Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Condylar fractures represent one of the most controversial issues in maxillofacial traumatology regarding classification, diagnoses and therapeutic management. Classification systems of condylar fracture is discussed. Diagnosis is usually based on history clinical examination and radiographic finding. Treatment ranges from observation, jaw exercises to closed or opened interventions. For years closed reduction was thought to be essentially complication-free. Several serious complications however have been reported including temporomandibular joint ankyloses, malocclusion, mandibular deviation and the generative joint pathology. The absolute and relative indications for open reduction is given. The debate between supporters of open or closed reduction is still continuing and the issue has not been resolved. However, the final choice treatment modality should takes into account the location of the fracture, age of the patient, presence or absence of other associated injuries, cosmetic impact of the surgery and presence of other systemic medical conditions.

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

3. Fractures of mandibular condyle can be counted among
the most controversial issues in maxillofacial
traumatology regarding classification, diagnosis and
therapeutic management.
Despite the fact that the temporomandibular joint is well
protected in the glenoid fossa, and that the condylar
process is relatively well protected by the zygomatic
arch against direct injury, condylar injuries are relatively
common. Condylar fractures represent 29-40% of the
fractures of the facial skeleton, and about 20-35% of all
mandibular fractures
.
(1)

4. In terms of strength, the condylar neck constitutes the
weakest region of the entire mandible and is therefore the
most susceptible to fracture as a result of indirect forces,
where the forces of impact are transmitted along the
mandible from distant sites such as the angle, body or
symphysis to the condylar neck. The central force in the
middle of chin can cause a bilateral condylar fracture. The
most common causative factors are physical trauma,
accident, fall, sports injury, gunshot wounds and industrial
hazard. Unilateral fractures occur approximately 3 times
more frequently than bilateral fractures do, but bilateral
fractures are not uncommon

5. Several classification systems have been developed.
Generally, there are two types of fracture,
intracapsular and extracapsular, but for practical
purposes, the anatomical level of the fracture is
divided into three sites: the condylar head
(intracapsular), the condylar neck (high or low) and
the subcondylar region (2). The fracture is farther
classified as: undisplaced, deviated, displaced (with
medial or lateral overlap, or complete separation),
and dislocated (outside the glenoid fossa) (3)

7. One of the most commonly used classifications was
that developed by Spiessel and Schroll (4). They
distinguish between fractures of the condylar base
and neck, and based on the fracture position and the
relationship between the fracture fragment and
glenoid fossa

8. Type I, condylar
neck fracture,
without deviation/
displacement of
the fragments.
Spiessel and Schroll, 1972

9. Type II, low condylar
neck fracture with
deviation/displacement.
Frequently there is still
contact between the
bone fragments
Spiessel and Schroll, 1972

10. Type III, high
condylar neck
fracture with
anterior, posterior,
medial, or lateral
deviation/displaceme
nt. As a rule, there is
no contact between
the fragments
Spiessel and Schroll, 1972

11. Type IV, low
condylar neck
fracture with
dislocation
Spiessel and Schroll, 1972

12. Type V, high
condylar neck
fracture with
dislocation
Spiessel and Schroll, 1972

13. Type VI, intracapsular
fracture. These occur
mostly in children
younger than 6 years.
Spiessel and Schroll, 1972

14. In addition, according to Lindahl (5), fractures of the
condyles can be classified into six classes, vertical slit
of the head (class I), horizontal break but mildly or not
displaced (II), displacement of the segments (III), there
may be medial overlap (IV) or lateral overlap (V) of
the displaced smaller proximal segment and a possible
partial or complete dislocation of the segment. Rarely,
fractures of the condyle may also be communited
(class VI) especially with gunshot injuries

15. History of falls, blows to the contralateral face or
ipsilateral preauricular area, or chin injuries should
alert the examiner to the possibility of a
condylar/subcondylar injury. Because of the U-shaped
mandibular anatomy, patients thought to have a single
mandibular fracture often have others. Also, the
patient with a subcondylar fracture often has another
mandibular fracture. Nevertheless, an isolated
subcondylar or intracapsular fracture is quite possible

16. By inspecting patients with a fracture of the mandibular condyle,
one or more of the following clinical signs and symptoms could
usually be noticed:
1) Swelling over the preauricular region
2) Possible bleeding from the ear
3) A laceration or contusion of the chin
4) Facial asymmetry due to soft tissue edema or secondary to
shortening of the mandibular ramus
5) Varying degree of limited mandibular movement
6) Pain and tenderness to palpation over the affected TMJ
7) Deviation of the mandibular midline with posterior open bite
8) Marked anterior open bite may indicate bilateral condylar
fractures

17. Chin injury, the associated condylar fracture

18. A fractured condyle does not translate down the articular
eminence on jaw opening. The unopposed translation of the
opposite condyle deviates the chin toward the fractured side

19. A fractured condyle usually is distracted antromedially by the lateral
ptergoid muscle. This produces a shortened functional height of the
ramus by the pull of the elevator muscles. The ipsilateral molar teeth
act as a fulcrum to produce a slight contralateral anterior open bite

20. Plain radiography (most commonly) and CT scanning
help to ascertain the location of the fracture, the
degree and direction of displacement, and the presence
or absence of associated injuries. Panoramic
radiography is a useful study. Anteroposterior (AP)
Towne’s view is particularly helpful for ascertaining
the mediolateral position of the respective fractured
segments, information not readily available from a
panoramic view

21. Subcondylar fracture ; Panorama

22. AP Towne’s View

23. CT scanning in axial and coronal planes can yield
much information about this area provided that the
sections are sufficiently close to obtain images of the
area and provided the practitioner is intimately
familiar with the pertinent anatomy. CT scanning does
provide the most information about intracapsular
fractures

24. Coronal section, CT Scan

26. Treatment ranges from observation, jaw exercises to
closed or open interventions (6). In almost every instance,
unless associated with other mandibular fractures, isolated
intracapsular fractures, should be treated solely with
physical therapy. If properly rehabilitated, most of the
patients regain proper occlusion and full range of
mandibular movements. In the early rehabilitative phase,
controlling the occlusion (usually by means of arch bars
and elastics) while emphasizing return of normal range of
motion is important. The patient should be instructed in
wide range of motion exercises immediately post injury

27. Treatment of subcondylar condyle is among the most
controversial issues in maxillofacial trauma (7).
Ideally, treatment of condylar fractures must realize
three main aims: consolidation of the bony fragments ,
anatomic correction of the segments, and restoration
of joint function which typically involves pain-free
movement mouth opening beyond 40 mm. and the
restoration of the preoperative occlusion and facial
symmetry. Of these three goals, the restoration of joint
function is the most important (8)

28. For years, closed treatment using inter maxillary
fixation was the preferred method of treatment and
was thought to be essentially complication free.
Basically, the technique is conservative nonsurgical
one. Thus it eliminates the need for hospital stay and
prevents the possible intra and postoperative
complications associated with open reduction, namely
bleeding, infection, auriculotemporal nerve injury,
facial nerve paralysis, and visible scaring. Although
anatomic reduction is not possible with closed
reduction, it was believed that the selective exercises
lead to functional adaptation and remodeling of the bony
structures and the surrounding soft tissues (9)

29. For closed reduction, intermaxillary fixation is conducted using
arch bar and wire, followed by maintaining of the fixation of
the maxilla and mandible for 2 to 4 weeks. Elastic traction is
then used for additional 2 weeks to maintain normal occlusion.
Aggressive physical therapy and close follow-up is then
conducted for a period of 6-12 weeks. Closed reduction is
indicated for pediatric and geriatric patients and for medically
compromised patients as well. Of the utmost importance for all
patients, is the physical therapy regimens. Physical therapy
consists of a series of opening exercises. Some devices on the
market, such as the Therabite, can assist a patient with these
exercises. An alternative and inexpensive method consists of a
stack of tongue blades that can be increased in number each
day

31. However, serious complications have been reported in
cases treated with closed reduction including,
temporomandibular Joint ankylosis, malocclusion,
mandibular deviation, and pathological changes to the
condylar process (10). Further, it has been noted that
patients treated by closed methods, compared to those
treated by open methods, developed asymmetries
characterized by significantly shorter posterior facial
and ramus heights on the side of injury, and more
tilting of the occlusal plane (11)

32. Open reduction means principally, exact anatomical
reduction under direct vision and at the same time
retention and internal fixation of the fracture by means of
functionally stable osteosynthesis.
Zide and Kent (12) summarized the indications for treating
subcondylar fractures in open manner as absolute and
relative:
Absolute Indications:
a. Displacement into the middle cranial fossa
b. Impossibility of obtaining adequate occlusion by closed
reduction
c. Lateral extracapsular displacement of the condyle
d. Invasion of a foreign body (e.g.: gunshot wound)

33. Relative Indications:
a. Bilateral condylar fracture in edentulous patients
when splinting is impossible
b. Unilateral or bilateral condylar fractures when
splinting is not recommended for medical reasons
or adequate post operative physiotherapy is
impossible
c. Bilateral condylar fractures associated with
comminuted mid-facial fractures
d. Bilateral condylar fractures associated with
significant pre-injury malocclusion

34. Multiple approaches are possible in order to visualize and
reduce submandibular fractures. Extraoral approaches
include the preauricular, retroauricular, retromandibular,
and submandibular incisions, often in combination.
Intraoral approaches include the mandibular vestibular
incision with or without the use of an endoscope. In both
cases, a transbuccal trocar for the placement of some or all
of the screws is usually necessary. Whatever approach is
chosen, once the fracture is exposed, it must be reduced.
Whether the fracture must be fixated and how stable that
fixation should be are also topics of much debate

35. Wire fixation and intramedullary pins have been used
to stabilize these fractures. More recently, miniplates
and screws are in use. Argument exists as to whether
these constitute rigid fixation. Certainly, a miniplate
that rigidly fixates the condylar segment in a
nonphysiologic position sets up the patient for pain,
poor function, and degenerative joint disease. Again,
occlusal control and physiotherapy remain crucial to
successful outcomes

36. position of two plates used to stabilize a subcondylar fracture

37. The debate between the supporters of open or closed
reduction is still continuing and the issue has not been
resolved. At present, except for the highly located
intraarticular fractures, open surgery appears to be the
main stream approach for treating mandibular fractures at
the condylar neck or subcondylar level. However, the final
choice of treatment modality for each individual patient
should takes into account a number of factors, including
position of the condyle, location of the fracture, age of the
patient, presence or absence of other associated injuries,
presence of other systemic medical conditions, history of
previous joint disease, cosmetic impact of the surgery, and
desires of the patient

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