J Oral Maxillofac Surg 67:1815-1820, 2009

Magnetic Resonance Imaging in the Postsurgical Evaluation of Patients With Mandibular Condyle Fractures Treated Using the Transparotid Approach: Our Experience
Antonio Saponaro, MD,* Alessandro Stecco, MD, Matteo Brucoli, MD, Felice Armienti, MD, Livia Stellin, MD, Francesca Favano, MD, Arnaldo Benech, PhD,** and Alessandro Carriero, MD
Purpose: To evaluate the morphostructural and functional modications of the temporomandibular

joint and the onset of parotid complications in patients with extracapsular monocondylar fractures treated by reduction with the application of a titanium microplate via a transparotid approach. Materials and Methods: The study was comprised of 20 patients (16 male patients and 4 female patients) with a mean age of 25 years (range, 15-44 years) who had undergone reduction of condyle fractures. Twelve months after surgery, all patients were examined by means of magnetic resonance imaging (MRI) of the temporomandibular joint and parotid gland on the treated side. MRI examination was performed by use of coronal T2-weighted turbo spin echo sequences, as well as parasagittal T1-weighted turbo spin echo and T2-weighted fast eld echo sequences. Images were acquired from the resting position to the position of maximum oral opening. Results: The 1-year clinical outcome in our patients was good. MRI showed, on the treated side, 5 cases of anterior dislocation of the disc (25%), 1 case of disc degeneration (5%), and 1 case of parotid stula (5%). Conclusion: Both trauma and surgical intervention can damage the meniscal capsuloligamentous complex. MRI allowed the complications due to the trauma and/or treatment to be identied and made it possible to compare the condyles and joint function. 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:1815-1820, 2009 The condyle is the locus minoris resistentiae of the mandible, and both direct and (more frequently) indirect traumas can cause its fracture as a result of the transmission of impact forces along the mandibular arch. The treatment of mandibular condyle fractures is one of the most widely debated subjects in maxillofacial traumatology because its aim of ensuring the
Received from Maggiore della Carit Hospital, Novara, Italy. *Medical Doctor, Department of Radiology. Medical Doctor, Department of Radiology. Medical Doctor, Department of Maxillofacial Surgery. Medical Doctor, Department of Radiology. Medical Doctor, Department of Maxillofacial Surgery. Medical Doctor, Department of Radiology. **Professor and Chair, Department of Maxillofacial Surgery, Amedeo Avogadro Eastern Piemonte University.

morphofunctional recovery of the involved structures can be achieved by means of a conservative functional treatment or surgical/functional therapy. Conservative treatment is currently preferred in children,1 whereas surgery is used in adults with compound and dislocated (extracapsular) condylar neck fractures. One of the possible surgical approaches is to use the
Associate Professor, Department of Radiology, Amedeo Avogadro Eastern Piemonte University. Address correspondence and reprint requests to Dr Saponaro: Maggiore della Carit Hospital, Radiologic Institute, Mazzini Avenue, 18, Novara, Italy; e-mail: antoniosaponaro2@virgilio.it
2009 American Association of Oral and Maxillofacial Surgeons

0278-2391/09/6709-0005$36.00/0 doi:10.1016/j.joms.2009.04.019

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MRI AND MANDIBULAR CONDYLE FRACTURE

Table 1. SPIESSL AND SCHROLLS CLASSIFICATION OF FRACTURES OF CONDYLAR HEAD AND NECK5

Table 2. TYPES OF FRACTURES EXAMINED

Type I II III IV V VI

Denition Fracture of condylar neck with no or minimal displacement Low fracture of condylar neck with displacementmostly with contact between fragments High fracture of condylar neck with displacementmostly without contact between fragments Low fracture dislocation of condylar neck High fracture dislocation of condylar neck Fracture (intracapsular) of condylar neck

Fracture Type Combined monocondylar and parasymphyseal fractures Combined monocondylar and body fractures Isolated monocondylar fracture Combined bicondylar and parasymphyseal fractures

No. of Patients 11 7 1 1

Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

transparotid route and stabilize the bone fragments by means of titanium plate osteosynthesis.2 Postoperative follow-up is important to verify posttrauma sequelae and the outcome of the operation, and magnetic resonance imaging (MRI) is currently the only examination capable of providing morphologic and functional information concerning the condyle-disc apparatus.3 Good fracture reduction also requires correction of the dislocated interarticular disc, and MRI makes it possible to assess the position of the disc and the capsuloligamentous system in relation to the condyle head throughout the various phases of mandibular movement.4 Though direct, the transparotid approach is not devoid of postoperative complications, but these can

be easily detected by means of MRI because of its high contrast resolution of soft tissue. The aim of this study was to evaluate morphostructural and functional modications of the temporomandibular joint (TMJ), as well as the appearance of any parotid alterations, in patients with extracapsular mandibular condyle fractures treated by means of reduction via the transparotid approach and the application of a titanium plate.

Materials and Methods

The study was comprised of 20 patients (16 male patients and 4 female patients) with a mean age of 25 years (range, 15-44 years) who had undergone the reduction of Spiessl and Schroll5 type III or V mandibular condyle fractures (Table 1) and, 12 months later, were examined by means of MRI of the TMJ and parotid gland on the treated side.

FIGURE 1. Surgical treatment of mandibular condyle fracture using transparotid access route. Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

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FIGURE 3. Monocondylar fracture (Spiessl and Schroll5 type III). The images on the left (section obtained by use of parasagittal T1-weighted TSE sequences acquired in intercuspidation) and in the center (section obtained by use of coronal T2-weighted TSE sequences acquired in intercuspidation) clearly show the intact titanium plate (arrows) duly adhering to the condyle and mandibular branch. The plate generates artifacts that do not involve the region of the condylar head and articular disc. The image on the right (section obtained by use of parasagittal T2-weighted fast eld echo sequences acquired in maximum oral opening) clearly shows the morphologically normal articular disc, which is physiologically hypointense and correctly interposed between the condylar head and glenoid tubercle. Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

FIGURE 2. Surface coils used to examine TMJ (bottom) and volume coil used to examine parotid gland (top). Also shown are the cushioned pads. Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

All the patients had been treated via the transparotid approach, which involves a pre-auricular incision, opening of the lax areolar tissue, and dissection of the parotid-masseter fascia and the parotid gland after isolation of the fascia of the facial nerve; this is followed by the vertical incision of the masseter muscle and exposure of the condylar region to the focus of the fracture, which is then reduced and stabilized by means of a titanium plate (Fig 1). None of the

patients was affected by any TMJ disease before the occurrence of the trauma. Of the patients, 11 patients had been treated for combined monocondylar and homolateral parasymphyseal fractures, 7 for combined monocondylar and mandibular body fractures, 1 for an isolated monocondylar fracture, and 1 for a bicondylar fracture (Table 2). At 12 months after surgery, the patients underwent MRI of the TMJ and parotid gland by use of a Philips Intera Achieva (1.5-T) superconductive tomograph (release 2.1; Philips Medical Systems, Best, The Netherlands) after having signed a written consent form. The TMJ examination was performed with ex phased array M coils (Philips Medical Systems), whereas the parotid gland was examined with a Sense Head coil (Philips Medical Systems). Cushioned pads were used to prevent any sideways movement of the head during image acquisition (Fig 2).

Table 3. PROTOCOL USED TO ASSESS PAROTID GLAND AND TMJ

Plane TSE T2 (parotid) TSE T1 (TMJ) FFE T2 (TMJ) TSE T2 (TMJ) FFE T2 (TMJ) Coronal Parasagittal Parasagittal Coronal Parasagittal

TR (msec) 120 450 108 2,800 108

FA TE (msec) (degrees) 3,590 10 23 88 14 90 90 20 90 30

Matrix 256 163 240 256 240 256 192 256 192 256

Th (mm) 5 1 3 3 3

Gap (mm) 1 0 0 0 0

NSA 1 4 4 2 2

FOV (cm2) 230 150 150 150 160

Abbreviations: TR, repetition time; TE, echo time; FA, ip angle; Th, thickness; NSA, number of averages; FOV, eld of view; FFE, fast eld echo.
Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

1818 The TMJ was rst examined with the subject in a resting position (with the mouth closed) by use of parasagittal T1-weighted turbo spin echo (TSE) and T2weighted fast eld echo sequences, as well as coronal T2-weighted TSE sequences, after which parasagittal T2weighted fast eld echo sequences were recorded with the mouth in various positions (from intercuspation to maximum opening) by use of dedicated spacers. To obtain the greatest spatial and contrast resolution, reduced elds of view were used (150 mm for the TMJ), thus making it possible to increase the noise-to-signal ratio. The parotid gland was examined by use of coronal T2-weighted TSE sequences (Table 3). We assessed the signal intensity, morphology, and position of the disc at various oral apertures; the morphology and signal intensity of the treated condyle; the signal intensity of the retrodiscal tissue; the presence of articular effusion; plate integrity; the presence of altered parotid signals; and the lengths of the treated and contralateral mandibular branches.

MRI AND MANDIBULAR CONDYLE FRACTURE

The images were separately evaluated by 3 radiologists with expertise in MRI whose interobserver concordance was 100%.

Results
MRI is capable of delineating the disc-capsule-ligament apparatus of the TMJ with high contrast resolution, which is why it is the imaging method of reference for studying disc and capsule alterations and evaluating the presence of intra-articular effusion. The titanium plate generated artifacts, but these did not limit diagnostic judgment (Fig 3). At 1 year after surgery, we found 5 cases of an anteriorly dislocated interarticular disc (25%) that was irreducible at the various degrees of oral aperture (Fig 4), 1 case of disc bromyxoid degeneration (5%) (Fig 5), and 1 case of parotid stula (5%) (Fig 6). None of the patients showed any signicant articular effusion, and the signal intensity of the bilaminar zone was normal in all cases.

FIGURE 4. Combined condylar and parasymphyseal fractures. Sagittal T2-weighted fast eld echo sequences acquired during mouth opening movements from intercuspidation (1) to maximum oral opening (4). The anteriorly dislocated bone is not trapped between the condyle and temporal bone. The condyle is also anteriorly dislocated, showing irreducible anterior dislocation of the condyle-disc complex. The disc was globular but free of degenerative alterations in signal intensity. Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

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1819 It should also be pointed out that the symptoms (pain, reduced joint function) tend to regress over time1 even in the case of an MRI-documented dislocation. In our experience the patients with a dislocated disc reported episodic articular noises when chewing and did not complain of any pain, and only 2 reported a mild functional limitation. The magnetic resonance images did not show any signs of reactive synovitis or retrodiscal tissue signal alterations in the bilaminar zone, a nding that is frequently seen in cases of chronic condyle-disc incongruity with symptomatic alterations in condyle-disc kinetics.10,11 The 1-year clinicoradiologic outcome was good in our patients because the surgical repositioning of the condyle guaranteed good occlusion and functional recovery, with only marginal morphostructural alterations that had little effect on articular function. MRI allowed the complications due to the trauma and/or treatment to be identied and made it possible to compare the condyles (on the coronal images) and joint function. Furthermore, the stabilization offered

FIGURE 5. Monocondylar fracture. Normal occlusion was present after surgical reduction and the positioning of a titanium plate. One year after treatment, the disc (inside the oval) was hyperintense as a result of bromyxoid degeneration (sagittal T2-weighted fast eld echo sequence). Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

There were no cases of plate rupture. The mandibular branch on the treated side was never shorter than the healthy contralateral branch. In 1 patient treated for bicondylar fractures (conservatively on one side and by means of osteosynthesis on the other), there was a consolidation defect on the unoperated side (Fig 7) whereas the operated side was well-consolidated.

Discussion
Condylar fractures have been classied into 6 types (Table 1).5 Our patients were affected by types III and V, because we excluded intracapsular, low, and compound fractures. Of our patients, 25% showed irreducible anterior dislocation of the articular disc, which may be a consequence of direct damage to the disc or the rupture of the articular capsule,3 which may also be damaged during the course of surgery. In such cases the action of the lateral pterygoid muscle exerts traction on the disc in an anteromedial direction because of its insertion at the level of the capsule and disc; in the case of low condylar fractures (ie, those in which the articular capsule remains intact), the percentage of disc dislocation decreases to 10%.6 The incidence of anterior disc dislocation is high in the healthy population and has been variously estimated as being between 21% and 33%7; however, it increases to 78% in cases of condylar fracture,8 although it is less frequent in surgically treated patients (25% in our study) than in patients treated conservatively (65%).6,9

FIGURE 6. The images document an altered intraparotid signal due to brotic fragment of a parotid stula (top, coronal section obtained by use of T2-weighted TSE sequences; bottom, axial section obtained by use of T1-weighted TSE sequences). Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

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MRI AND MANDIBULAR CONDYLE FRACTURE

FIGURE 7. Bicondylar fractures. Right condyle osteosynthesis with plate, and conservative treatment of left condyle (coronal T2-weighted TSE imaging). The right condyle fracture is well consolidated, unlike the conservatively treated fracture on the left side. Saponaro et al. MRI and Mandibular Condyle Fracture. J Oral Maxillofac Surg 2009.

by use of the microplate prevented long-term consolidation defects.

References
1. Hovinga J, Boering G, Stegenga B: Long-term results of nonsurgical management of condylar fractures in children. Int J Oral Maxillofac Surg 30:365, 2001 2. Baker AW, McMahon J, Moos KF: Current consensus on the management of fractures of the mandibular condyle. Int J Oral Maxillofac Surg 27:258, 1998 3. Choi BH, Yi CK, Yoo JH: MRI examination of the TMJ after surgical treatment of condylar fractures. Int J Oral Maxillofac Surg 30:296, 2001 4. Gallucci M, Bozzao A, Splendiani A, et al: Magnetic resonance in condylo-meniscal incoordination pathology of the temporomandibular joint. Indications, diagnostic accuracy and optimization of study techniques. Radiol Med 81:404, 1991 5. Spiessl B, Schroll K: Gelenk fortsatzund Gelenk koepfchen frakturen, in Nigst N (ed): Spezielle Frakturen-und Luxationslehre Bd. I/I. Stuttgart, Thieme, 1972

6. Oezmen Y, Mischkowski RA, Lenzen J, et al: MRI examination of the TMJ and functional results after conservative and surgical treatment of mandibular condyle fractures. Int J Oral Maxillofac Surg 27:33, 1998 7. Tasaki MM, Westesson PL, Isberg AM, et al: Classication and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. Am J Orthod Dentofacial Orthop 109:249, 1996 8. Sullivan SM, Banghart PR, Anderson Q: Magnetic resonance imaging assessment of acute soft tissue injuries to the temporomandibular joint. J Oral Maxillofac Surg 53:763, 1995 9. Choi BH: Magnetic resonance imaging of the temporomandibular joint after functional treatment of bilateral condylar fractures in adults. Int J Oral Maxillofac Surg 26:344, 1997 10. Mazza D, Stasolla A, Kharrub Z, et al: MRI evaluation of morpho-structural alterations of the retrodiscal tissue in condylo-meniscal incoordination of the TMJ: Usefulness of individualised T2-weighted TSE sequences. Radiol Med 107: 261, 2004 11. Westesson PL, Paesani D: MR imaging of the TMJ. Decreased signal from the retrodiskal tissue. Oral Surg Oral Med Oral Pathol 76:631, 1993