Injuries to the Mandibular

Condyle and Subcondylar

Region
John Hofheins
UAB OMFS
Overview
1. Anatomy
2. Examination
3. Injuries to the condylar region
4. Treatment
5. Outcomes
“Anatomy is
destiny”
Temporomandibular joint
• Biggest risks are CN VII &
Retromandibular Vein
• RMV
• Superficial temporal vein &
maxillary vein unite à RMV
• Forms within the parotid medial
to condylar neck deep to CN VII
• CN VII
• Main trunk 2 cm deep to the skin
surface at the middle of the
anterior border of the mastoid
process
• Al-Kayat & Bramley defined
several landmarks to estimate its
location
• 8-mm ”safe” zone for pre-
auricular incisions
• Al-Kayat and Bramley
• Mean distance from lowest
portion of the boney external
auditory canal to the
bifurcation of the facial nerve
was 2.3 cm and that from the
post-glenoid tubercle was
3mm
• Upper trunk of CN VII crosses
the zygomatic arch 0.8 – 3.5
cm from ant boney external
auditory canal
Injuries to the condylar region
• Mandibular fractures represent 45% of all facial fractures.
• Common causes:
• MVA
• Interpersonal violence
• Falls
• Sports related injuries
• Condylar & subcondylar fractures represent 29% mandibular fractures - Ellis
• Large amounts of force are transmitted to the condyles
• Relatively high incidence of skeletal & soft tissue injuries in the
condylar and subcondylar region
Soft tissue injuries
• Most commonly blunt trauma
• Rapid acceleration/deceleration injuries
• Disc displacement
• Damage to TMJ soft tissue can lead to chronic dysfunction
• Hyperemia of the capsule
• Hemarthrosis
• Shredding of the disc and articular surfaces
• More severe articular surface damage when no fracture
• However, damage to the disc is more common in fractures
 Skeletal Injuries Most common fracture
pattern

• Condylar neck & subcondylar regions

represent weak points on the mandible
• Unilateral fractures are more common
Classification Systems
• Spiessl and Schroll Classification of Condylar Process Fractures – 1972
• Type I – Fracture w/o displacement
• Type II – Low fracture w/ displacement
• Type III – High fracture w/ displacement
• Type IV – Low fracture w/ dislocation
• Type V – High fracture w/ dislocation
• Type VI – Intracapsular (diacapitular)
Classification continued
Evaluation/Examination
• Complete history and physical exam
• Mechanism of injury
• Areas injured
• Time course until pt presents to hospital
• Pt should have undergone thorough trauma eval ruling out other more serious
injuries
• Typical CC
• Pain
• Limited mouth opening
• Changes to occlusion
• Not unusual for pt to have no complains related to condylar injury at time
of presentation
 Examination
• Complete head and neck examination
• Characteristic findings of condylar &
TMJ injuries:
• Facial swelling
• Abrasions/lacerations to ant. mandible
• Ecchymosis
• Tenderness
• Facial asymmetry w/ chin deviation (less
common)
 Examination cont.
• Soft tissue injuries
• Hemarthrosis
• Often subtle or absent
• Pain/pressure in the ipsilateral pre-auricular region
• Increases w/ opening
• Decreased max opening
• Ecchymosis is generally absent
• Disc Displacement
• Often subtle or absent in acute setting
• Changes in occlusion
• Decreased max opening
• Opening is often rotational w/o translational component
• ”Soft tissue injuries of the TMJ in acute settings may be remarkable only for
their lack of findings on clinical exam” – Fonseca’s
 Examination cont.
• Oral exam:
• Dental trauma
• Occlusal changes
• Side of injury contacts first
• Open bite
• Limited opening
• Deviations
• Typically towards side of injury
• Facial widening
• Bilateral fractures w/ symphysis
 Radiographic Exam
• Radiographic eval serves 2 functions:
• Confirm the diagnosis of a fracture
• Allow detailed classification of the fracture
• Classically two plain films of the mandible taken at
90˚ to each other
• Typical mandibular series (4):
• Right and left lateral obliques
• Posterior/anterior
• Towne’s views
• Panoramic also used
• Computed Tomography (CT)
• Several investigations have found plain films with panos
are just as sensitive as CT
• However, less successful at classifying fractures
• MRI
• Diagnosis of soft tissue injuries
Treatment
• Goals:
• Reestablish normal form/function
• Reestablish occlusion with normal opening
• Patient should not be left with facial asymmetry
• No chronic joint pain
Treatment – Soft tissue
• Almost universally managed conservatively in the acute setting
• Hemarthrosis and joint effusions
• Soft diet, warm compresses, and anti-inflammatory medications
• Arthrocentesis has been used to clean out hemarthrosis in cases w/
intracapsular fractures
• Capsular tears and disk displacement
• Conservative management
• Physical therapy
• Many will not recover normal joint function w/ conservative therapy
alone
Treatment – Closed
• Traditionally ALL condylar fractures were managed closed w/ period
of MMF
• Recognized that true anatomic reduction was not achieved
• Children & teenagers
• Reestablish preinjury occlusion
• Typically via archbars
• MMF 1-3 weeks vs no continuous MMF
• Immediate guiding elastics
• Early rehab w/ range of motion exercises
Treatment – Closed cont.
• MMF disadvantages
• Hygiene/nutrition
• Limited joint mobility – Physical therapy
• Physiological changes:
• Muscle atrophy & shortening of fibers
• Degenerative changes of cartilage
• Shortening of tendons & joint capsule
• Decrease in fluid content of fibrous tissue
• Decrease in GAG content of joint fluid
• ALL fractures of the condylar process can be managed closed
• However, good outcomes become less predictable w/ dislocated or severely
displaced fractures
Treatment – Closed cont.
• MMF disadvantages
Is the patient willing to accept the possibility of a
• Hygiene/nutrition
• malocclusion or facial
Limited joint mobility asymmetry
– Physical therapy with a closed
• Physiological changes: procedure?
• Muscle atrophy & shortening of fibers
• Degenerative changes of cartilage
• Are they
Shortening willing
of tendons to capsule
& joint accept the morbidities
• Decrease in fluid content of fibrous tissue
associated
• Decrease in GAGwith anofopen
content joint fluidprocedure if a better
functional
• ALL outcome
fractures of is more
the condylar predictably
process achieved?
can be managed closed
• Good outcomes become less predictable w/ dislocated or severely displaced
fractures
Treatment - Open

• 1983 Zide & Kent described the

absolute and relative indications
for open treatment of condylar
fractures
 Treatment – Open cont.
• Pre-auricular approach
• Intraoral approach
• Submandibular approach
• Retromandibular approach
• Pre-auricular incision + retromandibular incision
(“face lift” approach)
• Endoscopically assisted approaches
 Treatment – Open cont.
• Pt is placed in MMF w/ elastics
• Prep and drape
• Incision is placed just behind the posterior border
of the mandible
• 5mm below the earlobe
• Biggest anatomical risks are CN VII & RMV
• Fracture is typically plated using a 4- to 6- hole 2.0
fracture plate
• Pt is taken out of MMF and occlusion is checked
• Closure
Treatment – Endoscopically assisted
• Goals of endoscopic techniques:
• Gain minimally invasive access to the subcondylar region
• Achieve anatomic reduction of fracture segments
• Maintain reduction with miniplate fixation
• Smaller incision & reduced risk for CN VII injury
• Can be accessed intraorally or via submandibular incisions
• Trocars may be used to allow access of drill
• Two-operator procedure
• One surgeon controls endoscope
• Second manipulates instruments
 Endoscopic Workflow
• Pt is placed in MMF w/ elastics
• Intraoral or submandibular incision
is made
• Plates can be introduced through
incision and positioned w/
endoscopic guidance
• Drill can be introduced either via
submandibular incision or via
trocar
• MMF elastics are removed and
occlusion is verified
Treatment Outcomes/Complications
• Children show excellent results when ALL fracture types are treated closed
• Greater capacity for bone healing/remodeling
• Infection and nonunion are rare compared to other mandible fractures
• Large body of literature comparing closed vs. open treatment
• Fonseca seems to support open treatment
• Closed has higher instances of:
• Facial asymmetry, chin deviation, less mandibular mobility, poorer occlusal results, post op joint
pain
• Peterson’s advocates the utility of closed
• Often issues evaluated in studies have little clinical significance
• Many complications were not “obvious” or subtle due due to adaptation
• Both techniques are predictable with a low morbidity
Summary
• Excellent results are achieved with both open and closed treatments
• Endoscopic techniques offer minimally invasive approaches with
direct visualization and reduced risk for damage to CN VII
Citations
• Al-Kayat, Adil, and Paul Bramley. “A Modified Pre-Auricular Approach to the Temporomandibular Joint and Malar
Arch.” British Journal of Oral Surgery, vol. 17, no. 2, 1979, pp. 91–103., doi:10.1016/s0007-117x(79)80036-0.
• Choi, Kang-Young, et al. “Current Concepts in the Mandibular Condyle Fracture Management Part I: Overview of
Condylar Fracture.” Archives of Plastic Surgery, vol. 39, no. 4, 2012, p. 291., doi:10.5999/aps.2012.39.4.291.
• Ellis. “Retromandibular Approaches.” AO Foundation Surgery Reference,
surgeryreference.aofoundation.org/cmf/trauma/mandible/approach/retromandibular-approaches#principles.
• Ellis, Edward. Surgical Approaches to the Facial Skeleton. Wolters Kluwer, 2019.
• Fonseca, Raymond J. Oral and Maxillofacial Surgery. Vol. 2, Elsevier, 2018.
• Jones, Jeremy. “Mandibular Condyle Fracture/Dislocation: Radiology Case.” Radiopaedia Blog RSS,
radiopaedia.org/cases/mandibular-condyle-fracturedislocation.
• Miloro, Michael, et al. Petersons Principles of Oral and Maxillofacial Surgery. Peoples Medical Pub. House-USA,
2012.
• Zide, Michael F., and John N. Kent. “Indications for Open Reduction of Mandibular Condyle Fractures.” Journal of
Oral and Maxillofacial Surgery, vol. 41, no. 2, 1983, pp. 89–98., doi:10.1016/0278-2391(83)90214-8.