Traumatic Dislocation of the Mandibular Condyle Into the Middle Cranial Fossa Treated with Immediate Reconstruction: a Case Report Joseph E

CILLO, SINN, AND ELLIS 859

grafting in a patient with AIDS, acute myocardial infarction, fection and acquired immunodeficiency syndrome. Am J Surg and severe left main coronary artery disease. J Cardiovasc Surg 180:228, 2000 44:55, 2003 18. James J, Hofland HW, Borgstein ES, et al: The prevalence of HIV 15. van Marle J, Tudhope L, Weir G, et al: Vascular disease in infection among burn patients in a burns unit in Malawi and its HIV/AIDS patients. S Afr Med J 92:974, 2002 influence on outcome. Burns 29:55, 2003 16. Chambers AJ, Lord RS: Incidence of acquired immune defi- 19. Patton LL, Shugars DA, Bonito AJ: A systematic review of ciency syndrome (AIDS)-related disorders at laparatomy in pa- complication risks for HIV-positive patients undergoing inva- tients with AIDS. Br J Surg 88:294, 2001 sive dental procedures. J Am Dent Assoc 133:195, 2002 17. Tran HS, Moncure M, Tarnoff M, et al: Predictors of operative 20. Diz Dios P, Fernandez Feijoo J, Vazquez Garcia E: Tooth ex- outcome in patients with human immunodeficiency virus in- traction in HIV sero-positive patients. Int Dent J 49:317, 1999

J Oral Maxillofac Surg 63:859-865, 2005 Traumatic Dislocation of the Mandibular Condyle into the Middle Cranial Fossa Treated With Immediate Reconstruction: A Case Report Joseph E. Cillo, Jr, DMD,* Douglas P. Sinn, DDS,† and Edward Ellis III, DDS, MS‡

While fractures of the mandible condylar process are his chief complaints were right-sided jaw pain, limited common, accounting for 29% to 40% of mandibular mouth opening, and malocclusion with an anterior open trauma,1 dislocation of the mandibular condyle through bite. Physical exam revealed chin deviation to the right (Fig the glenoid fossa and into the middle cranial fossa is rare. 1A), limited mouth opening (Fig 1B), malocclusion, right Less than 45 known cases have been reported in the preauricular tenderness to palpation, and a luxated maxil- literature.2 This report documents another occurrence lary right central incisor. There were no signs of hemo- of this rare event with its treatment and immediate typani or cerebrospinal ﬂuid otorrhea. reconstruction of the glenoid fossa with a cranial bone Plain radiographs (Fig 2) and computed tomography scans (Fig 3) revealed a superiorly displaced right mandib- graft. ular condyle in the middle cranial fossa. Immediate consultation with the Neurosurgical and Oral and Maxillofacial surgery teams was initiated and the patient taken to the Report of a Case operating room for treatment. Following induction of general anesthesia and nasotra- A 7-year-old boy reported to an outside hospital following cheal intubation, an incision extending from the right a 4-wheel all-terrain vehicle collision where he was thrown temporal line along the anterior aspect of the ear down to from the vehicle and struck his chin on the ground. He was the earlobe was completed and the temporomandibular transferred to the Children’s Medical Center of Dallas Emer- joint accessed in the standard fashion (Fig 4A).Once gency Room for treatment. He was neurologically intact and access to the temporomandibular joint was completed, it was noted that the mandibular condyle was dislocated through the fractured glenoid fossa into the cranial base Received from The University of Texas Southwestern Medical Cen- (Fig 4B). The neurosurgical team then performed a cra- ter, Dallas, TX. niotomy in the right temporal fossa region and the bony *Resident, Oral and Maxillofacial Surgery. window was removed (Fig 4C). With retraction of the †Former Professor and Chairman, Division of Oral and Maxillo- brain in the right temporal region, the right mandibular condyle was visualized (Fig 4D). With inferiorly directed facial Surgery. force applied to the posterior mandible and inferior pres- ‡Professor and Program Director, Division of Oral and Maxillo- sure placed on the condyle with a periosteal elevator, the facial Surgery. mandible was able to be reduced and placed back into Address correspondence and reprint requests to Dr Ellis: University the remnants of the glenoid fossa (Fig 4E). Following of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, reduction of the mandibular condyle, a dural tear with exposed brain matter was successfully repaired by the TX 75390-9109; e-mail: [email protected] neurosurgical team. Inspection of the right mandibular © 2005 American Association of Oral and Maxillofacial Surgeons condyle showed that it was intact without any evidence 0278-2391/05/6306-0026$30.00/0 of fracture. The right temporomandibular joint disk was doi:10.1016/j.joms.2005.02.029 found to be grossly medially displaced. The articular disk 860 RECONSTRUCTION OF TRAUMATIC DISLOCATION

FIGURE 2. Posteroanterior mandible x-ray showing deviation and canting of the mandible to the right side. Cillo, Sinn, and Ellis. Reconstruction of Traumatic Dislocation. J Oral Maxillofac Surg 2005.

was successfully repositioned and sutured into place with Nurolon suture (Johnson & Johnson, New Bruns- wick, NJ) (Fig 4F). A portion of the bony window that had been removed during the craniotomy was used to reconstruct the glenoid fossa from above the fracture site and sutured into place (Fig 4G). A sheet of Gelfilm (Phar- macia & Upjohn, Kalamazoo, MI), an absorbable gelatin film approximately 0.075 mm in thickness, was then placed above the temporomandibular disk to provide an additional barrier against adhesions between the articular surface and the dura. Lactosorb (Biomet, Inc, Warsaw, IN) plates and screws were then used to reconstruct the craniotomy site (Fig 4H). The maxillary right central incisor was repositioned and the patient placed into maxillomandibular fixation (MMF) with Erich arch bars. Postoperative panoramic and lateral cephalometric radiographs showed that the mandibular condyle had been restored to its proper position within the glenoid fossa and symmetrical inferior borders of the mandible (Fig 5). The patient did well postoperatively and was released from MMF at 3 weeks postoperatively. At 7 weeks, his facial symmetry was restored (Fig 6A), he had good mandibular mobility although he deviated to the right on wide opening (Fig 6B), and a normal occlusal relationship. His arch bars were then removed. The patient has continued to do well and is now 6 months postsurgery.

Discussion Dislocation of the mandibular condyle into the middle cranial fossa is a rare event, which is evident from

4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ FIGURE 1. Frontal photograph of patient demonstrating deviation of the chin to the right side (A). The patient’s ability to open his mouth was limited (B). Cillo, Sinn, and Ellis. Reconstruction of Traumatic Dislocation. J Oral Maxillofac Surg 2005. CILLO, SINN, AND ELLIS 861

The clinical examination in this case consisted of preauricular tenderness, mandibular deviation to the side of the injury, malocclusion with anterior open bite, and restricted mouth opening that were consis- tent with numerous previously reported cases.4–6,8 While no neurological deficits were noted in this case, previous cases have reported hearing loss,9 cerebrospinal fluid otorrhea, and facial nerve injury,10 as well as hemorrhaging from the external auditory ca- nal.8,9,11,12 Radiographic imaging in these cases is imperative to determine the exact nature of the injury because mandibular condyle dislocation into the middle cranial fossa may clinically mimic a subcondylar fracture. Plain radiographic imaging has been reported as being difficult to interpret condylar position.12 Therefore, computed tomography imaging is the most beneficial tool available to accurately diagnose these injuries.9,13,14 As evidenced in this case, computed tomography imaging (Fig 3) clearly reveals the position of the mandibular condyle displaced into the middle cranial fossa, while plain radiographs may be ambig- uous (Fig 2). Several treatment modalities have been proposed for treatment of this type of injury, ranging from closed reduction with intermaxillary fixation to craniotomy with open reduction and glenoid fossa reconstruction with autogenous8 and alloplastic materials.15 A protocol for treatment has been presented by Kroestch et al,4 who advocate closed reduction under general anesthesia with postoperative computed tomography scans to ascertain any possible new intracranial injuries. They only advocate craniotomy with open reduction and reconstruction for patients with FIGURE 3. Coronal (A) and sagittal (B) computed tomography show- neurologic complications or associated facial frac- ing displacement of the mandibular condyle into the middle cranial tures, long delays in treatment, or failed attempts at fossa. closed reduction. In our case, with a large amount of Cillo, Sinn, and Ellis. Reconstruction of Traumatic Dislocation. J Oral Maxillofac Surg 2005. displacement of the mandibular condyle into the middle cranial fossa, intracranial exploration was deemed necessary. This proved appropriate in our case be- the small number of reported cases, for several rea- cause dural lacerations were discovered and had to be sons. Experimental studies completed by Fonseca3 repaired. Traumatic damage to the dura has been have shown that the condylar head is much larger associated with meningitis, seizures, cerebrospinal than the glenoid fossa, making central luxation diffi- fluid leakage, and hematoma.16 cult. However, this type of injury is much more com- Immediate reconstruction with both alloplastic ma- mon in children because younger individuals can terials, such as titanium mesh, and autogenous have underdeveloped medial and lateral poles of the sources, such as rib or cranial bone, has been success- mandibular condyle, and a rounded condyle may be ful in reconstructing the glenoid fossa.8,12,15,17 The more easily superiorly displaced through the rela- goals of reconstruction have been to prevent recur- tively weak middle of the glenoid fossa into the mid- rent condylar dislocations, to restore posterior facial dle cranial fossa.4,5 Even in this situation, special cir- height, and to restore normal function to the joint.4 In cumstances must occur for this type of injury to take placing an autogenous cranial bone graft over the place. Seymour and Irby6 and Musgrove7 have sug- glenoid fossa defect, faster healing and support of the gested that the combination of an open-mouth posi- fossa likely occurs. A brief period of intermaxillary tion on impact with a posterior-superiorly directed fixation removes any load bearing on the joint. Gel- blow to the chin may produce such an injury. film, an absorbable gelatin film approximately 0.075 862 RECONSTRUCTION OF TRAUMATIC DISLOCATION CILLO, SINN, AND ELLIS 863

FIGURE 4. Photographs demonstrating surgical procedure. A, Outline of ex- tended pre-auricular incision. B, Expo- sure of the temporomandibular and lateral skull showing that the condylar process is impacted within the middle cranial fossa. C, Small craniotomy made through temporal bone. D, Re- traction of the dura showing the condyle. E, Dural tear being demon- strated. F, Condylar process has been replaced to its normal position in the mandibular fossa and the articular disc has been sutured to the posterior aspect of the condyle. G, Roof of the articular fossa (floor of the middle cranial fossa) reconstructed with calvarial bone. H, Craniotomy opening reconstructed with combination of calvarial bone and resorbable mesh. Cillo, Sinn, and Ellis. Reconstruction of Traumatic Dislocation. J Oral Maxillofac Surg 2005. 864 RECONSTRUCTION OF TRAUMATIC DISLOCATION mm in thickness, was placed between the cranial bone graft and temporomandibular disc to decrease the likelihood of adhesion development. It is com- monly used in neurosurgical procedures to cover dural defects because it does not produce an inflamma- tory reaction and absorbs at a sufficiently slow rate to permit adequate healing. In conclusion, superior dislocation of the mandibular condyle into the middle cranial fossa is a rare event that predominately occurs in children because of the anatomic composition of the mandibular condyle and the weakness of the middle glenoid fossa. Appropriate imaging is required to accurately diagnose these injuries as they may mimic subcondylar mandible fractures. Neurosurgical consultation is war- ranted in the majority of cases, and treatment options can vary from closed reduction to craniotomy and open reduction with reconstruction of the glenoid fossa with either alloplastic or autogenous materials. Acknowledgment

Neurosurgical expertise was provided by Angela Price, MD.

FIGURE 6. Frontal photograph (A) taken at 7 weeks postsurgery showing good facial symmetry. Mouth opening (B) at 7 weeks shows deviation to the right upon opening. Cillo, Sinn, and Ellis. Reconstruction of Traumatic Dislocation. J Oral Maxillofac Surg 2005.

FIGURE 5. Postoperative panoramic (A) and lateral cephalometric radiographs (B) showing repositioning of the right mandibular condyle References into the mandibular fossa. 1. Olson RA, Fonseca RJ, Zeitler DL, et al: Fractures of the Cillo, Sinn, and Ellis. Reconstruction of Traumatic Dislocation. mandible: A review of 580 cases. J Oral Maxillofac Surg J Oral Maxillofac Surg 2005. 40:23, 1993 KRETZSCHMAR, POSTMA, AND INMAN 865

2. Spanio S, Baciliero U, Fornezza U, et al: Intracranial dislocation 10. Zachariades N: Glenoid fossa fracture and facial nerve palsy. Int of the mandibular condyle: Report of two cases and review of J Oral Surg 14:564, 1985 the literature. Br J Oral Maxillofac Surg 40:253, 2002 11. Chuong R: Management of mandibular condyle penetration 3. Fonseca GD: Experimental study on fractures of the mandibu- into the middle cranial fossa: Case report. J Oral Maxillofac lar condylar process. Int J Oral Surg 3:89, 1974 Surg 52:880, 1994 4. Kroetsch LJ, Brook AL, Kader A, et al: Traumatic dislocation of 12. Melugin MB, Indresano AT, Clemens SP: Glenoid fossa fracture the mandibular condyle into the middle cranial fossa: Report of and condylar penetration into the middle cranial fossa: Report a case, review of the literature, and a proposal management of a case and review of the literature. J Oral Maxillofac Surg protocol. J Oral Maxillofac Surg 59:88, 2001 55:1342, 1997 5. Barron RP, Kainulainen VT, Gusenbauer AW, et al: Fracture of 13. Pepper L, Zide MF: Mandibular condyle fracture and disloca- the glenoid fossa and traumatic dislocation of the mandibular tion into the middle cranial fossa. Int J Oral Surg 14:278, 1985 condyle into the middle cranial fossa. Oral Surg Oral Pathol 14. Engevail S, Fischer K: Dislocation of the mandibular condyle Oral Radiol Endod 93:640, 2002 6. Seymour RL, Irby WB: Dislocation of the condyle into the into the middle cranial fossa: Review of the literature and middle cranial fossa. J Oral Surg 34:180, 1976 report of a case. J Oral Maxillofac Surg 50:524, 1992 7. Musgrove BT: Dislocation of the mandibular condyle into the 15. Long X, Hu C, Zhao J, et al: Superior dislocation of mandibular middle cranial fossa. Br J Oral Maxillofac Surg 24:22, 1986 condyle into the middle cranial fossa. A case report. Int J Oral 8. Sandler NA, Ozaki WH, Ochs MW, et al: Intracranial reduction Maxillofac Surg 26:29, 1997 of an intact mandibular condyle displaced into the middle 16. Pia HW: Open cranio-cerebral injuries. J Postgrad Med 27:133, cranial fossa. J Oral Maxillofac Surg 54:506, 1996 1981 9. Torres K, Lind O: Cranial dislocation of the mandibular con- 17. Christiansen RL: Condylar penetration into the middle cra- dyle: A case report with unusual hearing loss. J Craniomaxillo- nial fossa. J Craniomandib Disord Facial Oral Pain 3:100, fac Surg 23:302, 1995 1989

J Oral Maxillofac Surg 63:865-869, 2005

Intraoral Endoscopic Enucleation of a Central Mandibular Condylar Lesion David P. Kretzschmar, DDS, MS,* Gregory N. Postma, MD,† and J. Lucas Inman, MD‡

Surgeons are challenged daily to minimize invasive trauma surgery. Recent applications of endoscopic procedures for the benefit of their patients. Advance- techniques allow for a greater visualization of the ments in technology and equipment over the past 20 operative field by magnifying the view through the years have allowed surgeons from every discipline to aperature of telescopic lenses and transferring the diagnose and treat diseases through orifices and small image to a television monitor. Suarez-Cunqueiro et al2 incisions with the aid of the endoscope.1 Otorhino- published a report regarding the use of endoscopic laryngologists and oral and maxillofacial surgeons are techniques for the treatment of an ectopic mandibu- routinely using endoscopy for craniofacial surgery, lar molar.2 Other authors have suggested using endos- 3-5 cosmetic surgery, temporomandibular joint surgery, copy to access the mandibular ramus and condyle. sinus surgery, nasal surgery, laryngeal surgery, and This article presents an expanded application of endoscopic surgery for intraoral enucleation and curet- tage of a central lesion of the mandibular condyle in Received from the Wake Forest University School of Medicine, an asymptomatic 14-year-old female patient. The pre- Wake Forest University Baptist Medical Center, Winston-Salem, NC. surgical evaluation, radiographic studies, and differen- *Associate Professor, Oral and Maxillofacial Surgery. tial diagnoses are reviewed, and the operative proce- †Associate Professor, Otolaryngology, Center for Voice and Swal- dure is described. The final diagnosis is that of a lowing Disorders. solitary bone cyst of the left mandibular condyle. ‡Resident, Otolaryngology. Address correspondence and reprint requests to Dr Solitary Bone Cysts Kretzschmar: Oral and Maxillofacial Surgery, Wake Forest Univer- sity School of Medicine, Medical Center Blvd, Winston-Salem, NC Cysts and tumors within the mandibular condyle 27157; e-mail: [email protected] are extremely rare. Review of the subject reveals few © 2005 American Association of Oral and Maxillofacial Surgeons documented cases of a solitary bone cyst in this ana- 0278-2391/05/6306-0027$30.00/0 tomic region, and these cysts overall account for 6 doi:10.1016/j.joms.2005.02.026 about 2% of all cysts occurring within the jaws.