Vol. 87 No.

5 May 1999

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

ORAL AND MAXILLOFACIAL RADIOLOGY

Editor: Sharon L. Brooks

The value of coronal computer tomograms in fractures of the mandibular condylar process
Ronald Schimming, MD, DDS,a Uwe Eckelt, MD, DDS, PhD,b and Thomas Kittner, MD,c Dresden, Germany
UNIVERSITY OF DRESDEN

Objective. A prospective investigation designed to compare the diagnostic accuracy of conventional panoramic and posteroanterior mandibular radiographs with that of coronal computed tomography scans in cases of fracture of the mandibular condylar process was conducted. Study design. In all, 182 patients with a total of 249 fractures (some unilateral and some bilateral) of the mandibular condyle received conventional radiographs and coronal computed tomography scans as diagnostic procedures. The ability of these procedures to detect and correctly classify these fractures was determined, and their importance for therapeutic decisionmaking is described. Results. All clinically identified fractures were detected by means of both conventional and computed tomography imaging. However, only computed tomography scanning could correctly classify high condylar neck fractures. Conclusions. Especially in cases of high condylar neck fracture, coronal computed tomography scans were more useful than conventional radiographs in the determination of type of condylar fracture so that a correct treatment decision could be made.

(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:632-9)

Fractures of the mandibular condylar process as a result of direct or indirect trauma to the mandible play a major role in maxillofacial traumatology. They account for 21% to 52% of all mandibular fractures.1 No other fracture in the maxillofacial region has been so controversial in the literature with respect to classification, diagnosis, and therapeutic management. More than 80 papers relating to this injury have been published in English during the last 50 years.2 Different surgical procedures using functionally stable osteosynthesis methods and nonsurgical strategies have been described,3-12 and distinct classification systems have been suggested.13,14 In our department, treatment strategy is based on the classification of Spiessl and Schroll.13 All fractures in children less than 12 years of age are at first managed
Department of Oral and Maxillofacial Surgery. and Head, Department of Oral and Maxillofacial Surgery. cResearch Assistant, Department of Diagnostic Radiology. Received for publication July 23, 1998; returned for revision Sept 28, 1998; accepted for publication Jan 10, 1999. Copyright 1999 by Mosby, Inc. 1079-2104/99/$8.00 + 0 7/16/97858
bProfessor aResearch Assistant,

conservatively and subsequently treated functionally with orthognathic devices, in accordance with recommendations in numerous studies.11,15-17 However, the choice of therapeutic management in adults is controversial. Indications and contraindications for various treatment modalities have been described by Zide and Kent.18 In our department, all fractures involving dislocation of the condyle and angulation (displacement) of the condyle of more than 30 degrees are treated with open reduction through use of a functional stable lag screw osteosynthesis system described by Eckelt.6 Diacapitular (sagittal/intraarticular) fractures of the mandibular condyle are treated either conservatively or with pin fixation. Fractures with angulations of less than 30 degrees are treated conservatively and subsequently treated functionally. The recent expansion of surgical treatment for dislocated fractures of the mandibular condyle described in the literature1,19 should rely on precise and careful preoperative clinical and radiologic assessment. Clinical signs such as jaw deviation and limitation during mouth opening, changes in occlusion, and extraoral swelling of the preauricular region

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Schimming, Eckelt, and Kittner 633

Fig 1. Distribution of fracture frequency (n = 249).

can be indicative of unilateral or bilateral fractures of the condylar process.20 Panoramic radiographs (OPGs) and posteroanterior mandibular radiographs (PAMRs) are the conventional forms of radiography that are used. They provide an overall view of the fractured mandible and indicate displacement of the fractured condylar process in the anteroposterior and lateromedial directions. Two different goals must be achieved with these radiographs: first, the diagnosis of a condylar fracture must be confirmed; second, the fracture must be described and classified to determine whether surgery is indicated and to choose the best osteosynthesis technique or select a conservative alternative. Conventional radiodiagnosis (with OPGs and PAMRs) is helpful in describing the position of the condylar process fracture. However, in our experiences conventional radiodiagnosis has not always allowed correct assessment of fracture position. This has especially been true for some cases of high condylar neck fracture and diacapitular fracture in which additional fracture lines and definitive classification of the fracture type could not be determined. In such cases, coronal computed tomography (CT) is recommended.21-25 These findings were confirmed by an investigation of 40 patients with 46 fractures of the mandibular condylar process.26 However, only 16 of those patients received additional examinations with CT. The CT scans were done between 9 and 106 weeks after the primary injury. No further investigation comparing conventional radiodiagnosis and coronal CT scan in a large number of fractures of the mandibular condylar process has been done to date.

The purpose of this prospective investigation was to compare conventional radiographs (OPGs and PAMRs) and coronal computed tomographs with respect to diagnostic precision for the sake of investigating their effects on the analysis of those dimensions that determine the indication for surgical treatment (condylar fragment orientation, course of the fracture line, angulation degree, and dislocation of the condyle). Our hypothesis was that coronal CT scans may improve the diagnosis of fractures of the mandibular process and thus lead to more exact analyses of fracture lines and fracture types, thereby leading to more effective therapy.

MATERIAL AND METHODS For this prospective study, we examined 182 patients who between January 1992 and December 1997 had experienced various injuries that resulted in unilateral or bilateral fractures of the mandibular condyle (n = 249 fractures). All patients were treated consecutively in our department. The inclusion and exclusion criteria for this investigation were as follows: Inclusion criterion: Clinical diagnosis of a unilateral or bilateral condylar neck fracture based on clinical examination20 Exclusion criterion: Contraindications for direct coronal CT scanning of the condylar process (injuries of the cervical spine or severe intracranial injuries). Thirty-one patients who were treated during the same period for unilateral or bilateral condylar neck fractures did not fulfill the study protocol because of the severity of their injuries. For every patient in the study, the following radio-

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Fig 2. Analysis of fracture lines (n = 249).

Table I. Accuracy of conventional radiologic examinations

Spiessl I Detection (%) Correct classification (%) 100 100 Spiessl II 100 100 Spiessl III 100 70 Type of fracture* Spiessl IV 100 100 Spiessl V 100 75 Spiessl VI 100 100

*Fracture classification according to Spiessl and Schroll.13

logic examinations were carried out: (1) OPG with an Orthophos Plus (Siemens, Germany); PAMR (caudal eccentric posteroanterior skull examination with maximum opening of the mouth) with a Super 50 CPD (Philips). The technical data of investigation (kilovoltages, milliamperages, and time) were dependent on patient age and gender and were standardized for exposures. The specific doses were 8-30 mGy (surface dose) for the OPG and 1.3-10 mGy for the PAMR. All radiographs were of acceptable quality. In addition, a direct coronal CT scan of each fracture region was made with a Tomoscan SR 7000 (Philips). For this study, reconstruction of coronal cuts from axial scans was not done because a thinner slice (ie, a higher radiation dose) would then have been necessary.27 The following parameters were used for the coronal CT scan: mode, helical; kV, 120; mA, 200; field of view, 210; slice thickness, 3 mm; table feed, 3 mm; reconstruction index increment (RI), 3 mm; specific dose, 80-90 mGy. Two independent observers (one for each method) interpreted the results of the conventional radiologic

examinations and the coronal CT scans. In every case, the conventional investigation was done first. No information about the results from the conventional radiographs was available to the CT observer before the coronal CT scan was assessed. All fractures of the mandibular condyle were compared with respect to frequency and locality through use of the classification system described by Spiessl and Schroll13 in 1972. They distinguish the following fracture types: Spiessl I: fracture without angulation and dislocation Spiessl II: fracture at the basis of the condylar process with angulation Spiessl III: fracture at the condylar neck with angulation (high condylar neck fracture) Spiessl IV: fracture at the basis of the condylar process with dislocation Spiessl V: fracture at the condylar neck with dislocation (high condylar neck fracture) Spiessl VI: diacapitular fracture (intraarticular). The term diacapitular fracture was confirmed by Rasse et al in 1993.28 They performed an anatomical

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Schimming, Eckelt, and Kittner 635

Fig 3. OPG and PAMR show 4-fold mandibular fracture.

B
Fig 4. Coronal CT scan shows bilateral fracture of mandibular condyle in patient of Fig 3. Fig 5. OPG (A) and PAMR (B) show unilateral (right) condylar neck fracture.

study in which the temporomandibular joints (TMJs) of 20 human cadavers were sectioned to control the clinical findings. All fractures studied proved to be intracapsular and extracapsular and always involved the insertion of the lateral pterygoid muscle at the mandibular condyle. To ascertain whether there were any important differences among the different radiologic examinations, the ability of conventional techniques both to detect and to classify condylar fractures was determined. In all cases, the evaluation of detection was based on the clinical examination and clinical diag-

nosis of a unilateral or bilateral condylar neck fracture. The gold standard for fracture classification was the coronal CT image.

RESULTS In all, 182 patients with a total of 249 fractures of the mandibular condyle (some unilateral, some bilateral) entered our study. The average age of the 136 male and 46 female patients was 28.1 years; the subjects ranged in age from 12 to 82 years. There were 67 patients with bilateral fractures and 115 patients with unilateral fractures. Fig 1 shows the frequency of the distribution of

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ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY May 1999

Fig 6. Coronal CT scan shows unilateral fracture of right mandibular condyle in patient of Fig 5. Fig 8. Coronal CT scan shows unilateral fracture of right mandibular condyle in patient of Fig 7.

Fig 7. OPG and PAMR show unilateral (right) condylar neck fracture. Fig 9. OPG and PAMR show bilateral condylar neck fracture.

fractures according to coronal CT scan. The distribution was as follows: Spiessl I fractures, 8.0%, Spiessl II fractures, 32.1%; Spiessl III fractures, 3.2%; Spiessl IV fractures, 16.9%; Spiessl V fractures, 12.2%; Spiessl VI fractures, 27.6%. Using the coronal CT scans, we determined that most fractures (81.5%) exhibited oblique fracture lines (Fig 2). This is of importance for all types of fractures of the condylar process. In high fractures of the condylar neck (Spiessl III, V, and VI), horizontal fracture lines were revealed in 5.6% of the cases. Conventional radiologic examinations (OPGs and PAMRs) detected all clinically diagnosed fractures of the mandibular condylar process. However, as shown in Table I, conventional radiologic examinations did

not correctly classify all fractures, particularly in the case of high condylar neck fractures (Spiessl III and V). In 18 cases (6 Spiessl III and 12 Spiessl V) in which the fractures had been classified by conventional radiology, the oblique fracture line was first diagnosed in the coronal CT scan. The fracture line led to an inclusion of the condyle of the mandible and thus to a change in the fracture classification and the therapeutic procedure. The diagnosis and fracture classification by coronal CT scan was confirmed intraoperatively in each patient who received open fracture reduction. Furthermore, the coronal CT scan displayed a better overview of the fracture area and

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revealed additional fracture lines, particularly in cases of high condylar neck fracture (Spiessl III and V) and diacapitular fracture (Spiessl VI). A clinical example of this is shown in Figs 3 and 4, which illustrate the case of a patient with a 4-fold mandibular fracture, including a Spiessl II fracture on the right side and a Spiessl V fracture on the left side. Whereas conventional radiodiagnosis (Fig 3) for the deep fracture of the condylar process clearly indicated surgical therapy, it was nonetheless insufficient for the high fracture of the condylar neck. Only the coronal CT scan (Fig 4) revealed the exact location of the fracture fragment, thereby ruling out an additional fracture of the left condyle. A unilateral condylar neck fracture is displayed in Figs 5 and 6. Conventional radiographs (Fig 5) allowed the diagnosis of a high condylar neck fracture (Spiessl VI) on the right hand side, but only the coronal CT scan (Fig 6) could give the indication for subsequent surgical therapy (pin fixation) for this Spiessl VI fracture. Figs 7 and 8 show a unilateral fracture (Spiessl VI) of the right condylar neck. The coronal CT scan (Fig 8) revealed a comminuted fracture of the condyle, whereas conventional radiographs (Fig 7) only allowed the diagnosis of a Spiessl VI fracture. In this case, the coronal CT scan clearly indicates conservative functional fracture treatment. Figs 9 and 10 show a bilateral condylar neck fracture, with a Spiessl VI fracture on the left side and a Spiessl II fracture on the right side. The conventional radiographs (Fig 9) indicated the need for surgical treatment of the Spiessl II fracture (lag screw osteosynthesis); the coronal CT scan (Fig 10) revealed additional information that was necessary for pin fixation of the fracture on the right side.

Fig 10. Coronal CT scan shows bilateral condylar neck fracture in patient of Fig 9.

DISCUSSION CT is a suitable method of diagnosing high condylar process fractures and other facial fractures not seen in conventional radiographs.21-25 It allows visualization of anatomical structureseg, cortical bone loss, sclerosis, and changes in joint morphology and condyle position in the mandibular fossafree of superimposition, providing the viewer with 3dimensional information if sequential images are reconstructed (either mentally or pictorially by the computer). The usefulness of CT scans in follow-up investigations of fractures of the mandibular condyle and for investigation of morphologic changes has been described.26,29-33 Comparison of the results of conventional radiographs (OPGs and PAMRs) and coronal CT scans of 249 fractures of the mandibular condylar process

showed that coronal CT scans should be performed in all cases of high fracture of the mandibular condyle. In 18 cases of this fracture type, the fracture line was exactly determined only by coronal CT scan. The new fracture classification led to a new therapeutic approach in each of these cases. Instead of lag screw osteosynthesis, either conservative functional treatment or pin fixation of the fracture was undertaken. Coronal CT scans should be performed in cases of diacapitular fracture of the mandibular condyle because additional fractures of the condyle (Fig 4) were found only in coronal CT scans. The so-called chip fracture of the mandibular condyle was first described by Avrahami and Horowitz 34 in 1984. However, the authors could not find the described fracture by means of conventional radiographic procedures. Moreover, in cases of diacapitular fracture the coronal CT scan allows an exact description of the TMJ and the fractured fragments. The CT scan is a requirement for open reduction of this fracture type and subsequent fixation of the fracture with pins. In the case of conservative functional treatment, the CT scan may give additional information that would be useful in the planning of subsequent functional treatment. Despite their disadvantages, conventional radiographs allowed accurate diagnosis of low condylar fractures. In our opinion, a coronal CT scan should be done in all cases involving suspected fractures in the TMJ area, including high fractures of the condylar neck, so that all information necessary for treatment planning can be gathered.

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mandibular condylar process. J Craniomaxillofac Surg 1992;20:348-53. MacArthur CJ, Donal PJ, Knowless J, Moore HC. Open reduction-fixation of mandibular subcondylar fractures: a review. Arch Otolaryngol Head Neck Surg 1993;119:403-6. Walker RV. Condylar fractures: non-surgical management. J Oral Maxillofac Surg 1994;52:1185-8. Holl MB. Condylar fractures: surgical management. J Oral Maxillofac Surg 1994;52:1189-92. Ziccardi VB, Schneider RE, Kummer FJ. Wurzburg lag screw plate versus four-hole miniplate for the treatment of condylar process fractures. J Oral Maxillofac Surg 1997;55:602-7. Spiessl B, Schroll K. Gesichtsschdel. In: Ningst H, editor. Spezielle Frakturen- und Dislocationslehre. Stuttgart and New York: Thieme; 1972. Bd. I/1. Lindahl L. Condylar fractures of the mandible, I: classfication and relation to age, occlusion and concomitant injuries of teeth supporting structures and fractures of the mandibular body. Int J Oral Surg 1977;6:12-21. Chalmers J Lyons Club (Members of). Fractures involving the mandibular condyle: a post treatment survey of 120 cases. J Oral Surg 1947;5:45-73. Dahlstrm L, Kahnberg KE, Lindahl L. Fifteen year follow up on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18-23. Leake D, Douglas J, Habal MB, Murray JE. Long term follow up of fractures of the mandibular condyle in children. Plast Reconstr Surg 1971;47:127-31. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41:89-98. Eckelt U, Hlawitschka M, Feller KU, Schimming R. Comparative studies on the treatment of fractures of the mandibular joint process. In: Ravindranathan R, editor. Maxillofacial surgery. Vol. 3. Bologna: Monduzzi Editore; 1997. p. 379-83. Rowe NL, Williams JLC, editors. Maxillofacial injuries. Vol. I. New York: Churchill Livingstone; 1985. Fujii N, Yamasiro M. Computed tomography for the diagnosis of facial fractures. J Oral Surg 1981;39:735-41. Davis WM Jr. An interesting condylar fracture revealed by use of computed tomography. Oral Surg Oral Med Oral Pathol 1989;67:31-2. Zller J, Mende U, Eitel B. Diagnosis of dislocation-fracture of mandibular condyle. ZWR 1989;98:771-3. Yamaoka M, Furusuwa K, Iguchi K, Tanaka M, Okuda D. The assessment of fracture of the mandibular condyle by use of computerized tomography: incidence of sagittal split fracture. Br J Oral Maxillofac Surg 1994;32:77-9. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol 1993;22:145-88. Raustia AM, Phytinen J, Oikarinen KS, Altonen M. Conventional radiographic and computed tomographic findings in cases of fracture of the mandibular condylar process. J Oral Maxillofac Surg 1990;48:1258-62. Drexler D, Panzer W, Widemann L, Williams G, Zanki M. Die Bestimmung von Organdosen in der Rntgendiagnostik. Berlin: H. Hoffmann; 1985. Rasse M, Koch A, Traxler H, Mallek R. Der Frakturverlauf von diakapitulren Frakturen der Mandibula: eine klinische Studie mit anatomischer Korrelation. Z Stomatol 1993;90:119-25. Avrahami E, Frishman E, Weiss-Peretz J, Horowitz I. Computed tomography of healing condylar fractures with some clinical correlations. Clin Radiol 1993;47:269-73. De Bont LG, van der Kuijl B, Stegenga B, Vencken LM, Boering G. Computed tomography in differential diagnosis of temporomandibular joint disorders. Int J Oral Maxillofac Surg 1993;22:200-9. Choi BH. Comparison of computed tomography imaging before and after functional treatment of bilateral condylar fractures in adults. Int J Oral Maxillofac Surg 1996;25:30-3. Kahl B, Fischbach R, Gerlach KL. Temporomandibular joint

When the problem of radiologic diagnosis is being discussed, it should be mentioned that some patients with maxillofacial injuries receive these injuries during multitraumas, and direct coronal CT scans thus sometimes cannot be performedeg, when there are cervical spine injuries or intracranial injuries accompanied by high intracranial pressure. In these cases, axial CT scans are usually performed to obtain information about intracranial injuries. A coronal reconstruction of axial CT scans should be done to gather the information necessary for subsequent treatment in the case of a clinically diagnosed condylar neck fracture. Any comparison of CT and conventional radiography (OPGs and PAMRs) with respect to radiation risk is problematic, but it would appear from the literature that the risk is 1 order, if not 2 orders, of magnitude greater with the former.35,36 Therefore, the clinician must weigh these risks against the benefits in diagnostic yield in making the therapeutic decision. To reduce the radiation dose, a coronal CT scan without additional conventional radiographs should be performed in cases of clinically diagnosed isolated unilateral or bilateral condylar neck fracture. In cases of combined fracture of the mandible, conventional radiographs should be done first; coronal CT scanning should follow only when a high condylar neck fracture is likely. A coronal reconstruction of axial CT scans is recommended in cases of panfacial fracture for the sake of obtaining the equivalent information for subsequent midface and skull base reconstruction.
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morphology in children after treatment of condylar fractures with functional appliance therapy: a follow-up study using computed tomography. Dentomaxillofac Radiol 1995;24:37-45. 33. Dahlstrm L, Lindvall AM. Assessment of temporomandibular joint disease by panoramic radiography: reliability and validity in relation to tomography. Dentomaxillofac Radiol 1996;25:197-201. 34. Avrahami E, Horowitz I. Chip fracture of the mandibular condyle. Head Neck Surg 1984;6:978-81. 35. Huda W, Sandison GA. The use of the effective dose equivalent as a risk parameter in computed tomography. Br J Radiol 1986;59:2136-8.

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36. Gibbs SJ, Pujol A, McDavid WD, Welander U, Tronje G. Patient risk from rational panoramic radiography. Dentomaxillofac Radiol 1988;17:25-32. Reprint requests: Uwe Eckelt, MD, DDS, PhD Department of Oral and Maxillofacial Surgery University of Dresden Fetscherstr. 74 D-01307 Dresden Germany

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