Treatment of Traumatic Dislocation of the Mandibular Condyle Into The

Home , Mandibular fossa, Mandibular fracture, Skull fracture

Int. J. Oral Maxillofac. Surg. 2015; 44: 864–870

http://dx.doi.org/10.1016/j.ijom.2014.12.016, available online at http://www.sciencedirect.com

Case Report

TMJ Disorders

1 1, 1

Y. He , Y. Zhang , Z.-L. Li ,

1 2 2

J.-G. An , Z.-Q. Yi , S.-D. Bao

Treatment of traumatic 1

Department of Oral and Maxillofacial

Surgery, Peking University School and

Hospital of Stomatology, Haidian District,

dislocation of the mandibular Beijing, PR China; Department of

Neurosurgery, Peking University First

Hospital, Xicheng District, Beijing, PR China

condyle into the cranial fossa:

development of a probable

treatment algorithm

Y. He, Y. Zhang, Z.-L. Li, J.-G. An, Z.-Q. Yi, S.-D. Bao: Treatment of traumatic

dislocation of the mandibular condyle into the cranial fossa: development of a

probable treatment algorithm. Int. J. Oral Maxillofac. Surg. 2015; 44: 864–870.

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by

Abstract. This study summarizes our experience of treating three rare cases of

traumatic superior dislocation of the mandibular condyle into the cranial fossa and

provides a potential treatment algorithm. Between the years 2002 and 2012, three

patients with traumatic superior dislocation of the mandibular condyle into the

cranial fossa were admitted to our department. After evaluating the interval from

injury to treatment, the associated facial injuries including neurological

complications, and the computed tomography imaging ﬁndings, an individualized

treatment plan was developed for each patient. One patient underwent closed

reduction under general anaesthesia. Two patients underwent open reduction with

craniotomy and glenoid fossa reconstruction. All three patients were followed up for

1 year. Mouth opening and occlusal function recovered well, but all patients had

mandibular deviation during mouth opening. Closed reduction under general

anaesthesia, open surgical reduction with craniotomy, and mandibular condylotomy

Key words: mandibular condyle; superior dis-

are the three main treatment methods for traumatic superior dislocation of the

location; middle cranial fossa.

mandibular condyle into the cranial fossa. The treatment method should be selected

on the basis of the interval from injury to treatment, associated facial injuries Accepted for publication 23 December 2014

including neurological complications, and computed tomography imaging ﬁndings. Available online 7 February 2015

When the mandibular condyle collides the anatomical ‘safety mechanism’ for the certain anatomical or physiological con-

with the top of the glenoid fossa of the skull base. For this reason, the incidence ditions, the mandibular condyle may pen-

temporomandibular joint (TMJ) under rel- of mandibular condylar fracture is rela- etrate the mandibular fossa superiorly into

atively strong external force, mandibular tively high, representing 27–43% of man- the cranial fossa, and result in dislocation

1–3

condylar neck fractures often occur due to dibular fractures. However, under of the mandibular condyle into the cranial

Traumatic dislocation of the mandibular condyle 865

fossa (DMCCF). Such a situation is ex- rological complications, but other injuries had also suffered a delayed fracture of the

tremely rare. DMCCF was ﬁrst reported in may include mandibular fracture, brain mandibular body.

1963, and up until 2012, only 45 cases had concussion, brain contusion, intracranial Spiral CT was carried out for all three

been reported sporadically in the English haemorrhage, epidural haematoma, cere- patients on admission. After evaluating

language literature. The average age of brospinal ﬂuid leakage, hearing loss, ear the time interval between injury and

these patients at the time of injury was canal injury, and facial nerve injury. Neu- treatment, the associated facial injuries,

23.4 years and more than half were minors rological complications and other associ- and the CT imaging ﬁndings such as the

younger than 18 years of age. This injury ated facial injuries are important factors depth of penetration of the condyle into

is more common in female patients and the affecting the treatment strategy for the cranial fossa, we developed different

main cause is high-energy and high-speed DMCCF. treatment plans for the patients. One

trafﬁc accidents. Three procedures have been reported patient underwent closed reduction un-

4,8–23

Some special anatomical and physio- for the treatment of DMCCF : (1) der general anaesthesia and the other

logical states may help explain the mech- closed reduction under general anaesthe- two patients underwent open surgical

anism of this injury. Firstly, a small, round sia, (2) open surgical reduction with cra- reduction and glenoid reconstruction

condyle may penetrate the glenoid fossa niotomy, and (3) condylotomy. An (Table 1).

more easily than a normal, scroll-shaped individualized treatment based on the

condyle, which has been demonstrated patient’s status has been emphasized,

5 Closed reduction

experimentally by da Fonseca. Yale and many scholars recommend similar

6 4,9,21

et al. reported that 2.8% of cadavers in treatment procedures. Case 1 was a 13-year-old female patient.

their study had this kind of mandibular Between the years 2002 and 2012, three The patient had accidentally fallen on her

condyle. In addition, this morphology of patients with DMCCF were admitted to chin during exercise. After the injury she

the mandibular condyles is also found in our hospital. These three patients had in- experienced limitations of mouth opening

10-year-old children, which may explain juries with different features and received and malocclusion. The patient visited our

why this type of injury occurs most often individualized treatment. The treatment of hospital 6 h after the injury and no neuro-

in young people. Secondly, a high degree these three patients is summarized below. logical complication was found. Physical

of pneumatization of the temporal bone We also reviewed the previous literature examination showed deviation of the man-

weakens the top of the glenoid fossa and on this subject and concluded that the time dible towards the right side, 15 mm of

thereby reduces the resistance of the bone interval between injury and treatment, the mouth opening, an anterior open bite,

8,9

to impact. Thirdly, the absence of pos- associated facial injuries including neuro- and right-side premature contact of the

terior occlusion may lead to the conse- logical complications, and CT imaging posterior teeth. CT images showed a

quence that any violent force is transferred ﬁndings are the main factors affecting right-side glenoid fossa fracture and

directly to the TMJ along the ramus with- the treatment strategy. superior displacement of the right-side

out being distributed to the maxilla via the mandibular condyle into the skull

teeth. Finally, if the patient opens the (Fig. 1). The patient was undergoing or-

mouth at the time of impact to the chin, thodontic treatment.

Materials and methods

the violent force can be transferred direct- Intermaxillary elastic traction was ap-

ly to the condyle, which as mentioned During the years 2002 to 2012, three plied for 4 days, but failed. CT showed

above, lacks support from the teeth. patients with rare DMCCF were admitted incomplete intracranial displacement of

Mandibular asymmetry, limited mouth to the department of oral and maxillofacial the mandibular condyle without incar-

opening, and occlusal disorders are the surgery of our institution. All patients or ceration. After an evaluation of the situ-

main clinical features of DMCCF. These their legal guardians agreed to inclusion in ation, a timely treatment plan of closed

presentations are similar to the clinical this study and provided signed informed reduction under anaesthesia was made.

manifestations of unilateral condylar frac- consent. All three patients were females, Under general anaesthesia, the right

ture, which may lead to early-stage mis- aged 13 years, 25 years, and 22 years. One mandibular body was held manually

diagnosis and delayed treatment. Ohura patient was injured in a fall and two were and pushed downward; force was ap-

9 10

et al. and Spanio et al. reported that injured in motor vehicle accidents (MVA). plied mainly on the right lower molars.

misdiagnosis and delayed treatment occur These three patients were admitted to our After several attempts, the mandible re-

in about half of these patients. Panoramic hospital 1 day, 2 weeks, and 5 months after duction was achieved. The occlusion

and plain radiographs cannot provide de- they had sustained their injuries. The ﬁrst was recovered and then intermaxillary

tailed information for diagnosis. Comput- two patients had no neurological compli- ﬁxation was performed. Postoperative

ed tomography (CT), especially coronal cations. The third patient had a serious intermaxillary traction was applied for

CT, is the main diagnostic imaging meth- contusion of the brain at the time of the 1 month, and then mouth opening exer-

od. More than half of patients have no injury and presented to our hospital after cises were started. The patient was fol-

associated facial injuries, including neu- recovering from the contusion; this patient lowed up closely.

Table 1. Basic patient information.

Age, Cause of Interval between Neurological

Case Gender years injury injury and treatment complications Treatment

1 Female 13 Fall 1 day No Closed reduction

2 Female 25 MVA 2 weeks No Open reduction with craniotomy

3 Female 22 MVA 5 months Brain contusion Open reduction with craniotomy

MVA, motor vehicle accident.

866 He et al.

Fig. 1. Preoperative CT imaging ﬁndings of case 1. (A) Coronal CT scan: the right-side condyle displaced superiorly into the skull. (B) Sagittal CT

scan: the pneumocephalus at the fracture site.

Open surgical reduction and glenoid surgeon at the site corresponding to where ular deviation still being present. The

reconstruction the condyle penetrated the cranial cavity patient conﬁrmed that the postoperative

(Fig. 4A). An epidural dissection was occlusion was consistent with the occlu-

Case 2 was a 25-year-old female patient.

performed carefully to expose the condyle sion before injury, which suggested that

The patient had sustained a scalp contusion

inside the skull (Fig. 4B). Bone fragments the patient had mandibular deviation be-

and maxillofacial injury during a MVA.

around the mandibular condyle were re- fore the injury. Postoperative CT showed

The patient had no malignant vomiting or

moved and an intermaxillary screw was that the mandibular condyle was in the

neurological complications after the injury.

drilled into the condyle for auxiliary trac- glenoid fossa and the joint position was

The patient was admitted to our hospital 2

tion. The condyle was pushed inferiorly good (Fig. 5). Intermaxillary traction was

weeks after injury due to a limitation in

using a periosteal elevator and pulled carried out for 1 month after surgery and

mouth opening and malocclusion. Physical

down with an extracranial wire on the the patient was followed up regularly.

examination showed a right-side deviation

screw to achieve reduction of the condyle. Case 3 was a 22-year-old female who

of the mandible, 1 cm of anterior open bite,

During surgery, a partial dural tear was had suffered a serious brain injury and

and immobility of the mandible. CT exam-

observed; this was repaired using the tem- extensive skull base fracture during a

ination showed a skull base fracture in the

poral fascia tissue. Thereafter, the previ- MVA. The patient was in a coma for 2

right glenoid fossa, displacement of the

ously removed temporal bone was used to months following the injury and visited

right mandibular condyle into the skull,

reconstruct the glenoid fossa and was ﬁxed our hospital 5 months after injury due to

and incarceration at the fracture site

with a titanium miniplate. Titanium mesh malocclusion. Preoperative CT showed a

(Fig. 3). A treatment plan of open surgical

was used to repair the defect in the tem- right-side mandibular body fracture, a

reduction and simultaneous glenoid recon-

poral bone (Fig. 4C). The space between comminuted right-side glenoid fracture,

struction was made.

the glenoid fossa and the mandibular con- and DMCCF without bony adhesion be-

A pre-auricular and coronal incision

dyle was ﬁlled with the temporalis muscle tween the condyle and the skull base

was made to expose the outer surface of

and the wound was closed. (Fig. 6). The treatment plan comprised

the mandibular condyle, and a temporal

Postoperative examination showed that an open reduction with craniotomy and

bone window was made by a neuro-

the occlusion was stable despite mandib- simultaneous glenoid reconstruction.

Fig. 2. Postoperative coronal CT scans of case 1. (A) Immediately postoperative: the condyle is repositioned and the pneumocephalus remains.

(B) At 3 months postoperative: the pneumocephalus has disappeared. (C) At 1 year postoperative.

Traumatic dislocation of the mandibular condyle 867

Fig. 3. Preoperative CT images of case 2. (A) Three-dimensional reconstruction CT scan. (B) Coronal CT scan: the condyle is displaced

superiorly, deep into the skull.

A right-side pre-auricular and coronal the intracranial mandibular condyle was Results

incision was made and a neurosurgeon pushed inferiorly into the glenoid fossa,

Intermaxillary traction was performed for

assisted in the surgery. Some parts of and the reduction was achieved. The dura

all three patients for 1 month and the

the temporal bone, zygomatic arch, and was then repaired using the temporalis

patients were followed up for 1 year.

lateral bone plate of the glenoid fossa muscle. Meanwhile, reduction and ﬁxa-

Postoperative occlusion was good for all

were removed. The dura was carefully tion of the ipsilateral mandibular body

three patients, and the mouth opening

dissected to expose the displaced mandib- fracture was carried out. The temporal

ranged from 35 to 38 mm. However, all

ular condyle. The whole mandibular con- bone was trimmed, implanted into the

three patients had some degree of mandib-

dyle was observed to have penetrated the defect of the glenoid fossa and ﬁxed with

ular deviation while opening the mouth.

middle cranial fossa and there was ﬁbrous a titanium plate. Wound closure was then

For the ﬁrst case, CT scans taken im-

adhesion between it and the peripheral accomplished.

mediately after surgery showed that the

area of the glenoid fracture. After careful Postoperative CT showed a satisfactory

right mandibular condyle had been placed

dissection, the mandibular condyle was reduction of the mandibular condyle.

back into the glenoid fossa. No secondary

found to be movable. The mandibular Intermaxillary ﬁxation was maintained

intracranial haemorrhage was observed,

angle was clamped using a towel clamp for 1 month after surgery and the patient

although pneumocephalus remained

and pulled inferiorly. At the same time, was followed up regularly.

(Fig. 2A). CT scans done at 3 months after

Fig. 4. Photographs of the open reduction surgery in case 2. (A) Temporal craniotomy. (B) Exposure of the mandibular condyle dislocated into the

skull. (C) Condyle reduction, glenoid reconstruction using the temporal bone, and repair of the temporal defect using titanium mesh.

868 He et al.

Fig. 5. Postoperative CT scans of case 2 at 1 year. (A) Three-dimensional reconstruction CT scan. (B) Coronal CT scan: the condyle is

repositioned into the glenoid fossa.

surgery showed that the pneumocephalus Discussion with neurosurgeons. Open reduction can

had disappeared, the fracture at the top of be achieved when managing neurological

A review of the literature revealed three

the glenoid fossa had healed, and a new complications including intracranial hae-

methods used for the treatment of

morphology of the glenoid fossa had matoma with open surgery.

DMCCF: closed reduction under general

formed (Fig. 2B). One year after surgery, The principle of condylotomy is similar

anaesthesia, open reduction with craniot-

the orthodontic treatment was completed to that of surgical treatment of TMJ anky-

omy (with or without glenoid reconstruc-

and the occlusion was normal. The range 4,9,21 losis. This method can avoid neurological

tion), and condylotomy. All three

of mouth opening was 38 mm with a right- complications including brain injury, but

methods have their own advantages and

side mandibular deviation on mouth open- it may seriously affect joint function. This

disadvantages. Closed reduction under

ing. CT images showed that the joint method is suitable for cases with delayed

general anaesthesia does not involve open

position was stable (Fig. 2C). treatment, where there is extensive adhe-

surgery, so it is minimally invasive and

At the 1-year follow-up of the second sion between the mandibular condyle and

suitable for the early treatment of patients

case, the appearance and occlusion were the skull base.

who have no incarceration of the mandib-

the same as they had been before the Adopting an appropriate method is im-

ular condyle. However, there is the possi-

injury; the range of mouth opening was portant in the treatment of DMCCF. In a

bility of secondary intracranial 21

36 mm with a right-side mandibular devi- review of the literature, Koretsch et al.

haematoma after treatment. Such cases

ation. recommended that a deﬁnite diagnosis

should be observed closely for neurologi-

For the third case, the range of mouth should be carried out based on CT scans.

cal complications after closed reduction.

opening at 1 year after surgery was 35 mm For patients with no associated fractures,

Without reconstructing the glenoid fossa,

and the occlusion was restored, however who do not require a neurosurgical inter-

relatively long-term intermaxillary trac-

there was right-side mandibular deviation vention, and for whom an early diagnosis

tion is required after surgery.

on mouth opening. has been made, closed reduction under

Open reduction can achieve deﬁnite

general anaesthesia should be attempted

restoration of the joint position and can

after ﬁbre optic nasal intubation. CT scans

be performed simultaneously with glenoid

should be carried out immediately after

reconstruction. The recovery of joint func-

treatment to exclude secondary brain in-

tion is good. However, this method is

juries. For cases with associated facial

relatively more invasive and requires the

fractures or neurological complications,

cooperation of maxillofacial surgeons and

delays in treatment, or a failed closed

neurosurgeons. In addition, it may result in

reduction, more aggressive surgical treat-

secondary brain injury, intracranial infec-

ments such as condylotomy and open

tion, and cerebrospinal ﬂuid leakage. This

reduction should be considered. Ohura

method is suitable for cases in which 9

et al. suggested performing closed reduc-

closed reduction during early treatment

tion in young patients treated within 4

has failed and where there is deep protru-

weeks of injury, and that open reduction

sion of the mandibular condyle into the

should only be considered after closed

cranial fossa. For cases in which treatment

reduction has failed or for patients who

has been delayed for more than 4 weeks,

are receiving treatment more than 4 weeks

this method can be used if there is no bony

Fig. 6. Preoperative CT image of case 3. The after injury.

adhesion between the condyle and the

condyle has penetrated the skull, and there is The review of the literature and our

peripheral bone. Cases with neurological

no bony adhesion between it and the periph- treatment experience with the three cases

complications will require consultation

eral skull base. presented herein indicate that three factors

Traumatic dislocation of the mandibular condyle 869

affect the choice of treatment plan: (1) the emergency such as a subdural haematoma, successfully have been published since

time interval between injury and treat- the DMCCF should be treated simulta- 1995, by Barron et al., Koretsch

4 21 17

ment, (2) the presence of neurological neously. Struewer et al. reported a et al., and Harstall et al. In the ﬁrst

complications and associated facial inju- DMCCF case in which open surgery two reports, CT images showed that the

ries, and (3) CT imaging ﬁndings. was required for an associated epidural widest parts of the condyles had not en-

For patients treated early, closed reduc- haematoma; simultaneous reduction of tered the skull. In the last report by Har-

tion should be applied if there is no obvi- the mandibular condyle was carried out stall et al., the location of the condyle

ous incarceration of the condyle. Any at the time of haematoma removal and was not displayed clearly in the CT

treatment delay can add to the difﬁculty performing haemostasis. If no emergency images because the window width was

of this procedure. This view is consistent surgery is needed to address neurological chosen for soft tissues. However, no in-

with that of other scholars. However, the complications, whether other maxillofa- carceration at the basilar skull fracture

time frame distinguishing early and cial injuries require surgical treatment site was apparent. Nine reports have de-

delayed treatment is not ﬁxed, although should be taken into account. If open scribed performing open reduction or a

most scholars use 4 weeks as a reference surgery is needed, a simultaneous open mandibular condyle osteotomy for cases

9–

limit. reduction of the displaced mandibular treated within 4 weeks of injury.

21 14,16,18,22

The treatment plans for DMCCF condyle should be considered. In these cases, CT images

patients need to be established with close CT, especially coronal CT, is the ﬁrst showed that the mandibular condyles pro-

cooperation between oral–maxillofacial choice of examination to diagnose truded deep into the skull, the widest part

surgeons and neurosurgeons. Neurologi- DMCCF and to devise the treatment plan. of the condyle had entered the skull, and

cal complications and associated facial CT images should be examined to deter- closed reductions failed.

injuries are the main factors affecting mine the depth of condyle protrusion into For patients undergoing delayed treat-

decisions. In the review of Ohura et al., the cranial fossa and to identify the pres- ment, the degree of adhesion between the

they reported that more than half of 45 ence of incarceration at the site of the mandibular condyle and the associated

patients had no neurological complication glenoid fracture. For patients who are peripheral bone should be observed. Sur-

or other associated injuries, but that the undergoing early treatment, open reduc- geons should identify whether adhesioly-

remaining patients had associated injuries tion with a craniotomy may be safer and sis and reduction of the mandibular

including brain concussion, cerebral con- more effective than closed reduction if condyle can be achieved by surgery, rather

tusion, intracranial haemorrhage, epidural there is signiﬁcant incarceration of the than simply performing a mandibular con-

haematoma, cerebrospinal ﬂuid leakage, condyle at the site of the glenoid fracture. dyle osteotomy. In the third case presented

hearing loss, ear canal injury, and facial No comprehensive CT data were pro- herein, although the patient received treat-

nerve injury, and that 15 cases had man- vided in case reports before the 1990s. ment 5 months after injury, no obvious

dibular fractures at 19 sites. When open Three reports in which closed reduction adhesion was shown on CT, and an open

surgery is required to treat a neurosurgical under general anaesthesia was performed reduction was performed successfully.

Fig. 7. The treatment algorithm for patients with dislocation of the mandibular condyle into the cranial fossa.

870 He et al.

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Competing interests Kumaido K, Nakatsuka T. Dislocation of the condyle into the middle cranial fossa: report

bilateral mandibular condyle into the middle of a case, review of the literature, and a

None.

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Ethical approval

10. Spanio S, Baciliero U, Fornezza U, Pinna V, Superior dislocation of mandibular condyle

This study was approved by the ethics Toffanin A, Padula E. Intracranial disloca- into the middle cranial fossa. A case report.

committee of Peking University School tion of the mandibular condyle: report of two Int J Oral Maxillofac Surg 1997;26:29–30.

and Hospital of Stomatology (No. PKUS- cases and review of the literature. Br J Oral 23. Melugin MB, Indresano AT, Clemens SP.

SIRB-2012071). Maxillofac Surg 2002;40:253–5. Glenoid fossa fracture and condylar penetra-

11. Man C, Zhu SS, Chen S, Jiang L, Hu J. tion into the middle cranial fossa: report of a

Dislocation of the intact mandibular condyle case and review of the literature. J Oral

Patient consent

into the middle cranial fossa: a case report. Maxillofac Surg 1997;55:1342–7.

Int J Oral Maxillofac Surg 2011;40:118–20.

All patients or their legal guardians pro-

12. Taglialatela SC, Aliberti F, Scotto DCS, Address:

vided signed informed consent for publi-

Taglialatela SS, Facciuto E, Cinalli G. Dis- Yi Zhang

cation of the images.

Department of Oral and Maxillofacial

location of a fractured mandibular condyle

Surgery

into the middle cranial fossa: a case treated

Peking University School and Hospital

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