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Case Report
Alternative Management Approach of Dislocation and Hemarthroses
of the Mandibular Condyle into the Middle Cranial Fossa in a Mixed
Dentition: A Case Report and Review of the Literature
This article was published in the following Scient Open Access Journal:
Journal of Dental and Oral Health
Received February 11, 2016; Accepted October 07, 2016; Published October 14, 2016
Ida Anjomshoaa1* and Robert Pellecchia
2
The Brooklyn Hospital Center Division of Oral and
Maxillofacial Surgery, 151 Ashland place, Brooklyn,
NY, 11201, USA
2
Oral and Maxillofacial Surgery Program Director at
Geisinger Medical Center, 100 North Academy Ave,
Danville, PA 17822-1336, USA
1
Abstract
This case represents an alternative and more feasible approach to successful reduction
of an intact condyle into the middle cranial fossa in a child with mixed dentition. We describe
the treatment of a 7-year-old female who fell off her bicycle resulting in right mandibular
condyle dislocation into the middle cranial fossa. The patient was taken to the operating
room and the right mandibular condyle was manually disimpacted. Brackets and orthodontic
bands were cemented on teeth, and inter-arch stainless steel ligatures ties were placed
for inter-maxillary fixation for a period of four weeks. Our conservative management was
successful resulting in no relapse or ankylosis of the condyle. Orthodontic appliances can
provide a good alternative to conventional approaches for maxillomandibular fixation.
Arch bars in the mixed dentition are sometimes difficult to stabilize with compromise
in maintaining adequate oral hygiene. For a child, orthodontic bracketing is a far more
acceptable modality of treatment.
Case Report
Condyle dislocation is defined as displacement of the condyle out of the glenoid fossa
while it still remains within the joint capsule [1]. The condyle can be dislocated in many
directions, with antero-medial and anterior dislocation being the most common [2-4]. On
the contrary, dislocation of an intact condyle into the middle cranial fossa is very rare [24,6]. In general the condyle has a large head size compared to the glenoid fossa which makes
luxation out of the glenoid fossa much more difficult. 5 Impact to the condyle from trauma
more commonly results in ipsilateral or contralateral neck fracture as a defense mechanism
preventing the intrusion of the condyle into the brain [6-8]. Despite these characteristics of
the condyle there have been cases reported where the intact mandibular condyle has been
dislocated into the middle cranial fossa without the condyle fracturing itself. The purpose of
this case report is to provide an alternative management of this type of dislocation in a young
child in the mixed dentition.
A 7-year-old female fell off her bicycle and struck her chin to the ground on June 15th,
2013. She was taken to the emergency room at a regional hospital where her chin laceration
was repaired. According to the patient’s mother she did not have any loss of consciousness
at the time of the incident. X-rays of the mandible were done and the patient was discharged
home. The next day the mother came to Geisinger Medical Center stating that her daughter
felt worse. She was complaining of headaches, jaw pain and dizziness with multiple episodes
of nausea and vomiting. A maxillofacial computed tomography (CT) and a head CT were
ordered.
*Corresponding author: Ida Anjomshoaa, DMD,
Chief Resident, The Brooklyn Hospital Center Division
of Oral and Maxillofacial Surgery, 151 Ashland place,
Brooklyn, NY, 11201, USA, Tel: 718-250-8956, Fax:
718-250-8539, Email: [email protected]
Volume 2 • Issue 7 • 049
Upon clinical examination, the patient had moderate pinpoint tenderness to palpation
in the right temporomandibular joint (TMJ) and preauricular area. Swelling and trismus
were noted with a maximum incisal opening of 5 millimeters, and a slight deviation of the
lower third of the face to the affected side. She was alert and oriented to person, place, and
time and neurologically stable. She had no cranial nerve or sensory deficit. In the emergency
department Trauma Surgery, Ear Nose Throat, Pediatric Neuropsychology, Oral and
Maxillofacial Surgery (OMFS) and Neurosurgery were consulted. Maxillofacial CT revealed
a comminuted fracture of the squamous portion of the right temporal bone fracture in the
TMJ region and dislocation of the intact right mandibular condyle into the middle cranial
fossa (Figures 1a and 1b). The patient was admitted to the Pediatric Trauma Surgery Service.
From Neuropsychological and Neurosurgery testing, the patient was found to have normal
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Citation: Ida Anjomshoaa, Robert Pellecchia (2016). Alternative Management Approach of Dislocation and Hemarthroses of the Mandibular
Condyle into the Middle Cranial Fossa in a Mixed Dentition: A Case Report and Review of the Literature
Figure 1a: Coronal CT scan representing the right mandibular condyle
displaced superiorly into the middle cranial fossa.
Page 2 of 5
Figure 2a: Patient in intermaxillary fixation with orthodontic appliances and
stainless steel ligature ties.
Figure 2b: Patient ten days post-operatively following placement of elastics.
Figure 1b: Sagittal CT scan view revealing penetration of the condyle into
the middle cranial fossa.
cognitive ability and mental status with no evidence of psychiatric or
neuropsychological problems including post-traumatic amnesia.
Five days following the incident, the patient was taken
to the operating room by OMFS and Pediatric Dentistry. The right
mandibular condyle was manually disimpacted from the right middle
cranial fossa without any complication. Occlusion was reestablished
with repeatable occlusion demonstrated. Intra-operative radiographs
including lateral skull and Towne views were taken to verify the
position of the condylar head. Pediatric Dentistry placed orthodontic
bands on the maxillary and mandibular permanent first molars.
Orthodontic brackets were placed on the maxillary and mandibular
permanent central incisors and primary canines. Upper and lower
stainless steel arch wires, and inter-arch stainless steel ligatures ties
were placed for inter-maxillary fixation (IMF) (Figures 2a and 2b).
A post-operative maxillofacial CT was taken and the position of
condyle in the glenoid fossa was confirmed (Figure 3). Neurosurgery
determined that no further surgical intervention was needed unless
the patient became symptomatic indicating a neurological deficit.
The patient was kept in the hospital for one day post operatively by
Pediatric Trauma Surgery and was followed by OMFS. Post-operatively
the patient had continuing headaches and blurred vision in the right
eye and was evaluated further by Ophthalmology and Neurosurgery.
From their perspective the patient’s complaints were consistent with
underlying post-concussive symptoms with no changes in vision.
At the patient’s one-week follow-up appointment with OMFS, the
patient’s light wire fixation was changed to elastic fixation for three
Volume 2 • Issue 7 • 049
Figure 3: Post-operative Coronal CT scan image showing the right condyle
in correct position in relation to the glenoid fossa.
weeks (Figure 2b). The patient was followed up on a weekly basis. At
one month follow-up, the elastic fixation was removed. Orthodontic
appliances were left affixed to the mixed dentition. Following release
of the elastic traction, the patient had marked limited and painful
opening with maximum incisal opening of five millimeters. The
patient also continued to complain of occasional headaches, however
the blurred vision had resolved. A maxillofacial CT was performed
again and revealed bone like deposition around the condylar head,
which appeared reactive in nature without gross displacement into the
skull. Based on these findings possible hemarthrosis with subsequent
ankylosis of the condyle was suspected (Figures 4a and 4b). Based on
the clinical presentation and radiographic findings the patient was
taken back to the operating room for manipulation of the TMJ under
general anesthesia. On August 13th, 2013 the patient was evaluated
intraoperative to ascertain the movement of the right condyle
including translator movements. Following manual manipulation
of the TMJ the patient was opened to 30 mm. After the patient was
stabilized in Post Anesthesia Care Unit, she was discharged to home
and followed-up as an outpatient.
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Citation: Ida Anjomshoaa, Robert Pellecchia (2016). Alternative Management Approach of Dislocation and Hemarthroses of the Mandibular
Condyle into the Middle Cranial Fossa in a Mixed Dentition: A Case Report and Review of the Literature
Page 3 of 5
This may be due to underdeveloped medial and lateral poles of the
condyle in younger patients [11,14,15].
Figure 4a: One month post-operative maxillofacial CT revealing bone-like
deposition around the condylar head.
Signs and symptoms during clinical presentation of patients
with condyle displacement into the middle cranial fossa immediately
following the injury are valuable diagnostic clues to ensure prompt
identification and treatment of this injury. Common clinical
presentations include facial asymmetry with chin deviation towards
the affected side, malocclusion, trismus, anterior open bite, pain in
the preauricular region, and cerebrospinal fluid leakage or bleeding
from the ear on the injured side [10,11,13,14,16-19]. Neurological
deficits can also manifest in these types of injuries including facial
nerve injury, hearing loss and loss or altered state of consciousness
[6,20-24].
For definitive diagnosis CT imaging has become the gold
standard of imaging for this type of fracture11 .For optimal treatment
many factors need to be considered on an individual basis including
the patients age, treatment delay, extent of condyle displacement into
the middle cranial fossa, neurological symptoms and involvement
of adjacent vital structures including the middle meningeal artery,
posterior cerebral artery, and dural tears [3,19]. Different treatment
options have been presented based on these factors from closed to
open reduction with or without reconstruction of the glenoid fossa.
Figure 4b: Axial CT scan image revealing possible hemarthroses of the
condyle.
The patient began physical therapy after the second operation and
progressed quite well without pain or significant restriction of motion
with a stable occlusion. The patient was followed up inconsistently over
seven months due to multiple broken appointments. In her last visit
the orthodontic appliances were removed. Upon clinical examination
the TMJ was non tender and without click or crepitus bilaterally with
maximum mouth opening of more than 20 millimeters with mild
deviation to the ipsilateral side.
According to Kroertsch, et al. [14], closed reduction is a safer
procedure as it minimizes neurological injury. They state that open
reduction should be reserved for cases where other factors exist; such
as if there has been a delay in the patient’s treatment and diagnosis, or
closed reduction has failed. Neurological consultation is an important
consideration as some patients may not initially present a neurological
deficit but may develop deficits in a delayed manner. Similarly, in
young children, closed reduction has been advocated for injuries that
are diagnosed early within a four week post injury period where there
is none urological deficit [10,11,13,17,22].
There are multiple factors that predispose a patient to displacement
of the condyle into the middle cranial fossa, including the morphology
of the condyle, such as a small and/or rounded condylar head [5,6].
Impact with an open mouth, unopposed posterior occlusion, temporal
bone pneumatization, and congenital anomalies can all increase the
risk of displacement of the condylar head into the middle cranial fossa
[1,3,9-13].
In our case we chose to do closed reduction of the condyle and
IMF utilizing orthodontic brackets. The patient did not have any
neurological deficit and no significant fracture of the condylar itself.
Of the reported cases of this injury in children with a mixed dentition
no study was found to use orthodontic brackets to manage elastic IMF
in the healing phase (Table 1). Our approach considers two important
factors; one is the psychosocial aspect of using arch bars for IMF and
secondarily the difficulty of placing arch bars in children with mixed
dentition. Utilizing orthodontic brackets for IMF was much more
feasible and acceptable to the patient and parent in this case.
According to Rosa, et al. [13] there have been approximately 56
cases of displacement of the condyle into the middle cranial fossa with
37 of those cases reported in detail [13]. Of the reported cases there
have been very few reports of this injury in young children with a
mixed dentition (Table 1). Eleven cases of children under twelve years
of age with intrusion of the intact condyle into the middle cranial fossa
are represented in table. The case reports that involved fracture of the
condyle itself was excluded in the table. Of the represented cases most
were female with unilateral intrusion of the condyle. Eight cases (64%)
were treated with closed reduction and the remaining three cases were
treated with temporal craniotomy (Table 1). In general children and
young adults have a higher tendency toward displacement of the
condyle into the middle cranial fossa as compared to the elderly [14].
Some authors have suggested to reconstruct the glenoid fossa
in order to prevent recurrence of displacement of the condyle back
into the middle cranial fossa [14,15]. Defacianis, et al. [25], reported
unsuccessful results ten days after an immediate closed reduction in a
6-year-old girl which led to open reduction and reconstruction of the
glenoid fossa after seven months. However, the study did not disclose
if there was a post-operative maxillofacial CT taken which would
have indicated if the condyle had been successfully reduced in the
first attempt, potentially eliminating the need for an open reduction
procedure. In our case report the patient had no recurrences, and no
problem with joint function or facial asymmetry. However, despite a
short period of IMF as the initial management, a hemarthroses did
develop [26,27].
Discussion
Volume 2 • Issue 7 • 049
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J Dent Oral Health
Citation: Ida Anjomshoaa, Robert Pellecchia (2016). Alternative Management Approach of Dislocation and Hemarthroses of the Mandibular
Condyle into the Middle Cranial Fossa in a Mixed Dentition: A Case Report and Review of the Literature
Years
Number of
Unilateral
Gender/
Mechanism days prior
or
Operation
Age
of Injury
to surgical
Bilateral
intervention
Authors
Present
Anjomshoaa et al
case
2007
Magge
et al.
F/7
F/12
U
Collided
with another Immediate
child
Right frontotemporal
craniotomy,
reduction of
condyle externally
30
with traction and
stabilization with
MMF
yes
NS
1 year
NS
Open reduction
separating condylar
neck and leaving
none
the head in middle
cranial fossa
no
NS
not reported Not reported
Immediate
Open reduction by
temporal craniotomy 21 days
and MMF
yes
no
6 months
Deviation to
the right on
wide opening
U
Rosa et al.
F/5
U
2005
Cilloet al
M/7
U
MVA and
struck chin
on the
ground
U
MVA and
struck chin
on the
window
2002
Barron
et al.
2001
F/6
F/8
Defabianis et al
F/6
Post
Operation/
relapse
Neurologic
Follow-up
deficit
Closed reduction
with MMF using
orthodontic
brackets,light wires
and elastics
2006
Kroetsch et al.
Glenoid
Fossa reconstruction
Fell off
bicycle and
5 days
struck her
chin
Possible
MVA 3
years prior
2001
Duration of
stabilization
(days)
Page 4 of 5
7 days in
light wire and
no
21 days in
elastics
no
Mild deviation
to the
contralateral
side
7 months
Slight
deviation of
jaw to the
right from
loss of lateral
pterygoid
function
MMF
14 days in
MMF then
14 days
in training
elastics
no
no
24 months
Slight
deviation
to the left,
progressive
facial
asymmetry
U
Fell off
bicycle and
unknown
struck her
chin
MMF
7 days
no
no
24 months
Slight
deviation 2mm
to the right
U
Accidental
fall during
playing
Closed reduction
with MMF requiring
10 days
secondary treatment
with open reduction
yes
no
10 months
Improvement
in facial
asymmetry,
mouth opening
and deviation
Failed closed
reduction with
manipulative
reduction
secondarily used
14 days
Fergusson gag
between teeth on
ipsilateralside of the
injury with MMF and
elastics
no
no
24 months
Degenerative
changes of
condyle
no
no
10 months
Minimal
deviation
2 days
Immediate
1990
Baldwin et al
M/10
U
Chin blow
by an
opponent's 1 day
knee in a
game
1989
Paulette et al
F/11
U
Fell off
bicycle and
7 days
struck her
chin
Closed reduction
using towel clip with
unknown
MMF with wires and
elastics
Closed reduction
using a molt mouth
prop and secondary
direct manual
reduction with MMF
21 days in
MMF then
14 days
in training
elastics
no
no
8 months
Minimal
deviation
and slight
resorption of
condyle after 8
months
Closed reduction
with manipulation,
no MMF
N/A
no
no
18 months
Mild deviation,
progressive
remodeling of
the condyle
1985
Copernhaver et al
F/9
U
Fell off
bicycle and
2 days
struck her
chin
1983
Ihalainen&Tasanen
F/11
U
Fell off
bicycle and
Immediate
struck her
chin
F-female; M-male; U-unilateral; MVA-motor vehicle accident; MMF- maxillomandibularfixtion; NS-not stated; NA-not applicable.
Table 1: Reported Cases of Intrusion of Intact Mandibular Condyle into the Middle Cranial Fossa for patients under age of 12.
Conclusion
Use of orthodontic appliances can provide a good alternative
to conventional approaches for maxillomandibular fixation. Our
conservative management was successful resulting in no relapse or
Volume 2 • Issue 7 • 049
ankylosis of the condyle. However, a second procedure was required
in this case due to patient non-compliance with physiotherapy.
The use of orthodontic appliances affords clinicians options
regarding elastic traction especially in the immediate post-traumatic
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J Dent Oral Health
Citation: Ida Anjomshoaa, Robert Pellecchia (2016). Alternative Management Approach of Dislocation and Hemarthroses of the Mandibular
Condyle into the Middle Cranial Fossa in a Mixed Dentition: A Case Report and Review of the Literature
period. Arch bars in the mixed dentition are sometimes difficult to
stabilize with compromise in maintaining adequate oral hygiene.
For a child, orthodontic bracketing is a far more acceptable modality
of treatment. The importance of long-term follow-up with clinical
examination and CT imaging cannot be overstated particularly in
children under age 10 as ankylosis and/or facial asymmetries are
potential sequel following condylar injury in the growing patient [1].
Acknowledgements
Alison E Gomez, DMD
Resident, Pediatric Dentistry at Geisinger Medical Center
100 North Academy Ave, Danville, PA, 17822-1336
Karen Uston DDS, MS
Page 5 of 5
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Faculty at Geisinger Medical Center
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Copyright: © 2016 Ida Anjomshoaa, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
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