Oral and Maxillofacial Surgery Cases 6 (2020) 100134

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Oral and Maxillofacial Surgery Cases

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Non-surgical treatment of condylar fractures in children

Elnur Abdullayev b, 1, Chinqiz Rahimov a, 1, Ismayil Farzaliyev a,
Sanan Khankishiyev a, Parisa Foroughiasl a, *, 1
a
Department of Oral and Maxillofacial Surgery, Azerbaijan Medical University, Baku, Azerbaijan
b
Department of Oral and Maxillofacial Surgery, Clinical Medical Centre, Baku, Azerbaijan

A R T I C L E I N F O

Keywords:
Sub-condylar fractures
Mandibular fracture in children
Treatment of condylar fractures
Elastics application on fractures

The treatment tactics in case of mandibular fractures in children don’t differ much with adults one. The only one localization
requires a different approach is a mandibular condyle [8]. The cause of this difference could be explained by the incidence rate (15–86,
7%) and continuous development of the facial skeleton in children [19]. There are two options existing for the treatment of condylar
and sub-condylar fractures in children: surgical and conservative approach [2]. The indications for both age, fracture line localization,
a degree of dislocation and fracture pattern. In spite of reasonable results of open reduction and internal fixation as a treatment
method, it could be less effective in the case of condylar fractures in children. Therefore, a majority of pediatric cases aged 6–12 years
old is receiving conservative treatment [13]. However, there is still no common concept in the treatment of condylar fractures in
children [11]. This study aims to demonstrate the outcomes of conservative treatment done by the means of brackets and elastics
application.

1. Material and methods

Within the current study, 15 children aged 2–15 years old with condyle fractures treated conservatively and surgically. All patients
had undergone clinical investigation, blood and urine test and consulted with pediatricians and pediatric surgeon on the trauma. In all
cases, a computerized tomography (CT) scan with 3D reconstruction used as a method of choice for diagnosis of the fracture patterns.
Inclusion criteria for conservative treatment were under 12 years old and non-displaced or minimally displaced fracture with or
without altered occlusion and severely displaced fracture with or minimally altered occlusion. In this study some of the conditions
excluded such as displacement into middle cranial fossa, inability to get adequate occlusion, lateral extracapsular displacement of the
condyle and lateral extracapsular displacement of the condyle.
All cases analyzed retrospectively. We used similar specific treatment protocol in all of them, a treatment includes 4 oz elastic bands
for 2 weeks to get the first-class occlusion followed by application of 4 oz cross-midline elastic bands on injured site and Class III elastic
on opposite over next 4 weeks.

* Corresponding author.
E-mail address: dr.parisaforoughi@hotmail.com (P. Foroughiasl).
1
First Authors

https://doi.org/10.1016/j.omsc.2019.100134
Received 10 June 2019; Received in revised form 25 August 2019; Accepted 25 November 2019
Available online 20 January 2020
2214-5419/© 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

Fig. 1. Clinical investigation revealed: a) facial asymmetry; b) laceration in chin the region.

Fig. 2. Intra-oral investigation showed cross-bite occlusion.

Fig. 3. a) Low sub-condylar fracture; b) Slight dislocation of the condyle medially.

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E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

Fig. 4. (a) and (b). Application of Class III and midline 4 oz elastic bands.

Fig. 5. Clinical investigation 1 month after trauma: a) good mouth opening b) slight deviation. of intra-dental line.

Fig. 6. Radiological investigation showed: a) partial repositioning of the condyle b) partial ossification of the condyle.

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E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

Fig. 7. Clinical view of patient 6 month after trauma: a) good moth opening b) complete. repositioning of the intra-dental line.

Fig. 8. Radiological investigation showed: a) complete repositioning of the condyle; b) complete ossification of the condyle.

2. Cases

2.1. Case 1. – unilateral condylar fracture

8 years old girl admitted to the hospital with complaints of swelling in the left parotid region, limitation in mouth opening and
malocclusion. Upon analysis certain pathology related to trauma due to the fall. During a clinical investigation, painful swelling in the
left parotid region, cross-bite, limitation on mouth opening as well as lacerations in the mental region of the mandible was found
(Figs. 1 and 2). CT scan showed a low sub-condylar fracture of the right condyle with medial shift dislocation (Fig. 3).
A treatment protocol worked out, including the application of class I elastic bands for 2 weeks following to trauma, replaced by
class III and cross-midline elastic bands for the next 4 weeks (Fig. 4). A month later recall clinical investigation showed good mouth
opening with a slight deviation of an interdental line (Fig. 5). Radiological investigation detects partial repositioning of the condyle
with signs of ossification on the lateral aspect of one (Fig. 6).
6 months after trauma during clinical control good mouth opening with no any static or dynamic deviation of intra-dental line
observed (Fig. 7). The condyle showed a reasonable degree of reposition and remodeling on the radiological view (Fig. 8). A soft diet
and further follow-up recommended being done up to 16 years old.

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E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

Fig. 9. Clinical investigation revealed: a) no facial asymmetry b) laceration in the chin region.

Fig. 10. Intra-oral investigation showed open-bite occlusion.

Fig. 11. Radiological investigation showed bilateral condylar fracture with slight dislocation medially on: a) right side b) left side.

2.2. Case 2. – bilateral sub-condylar fracture

8 years old boy admitted to the hospital with complaints on minor swelling in the left and right parotid region, limitation in mouth
opening, malocclusion. Upon medical history certain pathology related to trauma due to the fall. During a clinical investigation,
painful swelling in the left and right parotid region, open-bite, mouth opening limitation, as well as lacerations in the mental region
were found (Figs. 9 and 10). CT scan showed a sub-condylar fracture of the right and left condyle with minor dislocation medial shift of

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E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

Fig. 12. Treatment of Class III and midline occlusion shift with 4 oz elastics (a) and (b).6 months after trauma during clinical control good mouth
opening with no any static or dynamic deviation of intra-dental line observed (Fig. 13). The Radiological view of condyle showed a reasonable
degree of reposition and remodeling (Fig. 14). A soft diet and further follow-up recommended being done up to 16 years old.

Fig. 13. Clinical investigation 6 month after trauma: a) and b) facial symmetry; c) good moth. opening; d) complete repositioning of the intra-
dental line.

both condyles (Fig. 11).

A treatment protocol worked out, including class I elastic bands for 2 weeks applied following to trauma, replaced by class III and
cross-midline elastic bands for the next 4 weeks (Fig. 12).

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 Table 1

E. Abdullayev et al.
Distribution of clinical and radiological data of the patients.
No Age/ The cause Localization of fracture Occlusion Pre- Deviation on mouth Condyle displacement Method of Occlusion Deviation on mouth Post OP radiological
Sex of injury OP opening Pre-OP treatment Post OP opening Post OP condyle status

1 7/b Fall L-side condyle þ L-side Mesial cross- 3 mm Anterior displacement ORIF I class 1 mm None
angle bite out of fossa
2 4/g Fall L-side condyle þ R-side Mesial cross- 3 mm Medial displacement Brackets þ elastics I class 0 mm Repositioning and
parasymphisis bite within fossa remodeling
3 14/b Sport L-side condyle Mesial cross- 4 mm Medial displacement Brackets þ elastics I class 1 mm Repositioning and
bite within fossa remodeling
4 8/b Fall L-side condyle Mesial cross- 4 mm Medial displacement Brackets þ elastics I Class 1 mm Repositioning and
bite within fossa remodeling
5 5/g Fall L-side condyle Mesial cross- 4 mm Medial displacement Plastic splint Mesial cross- 4 mm None
bite within fossa bite
6 11/b Fall L-side condyle Mesial cross- 4 mm Medial displacement Arch bar þ elastics I Class 1 mm Repositioning and
bite within fossa remodeling
7 4/b Fall L-condyle þ L-side Mesial cross- 5 mm Medial displacement out ORIF þ IMF screws I Class 1 mm Repositioning and
angle bite of fossa remodeling
8 4/b Fall Bilateral condyle Mesial open 0 mm Minimal medial Diet I Class 0 mm None
bite displacement within
fossa
9 12/b Fall L-side condyle þ R-side Mesial cross- 4 mm Medial displacement out ORIF I Class 0 mm None
body bite of fossa
10 15/b Fall Bilateral condyle Mesial open 0 mm Minimal medial Arch bar þ elastics I Class 0 mm None
bite displacement within
fossa
11 15/b Traffic L-side condyle þ Le For Mesial open 5 mm Total medial ORIF I Class 0 mm Repositioning and
7

III cross-bite displacement out of remodeling

fossa
12 11/b Fall R-side condyle þ L-side Mesial cross- 3 mm Total medial ORIF þ I Class 1 mm Repositioning and
body bite displacement out of condylektomy remodeling
fossa
13 2/b Fall L-side condyle þ R-side Mesial cross- 3 mm Medial displacement IMF screws þ I Class 1 mm Repositioning and
parasymphysis bite within fossa elastics remodeling
14 12/b Traffic R-side condyle þ L- Mesial cross- 4 mm Medial displacement ORIF þ Brackets þ I Class 0 mm Repositioning and
parasymphisis bite within fossa elastics remodeling
15 14/b Traffic L-side condyle Mesial cross- 3 mm Total medial ORIF I Class 0 mm Repositioning and

Oral and Maxillofacial Surgery Cases 6 (2020) 100134

bite displacement out of remodeling
fossa
16 14/g Fall Bilateral condyle Mesial open 0 mm Medial displacement ORIF I Class 0 mm Repositioning
bite within fossa
17 15/b Fall R-side condyle Mesial cross- 4 mm Total medial ORIF I Class 1 mm Repositioning and
bite displacement out of remodeling
fossa
18 7/b Fall L-side condyle þ R-side Mesial cross- 3 mm Medial displacement ORIF þ Brackets þ I Class 1 mm Repositioning and
parasymphysis bite within fossa elastics remodeling
19 10/g Traffic L-side condyle þ R-side Mesial cross- 4 mm Medial displacement ORIF þ Brackets þ I Class 0 mm Repositioning and
parasymphysis bite within fossa elastics remodeling
20 9/g Fall L-side condyle Mesial cross- 3 mm Total medial None Mesial cross- 3 mm None
bite displacement out of bite
fossa
21 3/b Fall R-side condyle 3 mm ORIF 3 mm None
(continued on next page)
 E. Abdullayev et al.
Table 1 (continued )
No Age/ The cause Localization of fracture Occlusion Pre- Deviation on mouth Condyle displacement Method of Occlusion Deviation on mouth Post OP radiological
Sex of injury OP opening Pre-OP treatment Post OP opening Post OP condyle status

Mesial cross- Total medial Mesial cross-

bite displacement out of bite
fossa
22 15/b Fall Bilateral condyle Mesial open 0 mm Total medial ORIF I Class 0 mm None
bite displacement out of
fossa
23 12/g Traffic Bilateral condyle Mesial open 0 mm Total medial ORIF I Class 0 mm Repositioning
bite displacement out of
fossa
24 12/g Fall L-side condyle Mesial cross- 3 mm Medial displacement ORIF I Class 0 mm None
bite within fossa
25 8/b Fall L-side condyle þ R-side Mesial cross- 2 mm Medial displacement ORIF I class 0 mm Repositioning
parasymphysis bite within fossa
26 6/g Fall L-side condyle Mesial cross 3 mm Medial displacement Arch bar þ elastics I class 0 mm Repositioning
bite within fossa
27 9/b Fall R-side condyle þ L-side Mesial cross 4 mm Total medial ORIF þ I class 2 mm None
body bite displacement out of condylectomy
8

fossa
28 8/b Fall Bilateral condyle þ R- Mesial open 0 mm Medial displacement IMF screws þ I class 0 mm Repositioning and
side body bite within fossa Brackets remodeling
þelastics
29 6/g Fall L-side condyle Mesial cross 4 mm Medial displacement Brackets I class 0 mm Repositioning and
bite within fossa þelastics remodeling
30 6/g Traffic R-side condyle þ Mesial cross 3 mm Medial displacement Brackets I class 0 mm Repositioning and
symphysis bite within fossa þelastics remodeling
31 2/b Fall R-side condyle þ Mesial cross 3 mm Medial displacement ORIF þ IMF screws I class 0 mm Repositioning and
symphysis bite within fossa þ elastics remodeling

Oral and Maxillofacial Surgery Cases 6 (2020) 100134

32 11/g Fall L-side condyle Mesial cross 5 mm Total medial ORIF I class 0 mm Repositioning
bite displacement out of
fossa
33 2/b Fall R-side condyle þ L-side Mesial cross 2 mm Minimal medial Ernst ligature I class 1 mm None
parasymphysis bite displacement within
fossa
34 6/g Bicycle R-side condyle þ L-side Mesial cross 4 mm Medial displacement Brackets I class 0 mm Repositioning and
body bite within fossa þelastics remodeling
35 6/g Fall L-side condyle þ R-side Mesial cross 3 mm Medial displacement Brackets I class 0 mm Repositioning and
parasymphysis bite within fossa þelastics remodeling
E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

Fig. 14. Radiological investigation showed complete repositioning and remodeling of the. condyle; a) right and b) left.

3. Results

Within the current study, 15 cases of treatment of condyle fractures analyzed. A slight male predilection showed (8 boys 62.85%
and 7 girls 37.14%) with mean age 8.71 years old. Distribution due to fracture localization was as follows: in 9 (34.28%) cases,
unilateral subcondylar fracture, in 3 cases (14.28%) bilateral sub-condylar fracture and in rest 4 (51.42%) cases condyle fracture
associated with different sites of the mandible. According to medical histories in 12 (77.14%) cases, the cause of the fracture was fall, in
1 (17.14%) traffic accident, in 1 (2.85%) fall from bicycle and in 1 (2.85%) sports trauma. During clinical investigation majority of
patients in 28 (80%) cases mesial cross-bite observed, in 6 cases (17.14%) mesial open bite, in one case mesial open cross-bite with
mean range of deviation while mouth opening 2.9142 mm. Radiological investigation revealed the majority of patients in 12(54.28%)
cases medial displacement of the condyle within fossa; in 3 (8.57%) cases minimal medial displacement within fossa detected.
Conservative treatment used as follows: in 7 (20%) of cases brackets and elastic bands, 3 (8.57%) arch bars and elastic bands, in one
case (2.85%) IMF screws and elastic bands, in one case (2.85%) combination of IMF screws, brackets and elastic bands; in one case
(2.85%) Erst ligature, in one (2.85%) plastic splint and in one (2.85%) soft diet. In one case patient’s parents refuses from any
treatment.
On 6 month of follow-up majority (14 patients [91.42%]) showed I Class occlusion with a mean range of dynamic deviation of
0.628 mm; in only 1(8.57%) cases patients showed mesial crossbite. A complete distribution of clinical data is showing in Table 1.

4. Discussion

As opposed to adults a treatment tactic of condylar fractures of the mandible in children is controversial and widely discussed in the
literature [3–5]. The applying of both surgical and non-surgical procedures seems still real and requires an individual approach. In
cases of malocclusion associated with minimal displacement of the condyle or rupture of cortical bone prescription of soft diet rec­
ommended. In these cases, the key point deviates the lower interdental line, which could be easily controlled. In cases of malocclusion
associated with a displacement of the condyle application of Maxillomandibular Fixation (MMF) is mandatory. In these cases, the key
point is age and dentition. Thus, for age under 1 years old the application of elastic bands for 2.5–3 weeks post trauma is recommended,
for age 1–3 years old MMF could be achieved by the means of individual splints supported by elastic bands. At the age of 3–7
application of MMF by the means of brackets or inter-maxillary fixation (IMF), use of screws are recommended [10]. However, one
should take into account that at the age of 2–6 mixed dentition could limit the application of MMF [12].
In this particular study, application of MMF by means of IMF screws and brackets is chosen. The main purpose of such treatment is
unloading of condyle, bringing one anatomical place and generating a favorable background for enchondral osteogenesis. The
treatment design included class I, 4 oz (4 oz ¼ 4 ounces ¼ 0,1134 kg) for the 2 weeks following trauma, which will be replaced by class
III and cross-midline elastic bands for the last repositioning of the condyle [10]. This allows minimal mouth opening what is important
for preventing fibrosis or ankylosis of TMJ [1,7].
In cases of severe malocclusion and a high degree of condyle dislocation the application of MMF essential for repositioning might be

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E. Abdullayev et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100134

protracted, thus has a great impact on ankyloses formation. Moreover, it is also influenced by the psychological status of the child.
Therefore, surgical treatment by the means of open reduction and internal fixation indicated. However, the fact subperiosteal
dissection, surgical trauma, and presence of titanium hardware could decrease the potential of bone for regeneration and have a
negative influence on the further growth of the facial skeleton [9,14,15]. Therefore, removal of the hardware is strictly recommended
2–3 month postoperatively. On the last decades, the application of Poly-L-lactide Absorbable (PLLA) plates and screws becomes more
popular [17,18]. However, its application could provoke inflammatory complications which were widely described in literature data
and further investigations are still necessary [6,16].

5. Conclusion

As opposed to the treatment modalities of the condylar fractures in adults should less aggressive in children. A treatment protocol of
condylar fractures in children should have an individual approach based on the age of the patient fracture line pattern and degree of
dislocation. CT scan seems to be mandatory for an exact diagnosis, which helps to determine the method of treatment. In children
conservative treatment which might last 6–14 weeks and showing reasonable results. Conservative treatment should start immediately
after trauma and include 2 steps – normal occlusion achievement, condylar repositioning.

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