Condylar Fracture

Muhammad Tahoor
D17015
Fractures involving the mandibular condyle are only
facial bone fracture= SYNOVIAL JOINT

Condylar & Subcondylar Fracture = 30% OF ALL

MANDIBULAR FRACTURE

Condyle = MAJOR GROWTH SITE

TRAUMA TO MANDIBULAR CONDYLE
DIVIDED INTO 3:
1. CONTUSION
2. DISLOCATION
3. FRACTURE
Contusion
(blood capillaries have been ruptured)
• Injury that maybe accompanied by a synovial effusion,
haemarthrosis or tearing of the meniscus
• Such injuries are difficult to diagnose without special imaging
techniques
• They may predispose to later degenerative changes in some cases
Dislocation
• Irreducible displacement of the condyle from the glenoid
fossa is usually anterior or medial
• Lateral, posterior or central dislocation rarely occur
Fracture
• Includes any fracture above the level of the sigmoid notch
• Fractures, fracture/dislocation and dislocations of the
condyle are all accompanied by the varying degree of
contusion
• if fracture extend into the joint space, haemarthrosis and
rupture of the meniscus is more likely to occur and such
injuries may predispose to later disturbance of function
Classification of Condylar Fracture
1. Lindhal’s classification
-Based on anatomic location of the fracture (level of condylar
fracture)
-Based on the relationship of the condylar segment to the
mandibular fragment (NECK)
-Relationship of condylar head to fossa
2. AO classification
3. Wassmund Classifcation
4. Rowe’s and Killey’s Classification
5. Maclennan System
Lindhal’s classification
Based on anatomic location of the fracture (level of condylar fracture)
1. Condylar head (intracapsular)
2. Condylar neck
3. Subcondylar (high or low)
Lindhal’s classification
Based on the relationship of the condylar segment to the mandibular
fragment
1. Non displaced (fissure fracture)
2. Deviated (simple angulation of the condylar process in relation to
distal mandibular segment without overlap)
3. Displaced with medial overlap
4. Displaced with lateral overlap
5. Displaced with anteroposterior overlap
6. No contact between the fracture segments
Lindhal’s classification
Based on the relationship between the condylar head and glenoid fossa
1. No displacement (condylar head appears in normal relation with
fossa)
2. Displacement (condylar head is in fossa but there is alteration of
joint space. Joint space is increased)
3. Dislocation (the condylar head/process is completely out of the
fossa)
AO Classification
• The condylar process and head is a subunit of the mandible and is
defined by an oblique line running backwards from sigmoid notch to
the upper massetric tuberosity
• Condylar process is differed into three subunits
-Head
-Neck
-Subcondylar (caudal) area
AO classification
Three lines are used to define these subregions:
1. The first line parallels the posterior border of the mandible
2. The sigmoid notch line runs perpendicular to the first line at the
deepest portion of the sigmoid notch
3. A line below the lateral pole of the condylar
head that is also perpendicular to the first line
Wassmund Classification
1. Minimal displacement of head (10-45˚) *C*
2. Fracture with tearing of medial joint capsule (45-90˚), bone still
contacting
3. Bone fragments not contacting, condylar head outside
of capsule medially and anteriorly displaced *A*
4. Head is anterior to articular eminence
5. Vertical or oblique fractures through condylar head
*B*
Rowe’s and Killey’s Classification
1. Intracapsular fractures or high condylar
-Fractures involving the articular surface
-Fractures above or through the anatomical neck, which donot
involve the articular surface
2. Extracapsular or low condylar fractures
3. Fractures associated with injury to the capsule ligament and
meniscus
4. Fractures involving adjacent bone
Maclennan System
1. No displacement
2. Fracture deviation (simple angulation of the fracture segments without
overlap or separation e.g. green stick fracture in children)
3. Fracture displacement ( when there is overlap of fracture fragment. This
overlap maybe in an anterior, posterior, lateral or medial. Medial is
commonest.)
4. Fracture dislocation (here the condylar head is completely dislocated out
of the articular fossa and out of the capsular confines. Again dislocation
can be medial or lateral and rarely anterior or posterior)
5. High condylar fracture with luxation
6. Head fracture or intracapsular fracture
Conservative management of condylar
fracture
• Anatomical reduction and subsequent fixation of condylar fractures is
difficult to achieve
• The majority of surgeons have traditionally favored a conservative
approach, avoiding direct disturbance of the fracture site and
concentrating on early restoration of function
• Good results were achieved by closed conservative management
Open reduction of condylar fractures
• Grossly displaced fracture/dislocation of the condyle, particularly
bilateral fractures, are unavoidably accompanied by malocclusion in the
dentate patient

• Simple immobilization by means of IMF doesn't always achieve a

satisfactory reduction of the fracture and malocclusion persists after
healing is complete
Absolute indication (open reduction)
A. Displacement of condyle into middle cranial fossa (MCF)
B. Impossibility of restoring occlusion
C. Lateral extracapsular displacement
D. Invasion by foreign body e.g. missile
Relative indication (open reduction)
a. When IMF is contraindicated for medial reasons
b. Bilateral fracture with associated midface fracture
c. Bilateral fracture with severe open bite deformity
NOTE:
Open reduction has some considerable risk to the branches of the
facial nerve ( 7th cranial nerve)
Major Complications
1. Ankylosis of TMJ
2. Disturbance of Growth
1. Ankylosis of TMJ
• It occurs following trauma
• Predisposing factors are
-AGE: the major incidence is below the age of 10
years
-Type of Injury: intracapsular crushing of the condyle
-Damage to meniscus: disruption of the meniscus is
likely to occur in two types of fracture
*a severe intracapsular compression injury
*a fracture/dislocation
2. Disturbance of Growth
• A small proportion of children in which the fracture involves the
condylar cartilage and the articular surface exhibit subsequent
disturbance of growth
• In some cases, fibrous or bony ankyloses of the TMJ is an additional
complication
• This reduces the normal functional movement of the jaw which
further inhibits growth
• A smaller mandible on the affected side
Treatment of condylar fractures
There are 3 treatment options:
1. Functional
2. Indirect immobilization
3. osteosynthesis
According to Treatment options
Condylar fracturs should be classified according to:
1. Under 10 years
2. 10-17 years
3. adults
According to Treatment options
Surgical Anatomy
1. Involving joint surface – intracapsular
2. Not involving joint surface – extracapsular
-high condylar neck
-low condylar neck
According to Treatment options
Site
1. Unilateral
2. Bilateral

Occlusion
1. Undisturbed
2. malocclusion
Children under 10 years of age:
• Most likely to develop growth disturbance or limitation of movement
• Malocclusion d/t condylar injury will be spontaneously corrected as
dentition develops
• Displaced condylar neck fractures will undergo full functional
restitution in most cases
• Unilateral and bilateral fractures are treated the same way
• Treatment should be entirely function where possible (to avoid
ankylosis)
• Indirect immobilization by IMF is indicated for control of pain and
should be released after 7-10 days
Adolescents 10-17 years of age
• Same principles apply to this group with some modification
• If malocclusion is present the capacity for spontaneous correction is
less than in the younger group
• Malocclusion is therefore an indication for IMF for 2-3 weeks
• this dentition is suitable for simple eyelet wires
Adults
Unilateral Intracapsular fractures:

• The occlusion is usually undisturbed and the fracture should be

treated conservatively without immobilization of the mandible
• Occasionally, slight malocclusion is noted, particularly when there is
an associated effusion in joint, in which case simple IMF with eyelet
wires should be applied for 2-3 weeks
Adults
Unilateral Condylar Neck Fracture

• In undisplaced fracture, occlusion is not disturbed and no active treatment

is necessary
• A fracture/dislocation will often induce significant malocclusion d/t
shortening of the ramus height and premature contact of the molar
teeth on that side
*A low condylar neck fracture is probably best treated by
open reduction in such situation
*A high condylar neck fracture with extensive displacement and
malocclusion, IMF is applied and maintained until stable bony union has
occurred i.e. 3-4 weeks
• Relapse maybe there so best treatment by combination of occlusal
grinding and spontaneous adaptation
Adults
Bilateral intracapsular Fractures
• Occlusion is usually slightly deranged in these cases
• Degree of displacement of both condyles may not be same and it is
best to immobilize the mandible for the 3-4 weeks required for stable
union
• To prevent chronic limitation of movement, post reduction
physiotherapy is effective
Adults
Bilateral condylar neck fracture

• These fracture present the major problem in treatment

• There is usually considerable displacement of one side or the other
• Even if displacement is not evident when first seen, the fractures are
inherently unstable and functional treatment is contraindicated
• Although the application of IMF will establish the occlusion, it will not
reliably reduce the fracture on both sides
Operative reduction of atleast one of the fractures to restore the
ramus height is desireable
Adults
Bilateral condylar neck fracture (continue)
• In the case of bilateral high condylar neck fracture where operative
reduction is likely to be difficult, IMF should be applied for 6 months
• When a bilateral fracture of this nature is associated with a major
midfacial fracture, operative reduction of both sides is desireable
• This situation maybe temporarily saved by the use of extra oral
fixation utilizing a box frame or halo
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