomandibular Joint Disorders and Orofacial Pain

Temporomandibular disorders (TMD) affect 5% to 12% of the United States population. This article discusses common conditions related to temporomandibular joints, including disc displacements, inflammatory disturbances, loose joint bodies, traumatic disturbances, and developmental conditions. Also addressed are the appropriate imaging modalities and diagnostic criteria for TMD.

Magnetic resonance imaging evaluation of temporomandibular joint and associated soft tissue changes following acute condylar injury

PURPOSE

This study evaluated the role of magnetic resonance imaging (MRI) in cases of acute condylar injury and assessed soft tissue damage such as disc displacement, capsular tear, and hemarthrosis within the temporomandibular joint (TMJ).

PATIENTS AND METHODS

This prospective study was conducted in 15 patients who presented with unilateral or bilateral condylar fracture or contusion with a unilateral or bilateral diagnosis of TMJ sprain/strain. Patients with trauma of less than 7 days previously with a unilateral or bilateral condylar fracture or contusion with a diagnosis of TMJ sprain/strain were included in the present study. The clinical diagnosis of TMJ sprain was made and further classified and graded according to the severity and type of injury. On confirmation of the diagnosis of condylar injury, patients underwent evaluation by MRI. All patients were treated by closed reduction of the condylar fracture and intermaxillary fixation for 14 to 21 days.

RESULTS

Of the 15 patients, 5 were children and 10 were adults. Of all 17 TMJ cases (2 bilateral, 13 unilateral), 2 condylar fractures were of the high variety and 13 were of the low variety. MRI diagnosis of disc displacement was established in 8 of 17 TMJ cases. There was a significant association between degrees of condylar injury and the MRI diagnosis of displaced disc and hemarthrosis. However, an MRI finding of capsular tear was not significantly associated with the degree of condylar injury.

CONCLUSIONS

Soft tissue changes of the TMJ can be predicted accurately by MRI and are in direct proportion to the severity of the condylar injury of the mandible. Among the soft tissue changes, disc displacement and hemarthrosis seem to affect the outcome of functional treatment.

Effects of soft tissue injury to the temporomandibular joint: report of 8 cases

Our aim was to describe the effects of soft tissue injury to the temporomandibular joint (TMJ), to analyse possible reasons for it, and to evaluate the results of treatment. Eight patients (12 joints) who developed disorders of the TMJ after trauma to the mandible without fracture of the condyle were treated in our department from 2009 to 2010. Magnetic resonance imaging (MRI) and computed tomography (CT) were used to check the condition of the joint. Five patients had their joints explored to relieve pain and improve mouth opening. MRI showed all 12 joints had displaced discs. CT showed that the surface of the condylar bone was "intact" immediately after injury but destroyed later in 8 joints. Exploration showed fibrous ankylosis in 5, osteoarthritis with intra-articular adhesions in 2, and internal derangement in 1. Four were treated by costochondral graft (CCG) with 7 symptomatic joints. The disc was repositioned in 1 case with 1 affected joint. The mean maximal incision opening at follow-up were significantly better than the one before treatment (mean 34 compared with 23 mm, p=0.02). Pain in the TMJ was relieved by operation in all patients so treated. The other 3 patients (4 joints) had no treatment because their symptoms were minor and mouth opening was not restricted. Soft tissue injuries of the TMJ can potentially lead to internal derangement, osteoarthrosis, and possibly fibrous ankylosis, which should be considered during follow-up. Displacement of the disc and damage to the condylar cartilage seem to be the causes of these complications. Surgical management is effective in the short term.

Soft tissue reduction during open treatment of intracapsular condylar fracture of the temporomandibular joint: our institution's experience

PURPOSE

To evaluate the effect of soft tissue reduction during open surgery of intracapsular condylar fracture (ICF) of the temporomandibular joint (TMJ).

MATERIALS AND METHODS

A total of 129 patients (164 TMJs) with ICF were treated from June 2004 to May 2009. Osteosynthesis was performed by different methods without stripping the lateral pterygoid muscle (LPM). The disc was reduced with or without transecting adhesions, release of the epimysium of the LPM, and anchorage to the condyle. Retrodiscal tissue tear was repaired. The patients were evaluated by computed tomography, magnetic resonance imaging, and clinical signs pre- and postoperatively.

RESULTS

Inferomedial displacement of the condylar segment and disc occurred in 97.6% of cases. Adhesion of the superior joint space was found in 37 of 160 TMJs (23.1%). Retrodiscal tissue tear combined with disc displacement was found in 119 of 160 TMJs (74.4%). The condylar stump was found to be superolaterally displaced in 30.6% (49/160) and laterally dislocated out of the fossa in 41.9% (69/160). A lateral capsular tear was observed in 87 of 160 TMJs (54.4%). The condylar fragments and the discs were reduced and fixed completely with preservation of the attachment of the LPM. Coronal CT revealed that 95.6% (130/160 cases) of ICFs were correctly reduced and fixed. Postoperative magnetic resonance imaging showed that the disc was reduced to its normal position in 40 of 42 TMJs. Long-term complications of 45 patients included fibrous ankylosis in 1 case (0.8%), mouth opening limitation (<2.5 cm) in 5 cases, (3.9%), condyle resorption in 3 cases (2.3%) that needed plate removal, facial nerve injury in 3 cases (2.3%), TMJ click in 2 cases (1.6%), mouth open with deviation in 7 cases (5.4%), and malocclusion in 1 case (0.8%).

CONCLUSION

Anatomic reduction of soft tissue was of benefit for biomechanical function of the TMJ and decreased the complications of open surgery.

Maxillofacial trauma--developments, innovations and controversies

Despite seat belt and alcohol legislation, craniofacial trauma still remains a common health problem and significant workload in many maxillofacial units. Although management has evolved considerably from "wiring teeth together", complex fractures can still result in cosmetic and functional deformity. Today's challenge is to consistently restore patients back to their pre-injury form and function-but this is not always possible. Greater understanding and developments have significantly improved outcomes, although controversy still exists in some areas. This review outlines some of these topics.

Applications of cone-beam computed tomography in fractures of the maxillofacial complex

Imaging plays an essential role in the evaluation of maxillofacial fractures both pre- and postoperatively. Several studies support the use of conventional two-dimensional imaging for traumas involving mainly the mandible, but for more complex situations advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging have higher indication. Nowadays, besides CT, cone-beam computed tomography (CBCT) has appeared as a reasonable and reliable alternative considering radiation dosage, image quality and comfort for the patient. The purpose of this study was to review the fracture patterns involving the maxillofacial complex, provide a technical and practical comparison between CT and CBCT, and finally present the potential applications of CBCT illustrated with clinical examples.

MR imaging assessment of temporomandibular joint soft tissue injuries in dislocated and nondislocated mandibular condylar fractures

BACKGROUND AND PURPOSE

Evaluation of temporomandibular joint (TMJ) soft tissue injuries after condylar fractures remains a challenge with use of conventional radiography and CT. The aim of this study was to explore MR imaging in the assessment of TMJ soft tissue injuries after condylar fractures.

MATERIALS AND METHODS

Eighty subjects (118 TMJs) with condylar fractures were examined with sagittal and coronal MR imaging. Proton attenuation and T2-weighted sequences were the key sequences in our imaging protocol. All of the condylar fractures were classified into condylar fractures with dislocation (group 1, 108 TMJs) and without dislocation (group 2, 10 TMJs).

RESULTS

MR imaging demonstrated the following TMJ soft tissue injuries: 1) disk displacements (91.5%, 105 [97.2%] in group 1 and 3 [30%] in group 2; P < .01). Almost all disk displacements in group 1 were in the anteroinferior direction; 2) abnormal signal intensities of retrodiskal tissues (87.3%, 98 [88.3%] in group 1 and 5 [50%] in group 2; P < .05); 3) joint effusion (85.6%, 95 [88%] in group 1 and 6 [60%] in group 2; P > .05); 4) abnormal inferoposterior attachments of disks (87.3%, 96 [88.9%] in group 1 and 7 [70%] in group 2; P > .05) and joint capsules (85.6%, 94 [87%] in group 1 and 7 [70%] in group 2; P > .05).

CONCLUSIONS

There were significant differences of disk displacement and signal intensities of retrodiskal tissues between both fractures. Most dislocated condylar fractures were characterized with anteroinferior disk displacements along with the fractured fragments. MR imaging could provide additional information of TMJ soft tissue injuries after condylar fractures.