Undiagnosed pediatric condylar fractures and ankylosis of the temporomandibular joint.

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.[45] 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.