dr jameel kifayatullah ,khyber college of dentistry peshawar

1. Controversies in the management
of Condylar Fractures
Dr jameel kifayatullah
TMO oral surgery
Khyber college of dentistry

2. Controversial fractures
• The most controversial fractures regarding
diagnosis and management(Villareal 2004).
• The major controversy is to open? or not to
open

3. Reasons for controversy
• There are many different methods to treat this
injury.
• Poor quality of the available data and the lack of
other important information.
• No definitive study performed that has shown
superiority of open v/s closed reduction.
• Basic mechanisms of repair of the condyle after
injury have not been fully appreciated.

4. CLOSED PROCEDURE

5. Closed procedure
• Traditionally all of the condylar fractures were
managed closed with maxillo mandibular fixation.
• Conservative approach should be regarded as the
first choice of treatment for condylar fracture.
(villareal 2004,smete 2003)
• As long as there is contact b/w the proximal and
distal fragments= union with acceptable
results(Maclennan,villarel etal)
• Closed reduction provides good results(Zide and
Kent 1983)

6. • Conservative methods technically
simpler,offer reduced overall morbidity
with satisfactory functional results with
infrequent ankylosis and avascular necrosis.
• Little justification for surgically exposing
the area provided the vertical height and
occlusion are maintained.

7. MacLennan and Simpson(1965)
• After reviewing large series of condylar
fractures concluded that a good result was
achieved by closed conservative
management in 93 % cases.

8. Complications of Closed
technique
• True anatomic reduction not achieved.
RESULTS are malocclusion,facial
asymmetry,decreased mouth opening.
dahlstron etal study
Decreased translation,deviation to the fractures side
of greater than 5mm with opening,abnormal
condylar head and shortened condylar/ramus
height on plain films.

9. Worsae and Thorn(1994)
• In the group treated closed there were
higher rate of facial asymmetry
impaired masticatory function
post operative joint pain

10. Marker and Nielson(2000)
• patients had minor complaints of slight
limitations of M.O Or deviation with
opening.
• complaints of joint pain on the side of
fracture.
• malocclusion related to initial injury.

11. Yang and Chen(2002)
• Of the 96 patients 30 were managed closed.
• Of the closed group 21% patients showed
facial asymmetry with chin deviation to the
fractured side.

12. Haug And Foss( 2000)
• Malocclusion
• Chronic pain
• Limited mobility
• Asymmetry
Occasionally associated with closed
reduction.

13. Takenoshita(1989) Zhang and
Obeid(1991)
• Closed treatment for more displaced
fractures is more prone to produce
suboptimal results
• Deviation on M.O
• Loss of ramus height
• malocclusion

14. Kent etal (1990)
• Late arthritic changes may occur 10-50
years later in cases treated by closed
reduction.

15. Silvennoinen etal
• 30% of their condylar process fractures had
persistent deviation on opening.

16. • Loss of posterior vertical dimension has
been demonstrated within 6 weeks after
closed treatment of condylar process
fractures.

17. • The combination of a damaged condylar process
and immobilization may cause a cicatricial
reduction in condylar translation,resulting in
deviation toward the side of fracture on opening or
in protrusion.
• Immobilization of a damaged joint leads to
degeneration of the articular surfaces and
development of fibrous adhesions,limiting
mobility.

18. Adaptations
• 3 main types of adaptation to restore TMJ
articulation to facilitate masticatory
function: 1)NM adaptation
2)skeletal adaptation
3)dental adaptation

19. NM Adaptation
nm adaptations are short term
adaptations that assist in
positioning the mandible until a
new skeletal articulation has been
reestablished.

20. NM adaptations
• Bilateral condylar fracture=posterior
collapse=premature contact of terminal
molars creating an anterior open bite.
• NM adaptation that occur are in the muscles
of mastication eg temporalis = increased
activity in temporalis=posteriorly directed
vector onto the coronoid process=rotate the
anterior portion of mandible superiorly
bringing incisors into contact.

23. Skeletal Adaptation
• Development of a new tm articulation after
condylar process fracture.
• Begins immediately after injury and continues for
many months afterwards.
• 3 methods:1)condylar regeneration
2)changes in the temporal
component of tmj and superior
movement of ramus
3)loss of posterior vertical
dimension(within 6 weeks after closed treatment)

24. Dental Adaptations
• With closed treatment of condylar process
fractures there is extrusion of incisors and
intrusion of molars.

25. Open techniques
Introduced in mid 1940 s.
1980 s miniplate fixation introduced
Open reduction aims at anatomical repositioning
and rigid fixation of the fragments,occlusal
stability,rapid return to function,maintenance of
vertical ramus dimension,no airway
compromise and less long term TMJD(Hovinga
etal 1999;Ellis etal 2000)

26. Open Reduction
• Open reduction of the condylar process
eliminates the need for extensive
remodelling.
• ORIF of the fractured condylar process
obviate the necessity for these NM,skeletal
and dental adaptations.

27. Open reduction
• Surgical treatment to reapproximate the fractures
segments has been advocated to avoid the
complications of
• Open bite
• Retrognathia
• Pain
• Reduced lateral and protrusive mobility
• Deviation on opening
(jeter etal 1988,Lachner etal 1991)

28. Haug and Assael 2001
List of indications for open treatment
• Patient preference
• Inability to establish normal occlusion with
a closed procedure
• Situation in which the stabilty of occlusion
was limited

29. palmieri 1999, Ellis and
throckmorton 2004)
• Surgically treated condylar fracture give
better results in terms of
occlusion,masticatory function,mouth
opening and bone morphology.

30. Surgical Approaches

31. Surgical Approaches

32. Open treatment methods

33. Open Treatment Methods

34. Open treatment methods

35. Complications of open treatment
• Difficulty of surgical access
• Extraoral scars
• Lesion of facial nerve
• Plate fracture
• Aseptic necrosis of the condylar segment
Secondary to loss of periosteal blood supply during
dissection for exposure.
• Haemorrhage(intraoperative bleeding from
maxillary artery injury)

37. – Berger(1943) warned that ORIF of condylar
process fractures using wires could cause
infection and necrosis of the condylar fragment.

38. James R Hayward(1993)
Advocated the factors affecting decision of closed
versus open reduction of condylar fractures:
• Age of patient
• Level of fracture
• Degree of displacement
• Direction of displacement
• Medical status of the patient
• Concomitant injuries
• Presence of dentition
• Status of existing dentition
• Ease in establishing adequate occlusion

39. Guidelines
• Fractures in growing
children(intracapsular+extracapsular) must be with
closed treatment(consensus).
• No consensus as regards the treatement of condylar
fracturs in adults.
• Open v/s closed treatment is judged individually.
• In adults the type of treatment must mainly be
chosen on case to case basis and the personal
experience of each professional.
• Intracapsular fracture in adults also managed closed.
• Conservative treatment required when the patients
past medical history doesn’t allow the

40. Intracapsular fracture

41. Zide and kent (1983)
• Outlined indications for open reduction as follows:
ABSOLUTE INDICATIONS
(a) displacement of condyle into middle cranial
fossa
(b) Impossibility of obtaining adequate occlusion by
closed treatement
(c) Lateral extracapsular displacement of condyle
(d) Invasion by foreign body e.g missile

42. RELATIVE INDICATIONS
(a)When IMF is C/I for medical reasons( e.g
alcoholism,seizure disorder,asthma,mental
retardation)
(b)bilateral condylar fractures associated with
comminuted midface fractures.
(c) Bilateral condylar fractures associated with
gnathologic problems (e.g retrognathia,open bite).

43. • Medial or lateral override (ORIF)

44. • Surgery should be performed in the adult
whenever the vascular supply of the
displaced part of the condyle is
compromised as in cases of severely
displaced condyles(i.e displacement greater
than 45 degree in either the coronal or
sagittal plane.

46. • ORIF should be contemplated for the
edentulous or the mandible with lack of
posterior support,and those with skeletal
abnormalities(such as open bite and
prognathism) that compromise occlusal
stability.
• To avoid/shorten duration of MMF.

47. Bilateral condylar neck fractures
• Operative reduction of atleast one of the
condyles to restore ramus height desirable.
• Bilateral high condylar neck fracture=
operative reduction likely to be difficult=go for
MMF for upto 6 weeks.
• When there is bilateral condylar neck fracture
associated with major mid facial fracture =go for
operative reduction of both sides.

49. • Displaced subcondylar fractures in adults
esp bilateral =ORIF.

50. Thank you