A comparative observational study based on two radiographic techniques in suspected unilateral mandibular condylar fracture

Shereen Fatima; Mohammad Ali R Patel; Aaisha Siddiqa; Neelakamal Hallur; Mohammed Arshad Hussain; Mohammed Haneef

doi:10.4103/sidj.sidj_45_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 2 | Page : 111-115

A comparative observational study based on two radiographic techniques in suspected unilateral mandibular condylar fracture

Shereen Fatima¹, Mohammad Ali R Patel², Aaisha Siddiqa¹, Neelakamal Hallur¹, Mohammed Arshad Hussain³, Mohammed Haneef⁴
¹ Department of Oral and Maxillofacial Surgery, Al-Badar Rural Dental College and Hospital, Kalaburagi, Karnataka, India
² Department of Dentistry, KBN Teaching and General Hospital, Gulbarga, Karnataka, India
³ Department of Orthodontics, Al-Badar Rural Dental College and Hospital, Kalaburagi, Karnataka, India
⁴ Department of Oral and Maxillofacial Surgery, Ministry of Health, Assir Region, Saudi Arabia

Date of Submission	28-Oct-2020
Date of Acceptance	28-Nov-2020
Date of Web Publication	28-Jan-2021

Correspondence Address:
Dr. Mohammad Ali R Patel
Department of Dentistry, KBN Teaching and General Hospital, Gulbarga, Karnataka
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/sidj.sidj_45_20

Abstract

Objective: This hypothetical comparative study aimed to compare two radiographic techniques based on the traditional radiograph (orthopantomography [OPG]) and computed tomography (CT) scans and find the best radiographic techniques to be used to confirm diagnostic accuracy and treatment planning in suspected unilateral condylar fractures.
Materials and Methods: All patients with suspected unilateral condylar fractures were initially subjected to a radiologic assessment through a conventional radiographic technique of OPG to select the treatment modality, that is, open or closed. Subsequently, all patients were made to undergo a standard CT scan for the study of the temporomandibular joint, with the same objective, that is, (eighty radiographic imaging: forty OPG + forty CT scan) was done to determine which radiographic technique is more helpful in determining the final clinical diagnosis including treatment planning of suspected unilateral mandible condyle fracture. The findings were compared and cross-checked with those of conventional radiographic analysis.
Results: It was found that out of the selected patients of confirmed forty unilateral condylar fractures, 33 patients were indicated for closed reduction by conventional radiography, were revealed to have a lateral extracapsular displacement on CT scan, and hence were treated by open reduction. Seven patients satisfied the criteria for closed reduction, both by conventional radiographs and CT scans.
Conclusion: Through this theoretical research, it was found that both radiographic techniques are indispensable, specific, and standard in the detection of mandibular fractures. It was noted that CT scan radiographic information might help alter the approach and the treatment plan and prevent erroneous management in mandibular condylar fractures.

Keywords: Computed tomography scan, orthopantomograph, temporomandibular joint

How to cite this article:
Fatima S, Patel MA, Siddiqa A, Hallur N, Hussain MA, Haneef M. A comparative observational study based on two radiographic techniques in suspected unilateral mandibular condylar fracture. Saint Int Dent J 2020;4:111-5

How to cite this URL:
Fatima S, Patel MA, Siddiqa A, Hallur N, Hussain MA, Haneef M. A comparative observational study based on two radiographic techniques in suspected unilateral mandibular condylar fracture. Saint Int Dent J [serial online] 2020 [cited 2023 Jun 2];4:111-5. Available from: https://www.sidj.org/text.asp?2020/4/2/111/308179

Introduction

Maxillofacial trauma is of increased frequency in the present-day scenario, and fractures of the mandibular condyle are common. Maxillofacial injuries resulting from blunt or penetrating trauma are tough to manage and require a coordinated alliance between Maxillofacial Surgeons, Emergency Physicians, Ophthalmologist, Plastic Surgeons, Neurosurgeons, and ENTs to manage them. Fractures of the mandibular condyle are common injuries that account for 20%–30%^[1] of fractures of facial bones and represent 20%–52%^[2] of all mandibular fractures. Approximately 84%^[3] are unilateral, and the etiology most commonly involves road traffic accidents, about 50%; interpersonal violence about 30%; falls approximately 10%; and sports injury approximately 10%.^[1],[2] There can be few maxillofacial trauma management aspects that generate more controversy than that of the fractures involving the mandible's condylar process.^[4] The indications for management of the mandibular condylar fractures are variable and inconsistent throughout the literature.^[5] The major controversy has been between the proponents of conservative treatment and advocates of surgical treatment.^[5] Radiology represents a first-level mandatory imaging technique in jawbone fracture patients with a traumatic injury. The following three different conventional X-ray techniques, including computed tomography (CT) scan, can be considered for fracture of the jawbone in today's era: posteroanterior view, an angled anteroposterior view called reverse Towne view, and bilateral oblique view.

Apart from routine clinical and diagnostic investigations, radiological assessment of patients sustaining trauma is essential and hence in the present study, it has been undertaken using conventional radiography and specialized imaging such as CT scan.^[6] It is of utmost importance that the imaging modulation used to confirm the condylar fracture's definitive detection accurately identifies the classification for which a traditional treatment can be decided. CT images allow three-dimensional (3-D) visualization of different mandibular condylar sections and help identify the condyle's relation with the articular fossa and medial, lateral, or anterior bone displacement of the fracture.^[6],[7] CT scan evaluation of a suspected intracapsular fracture can also offer excellent evaluation and is occasionally the single means of making a diagnosis when the condylar fracture is compressed.^{[8],[9],[10],[11]} Hence, CT supplies relevant information and helps in surgical planning and assessment of treatment of the patient. In this context, this hypothetical comparative study was undertaken to determine (absence or presence of fracture & Displacement, anatomical locating of fracture, type of displacement) the influence of CT scan on conventional imaging in diagnosis and the tentative treatment plan of unilateral condylar fractures.

Materials and Methods

In the current research for 6 months, 40 adult patients (34 males and 6 females) provisionally diagnosed with a unilateral condylar fracture were included. All of these selected patients were advised to do X-rays with both radiographic techniques. Both x-ray images were interpreted by a maxillofacial surgeon who had ten years of experience. General physical examination, routine hematological examination of all selected patients, and human immunodeficiency virus and hepatitis B surface antigen testing were performed. In addition, patients' chest X-rays and electrocardiograms were evaluated for surgical management. Ethical committee approval was taken, and patients were asked to sign a written informed consent form that explained the procedures. Any surgical or postoperative complications that occur due to surgery or intermaxillary fixation procedure were explained to all unilateral condylar fracture patients assigned for surgical or conservative management. The patients were selected in the study as per the following criteria:

Inclusion criteria

Individuals with isolated, suspected unilateral condylar fracture without associated fractures
Adult patients in the age group of 18–40 years.

Exclusion criteria

Individuals with bilateral condylar fracture
Those with condylar fracture associated with other maxillary–mandibular fractures
Patients who were not fit for surgical treatment under general anesthesia
Those with insufficient dentition to restore normal occlusion
Medically compromised patients and those with a history of temporomandibular joint (TMJ) dysfunction.

Radiological assessment

Conventional radiographs were taken using standard technique, and Wipro GE-LX1 T SCAN DUAL SLICE ( Siemen's Somatom Spirit, Germany 4th generation with rotary spiral technique) Located at KBN Medical College and Hospital, Kalaburagi, Karnataka was used for CT scan examination with the following scan parameters:

Slice thickness −3 mm
Scan time −7s at 120 kV and 140 mA
Projections −Axial and coronal.

All the patients with suspected mandibular condylar fractures were initially subjected to a radiologic assessment through a conventional radiographic technique of orthopantomography (OPG)/lateral TMJ view. A standard data record form was created for the study. On this standard data record form, patients' demographic data, the reinterpretation of OPG and CT-Scan images, treatment methods (Closed or Open Reduction method), and patient outcomes were recorded in this form. Based on the conventional/Standard CT Scan radiograph, the method of reduction in which the fracture would qualify was first assessed, then the final treatment plan was determined based on the assessment of both radiographic techniques (method of reduction open or closed) to which the fracture would quantify as per indications and contraindications stated by the American Association of Oral and Maxillofacial Surgeon Special Committee, 2003.^[9] The findings were compared and cross-checked with those of the conventional radiographic analysis.

Statistical analysis

Discrete (categorical) data were summarized in number (n) and percentage (%) and compared by the Chi-square test. A two-tailed (α = 2) P < 0.05 was considered statistically significant. The analysis was performed using SPSS software (Windows version 22.0 Chicago Inc., USA).

Results

A total of forty patients were evaluated. Among the patients, 34 (85.0%) were male and 6 (15.0%) were female. Thus, there was a male predominance with a 1:5.7 female-to-male ratio. Further, the patients belonged mostly to the age group of 18–30 years (70.0%), followed by 31–50 years (20.0%) and >50 years (10.0%) [Table 1].

Table 1: Distribution of age of the patients

Click here to view

Interpretation based on data collected by both imaging techniques used to identify the anatomical location of Unilateral condylar fracture (i.e., displacement and anatomical location of fractured condyle) is summarized in [Table 3] and depicted in [Figure 1]. The OPG located 2 (5.0%) cases at intra/extracapsular, 6 (15.0%) at subcondylar, and 32 (80.0%) at condylar neck, whereas CT scan located the corresponding locations at 7 (17.5%), 28 (70.0%), and 5 (12.5%), respectively. Radiologic evaluation by both imaging techniques was found to be statistically significantly different in unilateral corneal fracture detection (χ² = 36.72, P < 0.001) [Table 2] and [Figure 2].

Table 3: Distribution of locating condylar location after fracture by two imaging techniques

Click here to view

Figure 1: Bar graphs showing the anatomical locating of condylar fracture by two different imaging techniques

Click here to view

Table 2: Distribution of anatomically locating mandibular condyle fracture by two imaging techniques

Click here to view

Figure 2: Bar graphs showing the distribution of locating fracture anatomically by two imaging techniques

Click here to view

The distribution of anatomical locating of condylar fracture (i.e., displacement and anatomical location of fractured condyle) after fracture according to the two imaging techniques is summarized in [Table 3] and depicted in [Figure 1]. The OPG located 41 condylar locations, whereas the CT scan located a total of 68 condylar locations. Thus, the CT scan located 27 more condylar locations than that of the OPG. Of the total condylar locations, OPG located 25 (61.0%) as undisplaced, 8 (19.5%) as medially displaced, and 8 (19.5%) as laterally displaced, whereas in the CT scan, the corresponding locations were 15 (22.1%), 32 (47.1%), and 21 (30.9%), respectively. The locating condylar locations also differed statistically significantly between the two imaging techniques (χ² = 17.09, P < 0.001) [Table 3] and [Figure 1].

The distribution of treatment planning by two imaging techniques is summarized in [Table 4]. Both techniques showed a similar distribution of treatment planning, namely, 33 (82.5%) open reduction and internal fixation and 7 (17.5%) closed reduction (χ² = 0.00, P = 1.000) [Table 4].

Table 4: Distribution of treatment planning by two imaging techniques

Click here to view

Discussion

Before the advent of CT, surgeons entirely depended on their clinical acumen and correlation with conventional radiographs for a definitive diagnosis. However, the diagnosis tended to be less precise due to fractures' intricacies involving the complicated maxillofacial skeleton. Nevertheless, the actual course of the management of maxillofacial trauma is ultimately determined by surgical exploration. It appears that 3D CT images, by exposing more details of anatomy, help understand the spatial relationship of fracture with other anatomical landmarks, effectively ending the role of exploratory surgery. And thus, the use of CT scans has been making management more sensitive, thereby improving the outcomes.^{[12],[13],[14]} CT has now made it possible to appreciate the subtleties of the complex array of fractures involving the facial skeleton-like midfacial fractures and condylar fractures.^[9]

Radiological examination of the fractured condyle in the past included OPG, posterior and anterior views of the skull, reverse Towne's view, and TMJ projections. However, in conventional radiographs, the overlap of structures may impair a proper interpretation of images. Intracapsular fractures of mandibular condyle and fractures in a high portion of the condylar process are difficult to be seen in plain films. Contingent on the position, the image may miss the displacement of bone fragments, impairing a correct diagnosis. Conventional radiographs have not allowed accurate assessment of fracture position. This has especially been true for some cases of high condylar neck fractures in which additional fracture lines and definitive classification of the fracture type could not be assessed.^[10] CT scan allows visualization of cross-sectional images, which improves fractures' diagnosis by suppressing the undesired visual overlap of sections. CT scan has proved to be very suitable for evaluating the condyle's position in the lateromedial direction. CT scan can also clearly visualize the superior and medial parts of the condyle and the mandibular fossa.^{[10],[15],[16]}

CT scans have improved the efficacy of diagnosis of condylar fractures and have thus led to more accurate analyses of fracture types and fracture lines, thereby leading to more effective therapy.^[9],[10] It has been very useful for surgeons to select treating methods of condylar fractures.^[11] Kahl et al.,^[17] in their study on CT analysis of the TMJ, have appreciated the usefulness of CT as a diagnostic tool in TMJ trauma. They also emphasized that if open reduction is chosen as the treatment mode, CT is desirable because the added information makes preoperative planning more accurate and facilitates surgical intervention.^[9],[12] Even today the management of mandibular condylar fractures remains a major controversy in oral and maxillofacial surgery practice. Some variables affect the decision of closed versus open treatment.^[5],[6] Although an area of disagreement still exists, there are many areas of agreement. The main reason for choosing open reduction and internal fixation of condylar fractures is because it permits primary healing of unreduced and unstable condyle fractures in order to prevent deviation, occlusal discrepancies and decrease in the ramus height. Because of the potential for long-term morbidity and as the principles for treating fractures in this area vary widely from those used to treat other mandibular areas, special considerations must be given to condylar fractures.^[5] The treatment of condylar fracture has been plagued by controversy ever since its inception. Different authors have different schools of thought for condylar fractures based on individual clinical studies with contradicting results. Irrespective of the differing opinions, the ultimate goal undoubtedly is anatomic reduction^[7] of the fractured condyle, thereby preventing malocclusion, asymmetry, dysfunction, and mandibular hypomobility.^[7],[18]

CT scan is considered a gold standard radiographic technique for the diagnosis and management of condylar fractures. Still, in 2020, Shakya et al.^[19] concluded that CT scan could not provide a visual view of the fracture site including detailed surgical data advocating in the use of virtual evaluation for all condylar fractures in preoperative surgical planning. No research has been carried out on prediction on the comparison of OPG and CT scan radiographic imaging techniques used for diagnostic accuracy and treatment planning in mandibular condylar fractures. However, an attempt has been made to discuss and describe the results observed in this comparative study.

Conclusion

The value of CT cannot be underestimated in maxillofacial injuries. It is especially noteworthy that CT's information may help alter the approach and the treatment plan and prevent erroneous management. Traditional radiographic techniques have been used by maxillofacial surgeons for more than a decade and are their first choice of effective radiographic method in diagnosing and detecting jaw bone fractures. With this observational study, the author believes that CT scan is a fairly reliable method, like other conventional radiographs used to diagnosis of mandibular fractures. If CT scans can come up with a decrease in radiation exposure and cost in the near future, this radiographic technique can be routinely used in diagnosing maxillofacial trauma.

Availability of data material and consent

Datasets used and analyzed during the current study can be made available from the corresponding author upon appropriate request.

The patients enrolled in the study signed an informed consent form to participate and to publish the obtained data used in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Nardi C, Vignoli C, Pietragalla M, Tonelli P, Calistri L, Franchi L, et al. Imaging of mandibular fractures: A pictorial review. Insights Imaging 2020;11:30.
2.	Sawazaki R, Lima Júnior SM, Asprino L, Moreira RW, de Moraes M. Incidence and patterns of mandibular condyle fractures. J Oral Maxillofac Surg 2010;68:1252-9.
3.	Nardi C, Calistri L, Grazzini G, Desideri I, Lorini C, Occhipinti M, et al. Is panoramic radiography an accurate imaging technique for the detection of endodontically treated asymptomatic apical periodontitis? J Endod 2018;44:1500-8.
4.	Nardi C, De Falco L, Selvi V, Lorini C, Calistri L, Colagrande S. Role of cone-beam computed tomography with a large field of view in Goldenhar syndrome. Am J Orthod Dentofacial Orthop 2018;153:269-77.
5.	Bagheri SC, Chris J. Clinical Review of Oral and Maxillofacial Surgery. Vol. 2. Mosby: Elsevier Publication; 2014. p. 234.
6.	Watanabe H, Nomura Y, Kuribayashi A, Kurabayashi T. Spatial resolution measurements by Radia diagnostic software with SEDENTEXCT image quality phantom in cone beam CT for dental use. Dentomaxillofac Radiol 2018;47:1-6.
7.	Brandt MT, Haug RH. Open versus closed reduction of adult mandibular condyle fractures: A review of the literature regarding the evolution of current thoughts on management. J Oral Maxillofac Surg 2003;61:1324-32.
8.	Singh AT, Kaur J. Evaluation of Efficacy between 2 – dimensional and 3 – dimensional computed tomography in the management of maxillofacial trauma. J Oral Maxillofac Surg 2003;2:151-4.
9.	Silva CE, Antues VL, Cavalcanti MG. Interpretation of mandibular condylar fractures using 2D and 3D computed tomography. Brazil Dent J 2003;14:203-8.
10.	Park SS, Lee KC, Kim SK. Overview of mandibular condyle fracture. Arch Plast Surg 2012;39:281-3.
11.	Choi KY, Yang JD, Chung HY, Cho BC. Current concepts in the mandibular condyle fracture management part II: Open reduction versus closed reduction. Arch Plast Surg 2012;39:301-8.
12.	Guss DA, Clark RF, Peitz T, Taub M. Pantomography vs mandibular series for the detection of mandibular fractures. Acad Emerg Med 2000;7:141-5.
13.	Wu H, Luo J, Zhu Z. Clinical study of three dimensional reconstruction of computed tomography in diagnosis of condylar fractures. Hua Xi Kou Qiang Yi Xue Za Zhi 2000;18:42-4.
14.	Naeem A, Gemal H, Reed D. Imaging in traumatic mandibular fractures. Quant Imaging Med Surg 2017;7:469-79.
15.	Aydin U, Gormez O, Yildirim D. Cone-beam computed tomography imaging of dentoalveolar and mandibular fractures. Oral Radiol 2020;36:217-24.
16.	Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 1: Patterns of distribution of types and causes of fractures in 348 patients. Br J Oral Maxillofac Surg 2000;38:417-21.
17.	Kahl B, Fischbach R, Gerlach KL. Temporomandibular joint morphology in children after treatment of condylar fractures with functional appliance therapy: A follow-up study us computed tomography. Dentomaxillofac Radiol 1995;24:37-45.
18.	Nicolos BB. Radiology for maxillofacial trauma. In: Text for Oral and Maxillofacial Surgery, Peter Ward Booth. 1st ed. Vol. 1. Mosby: Elsevier Publication; 1999. p. 259-87.
19.	Shakya S, Zhang X, Liu L. Key points in surgical management of mandibular condylar fractures. Chin J Traumatol 2020;23:63-70.