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National Journal of Maxillofacial Surgery
 
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Table of Contents
EDITORIAL
Year : 2014  |  Volume : 5  |  Issue : 2  |  Page : 107-108  

Undiagnosed pediatric condylar fractures and ankylosis of the temporomandibular joint


Department of Oral and Maxillofacial Surgery, CDER, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication10-Apr-2015

Correspondence Address:
Dr. Ajoy Roychoudhury
Department of Oral and Maxillofacial Surgery, CDER, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.154807

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How to cite this article:
Roychoudhury A. Undiagnosed pediatric condylar fractures and ankylosis of the temporomandibular joint. Natl J Maxillofac Surg 2014;5:107-8

How to cite this URL:
Roychoudhury A. Undiagnosed pediatric condylar fractures and ankylosis of the temporomandibular joint. Natl J Maxillofac Surg [serial online] 2014 [cited 2019 Oct 19];5:107-8. Available from: http://www.njms.in/text.asp?2014/5/2/107/154807










For those of us who regularly treat temporomandibular joint ankylosis know that the major cause (70-80%) is undiagnosed closed condylar fracture or injury. [1] This has taken enormous proportions specially in the states of Uttar Pradesh, Bihar, and Jharkhand. Incidentally, these states have fared very poorly in health care set up in the 2009 report. [2] In a study at major National referral hospital, 85% of cases have been from these states. [3]

There is a plethora of reasons for this. Fall over the chin, which is most common etiology usually leads soft tissue injury (hematoma, laceration, abrasion) over the area of direct impact. [4],[5] The associated soft tissue injury may deflect the attention of clinician and parent from the actual site of fracture at condylar area, which by the way, due to its closed nature is not evident and is often missed in diagnosis. Moreover, many a times the associated soft tissue injury may not be present and illiteracy and fear of economic burden makes sure that such patient never visit the hospital. Advice is taken from elders of the house, who many a times ask patients to not use the joint. Pain in jaw movement is often deemed as a sequel to trauma with a hope that it will recover in due course. This creates a perfect environment for a fracture healing and excessive bone formation leading to ankylosis.

Poor literacy levels, nonavailability of dental health care provider in the public health center (PHC) further adds to missed diagnosis. Less than 20% of India's PHC have the services of a dentist. The dentist to population ratio is 1:10,000 in urban areas whereas in rural areas it is 1:150,000. [6] Diagnosing the condylar fracture needs a proper co-relation of radiographic findings and clinical signs and symptoms. Resources are limited at the PHCs and patients are often referred to the larger health center where again only medical specialists and medical health care providers are available. Most of our medical healthcare providers are not sensitized to diagnose a fracture of the condyle in a child especially when jaw movement is present albeit less than normal and with pain.

Lack of adequate medical and dental personnel in rural hospitals, illiteracy, economic burden, lack of knowledge about condylar injuries and its sequelae, uncooperative child and improper advice of elders or sometimes medical specialist in the wake of benign nature of the closed condylar injuries leads to developing ankylosis, which develops not instantly but over next few years.

It is totally unacceptable that at this juncture of economic and medical growth in India such preventable phenomenon is not acted upon. The need of the hour is: (1) Medical officers, village health nurses and other paramedic support staff of PHCs, private allopathic and nonallopathic practitioners and personnel involved with child healthcare programs like the Integrated Child Development Scheme, Accredited Social Health Activists which especially focus on pediatric age group should be trained regarding possibility of condylar injuries following maxillofacial trauma, especially with direct injury to the chin. (2) Vacancies in the primary healthcare tier should be filled so as to prevent dependence of the rural population on under-qualified private medical practitioners. (3) Dental surgeons who are better trained in maxillofacial trauma should be included in the primary healthcare setup. (4) A robust referral system is necessary so as to refer patients with maxillofacial injuries to dental surgeons and maxillofacial surgeons in areas where dental practitioners are unavailable. (5) Community health centers should be equipped with dental radiographic equipment, and patients with such injuries should be referred and radiographed at these centers. (6) Dental associations should take up this cause and sensitize the medical health care workers and specialist regarding the possibility of closed condylar injury in the event of chin trauma and proper referral to the dentist or maxillofacial surgeon. (7) Paramedical staff if trained regarding facial injuries in children can at least recommend that the patient may be examined by dental/maxillofacial surgeon. (8) The simple management of condylar fractures in pediatric age group consists of aggressive mouth opening exercises and regular follow-up to monitor mouth opening. Even an MBBS medical officer can institute such management protocol. If unsure of condylar fracture in such patients, mouth opening exercises should be advised, and patient's parents informed regarding the possibility of ankylosis and the need for follow-up with the practitioner for at least 6 months.

 
   References Top

1.
Roychoudhury A, Parkash H, Trikha A. Functional restoration by gap arthroplasty in temporomandibular joint ankylosis: A report of 50 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:166-9.  Back to cited text no. 1
    
2.
Gill K. Primary Evaluation of Service Delivery Under the NRHM. Findings from a Study in Andhra Pradesh, Uttar Pradesh, Bihar and Rajasthan. Working Paper 1/2009. PEO Planning Commission for India; 2009.  Back to cited text no. 2
    
3.
Nagori SA, Jose A, Bhutia O, Roychoudhury A. Undiagnosed mandibular condylar fractures causing temporomandibular joint ankylosis: A public health problem in northern India. Natl Med J India  [In press].  Back to cited text no. 3
    
4.
Karim T, Khan AH, Ahmed SS. Trauma of facial skeleton in children: An indian perspective. Indian J Surg 2010;72:232-5.  Back to cited text no. 4
    
5.
Singh G, Mohammad S, Pal US, Hariram, Malkunje LR, Singh N. Pediatric facial injuries: It's management. Natl J Maxillofac Surg 2011;2:156-62.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Vashisth S, Gupta N, Bansal M, Rao NC. Utilization of services rendered in dental outreach programs in rural areas of Haryana. Contemp Clin Dent 2012;3:S164-6.  Back to cited text no. 6
    



This article has been cited by
1 Study of risk factors for developing post-traumatic temporomandibular joint ankylosis
Krushna V. Bhatt,Ajoy Roychoudhury,Ongkila Bhutia,Renu Saxena,Viveknandhan Subbiah,Parthaprasad Chattopadhyay,Sudip Sen,Ravindra M. Pandey
European Journal of Oral and Maxillofacial Surgery. 2019; 3(1)
[Pubmed] | [DOI]



 

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