Annals of Plastic and Reconstructive Surgery Case Report

Published: 10 Aug, 2019

A Novel Technique to Treat Traumatic Lateral

Displacement of Condyle of the Mandible by Using a
Fabricated Titanium Cage
Anantheswar Rao YN*, Ashok B Chandrappa, Srikanth Vasudevan, Sudarshan N Reddy and
Ritu Batt
Department of Plastic, Micro, Cosmetic & Cranio-facial Surgery, Manipal Hospital, Old Airport Road, India

Abstract
Lateral displacement of condyle of the mandible is a rare, debilitating condition. It is most often
associated with trauma and its management is challenging. We discuss a new technique to handle
lateral displacement of mandibular condyle by using a titanium cage that we fabricated and obtained
a good final outcome.
Keywords: Condylar dislocation; Pan facial fracture; TMJ; Lateral displacement; Fabricated
titanium cage

Introduction
The main purpose of management of facial bone fractures is restoration of near normal
skeletal framework with optimum function. The important requirements for these are, an accurate
anatomical reduction of fracture/dislocated segments, and retention of these segments in alignment
by osteosynthesis. Failure to address these problems results in malunion and suboptimal functional
outcome.
OPEN ACCESS The Temporomandibular Joint (TMJ) is a sliding hinged type of joint between the mandible
and temporal bone of the skull. The condyle of the mandible articulates bilaterally in a concavity
*Correspondence:
known as the glenoid fossa. The mandible can dislocate in the anterior, posterior, lateral, or superior
Anantheswar Rao YN, Department
directions following trauma [1]. Anterior dislocation is the commonest while lateral dislocation
of Plastic Surgery, Manipal Hospital,
is rare and usually associated with mandibular fractures. Condylar and subcondylar fractures
97, Rustombagh, Old Airport Road,
constitute 26% to 40% of all mandible fractures [2]. The condylar head migrates laterally and
Bangalore, 560017, Karnataka, India,
superiorly and can often be palpated in the temporal fossa whenever there is a severe impaction
Tel: 080-25266646- 4350; E-mail:
trauma to the skull base [3,7].
[email protected]
Received Date: 22 Jul 2019 Treatment options for condylar fracture dislocation have changed from a conservative approach
Accepted Date: 05 Aug 2019 towards surgical treatment. Once anatomical reduction is achieved with good osteosynthesis, early
Published Date: 10 Aug 2019 mobilization within three weeks is imperative for functional recovery of the jaw and to prevent
Citation: stiffness. Rigid fixation of the condylar fracture prevents lateral displacement.
Anantheswar Rao YN, Chandrappa Enormous strides have been made in development of osteosynthesis techniques. The ideal
AB, Vasudevan S, Reddy SN, Batt R. implant material to achieve osteosynthesis should be biocompatible, easy for structural adaptation
A Novel Technique to Treat Traumatic and fix the fracture segments in a stable fashion. Various studies have shown that, titanium is the
Lateral Displacement of Condyle of most suitable implant material [4,5].
the Mandible by Using a Fabricated
Titanium Cage. Ann Plast Reconstr Case Presentation
Surg. 2019; 3(3): 1036. A 33 year old gentleman Mr. R.M was initially managed at a district hospital with an alleged
Copyright © 2019 Anantheswar history of road traffic accident. Previous records showed that the patient had a traumatic brain injury.
Rao YN. This is an open access CT face showed nasal bone fracture, bilateral Le Fort II maxillary fractures, right parasymphyseal
article distributed under the Creative fracture mandible and left condyle dislocation (Figure 1-3). After initial stabilization and
Commons Attribution License, which tracheostomy, patient was taken up for Open Reduction and Internal Fixation (ORIF) of facial
permits unrestricted use, distribution, bone fractures by Inter Maxillary Fixation screws (IMF) for achieving preliminary occlusion and
and reproduction in any medium, titanium miniplates and minis crews for osteosynthesis. Owing to the condylar dislocation on left
provided the original work is properly side, conservative management was carried out initially. Rubber bands were applied on the first
cited. postoperative day to maintain proper occlusion and continued for two weeks (Figure 4).

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Anantheswar Rao YN, et al., Annals of Plastic and Reconstructive Surgery

Figure 4: Post ORIF CT.

Figure 1: Pre-op CT (Frontal).

Figure 5: Pre-auricular approach.

Figure 2: Lateral dislocation of condyle.

Figure 6: Laterally dislocated condyle with ligament disruption.

Figure 3: Pre-op CT (Lateral).

Figure 7: Fabricated Titanium cage.
When the patient consulted our unit after a span of three weeks
from the time of initial surgery, he had an anterior open bite. Repeat 3.5 cm, was shaped into a rectangular trough shaped box with folded
CT scan showed persistent lateral condylar dislocation of left TMJ. anterior and posterior pillars. It was assumed that this cage which
In view of this, patient was once again taken up for open reduction was open only medially and closed in other directions would prevent
and internal fixation, utilizing pre-auricular approach (Figure 5). On further dislocation of TMJ out of the socket laterally, anteriorly and
exploration, the condyle was unstable and after successful reduction, posteriorly (Figure 8).
it was getting repeatedly dislocated laterally from the glenoid fossa.
The fracture was reduced anatomically and retained in position by
We were not able to achieve good occlusion, because of ligament us
use of our titanium cage. The upper border of the fabricated titanium
disruption, especially on the lateral side of TMJ, which was preventing
cage was fixed to the zygomatic arch with two titanium mini screws
a satisfactory anatomical reduction and retention of fracture segments
of 1.5 mm × 6 mm, to prevent any dislocation of reduced fragments
in the glenoid fossa (Figure 6).
anteriorly, laterally and posteriorly (Figure 9).
At this juncture, we decided to fabricate a titanium cage (Figure
Post operatively, rubber bands continued for two weeks. We
7). A rectangular piece of titanium mesh, measuring about 1.5 cm ×
achieved a good occlusion, without TMJ dislocation, by this ingenious

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Anantheswar Rao YN, et al., Annals of Plastic and Reconstructive Surgery

Figure 8: End on view of the cage.

Figure 11: Post-op occlusion.

Figure 9: Positioning & fixation of the cage.

Figure 12: Post-op CT showing cage in position.

Figure 10: Post-op mouth opening.

method. In addition, there was complete range of movements at TMJ

level (Figure 10 and 11). Repeat CT at the end of three months showed
excellent position of the condyle, TM joint and protective positioning
of the titanium cage (Figure 12 and 13).
Discussion Figure 13: Posterior view showing excellent condylar position.

The Temporomandibular Joint (TMJ) is a sliding hinge joint. include malocclusion, internal derangement of TM joint, traumatic
During mandibular movements, the left and right joints move arthritis, ankylosis of TMJ, growth disorder and facial asymmetry
synchronously with each other and in association with dental [8,9].
occlusion.
Different modalities of treatment are in use for lateral displacement
Temporomandibular joint dislocation is the dislodgement of the of TMJ. Conservative management includes closed reduction with
head of the condyle from its socket which can be partial or complete intermaxillary fixation using arch brand wire or rubber bands for 2 to
[6]. Dislocation can be anterior, superior, medial, lateral or posterior. 4 weeks. Surgical methods are indicated in those cases where patients
Anterior dislocations usually happen when the mouth closes from have not responded well to conservative methods [10].
extreme opening like yawning coupled with weakened per joint
fibrous capsule. Posterior dislocations typically result due to a direct The main surgical indication for adults is a dislocated condyle with
blow to the chin. Superior dislocations can occur from a direct blow or without associated fracture especially, if it is bilateral, as it becomes
when the mouth is slightly open. Medial dislocations are rare. difficult to bring in satisfactory anatomical reduction and alignment
through conservative treatment [11]. In 1933, Mayer described that
Complications of untreated mandibular condyle dislocations surgically created downward displacement of the zygomatic arch by

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Anantheswar Rao YN, et al., Annals of Plastic and Reconstructive Surgery

aligned osteoto my prevents further dislocation by obstructing the Hence, we strongly recommend this handy new technique, in
anteroinferior movement of condyle [11,12]. indicated patients.
LeClerc and Girard [12] performed a vertical osteotomy of the References
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complete range of movements of the TMJ and also addresses common
problems like postoperative jaw stiffness and TMJ ankylosis.

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