British Journal of Oral and Maxillofacial Surgery 45 (2007) 534537

A comparison of MRI, radiographic and clinical ndings of the position of the TMJ articular disc following open treatment of condylar neck fractures
Alexander Schneider a , Diana Zahnert a , Steffen Klengel b , Richard Loukota c, , Uwe Eckelt a
a b c

Department of Oral and Maxillofacial Surgery, University of Technology Dresden, Fetscherstrae 74, D-01307 Dresden, Germany Department of Radiology, University of Technology Dresden, Fetscherstrae 74, D-01307 Dresden, Germany Department of Oral and Maxillofacial Surgery, Leeds Teaching Hospitals NHS Trust, Leeds LS2 9LU, United Kingdom

Accepted 23 November 2006 Available online 12 January 2007

Abstract We examined the position and function of the articular disc after open treatment of condylar fractures by comparing magnetic resonance images (MRI) and radiographs with clinical data. MRI and radiographs were taken after treatment of 28 patients with 33 fractures of the mandibular condyles. In all cases, the disc was located in the fossa after open reduction and internal xation (ORIF). The MRI, radiographic and clinical ndings did not correlate, and damage to the temporomandibular joint (TMJ) could be seen more clearly on MRI than on clinical or radiographic examination. Damage to soft tissues seen on MRI after treatment was more pronounced in dislocated than in displaced fractures. 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: MRI; Condylar fractures; Disc

Introduction In fractures of the condylar neck, particularly those with major displacement or dislocation of the condylar head,1 the joint capsule is injured. During open reduction, the joint capsule should not be opened, if possible, to protect the joint.2 There are few publications about the condition of the soft tissues of the joint, in particular, regarding the articular disc after injury and treatment. Previous data have been obtained only from clinical follow-up and radiographs, which give merely an indirect assessment of the soft tissues. Magnetic resonance imaging (MRI) is the technique that most accurately displays the soft tissues. It has become the preferred method for displaying the disc and the ligaments of

the temporomandibular joint (TMJ) particularly in degenerative disorders (Fig. 1).35 MRI was therefore used to examine the position and function of the articular disc after open treatment of fractures of the condylar process. The results were correlated with clinical data and radiographic ndings.

Patients and methods We studied 28 patients (mean age 33 years, range 1565 years) with 33 fractures of the condylar neck that required open reduction and internal xation. Their injuries occurred over a 5-year period. The fractures were classied as dislocated or displaced (Table 1)6 and were treated by ostheosynthesis. The criteria for open treatment were fracture types IIV, with an angulation of the proximal fragment of more than 30 or a reduction in the height of the ramus of more than 5 mm or both.

Corresponding author at: Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, United Kingdom. Tel.: +44 113 343 6219; fax: +44 113 343 6264. E-mail address: rloukota@doctors.org.uk (R. Loukota).

0266-4356/$ see front matter 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjoms.2006.11.019

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position of the articular process in the sagittal axis and vertical to the diagonal axis of the condyle. In MR examinations, with the mouth open and closed, the position of the articular disc was viewed bilaterally relative to the joint surfaces of the condylar process and of the temporal bone. The position of the articular process relative to the joint cavity and to the articular prominence was also assessed. Pathological changes in the ligament and capsule, such as widening of the capsule or an increase in synovial uid, were also noted. Conventional radiographs were used to assess the position of the fragment (displaced or non-displaced) and arthritic changes (exostoses, deformation, or development of cysts). Fishers exact test was used to assess the signicance of differences among the MRI results between the displaced and dislocated fractures.

Results The clinical examination showed mouth opening of at least 30 mm in all the patients. In four patients, there was a limitation of protrusion to less than 5 mm, and in three, there was a limitation to less than 5 mm of the lateral excursion. Subjective responses at the time of follow-up indicated that 27 of the 28 patients were completely satised. The remaining patient complained of restricted mandibular mobility. After MR scanning, the function of the disc was shown to be normal in eight patients. The ventral excursion of the condyle was increased in four patients (Fig. 2). In all patients, the disc was in the anterocentral section of the condylar fossa and was only slightly displaced medially in one. The damage visible on the MRI increased from displaced to dislocated fractures (Table 2). There was an increase in

Fig. 1. Magnetic resonance image of fractured condylar process.

During the follow-up, the following variables were assessed and recorded on a proforma. All patients were assessed in a standard seated position: mouth opening (interincisal gap); protrusion (labial surface of upper incisors to labial surface lower incisors); and lateral excursion left and right (relative positions of upper and lower centre lines). Patients were also asked to ll in a standard Mandibular Functional Impairment Questionnaire.7,8 The radiological investigations comprised reverse Townes view (30 posteroanterior view of the neck of the mandibular condyle) and panoramic radiographs, together with MRI. The latter were taken using an 0.5 tesla device (Phillips Gyroscan T5 XPA; Phillips Eindhoven, The Netherlands) and a TJ-surface irrigator with oblique sagittal proton density and T2 weighted SE sequences, indicating the rst and second echo of the T2 weighted SE sequences (TR = 1800 ms, TE = 25/90 ms). MR images were individually planned by the
Table 1 Number of the condylar fractures examined in 28 patients classied according to the distribution described by Spiessl and Schroll6 Type I II III IV V VI Condylar fractures Fracture without displacement Low fracture with displacement High fracture with displacement Low fracture with dislocation High fracture with dislocation Intracapsular fracture (diacapitular) 33 0 6 3 18 6 0

Fig. 2. Sagittal magnetic resonance image with increased ventral excursion of the condylar process.

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Table 2 Findings on magnetic resonance images after 33 condylar fractures Fracture Dislocated (n = 24) Disc function Normal Anterior dislocation With reduction Without reduction Disruption of joint 12 2 4 6 Displaced (n = 9) 7 1 1 0 8 0 1 0

the operation, one condylar head was signicantly smaller than the rest. Other than those three cases, there were no apparent connections between the type of fracture and the radiographic ndings.

Discussion Many clinical studies have assessed the operative results of various osteosynthesis procedures on severely displaced condylar fractures, most of which have compared the ndings after open or closed treatment using clinical, functional, and radiological examinations.915 However, there have been few publications about the condition of capsular and discal soft tissues after treatment. Previous descriptions of MR examinations of damage to the TMJ were published in 1995 by Ozmen et al.16 (n = 6) and 1 by Eckelt and Klengel (n = 16). Only in Type IV fractures, arthritic changes were seen on radiographs. There was no correlation between the type of fracture and the radiographic ndings. All discs were found in the joint cavity after treatment, so it would seem that, even when the disc is dislocated during the fracture, a reduction of the condyle is sufcient to reduce the disc. The position of the disc immediately after the fracture is anteromedial, as described by Watabe et al.17 and Takaku et al.2 For correct repositioning and function of the disc, Takaku et al.2 advised early repositioning of fragments to avoid malposition or malfunction of the disc from a contracture of the damaged capsule and retrodiscal tissue. The effects on the soft tissues caused by displacement and even more by dislocation of the fractures are apparent in the ndings of the postoperative MRI (Table 2). These show anterior dislocation without reduction of the disc in the fossa, as well as disruption of the joint and the restricted or increased ventral excursion of the condylar process. There is a similar amount of restricted movement and increased ventral displacement of the condyle in dislocated fractures (Table 3), which may result from the mechanism of the fracture, swelling of soft tissues, or other factors such as haemorrhage, oedema, and brosis. Restrictions of the ventral excursion of the condyle were usually from anterior displacement of the disc in the fossa. The discrepancies described by Ozmen et al.16 between the clinical, functional, and MRI ndings were conrmed in the present study. An accurate long-term prognosis of the condition of the TMJ cannot be made, based on good clinical or functional outcomes in patients with abnormal MRIs, as described by M uller-Leisse et al.18,19 Marguelles-Bonnet 20 et al. found a good correlation between the clinical diagnosis of disc displacement and the results of MRI. However, they also showed that the clinical examination on its own was not sufcient to identify structural defects fully. Radiological examination did not correlate with the MRI results, and sel-

Ventral excursion of condylar process Normal 9 Increased 6 Restricted 7 No assessment 1 Data are number of fractures.

Fig. 3. Sagittal magnetic resonance image with anterior dislocation of the disc without reduction.

anterior dislocation with decreased reduction of the disc (Fig. 3) and restricted mobility of the condyle (Table 3). Increased excursion of the condylar process and joint disruption was seen only after dislocated fractures (Table 2). The differences among the MRI ndings between dislocated and displaced fractures were not signicant (p = 0.3 for disc function and 0.09 for excursion of the ventral condyle). The radiographic ndings showed that 3 of the 33 fractures treated openly had healed in slightly displaced positions (Table 3), each one being a Type IV fracture (Table 1). Six months after
Table 3 Radiological results after condylar fracture Type of fracture II III IV V Normal position 6 3 18 6 Displaced condylar head 0 0 3 0 Arthrosis of the condylar head 0 0 1 0

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dom gave any indication of the internal disruption. The lack of correlation illustrates the complexity of the morphology and function of the TMJ. The MRI showed damage to the soft tissue of the TMJ in a more sensitive way than the clinical examination. This non-invasive method of recording pathological changes in patients with clinical problems is useful in diagnosis and in the planning of treatment. In future studies, the comparison of the immediate MRI ndings after injury and the long-term results of postoperative treatment will be investigated. This should elucidate the healing process of the soft tissues.

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