1. by: dr. Ali Mohammed Hasan
BDS, MSc oral surgery

2.  The condyle presents an articular surface for articulation
with the articular disk of the temporomandibular joint; it
is convex from before backward and from side to side, and
extends farther on the posterior than on the anterior
surface.
 Its long axis is directed medialward and slightly backward.
 At the lateral extremity of the condyle is a small tubercle
for the attachment of the temporomandibular ligament.
 The articular surface of the
condyle is covered by fibrous
tissue, and interfaces with an
articular disk (or meniscus) of
avascular, non-innervated fibrous
tissue (collagen, fibroblasts).

3.  The neck is flattened from before backward, and
strengthened by ridges which descend from the forepart
and sides of the condyle.
 Its posterior surface is convex; its anterior presents a
depression for the attachment of the lateral pterygoid
muscle.

4.  It prevents posterior displacement of the mandible and
prevents the condyloid process from being driven upward
by a blow and fracturing the base of the skull.
 It also act as a suspenders that holds the jaw in place.

5.  Simple
 Greenstick fracture (rare, exclusively in children)
 Fracture with no displacement (Linear)
 Fracture with minimal displacement
 Displaced fracture
 Comminuted fracture
Extensive breakage with possible bone and soft
tissue loss
 Compound fracture
Severe with two or more fractures
 Pathological fracture
(osteomyelities, neoplasm and generalized
skeletal disease)

6.  Cycling trauma.
 Car traffic accident.
 Interpersonal violence.
 Gunshot.
 Falling from heights.
 Pathological process.

7.  Condylar fracture could be
 Intracapsular fracture
 Extracapsular fracture
 High condyle neck fracture
 Low condylar fracture
 Unilateralor bilateral fracture
 Condylar fracture with concomitant
mandibular fracture.
 Condylar fracture with pan-facial fracture.

8. Line A. A perpendicular line through the sigmoid notch
to the ascending ramus
1) Diacapitular (through the head of the condyle) fracture;
the fracture starts in the articular surface and may
extend outside the capsule.
2) Fracture of the condylar neck. The fracture line starts
above line A, and in more than half (the fracture
distance) runs above line A. High condylar fracture.
3) Fracture of the condylar base. The fracture line runs
behind the mandibular foramen and in more than half
the distance below line A. Low condylar fracture.

9.  The clinical examination should
consist of inspection and
palpation. It is best to proceed
in an orderly fashion and to
perform this evaluation as a
component part of the entire
head and neck examination of
the trauma patient. The skin of
the face and, in particular, the
area around the mandible should
be inspected for swelling,
hematomas, and lacerations. A
common site for a laceration is
under the chin, and this should
alert the clinician to the possi-
bility of an associated
subcondylar or symphysis
fracture

10.  The best routine to
evaluate facial
fractures is to start at
the top and work down,
assessing the stability of
the anatomic structures
in a mediolateral
fashion.
 Failure to detect the
translation of the
condyle, especially
when associated with
pain on palpation, is
highly indicative of a
fracture in this area.

11.  If bilateral condylar
fractures are pre-sent,
the occlusion may not
be deviated. The
midlines are often
coincident, and
premature contact is
present bilaterally on
the posterior dentition
with an anterior open
bite.
 Any significant deviation on
opening may be indicative of
subcondylar fracture on the
side to which the mandible
deviates.

12.  Swelling, pain, tenderness and restriction of movement
 Deviation of mandible towards the side of fracture
 Gagging of occlusion (premature contact on the
posterior teeth) with bilateral condylar displaced or
over-riding fractures
 Displacement of mandible toward the affected side
 Anterior open bite on opposite side of fracture
 Laceration of EAM
 Retroauricular ecchymosis
 Cerebrospinal leak and otorrhea in association with skull
base fracture

13.  Bilateral lateral oblique.
 30°PA.
 Panoramic view.
 Computed Tomography.

14.  The typical radiographic
findings when a
condylar fracture is
present are the
following: a shortened
condylar-ramus length;
the presence of a
radiolucent fracture
line or, in the case of
overlapped segments,
the presence of a
radiopaque double
density and evidence of
premature contact on
the side of fracture.

16.  1. Significant displacement or
dislocation, particularly if open
reduction is contemplated
 2. Limited range of motion with
a suspicion of mechanical
obstruction caused By the
position of the condylar segment
 3. Alteration of the surrounding
osseous anatomy by other
processes, such as previous
internal derangement or
temporomandibular joint
surgery, to the degree that a
pretreatment base-line is
necessary
 4. Inability to position the
multiple-trauma patient for
conventional radiographs (CT
scans may be the only useful
radiograph that can be obtained)

19.  Noroutine laboratory testing is indicated
unless dictated by the medical history.

20.  Goals of Therapy
1. Obtain stable occlusion.
2. Restore interincisal opening and mandibular
excursive movements.
3. Establish a full range of mandibular excursive
movements.
4. Minimize deviation of the mandible.
5. Produce a pain-free articular apparatus at
rest and during function.
6. Avoid internal derangement of the TMJ on the
injured or the contralateral side.
7. Avoid the long-term complication of growth
disturbance.

21.  No treatment.
 closed reduction (management).
 open reduction.
 endoscopically assisted.
 free plating and grafting.

22. 1) No Treatment:
No treatment is considered when no occlusal
discrepancy or functional impairment exists.
2) Closed Reduction:
 Condylar neck fractures in children <15
years
 Very high condylar neck fractures without
dislocation
 Intra-capsular fractures.
 Grossly comminuted fractures and gun shot.

23.  3) Open Reduction:
 1. Absolute indications
A. Limitation of function secondary to the
following:
1. Fracture into middle cranial fossa
2. Foreign body within the joint capsule
3. Lateral extracapsular dislocation of condylar
head.
4. Other fracture dislocations in which a
mechanical stop is present on opening,which is
confirmed radiographically
B. Inability to bring the teeth into occlusion for
closed reduction

24.  2. Relative indications:
 A. Bilateral condylar fractures with comminuted midface fractures in
which rigid internal fixation of the midface is not possible
 B. Situations when intermaxillary fixation is not feasible as a result of the
following:
1. Medical restrictions
a. Poorly controlled seizure disorder
b. Psychiatric disorders
c. Severe mental retardation
d. Concomitant injuries such as head injury or chest injury (unless
tracheostomy is planned)
2. Displaced fractures where dentures or splints are not feasible
because of severe mandibular atrophy
 C. Bilateral fractures in which it is impossible to determine what the
proper occlusion is as a result of loss of posterior teeth or the presence
of a preinjury skeletal malocclusion
 D .In fracture dislocation in adults to restore the position and function of
the meniscus (controversial)

25.  4) endoscopically assisted.
 it reduces the risk to the facial nerve and minimizes
scarring.
 Condylar neck fractures may be treatable by EAORIF as
long as there is sufficient bone stock to place at least two
bicortical screws in the proximal fragment.
 Subcondylar fractures are generally suitable for EAORIF as
long as significant comminution is not present.
 Using the intraoral approach, a ramus incision similar to
one for a mandibular osteotomy is made and the masseter
muscle stripped to create the optical cavity. A 4-mm 30°
endoscope with an adapted retractor provides direct vision
and this is aided by a Freer elevator with built in suction.
 Under vision and with special instruments the fracture is
manipulated and reduced

26.  5) Free plating and grafting:
 This is used with severe extensive
fractures/lesions in which a large portion of
bone is lost

27.  The mandible is manipulated so that the
teeth are in normal occlusion, followed by
mandibulo-maxillary fixation.
 This is achieved by the use of
 Arch bars
 Jelenko
 Erich pattern
 German silver notched
 Cap splints

28. Gunning’s splint
Bonded brackets
IMF screws
Dental wiring:
 Direct wiring
 Eyelet wiring
 Local anesthesia or sedation
Treatment can be performed
under GA or LA and when surgery
is contraindicated

31.  Differences in the length of IMF depend on
1) the age of the patient.
2) the type of fracture.
3) the presence of other fractures.
Ranging from 2-8 weeks until re-establishing a
preinjury occlusion.

32.  Criticism of the disadvantages of prolonged
immobilization of the jaws has included
patient complaints of
 panic, insomnia, social inconvenience, pho-
netic disturbance, loss of effective work
time, physical discomfort, weight loss, histo-
logic changes in the condylar head, and dif-
ficulty recovering a normal range of jaw
movement. This has led some clinicians to
seek alternative methods of treatment,
including the use of rigid internal fixation.

33.  A variety of surgical approaches to the fractured
condyle have been suggested, including:-
 intraoral.
 submandibular.
 retro-mandibular.
 preauricular.
 more recently, endoscopic.
 The most important factor in determining the
approach used is the level at which the fracture has
occurred.
 Modifying factors such as the degree of displacement
or dislocation and the planned method of fixation
may also have a bearing on the approach selected.

34.  Traditionallyfractures in the condylar neck
and above were best approached through a
preauricular incision.
 Subcondylar fractures and fractures
extending into the upper ramus region are
best approached using a retro-mandibular or
Hinds approach.

35.  The incision begins approximately 1 cm
below the lobe of the ear and 1 cm posterior
to the ramus of the mandible. The dissection
is carried down to the parotid gland, which is
retracted anteriorly, providing access to the
vertical fibers of the masseter muscle
overlying the ramus. These fibers are not
stripped but instead are separated bluntly
along their vertical course, allowing access
to the underlying ramus.

36.  Low sub-condylar fractures, especially those
with-out a significant degree of
displacement, may be easily approached
from an intra-oral incision.
 In severe anteromedial fracture dislocations
in which the condylar head is not retrievable
despite the choice of approach, a vertical
ramus osteotomy, followed by removal of the
osteotomized segment, has been
recommended.

40.  Transosseous wiring
 Circumferential wiring
 External pin fixation
 Bone clamps
 Trans-fixation with Kirschner wires

42.  Non-compression small plates
 Compression plates
 Miniplates
 Lag screws
 Resorbable plates and screws

44.  Locking recon
plate
 miniplate

45.  In cases in which open reduction internal fixation
is employed without the use of postoperative
IMF, follow-up visits should be used as
reinforcement sessions to remind the patient
about proper diet (soft mechanical diet) and
progressive increase in function.
 In most cases some form of IMF will have been
employed.
 The length of the fixation period, as previously
discussed, varies between 2 to 8 weeks
depending on many factors.
 At the end of this period, a systematic approach
for removal of the fixation is desirable.

46.  Children of less than 12 years of age rarely
require more fixation, but patients over the
age of 12 years show extreme variability,
regardless of fracture type.
 If the occlusion is stable and reproducible at
the time of IMF release, then jaw-opening
exercises are begun.
after release of IMF the patient should
 1)
be evaluated in 24 hours to confirm the
presence of a stable occlusion.

47.  2) The arch bars are left in place and
training elastics are used to permit
function while maintaining the occlusion.
 3) the elastics are used for 24 hours a
day in the 1st week where it is lightly
applied during daytime and more tightly
at night.
 4) in 2nd to 3rd week, day time elastics
may be completely abandoned and used
only at night.

48.  5) the patient should be allowed to function
without any guiding elastic fixation for
approximately 1 week. If, at that time, there
continues to be a stable occlusion, further
evaluation should continue for other
problems, such as limited mouth opening or
pain, and the arch bars may be removed.
 6) Throughout the post-IMF period,
aggressive maintenance of range of motion is
necessary. In some patients this may be as
simple as instructing them to open their
mouths as wide as possible in a symmetrical
manner.

49.  7) in other patients, Manually forcing the
teeth apart, use of a ratchet, mouth props,
progressive wedging of tongue blades
between the teeth.


50.  Delayed Union and Nonunion
 Infection
 Malunion
 Nerve injury
 Growth alteration
 Temporomandibular Joint
Dysfunction

51.  1)Internal Derangement:
A correlation exists between previous
condylar fracture and the development of
internal derangement of the TMJ.
There is a greater incidence of
temporomandibular joint pain, deviation
on opening and joint noise in patients
with previous condylar fractures.

52.  2) Ankylosis:
It is more likely to occur in children and is
associated with intracapsular fractures and
immobilization of the mandible.
 The most commonly accepted etiology is of
intra-articular hemorrhage, leading to
abnormal fibrosis and ultimately ankylosis.

53.  site and type of fracture.
 the age of the patient at the time of injury.
 the duration of IMF.
 the extent of damage to the disk.

54.  Intracapsular fractures are best treated closed.
 Fractures in children are best treated closed
except when the fracture itself anatomically
prohibits jaw function.
 Most fractures in adults can be treated closed.
 Physical therapy that is goal-directed and
specific to each patient is integral to good
patient care and is the primary factor
influencing successful outcomes, whether the
patient is treated open or closed.
 When open reduction is indicated, the procedure
must be performed well, with an appreciation
for the patient's occlusal relationships, and it
must be supported by an appropriate physical
therapy and follow-up regimen.