Seminar on condylar fractures

1. CONDYLAR FRACTURES
DR. JEFF ZACHARIA
POST GRADUATE STUDENT
DEPT. OF ORAL & MAXILLOFACIAL SURGERY
AJ INSTITUTE OF DENTAL SCIENCES

2. CONTENTS
• Introduction
• Growth and development
• Anatomy
• Pediatric condyle Vs Adult condyle
• Etiology
• Hunting bow concept
• Classifications
• Clinical features
• Radiographic diagnosis
• Treatment
• Surgical approaches
• Fixation
• Complications
• Open reduction Vs Closed reduction

3. INTRODUCTION

4. INTRODUCTION
The management of mandibular condylar injuries is one of the
most controversial areas in the treatment of facial trauma.
Fractures involving the mandibular condyle are the only facial
bone fractures which involve a synovial joint. These injuries
deserve special consideration apart from those of the rest of
the mandible due to their anatomic differences, variations in
clinical picture, unique management protocols and distinct
healing potential

5. GROWTH & DEVELOPMENT

6. GROWTH & DEVELOPMENT
Prenatal growth
• At 5th week IUL: area of mesenchymal condensation forms above developing
mandible
• At 10th week: it develops into cone shaped cartilage.
• At 14th week: the condylar cartilage undergoes ossification.
• At 4 months: it migrates downwards & fuses with Mandibular Ramus
Post natal growth
• Growth of soft tissue carries mandible forward away from cranial base.
• Bone growth occurs at condyle to maintain constant contact with cranial base.

7. ANATOMY

8. ANATOMY
• The condyle is an upward projection from the
postero-superior part of the ramus.
• Width: 15 to 20 mm and length: 8 to 10 mm
• Ovoid in shape in shape with the long axis angled
backwards between 15° – 33° to the frontal plane.

9. RELATIONS
Lateral
• Skin
• Parotid gland
• Temporal branch of
facial nerve
Inferior
• Maxillary artery & vein
Superior
• Middle cranial fossa
• Middle meningeal vessels
Medial
• Tympanic plate
• Spine of sphenoid
• Auriculotemporal N. &
Chorda tympani

10. ARTICULAR SURFACE
• It is a ginglymoarthrodial joint.
• Fibrocartilage covers the fossa, eminence & condyle.
• Greater repair capacity than hyaline cartilage
• Less susceptible to degeneration.

11. ARTICULAR DISC
• Posterior portion continues as the retrodiscal lamina
• Upper compartment permits gliding movement &
prevents the disc from slipping during the opening of
the mouth
• Lower compartment permits both gliding & rotatory
movements.
• The medial & lateral aspect of the disc is attached to the
condylar formation of the mandible.

12. LIGAMENTS OF TMJ
Fibrous capsule
• it is loose above the disc & tight
below the disc & is lined by
synovial membrane
Lateral ligament
• Strengthens the lateral part of the
capsule
Stylomandibular ligament
• It serves to limit excessive protrusion of the jaw.
Sphenomandibular ligament
• Its main task is to protect the TMJ from an excessive translation of the condyle, after 10 degrees of opening
of the mouth.

13. MUSCLE ATTACHMENT
Lateral Pterygoid muscle
Actions
1. Depresses the mandible
2. Protrudes the mandible
3. Lateral movements

14. PEDIATRIC CONDYLE VS ADULT CONDYLE
Parameter Child Adult
Cortical Bone Thin Thick
Condylar neck Broad Thin
Articular surface Thin Thick
Capsule Highly vascular Less vascular
Periosteum Highly active
osteogenic phase
Less active in latent
stage
Intracapsular fracture &
Hemarthrosis
Very common Rare
Re-modelling capacity
after trauma
Present Absent
Disturbance in growth Likely N.A.

15. ETIOLOGY

16. ETIOLOGY
In adults
• Motor vehicle accidents
• Interpersonal violence
• Work related injuries
• Contact sports
• Falls
In children
• Falls and bicycle accidents
• Motor vehicle accidents
In elderly
• Falls
• Assault and motor vehicle accidents

17. HUNTING BOW CONCEPT
• The mandible is similar to a hunting bow in shape, strongest in the
midline (symphysis) and weakest at both ends (condyles).
• A blow to the anterior mandibular body is the most common reason
for condylar fracture.
• A blow to the ipsilateral mandible causes a contralateral fracture in
the condylar region. If the impact is in the midline of the mandible,
fractures of the bilateral condylar region are very common.

18. MECHANISM OF INJURY (LINDAHL 1977)
• Kinetic energy imparted by a moving object through the
tissues of a static individual.
Eg, by a fist, bat or ball
• Kinetic energy derived from the moving individual striking a
static object
Eg, an epileptic fit or parade ground fracture
• Combination of the two
Eg, Road Traffic accidents

19. CLASSIFICATIONS

20. CLASSIFICATION
• Unilateral or bilateral condylar fractures
• Rowe & Killey’s classification
a) Simple fractures of condyle
b) Compound fractures of condyle
c) Comminuted fractures associated with zygomatic arch fractures

21. Wassmund’s classification (1934)
Type I
Fracture of the neck of the condyle with slight displacement of the head.
The angle between the head & the axis of the ramus varies from 10⁰ to 45⁰ .
These type of fractures tend to reduce spontaneously
Type II
An angle between 45⁰ to 90⁰ is seen between the head & the ramus. There
is tearing of the medial portion of the joint capsule.
Type III
The fragments are not in contact.
Head is displaced medially & forward due to the pull of lateral
pterygoid muscle & spasm

22. Type IV
• Fracture head articulates on or forward to the articular eminence.
Type V
• Vertical or oblique fracture through the head of the condyle

23. MacLennan’s classification (1954)
• No displacement: A crack fracture is seen without alteration of the normal
relationship of the condylar head to the glenoid fossa or neck to the ramus
• Deviation: Simple angulation exists between the condylar neck and the ramus.
• Displacement: Overlap occurs between the condylar process and the ramus.
• Dislocation: Disruption takes place between the condylar head and the glenoid
fossa.

24. Rowe and Killey’s classification (1968)
 Intracapsular fractures or high condylar fractures
a) Fractures involving the articular surface
b) Fractures above or through the anatomical neck, which do not
involve the articular surfaces.
 Extracapsular or low condylar or sub-condylar fractures
 Fractures associated with injury to the capsule, ligaments and meniscus.
 Fractures involving the adjacent bone—e.g. fracture of the roof of the
glenoid fossa or the tympanic plate of the external auditory meatus

25. Lindhal’s classification (1977)
Anatomic location of the fracture
a) Condylar head
b) Condylar neck
c) Sub-condylar
Relationship of condylar fragment to mandible
a) Undisplaced
b) Deviated
c) Displacement with medial or lateral overlap
d) Displacement with anterior or posterior overlap
e) No contact between fractured segments
Head fracture
Neck fracture
Sub condylar fracture

26.  Relationship of condylar head &
fossa
a) Nondisplaced
b) Displacement
c) Dislocation

27. Spiessel and Schroll classification (1972)
Nondisplaced fracture Low neck fracture with displacement High neck fracture with displacement
Low neck fracture with dislocation High neck fracture with dislocation Head fracture

28. Neff and Rasse’s modification (2006)
• Type A(VI A): Displacement of medial
condylar pole with preservation of the
vertical dimension
• Type B (VI B): The lateral condylar pole is
involved with loss of the vertical
dimension
• Type C (V): dislocation of the entire
condylar head

29. Loukota et al sub-classification (2005)
High condylar fracture
The fracture line starts above line A and
runs to over 50% of its length above line A.
Deep condylar fracture
The fracture line runs above the
mandibular foramen and is with over 50%
of its length below line A
A tangent line is placed between the dorsal gauge of the condylar
process and the mandibular angle. Line A is perpendicular to the
tangent line and crosses the deepest point of the semilunar notch

30. AOCMF CLASSIFICATION (2014)

31. STRASBOURG OSTEOSYNTHESIS RESEARCH GROUP (SORG)
CLASSIFICATION
• Diacapitular fracture: The fracture line starts in the
articular surface and may extend outside the capsule.
• Fracture of the condylar neck: The fracture line starts
somewhere above line A, the perpendicular line through
the sigmoid notch to the tangent of the ramus; in more
than half of cases, it runs above the line A in the lateral
view.
• Fracture of the condylar base: The fracture line runs
behind the mandibular foramen and, in more than half of
cases, below line A.

32. CLINICAL FEATURES

33. On inspection
• Preauricular Swelling
• Preauricular depression
• Lacerations on chin region
• Facial asymmetry
• Pain on lateral movements
• Deviation on opening
• Ear bleed
• CSF otorrhea
CLINICAL FEATURES
EXTRAORAL EXAMINATION

34. On palpation
• Inability to open jaws
• Tenderness associated with crepitation
• Deviation on opening – (same side)
• Firm pressure on the chin will cause
pain in the preauricular region

35. UNILATERAL FRACTURE
• Ipsilateral premature occlusion &
contralateral open bite due to loss of
vertical height.
• Deviation to the affected side
• Latero-protrusive movements are
limited
• Anterior open bite caused by the bilateral loss
of height with premature posterior contact.
• More restricted mandibular movements
• Complete disarticulation is possible.
BILATERAL FRACTURE
INTRAORAL EXAMINATION

36. RADIOGRAPHIC DIAGNOSIS

37. RADIOGRAPHIC DIAGNOSIS
• OPG
• Bilateral lateral oblique.
• Reverse Towne view.
• TMJ views
• Computed Tomography.
• CBCT

38. TREATMENT

39. AIMS OF TREATMENT
• Pain-free mouth opening with interincisal distance > 40 mm.
• Good movement of the jaw in all excursions.
• Restoration of the pre-injury occlusion.
• Stable TMJs.
• Good facial and jaw symmetry.

40. Treatment can be
• Closed reduction
• Open reduction with internal fixation

41. CLOSED REDUCTION

42. INDICATIONS OF NONSURGICAL MANAGEMENT
• Non displaced or incomplete fractures
• Condylar neck fractures with little or no displacement
• Fractures occurring in children
• Isolated Intracapsular fractures
• Medical illness or injury that inhibits the ability to receive GA

43. OPEN REDUCTION

44. ZIDE & KENT INDICATIONS (1983)
INDICATIONS FOR OPEN REDUCTION

45. MATHES TREATMENT PROTOCOL

46. AAOMS SPECIAL COMMITTEE ON PARAMETERS OF CARE
INDICATIONS FOR OPEN REDUCTION (2003)

47. SURGICAL APPROACHES

48. SURGICAL APPROACHES
All open approaches have three common aspects to their success
1- the ramus must be distracted
2- the proximal condyle must be controlled and manipulated
3- the fracture must be anatomically reduced

49. PREAURICULAR APPROACH
• Indications
 Antero medial displacement of proximal fragment
• Advantages
 Good esthetics
• Disadvantages
 No access to the angle of the mandible to distract the ramus inferiorly
 Limited ramus exposure makes the plate placement difficult.

50. PERTINENT ANATOMY
Parotid gland
• The superficial pole of the parotid gland lies directly on the TMJ
capsule.
Superficial temporal vessel
• It originates in the parotid at the level of the neck of the condyle.
• It crosses over the zygomatic process 16.68 ± 0.35 mm in front of
the tragus. approx. 3 cm superior, it gives off 2 terminal branches.

51. Auriculotemporal nerve
• The nerve is vulnerable to damage as it courses
10 – 13 mm inferior to the superior edge of
condyle.
• Damage is minimized by incising and dissecting
in close apposition to the cartilaginous portion
of the external auditory meatus

52. • In 1912, Blair advocated a curved or inverted “L” incision
commencing from the temporal hair line.
• It is a conventional preauricular approach, but an
anterosuperior extension (hockey-stick) is made in the hair-
bearing temporal skin
Advantage
• Improves the ability to retract anteriorly by the surgeon.
Blair’s incision

53. Al Kayat & Bramley incision
• Skin incision is similar to a question mark
• Begins antero – superiorly & curves backwards and downwards
until it meets the upper ear attachment
• Incision then follows ear attachment endaurally
Advantage
• Excellent visibility
• Facial planes can be easily identified
• Less bleeding
• Good cosmetic result

54. • The incision is wider and longer than the conventional
incision.
• The incision begins about a pinna’s length away from the
ear, antero-posteriorly just within the hair line, curves
backward and downward well posterior to the main
branches of the temporal vessels till it meets the upper
attachment of the ear.
Popwich & crane Modification of Alkayat & Bramley’s incision (1982)

55. Advantages of Popwich & crane modification
• Reduction in incidence of facial palsy
• Decreased hemorrhage
• Improved visibility & easier identification of facial planes.
• Reduction in post operative edema and discomfort
• Good cosmetic results.
• Avoidance of auriculotemporal nerve anesthesia/paresthesia
• Reduction in total operating time.

56. Dingman’s incision (1951)
• Incision is started in the fold at the junction of the anterior margin of
helix
• Carried downwards to upper portion of tragus where it is contained
inside the margin of tragus to anterior fold of lobule
• It again becomes visible at this point and is carried downwards to the
lower attachment of the ear.
Thoma’s incision (1958)
• It is an angulated vertical incision
• Incision is carried out across the zygomatic arch to avoid damage to the
main trunk of facial nerve

57. ENDAURAL INCISION
Described by Lempart
It is a preauricular incision carried behind the tragus of the ear
Indications
• Access to condylar head and neck.
• useful in young patients, who do not have a well-demarcated
preauricular skin fold
Advantages
• Good cosmetic result.
Disadvantages
• Tragus cartilage damage can result poor healing process.

58. RETROMANDIBULAR APPROACH
• Indications
 Sub-condylar fractures
• Advantages
 short distance between incision and fracture site
 Scar is less noticeable than that of a submandibular
incision
 Access for an osteotomy if required to reach the
condyle
• Disadvantage-
 scar is more visible than that of a preauricular
incision

59. PERTINENT ANATOMY
Main trunk of facial nerve
• After exiting the stylomastoid foramen, the nerve enters
the substance of the parotid where it divides into upper
and lower divisions just posterior to the mandible
• The approximate distance from the lowest point of the
external bony auditory meatus to the bifurcation of the
facial nerve is 2.3 cm (1.5 to 2.8 cm)
• Length of the facial nerve visible to the surgeon is 1.3 cm.

60. Retromandibular vein
Formed in the upper portion of the parotid
deep to the neck of the mandible, descends just
posterior to the ramus of mandible.

61. SUBMANDIBULAR/RISDON'S APPROACH
• Indications-
 Low neck fractures and ramal fractures
• Advantages –
 ability to distract the mandibular ramus
• Disadvantages-
 limited surgical site exposure
 difficult to reduce medially displaced condyle
 Plate and screw fixation restricted without a transbuccal trocar

62. PERTINENT ANATOMY
Marginal mandibular nerve
• It originates within the substance of parotid.
• runs forward below the angle of the mandible under the
platysma
• It lies superficial to the facial artery and anterior to facial
vein
• According to Rodel & Lang, the nerve lies almost 1. 4 to
1.74 cm from the inferior border of the mandible.
Rodel R, Lang J. Peripheral branches of the facial nerve in the cheek and chin area: Anatomy and clinical consequences. HNO. 1996;44:572–6

63. Facial artery and facial vein
• It is visible on the external surface of the mandible
around the anterior border of the masseter muscle
• The facial vein courses along the artery but lies posterior
to it and lies superficial to the gland.

64. INTRAORAL APPROACH
• Indications
 sub-condylar fractures or ramus fracture
• Advantages
 No visible scar
 No damage to the facial nerve
• Disadvantages-
 very limited access

65. CORONAL APPROACH
It is a extensive and more versatile approach to the upper and
middle regions of the facial skeleton, including the zygomatic
arch and TMJ.
Advantage
• Excellent access with minimum complications
• Scar is hidden within the hairline.
• Can be used in bilateral condylar fractures.

66. PERTINENT ANATOMY
Temporal branch of facial nerve
• The general course is from a point 0.5 cm below the tragus
to a point 1.5 cm above the lateral eyebrow.
• It crosses superficial to the zygomatic arch at an average
distance of 2 cm anterior to the anterior concavity of the
external auditory canal, but in some cases it is as near as 0.8
cm or as far as 3.5 cm anterior to the external auditory canal

67. RHYTIDECTOMY
It is a preauricular approach extended post auricularly under the ear lobe.
• Indications
 useful for procedures involving the condylar neck/head, or the
ramus itself.
• Advantage
 Less conspicuous scar
• Disadvantage
 Additional time for closure

68. PERTINENT ANATOMY
Greater auricular nerve
• Injury occurs when the dissection penetrates deep to the
sternocleidomastoid fascia over the middle portion of the
muscle where the nerve crosses the muscle belly
approximately 6. 5 cm below the caudal edge of the external
auditory canal.

69. POST AURICULAR APPROACH (ALEXANDER AND JAMES 1975)
Incision begins at superior aspect of external pinna, runs parallel and posterior
to post auricular flexure till the tip of the mastoid process.
Advantages
• Highly cosmetic incision
• Less risk of facial nerve damage
Disadvantages
• Risk of meatal stenosis
• Infections
• Limited anterior exposure

70. DIFFERENT METHODS OF OPEN REDUCTION

71. TRANSOSSEOUS WIRING
• Used in sub-condylar fractures extending through
the sigmoid notch
• Risk of damage to the maxillary artery
• Fracture segments are not stable because of the pull
from the lateral pterygoid muscle

72. K WIRE FIXATION
• A 0.0027 inch diameter K wire can be drilled vertically
through the main mandibular fragment from the angle,
avoiding the inferior alveolar bundle, so that it enters the
fracture interface and can be further inserted into the
condyle
• It provides transcortical stability
• Brown and Obeid modified this technique in 1984, in which
they used two interosseous wires to stabilize the K wire

73. BONE PINS
• Thoma (1945) had described a technique that
placed pins in the condylar neck and zygomatic
bone
• Archer (1975) described the insertion of pins into
the condylar head and neck which were connected
with an external bar and universal joints.

74. GLENOID FOSSA-CONDYLE SUTURE
• Wassmund (1935) described drilling a small hole through the lateral edge of the
glenoid fossa and the related edge of the condylar articulating surface.
• A chromic catgut suture was looped through and tied.
Drawback: can undergo resorption and result in premature loosening (Herfert 1961)

75. INTRAMEDULLARY SCREWS
• Petzel (1982) described use of an intramedullary screw
transfixing the distal and proximal fragments.
• The screw was inserted through a submandibular approach.
• Specialized instruments like tapping drills, a variety of lengths
of screws and specialized forceps are required for placing the
screws.
• Drawback: Rotation of the condylar head cannot be prevented

76. BONE PLATING
Area of tension and compression
• Throckmorton and Dechow (1994) demonstrated that the
highest levels of tensile strain occur on the anterior and
lateral surfaces, and the highest compressive strain occurs
on the posterior surface.
• Mayer et al (2002) demonstrated the presence of
compressive stress patterns along the posterior border of
the ramus and tensile stress patterns parallel and inferior to
the sigmoid notch

77. BONE PLATING
• Bone plates can be placed on a relatively small
proximal fragment first, allowing for the creation of
a handle to more effectively manipulate the
fragment into an appropriate reduction.
• Advantage: It gives higher stability and is relatively
easy to apply

78. EXTRACORPOREAL FIXATION
It involves vertical ramus osteotomy, extra oral fixation of the fractured
condyle to the osteotomy fragment, and re-fixation of the ramus
Indication
• High level fracture with medial displacement of condylar head
Advantage
• Anatomically accurate fixation
Drawback
• Avascular necrosis of ramus region
• Resorption of condyle

79. TREATMENT: ACCORDING TO AGE

80. PEDIATRIC CONDYLAR FRACTURES
• Mandible reaches its adult size by 14 – 16 years in girls and by
18 – 20 years in boys.
• Children of 7 years or younger show an increased prevalence
of dicapitular fractures, whereas children between the age of 7
– 17 years, show an increased prevalence of condylar neck
fractures.

81. CHILDREN UNDER 10 YEARS OF AGE
• This age group is more likely to develop growth disturbance or
limitation of movement
• Malocclusion following injury undergoes spontaneous correction.
• IMF is indicated for pain control and should be released after 7 – 10
days for both unilateral and bilateral fractures.
• For intracapsular fractures: careful follow up and treatment with
myofunctional appliances are instituted if mandibular growth is
reduced.

82. ADOLESCENTS 10 – 17 YEARS
• If malocclusion is present, it does not undergo spontaneous
correction as in the previous group.
• Malocclusion is corrected by IMF for 2 – 3 weeks.

83. ADULTS
Unilateral intracapsular fractures
 In case of no malocclusion, treatment should be conservative
without immobilization of the mandible.
 In case of malocclusion, treatment should be immobilization
with IMF for up to 2 – 3 weeks
Bilateral intracapsular fractures
 Malocclusion is usually present
 Treatment should be immobilization of the mandible for 3 – 4
weeks followed by physiotherapy to prevent chronic limitation
of jaw movement

84. Unilateral condylar neck fractures
• In undisplaced fractures, no treatment is necessary
• In high neck fractures with extensive displacement & malocclusion, IMF is maintained
for 3 – 4 weeks for stable bony union
Bilateral condylar neck fractures
• ORIF of at least one side to restore ramal height is desirable.
• In high neck fractures, IMF should be applied for up to 6 weeks

85. OPEN REDUCTION VS CLOSED REDUCTION

86. OPEN REDUCTION VS CLOSED REDUCTION
Hidding et al (1999) compared the 1 to 5 year postoperative findings of 20 patients treated
with ORIF to 14 who were managed conservatively. They found that deviation on opening
occurred in 64% of patients treated conservatively compared with 10% managed with ORIF.
Oezmen et al evaluated 30 patients with healed condylar fractures 6 to 24 months after
treatment. Ten were managed conservatively and 30 by ORIF. The MRI revealed 30% disc
displacement in CRMMF and 10% in ORIF
Haug and Assael (2000) reported the long-term postoperative results of 10 patients treated with CRMMF
and 10 by ORIF and found that there were no statistically significant differences between the ORIF and
CRMF groups for ranges of motion, occlusion, contour, and motor or sensory function. The ORIF group
was associated with perceptible scars, and the CRMMF group with chronic pain.

87. Ellis & Throckmorton evaluated postoperative bite forces. This investigation included 155
patients, 91 treated closed and 64 treated by ORIF and found no differences between the two
groups for maximum bite forces at any time period during the study
Ellis et al did a comparison of postoperative measures of mandibular and facial morphology in
146 patients, 81 treated by closed reduction and 65 by ORIF, The investigators found that
patients whose condylar process was treated closed had a shorter ramal height on the side of
the injury, and more tilting of the occlusal and bigonial planes toward the fractured side, than
those treated by ORIF
Ellis et al evaluated the rate of recovery of mandibular motion in 136 patients, of whom 74
were treated by closed methods and 62 by ORIF. They concluded that patients treated with
ORIF had greater mobility than those treated closed.

88. COMPLICATIONS

89. Early complications
• Fracture of the tympanic plate
• Fracture of the glenoid fossa with or without displacement
of the condylar segment into the middle cranial fossa
• Damage to facial nerve
• Vascular injury
Intra Op complications
• Damage to the facial nerve
• Excessive hemorrhage

90. Late complications
• Malocclusion
• Growth disturbance
• Temporomandibular joint dysfunction
• Ankylosis
• Asymmetry
• Non union and malunion
• Infection
• Condyle resorption
• Frey’ssyndrome

91. RECENT ADVANCES

92. ENDOSCOPY
• Instruments required
 Angled drills, a 30 degree angled 4mm endoscope, screwdrivers,
illuminating hooks and retractors
• Advantages
 minimally invasive with invisible scars
 The possibility of nerve damage during this technique is very low
• Disadvantage
 Increased operating time

93. NEWER PLATING SYSTEMS
• Three dimensional plates are considered to give more stability than the conventional two
mini plates.
Strut plate Lambda plate Trapezoidal plate

94. Bioresorbable plates
• These are strong, adaptable and provides adequate stability
• Composed of
 Polyglycolic acid
 Polylactic acid
 Polyesterpolyparadioxanon
• They resorb quickly without any foreign body reaction
• Provides adequate strength for 6 – 8 weeks and takes 12 – 18 months for
complete resorption