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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 3  |  Page : 285-288

A rare case report of fracture of the articular eminence diagnosed for the first time using cone-beam volumetric imaging


Department of Oral Medicine and Radiology, Sree Mookambika Institute of Dental Sciences, Kulasekharam, Tamil Nadu, India

Date of Submission21-Feb-2016
Date of Acceptance06-Dec-2016
Date of Web Publication13-Dec-2016

Correspondence Address:
Dr. Tatu Joy Elenjickal
Department of Oral Medicine and Radiology, Sree Mookambika Institue of Dental Sciences, Kulasekharam, Kanyakumari, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.195659

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   Abstract 

Articular eminence fractures are a rarity in practice and documented cases of articular eminence fractures are far and few and range around 3 to 4, and are due to trauma. To the best of our knowledge, this is the first case of self-inflicted articular eminence fracture documented to date. A high degree of clinical acuity, suspicion, and cutting edge imaging techniques are required to identify and diagnose fractures of the articular eminence. In this case report, we report a case presenting with unexplained facial pain and diagnosed using cone-beam volumetric imaging as fracture of the articular eminence. We attempt to highlight cone-beam volumetric imaging as a diagnostic tool with considerable benefits in the identification and diagnosis of sublime pathologies of the maxillofacial region.

Keywords: Articular eminence, arthritis, CBCT, disk interference


How to cite this article:
Elenjickal TJ, Ram SK. A rare case report of fracture of the articular eminence diagnosed for the first time using cone-beam volumetric imaging. J Indian Acad Oral Med Radiol 2016;28:285-8

How to cite this URL:
Elenjickal TJ, Ram SK. A rare case report of fracture of the articular eminence diagnosed for the first time using cone-beam volumetric imaging. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2019 Jun 25];28:285-8. Available from: http://www.jiaomr.in/text.asp?2016/28/3/285/195659


   Introduction Top


Fractures are among the most common pathologies that a maxillofacial clinician confronts in his practice and possible common investigations performed for the same would range from plain film radiography to advanced imaging techniques such as computed tomography and more recently cone-beam volumetric imaging or cone-beam computed tomography (CBCT). In practice, trauma and direct injury are the histories which will often give a clue to the clinician about a suspect fracture and prompt investigations. However, self-inflicted trauma or occult trauma may not be revealed in the patient's history and may pose a diagnostic and therapeutic challenge to the clinician. Fractures of the articular eminence are a rare entity and only three cases have been documented to the best of our knowledge. These have been associated with a history of direct trauma. Here, is an unusual case of articular eminence fracture due to self-corrected disc interference. The incidence of fractures of the articular eminence may be higher than reported; such fractures are masked by other major injuries or simply not visualized on plain film. Indeed, in the present case, there was evidence of fracture in the panoramic radiograph, however, it was not localizable as the eminence fracture; the fracture was identified by CBCT as a fragment from the eminence.


   Case Report Top


A 69-year-old female patient reported with 3-month history of right-sided sharp continuous facial pain radiating to the right ear and temporal region. The patient gave a history of difficulty in opening the mouth a few weeks ago which she opened forcibly, and noticed a loud popping sound followed by the present pain. Her medical history revealed that the patient was osteoarthritic, hypertensive with dyslipidemia, had bilateral renal calculi, and left-sided hydronephrosis, and on irregular medication. General examination revealed a rheumatoid nodule on the right little finger, bilateral deviation of second toe, and severe tenderness of the right TMJ and muscles of mastication. Intraoral examination was not significantly contributory.

Orthopantomograph showed an irregular radiopacity of size 1 × 1 cm seen in the inferior soft tissue space of right articular eminence [Figure 1]. CBCT was advised to view this fragment three dimensionally and to know its anatomical location and orientation. With the CBCT the head of condyle was viewed from all sides, and the probability of fracture of the condylar head was eliminated. The irregular discontinuity along the surface of the articular eminence, and the morphology of the fractured fragment lead to the confirmation of the diagnosis of articular eminence fracture [Figure 2] and [Figure 3]. The patient was informed about the situation. Considering the age, surgical removal of the fragment was not carried out. She was treated conservatively by advising soft diet and to consciously limit mandibular movements. The patient reported with complete remission of the severe pain and mild persisting arthralgia in 2 weeks. She was asked to report for a review with OPG/CBCT after 6 months, during which she was found to be completely asymptomatic, however, she refused to undergo a roentgenographic examination as she was pain free. She was lost for further review.
Figure 1: Orthopantomograph showing an irregular radiopacity of size 1 cm × 1 cm seen in the inferior soft tissue space of right articular eminence

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Figure 2: Three-dimensional reconstruction showing fractured fragment of articular eminence

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Figure 3: Axial view of cone-beam computed tomography image showing the fractured fragment

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   Discussion Top


Articular eminence fractures are an uncommon clinical presentation or possibly an underdiagnosed clinical presentation owing to its relatively asymptomatic presentation and subtle radiographic presentation. Keith et al. presented a case of compound fracture of the articular eminence owing to direct trauma, which was managed by repositioning the fractured fragment and stabilized by intermaxillary fixation.[1] In our case, we chose to not carry out surgical intervention and manage the situation by conservative means considering the age and willingness of the patient. Miyauchi et al. presented a case of articular eminence fracture in a 24-year-old male, which presented as a temporomandibular disorder and which occurred because of a traffic accident. The case was successfully managed by conservative measures.[2] Tay and Peck reported a case of isolated fracture of the articular eminence sustained to a high impact fall and was managed successfully by conservative means.[3] The management of fractures of the articular eminence would consist of surgical intervention with reduction of the fracture if it was interfering with functionality. If such is not the case, a conservative approach consisting of symptomatic management of pain coupled with oral physiotherapy to maintain functionality is recommended.[3]

Our case report highlights the efficacy of CBCT in the assessment of maxillofacial injuries, which are not easily delineated using conventional imaging methods. Literature of the uses and efficacy of CBCT has beyond doubt proven it to be an imaging modality far outweighing conventional imaging and in some instances, the multidetector CT (MDCT) as well. CBCT is superior to panoramic radiography as condylar and coronoid fractures and the anterior part of the mandible are more difficult to detect due to superimposition.[4],[5] Some authors demonstrated that CBCT was superior to conventional radiographs for the detection of fracture lines of patients with a maxillofacial trauma and provided more detailed information regarding subtle dentoalveolar fractures.[6],[7] While the MDCT have long since been used for the assessment of traumatic injuries, some authors stated that axial CT is not recommended for angle fractures and for the diagnosis of minimally displaced fractures.[8],[9]

Our report is the first instance of articular eminence fracture diagnosed using CBCT. It clearly presents conventional radiography as an initial screening tool but with CBCT imaging far outweighing the former, in clearly identifying the pathology with certainty and helping determine a course of management. Decision-making by the surgeon is facilitated as the question as to whether a fracture exists or not is clearly answered by CBCT imaging. The diagnostic certainty is higher for the surgeon with CBCT imaging compared to conventional radiography. Moreover, the outcome efficacy for the patient is higher according to level 5 of Fryback and Thornbury as clinical follow-up controls with medical CT scans providing higher radiation or redundant conventional radiographic examinations are minimized or avoided. CBCT provides useful additional information compared to conventional imaging concerning mandibular fractures and therefore can be recommended as an alternative compared to the MDCT scan for ambulatory patients.[10],[11]

Advanced cross-sectional imaging techniques such as CT are used in dentomaxillofacial imaging to solve complex diagnostic and treatment-planning problems, such as those encountered in craniofacial fractures, endosseous dental-implant planning, and orthodontics, among others. With the advent of CBCT technology, cross-sectional imaging that had previously been outsourced to medical CT scanners has begun to take place in dental offices.[12] A relatively low patient dose for dedicated dentomaxillofacial scans is a potentially attractive feature of CBCT imaging. An effective dose in the broad range of 13–498 Sv can be expected, with most scans falling between 30 and 80 Sv, depending on exposure parameters and the selected field of view (FOV) size. In comparison, standard panoramic radiography delivers 13.3 Sv and MDCT with a similar FOV delivers 860 Sv.[13],[14]


   Conclusion Top


Thus, CBCT is an attractive, efficient, and purposeful imaging modality in the diagnosis of subtle changes of the maxillofacial region with immense value in the diagnosis and management of maxillofacial injuries, as highlighted by our report of an articular eminence fracture detected by CBCT.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Keith O, Jones GM, Shepherd JP. Fracture of the articular eminence. Report of a case. Int J Oral Maxillofac Surg 1990;19:79-80.  Back to cited text no. 1
    
2.
Miyauchi K, Sano K, Nagai M, Ogasawara T, Nakamura M, Kitagawa Y, et al. Occult fractures of articular eminence and glenoid fossa presenting as temporomandibular disorder: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol 2006;101:e101-5.  Back to cited text no. 2
    
3.
Tay AB, Peck RH. Solitary Fracture of the articular eminence: A case report. J Oral Maxillofac Surg 2001;59:808-10.  Back to cited text no. 3
    
4.
Ziegler CM, Wörtche R, Brief J, Hassfeld S. Clinical indications for digital volume tomography in oral and maxillofacial surgery. Dentomaxillofac Radiol 2002;31:126-30.  Back to cited text no. 4
    
5.
Scarfe WC. Imaging of maxillofacial trauma: Evolutions and emerging revolutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:S75-96.  Back to cited text no. 5
    
6.
Choudhary AB, Motwani MB, Degwekar SS, Bhowate RR, Banode PJ, Yadav AO, et al. Utility of digital volume tomography in maxillofacial trauma. J Oral Maxillofac Surg 2011;69:e135-40.  Back to cited text no. 6
    
7.
Ilgüy D, Ilgüy M, Fisekcioglu E, Bayirli G. Detection of jaw and root fractures using cone beam computed tomography: A case report. Dentomaxillofac Radiol 2009;38:169-73.  Back to cited text no. 7
    
8.
Klenk G, Kovacs A. Do we need three-dimensional computed tomography in maxillofacial surgery? J Craniofac Surg 2004;15:842-50.  Back to cited text no. 8
    
9.
Markowitz BL, Sinow JD, Kawamoto HK Jr, Shewmake K, Khoumehr F. Prospective comparison of axial computed tomography and standard and panoramic radiographs in the diagnosis of mandibular fractures. Ann Plast Surg 1999;42:163-9.  Back to cited text no. 9
    
10.
Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991;11:88-94.  Back to cited text no. 10
    
11.
Kaeppler G, Cornelius CP, Ehrenfeld M, Mast G. Diagnostic efficacy of cone-beam computed tomography for mandibular fractures. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:98-104.  Back to cited text no. 11
    
12.
Miracle AC, Mukherji SK. Conebeam CT of the head and neck, Part 2: Clinical applications. AJNR Am J Neuroradiol 2009;30:1285-92.  Back to cited text no. 12
    
13.
Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:106-14.  Back to cited text no. 13
    
14.
Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography, cone beam computed tomography systems and conventional radiography. Dentomaxillofac Radiol 2004;33:83-6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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