Advances in the Management

of Mandibular Condylar
Fractures
Editor
MARTIN B. STEED

ATLAS OF THE ORAL AND

MAXILLOFACIAL SURGERY
CLINICS OF NORTH AMERICA
www.oralmaxsurgeryatlas.theclinics.com
Consulting Editor
RICHARD H. HAUG

March 2017  Volume 25  Number 1

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 Advances in the Management of Mandibular Condylar Fractures
Contributors
EDITOR
MARTIN B. STEED, DDS, FACS
Associate Professor and Chair, Department of Oral and
Maxillofacial Surgery, James B. Edwards College of Dental
Medicine, Medical University of South Carolina, Charleston,
South Carolina
AUTHORS
MELISSA AMUNDSON, DDS
Director of Resident Education, Head and Neck Institute,
Attending Surgeon, Trauma Service, Legacy Emanuel
Medical Center, Portland, Oregon
R. BRYAN BELL, MD, DDS, FACS, FACD
Consultant, Head and Neck Institute, Attending Surgeon,
Trauma Service, Legacy Emanuel Medical Center, Director,
Providence Oral, Head and Neck Cancer Program and Clinic,
Providence Cancer Center, Clinical Professor, Oregon Health
and Science University, Portland, Oregon
ERIC L. BISCHOFF, DMD
CMDR, US Navy, Former Resident, Baylor University Medical
Center, Texas A&M University School of Dentistry, Dallas,
Texas
PAOLO BOFFANO, MD, PhD
Division of Otolaryngology, Maxillofacial Surgery and
Dentistry, Aosta Hospital, Aosta, Italy
RYAN CARMICHAEL, DDS, MD
Resident, Baylor University Medical Center, Texas A&M
University School of Dentistry, Dallas, Texas
ALLEN CHENG, MD, DMD
Director, Oral/Head and Neck Cancer Program, Legacy
Good Samaritan Medical Center, Attending Surgeon, Trauma
Service, Legacy Emanuel Medical Center, Consultant, Head
and Neck Institute, Portland, Oregon
PIERRE CORRE, MD
Department of Maxillo-Facial Surgery and Stomatology, CHU
de Nantes, Nantes, France
LARRY L. CUNNINGHAM Jr, DDS, MD, FACS
Professor and Chief, Division of Oral and Maxiollofacial
Surgery, University of Kentucky College of Dentistry,
Lexington, Kentucky
iii
ERIC J. DIERKS, MD, DMD, FACS, FACD
Medical Director, Head and Neck Institute, Chief of
Maxillofacial Trauma, Trauma Service, Legacy Emanuel
Medical Center, Clinical Professor, Oregon Health and
Science University, Portland, Oregon
HANY A. EMAM, BDS, MS
Assistant Professor, Division of Oral and Maxillofacial
Surgery and Dental Anesthesiology, College of Dentistry,
The Ohio State University, Columbus, Ohio
COURTNEY A. JATANA, DDS, MS
Assistant Professor, Division of Oral and Maxillofacial
Surgery and Dental Anesthesiology, College of Dentistry,
The Ohio State University, Columbus, Ohio
DEEPAK G. KRISHNAN, DDS, FACS
Associate Professor in Surgery, Residency Program Director,
Oral Maxillofacial Surgery, University of Cincinnati,
Cincinnati, Ohio
AMY KUHMICHEL, DMD
Private Practice, Adjunct Assistant Professor of Surgery,
Emory School of Medicine, Atlanta, Georgia
PHILIPP KUPFER, MD, DMD
Chief Resident, Oral and Maxillofacial Surgery, Oregon
Health and Science University, Portland, Oregon
STEPHEN P.R. MACLEOD, BDS, MBChB, FDSRCS,
FRCS, FACS
Program Director, Oral and Maxillofacial Surgery Residency,
Director, Division of Oral and Maxillofacial Surgery & Dental
Medicine, Joseph R. and Louise Ada Jarabak Professor of
Surgery, Department of Surgery, Oral Health Center, Loyola
University Medical Center, Maywood, Illinois
iv Contributors
GLENN MARON, DDS
Private Practice, Adjunct Assistant Professor of Surgery,
Emory School of Medicine, Atlanta, Georgia
GREGORY M. NESS, DDS
DP Snyder Professor of Oral Surgery and Residency Program
Director, Division of Oral and Maxillofacial Surgery and
Dental Anesthesiology, College of Dentistry, The Ohio State
University, Columbus, Ohio
ASHISH PATEL, MD, DMD
Attending Surgeon, Trauma Service, Legacy Emanuel
Medical Center, Attending Surgeon, Providence Oral, Head
and Neck Cancer Program and Clinic, Providence Cancer
Center, Consultant, Head and Neck Institute, Portland,
Oregon
DAVID B. POWERS, MD, DMD, FACS, FRCS (Ed)
Associate Professor of Surgery, Director, Duke
Craniomaxillofacial Trauma Program, Division of Plastic,
Reconstructive, Maxillofacial and Oral Surgery, Duke
University Medical Center, Durham, North Carolina
LIKITH V. REDDY, DDS, MD, FACS
Associate Professor and Program Director, Department of
Oral and Maxillofacial Surgery, Baylor University Medical
Center, Texas A&M University School of Dentistry, Dallas,
Texas
STEFANO RIGHI, MD
Division of Otolaryngology, Maxillofacial Surgery and
Dentistry, Aosta Hospital, Aosta, Italy
CALEB M. SCHADEL, DDS
Resident Surgeon, Department of Oral and Maxillofacial
Surgery, James B. Edwards College of Dental Medicine,
Medical University of South Carolina, Charleston, South
Carolina
GEOFFREY SCHREIBER, DDS
Resident, Department of Oral & Maxillofacial Surgery, Emory
Healthcare, Atlanta, Georgia
SUSAN K. SNYDER, DMD, MD
Chief Resident, Oral and Maxillofacial Surgery, University of
Kentucky, Lexington, Kentucky
MARTIN B. STEED, DDS, FACS
Associate Professor and Chair, Department of Oral and
Maxillofacial Surgery, James B. Edwards College of Dental
Medicine, Medical University of South Carolina, Charleston,
South Carolina
CAMERON J. WALKER, DDS
Resident, Oral and Maxillofacial Surgery, Oral Health Center,
Loyola University Medical Center, Maywood, Illinois
 Advances in the Management of Mandibular Condylar Fractures v

Contents
Preface: Where Are the Advancements in the Management of Mandibular Condylar Process
Fractures? ix
Martin B. Steed

Classification of Mandibular Condylar Fractures 1

David B. Powers

Anatomy and Biomechanics of Condylar Fractures 11

Cameron J. Walker and Stephen P.R. MacLeod

Introduction 11
Overview of anatomy 11
Biomechanics of condylar fractures 14
Summary 15

Virtual Surgical Planning and Intraoperative Imaging in Management of Ballistic Facial and
Mandibular Condylar Injuries 17
Philipp Kupfer, Allen Cheng, Ashish Patel, Melissa Amundson, Eric J. Dierks, and R. Bryan Bell

Introduction 17
Surgical procedure 21
Summary 23

The Role of Intra-articular Surgery in the Management of Mandibular Condylar Head

Fractures 25
Paolo Boffano, Pierre Corre, and Stefano Righi

Introduction 25
Content 25
Imaging and surgical planning 26
Indications 27
Surgical approaches 27
Surgical techniques 28
Complications 33
Summary 33

The Biology of Open Versus Closed Treatment of Condylar Fractures 35

Susan K. Snyder and Larry L. Cunningham Jr

Vascular supply 35
Structural adaptations 37
Summary 45
vi Contents

Secondary Treatment of Malocclusion/Malunion Secondary to Condylar Fractures 47

Glenn Maron, Amy Kuhmichel, and Geoffrey Schreiber

Splint therapy and physical therapy 47

Conservative treatment 48
Equilibration 48
Orthodontic correction of bilateral condylar process fractures 48
Arthroplasty/Total joint replacement 49
Orthodontics and orthognathic surgery 52
Case report 53
Treatment protocol 53
Summary 53

Matching Surgical Approach to Condylar Fracture Type 55

Hany A. Emam, Courtney A. Jatana, and Gregory M. Ness

Introduction 55
Identifying fractures by location 55
Surgical approaches 55
Submandibular/periangular 56
Retromandibular 56
Preauricular/endaural 58
Retroauricular 59
Transoral 60
Summary 61

Soft Tissue Trauma in the Temporomandibular Joint Region Associated with Condylar
Fractures 63
Deepak G. Krishnan

Introduction 63
Internal injuries to the temporomandibular joint 63
Penetrating soft tissue temporomandibular joint trauma 64
Hemarthrosis of the joint 64
Damage to the joint surfaces, disc, and disc displacement 64
Damage to the glenoid fossa 64
Changes to soft tissue injuries following repair of the fractures 65
Healing of soft tissue injuries in closed treatment of mandibular fractures 65
Healing of soft tissue injuries in open treatment of mandibular fractures 66
Summary 66

Plating Options for Fixation of Condylar Neck and Base Fractures 69

Eric L. Bischoff, Ryan Carmichael, and Likith V. Reddy

Introduction 69
Surgical approach 69
Biomechanics of the condylar neck and base 69
Plating options 70
Summary 73
 Contents vii

Management of Pediatric and Adolescent Condylar Fractures 75

Martin B. Steed and Caleb M. Schadel

Introduction 75
Craniofacial growth and development 75
Frequency of pediatric condylar fractures 76
Diagnosis 77
Closed versus open treatment 77
Uncommon injuries and complications 80
Summary 83
viii Advances in the Management of Mandibular Condylar Fractures

ATLAS OF THE ORAL AND MAXILLOFACIAL

SURGERY CLINICS OF NORTH AMERICA
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 Advances in the Management of Mandibular Condylar Fractures
Preface
Where Are the Advancements in the
Management of Mandibular Condylar
Process Fractures?
Martin B. Steed, DDS, FACS
Editor
Many surgical lectures begin with an introduction describing
the history of the management of an injury or pathology. This
is then followed by a sequential discussion of the sentinel
modifications that have been witnessed and accepted.
When one listens to such a talk on mandibular condyle
fractures, it is sometimes apparent that, for many of these
injuries, we still treat them in a manner similar to the first slide
on the PowerPoint.
But while the debate on optimal treatment of fractures of
the mandibular condylar process continues, it does so now
in an environment in which we are witnessing accelerated
advancement in surgical technology. Improved imaging,
instrumentation, fixation methods/materials, and virtual sur-
gical planning provide us with novel opportunities to improve
care for our patients. Our clinical outcomes research is
beginning to show a trend toward improved outcomes with
open treatment.
It was within this environment that I was recently fortunate
enough to be a part of a Strasburg Osteosynthesis Research
Group advanced module dedicated exclusively to the
management of mandibular condylar process fractures.
Listening to presentations from the likes of Ed Ellis, Richard
Loukota, Eric Dierks, David Powers, and Stephen Macleod, I
realized that advances are, in fact, being made. We are now
beginning to understand what the adaptations are that allow
most patients to accommodate and retain function after a
Atlas Oral Maxillofacial Surg Clin N Am 25 (2017) ix
1061-3315/17/ª 2016 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.cxom.2016.12.001
condylar process fracture. We have become better able to
classify these injuries (especially intracapsular/dicapitular)
and anticipate those that may not be amenable to closed
treatment and subsequent adaptations. We are getting
better at identifying the limitations of closed treatment.
For those fractures that have classically been more
difficult to treat, such as high severely displaced fractures,
we now have been introduced to approaches, instrumen-
tation, and fixation methods that were not previously within
our armamentarium. Virtual surgical planning and intra-
operative navigation are actively being explored for the
trauma patient.
I felt that the illustrative nature of this Atlas of the Oral and
Maxillofacial Surgery Clinics of North America would lend
itself well to clearly showing facial trauma surgeons where
these advances are being made.
Martin B. Steed, DDS, FACS
Medical University of South Carolina
Department of Oral and Maxillofacial Surgery
173 Ashley Avenue
BSB 453 MSC 507
Charleston, SC 29425, USA
E-mail address:
steedma@musc.edu
oralmaxsurgeryatlas.theclinics.com
Classification of Mandibular Condylar
Fractures
David B. Powers, MD, DMD, FRCS (Ed)
KEYWORDS
 Classification system  Mandibular condylar process fractures  Management regimen  Open versus closed
KEY POINTS
 There is no universal gold standard classification system for mandibular condylar process fractures.
 A clinically relevant mandibular condyle classification system should be easy to understand, and be easy to recall, for
implementation into the management of a condylar fracture.
 An accurate appreciation of the location of the mandibular condylar fracture assists with the determination of either an
operative or nonoperative management regimen.
Various classification systems describing mandibular condylar
fractures have been developed and published, essentially
since the development of treatment protocols for these
injuries.1e8 The universal application of a single classification
system is highly controversial, if not impossible, because of
variability in terminology, grammatical differences, native
language challenges, and regional preferences for a specific
system. It is beyond the scope of this article to present a
comprehensive review of all of the available classification
systems in the literature, but instead the focus is to develop
an understanding of which classification system presents
for the reader key factors in the description of the location
of the injury, the structures involved, and implications for
management.
A clinically relevant classification system should comprise
several key elements specifically: the anatomic position of the
fracture, the degree of displacement and/or dislocation, and a
simple classification scale construction that allows for ease of
recall and comprehensibility. The anatomic position of the
fracture is a critical component of any useful classification
system. Any structural reference site should be easily identi-
fiable, even within significant fracture patterns, and have
applicability over a wide variety of treatment protocols.
Considerable variability exists between the use of the terms
“displacement” and “dislocation.” Native English-speaking
countries use the term displacement with the understanding
there remains some degree of bony contact between the
fractured and dislodged bony fragments while the condylar
head remains within the articulating fossa. Further confusion
exists when the condylar head remains within the fossa, but
there is no longer contact between the fractured bony frag-
ments. In circumstances such as this, they may be described as
displaced fractures, whereas conditions where fractured bony
Duke Craniomaxillofacial Trauma Program, Division of Plastic, Recon-
structive, Maxillofacial and Oral Surgery, Duke University Medical Center,
Box 2955, Durham, NC 27710, USA
E-mail address: David.Powers@duke.edu
Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-
1061-3315/16/Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.cxom.2016.11.001
contact remains can be referenced as deviated fractures.
Dislocation refers to fractures where the condylar head is
totally dislodged from the articulating fossa. For the purposes
of clarity for this article, the terms displacement and dislo-
cation as proposed by Loukota are used, displacement refers to
shifting between the fracture segments, and dislocation de-
scribes alteration between components of the temporoman-
dibular joint (TMJ) (Fig. 1).
The anatomic position of the fracture is the most critical
component of any classification system. The most widely
referenced are discussed next, with a description of each of
the relevant components associated with each one. In 1927,
Wassmund2 distinguished between fractures of the condylar
head and the condylar neck. The condylar head fractures were
identified as either comminuted head fractures or “chip frac-
tures” not affecting continuity.2 The condylar neck fractures
were further isolated to
 Vertical neck fractures secondary to shearing
 Transverse neck fractures secondary to bending
 Oblique neck fractures caused by a combination of
shearing/bending
Wassmund3 continued his work and in 1934 described dis-
located fractures into three categories:
 Type I: 10 to 40 angulation of the condylar head with
bony contact between the fragments
 Type II: 50 to 90 angulation of the condylar head with
slight bony contact between the fragments
 Type III: Severe medial displacement with no contact
between the bony fragments
The classification systems continued to become more
descriptive when in 1952 MacLennan4 divided condylar frac-
tures into sections according to anatomic location, the posi-
tion of the condylar head within the articulating fossa, and
oralmaxsurgeryatlas.theclinics.com
2 Powers

Fig. 1 Common definitions to describe the position of condylar head in relation to mandibular condylar fractures.

the association of between the larger/smaller fracture
segments:
 Low condylar neck fracture line starts at the sigmoid
notch and extends caudally and obliquely to the posterior
border of the ramus
 High condylar neck fracture begins above the sigmoid
notch with involvement of the condylar neck
 Subcondylar fractures consist of posterior oblique frac-
tures of the mandibular ramus
 Complete luxation fractures have avulsion of the condylar
process
Classification of Mandibular Condylar Fractures 3

MacLennan4 further described the differences among simple Commonly accepted in the European literature, they differ-
“bending” of the condylar process, displacement fractures, entiated between fractures of the condylar base and neck,
and dislocation fractures: noting the degree of angulation associated with deviation,
displacement, or dislocation:
 Class I: no deviation (bending)
 Class II: deviation (bending) at the fracture level
 Type I: condylar neck fracture without deviation/
 Class III: displacement (condylar head remains within
displacement (Fig. 2)
fossa)
 Type II: low condylar neck fracture with deviation/
 Class IV: dislocation (condylar head outside of fossa)
displacement (Fig. 3)
 Type III: high condylar neck fracture with deviation/
Rowe and Killey5 described in 1955 a more simplified clas- displacement (Fig. 4)
sification system based on the anatomic dimensions of the TMJ  IIIa: ventral
capsule and the surrounding structures of the TMJ:  IIIb: medial
 IIIc: lateral
 Intracapsular fractures  IIId: dorsal
 Extracapsular fractures  Type IV: low condylar neck fracture with dislocation
 Fractures associated with the TMJ capsule, TMJ liga- (Fig. 5)
ments, articulating disk, and bony structures surrounding  Type V: high condylar neck fracture with dislocation
the TMJ (Fig. 6)
 Type VI: intracapsular fracture of the condylar head
(Fig. 7)
Dingman and Natvig6 proposed a classification system in
1964 that incorporates the insertion of the lateral pterygoid
muscle at the condylar neck:
Lindahl8 in 1977 published the most comprehensive
 High condylar neck fracture: fracture line is at or above description of mandibular condylar head fractures to date
the level of the lateral pterygoid attachment on the fovea within the literature. This classification system, although
of the condylar apparatus highly descriptive, is also complicated because it describes the
 Intermediate condylar neck fracture: fracture line is location of the fracture, deviation, and/or displacement and
below the level of insertion of the lateral pterygoid position of the condylar head within the articulating fossa
 Low condylar neck fracture: fracture begins at or below (Fig. 8):
the sigmoid notch and extends to the posterior border of
the mandibular ramus
 1: Fracture level
 1a: condylar head
In 1972, Spiessl and Schroll7 published their comprehensive  1b: condylar neck
manuscript on the location of the condylar neck fractures.  1c: subcondylar/condylar base

Fig. 2 Spiessl and Schroll, type I. Condylar fractures without considerable displacement. Referred to in the European literature as
“collum fractures” without considerable displacement.
4 Powers

Fig. 3 Spiessl and Schroll, type II. Low condylar neck fractures with displacement. Referred to in the European literature as “deep
collum” fractures with displacement.

 2: Deviation and displacement  4: Condylar head fracture

 2a: bending/deviation with medial overlapping
segments
 2b: bending/deviation with lateral overlapping
segments
 2c: bending/displacement without overlapping
 2d: nondisplaced fracture without deviation
 3: Relation between condylar head and fossa
 3a: no dislocation
 3b: slight dislocation
 3c: moderate dislocation
 3d: severe and/or complete dislocation
 4a: horizontal
 4b: vertical
 4c: compression fracture
Lindahl8 defines the subcondylar fracture line as starting at
the sigmoid notch and extending to the posterior border of the
mandible. A condylar neck fracture is located at the condylar
process below the level of the condylar head. A condylar head
fracture essentially has most of its fracture components, or the
entirety of the fracture, contained within the TMJ capsule.8

Fig. 4 Spiessl and Schroll, type III. Superior condylar neck fractures with displacement. Referred to in the European literature and “high
collum” fractures with displacement.
Classification of Mandibular Condylar Fractures 5

Fig. 5 Spiessl and Schroll, type IV. Low condylar neck fractures with dislocation. Referred to in the European literature as “deep collum”
fractures with dislocation.

Lindahl’s classification system remains highly accurate in the  Type C: the uppermost portion of the fracture is below
description of the fracture location, but is unwieldy and diffi- the level of the lateral ligament, resulting in a loss of
cult to recall because of the multiple subsections involved in a ramus height (Fig. 11)
complete description of the fracture site.
Modifications to the descriptions of Spiessl and Schroll
Ellis and coworkers13 in 1999 described a more simplified
were conducted by numerous authors adding the component
classification system, which dealt with the location of the
of condylar head integrity (diacapitular fracture) for type V
fracture and the degree of dislocation and/or displacement
and type VI fractures. These included Rasse9 in 1993, Neff and
(Fig. 12):
coworkers10 in 1999, Hlawitschka and Eckelt11 in 2002, and
Loukota and coworkers12 in 2010. In total, the changes evolved
 Condylar head fracture: intracapsular fracture
into the following clarifications of the Spiessl and Schroll
 Condylar neck fracture: fracture below the condylar
system:
head, but on or above the lowest point of the sigmoid
notch
 Type A: continuous bony contact within the articular
 Condylar base fracture: fracture in which the fracture line
fossa, with a component of the condylar head remaining
is located below the lowest point of the sigmoid notch
and the fracture supported without loss of ramus height
(Fig. 9)
 Type B: loss of support within the articulating fossa and Radiographic interpretations of the Ellis classification sys-
subsequent loss of mandibular ramus height (Fig. 10) tem included13

Fig. 6 Spiessl and Schroll, type V. Superior condylar neck fractures with dislocation. Referred to in the European literature as “high
collum” fractures with dislocation.
6 Powers

Fig. 7 Spiessl and Schroll, type VI. Intracapsular fractures. Diacapitular fractures.

Fig. 8 Displaced condylar neck fractures in which there is variable degrees of contact between the fractured and dislocated bony
segments. In all circumstances, the condylar head remained within the fossa.
Classification of Mandibular Condylar Fractures
Fig. 9 Diacapitular fractures, type A. Continuous bony contact
within the articular fossa. No loss of ramus height.
 No detectable dislocation and correct positioning of the
condylar head
 Slight dislocation: most of the condylar head remains
within the articulating fossa and the degree of angula-
tion/bending of the condylar process is less than 20
Fig. 10 Diacapitular fractures, type B. Loss of support within the
articular fossa and loss of height of the mandibular ramus.
7
Fig. 11 Diacapitular fractures, type C. The most superior portion
of the fracture is below the level of the lateral ligament. Loss of
ramus height is appreciated due to involvement of the entirety of
the condylar head.
 Severe dislocation: the condylar head is either on the
articulating eminence or even further anteriorly, and the
degree of angulation/bending of the condylar process is
greater than 20
In 2005, Loukota and coworkers14 proposed a classification
system for fractures of the condylar process of the mandible,
which was subsequently adopted by the Strausbourg Osteosyn-
thesis Research Group. This protocol described “Line A,” which
is a perpendicular line that extends through the lowest extension
of the sigmoid notch to the mandibular ramus. The purpose of
the line is to identify a component of the structural anatomy of
the mandible that is easily reproducible even in cases of signif-
icant condylar trauma. Additionally, clarification of the condylar
head fracture (diacapitular fracture) was noted, and presented
a definition for the term “minimal displacement” (Fig. 13)14:
 Diacapitular fracture: the fracture line starts in the articular
surface and may extend outside the TMJ capsule (Fig. 14)
 Condylar neck: the fracture line starts somewhere above
Line A and runs above Line A for more than half of its
length (Fig. 15)
 Condylar base: the fracture line extends behind the
mandibular foramen and runs below Line A for more than
half of its length (Fig. 16)
 Minimal displacement: displacement of less than 10 or
overlap of the bone edges by less than 2 mm, or both
Loukota noted the need for additional clarification of the
location of high and low fractures, offering their definitions as
potential answers to those questions.
 Fig. 12 (A, B) Simplified classification system as described by Ellis.

Fig. 13 Strausbourg Osteosynthesis Research Group classifica-

tion. The key landmark in the Strausbourg Osteosynthesis Research Fig. 15 Condylar neck fracture. The fracture line starts above
Group classification is Line A, a perpendicular line through the Line A, and more than half of the fracture is above Line A in the
sigmoid notch to the tangent of the ramus. lateral view.

Fig. 14 Diacapitular fracture extending outside the temporo- Fig. 16 Condylar base (subcondylar) fracture. The fracture line
mandibular joint capsule without displacement of the articulating runs posterior to the mandibular foramen, and more than half the
surface of the condylar head. length of the fracture extends below Line A.
Classification of Mandibular Condylar Fractures 9

system highlights numerous avenues of fracture location,

identification, displacement, comminution, and dislocation.
There is an attempt at clarity in identifying the location of the
condylar fracture:

 Condylar head: the condylar head reference line runs

perpendicular to the posterior ramus below the lateral
pole of the condylar head
 Condylar neck: the sigmoid notch line running through the
deepest point of the sigmoid notch perpendicular to the
ramus line extending superiorly to the condylar head
 Base of the condylar process: the sigmoid notch line
running through the deepest point of the sigmoid notch
perpendicular to the ramus line extending inferiorly

This protocol addresses each section of the mandibular

Fig. 17 AO Foundation classification of “high-neck” and “low-neck”
mandibular condylar fractures.
The AO Foundation15 expanded on Ellis’ classification with
the determination of “high-neck” and “low-neck” fractures
within the online AO Surgery Reference in 2010, providing
greater detail to the location of “high and low” as theorized by
Loukota:
 The first line parallels the posterior border of the
mandible
 The sigmoid notch line runs perpendicular to the first line
at the deepest portion of the sigmoid notch
 There is a line below the lateral pole of the condylar head
that is also perpendicular to the first line
 A line is drawn half way between the lateral pole line
and the sigmoid notch line
 A “high-neck” fracture is above this line, whereas a
“low-neck” fracture is below (Fig. 17)
In 2014, Neff and coworkers16 published the Comprehensive
AOCMF Classification System: Condylar Process Fractures. This
condylar process fracture independently, with unique classifi-
cations for the degree of displacement, comminution, dislo-
cation, and angulation noted. A representative diagnostic
chart of the classification system is noted in Table 1.
The accuracy, but inherent complexity, of this classification
system is easily noted by reviewing Table 1. As such, the clinical
usefulness of this classification system may be somewhat
limited, because recall by the surgeon is hampered by having to
remember multiple subsections and scaling protocols.
An overview of the various classification systems for
mandibular condylar fractures has been conducted throughout
this article. The creation of the consensus mandibular condylar
classification system will continue to be a source of debate,
and frustration, because of the many valid points brought
forward by operative surgeons as to how their preferred
classification system highlights individual criteria they find
important. For the purposes of the remainder of this text, the
description of Line A as presented by Loukota is the preferred
method to describe the location of the condylar fractures. The
term dislocation refers to the luxation status of the condylar
head within the articulating fossa. Displacement refers to
the fracture line status. The degree of displacement is
considered as

Table 1 Comprehensive AOCMF classification system: condylar process fractures

Specific Level-3 Condylar Process System Subregions
Parameters Code and Description Process Head Neck Base
Location M Z medial to the pole zone/P Z within or lateral to the pole zone d x d d
Fragmentation 0 Z none/1 Z fragmented minor/2 Z fragmented major d x x x
Vertical apposition 0 Z complete/1 Z partial/2 Z lost d x d d
Sideward displacement 0 Z none/1 Z partial/2 Z full d d x x
Direction a Z anterior/p Z posterior and m Z medial/l Z lateral d d x x
Angulation 0 Z none (up to 5 )/1 Z > 5 e45 /2 Z > 45 d d x x
Direction a Z anterior/p Z posterior and m Z medial/l Z lateral d d x x
Displacement head 0 Z no displacement/1 Z displacement/2 Z dislocation x d d d
fragment/fossa Direction a Z anterior/p Z posterior and m Z medial/l Z lateral x d d d
Displacement caudal 0 Z no displacement/1 Z displacement xa d d d
fragment/fossa Direction a Z anterior/p Z posterior and l Z lateral xa d d d
Distortion of condylar head 0 Z orthotopic/1 Z dystopic x d d d
Overall loss of ramus height 0 Z no change of height/1 Z loss of height/2 Z increase of height x d d d
Adapted from Neff A, Cornelius CP, Rasse M, et al. The Comprehensive AOCMF classification system: condylar process fractures: level 3 tuto-
rial. Craniomaxillofac Trauma Reconstr 2014;7(Suppl 1):S46; with permission.
10
 Minimal displacement: displacement of less than 10 or
overlap of the bone edges by less than 2 mm, or both
 Moderate displacement: displacement between 10 and
45 or overlap of the bone edges by greater than 2 mm, or
both
 Severe displacement: displacement greater than 45 or
loss of overlap of the bone edges, or both
The operative surgeon should feel comfortable using the
classification system that best delineates the location and
description of the condylar fracture in a manner that affords
the clearest understanding of the injury sustained by the pa-
tient. Once the determination has been made regarding the
location and anatomic components of the injury, the surgeon
can then appropriately discuss the inherent risks/benefits of
open versus closed operative management with the patient
and decide on a course of action.
References
1. Wermeker K. Incidence, etiology and classification of condylar
fractures. In: Kleinheinz J, Meyer C, editors. Fractures of the
mandibular condyle: basic considerations and treatment. London:
Quintessence Publishing; 2010. p. 29e40. Chapter 4.
2. Wassmund M. Frakturen und luxationen des gesichtsschädels unter
berücksichtigung der komplikationen des hirnschädels. Ihre klinik
und therapie. Berlin: Meusser; 1927.
3. Wassmund M. Über luxationsfrakturen des kiefergelenks. Dtsch
Kieferch 1934;1:27e54.
4. MacLennan WD. Consideration of 180 cases of typical fractures of
the mandibular condylar process. Br J Plast Surg 1952;5(2):122e8.
5. Rowe NL, Killey HC. Fractures of the facial skeleton. Edinburgh
(United Kingdom): E & S Livingstone Ltd; 1955. p. 102e204.
6. Dingman RO, Natvig P. Surgery of the facial fracture. Philadelphia:
Saunders; 1964. p. 177e84.
Powers
7. Spiessl B, Schroll K. Spezielle frakturen- und luxationslehre. Ein
kurzes handbuch in fünf bänden. Band I/1 Gesichtsschädel. H.
Ningst. Stuttgart (West Germany): Georg Thieme Verlag; 1972.
8. Lindahl L. Condylar fractures of the mandible. I: classification and
relation to age, occlusion and concomitant injuries of the teeth
and teeth-supporting structures and fractures of the mandibular
body. Int J Oral Surg 1977;6(1):12e21.
9. Rasse M. Diakapituläre frakturen der mandibula. Eine neue oper-
ationsmethode und erste ergebnisse. Stomatolgie 1993;(90):
413e28.
10. Neff A, Kolk A, Deppe H, et al. Neue aspekte zur indikation der
operativen versorgung intraartikulärer und hoher kiefergelenklux-
ationsfrakturen [New aspects for indications of surgical manage-
ment of intra-articular and high temporomandibular dislocation
fractures]. Mund Kiefer Gesichtschir 1999;3(1):24e9 [in German].
11. Hlawitschka M, Eckelt U. Assessment of patients treated for
intracapsular fractures of the mandibular condyle by closed
techniques. J Oral Maxillofac Surg 2002;60(7):784e91.
12. Loukota R, Neff A, Rasse M. Nomenclature/classification of frac-
tures of the mandibular condylar head. Br J Oral Maxillofac Surg
2010;48(6):477e8.
13. Ellis E 3rd, Palmieri C, Throckmorton GS. Further displacement of
condylar process fractures after closed treatment. J Oral Max-
illofac Surg 1999;59(2):120e9.
14. Loukota RA, Eckelt U, De Bont L, et al. Subclassification of frac-
tures of the condylar process of the mandible. Br J Oral Maxillofac
Surg 2005;43:72e3.
15. AO Foundation Web site. Available at: https://www2.aofoundation.
org/wps/portal/!ut/p/a1/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_
A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAwCTYEKIvEocDQnTr8BDuBo
QEi_l35Uek5-EtCp4c76US6huYZ-6SBDHfOSjC3S9aOKUtNSi1KL9D
Lyi0v0I8rLy430EvPT8kvzUsBe1MsvStcvyA2NqPIsdgQA63nsuA!!/dl5/
d5/L2dJQSEvUUt3QS80SmlFL1o2XzJPMDBHSVMwS09PVDEwQVNFM
UdWRjAwMFE1/?boneZCMF&segmentZMandible&showPageZ
diagnosis. Accessed September 19, 2016.
16. Neff A, Cornelius CP, Rasse M, et al. The comprehensive AOCMF
classification system: condylar process fractures: level 3 tutorial.
Craniomaxillofac Trauma Reconstr 2014;7(Suppl 1):S44e58.
Anatomy and Biomechanics of Condylar
Fractures
Cameron J. Walker, DDS a,*, Stephen P.R. MacLeod, BDS, MBChB, FDSRCS, FRCS b

KEYWORDS
 Condylar fracture  Biomechanics  Anatomy  Temporomandibular joint

KEY POINTS
 The anatomy of the condylar region is complicated, but understandable and negotiable.
 The bilateral, diarthrodial nature of the mandible gives rise to unique biomechanical constraints that are altered by injury
to the condyle.
 Understanding of the anatomy and biomechanics aids surgeons in diagnosis, appropriate treatment planning, and surgical
approaches to condylar fractures.

Introduction reduction and internal fixation of condylar fractures has

Facial fractures were described as early as the seventeenth
century BC in the Edwin Smith surgical papyrus.1 In the eigh-
teenth century, the French surgeon Desault2 described the
unique propensity of the mandible to fracture in the narrow
subcondylar region, which is commonly observed to this day. In
a recent 5-year review of the National Trauma Data Base with
more than 13,000 mandible fractures, condylar and subcon-
dylar fractures made up 14.8% and 12.6% of all fractures
respectively; taken together, more than any other site alone.3
This study, along with others, have confirmed that most mod-
ern-age condylar fractures occur in men, and are most often
caused by motor vehicle accidents, and assaults.4
Historically, condylar fractures were managed in a closed
fashion with various forms of immobilization or max-
illomandibular fixation, with largely favorable results. Although
the goals of treatment are the restoration of form and function,
closed treatment relies on patient adaptation to an altered
anatomy, because anatomic repositioning of the proximal
segment is not achieved. However, the human body has a
remarkable ability to adapt, and it remains an appropriate
treatment of a large number of condylar fractures, including
intracapsular fractures, fractures with minimal or no displace-
ment, almost all pediatric condylar fractures, and fractures in
patients whose medical or social situations preclude other
forms of treatment. With advances in the understanding of
osteosynthesis and an appreciation of surgical anatomy, open
become more prevalent. Zide and Kent5 first outlined the in-
dications for open reduction of mandibular condylar fractures in
their classic article in 1983. Several surgical approaches have
been described to access the condylar region, allowing
anatomic reduction and trends toward earlier function of the
condyle, reducing risks of ankylosis or reduced functional ca-
pabilities. However, there are some condylar fractures that
continue to prompt debate among surgeons regarding the best
course of treatment. Regardless of the management, the
starting point is a thorough understanding of the regional
anatomy and the biomechanics of the fractured condyle.
Overview of anatomy
Bony architecture
The mandibular condyle articulates with the squamous portion
of the temporal bone to form the temporomandibular joint
(TMJ). The concavity on the temporal bone where the mandib-
ular condyle lies in the rest position is termed the glenoid fossa.
Anteriorly is the articular eminence, which the condyle trans-
lates down during function. Posterior to the glenoid fossa is the
tympanic plate, which tapers to the postglenoid tubercle. The
condylar head is roughly 15 to 20 mm wide and 8 to 10 mm long.6
The articular surfaces are covered with a fibrocartilage con-
nective tissue.

Disclosures: The authors have nothing to disclose. Temporomandibular joint disk

a
Oral and Maxillofacial Surgery, Oral Health Center, Loyola Univer-
sity Medical Center, Maguire Building 105, 2160 South 1st Avenue, The TMJ disk lies between the mandibular condyle and temporal
Maywood, IL 60153, USA
b bone, separating the joint into 2 compartments: superior and
Oral and Maxillofacial Surgery Residency, Division of Oral and
Maxillofacial Surgery & Dental Medicine, Department of Surgery, Oral inferior (Fig. 1). It is thought that it forms under compression
Health Center, Loyola University Medical Center, Maguire Building 105, during development from the posterior insertion of the lateral
2160 South 1st Avenue, Maywood, IL 60153, USA pterygoid muscle to the Meckel cartilage.7 The disk is a bicon-
* Corresponding author. cave structure composed of dense fibrous connective tissue, and
E-mail address: cwalkerdds@gmail.com is commonly described as having 3 discrete zones: thick anterior

Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-

1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.002 oralmaxsurgeryatlas.theclinics.com
2 Walker & MacLeod
Fig. 1 Lateral view of the TMJ. (From Morris, C. The anatomy of
the face mouth and jaws. In: Kademani D, Tiwana PS, editors.
Atlas of oral and maxillofacial surgery. St Louis (MO): Saunders;
2016. p. 48; with permission.)
and posterior areas bridged by a thinner intermediate zone.
The central portion of the disk is devoid of vascular supply or
innervation, which are supplied from the periphery, predomi-
nately by the retrodiskal tissue.7,8
Capsule and ligaments
The capsule encloses the TMJ complex. It contains a synovial
membrane on the inner aspect, which is responsible for the
production of the synovial fluid that fills and nourishes the joint
space. It is formed by the medial and lateral capsular liga-
ments, which span from the mandible to the temporal bone.
Inside the capsule are the medial and lateral diskal ligaments,
or collateral ligaments, which connect the disk to the poles of
the condyle (Fig. 2). The lateral ligament, or temporoman-
dibular ligament, overlies the capsule, extending from the
lateral aspect of the temporal bone to the neck of the condyle.
The lateral ligament consists of a horizontal component that
resists posterior displacement, and an oblique component that
limits rotational movement, and is considered to play an
important role in joint stabilization. The strength of this liga-
ment may in part be responsible for causing condylar neck
fractures below its insertion.7
There are 2 noncapsular ligaments that have limited func-
tional impact on the joint, but are routinely described for sake
of completion. The sphenomandibular ligament extends from
the spine of the sphenoid bone to the lingula of the mandible,
and is derived from the Meckel cartilage.9 The stylomandibular
ligament attaches to the styloid process of the temporal bone
and the posterior angle of the mandible, coursing between the
masseter and medial pterygoid muscles.
Muscles of mastication
The 4 primary muscles of mastication that act on the TMJ are
the lateral and medial pterygoids, the masseter, and the
Fig. 2 Anteroposterior view of the TMJ. Expanded view also
shows the position of the facial nerve when in the temporal danger
zone. Note that superior to the zygomatic arch, the temporalis
fascia splits into superficial and deep with an intervening temporal
fat pad. SMAS, superficial muscular aponeurotic system. (From
Morris, C. The anatomy of the face mouth and jaws. In: Kademani
D, Tiwana PS, editors. Atlas of oral and maxillofacial surgery. St
Louis (MO): Saunders; 2016. p. 48; with permission.)
temporalis (Fig. 3). All 4 are innervated by the anterior branch
of the mandibular division of the trigeminal nerve. Although
anatomic variances exist, the lateral pterygoid is most
commonly composed of 2 distinct heads.10 The superior head
originates from the base of the greater sphenoid wing and in-
serts into the auricular disk. The inferior head originates from
the lateral surface of the lateral pterygoid plate and inserts on
the pterygoid fovea, on the front of the condylar neck. Their
action together serves to pull the condyle and the disk simul-
taneously down the articular eminence. MRI and cadaveric
studies have also identified a third head to the lateral ptery-
goid muscle in a portion of the population, which inserts in the
TMJ disk and may play a role in disk stabilization.11,12 The
medial pterygoid muscle originates on the medial surface of
the lateral pterygoid plate and courses laterally, inferiorly, and
posteriorly to insert at the inner surface of the mandibular
angle. Together with the masseter, the two make up the
mandibular sling. The masseter originates from the inferior
zygomatic arch, inserts on the lateral ramus, and has 2 heads,
as shown in Fig. 3. The temporalis is a fan-shaped muscle with
a broad origin along the lateral temporal bone, which inserts as
a tendon along the coronoid process and anterior ramus, and as
such is the most powerful adductor of the mandible.7 Although
several other muscles, such as the digastric, suprahyoid, and
infrahyoid muscles, are involved in mandibular function, they
are weaker muscles, whose role in mouth opening is aided by
gravity.
Anatomy and Biomechanics of Condylar Fractures
Fig. 3 Muscles of mastication. (A) Masseter muscle showing 2 heads. (B) Temporalis muscle. (C) Medial pterygoid muscle and lateral
pterygoid muscle. (From Meuten J, Powers K, Frost D, et al. Applied surgical anatomy of the head and neck. In: Fonseca RJ, Walker RV,
Barber D, et al, editors. Oral and maxillofacial trauma. 4th edition. St Louis (MO): Saunders; 2013. p. 193; with permission.)
Vasculature
The arterial blood supply of the TMJ is ultimately provided by
the 2 terminal branches of the external carotid: the superficial
temporal artery and the maxillary artery. The superficial
temporal artery arises posterior to the mandible near the pa-
rotid and accompanies the auriculotemporal nerve. The su-
perficial temporal artery is frequently encountered during a
preauricular approach to the TMJ region and can be ligated.
The maxillary artery gives rise to several smaller vessels, the
first 2 of which are the deep auricular and the anterior tym-
panic, which lie in the parotid and course posteriorly and su-
periorly to bring arterial blood supply to the tympanic plate13
(Fig. 4). The middle meningeal artery passes medial to the
condyle before entering the cranium, and as such may be
Fig. 4 Maxillary artery and branches. (From Meuten J, Powers K,
Frost D, et al. Applied surgical anatomy of the head and neck. In:
Fonseca RJ, Walker RV, Barber D, et al, editors. Oral and maxil-
lofacial trauma. 4th edition. St Louis (MO): Saunders; 2013. p. 200;
with permission.)
3
damaged by displacement of the condylar head, or surgical
manipulation. It lays an average of 31 mm (range, 21e43 mm)
in a transverse direction from the zygomatic arch.14 The
masseteric artery, a branch of the second portion of the
maxillary artery, courses over the coronoid notch supplying the
anterior joint, before entering deep to the masseter muscle.13
The posterior deep temporal branch of this second portion may
also contribute to the vascular supply of the joint.
Conceptually, the condylar head receives its blood supply
directly from 3 sources: the medullary bone of the mandible,
supplied by the inferior alveolar artery; the periosteum over-
lying the condyle; and the muscular attachment of the lateral
pterygoid. This anatomy explains why a fractured condylar can
remain viable even though the bony connection has been
severed by fracture and the periosteum stripped by a surgical
approach, because the muscular attachment of the lateral
pterygoid remains in place. However, plating of the condylar
head and replacing it as a free bone graft has been described
with success in cases of traumatic displacement or resection.15
Although this is best avoided if possible, it speaks to the
abundant blood supply of the area.
The venous return is by the retrodiskal plexus, which fills
when the condyle moves anteriorly. The superficial temporal
and maxillary veins in turn join to form the retromandibular
vein, which drains into the external jugular vein.
Innervation
It is imperative for surgeons to have a thorough understanding
of the sensory and motor innervation of the TMJ, because both
are encountered on approach to the region. Not only does this
anatomic knowledge affect the surgical approach but it aids in
explanation of preoperative findings and in discussion of
postoperative risks with the patient.
Sensory innervation to the TMJ is by the mandibular division of
the trigeminal nerve (cranial nerve V), which exits the skull
through the foramen ovale. The auriculotemporal nerve is the
first branch of the posterior division, and provides sensory
innervation and proprioception from the TMJ. It also carries
postganglionic fibers from the glossopharyngeal nerve (cranial
4 Walker & MacLeod
nerve XI), which travel with the auriculotemporal nerve after
synapsing in the otic ganglion, and provide autonomic innervation
to the parotid gland. After emerging from the mandibular divi-
sion, the auriculotemporal nerve crosses medial to the condyle
where it lies in direct contact with the condylar neck or capsule,
and then ascends superiorly with the superficial temporal ar-
tery.16 During a preauricular approach, the auriculotemporal
nerve can be severed without consequence, and may even alle-
viate some postoperative discomfort. Additional sensory inner-
vation is provided anteriorly by the masseteric nerve, and
posteriorly by the posterior deep temporal nerve.6 Both are
branches from the anterior aspect of the mandibular division of
the trigeminal nerve, and provide some sensory fibers to the TMJ,
before innervating the muscles after which they are named.
The motor innervation to the muscles of facial expression is
via the facial nerve (cranial nerve VII), after it emerges from the
stylomastoid foramen. It then travels within the temporopar-
ietal fascia and branches within the parotid gland into its 5
terminal branches: the temporal, zygomatic, buccal, marginal
mandibular, and cervical branches (see Fig. 2). Al-Kayat and
Bramley17 studied the distance of the facial nerve from the
anterior margin of the bony auditory meatus and found that it
lies at an average distance of 20 mm anteriorly, but may vary
from 8 to 35 mm. For this reason the preauricular approach to
the TMJ involves placing the incision in a skin crease near the
tragus, or in an endaural fashion. When dissection is carried
down through the superficial temporal fascia in a posterior
plane along the initial incision, the tissue can be safely retrac-
ted anteriorly along with the facial nerve, with the knowledge
that the surgeon is now operating in a plane deep to it.
The branches of the facial nerve are also encountered in a
transparotid approach to the condyle. The approach takes
advantage of the space between the main temporozygomatic
and buccocervical branches to safely and directly approach the
condylar region. In a prospective study of 51 condylar fractures
treated with open reduction and internal fixation via a trans-
parotid approach, Downie and colleagues18 noted 7 transient
cranial nerve VII deficits of the buccal branch, all of which
resolved in an average of 4 months postoperatively. This finding
speaks to the efficacy and safety of this approach.
The facial nerve is again encountered in a submandibular or
periangular approach to the mandible. Note that the marginal
mandibular branch has been found in cadaver studies to sub-
divide into 2 branches 67% of the time, followed by 1, 3, and
(least likely) 4 branches.19 Posterior to the facial artery and
vein, the marginal mandibular branch may course as far as 1 cm
inferior to the mandibular border, and anterior to these vessels
is above the mandibular border.19 For this reason a subman-
dibular incision should be placed in a skin crease at least 1.5 to
2 cm inferior to the mandible and carried down through sub-
mandibular gland fascia. The dissection can then safely be
carried down to the mandible with retraction of the facial
nerve superiorly. If encountered, the cervical branch of the
facial nerve can be severed without complication, whereas
severing the marginal mandibular branch results in post-
operative paresis of the lower lip.
Biomechanics of condylar fractures
Joint mechanics
As previously mentioned, the TMJ disk separates the joint into
a superior and an inferior compartment. It is the inferior
compartment that is responsible for rotational movement,
and the superior compartment where the translational
movement of each condyle takes place. Because of these two
unique properties the TMJ is termed a ginglymoarthrodial
joint. Not all animals are capable of the translational
component. It is hypothesized that the translational compo-
nent may provide for further opening without impinging on
cervical structures.
Mandibular function is often described as a class III lever in
which force is applied between the fulcrum and load20 (Fig. 5).
The TMJ acts as the fulcrum in this system, with the muscu-
lature applying force between the joint and the masticatory
load, and ultimately transmitting variable loads to the TMJ
during mastication.
Fracture patterns and symptoms
The U-shaped mandible distributes forces that are applied to
it. As a weaker area, fractures are often seen in the subcon-
dylar region, caused by tensile stress when a force is applied
elsewhere, which supports the frequent finding of a second,
distant mandible fracture, such as a contralateral para-
symphysis fracture. This fracture is also often quoted as a
potential defense mechanism that prevents the intracranial
intrusion of the condyle into the middle cranial fossa above
through the roof of the glenoid fossa, which can be less than a
millimeter thick.21
Signs and symptoms of condylar fractures include pain over
the preauricular area and limited incisal opening. Unilateral
condylar fractures produce an ipsilateral premature occlu-
sion, with a contralateral open bite, owing to the loss of
vertical height. Deviation to the affected side on opening is
common because of the interruption of the action of the
lateral pterygoid muscle. Laterotrusive movements are
limited away from the fractured side, but may be preserved
toward the fracture. Bilateral condylar fractures, usually
sustained by an indirect blow to the chin, as seen in the so-
called guardsman fracture, produce an anterior open bite
caused by the bilateral loss of height with premature posterior
contact. The condylar head is usually displaced anteriorly and
medially in the direction of the force from the lateral ptery-
goid muscle, although lateral displacement and complete
disarticulations are also possible.
Fig. 5 The mandible may function as a class III lever system, in
which the muscle force is between the TMJ (fulcrum or axis) and
the occlusal load. (From Ellis E, Throckmorton GS. Treatment of
mandibular condylar process fractures: biologic considerations. J
Oral Maxillofac Surg 2005;63:115; with permission.)
Anatomy and Biomechanics of Condylar Fractures 5

Fig. 6 What happens with unilateral condylar process fracture. When biting on the side opposite the fracture, the fractured joint is
expected to be loaded more than the nonfractured side joint (A). However, it has been shown that, in patients with such injuries, the
mean force vector (FV) moves toward the uninjured side so that the relative loading of the damaged joint is reduced (B). This process
occurs by selective increase in the muscles on the nonfractured side and a relative decrease in the activity of the muscles on the featured
side. When biting on the fractured side (C), it would normally be expected that the uninjured joint would have most of the loads. There is
less need for neuromuscular compensations to occur in this instance because the major loads would occur to the uninjured joint, not the
fractured joint (D). (From Ellis E, Throckmorton GS. Treatment of mandibular condylar process fractures: biologic considerations. J Oral
Maxillofac Surg 2005;63:115.)

Adaptations to fracture statistically significant reduction in the incidence of maloc-

When a condylar fracture is sustained, the patient adapts to
the injury with skeletal, muscular, and dental compensations.
Surgeons minimize dental compensations and malocclusions
by treating condylar fractures either with open reduction and
internal fixation or with maxillomandibular fixation. Ellis and
Throckmorton20 studied the masticatory function of patients
with condylar fractures, and showed that patients increase
the masseter activity on the nonfractured side, and decrease
activity on the injured side, which transfers load away from
the injured condyle (Fig. 6). This adaptation acts as a
neuromuscular splinting mechanism. It is most evident when
the occlusal load is on the opposite side, because this creates
more stress on the injured condyle.20 In a separate study
these investigators also noted that less neuromuscular
compensation is required if open reduction of fragments is
undertaken.22
With closed treatment, and on healing, the mandibular
condyle often reestablishes an articulation that is more ante-
rior and lower on the eminence, which may reduce the trans-
lational component of mandibular opening. In theory, this
skeletal compensation is avoided with open reduction of the
fracture. As previously mentioned, historically most condylar
fractures were treated closed, and decades of literature have
revealed a small numbers of complications, because of the
remarkable ability of these skeletal, dental, and neuromus-
cular adaptations. However, a recent meta-analysis reported a
clusion and lateral deviation on opening, as well as improved
protrusive and laterotrusive movements with surgical therapy
compared with closed management.23 A lower incidence of
infection was the only variable studied that favored closed
management, whereas differences in maximum opening and
pain were not significant.23
Summary
Ultimately, the patient and the individuality of the fracture
determine the course of treatment. A thorough understanding
of the anatomy of the condylar region is paramount for facial
trauma surgeons. Understanding this, along with the biome-
chanics of the injury, helps to guide surgeons in therapy.
References
1. Breasted JH. The Edwin Smith Surgical papyrus (facsimile and hi-
eroglyphic transliteration with translation and commentary, in two
volumes). Chicago: The University of Chicago Press; 1930.
2. Bichat X. Memoire sur la fracture des condyles de la machoire
inferieure. Paris: Euvres Chirurgicales; 1813.
3. Afrooz PN, Bykowski MR, James IB, et al. The epidemiology of
mandibular fractures in the United States, Part 1: a review of
13,142 cases from the US National Trauma Data Bank. J Oral
Maxillofac Surg 2015;73:2361e6.
6 Walker & MacLeod
4. Sawazaki R, Lima Júnior SM, Asprino L, et al. Incidence and pat-
terns of mandibular condyle fractures. J Oral Maxillofac Surg 2010;
68:1252e9.
5. Zide MF, Kent JN. Indications for open reduction of mandibular
condyle fractures. J Oral Maxillofac Surg 1983;41:89e98.
6. Fletcher MC, Piecuch JF, Lieblich SE. Anatomy and pathophysiology
of the temporomandibular joint. In: Milora M, Ghali GE, Larsen P,
et al, editors. Peterson’s principles of oral and maxillofacial sur-
gery. 3rd edition. Shelton (CT): People’s Medical Publishing House;
2012. p. 1033e47.
7. Rayne J. Functional anatomy of the temporomandibular joint. Br J
Oral Maxillofac Surg 1987;25:92e9.
8. Wink C, St Onge M, Zimny ML. Neural elements in the human tempo-
romandibular articular disc. J Oral Maxillofac Surg 1992;50:334e7.
9. Ogutcen-Toller M. The morphogenesis of the human discomalleolar
and sphenomandibular ligaments. J Craniomaxillofac Surg 1995;
23(1):42e6.
10. Kertesz T, Liebgott B, Clokie CML, et al. Poster 6: architecture of
the human lateral pterygoid muscle: a novel 3-dimensional anal-
ysis. J Oral Maxillofac Surg 2003;61(8):83e4.
11. Filho HP, Guimaraes AS, Galdames ICS. Prevalence of the third
head of the lateral pterygoid muscle: a magnetic resonance image
study. Int J Morphol 2009;27(4):1043e6.
12. Fujita A, Iizuka T, Dauber W. Variation of the heads of the lateral
pterygoid muscle and morphology of articular disc of human
temporomandibular joint - anatomical and histological analysis. J
Oral Rehabil 2001;28(6):560e71.
13. Meuten J, Powers K, Frost D, et al. Applied surgical anatomy of the
head and neck. In: Fonseca RJ, Walker RV, Barber D, et al, editors.
Oral and maxillofacial trauma. 4th edition. St Louis (MO): Saun-
ders; 2013. p. 177e219.
14. Talebzadeh N, Rosenstein TP, Pogrel MA. Anatomy of the structures
medial to the temporomandibular joint. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999;88:674e8.
15. Boyne PJ. Free grafting of traumatically displaced or resected
mandibular condyles. J Oral Maxillofac Surg 1989;47:228e32.
16. Schmidt BL, Pogrel MA. The distribution of the auriculotemporal
nerve around the temporomandibular joint. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1998;86:165e8.
17. Al-Kayat A, Bramley P. A modified pre auricular approach to the
temporomandibular joint and malar arch. Br J Oral Surg 1979;17:
91e103.
18. Downie JJ, Devlin MF, Carton AT, et al. Prospective study of
morbidity associated with open reduction and internal fixation of
the fractured condyle by the transparotid approach. Br J Oral
Maxillofac Surg 2009;47:370e3.
19. Dingmann RO, Grabb WC. Surgical anatomy of the mandibular
ramus of the facial nerve based on the dissection of 100 facial
halves. Plast Reconstr Surg Transplant Bull 1962;29:266e72.
20. Ellis E, Throckmorton GS. Treatment of mandibular condylar pro-
cess fractures: biological considerations. J Oral Maxillofac Surg
2005;63:115e34.
21. Matsumoto K, Honda K, Sawada K, et al. The thickness of the
roof of the glenoid fossa in the temporomandibular joint: rela-
tionship to the MRI findings. Dentomaxillofac Radiol 2006;35(5):
357e64.
22. Ellis E 3rd, Throckmorton GS. Bite forces after open or closed
treatment of mandibular condylar process fractures. J Oral Max-
illofac Surg 2001;59(4):389e95.
23. Chrcanovic BR. Surgical versus non-surgical treatment of mandib-
ular condylar fractures: a meta-analysis. Int J Oral Maxillofac Surg
2015;44(2):158e79.
Virtual Surgical Planning and
Intraoperative Imaging in Management
of Ballistic Facial and Mandibular
Condylar Injuries
Philipp Kupfer, MD, DMD a, Allen Cheng, MD, DMD b,c,d, Ashish Patel, MD, DMD b,c,e,
Melissa Amudson, DDS b,c, Eric J. Dierks, MD, DMD a,b,c, R. Bryan Bell, MD, DDS a,b,c,e,*

KEYWORDS
 Ballistic  Gunshot  Virtual surgical planning  Intraoperative imaging

KEY POINTS
 The type of ballistic determines the extent of the injury and timing of treatment.
 Staged treatment not only is helpful for surgical planning but also allows for more predictability.
 Virtual surgical planning can help determine treatment sequence and decrease operative time.
 Intraoperative imaging helps increase operative accuracy and helps prevent cumulative error and in some cases
reoperation.
 Intraoperative navigation can help identify fracture fragments and assist with hardware placement.

Introduction Ballistic injuries inherently bare the question whether the

Gunshot wounds to the maxillofacial area are relatively com-
mon in the United States. However, with increasing terror at-
tacks around the world, treatment of gunshots should be part
of every facial trauma surgeon’s armamentarium.
Imaging is essential in managing facial gunshots. Although
computed tomographic (CT) scan has become the mainstay of
imaging for extensive facial injury, the use of and availability of
intraoperative CT scans are still limited. Virtual surgical planning,
on the other hand, does not require additional equipment; it does,
however, require additional time for preoperative planning.
In order to manage and treat gunshot wounds, it is crucial to
understand the extent of the injury. The extent is determined by
the energy produced by the projectile. The kinetic energy equation
(KE Z 1/2 mass  velocity2) illustrates the importance of velocity.
It is therefore helpful to separate ballistic injuries by velocity.
 High velocity greater than 300 m/s
 Low velocity less than 300 m/s
 Shotgun
a
Oregon Health and Science University, 3181 Southwest Sam Jackson
Park Road, Portland, OR 97239, USA
b
Head and Neck Institute, 1849 Northwest Kearney, Suite 300,
Portland, OR 97209, USA
c
Trauma Service, Legacy Emanuel Medical Center, 2801 North Gan-
tenbein, Portland, OR 97227, USA
d
Oral/Head and Neck Cancer Program, Legacy Good Samaritan
Medical Center, 1015 Northwest 22nd Avenue, Portland, OR 97210, USA
e
Providence Oral, Head and Neck Cancer Program and Clinic, Providence
Cancer Center, 4805 Northeast Glisan, Suite 2N35, Portland, OR 97213, USA
* Corresponding author. Head and Neck Institute, 1849 Northwest
Kearney, Suite 300, Portland, OR 97209.
E-mail address: rbryanbell@hnsa1.com
ballistic fragments should be removed. Guidelines exist to
answer that question.
Open versus closed treatment of condyle fractures is still
debated and often depends on training background. It is,
however, important to determine if the condylar fragment is
salvageable and if application of hardware is possible on the
remaining condylar fragment.
Surgical Technique
Preoperative planning
Given the close anatomic proximity, ballistic injuries to the condyle
are often associated with vascular injury. Controlling bleeding is
essential in the initial evaluation. Packing and targeted ligation can
assist in hemostasis. Ligation of the external carotid artery usually
is not very effective. On the other hand, superselective angiog-
raphy with embolization can be helpful and should be considered in
selective cases with difficult-to-control hemorrhage.
Once hemostasis is achieved, the mechanism of the injury
needs to be considered. High-velocity gunshot wounds cause
injury by 3 mechanisms:
1. Penetration
2. Cavitation
3. Fragmentation
Penetration injuries are caused by the direct path of the
projectile as it passes through the body. Cavitation injury is
caused by the energy dispersed by the projectile; this is also
referred to as “shock wave.” The damage caused by cavitation
is often not clinically visible on initial examination.

Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-

1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.05.012 oralmaxsurgeryatlas.theclinics.com
2 Kupfer et al.
Fig. 1 Injury resulting in maxillary cant and impaction (A), which will need to be addressed before aligning the mandible to the maxilla (B).
Fragmentation can not only come from the projectile itself but
also can come from secondary sources when the bullet engages
solid structures such as bone, teeth, or dental restorations.
Low-velocity gunshots have much less energy, and as a
result, a smaller, more linear path of injury with less cavita-
tion. Low-velocity injuries still carry an 11% mortality within
the first 24 hours.
Timing of treatment needs to be considered and should
depend on the velocity of the injury. Infection rates are similar
between delayed and immediate reconstruction and should
therefore not be the determining factor for timing. Particularly
in high-velocity injuries, there is an increased amount of
wound contracture and die back, which can lead to less pre-
dictable results and future functional deformities. It is advis-
able to first debride the wound and allow for die back to occur
before permanent reconstruction.
The invention and implementation of Intraoperative
Perfusion Assessment Systems in which a fluorescent tracer is
injected intravenously and perfusion is recorded with a fluo-
rescent camera could help determine the extent of the
ballistic injuries not visible to the human eye. This imaging
modality can identify a lack of perfusion and possibly more
accurately identify the amount of die back that is to be
expected. At this point, how to best implement this tech-
nology and what clinical indications it has is yet to be
determined, and it is hoped will be elucidated in future
research studies.
Fig. 2 Loss of condylar height bilaterally as the right (A) and left (B) fracture segments overlap.
The necessary delay in definitive treatment to allow for die
back to occur allows time for virtual surgical planning. Staged
treatment is often mandated to accommodate for other asso-
ciated injuries. Although delayed reconstruction is preferred,
there have been reports that found the need for fewer and less
complex revisions after immediate reconstruction.
A high-quality 1-mm-slice CT scan is ideal for virtual sur-
gical planning and often required when considering custom
hardware fabrication. Although larger slice spacing CT scans
can be used to make the virtual planning, they are less
accurate and do not allow for custom hardware fabrication.
Dental restorations and other implanted metallic material
can cause significant scatter in medical grade CT scans.
Cone beam computed tomography (CBCT), on the other
hand, causes less scatter but is often not available in the
hospital setting. Digital CT scans are easily uploaded for
virtual surgical planning. Planning can be done by the sur-
geon independently, but it is often helpful and more efficient
to enroll the help of an experienced third party, usually
resulting in a virtual planning session easily accessed via
phone or Internet.
Questions to consider for planning include the following:
1. Is the maxilla stable? (Fig. 1)
2. Is there a Unilateral or a bilateral condyle fracture?
3. What is the state of the dentition?
4. Is there loss of posterior mandibular height? (Fig. 2)
Ballistic Facial and Mandibular Condylar Injuries
Fig. 3 Restoration of right (A) and left (B) mandibular condylar height after open reduction internal fixation.
5. Is there increased width between the mandibular angles?
6. Is there damage to the temporomandibular joint?
7. Is there damage to the cranial base?
8. Are there bullet fragments and should they be removed?
Often ballistic injuries are not limited to the mandible.
Injury to the maxilla results in an unstable maxillary position
and needs to be taken into account during planning. A mobile
or malpositioned maxilla can lead to a cant or vertical maxil-
lary deficiency. If this is not corrected and stabilized before
aligning of the mandible to the maxilla, an overall cant will be
included in the final reconstruction (see Fig. 1).
The existing dentition can be helpful in establishing the
anatomic position of the maxilla and mandible and allows for
intermaxillary fixation. If the patient is edentulous, the surgi-
cal plan changes because occlusion is less paramount in those
cases.
When considering the surgical repair of condylar fractures,
the goal is to re-establish posterior mandibular height (Fig. 3).
Often unilateral condylar fracture can be treated closed if a
stable occlusion exists.
If there is an additional mandibular fracture outside the
condyle, the width of the mandible will be affected (Fig. 4).
The width between the mandibular angles needs to be re-
established during the planning session to prevent widening
of the mandible. Direct damage to the temporomandibular
Fig. 4 Loss of posterior mandibular height and widening of the mandible preoperatively.
3
joint needs to be evaluated and is considered an indication
for surgical repair or even total replacement of the joint if
necessary.
When present, damage to the cranial base and cranium
needs to be included in the surgical plan and may require the
assistance of neurosurgery.
Several factors can influence the decision if a remaining
bullet needs to be removed.
When bullet fragments should be removed:
1. Bullet in joints, cerebral spinal fluid, or globe
2. Bullets causing impingement on nerves
3. Bullets within the lumen of vessels
4. Bullets contributing to lead poisoning
5. Bullets that are visible or easily palpable
6. Bullets required for medicolegal examination
During the virtual surgical planning session, the condylar
segment is brought back into its original position and
posterior mandibular height is re-established (see Fig. 4;
Fig. 5).
Other facial fractures can be addressed at the same plan-
ning session, and mandibular width can be virtually re-estab-
lished. Gunshot injuries are most often associated with hard
and soft tissue defects, all of which need to be considered
during virtual planning (Fig. 6).
4 Kupfer et al.
Fig. 5 Virtual repositioning of the condylar segment and the re-established posterior mandibular height and mandibular width.
Upon completion of the individual virtual planning, several
options exist, as follows:
a. The plan can be used solely as a guide for the operation.
b. A stereolithic model can be fabricated from which hardware
can be prebent.
c. Custom hardware and cutting jigs can be fabricated for
reconstruction (Figs. 7e9)
Intraoperative navigation can be helpful to locate bullet
fragments as well as locate displaced condylar segments. For
the evaluation of the final mandibular height, however, intra-
operative CT is more useful. Intraoperative CT and more
recently intraoperative CBCT let the surgeon assess the newly
established position of the facial skeleton and make adjust-
ments before leaving to operating room.
Preparation and Patient Positioning
1. Obtain consent from the patient for intraoperative imaging
in addition to the planned procedure.
2. Inform the operating room well in advance that intra-
operative imaging will be used (CT, navigation, and/or
Intraoperative Perfusion Assessment Systems).
3. Inform the operating room if additional equipment is needed,
such as an endoscope if an endoscopic-assisted intraoral
approach is planned.
Fig. 6 Extensive soft and hard tissue defects secondary to a gunshot injury.
4. Confirm that the virtual surgical plan is completed, and any
custom hardware is ready and available for the case.
5. Consider surgical airway management if the injury involves
both jaws.
6. Position the patient in the supine position. It is important to
use a CT-compatible headrest if intraoperative imaging is
planned. Switching the headrest during the case is time
consuming and difficult and should therefore be avoided.
The patient should be positioned as cephalad as possible on
the operating room table to allow for the CT scanner to
capture as much of the mandible as possible. The shoulders
of the patient rather than the operating room table should
be the limiting factor for the extent of the intraoperative
CT scan.
Surgical Approach
1. Existing wound: Most often, an existing entry or exit wound
is present that can be included in the incision design.
2. Extraoral: The standard extraoral approaches can be used
for the mandibular condyle: retromandibular, preauricular,
retroauricular, and submandibular approaches are options
depending on fracture location and extent.
3. Intraoral: Intraoral approaches to the condyle are
possible but often not indicated due to the presence of an
existing extraoral wound, or the damage to the condyle
is too complex for a simple reduction with endoscopic
visualization.
Ballistic Facial and Mandibular Condylar Injuries
Fig. 7 Precontoured plate.
Surgical procedure
1. Depending on the velocity and type of injury, a separate
procedure should be planned for debridement and possible
surgical airway access before the final reconstructive
operation, allowing for tissue die back and virtual surgical
planning.
Fig. 8 Custom cutting jig for both the recipient mandible (A) and the donor fibula (B).
5
2. The same surgical principles apply to ballistic condyle in-
juries as to other condyle fractures resulting from other
mechanisms.
3. Inform the imaging team well in advance (30 minutes in the
authors’ institution) that you will be ready for intra-
operative CT scan.
4. Use a sterile clear plastic bag to cover the patient. This
cover maintains the sterile feel and allows for visualization
for the patient during the scan (Fig. 10).
5. Evaluate the scan immediately after completion in order to
evaluate the status of the current reconstruction and next
steps.
Potential Complications
1. Infection
2. Loss of vertical height
3. Widening of the mandible
4. Compromised condylar fragment
In addition to these standard complications for condylar frac-
tures, an increased risk for infection exists given the nature of
the injury. Antibiotics and surgical drain placement should
therefore be considered during the operation. Loss of vertical
height is common because many ballistic condylar fractures
have a component of comminution that results in a bony defect.
When encountered together with other mandibular fractures,
widening of the mandible is possible. Special attention should be
given to the viability of the condylar segment. Because of the
mechanism of injury, the condyle has an increased risk for ne-
crosis if it is not already so comminuted that surgical repair is
impossible. In cases where the condyle and the temporoman-
dibular joint are not repairable, total joint replacement should
be considered. If a total joint replacement is necessary, this can
also be performed with virtual surgical planning as well. In se-
lective cases, this can also be combined with a sagittal split
osteotomy on the opposite side (Fig. 11).
“Pearls and Pitfalls”
 Going too soon: Operating too early particularly on high-
velocity gunshot wounds makes the operations less
predictable because of expected soft tissue die back.
Operating without a solid plan will increase time in the
operating room and can lead to less predictable outcomes.
6 Kupfer et al.
Fig. 9 Complex reconstruction with fibular free flap using custom cutting jig.
 Going too late: Late operations are complicated by
increased scarring and malunion of existing fractures.
 Positioning: Preoperative preparation and positioning are
crucial in order to avoid lengthy intraoperative delays.
 Fixate proximal segment first: Similar to other condylar
fractures, it is often easiest to fixate the proximal
condylar segment first and then use the hardware to assist
in reducing the segment before applying screws to the
distal segment.
 Prefabricated hardware can help capture proximal seg-
ments and reduce condylar fragments reliably.
 Close follow-up: Prepare for further operations and close
follow-up for several years. Scar revisions are frequent
with gunshot injuries, but the patient also needs to be
followed for infection, necrosis of the remaining condylar
segment, and changes in occlusion. Some patients will
need free-flap reconstruction, and the selective patient
might need total temporomandibular joint replacement in
the future.
 Postoperative imaging: Postoperative imaging is crucial
for evaluating the success of treatment and adjusting
treatment approaches for future patients.
 Handling of evidence: Often bullet fragments in this patient
population are considered evidence. Specific hospital pro-
tocol needs to be followed in order to assure proper
handling, marking, and documentation of bullet fragments.
Fig. 10 Setup of intraoperative CT with sterile cover at the au-
thors’ institution.
 Intraoperative Perfusion Assessment Systems is promising
technology, but impact and utility for ballistic facial
trauma are yet to be determined; further research is
needed.
 Communication is key: Virtual surgical planning and
intraoperative imaging add organizational complexity to
the case. In order for all pieces of the surgical puzzle to
fall into place during the operation, exquisite attention
needs to be paid to preoperative and intraoperative
communication.
Immediate Postoperative Care
 Security
 Psychiatric evaluation
 Intensive care unit
 Early mobilization if possible
 Watch for segment necrosis
The postoperative care of facial gunshot wounds is similar to
the care of other pan facial trauma patients with few ex-
ceptions. Often patients admitted with gunshot wounds
require special security measures in order to protect the pa-
tient and medical staff during the hospitalization from
repeated attempts to end the patient’s life by the shooter. If
the gunshot was self-inflicted, psychiatric evaluation and care
are paramount, and the appropriate service should be con-
sulted as soon as possible. In both cases, the help of case
managers and counselors is important to assist not only the
patient but also the family and loved ones in the healing
process.
Given that gunshot wounds are considered contaminated
wounds, antibiotic coverage is important, although the dura-
tion of coverage is not clear. Repeat examination to look for
signs of infection is the standard of care. The possibility of
proximal segments necrosis after condylar head fractures from
a gunshot wound exists and should be considered if healing
does not progress as expected.
Rehabilitation and Recovery
 Physical therapy and early mobilization of the temporo-
mandibular joint
 Close follow-up for infection and necrosis of remaining
condylar fragment
 Continued psychiatric care
Ballistic Facial and Mandibular Condylar Injuries
Fig. 11 Virtual surgical planning in preparation for left total joint replacement and right sagittal split osteotomy.
Clinical Results in the Literature
Limited results exist in the literature regarding virtual surgical
planning and intraoperative imaging specific to ballistic facial
and condylar injuries.
Summary
 The timing for ballistic facial and condylar injuries is
determined by the velocity of the projectile.
 Virtual surgical planning helps determine treatment
sequence.
 Virtual surgical planning can potentially save time and
increase accuracy or surgical repair.
 Intraoperative CT scan is helpful to identify errors early
and possibly prevent reoperation.
 Navigation can be helpful in reducing fracture fragments.
 The utility of Intraoperative Perfusion Assessment Sys-
tems for facial ballistic injuries is yet to be determined.
 Close follow-up of the patient is paramount to identify
infection and possible condylar segment necrosis early.
 In some cases, condylar reconstruction is not possible,
and virtual surgical planning can assist in planning for
joint replacement.
 Team communication is crucial in order to make the
operation progress smoothly and efficiently with as little
down time as possible.
Further readings
Bell RB. Computer planning and intraoperative navigation in cranio-
maxillofacial surgery. Oral Maxillofacial Surg Clin N Am 2010;22(1):
135e56.
Bui TG, Bell RB, Dierks EJ. Technological advances in the treatment of
facial trauma. Atlas Oral Maxillofac Surg Clin North Am 2012;20(1):
81e94.
Dienstknecht T, Horst K, Sellei RM, et al. Indications for bullet removal:
overview of the literature, and clinical practice guidelines for Eu-
ropean trauma surgeons. Eur J Trauma Emerg Surg 2012;38(2):
89e93.
7
Ellis E 3rd, McFadden D, Simon P, et al. Surgical complications with
open treatment of mandibular condylar process fractures. J Oral
Maxillofac Surg 2000;58(9):950e8.
Gelesko S, Markiewicz MR, Bell RB. Responsible and prudent imaging in
the diagnosis and management of facial fractures. Oral Maxillofacial
Surg Clin N Am 2013;25(4):545e60.
Gruss JS, Antonyshyn O, Phillips JH. Early definitive bone and soft-
tissue reconstruction of major gunshot wounds of the face. Plast
Reconstr Surg 1991;87(3):436e50.
Haug RH, Assael LA. Outcomes of open versus closed treatment of
mandibular subcondylar fractures. J Oral Maxillofac Surg 2001;
59(4):370e5 [discussion: 375e6].
Hlawitschka M, Loukota R, Eckelt U. Functional and radiological results
of open and closed treatment of intracapsular (diacapitular)
condylar fractures of the mandible. Int J Oral Maxillofac Surg 2005;
34(6):597e604.
Hyde N, Manisali M, Aghabeigi B, et al. The role of open reduction and
internal fixation in unilateral fractures of the mandibular condyle: a
prospective study. Br J Oral Maxillofac Surg 2002;40(1):19e22.
Markiewicz MR, Bell RB. Modern concepts in computer-assisted cra-
niomaxillofacial reconstruction. Curr Opin Otolaryngol Head Neck
Surg 2011;19(4):295e301.
Peled M, Leiser Y, Emodi O, et al. Treatment protocol for high veloc-
ity/high energy gunshot injuries to the face. Craniomaxillofac
Trauma Reconstr 2012;5(1):31e40.
Stokbro K, Aagaard E, Torkov P, et al. Surgical accuracy of three-
dimensional virtual planning: a pilot study of bimaxillary orthog-
nathic procedures including maxillary segmentation. Int J Oral
Maxillofac Surg 2016;45(1):8e18.
Stuehmer C, Blum KS, Kokemueller H, et al. Influence of different types
of guns, projectiles, and propellants on patterns of injury to the
viscerocranium. J Oral Maxillofac Surg 2009;67(4):775e81.
Stuehmer C, Blum KS, Kokemueller H, Tavassol F, Bormann KH,
Gellrich NC, Rücker M. Influence of different types of guns, pro-
jectiles, and propellants on patterns of injury to the viscer-
ocranium. J Oral Maxillofac Surg 2009;67(4):775e81.
Trost O, Trouilloud P, Malka G. Open reduction and internal fixation of
low subcondylar fractures of mandible through high cervical trans-
masseteric anteroparotid approach. J Oral Maxillofac Surg 2009;
67(11):2446e51.
Vásconez HC, Shockley ME, Luce EA. High-energy gunshot wounds to
the face. Ann Plast Surg 1996;36(1):18e25.
Vayvada H, Menderes A, Yilmaz M, et al. Management of close-range,
high-energy shotgun and rifle wounds to the face. J Craniofac Surg
2005;16(5):794e804.
The Role of Intra-articular Surgery in the
Management of Mandibular Condylar
Head Fractures
Paolo Boffano, MD, PhD a,*, Pierre Corre, MD b, Stefano Righi, MD a

KEYWORDS
 Mandibular condyle  Fracture  Condylar head  Diacapitular fractures  Intracapsular

KEY POINTS
 Treatment of mandibular condyle fractures is still controversial, with surgical treatment slowly becoming the preferred
option.
 Fractures of the condylar head (diacapitular fractures) are still treated conservatively at many institutions.
 Open treatment for diacapitular fractures allows restoration of the anatomic position of the fragments.
 Open treatment for diacapitular fractures allows immediate functional movement of the jaw and avoids the ankylosis of
the temporomandibular joint induced by trauma.
 Several techniques have been proposed to reduce and fix fractures of the condylar head, including standard bone screws,
resorbable screws, and resorbable pins.

Introduction Content

The condyle is among the most common sites of mandibular Classifications

fractures, ranging from 21% to 49% in the literature.1e20 Treat-
ment of mandibular condyle fractures remains controversial,
with surgical treatment slowly becoming the preferred option.
However, intracapsular fractures of the condylar head are still
treated conservatively at many institutions.1e3 Fractures of the
condylar head are usually treated conservatively because of the
difficulty in the exposure and fixation and the risk of facial nerve
damage. However, open surgery can give early recovery of oc-
clusion and movement of the jaw.5,6 Furthermore, extensive
condylar deformation, disc displacement, height reduction of
the mandibular ramus, temporomandibular joint (TMJ) anky-
losis, dysfunctional complaints (such as limitation of mandibular
mobility, crepitation, lateral deviation during mouth opening),
and occlusal disturbances have also been described after closed
or conservative treatment of diacapitular fractures.7,8
Recently, maxillofacial surgeons have begun to perform open
treatment for intracapsular fractures more frequently, because
it should allow to restore the anatomic position of the fragments
and disc (Fig. 1), as well as an immediate functional movement
of the jaw.9,10 Several techniques have been proposed to reduce
and fix fractures of the condylar head, such as standard bone
screws, resorbable screws, resorbable pins, and cannulated lag
screws.6
a
Division of Otolaryngology, Maxillofacial Surgery and Dentistry,
Aosta Hospital, viale Ginevra 3, Aosta 11100, Italy
b
Department of Maxillo-Facial Surgery and Stomatology, CHU de
Nantes, 85 rue Saint-Jacques, Nantes 44093, France
* Corresponding author.
E-mail address: paolo.boffano@gmail.com
Several classifications have been proposed for intracapsular
fractures. According to the classification of intracapsular
fractures of He and colleagues,10 4 types of fractures can be
identified:
Type A (a fracture line through the lateral third portion of
the condylar head with decrease of the ramus height)
Type B (a fracture line through the central third portion of
the condylar head without decrease of the ramus height)
Type C (a fracture line through the medial third portion of
the condylar head without decrease of the ramus height)
Type M (a comminuted fracture with multiple fragments,
usually more than 3, of the condylar head) (Table 1)
(Fig. 2).
Another classification was proposed by Neff and col-
leagues,11 which classified intracapsular fractures as
Type A fractures (with displacement of the medial parts of
the condyle maintaining vertical mandibular dimensions)
Type B fractures (affecting the lateral condyle with decrease
of ramus height)
Type M fractures (fractures that include high extracapsular
fracture dislocations) (Table 2) (see Fig. 2).
A further classification of intracapsular fractures was sug-
gested by Jing and colleagues,12 who proposed to divide the
posterior plane of the condylar head into 3 vertical sections

Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-

1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.001 oralmaxsurgeryatlas.theclinics.com
2 Boffano et al.

Fig. 1 Intra-articular soft tissue reduction with open treatment of condylar fracture. Constructed profiles of reduction and fixation of
condylar fragment and soft tissue. (A) Condylar fragment and disc were typically displaced anteriomedially. Adhesion was formed at superior
joint space. Retrodiscal tissue was torn. (B) Osteosynthesis with preservation of the attachment of lateral pterygoid muscle from the condylar
fragment. (C) Transecting joint space adhesions and release of the epimysium of lateral pterygoid muscle through an anterior capsulotomy
(thin black arrow) before the disc was replaced and anchored to the condyle (thick white arrow) with suture of posterior attachment (thick
black arrow). (From Chen M, Yang C, He D, et al. Soft tissue reduction during open treatment of intracapsular condylar fracture of the
temporomandibular joint: our institution’s experience. J Oral Maxillofac Surg 2010;68:2189e95; with permission.)

equally: a medial section, a central section, and a lateral
section. Fractures would be distinguished into type M (medial),
type C (central), and type L (lateral) according to the location
of the fracture line within the sections (Table 3) (Figs. 3 and 4).
Because of these various classifications, it is difficult to
obtain a clear picture of the epidemiology of intracapsular
fractures types.
Table 1 He and Yang’s classification of intra-articular frac-
tures of the condylar head
Type Characteristics
A A fracture line through the lateral third portion of
the condylar head with decrease of the ramus height
B A fracture line through the central third portion of the
condylar head without decrease of the ramus height
C A fracture line through the medial third portion of the
condylar head without decrease of the ramus height
M A comminuted fracture with multiple fragments (usually
more than 3) of the condylar head
From He D, Yang C, Chen M, et al. Intracapsular condylar fracture
of the mandible: our classification and open treatment experience.
J Oral Maxillofac Surg 2009;67:1672e79.
Imaging and surgical planning
Computed tomography (CT) seems to be fundamental for an
appropriate diagnosis and assessment of condylar head
fractures, as well as for an accurate management plan-
ning.5,10,12 In fact, CT scans show the precise location of
the fracture, size and position of the fragment, and the
relationship between the ramus stump, fracture segment,
and glenoid fossa,2,10 thus proving to be the gold standard
method for the diagnosis and classification of intracapsular
fractures10(Fig. 5).
MRI can also be used to complete the evaluation of soft
tissue changes in the temporomandibular joint (TMJ) after
condylar fracture, although in a trauma/emergency setting the
patient could obviously present several contraindications
(Fig. 6).
Finally, the use of computer-assisted preoperative simula-
tion has been proposed to gain more information about the
operative site and simulate the reduction and fixation of
the fragment and the stump, thus providing information about
the position and the angle of the hole to be drilled and the
length of the screw to be placed (Fig. 7).5,9 Software such as
Mimics (Materialise, Leuven, Belgium) and SimPlantTM (Mate-
rialise NV) have been used to enable this.
The condylar segments could be virtually repositioned,
adjusted, and made as identical as possible to the image of the
The Role of Intra-articular Surgery
Fig. 2 Illustration of the He classification. (A) Zoning of the condylar head. (B) Classification of intracapsular fractures according to the
location of the fracture line. (C) The location of the central point of the fracture line (asterisk) determines the type of the fracture.
A, type A fracture; B, type B fracture; C, central; C, type C fracture; L, lateral; M, medial. (From He D, Yang C, Chen M, et al. Intracapsular
condylar fracture of the mandible: our classification and open treatment experience. J Oral Maxillofac Surg 2009;67:1672e9; with
permission.)
residual condyle and the glenoid fossa. After the virtual
reduction, the width of the reduced condyle could also be
measured to decide preoperatively the length and position of
screw for fixation of the fractured condylar head (Fig. 8).5,9
This simulation may even be of use for delayed bilateral
condylar head fractures that have failed nonsurgical treatment
(Figs. 9 and 10).
Indications
The indications for operative treatment of condylar head
fractures have been continuously changing (Table 4). In past
years, absolute indications for surgical treatment included
diacapitular fractures in which the stump of the ramus dislo-
cates laterally out of the glenoid fossa.1,8,10
Furthermore, surgery has been increasingly proposed for
significantly displaced or dislocated fractures that make
rehabilitation more difficult and may cause potential TMJ
problems.1,8,10,12
Most surgeons doe not advocate open treatment for any kind
of condylar head fractures in children because of their
remodeling capacity and good functional adaptive regenera-
tion, although active mobilization of the joint with vigorous
Table 2 Neff’s classification of intra-articular fractures of the
condylar head
Types Description
A Fractures with displacement of the medial parts of the
condyle maintaining vertical mandibular dimensions
B Fractures affecting the lateral condyle with decrease
of mandibular height
M Fractures including high extracapsular fracture/
dislocations
From Neff A, Kolk A, Deppe H, et al. New aspects for indications
of surgical management of intra-articular and high temporomandib-
ular dislocation fractures. Mund Kiefer Gesichtschir 1999;3:24e9.
[in German].
3
mouth-opening exercises has to start early in such cases to
avoid development of ankylosis.2,7
Several doubts on the advantages of an open treatment
have been suggested in cases of undisplaced or comminuted
diacapitular fractures too.2
Surgical approaches
Various approaches for intracapsular condylar fractures have
been reported in the literature, although the most commonly
used are the preauricular and retroauricular approaches.1e20
The incision of preauricular approach can be placed in
different regions related to the tragus (Fig. 11). With such an
approach, the exposure of this area may be limited because
of the presence of the facial and auriculotemporal nerves
in the way. Furthermore, the superficial temporal vessels
are often encountered. Therefore, postoperative concerns
following preauricular approach are related to facial nerve
injury, the possibility of a visible scar, and the risk for Frey
syndrome.1e20
On the contrary, with the retroauricular approach (Fig. 12),
the frontal branch of the facial nerve and the auriculotemporal
nerve have to be located and protected within the substance of
the anteriorly retracted flap. A wider exposure of the condylar
head may be obtained, thanks to this approach, which is re-
ported to be associated with a low risk for facial nerve injuries,
auditory stenosis, aesthetic deformity, vascular injuries, sali-
vary fistulas, and Frey syndrome.1e20
Table 3 Jing’s classification of intra-articular fractures of the
condylar head
Types Description
M Fractures of the medial section of the condylar head
C Fractures of the central section of the condylar head
L Fractures of the lateral section of the condylar head
From Jing J, Han Y, Song Y, et al. Surgical treatment on displaced
and dislocated sagittal fractures of the mandibular condyle. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111: 693e9.
4 Boffano et al.

Fig. 3 Types of condylar head fracture as suggested by Neff. (A), Type A, through the medial part of the condylar head. (B), Type B,
through the lateral part. (C), Type C, near the attachment of the lateral capsule. (From Loukota RA, Abdel-Galil K. Condylar fractures. In:
Booth PW, Epley BL, Schmelzeisen R, editors. Maxillofacial trauma and esthetic facial reconstruction. 2nd edition. Philadelphia: Elsevier,
2012; with permission.)

Surgical techniques

Fractures of the condylar head are usually treated conserva-

tively because of the difficulty in the exposure and fixation and
the risk of facial nerve damage. Different from conservative
treatment, open surgery can give early recovery of occlusion
and movement of the jaw,5,6 thus lowering the risk for condylar
deformation, height reduction of the mandibular ramus,
dysfunctional complaints, and TMJ ankylosis.7,8
The most frequently used surgical approach for intra-
capsular fractures has been the preauricular approach,
although retroauricular and endaural approaches have been

Fig. 4 Illustration of the Jing classification (condylar head of the

right side). The posterior plane of the condylar head was divided
into 3 vertical sections equally. They were the medial section,
central section, and lateral section, respectively. Sagittal fractures
of the mandibular condyles were distinguished into type M (medial),
type C (central), and type L (lateral) according to the location of the
fracture line within the sections. (From Jing J, Han Y, Song Y, et al. Fig. 5 CT of a patient with bilateral condylar head fracture.
Surgical treatment on displaced and dislocated sagittal fractures of (From Kisnisci R. Management of fractures of the condyle, condylar
the mandibular condyle. Oral Surg Oral Med Oral Pathol Oral Radiol neck, and coronoid process. Oral Maxillofac Surg Clin 2013;25(4):
Endod 2011;111(6):693e9; with permission.) 573e90; with permission.)
The Role of Intra-articular Surgery 5

Fig. 6 Intracapsular fracture of the mandibular condyle. Parasagittal proton density-weighted (A) and T2-weighted (B) MR images. On
top of the mandibular condyle, consecutive delineation of cortical bone was not preserved (arrows), suggestive of fracture. Instead, there
was a lesion with an intermediate signal intensity on T2-weighted image (B), as well as slightly higher signal on proton density-weighted
image (A), suggesting relatively acute hematoma. (From Sano T, Otonari-Yamamoto M, Otonari T, et al. Osseous abnormalities related to
the temporomandibular joint. Semin Ultrasound CT MRI 2007;28:213e21; with permission.)

proposed too. The common dissection is behind the superficial
temporal vessels to the TMJ area. Because the middle temporal
vein, which is an important branch of the superficial temporal
vein, crosses the zygomatic arch, most of the time, it has to be
ligated for better exposure.8 The complications associated
with these surgical approaches include facial nerve injury,
impaired circulation in the ear, bleeding, and scarring.2,16
Several osteosynthesis techniques have been proposed to
reduce and fix fractures of the condylar head, such as standard
bone screws, resorbable screws, resorbable pins, and cannu-
lated lag screws.6
First of all, reduction and stabilization of these fractures
before fixation remains a challenge because of the limitation of
spaces.

Fig. 7 Preoperative design of location and direction of the screw insertion. Points were fixed on a coronal slice. Screw length and di-
rection were determined by calculating the length of the line from 3 to 4 and the angle of line 3 to 4 to the lateral border of the mandibular
ramus. (From Guo SS, Zhou WN, Wan LZ, et al. Computer-aided design-based preoperative planning of screw osteosynthesis for type B
condylar head fractures: a preliminary study. J Craniomaxillofac Surg 2016;44(2):167e76; with permission.)
6 Boffano et al.

Fig. 8 Postoperative confirmation of screw insertion. The procedure for the points fixing and the angle calculation of the screw insertion
was the same as that done preoperatively. (From Guo SS, Zhou WN, Wan LZ, et al. Computer-aided design-based preoperative planning of
screw osteosynthesis for type B condylar head fractures: a preliminary study. J Craniomaxillofac Surg 2016;44(2):167e76 with permission.)

The following methods can be used:
 The manipulation of the condylar head with 2 small re-
tractors and additional manipulation with periosteal
elevators
 The use of a periodontal probe to locate the medial
fragment with reduction and stabilization of the fracture
using hooks and periodontal elevators
 The stabilization of the fracture by K-wires (Fig. 13)
 The retrieval of the proximal fragment with a screw
 The use of a repositioning pin to assist in reduction and
fixation of the proximal condylar fragment with only
minimal dissection, before the placement of the perma-
nent osteosynthesis screws (Fig. 14)
As for fixation options, several options can be adopted:

 Lag screw or long screw fixation technique

 The use of 2 lag screws (although not always possible
because of the small size of the fractured fragment)
(Fig. 15)

Fig. 9 Calculation of the mandibular 3-D model by Mimics 15.0
on computer. (From Zhang B, Yang M, Zhou Q, et al. Delayed
open reduction and single screw internal fixation as a treatment
option in cases of failed non-surgical treatment of bilateral
condylar head fractures with fragmentation. J Craniomaxillofac
Surg 2016;44:1655e61; with permission.)
Fig. 10 Repositioning of the fracture segments into the right
place and measure the referential data. (From Zhang B, Yang M,
Zhou Q, et al. Delayed open reduction and single screw internal
fixation as a treatment option in cases of failed non-surgical
treatment of bilateral condylar head fractures with fragmenta-
tion. J Craniomaxillofac Surg 2016;44:1655e61; with permission.)
The Role of Intra-articular Surgery 7

Table 4 Evolution of indications for intra-articular surgery of condylar head fractures

Author, Year Absolute Indications Relative Indications
7
Hlawitschka et al, 2005 Displaced, intracapsular fractures, with decrease of
ramus height
Vesnaver,2 2008 Type B (Neff’s classification) fractures
He et al,10 2009 Any type of intracapsular fractures in which the stump of Types A and B (He and Yang’s classification)
He et al,8 2010 the ramus dislocates laterally out of the glenoid fossa fractures
Jing et al,12 2011 Displaced or dislocated intracapsular fractures
Chen et al,1 2012 Any type of diacapitular fractures in which the stump of Significantly displaced or dislocated fractures
the ramus dislocates laterally out of the glenoid fossa that make the rehabilitation more difficult
and which cannot be reduced by closed treatment and may cause potential TMJ problems

 The use of headless bone screw or cannulated screw A soft diet for some weeks can be suggested. Early post-
systems (Fig. 16) operative functional exercise seems to be controversial.
 Resorbable screws As for soft tissue management, it would be better not to
strip the lateral pterygoid muscle from the medially displaced
fragment, although this would ease reduction.1,2 In fact, dis-
Titanium osteosynthesis with lag screws or long screw
insertion of this muscle would compromise the vascular supply
osteosynthesis generally has been shown to be successful in the
to the medial bony fragment, which could lead to its ischemic
repositioning of fractured fragments, although titanium plates
necrosis and resorption.1,2 Finally, it is also necessary to repair
and screws might cause atrophy of the bone by stress shielding.
the joint’s soft tissues, in particular, the intra-articular disc
To overcome these shortcomings, resorbable material has been
and the joint capsule.2 The disc, which is typically displaced
proposed, as it would provide reliable stability for the fixation
anteriorly and medially following diacapitular fractures, should
of mandibular condylar fractures.6,9,16 Other advantages
be replaced in its anatomic position (see Fig. 11).1
associated with resorbable osteosynthesis materials would be
elimination of the risk for secondary operations or dislocation
of titanium screws and plates in the joint or at the skull base.16
Following the surgical treatment of intracapsular fractures,
there is no need for postoperative intermaxillary fixation.

Fig. 11 Preauricular approach utilized for open reduction and

fixation of the fractures and the disc on the left side. Arrow: the
articular disc. (From Zhang B, Yang M, Zhou Q, et al. Delayed
open reduction and single screw internal fixation as a treatment
option in cases of failed non-surgical treatment of bilateral
condylar head fractures with fragmentation. J Craniomaxillofac
Surg 2016;44:1655e61; with permission.)
Fig. 12 Exposure of the mandibular condylar head via a retro-
auricular approach. (From Arcuri F, Brucoli M, Benech A. Analysis
of the retroauricular transmeatal approach: a novel transfacial
access to the mandibular skeleton. Br J Oral Maxillofac Surg
2012;50(2):e22e6; with permission.)
8 Boffano et al.

Fig. 14 Repositioning pin within a handle of a mini-screwdriver

(Martin Medezintechnik, Tuttlingen, Germany). (From Schneider
M, Loukota R, Eckelt U. Reduction of diacapitular fractures of the
mandibular condyle using a special repositioning pin. Br J Oral
Maxillofac Surg 2009;47(7):558e9; with permission.)

Fig. 13 Composite of K-wire in place and cannulated drill

passing over K-wire. (From Loukota RA. Fixation of dicapitular
fractures of the mandibular condyle with a headless bone screw. Br
J Oral Maxillofac Surg 2007;45(5):399e401; with permission.)

Fig. 15 Demonstration of the temporary and lateral screw technique with the mandible sample. (A) Model of the sagittal condylar
fracture. (B) A temporary screw inserted in the posterior surface of the fragment. (C) Drilling a gliding hole for the lateral lag screw. (D)
Drilling traction hole for the lateral lag screw. (E) Inserting the lateral lag screw and drilling the positioning hole for the lateral position
screw. (F) Inserting the lateral position screw and removing the temporary screw. (From Meng FW, Liu YP, Hu KJ, et al. Use of a temporary
screw for alignment and fixation of sagittal mandibular condylar fractures with lateral screws. Int J Oral Maxillofac Surg
2010;39(6):548e53; with permission.)
The Role of Intra-articular Surgery
Fig. 16 Composite of cannulated screw passing along K-wire into
predrilled hole and screw in place with K-wire removed. (From
Loukota RA. Fixation of dicapitular fractures of the mandibular
condyle with a headless bone screw. Br J Oral Maxillofac Surg
2007;45(5):399e401; with permission.)
If the posterior attachment is torn, the disc should be su-
tured with the posterior attachment.1 In addition to anatomic
bony reduction, appropriate management of soft tissues is
crucial for a properly functioning TMJ.2
Complications
Complications of open treatment are few, although some cases
of facial nerve injury have been reported because of the still-
challenging nature of the surgical treatment of intracapsular
fractures. Instead, postoperative malocclusion and mouth
opening limitation are rare.
Condylar head resorption has been reported, but it is
important to remember that an aseptic condylar necrosis can
still be the result of the trauma, with an almost complete
resorption of the condylar process being observed even
following closed functional treatment.
Summary
In conclusion, the keys for successful surgical treatment of
intracapsular fractures seem to be a proper preauricular or
retroauricular approach with careful dissection to prevent
facial nerve injury, a careful repositioning of the condylar head
without stripping it from the lateral pterygoid muscle and
destroying the condylar cartilage surface, and a stable fixation.
9
There is no consensus about a gold standard fixation tech-
nique for intracapsular fractures, as this surgery could be still
considered experimental in numerous centers.
Open reduction and internal fixation (ORIF) of selected intra-
capsular fractures seems to be successful in a high percentage of
cases, improving postoperative function and bony healing.
Nevertheless, closed treatment remains a valid option due to
lack of surgical complications. Therefore, the most appropriate
treatment, either closed or open, for intracapsular fractures,
must still be selected according to the individual patient.
References
1. Chen M, Yang C, He D, et al. Soft tissue reduction during open
treatment of intracapsular condylar fracture of the temporoman-
dibular joint: our institution’s experience. J Oral Maxillofac Surg
2012;68(9):2189e95.
2. Vesnaver A. Open reduction and internal fixation of intra-articular
fractures of the mandibular condyle: our first experiences. J Oral
Maxillofac Surg 2008;66(10):2123e9.
3. Jones SD, Sugar AW, Mommaerts MY. Retrieval of the displaced
condylar fragment with a screw: simple method of reduction and
stabilisation of high and intracapsular condylar fractures. Br J Oral
Maxillofac Surg 2011;49(1):58e61.
4. Loukota RA, Neff A, Rasse M. Nomenclature/classification of
fractures of the mandibular condylar head. Br J Oral Maxillofac
Surg 2010;48(6):477e8.
5. Iwai T, Yajima Y, Matsui Y, et al. Computer-assisted preoperative
simulation for screw fixation of fractures of the condylar head. Br J
Oral Maxillofac Surg 2013;51(2):176e7.
6. Abdel-Galil K, Loukota R. Fixation of comminuted diacapitular
fractures of the mandibular condyle with ultrasound-activated
resorbable pins. Br J Oral Maxillofac Surg 2008;46(6):482e4.
7. Hlawitschka M, Loukota R, Eckelt U. Functional and radiological
results of open and closed treatment of intracapsular (diac-
apitular) condylar fractures of the mandible. Int J Oral Maxillofac
Surg 2005;34(6):597e604.
8. He D, Yang C, Chen M, et al. Modified preauricular approach and
rigid internal fixation for intracapsular condyle fracture of the
mandible. J Oral Maxillofac Surg 2010;68(7):1578e84.
9. Wang WH, Deng JY, Zhu J, et al. Computer-assisted virtual
technology in intracapsular condylar fracture with two
resorbable long-screws. Br J Oral Maxillofac Surg 2013;51(2):
138e43.
10. He D, Yang C, Chen M, et al. Intracapsular condylar fracture of the
mandible: our classification and open treatment experience. J Oral
Maxillofac Surg 2009;67(8):1672e9.
11. Neff A, Kolk A, Deppe H, et al. New aspects for indications of
surgical management of intra-articular and high temporomandib-
ular dislocation fractures. Mund Kiefer Gesichtschir 1999;3(1):
24e9 [in German].
12. Jing J, Han Y, Song Y, et al. Surgical treatment on displaced and
dislocated sagittal fractures of the mandibular condyle. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2011;111(6):693e9.
13. Kermer CH, Undt G, Rasse M. Surgical reduction and fixation of
intracapsular condylar fractures. A follow up study. Int J Oral
Maxillofac Surg 1998;27(3):191e4.
14. Pilling E, Schneider M, Mai R, et al. Minimally invasive fracture
treatment with cannulated lag screws in intracapsular fractures of
the condyle. J Oral Maxillofac Surg 2006;64(5):868e72.
15. Loukota RA. Fixation of dicapitular fractures of the mandibular
condyle with a headless bone screw. Br J Oral Maxillofac Surg 2007;
45(5):399e401.
16. Müller-Richter UD, Reuther T, Böhm H, et al. Treatment of intra-
capsular condylar fractures with resorbable pins. J Oral Maxillofac
Surg 2011;69(12):3019e25.
17. Yang ML, Zhang B, Zhou Q, et al. Minimally-invasive open reduction
of intracapsular condylar fractures with preoperative simulation
10
using computer-aided design. Br J Oral Maxillofac Surg 2013;51(3):
e29e33.
18. Yu YH, Wang MH, Zhang SY, et al. Magnetic resonance imaging
assessment of temporomandibular joint soft tissue injuries of
intracapsular condylar fracture. Br J Oral Maxillofac Surg 2013;
51(2):133e7.
Boffano et al.
19. Schneider M, Loukota R, Eckelt U. Reduction of diacapitular frac-
tures of the mandibular condyle using a special repositioning pin.
Br J Oral Maxillofac Surg 2009;47(7):558e9.
20. Boffano P, Benech R, Gallesio C, et al. Current opinions on surgical
treatment of fractures of the condylar head. Craniomaxillofac
Trauma Reconstr 2014 Jun;7(2):92e100.
The Biology of Open Versus Closed
Treatment of Condylar Fractures
Susan K. Snyder, DMD, MD a,*, Larry L. Cunningham Jr, DDS, MD b

KEYWORDS
 Subcondylar fracture  Closed versus open treatment  Vascular supply  Physical therapy  Bone adaptations
 Cartilage adaptations  Occlusal adaptations

KEY POINTS
 Closed treatment is indicated for children less than 12 years of age and this is best understood in relation to the regen-
erative and remodeling capacity of the condyle.
 Vascular supply affects the remodeling capacity of the condyle.
 Immediate mobilization and physical therapy are important to the outcomes in closed and open treatment by affecting
remodeling with local cytokines; intermaxillary fixation is not supported.
 Complex neuromuscular, skeletal, and occlusal adaptations affect functional outcomes.
 Except for occlusion, most functional outcomes of closed and open treatment are clinically similar.

There are several methods to treat condylar fractures: Condylar head

1. Closed treatment with maxillomandibular fixation (MMF)
2. Closed treatment without MMF
3. Open reduction and internal fixation
There is consensus as to the treatment of pediatric frac-
tures with closed methods, whereas there is lack of consensus
as to the best choice in the treatment of adult fractures. His-
torically closed treatment was favored and resulted in overall
satisfactory results. In the last 25 to 35 years, open reduction
has been used with greater frequency. The fact that both
treatment options usually result in an adequate outcome can
be explained by the biology and adaptability of the temporo-
mandibular joint (TMJ), bone, musculature, and dentition. This
article further informs clinical decision making by reviewing
what is known about the biology behind these treatment
methods.
Vascular supply
Temporomandibular joint
Condylar head blood flow is primarily through the TMJ capsule,
with some endosteal and muscular contributions.
Condylar process
It has not been conclusively established what the nutrient
artery to the condylar process is. Contributions come from
the periosteal perforators, endosteal, and medullary blood
supply. Perforators come from the TMJ capsular plexus,
branches of the lateral pterygoid, and the medullary blood
supply from the inferior alveolar artery (Fig. 2). Fetal models
show the dominance of the arteries entering from the pe-
riphery.3 However, the principal blood supply in adults is
likely from a sub-branch of the inferior alveolar artery.4
Funakoshi3 showed 3 main patterns of this temporomandib-
ular branch: type I, with inferior course at the foramen
turning at the ramus toward the condyle with branching; type
II, with shorter inferior course to the retromolar trigone area;
and type III, traveling directly to the condyle and seen more
often in edentulous individuals and smaller mandibles (Figs.
3A, 4, and 5B).

The TMJ is supplied by many named vessels that branch and

contribute to the articular capsule. These vessels are primarily
branches of the superficial temporal artery and maxillary ar-
tery1,2 (Fig. 1). This plexus of vessels is richest to the posterior
zone of retrodiscal tissue.
a pensates for this interruption in blood flow.4,5 Similarly for
Oral and Maxillofacial Surgery, University of Kentucky, 800 Rose
Street, Lexington, KY 40536, USA
b
Division of Oral and Maxillofacial Surgery, University of Kentucky
College of Dentistry, 800 Rose Street, Lexington, KY 40536, USA
* Corresponding author.
E-mail address: ssn223@uky.edu
Compensation
When the condyle is fractured, the medullary supply is
disturbed and the other sources become dominant. Studies
show that rapid retrograde flow and hypervascularity com-
intracapsular approaches, Satko and colleagues5 showed in a
rabbit model that condylar perfusion was interrupted by
disruption of the posterior discal attachment. Initially condylar
blood flow decreased but it was reestablished within weeks.
During the interruption, anterior blood supply from the

Atlas Oral Maxillofacial Surg Clin N Am 25 (2017) 35–46

1061-3315/17/ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.006 oralmaxsurgeryatlas.theclinics.com
36 Snyder & Cunningham Jr

Fig. 1 (A) Posterior computed tomography (CT) three-dimensional (3D) rendering of the right temporomandibular joint in a 30-year-old
woman. External carotid artery (a), internal maxillary artery (b), superficial temporal artery (c), transverse facial artery (d), small
diverging arteries (e), middle meningeal artery (g), retrodiscal tissue (i), ramus (l), condyle (m). (B) Posterior CT 3D rendering of the left
temporomandibular joint in a 30-year-old woman. External carotid artery (a), internal maxillary artery (b), transverse facial artery (d)
with small diverging arteries (e), inferior dental artery (f), middle meningeal artery (g), anterior tympanic artery (h), retrodiscal tissue (i),
ramus (l), condyle (m). (From Cuccia AM, Caradonna C, Caradonna D, et al. The arterial blood supply of the temporomandibular joint: an
anatomical study and clinical implications. Imaging Sci Dent 2013;43:39; with permission.)

transverse facial artery and its branches increased (Fig. 6). The
joint tissues showed no major histologic changes. There is also
evidence that many variations in vascular patterns exist, some
of which may lead to increased susceptibility to necrosis of the
lateral aspect of the condylar head.2
Role in outcomes
A major advantage of closed treatment is that vascular supply
is undisturbed by surgical intervention and therefore main-
tains the maximum immediate blood supply to support
condylar regenerative capacity. At the other extreme, multi-
ple publications have shown the ability of the condyle to heal
after removal and replantation. Healing after removal and
replantation is followed by resorptive changes that are
morphologic, such as flattening of the condylar head. When
successful, function and occlusion are maintained. The
morphologic changes are shown to occur in the first 2 years
and are stable at 15-year follow-up.6 When replantation is
unsuccessful, it can be followed by partial or complete
condylar resorption.7
Decreasing vascular supply decreases the predictability of
healing. In human studies comparing closed treatment and
Open Versus Closed Treatment of Condylar Fractures
Fig. 2 Condylar process supply: endosteal, periosteal perfora-
tors, medullary blood supply.
extracorporeal reduction, the extracorporeal reduction had
6.5 times more resorption and also had more postoperative
complications.8 Stripping all soft tissue supply results in
vascular ischemia, necrosis, and ultimately some form of
regeneration, which is unpredictable. In a study comparing
vertical ramus osteotomies in monkeys, when the nonpedicled
group was stripped of its capsular and lateral pterygoid
attachment on the proximal segment, blood supply and
viability of the bone were compromised. In contrast, the
pedicled specimens showed no such osteonecrosis. The non-
pedicled bone subsequently degenerated because of ischemia
and underwent delayed healing over a few weeks with new
irregular trabecular bone concomitant with revascularization9
(Fig. 7AeE).
Cartilage
Marciani and colleagues10 showed in a monkey model that loss
of blood supply to the cartilage also led to degenerative
changes in the condyle similar to osteoarthritis with loss
of the fibrocartilage articular surface. They used a cryoprobe
to freeze the condylar head and neck. The condyle necrosed
and was replaced by new bone, losing its fibrocartilage
cap but, remarkably, remaining functionally and skeletally
stable.
Fig. 3 (A) Tracing and (B) photomicrograph showing type I temporomandibular branch of the inferior alveolar nerve. (From Funakoshi K.
Nutrient arteries of the temporomandibular joint: an anatomical and a pathological study. Okajimas Folia Anat Jpn 2001;78(1):7e16; with
permission.)
37
Fig. 4 (A) Tracing and (B) photomicrograph showing type II
temporomandibular branch of the inferior alveolar nerve. (From
Funakoshi K. Nutrient arteries of the temporomandibular joint: an
anatomical and a pathological study. Okajimas Folia Anat Jpn
2001;78(1):7e16; with permission.)
Structural adaptations
Articular disc
Injuries
Repair of soft tissue injury to the TMJ capsule, disc, and ret-
rodiscal tissues plays an important role in rehabilitation and
function of the TMJ. Endoscopic and MRI studies show that
hemarthrosis and vascular hyperemia are common in the
injured capsule when the joint is traumatized by condylar
fractures (Fig. 8). Hemarthrosis resolves with functional reha-
bilitation and has little long-term consequence.11e16
Other injuries to the disc and capsule have more significant
consequences, but with appropriate physical therapy (PT) do
not usually cause serious restriction in movement. When disc
displacement occurs it is typically anterior-medial because of
the pull of the superior head of the lateral pterygoid, and in
some studies shows an incidence as high as 30% in displaced
fractures15 (Fig. 9). Disc perforations are rarer. Capsular injuries
(including tears) are greater with nonfracture injuries, whereas
disc injuries are greater in dislocated fractures.12 There is some
evidence in a rat model that removing the capsule and disc
results in impaired repositioning of the condyle and remodeling
in growing rats. Although an injury this extreme is rare, it shows
that the disc and capsule may play an important role in repo-
sitioning the condyle and influence remodeling.17
Disc position
Studies using MRI to show disc position after treatment show
that open reduction may result in improved anatomic disc
38 Snyder & Cunningham Jr

Ankylosis as a complication of condylar fracture is rare; the

incidence may be as low as 0.4%.20 Injury to the TMJ disc and
capsule is the setup for condylar bone contact with the glenoid
fossa. Closed treatment with MMF and loss of vertical height in
combination with intracapsular fractures of the condyle in-
crease the risk of ankylosis12,20,21 (Fig. 11). Early mobilization
with either open or closed treatment decreases the risk of
ankylosis.

Fig. 5 (A) Tracing and (B) photomicrograph showing type III

temporomandibular branch of the inferior alveolar nerve. (From
Funakoshi K. Nutrient arteries of the temporomandibular joint: an
anatomical and a pathological study. Okajimas Folia Anat Jpn
2001;78(1):7e16; with permission.)
repositioning compared with closed treatments; however,
these studies are of small series only.11,18 Neither technique
reliably results in recapturing the disc. High condylar fractures,
as opposed to low condylar fractures, seem to have less success
recapturing the disc.15 Initially a malpositioned disc may result
in functional differences, including limited opening, excur-
sions, and deviation on opening, possibly caused by restriction
in rotation and translation at the joint. Malposition of the disc
does not affect occlusion, and, after appropriate functional
rehabilitation, differences resolve.11,18,19 Closed and open
functional results are adequate despite disc malpositioning and
decreased translation, possibly because of the adaptations
made in the contralateral joint and neuromuscular system.
Role of rehabilitation
The importance of early physical rehabilitation and early
timing for open treatment in order to optimize restoration to
function may in part be caused by the formation of scar tissue
in the disc, retrodiscal tissue, and capsule. Many different
imaging changes may be seen on MRI caused by scarring and
formation of fibrous tissue in the glenoid fossa11 (Fig. 10). Scar
tissue formation in the capsule and retrodiscal tissues can
prevent reduction of the disc.16 The TMJ capsule constricts
when lacerations heal by fibrosis. In general, more prolonged
PT is needed to restore function for more severe injuries.19
Bone and cartilage
The success of closed treatment is largely caused by the ability
of bone to remodel. This ability is key to the success of closed
treatment. Children up to 12 years of age show a robust ca-
pacity to regenerate a condylar process and an extended
period of adaptive remodeling. Remarkably, displaced frac-
tures remodel and the condyle is ultimately repositioned in the
glenoid fossa. Remodeling continues for several years22e26
(Fig. 12). The condyles may have radiographic and morphologic
changes, such as flattening, but reestablish a normal head-
fossa relationship. There is also a small degree of change in the
glenoid fossa, generally a mild flattening.25,26 When incom-
plete remodeling occurs it does not increase the incidence
of dysfunction.24 Given this remarkable regenerative and
remodeling capacity, it is generally accepted and supported
in the literature that the outcomes for children treated
closed or open are similar. Given the risks of surgery and little
to no advantage of open treatment, closed treatment is the
preferred modality.
Condylar cartilage is covered by a fibrous layer of mesen-
chymal cells that migrate into the immature intermediate
cartilage zone where they differentiate into chondrocytes.
When the condyle is separated from the glenoid fossa by
trauma or protrusive orthodontic appliances, the condylar cap
hypertrophies.27,28 This capacity decreases with age.29
When a fracture occurs, healing occurs by means of carti-
laginous callus formation. Teixeira and coleagues30 showed in
rats the initial immune infiltration at the site of fracture with
areas of devitalization, followed by osteoclastic activity and
simultaneous chondroblastic and osteoblastic activity with

Fig. 6 (A) One-week postoperative specimen showing intact transverse facial artery (T) and superficial temporal artery (S) but no
condylar perfusion (C). Medial (M) and lateral (L) articular branches of the superficial temporal artery were disrupted by surgery. (B) Two-
week postoperative specimen showing increasing vascularity. Deep branches of the transverse facial artery (D), main trunk of the
transverse facial artery (T), and medial articular branches are now visible (M). Condyle is still unperfused (C). (C) Three-week post-
operative specimen showing a well-developed arterial pattern and well-perfused condyle (C), retrodiscal tissue (R), transverse facial
artery (T), medial articular artery (M), lateral articular artery (L), superficial temporal artery (S), internal maxillary meatus (E). (From
Satko C, Blaustein D. Revascularization of the rabbit temporomandibular joint after surgical intervention: a histologic and microangio-
graphic study. J Oral Maxillofac Surg 1986;44:871e6; with permission.)
Open Versus Closed Treatment of Condylar Fractures 39

Fig. 7 (A) Microangiogram of immediate pedicled specimen. Arrows show avascular areas below detached soft tissue. Condylar area (C)
perfused, extravasated Micropaque (E), capsular ligament (L), lateral pterygoid muscle (Lp), masseter muscle (Ma), medial pterygoid
muscle (Mp), distal segment (S), temporal bone (T). (B) Microangiogram of immediate nonpedicled specimen showing lack of perfusion of
contrast into proximal segment. Arrows show area of avascular zone circumscribing proximal segment. Intraosseous vascular architecture
distal segment (S). (C) Microangiogram at 6 weeks for nonpedicled group showing vascular proliferation into proximal segment (arrows).
(D) Microangiogram at 6-weeks for pedicled group showing numerous small blood vessels (arrows) arising from the lateral pterygoid
muscle, periosteum, and capsule penetrating cortices and anastomosing with intraosseous vessels. (E) Photomicrograph of the TMJ of
12-week pedicled group showing regular trabecular patterns perpendicular to articular surface. (F) Microangiogram of 12-week non-
pedicled group showing generalized hypervascularity. (From Bell W, Kennedy J. Biological basis for vertical ramus osteotomiesda study of
bone healing and revascularization in adult rhesus monkeys. J Oral Surg 1976;34:215e24; with permission.)

resulting endochondral bone formation (Fig. 13A, B).31 After
3 months of healing by callus formation, the condyle is repo-
sitioned in the fossa. Poorer bone remodeling occurs in older
children23 (see Fig. 12). The process of osteogenesis is not
significantly different between closed and open groups.
Equivalent histologic and morphologic changes were shown by
Boyne6 in a comparison study of rhesus monkeys divided into
groups treated with soft diet only, MMF, and open treatment
comparable with children less than 12 years old for unilateral
displaced condylar fractures.
Remodeling occurs in the cartilaginous zone in adults as
well. However, adult animals have a bony cortical cap with
fibrocartilage and overall less cartilage with less regenerative
capacity. There is less remodeling of the entire condylar pro-
cess with open reduction and internal fixation (ORIF)6,11 and
the cartilage cap.32 At the most basic level, open treatment
may simply bring the bones in closer proximity and the joint
closer to normal articulation, decreasing the amount of
remodeling needed to reestablish articulation.
Changes also occur in the contralateral joint. The
condylar bone initially responds with an increase in mitotic
activity in the mesenchymal and intermediate cell layer
between the fibrous cap and cartilage. This proliferation also
occurs on the contralateral condyle and enhances the
adaptive process.33 The mechanism of these changes is likely
related to a complex interaction of local inflammatory
40 Snyder & Cunningham Jr

Fig. 8 (A) Coronal MRI of subcondylar fracture 2 days after injury in closed position showing swelling and high signal intensity in the TMJ,
including the subcutaneous tissue, higher than normal signal intensity of the joint capsule, irregular joint capsule (small arrows) with low
intensity of the disc surfaces, and high signal intensity along the line of fracture to the pterygomandibular region. White arrow shows area
of possible tear. (B) Sagittal MRI of condylar fracture 12 days after injury in closed-mouth position. Condylar segment and disc are dis-
placed anteriorly. Joint effusion is present in the upper joint space, retrodiscal tissue is thickened and has high signal intensity, tear in disc
is seen (arrows). (From Takaku S, Yoshida M, Sano T, et al. Magnetic resonance images in patients with acute traumatic injury of the
temporomandibular joint: a preliminary report. J Craniomaxillofac Surg 1996;24:173e7; with permission.)

Fig. 9 (A) CT before operation (left) and MRI after operation

(right) of 60-year-old patient with a dislocated condylar fracture.
Articular disc (arrow) is in the correct position. (B) CT before
operation (left) and MRI after operation (right) of 26-year-old
patient with a dislocated condylar fracture. Articular disc (arrow)
is anteriorly displaced. (From Choi BH, Yoo JH. MRI examination of
the TMJ after surgical treatment of condylar fractures. Int J Oral
Maxillofac Surg 2001;30:296e9; with permission.)
Fig. 10 (A) Coronal CT of ankylosis secondary to sagittal frac-
ture of the left condyle showing bifid condyle with lateral anky-
losis (arrow). (B) Operative view of lateral ankylosis (arrow).
(From Zhang Y. Clinical investigation of early post-traumatic
temporomandibular joint ankyloses and the role of repositioning
discs in treatment. Int J Oral Maxillofac Surg 2006;35:1096e101;
with permission.)
Open Versus Closed Treatment of Condylar Fractures
Fig. 11 (A) Postinjury tracings of 2-year-old boy after bilateral
dislocated subcondylar fractures (left). Follow-up tracings at
11 years 11 months (right) showing complete remodeling and
repositioning within the glenoid fossa. (B) Postinjury tracings of
11-year-old girl after right condylar neck fracture (left). Follow-up
tracings 8.5 years later (right) showing moderate remodeling of
bilateral condyles and repositioning within the glenoid fossa. (C)
Postinjury tracings of a patient 13 years and 8 months old after left
subcondylar fracture (left). Follow-up tracings 8 years 2 months
later (right) showing poor remodeling of bilateral condyles and
mandibular asymmetry. (From Gilhuus-Moe O. Fractures of the
mandibular condyle: a clinical and radiographic examination of 62
patients injured in the growth period. Trans Int Conf Surg
1970;121e30; with permission.)
mediators, growth factors, and hormones. In a study of rats,
remodeling and expression of connective tissue growth
factor and type II collagen were found to be altered in both
the injured and uninjured contralateral condyle.34 In vitro
studies show that compressive forces induce differentiation
and maturation of chondrocytes.35 In the rat model, lack
of function is associated with decreased cartilage prolifer-
ation, decreased proteoglycan levels, less dense bone ma-
trix, and decreased osteogenesis, resulting in generally
smaller mandibles.34
41
The effects of tension, stretch, and loading on condylar
remodeling may be partly why rehabilitation becomes a more and
more important aspect of the treatment of condylar fractures,
closed or open. Remodeling occurs for function, repair, and
growth. Stretch and strain activate local messengers to stimulate
both osteoblastic cells such as with cytokines including vascular
endothelial growth factor (VEGF), insulin-like growth factor,
bone morphogenic protein-2 (BMP-2) and simultaneously activate
osteoclastic cells with local messengers such as interleukin-6,
osteoprotegerin (OPG), receptor activator of nuclear factor
kappa-B ligand (RANKL). In vitro studies show that bone matrix is
increased when osteoblasts are placed under higher strain. Small
amounts of strain have been shown to be antiinflammatory,
inhibiting interleukin-mediated cyclooxygenase-2 and prosta-
glandin E2 cytokine synthesis. However, when strain is too much,
local responses become inhibitive because of the balance shifting
to proinflammatory mediators via upregulation of genes in the
nuclear factor kappa-B pathway. This strain-induced inflamma-
tion is more exaggerated in older tissues.35
Chondroblast differentiation and proliferation are also
stimulated by strain. However, similar to the importance of
pulse exposure of anabolic steroids for bone, the frequency of
the strain is also important.35
Occlusal and skeletal adaptations
With closed treatment, the condylar segments override or lose
vertical height. Skeletal and dental changes contribute to the
adaptations made to form a new articulation. Heurlin and
colleagues36 showed in monkeys that shortening of the ramus,
deviation to the ipsilateral side, and dental movements in all
planes helped to reestablish occlusion. Posterior teeth then act
as the new pivot point for mastication. Classically, the side of
the fracture has premature posterior occlusion and anterior
open bite, the mandibular plane becomes steeper, and the chin
is deviated to the ipsilateral side. Ellis37,38 suggests that these
are simply adaptations to reestablish occlusion. In adults, the
deviation is typically toward the fractured side. In children,
subcondylar fractures are more likely to cause deviation to the
contralateral side, whereas neck and head fractures deviate
more often toward the ipsilateral side. This difference is
perhaps caused by cartilage hypertrophy in adults and injury to
the cartilage in children.39
Despite the potential for changes in vertical dimension of
occlusion (VDO) and symmetry, closed methods largely produce
acceptable occlusal results in children with some canting to-
ward the fractured side and change in occlusal plane angle26
(Fig. 14). Occlusal plane changes are roughly half of the bigonial
angle change. Dental adaptations producing intrusion of the
ipsilateral side molars account for this difference.40 Most often
the changes are small and, from a facial esthetic standpoint,
acceptable. It is not possible to accurately predict in which
cases asymmetric growth and growth disturbances may occur
that will require later orthodontics and orthognathic surgery.26
Although closed treatment results in more ramus height loss
and loss of VDO, these findings have no correlation with functional
outcomes. This lack of correlation may partly be caused by the
condyle in closed treatment often reestablishing articulation
more inferiorly and anteriorly on the articular eminence.41
Changes in occlusal plane, mandibular plane angle, and
symmetry are not likely to improve over time with closed
treatment in adults. This finding may be partly caused by the
lack of growth potential compared with changes that occur over
42
Fig. 12 (A) Histologic appearance of fracture at 1 month showing callus formation and cartilaginous tissue between proximal and distal
bony segments. (B) Histologic appearance of fracture at 3 months with condyle repositioned in the glenoid fossa with evidence of
remodeling (arrows). (From Teixeira A, Luz J, Araujo V, et al. Healing of the displaced condylar process fracture: an experimental study. J
Craniomaxillofac Surg 1998;26:326e30; with permission.)
years in children. ORIF is able to achieve better immediate re-
sults by restoring occlusal relations, skeletal symmetry, and
posterior facial height. Ellis and Throckmorton40 showed that
open-treated condyles had less than 0.5 mm of facial height
shortening at all follow-up times, whereas closed-treated con-
dyles had increased shortening, averaging 5 mm at 3 years.
Immediately following injury, function of the rotating and
sliding ginglymoarthrodial joint is disturbed. If occlusion is off,
closed treatment requires arch bars or some other dental fix-
ation. This condition necessitates a stable maxilla and an
adequate compliment of teeth, ideally with bilateral posterior
occlusion to help prevent vertical collapse. Patients with poor
dentition, no posterior stops, or concurrent midface fractures
are poor candidates for closed treatment. Although there are
many studies that report acceptable occlusal results with
closed treatment,42e44 there is a wide variation in reported
malocclusion, from 0.4% to almost 30%.45e47 Although the ev-
idence is not conclusive, closed treatment of more displaced
condylar fractures is more likely to result in malocclusion than
open treatment.48
Closed treatment requires more occlusal and skeletal adap-
tations than open reduction. Condyle position changes with PT,
arch bars, and the stresses and strains of mastication,49 and
dental compensation helps reestablish occlusion.50 In contrast,
open treatment requires less dental adaptation40 and the
condylar remodeling that may facilitate long-term results in
closed treatment is, in contrast, decreased.32,51 Open treatment
typically reestablishes occlusion immediately and occlusal dif-
ferences improve more gradually with closed treatment.48 Both
may require adaptations during the initial rehabilitation.
Mastication and neuromuscular adaptations
Early changes
The muscular component completes the musculoskeletal
system. Function is perhaps the most important outcome
Snyder & Cunningham Jr
measurement of successful treatment. Complex neuromuscular
adaptations occur immediately after treatment and are variable
from individual to individual. The extent of these adaptations
can be remarkable. For example, some bilateral condylar frac-
tures in which both posterior stops are lost are able to use
neuromuscular changes to reestablish occlusion.37 The natural
pull of the masseter causes premature posterior contact on the
side of fracture and an anterior open bite develops (Fig. 15A).
Talwar and colleagues52 showed that selective activation of the
posterior fibers of the temporalis muscle in combination with
decreased activity in the suprahyoids and masseter causes a
change in the overall vector with closure, allowing increased
incisor overlap and decreased open bite (Fig. 15B). This
compromise results in improved occlusion, but bite forces and
function are compromised at this time without a vertical stop.37
Load
In normal function, the contralateral joint to the loading joint
bears more load. Ellis and Throckmorton53 found that, despite
the immediate improved repositioning of the condyle with
fixation, open treatment of condylar fractures did not signifi-
cantly improve initial maximal bite forces. Both closed and
open treatment groups had initially reduced bite forces that
normalized 6 weeks to 6 months postoperatively. In both open
and closed groups, biting on the fractured side is normal.54
When biting on the nonfractured side, muscle recruitment is
altered such that load is selectively reduced on the fractured
side by increasing the masseter on the working nonfractured
side by 1.5 times and thus reducing load on the fractured
balancing side.53 Ratio of working to balancing side muscle
recruitment is smaller in the open group, suggesting slightly
less neuromuscular adaptation, but the amount was not sta-
tistically significant. Changes are not lasting and ratios
normalized 2 years postoperatively.
In addition, it is hypothesized that the lateral pterygoid
muscle may play a role in the redistribution of loads. With
Open Versus Closed Treatment of Condylar Fractures 43

Fig. 13 (A) Superimposition tracing of left condylar neck fracture (solid) with the opposing uninjured condyle (dotted) at 7 years (left)
and 23 years (right); right condyle is regenerated but 10 mm shorter than the opposite side with increased antegonial notching. (Right) At
age 31 years with chin 5 mm right of MSP, 10 cant, no functional problems, and no esthetic complaints. (B) Superimposition tracings (left)
of right condylar fracture (dotted) with opposing unfractured side (solid) at postinjury ages of (left to right) immediately following
trauma; 3 months with ramus shortening of 3 mm; 20 months with equal length; and 17 years with overdevelopment of 3 mm. (Right)
Seventeen years after trauma with no obvious facial deformity. Subtle upward lipslit left mouth and equivalent cant, right angle is lower
and slightly fuller. (C, top) Superimposition tracings of right condylar fracture (dotted) with opposing unfractured side (solid) at (left to
right) postinjury at age 5 years, 6 weeks after trauma with 8 mm total ramus and condyle shortening; 15 months, 9 mm shorter; 7 years
(age 12 years), 2 mm shorter; 11 years (age 16 years) with no difference in length. (Bottom) At age 16 years (11 years after trauma) with
chin on MSP, normocephalic profile, normal opening without deviation. (D, top) Superimposition tracings of right condylar fracture
(dotted) with opposing unfractured side (solid) at (left to right) postinjury at age 10 years, 5 months; 5 months; 2 years (age 12 years); and
19 years (age 29 years). (Bottom) Nineteen years after trauma with symmetric profile, chin on MSP, no cant, right angle slightly lower and
fuller. MSP, mid-sagittal plane. (From Hovinga J, Boering G, Stegenga B. Long-term results of nonsurgical management of condylar
fractures in children. Int J Oral Maxillofac Surg 1999;28:429e40; with permission.)

chewing, excursion occurs to the balancing side and translation
is greater on the working side. When lateral pterygoid function
is reduced, more load is placed on the contralateral balancing
joint.55 These neuromuscular adaptations are likely a biolog-
ical mechanism to protect the fractured site.
Opening
After skeletal articulation is reestablished, studies show that
mastication largely normalizes over time between open and
closed groups. Electromyogram (EMG) activity normalizes
compared with controls and in fractured compared with non-
fractured sides. During normal opening and protrusion, supra-
hyoid muscles act to rotate the condyle at the start of opening
and translation is largely caused by the inferior head of the
lateral pterygoid muscle. Initially closed treated groups had
better opening, likely secondary to the trauma caused by
surgical intervention in open groups.55
Ligaments play a restrictive and guiding role on opening.
This role may help explain deviation on opening. In a condylar
fracture the temporomandibular ligament is disturbed. The
44 Snyder & Cunningham Jr

Fig. 14 (A) Free-body (left) and lateral skull (right) diagrams showing action of mandibular elevators with suprahyoid muscle causing
loss of posterior vertical dimension with condylar fracture. (B) Free-body (left) and lateral skull (right) diagrams showing action of
posterior temporalis muscles and minimal activity of the elevators and suprahyoid muscles. Mandible can rotate closed with axis at the
mandibular angle and ramus (bottom). (From Ellis E, Throckmorton G. Treatment of mandibular condylar process fractures: biological
considerations. J Oral Maxillofac Surg 2005;63:115e34; with permission.)

temporomandibular ligament is thought to help maintain Excursion

condylar contact with the eminence during opening.56,57
Repositioning the condylar head in open treatment may help
restore function of the temporomandibular ligament, although
the difference in function is not clinically significant.56
Closing
On closing, EMG activity shows reduced adductor activity. As
previously discussed, posterior temporalis activity is increased
and masseter activity decreased on the working side to help
coordinate closing the teeth on the working side. After most
fractures, the lateral pterygoid muscles are still inserted to the
disc and condylar head. In both open and closed treatment
groups translation is reduced and load distribution altered.
Both groups show increased length in the closing masticatory
cycle in unilateral and bilateral fractures.56 The superior head
of the lateral pterygoid has a limited role in closure of the
mandible through rotation and its disruption therefore may not
have much effect on closing.
Throckmorton and Ellis58 showed that open-treated unilateral
condylar fractures recovered normal excursion faster on both
the fractured and nonfractured sides. Both closed and open
treatment groups had reduced excursion at 6 weeks but the
open group recovered fully by 1 year. With subsequent PT,
closed treatment groups still had decreased excursion to the
nonfracture side at 3 years.58 Presumably this is caused by
reestablishment of continuity of the mandible earlier, enabling
the inferior limb of the lateral pterygoid to regain function.
The influence of the lateral pterygoid muscle on differences
in excursive motion in condylar fractures is supported by even
slower recovery in condylar head fractures and more equal
recovery between open and closed groups in excursions to the
fractured side.58 The former likely causes more dysfunction in
the lateral pterygoid and the latter more equal function caused
by the uninjured lateral pterygoid function in the contralateral
side. Greater excursions are needed for efficient bolus break-
down. Typically, diet is modified to liquid and soft foods, so
this may not be clinically significant.

Deviation
For excursive movements, the closed treatment group had
increased deviation toward the fractured side. This finding is
possibly caused by the fact that, in closed treatment, condylar
movements have been shown to have extended rotation and
decreased translation corresponding with activity of the
lateral pterygoid.22,55 This finding is similarly supported in a
study by Palmieri and colleagues59 in which closed treatment
groups had decreased change in ramus angle on opening. In
open treatment groups, deviation was more at 2 to 3 years;
deviation was toward the nonfractured side. Functionally
these differences have little impact on treatment outcomes.
PT such as repeated opening exercises in the mirror may help
correct deviation.

Fig. 15 Temporomandibular ligament and condylar position.
EAC, external auditory canal.
Condylar displacement
Palmieri and colleagues59 found a statistically significant dif-
ference in the condylar mobility and the amount of condylar
displacement medially and anteriorly. Correlation of coronal
displacement of the condyle and negative motion variables
Open Versus Closed Treatment of Condylar Fractures
indicated that more displaced fractures had less mobile con-
dyles. These findings support the decision to surgically repo-
sition more displaced condylar fractures.
Summary
Fixation is not necessary for healing. Unlike other parts of the
mandible, fractures of the condyle rarely result in malunion
even without treatment.6 There is a wide variety of treatment
recommendations, including immediate mobilization with soft
diet, MMF for 2 to 6 weeks, and immediate mobilization with
soft diet. Biology seems to support early mobilization in both
closed and open treatments. Early mobilization has equal
occlusal results to those with periods of MMF37 and helps pa-
tients to return to normal function earlier. In contrast, MMF has
been shown to reduce motion corresponding with the length of
immobilization.60
Physiotherapy has been shown to be more conducive to
regenerative changes than MMF.38,60e63 MMF causes restriction
in motion, which in turn causes degenerative thinning of
cartilage and the proliferative zone, adhesions within the
joint, atrophy, and cell death similar to degenerative changes
seen in osteoarthritis. On histology these changes were shown
in a comparison study of mice by Glineburg and colleagues.64
Even after the MMF group remobilized, atrophy persisted. It
required 8 months of rehabilitation after MMF before equiva-
lent results to those of the early mobilizers were produced.
The initially atrophic changes in cartilage may be reversible
because of the ability of the perichondrium to differentiate.
However, the required chondroblastic differentiation from
perichondrium may be reduced in older individuals. Existing
evidence shows that MMF offers no advantage and delays re-
turn to the pretraumatic function.
Bone and cartilage cells typically thrive in environments
with moderate mechanical stimulation. Endochondral bone
formation and remodeling require a complex combination of
catabolic and inflammatory pathways simultaneously at work
with anabolism.35 Although clinicians are only beginning to
understand the nuances and complexity of how mechano-
transduction pathways and environment influence biology,
these pathways are supportive of early, gentle, and frequent
PT in rehabilitation of TMJ function. The advantageous effects
of low levels and frequent strain on bone and cartilage sup-
port PT methods such as immediate mobilization, liquid diet
progressing to a soft diet, frequent stretch to improve open-
ing, excursive and protrusive motion, and other techniques
such as guiding elastics to help harmonize remodeling tissue
and settle occlusion in contrast with the debilitating effect of
MMF. In the future, other biochemical pathways that enhance
healing may become useful. In combination with physical
rehabilitation this may further enhance how condylar frac-
tures are treated.
Risks of open treatment in children outweigh the benefits.
In patients less than 12 years old, regenerative capacity is
optimized and closed treatment is indicated when possible.
The condyle shows a remarkable ability to remodel and
regenerate after cartilage and bone necrosis. Healing at all
ages depends on revascularization from a rich anathematic
network. At minimum, all condylar fractures have a compro-
mised medullary blood supply. Closed treatment does not
further disturb supply. With any open approach it is important
to consider the blood supply and avoid devascularization by
unnecessarily removing muscle attachments and the TMJ
45
capsule. When blood supply is preserved, remodeling is more
predictable because viable bone, remodeling, and regenera-
tive capacity are maximized.
Over the last few decades, treatment of adult subcondylar
fractures has shown an increase in open treatment. Although
open treatment is advantageous in cases of multiple mandible
fractures, loss of VDO, dislocation, and malocclusion, the
additional risks of open treatment must carefully be weighed.
When clinically appropriate, closed treatment continues to be
a viable, less risky modality with satisfactory results. Open
treatment has significant risks, including injury to marginal
mandibular or temporal branches of the facial nerve, scarring,
infection, hematoma, and hardware failure, and it requires
additional expense and the use of surgical center facilities.
This article informs clinical decision making to undergo open or
closed treatment on a case-by-case basis with a discussion of
the biology behind both treatment modalities.
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Secondary Treatment of Malocclusion/
Malunion Secondary to Condylar
Fractures
Glenn Maron, DDS a,*, Amy Kuhmichel, DMD a, Geoffrey Schreiber, DDS b

KEYWORDS
 Malocclusion  Malunion  Condylar fracture  Secondary treatment

KEY POINTS
 Careful evaluation of the malocclusion, TMD symptoms, and myofascial pain dysfunction help to guide the practitioner
along appropriate treatment modalities.
 Conservative treatment involving splint therapy, physical therapy, and orthodontic correction and equilibration can be
applied to correct minor malocclusions after condylar fractures.
 Joint symptoms and functional impairment may indicate the need for arthroplasty or total joint replacement.
 Orthognathic surgery is a beneficial option for the patient with significant malocclusion; the use of virtual surgery allows for
presurgical assessment in determining if unilateral versus bilateral mandibular osteotomies are indicated.

Subcondylar and condylar fractures account for 29% to 32% of unacceptable. Secondary treatment of these injuries can be
all mandible fractures seen in the United States.1 The treat- frustrating, but also rewarding. Clinicians need to focus
ment of these injuries, as noted elsewhere in this issue, con- treatment plans based on listening to patients and not focus on
tinues to remain controversial. The results of open and closed how a condyle may look on imaging. Ultimately success is
treatment often leave the patient with less than desired based on patient function and satisfaction.
mandibular function and occlusion. Complications associated
with treatment of condylar and subcondylar fractures range
Splint therapy and physical therapy
widely in the oral and maxillofacial literature. Diagnostic er-
rors, poor surgical technique, healing disorders, or complica-
A crucial step in the course of treatment of posttraumatic
tions may lead to the establishment of posttraumatic
malocclusion is determining the presence or absence of
mandibular deformities. Nonunion, malunion/malocclusion,
temporomandibular disorder and/or myofascial pain. If there
and/or facial asymmetry can be found early during the healing
are no symptoms the patient should move toward evaluation
process or as long-term sequelae after the initial mandibular
for correction of the malocclusion. When signs and symptoms
fracture repair. Although occasionally these problems are
are present they should be addressed conservatively using
solved in a nonsurgical manner, reoperations play an important
splint therapy, masticatory complex rest, physical therapy,
role in the management of these untoward outcomes.
nonsteroidal inflammatory drugs, and muscle relaxants when
In analyzing a patient’s condition it is also important to keep
indicated.
in mind the end point or goal of therapy (Box 1). The patient’s
Splint therapy should be done with a stabilization splint that
complaints and concerns are often multifactorial and guidance
provides even bilateral contacts. There is no supporting
by the practitioner is essential. The factors that are most sig-
evidence for anterior versus group function, particularly in this
nificant are also different for each patient. Some patients are
population. The splint should be worn by the patient continu-
happy to be able to open normally without pain, whereas other
ously, and close follow-up should be provided for regular ad-
patients believe even the slightest malocclusion may be
justments. These adjustments are necessary as the condylar
process remodels to a stable articulation. Once the splint can
be worn without change in occlusion then treatment is dis-
cussed for correction of the malocclusion.
Disclosure Statement: The authors have nothing to disclose.
a Jaw exercises for increased range of motion should be
Private Practice, Emory School of Medicine, 5505 Peachtree
Dunwoody Road, Suite 660, Atlanta, GA 30342, USA promoted, which may also help if the patient has pain with
b
Department of Oral & Maxillofacial Surgery, Emory Healthcare, 930 function.2 Adjunctive physical therapy may be warranted by a
Cumberland Road Northeast, Atlanta, GA 30306, USA physical therapist trained in TMD depending on the patient’s
* Corresponding author. symptoms. Therapy should be geared toward improvement in
E-mail address: glennm@jawsoms.com mobility and pain. Thermal, transcutaneous electrical nerve

Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-

1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.003 oralmaxsurgeryatlas.theclinics.com
2 Maron et al.
Box 1. Goals of therapy in late secondary
treatment of mandibular condylar process
fractures
 Obtain stable occlusion
 Restore interincisal opening
 Establish a full range of mandibular excursive
movements
 Minimize deviation of the mandible
 Produce a pain-free masticatory complex at rest and
during function
 Avoid internal derangement of the temporomandibular
joint on the injured or the contralateral side
 Avoid the long-term complication of growth disturbance
stimulation unit, and dry needling may be used to treat the
inflammation and pain. Exercise therapy and heat may be used
for hypomobility.
If the patient’s symptoms resolve the practitioner and pa-
tient can be more assured that if the malocclusion is corrected,
then the symptoms will likely improve. When the symptoms of
TMD remain with the previously fractured condyle, one should
consider a temporomandibular joint (TMJ) total joint pros-
thesis or concomitant open joint surgery with or without
orthognathic surgery for correction of the malocclusion. If the
patient develops symptoms in the joint not affected by the
traumatic event, then the splint may be inappropriately
loading that joint. If the patient’s symptoms resolve with splint
therapy and the malocclusion is minor, the patient could be
monitored for dental compensation without any treatment or
with the use of orthodontic therapy.
Conservative treatment
The common types of malocclusion for condylar fractures
depend on a unilateral versus bilateral condylar fractures.
Posttraumatic malocclusion from a unilateral condylar process
fracture with displacement likely results in a unilateral open bite
of the contralateral side of the fracture with deviation on
opening to the ipsilateral side. This is caused by the loss of
mandibular ramus height and decreased posterior facial height
on the ipsilateral side. This results in a clockwise or posterior
rotation of the mandibular plane on the ipsilateral side of the
fracture. The common malocclusion for a bilateral condylar
fracture is an anterior open bite (AOB). This is caused by the loss
of mandibular ramus height bilaterally causing clockwise or
posterior rotation of the mandibular plane bilaterally. Both of
these problems may cause significant problems for a patient.
Their functional imbalance could lead to dysphonia, alteration in
their anterior guidance, reduction in functional activity, pain,
and poor aesthetics. As an oral and maxillofacial surgeon, one
must determine if it is appropriate to perform surgical correction
of the malocclusion. The answer must be discerned by the pa-
tient’s desire for surgery, what the goals of treatment are for the
patient, and whether the issue can be corrected without surgery.
Equilibration
Dental equilibration can be completed through occlusal ad-
justments. Two studies that looked at using occlusal
adjustment for closure of an AOB found a mean closure of open
bite anteriorly by an average of 2.28 mm and another by
2.38 mm. There was 33.3% relapse among the patients of the
first study.3,4 This procedure can also cause the risk of dentin
hypersensitivity depending on the amount of reduction along
with future occlusal wear leading to dentin exposure. One
study found resolution of the dentin hypersensitivity by the
fifth month.4 There is little literature in support of this course
of treatment and its use should be weighed heavily against
other treatment options. However, for minor malocclusions,
this treatment option could be considered.
Orthodontic correction of bilateral condylar
process fractures
The long-time accepted treatment of a skeletal open bite has
been orthodontics followed by orthognathic surgery. Because
bilateral condylar process fractures create a skeletal AOB,
surgery is the best option. In certain instances, the patient may
be averse to undergoing surgical correction of this problem or
their AOB may be minimal. After a minimum of 6 months of
monitoring, any condylar resorption should be considered
stable. With the use of orthodontics alone to close an AOB the
relapse rates are high. At 10-year follow-up after correction of
patients with an AOB, an open bite of 3 mm or more was found
in more than 35% of patients.5 Other studies have looked at the
use of skeletal anchorage devices for orthodontic closure of
AOB, and there are even several case reports of closure of an
AOB in patients with previous condylar fractures.6e8 These
devices are able to intrude the lower molars by 3 to 5 mm.9
There are several case reports of using mini-implants for
maxillary molar intrusion. In one study they showed a range of
intrusion of the maxillary molars by 1.5 mm to 3.3 mm (mean,
1.9 mm) with closure at the incisors of 3 mm to 4.5 mm.10
Although these results are promising it has been shown that
long-term stability is low and many studies do not have long-
term follow-up.11 Most studies advocate for a postretention
period of at least 4 months before removal of the anchorage
devices.10 Others advocate for excessive intrusion to account
for relapse.12 It should also be taken into account that for
these bodily movements of the posterior dentition, a long
treatment period is required. The use of these devices may
Fig. 1 TMJ concepts total joint prosthesis.
Secondary Treatment of Malocclusion/Malunion 3

Fig. 2 Preoperative computed tomography demonstrating position of a 52-year-old woman 12 weeks after undiagnosed right mandibular
condylar process fracture resulting in loss of right mandibular vertical ramus height and left posterior open bite malocclusion.

prove to be a viable treatment option in the population of
patients with posttraumatic open bites, but further scientific
investigation is warranted.
Arthroplasty/Total joint replacement
In open and closed treatment of condylar fractures, post-
operative malocclusion can occur. Reductions in ramus height
and those with dislocated fractures are prone to functional
disorders of TMJ but also occlusal disorders.13 Soft tissue injury
of the joint can occur at the time of condylar fracture and can
involve hemarthrosis and disk displacement. Also, injury of the
temporomandibular disk at the time of fracture can be
responsible for disk degeneration.14 After injury, the TMJ may
incur secondary osteoarthrosis (arthritis), aseptic necrosis,
bifid deformity of the condyle, fibrous ankylosis, or osseous
ankylosis. Also, condylar head fractures are more prone to lead
to postoperative ankylosis of the TMJ.15

Fig. 3 Preoperative VSP evaluating feasibility of performing only a reosteotomy of the right condylar process. This demonstrated the
amount of remodeling that had already taken place at the fracture site and the inability of the contralateral left condylar/fossa to
accommodate this method of treatment. The red areas over the left condylar head demonstrate the interferences this would result in.
4 Maron et al.
Fig. 4 Preoperative VSP evaluating feasibility of performing a left mandibular sagittal split osteotomy (LSSO) with concurrent reosteotomy
of the right condylar process fracture. This again revealed the significant “gap” that would result at the right side without bony contact.
Significant variations in tolerating occlusal disturbance vary
among individuals. Occlusal disorders can involve working or
nonworking side interferences, premature contact, or the lack
of contact in an area of the dentition. Patients should be
interviewed regarding subjective symptoms, such as TMJ pain,
limitation to daily activities, and alleviating and aggravating
factors. The clinical examination involves palpation of the
masticatory muscles for pain, measuring the maximum inter-
incisal opening, lateral excursive movements, protrusive
movement, joint sounds, and occlusal evaluation. In fibrous
ankylosis the involved condyle only demonstrates rotational
movement with a maximum opening of less than 20 mm with
deviation to the affected side with no translational. In bony
ankylosis the patient’s range of motion is further limited to 5
mm to 7 mm.16 This clinical information in conjunction with
imaging, such as computed tomography and/or MRI, can help
aid in diagnosis.
Conservative therapies previously discussed, such as phys-
ical therapy and splint therapy, are initiated and ongoing
monitoring is used to evaluate the patient’s progress. Splint
therapy also is used as a diagnostic aid to determine the sta-
bility of the condylar ramus unit.
A gap arthroplasty is a surgical option in this patient popu-
lation. An osteotomy is created inferior to the posttraumatic
altered condyle to allow free movement of the mandible and
improve range of motion. Autogenous or alloplastic interposi-
tional materials can be used to decrease the risk of reankylosis.
Autogenous materials include temporalis muscle/fascia, fat,
dermis, and auricular cartilage. Silicone, acrylic, polyethylene,
metals, and ceramic have been described as possible allo-
plastic interpositional materials.17 Material migration, foreign
body reaction, and fragmentation may occur with alloplastic
materials. After the resection of the condyle, the mandible is
mobilized to determine if adequate range of motion has been
achieved. If inadequate mandibular movement is present
further dissection of the temporalis/coronoidectomy,
masseter, and medial pterygoid musculature can be consid-
ered.18 The temporomandibular disk can also be inspected
during this procedure for pathology and if present can be
corrected.
Because of the created bony gap often the vertical height of
the ramus is further decreased. This can result in a worsening
malocclusion. A consideration to help stabilize the vertical
dimension is joint reconstruction. The two most widely dis-
cussed joint reconstruction options include TMJ prosthesis/
total joint reconstruction (alloplast) and autogenous methods,
such as costochondral graft or a ramus osteotomy.
Markowitz and coworkers19 described the possibility of
reconstructing the mandibular condyle by performing a ramus
osteotomy and sliding the proximal segment superiorly into the
articular fossa. This approach has the benefit of being autog-
enous without donor site morbidity. The costochondral graft
has the benefit of being biologically compatible with growth
potential. Nelson and Buttrum20 discussed that the biologic
Secondary Treatment of Malocclusion/Malunion 5

Fig. 5 Preoperative VSP evaluating feasibility of performing a traditional bilateral sagittal split osteotomy. The difficult intraoperative right
proximal segment positioning likely to be encountered is now readily visualized, despite the relatively small moves at the Dalpont sites.

reconstruction of the adult TMJ is preferable to alloplastic
reconstructions because just as in the growing child, the adult
articulation must adapt to the demands of the functional ma-
trix. However, the growth is unpredictable and this graft option
in comparison with a prosthesis has the added disadvantage of
resorption, reankylosis, and donor site morbidity. A further
disadvantage is that an immobilization period is usually
necessary until consolidation and functional stability of the
grafts has taken place.21
A TMJ prosthesis (Fig. 1) has the advantages of no donor site
morbidity, early/immediate return to function, and consistent
condyle and fossa anatomy. Disadvantages of alloplastic joint
replacement include higher cost and hardware failure.16 All
patients undergoing gap arthroplasty or joint reconstruction
run the risk of potential injury to the facial nerve, Frey syn-
drome, and parotid gland injury. The postoperative use of arch
bars/elastics to help guide the patient into reproducible oc-
clusion should be considered. Physical therapy is an important
adjunct to ensure the improvement of function and decrease in
discomfort. Physical therapy is an important adjunct to ensure
the improvement of function and decrease in discomfort. Use
of tongue blades or Therabite (Atos Medical, Inc, West Allis,

Fig. 6 Final position of virtual surgical planning for bilateral sagittal split osteotomies.
6 Maron et al.
Fig. 7 Panoramic film.
WI) for opening should be considered in the early postoperative
period to prevent decreased maximal incisal opening caused by
scar tissue formation. As in management of patients with TMD,
a surgical plan that includes total joint replacement should be
considered as the last option when other procedures do not
achieve the desired goals. Counseling the patient about all
potential risks is crucial before surgery.
Orthodontics and orthognathic surgery
Once it has been determined that a malocclusion or malunion is
too significant to be treated by occlusal equilibration or or-
thodontic therapy alone, one must consider the surgical op-
tions for these patients. Philosophically speaking, combining
orthodontic therapy with orthognathic surgery to correct
malocclusion provides the most ideal result. However, if ideal
occlusion exists on articulated models one can consider pro-
ceeding without orthodontics. Combining orthodontics with
Fig. 8 (AeC) Postoperative 3D computed tomography reconstruction.
surgery allows for correction of major malocclusions as long as
the posttrauma condyles are functional, and within the fossae.
Appropriate evaluation of mounted models or analysis of
digital virtual treatment plan via systems, such as Suresmile
(OraMetrix, Inc, Richardson, TX) or 3D systems, gives the best
idea of the potential benefits and pitfalls of combined surgical
and orthodontic case planning. With the advent of computed
tomography scanning, 3D imaging and virtual surgical planning
(VSP) have gained a foothold in orthognathic surgery. VSP is
rapidly replacing traditional model surgery in many parts of the
country and the world. It allows the ability to show the patient
what can be accomplished before beginning any actual treat-
ment. In the event of a unilateral fracture malunion, previous
authors have suggested unilateral mandibular osteotomies to
correct the malocclusion, whereas if there was a bilateral
condylar fracture with resulting functioning condyles but a
developed AOB, Le Fort maxillary surgery may be the best
option. The use of VSP allows one to perform osteotomies in 3D
and assess how this will impact the occlusion in a much more
precise manner than traditional model surgery (Figs. 2e6). The
ability to view segment movement and bone position change in
multiple planes is unparalleled. In a retrospective study 21
patients with posttraumatic malocclusion caused by condylar
process fractures, orthognathic surgery was used to success-
fully restore proper occlusion. Group I with 15 patients was
treated with unilateral or bilateral mandibular ramus osteot-
omies for asymmetric malocclusion. In group II six patients
were treated with either a Le Fort I osteotomy (n Z 5) or
bilateral ramus osteotomies (n Z 1) for AOB.4
The timing of surgery should be at least 6 months after the
initial injury because the risk of remobilizing a malunion within
the first 6 months after the failed initial surgery compromises
the result. The benefit of Le Fort osteotomy for treatment of
Secondary Treatment of Malocclusion/Malunion
Fig. 9 Treatment protocol.
the open bite deformity lies in not having to manipulate the
condyles in this patient pool. This is similar to how we manage
patients with TMD internal derangement or those with idio-
pathic condylar resorption. Any time we can avoid operating on
the lower jaw we decrease the risk of redeveloping or reac-
tivating pain or altered function. However, in cases where the
patient has an asymmetry of the mandible as a result of the
fracture, obviously mandibular surgery is indicated. Review of
the literature supports the use of either unilateral or bilateral
ramus osteotomies. We have found that clinically, even in
cases of a unilateral fracture, the use of bilateral sagittal
ramus surgery provides a better result. Additionally, the use of
the sagittal split osteotomy with rigid fixation has the benefit
of earlier function thus preventing risk of long-term trismus.
Case report
A.L. is a 52-year-old woman status post bilateral subcondylar
and symphysis mandible fracture in November 2009. The pa-
tient was treated at another facility with 8 weeks of maxillo-
mandibular fixation. After release of fixation the patient had a
significant malocclusion with pain and condylar deformity
(Fig. 7). She was referred to us at that time. Late in 2010, the
patient underwent a revision arthroplasty and plication pro-
cedure to reconstruct a stable left TMJ. The patient gained
stability and did well using an oral orthodontic splint. Despite a
stable and functional joint, the patient was still concerned
about the significant posttraumatic malocclusion and had
7
orthodontic treatment followed by maxillary and mandibular
orthognathic surgery (Fig. 8). The patient was followed for
2 years after surgery and has a stable and repeatable occlusion
with no pain and good range of motion.
Treatment protocol
Developing a protocol for dealing in this patient population is
helpful for the surgeon when evaluating and managing these
patients after their initial trauma and treatment. We hope to
propose a logical treatment regimen for patients with minor
malocclusions and those with significant malunions (Fig. 9).
This decision tree is an initial guide in considering management
decisions to best achieve treatment goals.
Summary
The patient who presents with the sequela of malocclusion or
malunion after suffering subcondylar or condylar fractures has
the right to expect that clinicians can provide solutions for
their dilemma. Treatments can be simple or complicated
depending on the severity of the problem. The ultimate goal is
to restore function and occlusion, in a pain-free manner, as
close to the preinjury architecture as possible. As technology
advances, the tools that can be applied to these situations also
advance and expand. In our literature search for this article we
came upon a paper that was written in 1945 that stated “it is
inevitable that there would be disappointment with the
8 Maron et al.

outcome of the treatment for the fractured mandible.”22 Cli- 10. Sherwood K. Closing anterior open bites by intruding molars with
nicians have come so far since that time and are continuing to titanium miniplate anchorage. Am J Orthod Dentofacial Orthop
develop better treatment protocols for patients. The focus also 2002;122:593e600.
has to remain on listening to the patient’s goals and desires and 11. Ghafari J, Haddad R. Open bite: spectrum of treatment potentials
and limitations. Semin Orthod 2013;19:239e52.
not allow treatment plans to be solely guided by radiograph
12. Park HS, Kwon OW, Sung JH, et al. Nonextraction treatment of an
findings and the inherent desire as surgeons to “fix” things. open bite with microscrew implant anchorage. Am J Orthod Den-
tofacial Orthop 2006;130:391e402.
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temporomandibular joint disorders in patients with unilateral
condylar fracture. A prospective one-year study. Int J Oral Max-
1. Noh K, Choi W, Pae A, et al. Prosthetic rehabilitation of a patient
illofac Surg 1998;27:280e5.
with unilateral dislocated condyle fracture after treatment with a
14. Wu X, Hong M, Sun K. Severe osteoarthrosis after fracture of the
mandibular repositioning splint: a clinical report. J Prosthet Dent
mandibular condyle: a clinical and histologic study of seven pa-
2013;109:367e72.
tients. J Oral Maxillofac Surg 1944;52:138e42.
2. Ellis E 3rd, Walker RV. Treatment of malocclusion and TMJ
15. Xiang G, Long X, Deng M, et al. A retrospective study of tempo-
dysfunction secondary to condylar fractures. Craniomaxillofac
romandibular joint ankyloses secondary to surgical treatment of
Trauma Reconstr 2009;2(1):1e18.
mandibular condylar fractures. Br J Oral Maxillofac Surg 2014;52:
3. Janson G, Crepaldi MV, Freitas KM, et al. Stability of anterior open-
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bite treatment with occlusal adjustment. Am J Orthod Dentofacial
16. Fonseca R, Marciani R, Turvey T. Oral and maxillofacial surgery. St
Orthop 2010;138(1):14.e1-e7.
Louis (MO): Saunders; 2009.
4. Janson G, Crepaldi MV, Freitas KMS, et al. Evaluation of anterior
17. Guven O. Treatment of temporomandibular joint ankylosis by a
open-bite treatment with occlusal adjustment. Am J Orthod Den-
modified fossa prosthesis. J Craniomaxillofac Surg 2002;32(4):
tofacial Orthop 2008;134(1):10e1.
296e9.
5. Al Yami EA, Kuijpers-Jagtman AM, van’t Hof MA. Stability of or-
18. Kaban LB, Perrott HD, Fisher K. A protocol for management of
thodontic treatment outcome: follow-up until 10 years post-
temporomandibular joint ankylosis. J Oral Maxillofac Surg 1990;
retention. Am J Orthod Dentofacial Orthop 1999;115:300e4.
48(11):1145e51.
6. Cousley R, Gibbons AJ. Correction of the occlusal and functional
19. Markowitz NR, Allan P, Duffy M. Reconstruction of the mandibular
sequelae of mandibular condyle fractures using orthodontic mini-
condyle using ramus osteotomies: a preliminary report. J Oral
implant molar intrusion. J Orthod 2014;41(3):245e53.
Maxillofac Surg 1989;47:367e77.
7. Yao CC, Lee JJ, Chen HY, et al. Maxillary molar intrusion with fixed
20. Nelson C, Buttrum J. Costochondral grafting for posttraumatic
appliances and mini-implant anchorage studied in three di-
temporomandibular joint reconstruction: a review of six cases. J
mensions. Angle Orthod 2005;75(5):754e60.
Oral Maxillofac Surg 1989;47:1030e6.
8. Yanagita T, Adachi R, Kamioka H, et al. Severe open bite due to
21. Raveh J, Vuillemin T, Ladrach K, et al. Temporomandibular joint
traumatic condylar fractures treated nonsurgically with implanted
ankylosis: surgical treatment and long-term results. J Oral Max-
miniscrew anchorage. Am J Orthod Dentofacial Orthop 2013;143:
illofac Surg 1989;47:900e6.
S137e47.
22. Burdick C, Lifton J. Correction of malunion of a mandibular frac-
9. Umemori M, Sugawara J, Mitani H, et al. Skeletal anchorage system
ture with disfiguring malocclusion. Am J Orthod Oral Surg 1945;31:
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310e7.
115:166e74.
Matching Surgical Approach to Condylar
Fracture Type
Hany A. Emam, BDS, MS , Courtney A. Jatana, DDS, MS , Gregory M. Ness, DDS*
KEYWORDS
 Surgical approaches  Condylar fractures  Open reduction of condylar fractures
KEY POINTS
 Head and neck trauma surgeons must have an acute knowledge of surgical principles to approach a condylar fracture with
an open surgical technique.
 An understanding of the classification of the fracture and the appropriate surgical access for visibility and reduction is
critical.
 Practicing good surgical principles to avoid vessel and nerve injury is equally important for successful reduction of these
fractures.
Introduction
Condylar fractures account for 25% to 35% of all mandibular
fractures. Because of their high incidence and frequent
complexity, several treatment options have been described for
these fractures. Broadly, the 2 main methods are defined as
either conservative (closed) or surgical (open) treatment.
Conservative therapy consists of 10 to 14 days of immobili-
zation, which is accomplished by the control of occlusion with
the use of arch bars and intermittent maxillomandibular fixa-
tion. Typically, this method is chosen because of the difficulty
in exposure of the condyle, the risk of facial nerve injury, and
the technical challenge in open reduction osteosynthesis of
condylar fractures. However, there are negative consequences
of conservative therapy, which can include malocclusion,
reduced facial height and asymmetry, chronic pain, and a
reduction in mobility.
In contrast, indications for surgical intervention are not
universally clear, with varying conclusions drawn from the
published evidence. Several studies comparing conservative
with surgical treatment have shown that open reduction and
rigid fixation leads to better results. Some studies report that
better functional outcome can occur with open treatment.
Identifying fractures by location
Regardless of method chosen, the means of access to the
fractured condyle is important in the initial treatment decision
process. A necessary prerequisite for choosing between con-
servative and surgical treatment and determining appropriate
access for treatment of condylar fracture is to identify the
Division of Oral and Maxillofacial Surgery and Dental Anesthesiology,
College of Dentistry, The Ohio State University, 305 West 12th Avenue,
Postle Hall, Columbus, OH 43210, USA
* Corresponding author.
E-mail address: ness.8@osu.edu
Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-
1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.004
location of the fracture. A fracture that is located above the
mandibular foramen and runs from the posterior edge of
the ramus into the sigmoid notch is classified as a fracture of
the condylar process. A fracture of the condylar head is
referred to either as intraarticular or diacapitular (Fig. 1).
However, within these broad definitions are many fine dis-
tinctions, and differing published classification schemes can
complicate injuries and the access needed to reach them.
Classification of condylar fractures is discussed in detail
elsewhere, but this article uses a basic well-known system for
determining appropriate access. Loukota developed this simple
nomenclature to minimize the difficulty of fracture visualiza-
tion and the confusion in the international terminology of the
widely cited 6 types in the Spiessl and Schroll classification.
Instead, Loukota suggested the following terms (Figs. 2 and 3):
1. Neck: fracture line is mostly above line A in the lateral view
(Fig. 2A), where line A is the perpendicular line through the
sigmoid notch to the tangent of the ramus
2. Base: fracture line runs behind the mandibular foramen and
mostly below line A (Fig. 2B)
3. Diacapitular (head): through the head of the condyle (Fig. 2C)
Surgical approaches
The decision on a particular approach to reach a fracture
depends on the location of the injury and the height, location,
and type of osteosynthesis being considered. Incisions
used to reach condylar and subcondylar fractures include
intraoral, periangular, retromandibular, preauricular, and
retroauricular. Approaches to the subcondylar base and neck
should be distinguished from head (diacapitular) fractures.
Diacapitular fractures can be accessed through the preaur-
icular or retroauricular approaches. Neck fractures can be
accessed through intraoral, periangular, retromandibular, and
preauricular and postauricular incisions. Base fractures can be
accessed through intraoral, periangular, and retromandibular
incisions (Fig. 4).
oralmaxsurgeryatlas.theclinics.com
2 Emam et al.

Submandibular/periangular

This approach is appropriate when access to the base and neck

are required for open reduction. To allow for full access a slight
extension of the classic submandibular incision in a backward
and upward direction to the periangular region allows full ac-
cess. The incision is marked 2 to 3 cm below the lower border
of the mandible and is approximately 3 to 4 cm in length
(Fig. 5). Anatomic planes transected include skin, subcutane-
ous fat tissue, and platysma. After division of the platysma,
meticulous dissection through the superficial layer of the deep
cervical fascia is performed to avoid injury to the mandibular
branch of the facial nerve and inadvertent bleeding of the
facial vein and artery, which may be divided to allow soft tissue
reflection. After reflection of the muscular sling and perios-
teum, careful retraction of the mandibular branch of the facial
nerve in a caudal direction is advised. With this access, mini-
plate and lag screw osteosynthesis can be achieved.

Retromandibular

This approach begins with a standard incision but, after the

skin and subcutaneous planes have been transected, 3 options
have been described for the final dissection to the condyle. In
all cases, the skin incision is marked 5 to 10 mm below the ear
lobe and should run parallel to the posterior border of the
Fig. 1 Black line indicating fracture line above mandibular fo-
mandible and be 3 to 4 cm long (Fig. 6).
ramen to the sigmoid notch (condylar process). Red line indicating
The first variation of the deeper dissection is termed the
fracture line of the condylar head (diacapitular).
transparotid approach. The parotid capsule is carefully iden-
tified and divided horizontally through the space between the

Fig. 2 Loukota classification. (A) Fracture of the condylar neck (above line A). (B) Fracture of the condylar base (below line A). (C)
Diacapitular fracture (through the head of the condyle). (From Loukota RA, Eckelt U, De Bont L, et al. Subclassification of fractures of the
condylar process of the mandible. Br J Oral Maxillofac Surg 2005;43(1):73; with permission.)
Surgical Approach for Condylar Fracture Types
Fig. 3 Loukota classification.
paths of the buccal and zygomatic branches of the facial nerve.
The parotid fascia and masseter muscle are dissected with final
exposure of the condylar fracture (Fig. 7).
The second variation is termed direct because it goes
straight through the parotid gland, posterior to the border of
the mandible. The facial nerve may require formal dissection
in this exposure to help with access to the lateral aspect of the
posterior border of the mandible.
Fig. 4 Matching fracture type to surgical access with the Loukota and Spiessl classifications.
3
Fig. 5 Skin marking of location of the classic submandibular
incision 2 cm below inferior border of mandible.
The third variation is described as the deep approach
because it involves dissection to the sternomastoid followed by
progression anteriorly toward the medial aspect of the poste-
rior border of the mandible. Despite this deeper dissection
4 Emam et al.

Fig. 6 Standard retromandibular skin incision. Fig. 8 Excellent visibility and access for osteosynthesis repair.

pathway, the retromandibular approach is an efficient and safe

way to expose the fracture site (Fig. 8). Disadvantages include
potential for formation of a sialocele or salivary fistula if the
parotid capsule is ineffectively closed.

Preauricular/endaural

This incision is most commonly used to access diacapitular

fractures. Regardless of the modification to the incision, the
result allows maximum lateral and anterior exposure of the
condyle. The skin incision is a 2.5-cm curvilinear line following
the tragus and helix of the ear with possible extension to the
temple (Fig. 9). This extension onto the temple can help
minimize unnecessary traction that may cause weakness of the
facial nerve. Once the superficial temporal fascia plane is
reached, it should be incised and carefully retracted while

Fig. 9 Preauricular skin incision line. The dotted line notes the
endaural skin incision line. (From Ness GM, Arthroplasty and dis-
cectomy of the temporomandibular joint. Atlas Oral Maxillofac
Fig. 7 Capsule of parotid gland. Surg Clin North Am 2011;19:177e87; with permission.)
Surgical Approach for Condylar Fracture Types 5

dissection proceeds deep until the anatomic separation of the Retroauricular

temporalis fascia (divided by fatty tissue) is seen (Figs. 10 and
11). Next, the dissection follows inferiorly between the su-
perficial and the fat pad above the deep temporal fascia, until
reaching the lateral aspect of the zygomatic arch and the
posterior root of the arch. Vertical incision through the peri-
osteum over the root of the zygomatic arch, which is contin-
uous with the parotidomasseteric fascia, exposes the
temporomandibular joint (TMJ) capsule and temporomandib-
ular ligament and protects the facial nerve (Fig. 12). Disad-
vantages of this approach are the potentially unaesthetic
preauricular crease scar along its entire length, as well as the
possibility of bleeding from the superficial temporal artery.
The endaural technique varies from this approach in that
most of the scar is camouflaged behind the tragus; however,
there is a slight risk of perichondritis with this technique (see
Fig. 9).
The postauricular approach was originally described by Bock-
enheimer and later modified by Axhausen (Kreutziger). This
incision has the best esthetic result because it is hidden in the
postauricular crease. The disadvantages of this approach
include possible stenosis of the auditory canal, infection that
can potentially lead to necrosis of the ear cartilage, and
anesthesia of the auricle. This approach is not advisable in
patients who must depend on wearing glasses in the early
postoperative period. Closure is more time consuming, and
must be meticulous to minimize complications. Using this
incision allows for good posterior and lateral joint exposure,
whereas anterior exposure can be limited. The incision is
parallel and approximately 3 mm posterior to the postauricular
flexure. The inferior portion of the incision curves over the
mastoid tip, whereas superiorly it stops at the attachment of

Fig. 10 The tissue planes superficial and slightly anterior to the TMJ. br., branch; m., muscle; SMAS, superficial muscular aponeurotic
system. (From Agarwal CA, Mendenhall SD, Foreman KB, et al. The course of the frontal branch of the facial nerve in relation to fascial
planes: an anatomic study. Plast Reconstr Surg 2010;125:536; with permission.)
6 Emam et al.

Fig. 11 Dissection to the superficial temporal fascia. (A) Exposure of the superficial temporal vein. (B) Clean white surface of the
superficial temporal fascia. (C) Senn retractors in each soft tissue pocket, delineating tissue to be sharply dissected. (D) Sharp dissection of
the remaining soft tissues. (From Ness GM, Arthroplasty and discectomy of the temporomandibular joint. Atlas Oral Maxillofac Surg Clin
North Am 2011;19:177e87; with permission.)

the pinna within the hairline. Once marked, the incision is
carried sharply down to the postauricular muscle to the fascia
overlying the mastoid bone and the temporalis fascia superi-
orly, dissecting anteriorly. The external auditory canal (EAC) is
a landmark, and is exposed on the superior and inferior aspects
through this approach. Next, a complete transaction of the EAC
is made at the bony cartilaginous junction. Similar to the
preauricular approach, the temporal fascia is incised at the
superior mark of the incision. This fascia is dissected above
the temporalis muscle in an anterior-inferior direction. At the
junction of the temporal fat pad, the same dissection plane is
developed as the superficial layer is elevated as it approaches
and attaches to the superior border of the zygomatic arch.
Anterior dissection is performed in a subperiosteal plane,
which protects the facial nerve. The anterior border of the
temporomandibular ligament and capsule are the most ante-
rior landmarks with this dissection. Inferior dissection stops at
the attachment of the temporomandibular ligament and
capsule to the condyle.
Transoral
This approach is used to avoid the risk of a skin incision scar, to
reduce the risk of facial nerve injury, as well as the potential
reduction of postoperative facial edema that may occur.
However, this access does limit visibility and has not been
popular for reduction of condylar fractures without additional
measures. Endoscopic-assisted fixation allows trauma surgeons
to avoid large skin incisions. The transoral incision is created

Fig. 12 Exposure of the lateral capsule. (A) Incision through the superficial temporal fascia. (B) Subperiosteal dissection along the
lateral surface of the zygomatic arch, identifying the parotidomasseteric fascia. (C) The lateral capsule following sharp release of the
parotidomasseteric fascia. (From Ness GM, Arthroplasty and discectomy of the temporomandibular joint. Atlas Oral Maxillofac Surg Clin
North Am 2011;19:177e87; with permission.)
Surgical Approach for Condylar Fracture Types
along the anterior aspect of the ascending mandibular ramus.
Fixation techniques for this approach require intensive
advanced surgical training, special instrumentation, and a
steep learning curve. Advantages have included excellent
functional results without the risk of facial nerve damage and
visible scars. However, despite allowing access to the condyle,
endoscopically assisted surgery may make repositioning a
medially dislocated or proximally rotated fracture fragment a
challenging exercise.
7
Summary
Head and neck trauma surgeons must have an acute knowledge
of surgical principles to approach a condylar fracture with an
open surgical technique. An understanding of the classification
of the fracture and the appropriate surgical access for visibility
and reduction is critical. Practicing good surgical principles to
avoid vessel and nerve injury is equally important for suc-
cessful reduction of these fractures.
Soft Tissue Trauma in the
Temporomandibular Joint Region
Associated with Condylar Fractures
Deepak G. Krishnan, DDS
KEYWORDS
 Soft tissue injury  Temporomandibular joint injury  Condyle fractures  Intracapsular injury  Articular injury
KEY POINTS
 The role of soft tissue injury within the temporomandibular joint (TMJ) in mandibular fractures in general and condyle
fractures in particular has been often overlooked.
 With improved MRI and the cumulative information gathered from clinical observation, arthroscopic studies and MRI have
given us a new insight into the severity and the natural history of soft tissue damage to the TMJ in trauma.
 There is emerging evidence suggesting concomitant repair of soft tissue injury may lead to improved long-term functional
outcome.
Introduction
Advances in MRI have shed new light to the curious clinician’s
intrigue of what goes on around and within the temporoman-
dibular joint (TMJ) that is involved in condyle fractures.
Although for decades clinicians have argued over the various
modalities of management of condyle fractures, only recently
have we started investigating changes within the joint in such
injuries and the influence the different modalities of man-
agement elicit on the joint. The more we understand intra-
articular changes, the more we are inclined to consider a
paradigm shift in the management of condylar injuries.
Perhaps re-aligning the bony fragments is only one aspect of
the management of these injuries and soft tissue repair war-
rants some attention to achieve complete functional rehabili-
tation of the injured mandible.
Internal injuries to the temporomandibular joint
Historically, there has been a tendency to treat most fractures
of the condyle closed. Not only has this proven to be effective
and economical, and often indicated in patients who may not
be fit for open surgery, but there is a school of thought that
suggests that intracapsular fractures must be managed with
closed treatment.
Large meta-analyses of management of fractures of the
condyle has shown no significant difference was found between
closed and open treatments with respect to range of motion
and lateral excursions and that in some high-quality studies,
the difference of all outcomes measured over time is essen-
tially marginal between the 2 groups.
Oral Maxillofacial Surgery, University of Cincinnati, 231 Albert Sabin
Way, Cincinnati, OH 45219, USA
E-mail address: deepak.krishnan@uc.edu
Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-
1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.11.002
Interestingly, earlier studies have looked at functional and
radiological results of open and closed treatment of intra-
capsular fractures of the mandible. However, the soft tissues
of the joint were not studied or reported in detail in studies
that focused primarily on the postoperative radiographic
appearance of the condyles using orthopantomograms,
reversed Towne view, Submentovertex view, and axiograms
and those that did show that open treatment had better results
in TMJ function.
In fact, our current literature is not exactly overwhelmed by
studies showing intra-articular or soft tissue injuries to the
joint in mandibular trauma. In contrast, orthopedic literature
is abounding with reports that correlate fractures close to or
within a joint that lead to future arthritis and degenerative
joint disease.
One must assume that considering the significant force that
it takes to fracture condyles, the soft tissues in those regions
must be sustaining significant injuries in that impact. Despite
this assumption, posttraumatic TMJ symptoms are relatively
uncommon. This of course is barring the incidence of TMJ
ankylosis following intracapsular trauma, especially in younger
patients.
The role of meniscal injury in the causation of ankylosis of
the TMJ has been debated over time. Goss and Bosanquet
conducted a unique study in 1990 in which they were able to
arthroscopically examine the joints of 20 patients with
mandibular trauma. Each patient had an arthroscopic exami-
nation of the superior surface of the disc and temporal fossa,
and the internal aspects of the posterior and medial capsule
were examined for damage before repair of the mandible
fractures. Most patients in the study had condylar injuries.
Most of the joints exhibited hemarthrosis, with structural
damage to both the disc and temporal surface. The apparent
extent of damage correlated with the time elapsed since injury
with more hyperemia and hemarthrosis exhibited in more
recent injuries. Cumulative summary of findings from this study
oralmaxsurgeryatlas.theclinics.com
2 Krishnan
suggested a natural history of intra-articular and soft tissue
damage to the joint from mandibular trauma; bruising and
bleeding into the superior joint space (inferior joint space was
not examined) and tearing and shredding of the disc and
temporal surface of the joint happened first and resolved
rather quickly. Disc displacement did not appear to occur from
the trauma. Long-term follow-up was not available. Jones and
Van Sickels did a similar study and found similar results.
Such studies may not pass the stringent regulations of
human research in this day and age. However, soft tissue in-
juries of the TMJ have been studied extensively using MRI.
Early studies by Sullivan and colleagues identified joint effu-
sions (hemarthroses?) and disc displacements but could not
quantify the degree of such a displacement.
More recent studies with higher-resolution and cinematic
MRIs have been able to prospectively identify the following
general patterns of soft tissue. These MRIs were accurate in
identifying more damage to the soft tissue that correlates with
severity of damage of the condylar complex.
Penetrating soft tissue temporomandibular joint
trauma
Penetrating injuries to the soft tissues of the TMJ are not un-
common. Foreign objects, such as shrapnel, can become dis-
lodged in the TMJ and affect mandibular function, can cause
discomfort, and may be challenging to retrieve. Such pene-
trating injuries and their surgical removal can potentially cause
more scarring and may require more rigorous postoperative
functional rehabilitation. Sometimes severe injuries may
require reconstruction of hard and soft tissues by using one of
many reconstructive strategies (Fig. 1).
Hemarthrosis of the joint
The closed off joint spaces, superior and inferior spaces in the
TMJ, serve as reservoirs that collect blood following trauma.
Several investigators have proven that a hemarthrosis can be
created experimentally by inducing trauma directly and indi-
rectly to the TMJ area in animal studies. Further, as pointed
out earlier, hemarthrosis is the first response elicited on
Fig. 1 Surgical management of a projectile within the temporomandibular joint. (A) Axial view of shrapnel in the TMJ. (B) Coronal view
of the same shrapnel in the TMJ: the bullet traversed the capsule, destroyed the disc, and fractured the condylar head before being
dislodged in the medial aspect of the joint.
arthroscopy as well as MRI studies of the traumatized
mandible. Significant malocclusion noted in most patients with
displaced mandible fractures overshadow the clinician’s sus-
picion of something as subtle as clinical symptoms of
hemarthrosis. In nondisplaced and green stick fractures or
sometimes in the absence of fractures, patients with history of
trauma may present with pain and swelling in the TMJ area and
a mild open bite on the affected side, suggestive of a distur-
bance in the position of the TMJ as altered by the hemarth-
rosis. This usually tends to resolve rather quickly, usually
within the first couple of days. There is some evidence sug-
gesting a permanent fibrosis occurs following any hemarthrosis
in all joints (Fig. 2).
Damage to the joint surfaces, disc, and disc
displacement
Most studies have found a gradient in injury patterns within the
joint when mandibular trauma occurs. Although most joints
have some bruising and bleeding, severe trauma causes dam-
age to the joint surfaces. More severe injuries lead to more
scarring and limitation of joint function. There is strong clinical
evidence that suggests that injuries that lead to damage to
joint surfaces and the disc cause fibrous ankylosis and possibly
bony ankylosis. Ruptures of the periosteal sheath and joint
capsule cause extravasation of blood eventually leading to
heterotopic bone formation. When the barrier formed by the
disc is eliminated, if the disc is either torn or displaced
severely, bony surfaces of the condyle and the fossa that never
contacted can come to contact and lead to ankylosis. Severe
trauma can cause capsular penetration as well as significant
disc displacement (Fig. 3).
Damage to the glenoid fossa
A series of studies by Honda and colleagues have looked into
the thickness of the thinnest part of the glenoid fossa.
Cadaveric studies suggest that an average thickness of the roof
of the glenoid fossa is 0.9 mm. Subsequent MRI and cone-beam
computed tomography measurement studies corroborated the
same.
Soft Tissue Trauma in the TMJ Region
Fig. 2 Bright T2 signal in the superior joint compartment showing hemarthrosis (arrow). (From Tripathi R, Sharma N, Dwivedi AN, et al.
Severity of soft tissue injury within the temporomandibular joint following condylar fracture as seen on magnetic resonance imaging and
its impact on outcome of functional management. J Oral Maxillofac Surg 2015;73(12):2379.e1e7; with permission.)
Essentially the thickness of the roof of the glenoid fossa can
be compromised in significant axial loading of the condylar
head. This kind of trauma that can cause the mandibular
condyle to penetrate the glenoid fossa and breach the middle
cranial fossa does occur. This would suggest dislocation of the
disc and rupture of the capsule (Fig. 4).
Changes to soft tissue injuries following repair of
the fractures
Although recent advances in imaging have increased our un-
derstanding of what happens within the TMJ in mandibular
trauma, how does this affect postoperative function and
rehabilitation? Even without ever being aware of these changes
at an arthroscopic or histologic level, we managed to get away
with treating condylar and other mandibular injuries with
closed management or open reductions and fixation devices
and most of our patients did well. We had always attributed
significant intracapsular injuries to future ankyloses. We have
paid much attention to the bony healing for all these years and
now we are interested in the soft tissue healing. So what has
changed?
Healing of soft tissue injuries in closed treatment
of mandibular fractures
Some interesting and meticulous work by Yang and
colleagues has helped characterize soft tissue healing
3
patterns within the TMJ in mandibular fractures that un-
dergo closed treatment. Their study included 12 patients
with 17 intracapsular fractures that all had an MRI 1 week
after closed treatment and at least 3 months after the
injury. They not only were able to characterize the varied
patterns and severity of soft tissue injuries within the joint,
but also found the following about the intra-articular
changes at the 3-month follow-up MRI: “.features are
characterized by anteromedial displacement of the articular
disc, elongation and thickening of the retrodiscal tissue, and
reactive bone formation at the condylar head. The presence
of a portion of the disc between the residual condyle and the
fossa prevented the development of osteoarthritis and
ankylosis. Perforation of the bilaminar tissue and contact
between the residual condyle and the fossa promoted
osteoarthritic changes and ankylosis.” Until these data were
available, we were largely relying on computed tomography
scans for understanding condylar remodeling and bony
healing. Although we knew that mandibular fractures,
especially intracapsular fractures, were associated with
disc damage and internal derangement, imaging related to
long-term healing of the soft tissues was not available
until recently. In fractures treated closed, the TMJ soft
tissues healed by disc displacement with retrodiscal tissue
elongation, fibrosis, and regenerative bone formation on
the surface of the condyle. Perforation of the disc
and direct contact between the. bony surfaces lead to
ankylosis.
Tripathi and his colleagues in a similar study found that in
patients treated closed, those patients with hemarthrosis
4 Krishnan
Fig. 3 Coronal magnetic resonance image of a 13-year-old child
showing a right subcondylar fracture and a tear of the joint capsule
(arrow). (From Dwivedi AN, Tripathi R, Gupta PK, et al. Magnetic
resonance imaging evaluation of temporomandibular joint and
associated soft tissue changes following acute condylar injury. J
Oral Maxillofac Surg 2012;70(12):2833; with permission.)
alone had the best outcome, whereas patients with hemarth-
rosis and disc displacement had poorer outcomes as defined by
limited mouth opening and restricted range of motion, long
term.
Fig. 4 Penetration of glenoid fossa and middle cranial fossa by
fractured condylar head (arrow) as seen on 3-dimensional
computed tomography scan viewed from inside the skull.
Healing of soft tissue injuries in open treatment
of mandibular fractures
There is mounting evidence to suggest that anatomic repair
and reduction of soft tissue injuries within the TMJ done at the
same time as bony repair is of benefit with regard to post-
operative biomechanical and functional rehabilitation. In an
impressive study published by Chen and his colleagues in 2010,
164 TMJs with intracapsular fractures were open treated. Bony
fractures were reduced and fixated using contemporary
osteosynthesis techniques. The disc was reduced with or
without transecting adhesions, retrodiscal tissue tear was
repaired, and the results were reviewed and compared by MRI
preoperatively and postoperatively up to 5 years. Intra-
operatively, typically in the same direction as the condyle,
often anteriorly and medially; if the displacement was signifi-
cant, the posterior attachment was torn and required repair.
Older fractures started to form adhesions in the superior joint
space. They also found that an MRI was not always reliable in
detecting retrodiscal and capsular tears, which they encoun-
tered on opening the joints. Most intracapsular fractures
required some soft tissue repair, including simple repairs and
release of adhesions, to replacement of the disc with adjacent
fascia. Most of their patients maintained the disc position
following repair in long-term follow-up MRIs. Mouth opening
and TMJ function was impressive in long-term clinical follow-
up. They believe that open treatment of condyle fractures,
especially of the intracapsular variety, enables not only
anatomic bony reduction but also repair and reconstruction of
the soft tissues in the joint, which has proven benefits in their
patients.
Summary
The role of soft tissue injury within the TMJ in mandibular
fractures in general and condyle fractures in particular has
been often overlooked. With improved MRI and the cumulative
information gathered from clinical observation, arthroscopic
studies and MRI have given us a new insight into the severity
and the natural history of soft tissue damage to the TMJ in
trauma. There is emerging evidence suggesting concomitant
repair of soft tissue injury may lead to improved long-term
functional outcome.
Further readings
Dwivedi AN, Tripathi R, Gupta PK, et al. Magnetic resonance imaging
evaluation of temporomandibular joint and associated soft tissue
changes following acute condylar injury. J Oral Maxillofac Surg
2012;70:2829.
Goss AN, Bosanquet AG. The arthroscopic appearance of acute
mandibular trauma. J Oral Maxillofac Surg 1990;48:780e3.
Grossmann E, Silva AN Jr, Collares MV. Surgical management of a pro-
jectile within the temporomandibular joint. J Craniofac Surg 2012;
23(2):613e5.
Hlawitschka M, Loukota R, Eckelt U. Functional and radiological results
of open and closed treatment of intracapsular (diacapitular)
condylar fractures of the mandible. Int J Oral Maxillofac Surg 2005;
34:597e604.
Jones JK, Van Sickels JE. A preliminary report of arthroscopic findings
following acute condylar trauma. J Oral Maxillofac Surg 1991;49:55.
Liu Y, Bai N, Song G, et al. Open versus closed treatment of unilateral
moderately displaced mandibular condylar fractures: a meta-analysis
Soft Tissue Trauma in the TMJ Region
of randomized controlled trials. Oral Surg Oral Med Oral Pathol Oral
Radiol 2013;116:169e73.
Sullivan SM, Banghart PR, Anderson Q. Magnetic resonance imaging
assessment of acute soft tissue injuries to the temporomandibular
joint. J Oral Maxillofac Surg 1995;53:763.
Tripathi R, Sharma N, Dwivedi AN, et al. Severity of soft tissue injury
within the temporomandibular joint following condylar fracture
as seen on magnetic resonance imaging and its impact on
5
outcome of functional management. Oral Maxillofac Surg 2015;
73(12):2379.
Woodbury SC, Stanton DC, Quinn PD, et al. Options for immediate
reconstruction of the traumatized temporomandibular joint. J
Craniomaxillofac Trauma 1998;4(2):22e9.
Yang X, Yao Z, He D, et al. Does soft tissue injury affect intracapsular
condylar fracture healing? J Oral Maxillofac Surg 2015;73(11):
2169e80.
Plating Options for Fixation of Condylar
Neck and Base Fractures
Eric L. Bischoff, DMD a,b, Ryan Carmichael, DDS, MD b, Likith V. Reddy, DDS, MD c,*
KEYWORDS
 Condylar neck  Base fracture  Subcondylar fracture
KEY POINTS
 There are multiple plating options to consider when performing an open reduction of a condylar neck or base fracture.
 The literature shows that bite force is reduced significantly after a subcondylar fracture during the healing period,
returning to only 60% of normal bite force at 6 weeks.
 This raises the question as to how much is enough when considering fixation of subcondylar fractures.
 All plating options presented in this article have been shown in the literature to successfully treat subcondylar
fractures.
Introduction
The mandibular condyle or subcondylar region is one of the
most common sites of mandibular fracture encountered,
occurring between 25% and 35% of all mandibular fractures.1,2
There is some trend evidence to support the benefits of open
surgical management over that of closed treatment of
mandibular condylar neck and base fractures. A recent sys-
tematic review and meta-analysis by Al-Moraissi and Ellis3
confirmed that open reduction and internal fixation provide
superior functional clinical outcomes compared with closed
reduction in the management of adult condylar fractures.
Several different surgical approaches as well as plating options
are available to oral and maxillofacial surgeons once a decision
to treat the condylar fracture open has been made.
Surgical approach
The common approaches to this area typically include the
retromandibular, transparotid, and submandibular. The various
surgical approaches to the condylar neck and base fractures
are discussed. (See Hany A. Emam and colleagues’ article,
“Matching Surgical Approach to Condylar Fracture Type,” in
this issue). An important consideration when determining a
plating scheme for this type of fracture is an appreciation for
the limited visibility and challenges of surgical access to this
particular area.4
a
US Navy, USA
b
Baylor University Medical Center, Texas A&M University School of
Dentistry, Dallas, TX 75246, USA
c
Department of Oral and Maxillofacial Surgery, Baylor University
Medical Center, Texas A&M University School of Dentistry, 3302 Gaston
Avenue, Dallas, TX 75246, USA
* Corresponding author.
E-mail address: lreddy@tamhsc.edu
Atlas Oral Maxillofacial Surg Clin N Am 25 (2017) 69–73
1061-3315/17/ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.11.003
Biomechanics of the condylar neck and base
The mandible can be considered a class III lever, with the
fulcrum of rotation the condyle; the load occurs at the denti-
tion and the force exerted largely comes from the muscles of
mastication.5,6 Several muscles are responsible for the move-
ment of the mandible and thus for the forces exerted on the
mandible. The masseter and medial pterygoid combine to
generate a vector that is directed superior and anterior di-
rection from the angle of the mandible. The temporalis gen-
erates a force vector originating from the coronoid process and
directed superior and slightly posterior. The lateral pterygoid
exerts a vector from the condyle anterior and medial direc-
tion.7 Others muscles also contribute to the movement and
force generated on the mandible; however, those listed are the
most pertinent to a discussion of fractures of the mandibular
condylar neck and base.
Normal physiologic movement and the force vectors
generated create lines of compression and tension within the
mandible. The lines of tension at the condylar neck and base
run approximately perpendicular to the posterior aspect of the
ascending ramus following the curvature of the sigmoid notch
and extending superiorly through the coronoid process. The
lines of compression run approximately perpendicular to the
lines of tension. They run parallel to the posterior aspect of the
ascending ramus and then curve along the angle to continue
parallel to the inferior border of the mandible.4 Ultimately,
this results in a tension band at the anterior/superior (sigmoid
notch) aspect of a condylar neck and base fractures and a
compression band at the posterior aspect.
Fractures of the condylar neck and base typically occur as a
result of forces far greater than those that exist in the normal
physiologic range.8 The goal of reduction of these fractures is a
restoration of the ability to withstand a functional load in a
normal physiologic range or the ability to tolerate the normal
tension band and compression band that exist in the condylar
neck. The literature shows that the functional force applied to
the mandible after a subcondylar fracture is significantly
oralmaxsurgeryatlas.theclinics.com
70
reduced. There are also significant neuromuscular adaptations
that alter the forces exerted on the condylar neck during the
healing phase after a fracture.9
Plating options
There are several different plating options available for in-
ternal fixation of the condyle and subcondylar fracture, none
of which has been extensively studied clinically. A single plate,
dual plates, specially designed geometric condylar plates
(trapezoid, rhomboid, and so forth), lag screws, and resorbable
fixation systems have all been described. Titanium plates and
screws are considered the most reliable materials if proper site
selection, sufficient quantity or rigidity, and handling and
placement techniques are used; however, titanium hardware
still poses risk of future failure, which may require re-entry
operation with its own added esthetic, functional, and finan-
cial risks.10 Resorbable materials may be able to alleviate or
overcome some of the disadvantages that titanium plates
potentially pose.
Single Plate
There is little debate regarding the functional stability gained
with a 2-plate fixation scheme when treating a subcondylar
fracture in comparison to a single straight plate. This has
been illustrated over the years with biomechanical analyses
using finite element analysis and in vitro studies as well as
clinical retrospective review.11e15 Commonly a single plate
may be the only feasible option in fixating a mandibular
condyle fracture due to the often limited exposure and bony
architecture available for plates and screws. Screw length
also becomes important in the search to gain added stability if
only a single plate is used. A comparative biomechanical
evaluation by Asprino and colleagues13 demonstrated superior
performance in peak load and peak displacement of a single
plate with 8-mm screws compared with 6-mm screws. Com-
plications of subcondylar fracture repair seem to differ
Fig. 1 Fixation of subcondyle fracture (A) with rigid single plates with 2 (B) and 3 (C) bicortical screws on each side.
Bischoff et al.
depending on the fixation scheme used and may be seen more
frequently when a single plate design is used as displayed by
Hammer and colleagues.16 They demonstrated in a series of
30 patients that plate fracture, screw loosening, infection, or
malposition occurred in 35% of the fractures stabilized with a
single miniplate, whereas no hardware failure was identified
in other plating schemes used. In vitro strain measurements at
the condylar process have shown that the highest levels of
tensile strain occur on the anterior and lateral surfaces
whereas the medial surface had the lowest level of tensile
strain. The highest compressive strain levels occurred on the
posterior surface, and lateral surface had the lowest levels of
compressive strain.17 As previously described by Champy and
colleagues18 and now widely accepted, an appreciation of the
areas of tension and compression can be applied to provide a
functionally stable fixation. To apply Champy and colleagues’
principles with fixation along the lines of tension at the sub-
condylar region suggests fixation anteriorly along the lines of
tension as opposed to the common method of a single pos-
teriorly aligned plate. As also noted by Meyer and col-
leagues,19 placement here may be more difficult because the
bone is often very thin further anteriorly. Therefore, if only a
single plate is used, at least 2 screws should be engaged on
each side of the fracture, with use of longer screws with
bicortical engagement. Additionally, a larger profile plate,
such as a 2.0, 2.4, or minidynamic compression plate, should
be used and applied along the lines of tension if accessible
(Fig. 1).
Two Plates
As previously discussed, a biomechanical advantage is
evident when 2 plates are used compared to 1 single straight
plate in evaluating fixation schemes for subcondylar frac-
tures. This allows stabilization at the anterior and posterior
aspects of the condylar neck and seemingly has the favorable
effect of repairing tension and compression paths of the
subcondylar region as well as resisting any torsional forces
that may not be opposed with a single plate (Fig. 2). One of
Fixation of Condylar Neck and Base Fractures
Fig. 2 Reduction (A) and fixation (B) of subcondyle fractures with 2 plates stabilizing anterior and posterior aspects of condyle neck.
the few clinical evaluations comparing fixation of condylar
neck fractures was done by Choi and colleagues14 in a
retrospective study of 37 patients with 40 fractures in which
a single miniplate, a minidynamic compression plate, or
double miniplates were analyzed. They saw plate fracture or
screw loosening exclusively in cases stabilized with either a
single miniplate or minidynamic compression plate and no
cases of inadequate stability observed when 2 miniplates
were used and thus concluded that a 2-miniplate fixation
technique provides functionally stable fixation for fractures
of the condylar neck. In theory, the application of 2 plates
would require a larger exposure that may potentially subject
patients to a higher risk of facial nerve injury, but this has
not been shown to present itself in the literature. Choi and
colleagues14 observed a lower rate of neurologic complica-
tion with 2 miniplates compared with 1 miniplate, and this
specific complication may be avoidable with increased
experience.
Fig. 3 Reduction and fixation (A and B) of subcondyle fracture with rhombic-shaped geometric plate (C) for tensile and compressive
forces.
71
Geometric Plates
New in the management of subcondylar fracture fixation
scheme is the use of an unconventional geometric plate.
Various plating companies have now developed their own
version of a subcondylar plate, which has been designed spe-
cifically for fixation of these fractures (Fig. 3). These plates
have not yet been sufficiently studied clinically but may offer
some biomechanical advantages when selecting a fixation
scheme and conceivably provide the mechanical advantages of
2 plates with fixation along compression and tension lines
packaged into a single-plate design. Darwich and colleagues11
looked at the performance of 5 different plating techniques
using finite element analysis, including the geometric trape-
zoidal and square plates (Fig. 4). They analyzed a single
straight plate, 2 parallel straight plates, and 2 angulated
straight plates in addition to the trapezoidal plate and square
plates. They were able to compare the maximum displacement
72 Bischoff et al.

Fig. 4 Reduction and fixation (A and B) of subcondyle fractures by trapezoidal plate (C) that is a superior configuration compared to
single linear plate.

and strain placed on a subcondylar fracture after simulated
fixation with the varying plating schemes. Their results showed
that a trapezoidal geometric plate was clearly superior, with
peak displacement close to that seen in the normal mandibular
model. As they suggested, it might be assumed that 2 plates
with 8 screws would be more rigid than a design like the
trapezoidal plate consisting of only 4 screws but that was
shown to not be true.11 In an in vitro study, Meyer and col-
leagues19 demonstrated that a 3-D rectangular plate provided
the best biomechanical compromise to ensure primary stability
of subcondylar fractures when compared with a single mini-
plate and lag screw, but, as noted by Meyer and colleagues,5
this design did not conform precisely to the tensile strain lines
that run parallel to the boundary of the sigmoid notch. A later
study by Meyer and colleagues20 presented a trapezoidal plate
as the best design for fixation of condylar fractures. These
plates were designed to closely follow the tensile strain lines
along the rim of the sigmoid notch anteriorly combined with a
posterior arm to parallel the condylar axis free of harmful
bending strains.20 This technique has the advantage of allow-
ing the use of only 1 plate yet fulfills the principles of func-
tionally stable osteosynthesis without added periosteal
stripping and needs only 2 monocoritcal screws to be placed in
the condylar segment. Other designs are available and similar
in concept, attempting to provide the best biomechanical
advantage in fixating along ideal osteosynthesis lines without
the need for 2 separate plates while still establishing func-
tionally stable fixation (Fig. 5). The success of these geometric

Fig. 5 Reduction and fixation (A and B) of subcondyle fracture with single Y-shaped plate (C) that follows ideal osteosynthesis lines.
Fixation of Condylar Neck and Base Fractures
plates still needs to be studied and verified in a clinical setting
but seem to be a promising solution in fixation of subcondylar
fractures.
Resorbable Materials
Another option and alternative to the standard use of tita-
nium plates and screws is the use of resorbable materials for
fixation of the mandibular condyle. These materials spare
potential reoperation for such reasons as loosened or failing
hardware; however, they are generally not as stable as tita-
nium plates and screws. Abdel-Galil and Loukota21 described a
case report with the use of ultrasound-activated resorbable
pins (SonicWeld Rx, KLS Martin [Gainesville, FL]) in a patient
with bilateral dislocated and comminuted condylar fractures
who had a favorable outcome without complication.
Schneider and colleagues22 described the use of 3-D, indi-
vidually molded, resorbable mesh fixed by ultrasound-acti-
vated pins (Resorb x, KLS Martin). With this technique, the
mesh is warmed in a water bath and adapted to the reduced
fracture site until the mesh had solidified and stabilized the
fracture, with additional ultrasound-activated resorbable pins
used to further fixate the mesh. Their series consisted of 5
patients with laterally displaced condylar base fractures and
at least 6 months’ follow-up. During that period, they saw no
impairment of wound healing, and objective measures, such
as mouth opening, lateral excursive movement, and deviation
during opening, were unaffected.22 The use of resorbable
fixation systems also represents an area that may show
promise in fixation of subcondylar fractures as the technology
improves and as the clinical results are analyzed further.
Summary
There are multiple plating options to consider when performing
an open reduction of a condylar neck or base fracture and all
those presented in this article have been shown in the litera-
ture to have successful outcomes. The literature shows that
bite force is reduced significantly after a subcondylar fracture
during the healing period, returning to only 60% of normal bite
force at 6 weeks.9 This raises a question as to how much is
enough when considering fixation of subcondylar fractures. All
plating options presented in this article have been shown in the
literature to successfully treat subcondylar fractures.
References
1. Ellis E, Throckmorton GS. Treatment of mandibular condylar pro-
cess fractures: biological considerations. J Oral Maxillofac Surg
2005;63:115e34.
2. De Riu G, Gamba U, Anghioni M, et al. A comparison of open and
closed treatment of condylar fractures: a change in philosophy. Int
J Oral Maxillofac Surg 2001;30:384e9.
3. Al-Moraissi EA, Ellis E 3rd. Surgical treatment of adult mandibular
condylar fractures provides better outcomes than closed treatment:
a systematic review and meta-analysis. J Oral Maxillofac Surg 2015;
73(3):482e93. 12p. CINAHL Complete. Web. 22 May 2016.
73
4. Wagner A, Krach W, Schicho K, et al. A 3-Dimensional finite-
element analysis investigating the biomechanical behavior of the
mandible and plate osteosynthesis in cases of fractures of the
condylar process. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2002;94(6):678e86.
5. Meyer C, Kahn JL, Boutemi P, et al. Photoelastic analysis of bone
deformation in the region of the mandibular condyle during
mastication. J Craniomaxillofac Surg 2002;30(3):160e9.
6. Sikes JW Jr, Smith BR, Mukherjee DP. An in vitro study of the effect
of bony buttressing on fixation strength of a fractured atrophic
edentulous mandible Model.Including commentary by Tucker MR.
J Oral Maxillofac Surg 2000;58(1):56e61.
7. Trainor PG, McLachlan KR, McCall WD. Modelling of forces in the
human masticatory system with optimization of the angulations of
the joint loads. J Biomech 1995;28(7):829e43.
8. Tuchtan L, Piercecchi-Marti MD, Bartoli C, et al. Forces trans-
mission to the skull in case of mandibular impact. Forensic Sci Int
2015;252:22e8.
9. Ellis E III, Throckmorton GS. Bite forces after open or closed
treatment of mandibular condylar process fractures. J Oral Max-
illofac Surg 2001;59(4):389e95.
10. Kisnisci R. Management of fractures of the condyle, condylar neck,
and coronoid process. Oral Maxillofac Surg Clin North Am 2013;
25(4):573e90. CINAHL Complete. Web. 23 May 2016.
11. Darwich MA, Albogha MH, Abdelmajeed A, et al. Assessment of the
biomechanical performance of 5 plating techniques in fixation of
mandibular subcondylar fracture using finite element analysis. J
Oral Maxillofac Surg 2016;74(4):794e1-8. Scopus. Web. 22 May
2016.
12. Conci RA, Tomazi FH, Noritomi PY, et al. Comparison of neck screw
and conventional fixation techniques in mandibular condyle frac-
tures using 3-Dimensional finite element analysis. J Oral Maxillofac
Surg 2015;73(7):1321e7. CINAHL Complete. Web. 22 May 2016.
13. Asprino L, Consani S, de Moraes M. A comparative biomechanical
evaluation of mandibular condyle fracture plating techniques. J
Oral Maxillofac Surg 2006;64(3):452e6. CINAHL Complete. Web. 22
May 2016.
14. Choi B-H, Yi C-K, Yoo J-H. Clinical evaluation of 3 types of plate
osteosynthesis for fixation of condylar neck fractures. J Oral
Maxillofac Surg 2001;59(7):734e7. Scopus. Web. 22 May 2016.
15. Choi BH, Kim KN, Kim HJ, et al. Evaluation of condylar neck frac-
ture plating techniques. J Craniomaxillofac Surg 1999;27:109.
16. Hammer B, Schier P, Prein J. Osteosynthesis of condylar neck
fractures: a review of 30 patients. Br J Oral Maxillofac Surg 1997;
35:288.
17. Throckmorton GS, Dechow PC. In vitro strain measurements in
the condylar process of the human mandible. Arch Oral Biol 1994;
39:853.
18. Champy M, Loddé JP, Schmitt R, et al. Mandibular osteosynthesis
by miniature screwed plates via a buccal approach. J Maxillofac
Surg 1978;6(1):14e21.
19. Meyer C, Serhir L, Boutemi P. Experimental evaluation of three
osteosynthesis devices used for stabilizing condylar fractures of
the mandible. J Craniomaxillofac Surg 2006;34:173.
20. Meyer C, Martin E, Kahn JL, et al. Development and biomechanical
testing of a new osteosynthesis plate (TCP) designed to stabilize
mandibular condyle fractures. J Craniomaxillofac Surg 2007;35:84.
21. Abdel-Galil K, Loukota R. Fixation of comminuted diacapitular
fractures of the mandibular condyle with ultrasound-activated
resorbable pins. Br J Oral Maxillofac Surg 2008;46:482e4.
22. Schneider M, Stadlinger B, Loukota R, et al. Three-dimensional
fixation of fractures of the mandibular condyle with a resorbable
three-dimensional osteosynthesis mesh. Br J Oral Maxillofac Surg
2012;50(5):470e3. Scopus. Web. 22 May 2016.
Management of Pediatric and Adolescent
Condylar Fractures
Martin B. Steed, DDS*, Caleb M. Schadel, DDS

KEYWORDS
 Pediatrics  Adolescents  Condylar fracture  Closed reduction  Open reduction  Internal fixation

KEY POINTS
 Mandibular condyle fractures are a common site of fracture in children involved in maxillofacial trauma.
 Condylar fractures in children may often go undiagnosed and thus untreated.
 Condylar fractures in children can have long-term effects on mandibular growth.
 There is no definitive age that defines the treatment of condylar fractures in children versus teenagers.
 Closed treatment of pediatric and adolescent condylar fractures remains to be the most commonly used treatment
technique, open reduction is rarely indicated.

Introduction temporomandibular joint disorders or ankylosis. It is therefore

The management of mandibular condyle fractures in the
pediatric and adolescent population presents the surgeon with
unique challenges. The distribution and fracture patterns of
the mandibular condyle at various stages of development
predictably follow the developmental anatomy of the lower
jaw1 (Fig. 1). The anatomy of a child’s (age 2e5) mandible
predisposes itself to intracapsular comminuted fracture pat-
terns in the regenerative setting of a thin cortex with perios-
teum in a very active osteogenic phase (Fig. 2). Although
anatomic reduction using wide exposure and rigid internal
fixation has gained increasing support for mandibular condylar
process fractures in adults, this method of treatment is seldom
useful in children. Conservative closed treatment of the
condyle fracture in children without open reduction and in-
ternal fixation remains the standard today for most injuries.
Despite encountered postsurgical radiographic abnormalities,
conservative management of condylar fractures in children
usually yields satisfactory to excellent clinical results.
The condyle as a subunit is an important area of growth
in the developing mandible. As a result, any trauma to the pe-
diatric or adolescent condyle has the potential to disrupt growth
and has long-term adverse effects. Possible traumatic fracture
complications include pain, malocclusion, masticatory dysfunc-
tion, facial asymmetry, restricted mandibular movements, and
The authors have nothing to disclose.
Department of Oral and Maxillofacial Surgery, James B. Edwards
College of Dental Medicine, Medical University of South Carolina, 173
Ashley Avenue, Charleston, SC 29425, USA
* Corresponding author. Department of Oral and Maxillofacial Sur-
gery, James B. Edwards College of Dental Medicine, Medical University
of South Carolina, 173 Ashley Avenue, BSB Room 453, MSC 507,
Charleston, SC 29425.
E-mail address: steedma@musc.edu
imperative for the surgeon to be able to properly identify and
diagnose mandibular condyle fractures and provide appropriate
treatment to help avoid these potential complications. The
overall goal of treating mandibular condyle fractures in the
growing patient is to reduce these risks and restore function,
symmetry, and occlusion, while not interfering with mandibular
growth.
In general terms, a patient is considered to be a pediatric
patient from birth until the age of 18, whereas the World
Health Organization defines adolescence as the period in
human growth and development that occurs after childhood
and before adulthood, from ages 10 to 19. It is important to
note that in terms of treating maxillofacial trauma, including
condylar fractures, there is no clear delineation between a
pediatric patient and an adolescent patient in terms of
treatment.
Craniofacial growth and development
For surgeons who treat pediatric facial fractures, an under-
standing of craniofacial growth and development can guide
clinical treatment. It is the anatomy of the pediatric mandible
that determines its response to trauma. The general pattern
of normal facial growth occurs in a downward and forward
motion along with concurrent lateral expansion, depending on
the amount and location of apposition and resorption of bone
(Fig. 3). Differences in the rate and location of apposition and
resorption of bone are responsible for characterizing the
typical growth pattern of the face, and any disturbance
can cause skeletal and/or dental malocclusions. The mandible
follows the downward and forward growth pattern of the face
with the addition of upward and backward growth of the
condyles to maintain contact with the glenoid fossa. Vertical
height is gained at the condyle through endochondral
replacement, and height is added via remodeling of the ramus

Atlas Oral Maxillofacial Surg Clin N Am 25 (2017) 75–83

1061-3315/17/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.005 oralmaxsurgeryatlas.theclinics.com
76
Fig. 1 Developmental anatomic differences between the
mandibular condyle of a child and adult.
(Fig. 4). Skeletal maturity of the maxilla and mandible is
reached by approximately 14 to 16 years of age in girls and 16
to 18 years of age in boys. With respect to the mandible, it is
the last bone in the face to reach skeletal maturity and is
vulnerable to growth-related injuries for the longest time
period. The age of a patient and stage of mandibular growth
can have a large impact on the fracture patterns seen and
thus influence the treatment. The following are some age
relevant points related to the development of the condylar
region.
Ages 0 to 2
 The condylar neck is short and thick and engages a
shallow glenoid fossa
 Extensive vascular channels are found in the condylar
head that make it vulnerable to a crush-type injury
 Unlike older age groups, the short stocky nature of the
condylar neck makes it relatively resistant to fracture,
whereas the regenerative capacity is significant (Fig. 5)
Ages 3 to 12
 A more adultlike configuration of the condylar process
and glenoid fossa begins to develop
Fig. 2 Condylar process of the newborn. Illustrating the broad condylar head and relatively thick condylar neck. (From Paulsen F,
Waschke J. Sobotta atlas of human anatomy. Vol. 3, 15th edition. Munich: Elsevier GmbH; 2013. p. 1e96; with permission.)
Steed & Schadel
Fig. 3 Illustration showing vector of growth of the mandible. In
the mandible, there is resorption of bone at the anterior ramus with
bone apposition on the posterior ramus and the free margins of the
condyle, causing the mandible to grow downward and forward.
(Adapted from Digman SW, Hayes SL, Niel JG. Pediatric dentoal-
veolar surgery. Munich, Germany: Saunders; 2009. p. 165e84; with
permission.)
 Although unlike adults, there still remains an enormous
potential for regeneration and remodeling in this age
group (Fig. 6)
Ages 13 to 18
 Although the capacity for extensive new bone formation is
equivalent to that of children, teenagers lack the corre-
sponding capacity for condylar remodeling that is found in
the younger groups (Fig. 7)
Frequency of pediatric condylar fractures
Pediatric mandibular fractures represent fewer than 10% of all
mandibular fractures.2 The condyle is well represented in this
group, however. Imahara and colleagues3 reported that
mandibular fractures account for 32.7% of all facial fractures in
children, based on analysis of the National Trauma Data Bank
Pediatric and Adolescent Condylar Fractures
Fig. 4 Mandibular growth resulting from apposition and resorp-
tion of bone. Primary areas of bony apposition include superior
surface of alveolar process and posterior and superior surfaces
of mandibular ramus. (From Enlow OH, Harris DB. A study of the
postnatal growth of the human mandible. Am J Orthod 1964;
50(1):25e50; and Redrawn from Enlow DH. The human face. New
York: Harper & Row; 1968.)
including a total of 277,008 pediatric trauma patient admis-
sions and a total of 12,739 facial fractures. More than 20% of
pediatric mandible fractures were found to involve the condyle
(11.8%) or the subcondylar region (9.4%) (Fig. 8). Owusu and
colleagues4 recently reported a national analysis retrospective
study on the patterns of pediatric mandible fractures in the
United States among patients younger than 18. Patient de-
mographics, fracture site, and mechanism of injury were
analyzed by using the Healthcare Cost and Utilization Project’s
National Emergency Department Sample. There were a total of
1984 records representing 8848 pediatric mandible fractures.
Based on this study, the most frequently fractured site was the
condyle at 14.6%; however, the fracture site and mechanism of
injury varied based on gender and age. The mean age for
mandible fractures based on this study was 14 years with a
male-to-female ratio of 4:1. For patients younger than 12, the
most frequent fracture site was the condyle at 27.9% and the
Fig. 5 Condylar regenerative capacity in a 2-year-old boy who sustained symphysis and bilateral condylar fractures from a high fall.
Preoperative coronal CT of the bilateral condylar neck fractures. Coronal CT at 2.5 years later showing good remodeling of the bilateral
condylar processes. (Adapted from An J, Jia P, Zhang Y, et al. Application of biodegradable plates for treating pediatric mandibular
fractures. J Craniomaxillofac Surg 2015;43(4):518; with permission.)
77
most common mechanism was falls. For teenaged patients as
well as male patients, the most common site of fracture was
the angle and the most common cause was assault. For female
patients, the condyle was the most frequent site of fracture at
20.3%, while it was 13.1% in male patients.
Diagnosis
A clinical and radiographic examination is necessary to obtain
an accurate diagnosis for facial fractures, including those of
the mandible. The diagnosis of pediatric mandible fractures is
often difficult due to the limited ability to obtain accurate
subjective complaints, such as pain, malocclusion, or inferior
alveolar nerve dysfunction from the patient. The ability to
elicit subjective findings from a patient increases with age, but
imaging often remains the best method for the diagnosis of
fractures in younger patients. Proffit and colleagues5 reported
that pediatric condylar fractures are often undiagnosed and
may be involved in 5% to 10% of all severe mandibular de-
ficiencies or asymmetry problems. They believe that the inci-
dence of condylar fractures is much higher than commonly
thought. Common clinical findings of condylar fractures include
the following:
 Submental ecchymosis or laceration
 Malocclusion
 Preauricular edema or tenderness to palpation
 Chin deviation toward the affected side (unilateral
fracture)
 Shortening of the ramus on the affected side (unilateral
fracture)
 Posterior displacement of the mandible (bilateral
fracture)
 Anterior open bite (bilateral fracture)
Plain films of children are often difficult to obtain secondary
to patient cooperation, and short condyle-ramus complex
fractures can often be missed due to overlap. Computed to-
mography (CT) is often necessary to adequately diagnosis this
area.
Closed versus open treatment
The optimal treatment of mandibular condylar fractures
continues to be controversial, with both surgical and
78 Steed & Schadel

Fig. 6 Radiological images of a 5-year-old boy with a medial displaced condylar fracture. (A) Preoperative CT scan. (B) Postoperative
modified Towne view. (C) Postoperative CT scan. (D) Postoperative CT scan after 6 months. (E) Postoperative CT scan after 3 years. (From
Kim JH, Nam DH. Closed reduction of displaced or dislocated mandibular condyle fractures in children using threaded Kirschner wire and
external rubber traction. Int J Oral Maxillofac Surg 2015;44(10):1258; with permission.)

Fig. 8 Fracture location among 4169 pediatric patients with

mandible fractures (ages 0e18 years). (From Imahara SD, Hopper
Fig. 7 Coronal CT scan view of a bilateral condylar process RA, Wang J, et al. Patterns and outcomes of pediatric facial
fracture in a 14-year-old demonstrating a fracture pattern more fractures in the United States: a survey of the National Trauma
similar to that of a skeletally mature adult. Data Bank. J Am Coll Surg 2008;207(5):712; with permission.)
Pediatric and Adolescent Condylar Fractures
nonsurgical treatment options being debated. In adults, there
are well-documented absolute indications, as well as relative
indications, for open reduction and internal fixation of
condylar fractures. In children, closed treatment is most
commonly the treatment of choice for condylar fractures
given that the condylar complex rapidly remodels. The use of
functional appliances has been shown to be a successful
closed treatment option for condylar fractures by reestab-
lishing the vertical dimension and encouraging the remodel-
ing of the hard and soft tissues of the temporomandibular
joint (Fig. 9). The design of a functional appliance must be
determined based on specific treatment objectives with the
overall goal of establishing a balanced and functional occlu-
sion.6 A retrospective study demonstrated that a removable
occlusal splint worn for 1 to 3 months had satisfactory clinical
outcomes. The thickness of the splint and the duration of
wear were determined according to the age, the develop-
mental stage of the dentition, the level of the fracture, and
the degree of dislocation.7 Open reduction and internal fix-
ation of condylar fractures is often reserved for adult pa-
tients; however, in certain situations open reduction of
pediatric condylar fractures may be considered. The age at
which the decision to treat closed versus open is not always
apparent. Multiple studies have been completed to evaluate
the outcome of pediatric condylar fractures depending on the
treatment modality chosen.
For closed treatment of mandibular condyle fractures, a
period of maxillomandibular fixation may be used. The time
period for maxillomandibular fixation has traditionally been 7
to 10 days. The most common maxillomandibular fixation
methods include the following:
 Erich arch bars
 Risdon cable
 Ivy loops
For pediatric patients with either primary or mixed denti-
tion, traditional arch bars are sometimes hard to place and
have decreased retention due to the short and bulbous nature
of primary tooth crowns. This may necessitate the use of cir-
cum-mandibular wires, piriform wires, circum-zygomatic
wires, or a combination of these to secure the arch bar
(Fig. 10). An alternative to arch bar placement is the use of
Risdon cables, which have the advantage of better adaptation
to primary or mixed dentition with better retention. Risdon
cables consist of a braided 24-gauge stainless steel wire
fastened around the most posterior molars bilaterally and
secured to the remaining dentition with circumdental ligature
wires that are finally twisted into rosettes to allow for place-
ment of elastics or wire fixation.
A comparison of rigid intermaxillary fixation and guiding
elastic therapy for the nonsurgical treatment of condylar
Fig. 9 Functional appliance. (From Taveres C, Allgayer S. Conservative orthodontic treatment for a patient with a unilateral condylar
fracture. Am J Orthod Dentofacial Orthop 2012;141(5):e79; with permission.)
79
Fig. 10 Panoramic film showing the use of both per-alveolar
wires and circum-mandibular wires to secure segmental Erich
arch bars in a mixed dentition child sustaining a left condylar
fracture.
fractures in pediatric patients was conducted by Tabrizi
and colleagues.8 In their prospective study, 61 children
younger than 12 were divided into 2 groups and treated
with arch bars and either rigid wire fixation or guiding elastics
for 7 to 12 days. According to this study, there is no statis-
tically significant difference in outcome based on the
method of intermaxillary fixation used; however, children
were shown to tolerate guiding elastics better and enjoyed
having limited function during treatment versus rigid wire
fixation.
A recently published retrospective study demonstrated
that closed treatment of condylar fractures yields satisfac-
tory results in pediatric patients based on a chart review
covering a 20-year period.9 In this chart review study, there
were a total of 64 patients with 92 condylar fractures. Of
these patients, 35 had a condylar fracture in addition to
another site of mandible fracture, whereas 29 had an iso-
lated condyle fracture. CT imaging was reviewed for each
patient and each mandibular condyle fracture was charac-
terized based on both the Strasbourg Osteosynthesis
Research Group and Lindahl classification methods. It is
important to note that these classification systems were
developed based on adult condyle fractures and their utility
in the pediatric patient has not been fully evaluated. The
treatment modalities of condylar fractures in this study were
classified as conservative, maxillomandibular fixation, or
open reduction and internal fixation. Conservative treatment
included observation, soft diet, and opening exercises. For
the purpose of this study, closed treatment included treat-
ment that did not involve open surgical exposure of the
fracture. No condylar fracture in this report was managed
with open reduction and internal fixation. On follow-up,
complications were seen in 10 patients, with malocclusion
being the most common complication, which was seen in 5
patients.
80 Steed & Schadel

Schiel and colleagues10 recently published an article
evaluating the possible benefits of open surgery on pediatric
patients with displaced condylar fractures via an endoscopi-
cally assisted reduction and fixation using a transoral
approach (Fig. 11AeD). Clear operative indications in younger
patients have not yet been established; however, this study
uses the criteria of displacement of the condylar fracture
greater than 45 combined with loss of height of the
ascending ramus as indications for open surgical treatment.
The transoral endoscopically assisted reduction and fixation
surgical approach to condylar fractures has been used as a
means to avoid surgical scarring and facial nerve damage,
allow an earlier return to function, and lower the risk of
temporomandibular joint dysfunction as opposed to a
transfacial approach. This technique has not often been
applied to the pediatric and adolescent patient population.
Scheil and colleagues10 demonstrated success of this tech-
nique by treating 6 patients younger than 16 with severely
displaced condylar fractures. All patients showed normal
occlusion and pain-free unrestricted function of the tempo-
romandibular joint at a median follow-up of 24.5 months. It
was concluded that the transoral endoscopic approach is a
reliable solution to treating condylar fractures in children and
teenagers.
Müller-Richter and colleagues11 present cases in which
teenagers may be treated in a more similar fashion to adults
through the use of polymer resorbable pins for even
intracapsular fractures (Fig. 12). Although few studies to
date have investigated growth in the pediatric condylar
fracture treated with titanium fixation, He and colleagues12
demonstrated that for pediatric patients, only 63.2% had
continuous condyle growth; the other 36.8% developed
mandibular midline deviation, but no patient had malocclu-
sion (Fig. 13).
Uncommon injuries and complications
An example of an uncommon injury involving the mandibular
condyle is intracranial intrusion of the condyle through the
glenoid fossa into the middle cranial fossa (Fig. 14AeG). In
adults, blunt trauma to the chin typically results in fractures
to the narrow neck of the mandibular condyle rather than
transmission of the force to the glenoid fossa. The thicker and
broader condylar neck seen in pediatric patients helps to
explain the higher proportion of this injury in children,
although remaining a rare fracture pattern. The increased
pneumatization of the temporal bone and absence of poste-
rior dentition are additional contributing factors. The intru-
sion of the mandibular condyle into the cranial cavity can
result in neurologic manifestations, such as hearing deficits,
cerebrospinal fluid otorrhea, facial nerve paralysis, and
altered consciousness from cerebral contusions or hema-
tomas. Treatment goals include reducing the mandibular

Fig. 11 A 7-year-old boy with condylar base fracture on the right. (A) Preoperative CT 3-dimensional (3D) reconstruction. (B) Preop-
erative coronal CT shows 90 fracture displacement. (C) Postoperative CT 3D reconstruction shows triangular plate application with a 3-
hole plate (2-screw fixation) directly below the sigmoid notch and a 4-hole plate (4-screw fixation) along the posterior border. (D)
Postoperative coronal CT shows anatomic reduction of the fracture. (From Schiel S, Mayer P, Probst F, et al. Transoral open reduction and
fixation of mandibular condylar base and neck fractures in children and young teenagersda beneficial treatment option? J Oral Maxillofac
Surg 2013;71(7):1221e23; with permission.)
Pediatric and Adolescent Condylar Fractures
Fig. 12 Use of resorbable pin fixation. (A) Reduction of
fracture and its stabilization with 1.2-mm2 microplate. (B)
Insertion of polylactide pin. (C) Final fixation with 2 pins before
microplate removal. (From Müller-Richter, Reuther T, Böhm H,
et al. Treatment of intracapsular condylar fractures with
resorbable pins. J Oral Maxillofac Surg 2011;69(12):3019; with
permission.)
condyle back into the temporomandibular capsule, reestab-
lishing the preinjury occlusion, and possible glenoid fossa
reconstruction. Neurosurgical consultation is mandatory for
possible intervention for dural tears or other intracranial
injuries.13
81
Fig. 13 Condyle growth after open reduction and rigid fixation.
(A) CT scan of a 10-year-old girl with bilateral displaced intra-
capsular condylar fracture before operation. (B) CT scan after
open reduction and rigid fixation. (C) CT scan 2 years after the
operation shows bilateral condyle growth after open reduction and
rigid fixation. (From He D, Yang C, Chen M, et al. Modified pre-
auricular approach and rigid internal fixation for intracapsular
condyle fracture of the mandible. J Oral Maxillofac Surg
2010;68(7):1582; with permission.)
Temporomandibular ankylosis is one of the most serious
complications of the intracapsular pediatric mandible frac-
ture (Fig. 15) and may lead to impairment of speech, diffi-
culty in mastication, and poor oral hygiene. It is a rare
complication and is often thought to occur most commonly
82 Steed & Schadel

Fig. 14 A 5-year-old girl with an impacted left mandible condyle into the middle cranial fossa after a fall from her bed. (A) Preoperative
frontal view showing facial asymmetry in the lower one-third of the face, mandibular chin deviation, and abrasion. (B) Postoperative
frontal view showing restored facial symmetry. (C) Postoperative mouth opening restored to premorbid state. (D) Preoperative intraoral
view showing mandibular deviation to the left with ipsilateral posterior crossbite. (E) Postoperative intraoral view showing occlusion
restored to the premorbid state. (F) Preoperative panoramic radiograph showing deviation of the mandible, the left condylar head and
neck superimposed by the skull base, and mastoid air cells. (G) Postoperative panoramic radiograph showing morphologic changes at the
left condylar head. (From [F, G] Arya V, Chigurupati R. Treatment algorithm for intracranial intrusion injuries of the mandibular condyle. J
Oral Maxillofac Surg 2016;74(3):580; with permission.)

with undiagnosed and thus untreated condylar fractures.
The active osteogenic capacity of the child’s condyle, espe-
cially in comminuted injuries, predisposes itself to this form
of overexuberant healing in the setting of limited postinjury
movement. Ankylosis of the temporomandibular joint in
growing children can lead to growth and development dis-
turbances that may require surgical intervention, depending
on the severity. Correct diagnosis and treatment, with early
return to function, may lead to decreased incidence of
posttraumatic bony ankylosis.
Pediatric and Adolescent Condylar Fractures
Fig. 15 Temporomandibular ankylosis of intracapsular pediatric
mandible fracture.
Summary
The mandibular condyles are a common site of fracture in both
children and adolescents, and require thoughtful consideration in
management to avoid disturbances in growth. The goal of man-
aging condylar fractures in the growing patient must be aimed at
restoring function and symmetry while avoiding complications of
malocclusion and temporomandibular joint dysfunction. Treat-
ment may be surgical or nonsurgical. Management can involve
conservative treatment ranging from observation with a soft diet
and physiotherapy to intermaxillary fixation with either rigid
fixation or guiding elastics. If intermaxillary fixation is used, the
typical method is guiding elastics for a period of 7 to 12 days
followed by physiotherapy. Because conservative management
of condylar fractures has been shown to yield satisfactory results,
open surgical reduction of condylar fractures is rarely used in the
pediatric and adolescent patient population. It is important to
remember that children are not simply “small adults” and that
the use of “adult” treatment may be unsuitable in certain situ-
ations. There is currently no definitive age or set of guidelines
that defines the treatment of condylar fractures in children
versus teenagers based on age, instead this is left up to practi-
tioners to determine on a case-to-case basis. As patients grow and
83
mature, they experience decreased bone remodeling capacity
and the indication of open reduction and internal reduction in-
creases; however, it is unclear at exactly what age this occurs.
Because of the growing nature of children, long-term follow-up
and evaluation at regular intervals is needed until mandibular
growth has completed so as to avoid growth disturbances.
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