2. CONTENTS
• Development of condyle
• Anatomy of the condyle
• Incidence & etiology
• Mechanism of injury
• Clinical examination
• Signs and symptoms
• Classification
3. • Management options
• Criteria for Open reduction
• Surgical Considerations
a. Approaches
b. Reduction maneuvers
c. Types of Fixation
• Condyle with associated fractures
• Head fractures
• Pediatric fractures
• Delayed fractures
• Complications
• Conclusion
4. DEVELOPMENT
• Meckel’s cartilage
• Intramembranous
ossification
• Condensation of
mesenchyme just lateral
to Meckel’s cartilage
• Cartilage disappears as
bony mandible develops
5. Anatomy of condyle
• Represents inferior articular surface of
TMJ
• Its axis is perpendicular to ramus, to
which connected by thin neck (collum)
• Oblique directed medially and slightly
backwards, forming angle of 25◦ with
frontal plane
• Surface is convex & displays 3 parts from front to back
1. Front- fossa of lateral pterygoid muscle
2. Anterior slope of condyle, inlined at angle of 45◦ from
horizontal & meeting the temporal articular tubercle
3. Back – posterior side of condyle, which descends 5mm
beneath the apex or rounded crest separating the two
slopes
6. • Has 2 poles – lateral & medial to
which disc is attached with strong
ligaments
• Average dimensions of condyle:
AP 8.5 mm & ML 21mm
• Collum that it supports is 10mm
AP & 7mm ML diameter
• Base is 22mm in sagittal AP & only
5mm in transverse diameter-
extremely fragile & vulnerable to
# in adults
7. 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 Less common
Remodelling capacity
following trauma
Present Absent
Disturbance in
growth
Likely Rare
8. Blood Supply
• Branches from Superficial
temporal artery
• Deep auricular artery-
branch of maxillary artery
Venous drainage
Superficial temporal vein
10. Incidence
Haug, R. H., Prather, J., & Thomas Indresano, A.
(1990). An epidemiologic survey of facial fractures
and concomitant injuries. Journal of Oral and
Maxillofacial
11. Etiology
• Trauma
• Motor vehicle accident
• Interpersonal violence
• Fall from heights
• Ballistic injuries
• Pathological process
12. Rowe & Williams Vol 1
MECHANISM OF INJURY
As Proposed by Lindahl in 1977
13. Clinical Examination
• Preauricular pain & swelling
• Restricted mandibular excursion
• Deviation on ipsilateral side on
opening
• Posterior gagging of occlusion
• Anterior open bite
• Laceration of EAC – ear bleed
• CSF rhinorrhea & otorrhea with
associated skull base #
16. Radiographic Evaluation
• Conventional – reverse townes & Panoramic
• CT – gold standard
diagnostic accuracy CT 90 % , OPG 73 %
Chacon GE, A comparative study of 2 imaging
techniques for the diagnosis of condylar fractures in
children. J Oral Maxillofac Surg. 2003
17. • Other Adjunct investigation
• MRI- assess non osseous TMJ & disc
• CT Angiography - close relationship of condyle
with ICA
• When foreign body is close to maxillary artery
mean distance between the artery and the
medial border of the subcondylar portion of
the mandible was 6.8 mm
Orbay 2007 ,Maxillary Artery: Anatomical Landmarks and
Relationship with the Mandibular Subcondyle. Plastic and
Reconstructive Surgery
18. Classification
• Displacement – shifting between fracture bony
fragments
• Dislocation –shifting between components of
TMJ
• Proposed by Loukota et al 2005 & as adopted by
Strasbourg Osteosynthesis Research
Group(SORG)
19. Wassmund -1934
• Type I – 10◦ to 45◦ angulation of condylar head with
bony contact between the fragments. Reduce
spontaneously
• Type II – 45◦ to 90 ◦ angulation of condylar head with
slight bony contact between the fragments. Tearing of
medial portion of joint capsule
• Type III – Severe medial displacement with no contact
between the bony fragments. Open reduction
advocated.
• Type IV – Fractured head articulates on/ forward to
eminence
• Type V – Vertical / oblique # through head of condyle -
rare
20. MacLennan 1952
• Class I: no deviation (bending)
• Class II: deviation (bending) at the fracture
level
• Class III: displacement (condylar head remains
within fossa)
• Class IV: dislocation (condylar head outside of
fossa)
21. Rowe and Killey, 1955
• Intracapsular fractures
• Extracapsular fractures
• Fractures associated with the TMJ capsule,
TMJ ligaments, articulating disk, and bony
structures surrounding the TMJ
22. Dingman and Natvig , 1964
• High condylar neck fracture: fracture line is at or
above the level of the lateral pterygoid
attachment on the fovea of the condylar
apparatus
• Intermediate condylar neck fracture: fracture
line is below the level of insertion of the lateral
pterygoid
• Low condylar neck fracture: fracture begins at or
below the sigmoid notch and extends to the
posterior border of the mandibular ramus
23. Spiessl and Schroll, 1972
• Type I: condylar neck fracture
without deviation / displacement
• Type II: low condylar neck fracture
with deviation/displacement
• Type III: high condylar neck
fracture with deviation /
displacement
IIIa: ventral
IIIb: medial
IIIc: lateral
IIId: dorsal
24. • Type IV: low condylar neck
fracture with dislocation
• Type V: high condylar neck
fracture with dislocation
• Type VI: intracapsular
fracture of the condylar
head
26. • 2: Relationship of condylar fragment to mandible
2a: angulation with medial override
2b: angualtion with lateral override
2c: angulation without override
2d: nondisplaced / fissure #
• 3: Relationship of condylar head to fossa
no displacement (0)
slight displacement (1)
moderate displacement(2)
Dislocation (3)
27. Ellis et al, 1999
• Condylar head fracture:
intracapsular fracture
• Condylar neck fracture:
fracture below the
condylar head, but on or
above the lowest point
of the sigmoid notch
• Condylar base fracture:
fracture in which the
fracture line is located
below the lowest point
of the sigmoid notch
28. Loukota et al -2005, SORG
• Diacapitular fracture: the fracture line starts in
the articular surface and may extend outside the
TMJ capsule
• Condylar neck: the fracture line starts
somewhere above Line A and runs above Line A
for more than half of its length
• Condylar base: the fracture line extends behind
the mandibular foramen and runs below Line A
for more than half of its length
• Minimal displacement: displacement of less than
10 or overlap of the bone edges by less than 2
mm, or both
29. Dicapitular FractureLine A- perpendicular line through the
sigmoid notch to tangent of the ramus
Condylar neck fracture Condylar base (subcondylar) fracture
30. AO modification of Ellis ,2010
Line 1- parallels the posterior border
of mandible
Line 2- runs perpendicular to line 1
at deepest portion of the sigmoid
notch
Line 3- below lateral pole of
condylar head, also perpendicular to
line 1
A line is drawn half way between
the lateral pole line and the sigmoid
notch line
“high-neck” # is above this line,
“low-neck” # is below the line
31. MRI based classification 2018
A- without loss of ramal height – no disk displacement
B- without loss of ramal height – with disk displacement
C – with loss of ramal height – regardless of disk
Ying et al. BJOMS(2018)
32. Management
• Non surgical/ conservative
1. Observation
2. Functional ( training with elastics )
3. Closed management (MMF)
• Surgical - ORIF
34. 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 temporomandibular
joint on the injured or the contralateral side.
7. Avoid the long-term complication of growth
disturbance.
Peterson 2nd edition
35. Indications for ORIF
Zide and Kent’s indications for open reduction (1983)
For Both Adults & Children
Mainly for Adults
36. Mathes Treatment protocol 1983
OPEN REDUCTION
• Malocclusion with CR
• Fragment angulation:
> 30°
• Bone gap: ≥ 4-5mm
Lateral override
• Lack of contact of #
fragment
PREFERRED FOR OPEN REDUCTION
• Any low, dislocated subcondylar #
• Low condylar # with multiply mandible
/ Le Fort #
• Low condylar # with head out of fossa
• Condylar fragment 14°- medial tilt
• Ramus shortening - 5%
• Bilateral fracture with open bite
• Gross fracture end mal-alignment
• Fracture – dislocation
• Abnormal function, malocclusion
37. Management of subcondylar # base on
SORG (2007)
• Two proven indication
1. Ramus Height shortening
2. Displacement of condyle
•Class 1 – Closed reduction
ramus shortening <2mm,
displacement <10o
•Class 2 – ORIF
ramus shortening 2-15mm,
displacement 10o to 45o
•Class 3 – ORIF
ramus shotening > 15mm,
displacement >45o
38. Nonsurgical Management
• Functional Training with elastics
• Neuromuscular adjustment for
proper occlusion
• For period of 4-6 weeks
Unilateral #
1-2 class II elastics on fractured site
to draw mandible anteriorly.
Less elastics to promote active use
of mandible
Bilateral #
B/L class II elastics with vertical
elastics anteriorly
Complete elastics at night
Condylar Process Fractures of the Mandible
Edward Ellis III, Facial plastic surgery clinics 2000
39. • Goals
MO > 40mm, without deviation
Lateral excursions >10mm
Protrusive excursions >5mm
• Weaning from elastics
2-3 weeks: Obtain pre traumatic occlusion
Next 2-3 weeks : Used only while sleeping
Arch bars left in place
U/L – 2 months
B/L – 3 months
Functional Training with elastics
40. MMF Period for Condylar #
• Recommended period: 7 days – 6 weeks
• Children: 7-10 days ( to prevent ankylosis )
Killey’s Fractures of Mandible 3rd Edition
41. Closed management Maneuvers
• Hypomochlion : Hypo- small, Mochlion - lever
Thelekkat, Yeshaswini & Aravindakshan, shyam mohan. (2014). Hypomochlion
aided reduction for sub-condylar fractures. Kerala dental journal
Class III Lever
42. AAOMS Parameters of Care 2017
Closed reduction
• Nondisplaced/displaced #
where from/function can be
restored
• # dislocations / comminution
in growing child where
form/function can be restored
• Medical contraindications to
ORIF
Open reduction ( including
Endoscopic )
• # dislocation of condyle
• Mechanical interference with
function
• # with loss of AP & vertical
dimension that cannot be
managed by closed reduction (eg,
edentulous patient, multiple facial
fractures)
• Compound #
• Displacement into middle cranial
fossa
• Patient/surgeon preference
• Prevention of Complication of
MMF
Ochs, M., Chung, W., & Powers, D. (2017). Trauma
Surgery. Journal of Oral and Maxillofacial Surgery
43. Surgical Considerations
1. Ramus must be distracted.
2. Proximal condyle must be controlled &
manipulated.
3. # must be anatomically reduced & plated with
more than one screw on the proximal
segment
45. 1. Preauricular approach
• Indications
– Wire fixation of high, anteromedially
displaced proximal fragment
• Advantages.
– access to superiormost portion of joint.
• Disadvantages.
– not indicated for placement of plate and
screw fixation.
– no access to distract the ramus inferiorly;
– osteosynthesis plate placement extremely
difficult
– increased risk of necrosis of condyle
46. • Incision: skin fold along the entire
length of ear
• Dissect along anterior portion of EAC
to avoid damage to the superficial
temporal vessels and
auriculotemporal nerve
• Incise the superficial layer of the
temporalis fascia just anterior to the
tragus at the zygoma, continuing in
antero-superior direction
• Oblique incision made through
capsule near root of zygoma to enter
joint capsule & Condylar #
48. 3. Submandibular Approach
• Indications
– axial anchor screw fixation.
• Advantages
– ability to distract mandibular ramus
and direct access of the gonial angle.
• Disadvantages
– limited surgical site exposure (the
incision is distant from the fracture),
– difficult to reduce medially displaced
condyles
– plate and screw fixation restricted
without a transfacial trocar.
49.
50. Retromandibular Approach
• Indications
– any fracture that is large enough to be
reduced and stabilized by ORIF using
plates and screws.
• Advantages.
– best access to the fracture site
– no need for a transfacial trocar
– facial scar is less noticeable than
submandibular incision
– effective in patients with edema
– access for an osteotomy if required
• Disadvantages
– scar is more noticeable than with a
preauricular incision.
51. Rhytidectomy Approach
• same access as that of the
retromandibular approach,
with better cosmesis.
• This approach must be
drained with closed suction
drainage postoperatively
52. TransMasseteric anteroparotid
Approach ( Peri-angular )
• Indications
– provide access to high & low
subcondylar and ramus fractures
• Advantages
– quick and direct access to fracture sites
for direct plating and screw fixation,
– with excellent exposure and the ability
to distract mandibular ramus because of
access to the gonial angle,
– better access
• Disadvantages
– a visible scar that is more noticeable
than with the other approaches and
there is potential damage to the facial
nerve.
53. • Make the incision at the line
connecting the intersections of
the last third on the posterior
ramus line and first third on the
inferior border line, the
intersection closest to the gonial
angle in each direction
• The initial incision is to the depth
of the parotidomasseteric fascia
(SMAS), followed by extensive
subcutaneous undermining in all
directions to allow for maximal
exposure.
54. Intraoral Approach
• Indications.
– low subcondylar fractures.
– Axial anchor screws /miniplate fixation may
be used.
• Advantages.
– visible scar avoided & damage to facial nerve
is minimized.
• Disadvantages
• Intraoral Approach without Endoscope.
– poorest access of all the approaches,
– difficult to ascertain the adequacy of
reduction
– high rate of complications.
• Endoscope-Assisted Intraoral Approach.
– More time-consuming, steep learning curve,
– poor visibility of the posterior ramus,
– difficulty in reducing certain fracture types
56. Matching fracture type to surgical
access
Emam ,Matching Surgical Approach to Condylar Fracture Type.
Atlas of the Oral and Maxillofacial Surgery Clinics (2017)
57. • Most important
factor in determining
approach used: Level
of Fracture
• Modifying Factors:
Degree of
displacemennt or
dislocation
Time elapsed after
trauma
58. Approaches
A. Displaced, not dislocated
1. Base # : High submandibular incision/
endoscopy assisted
2. Neck : Retromandibular
3. Head : Preauricular
B. Dislocated
Approach : One level Higher
C. Mal-united at any level
Preauricular ± Combination
59. Condyle Fixation Techniques
Single Miniplate Double MIniplate Indirect Lag screw- Kernel
Direct Lag screw -
Brown
K wire- Stephenson
& Graham
Trans osseous
wiring - Masser
Lag screw &
Pin- Rasse
60. What is Ideal Fixation ?
Meyer’s Line of Osteosynthesis
Christopher Meyer
J Cranio-Maxillofac Surg 2002
Single Miniplate
Center/ Long axis of condyle
Close to Posterior Border
Two Miniplates
In Triangular Fashion
1st plate below Sigmoid Notch
2nd plate Along Posterior Border
Fixation with specific
implants for the
subcondylar region.
61. What to do first ?
Dentate First
More force needed to
distract mandible
Condyle First
Less force needed to distract
mandible
Condyle reduction is easier
62. Inferior Distraction of Ramus
• Manual Method – with surgeon’s hand intraorally
• Instruments – Allies, Towel clip
• Specialised retractors
• Screw with wire in 16 G Cannula
63. Bilateral Condyle Fractures
Problems:
●Mandible in 4 pieces ● ↑ intergonial width
● Lingual splay ● Flaring of Rami
Chen, Functional outcomes following surgical treatment
of bilateral mandibular condylar fractures. IJOMS (2011)
64. 1. Ellis Maneuver
Facial width problems associated with rigid fixation
of mandibular fractures: Case reports. JOMS, Ellis, E.,
& Tharanon, W. (1992).
65. 2.Muselet Technique
Temiz (2015) A useful method for the reduction of laterally displaced
mandibular condyles: The muselet technique. Journal of Plastic,
Reconstructive & Aesthetic Surgery
66. What if Head # is not treated ?
• TMJ internal derangement
• Bifid condyle
• Ankylosis
• Asymmetry
• Restricted / painful mouth
opening
• Functional remodelling of
condyle
67. Classification of Head #
• Neff, 2002
A : Medial
B : Lateral
M: Comminuted
• Dongmei He, 2009
A :Lateral, with ramal height reduction
B :Middle, without
C : Medial, without
M : Comminuted
He, D (2009). Intracapsular Condylar Fracture of the
Mandible: Our Classification and Open Treatment
Experience. JOMS
68. Treatment of Condylar Head #
• Type A – Open
• Type B – Closed in most cases ( fragment small
& deep)
• Type C – Closed / Removal of fragment
69. Injury to Articular apparatus
• Effusion : Hemorrhagic or serous
• Soft tissue injury : Disk
Capsule
Ligaments
• Dislocation of the condyle from the fossa
Without fracture
With fracture other than condyle
With associated condylar fracture
• Fracture
Non-displaced Dislocated
Deviated Comminuted
Displaced Involving adjacent bony structures
• Combinations of the above
Peterson 2nd Edition
70. MRI based articular soft tissue injury
• Grade I - hemarthrosis only – best outcome
• Grade II - hemarthrosis and disc displacement
• Grade III - hemarthrosis, disc displacement &
capsular tear
• Grade IV - disc perforation in association with
Grade I,II or III
All fractures managed non-surgically, 100 % had
restricted joint movement & joint noise
Tripathi (2015). 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. JOMS
71. Pediatric Condylar Fractures
Concerns :
• Imaging problems
• Early management &
long term follow up
• Protocol of IMF
• 2nd surgery for
hardware removal
• Growth disturbance
• Ankylosis
• RESTITUTIONAL
REMODELING – Role
of Condylar Cartilage
72. Grunwaldt et al,Pediatric facial fractures: demographics, injury
patterns, and associated injuries in 772 consecutive patients. Plast
Reconstr Surg 2011;
73. Costello (2012). Growth and Development Considerations for Craniomaxillofacial
Surgery. Oral and Maxillofacial Surgery Clinics of North America
75. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open
ReductionVs Closed Reduction, Choi et al , Archieves of Plastic Surgery 2012
76. Mal-united Condylar fractures
• Malocclusion
• Reduced bite force
• Deviation in mouth
opening
• Asymmetry due to loss
of ramus height
• Temporal & masseteric
pain- hypertonic facial
muscles
• TMJ dysfunction
• Ankylosis
Common causes :
• Closed management
• Mismanaged primary
ORIF
77. Time elapsed
after trauma
Recommended treatment Author
< 3 months Conservative treatment Ellis E, Walker
RV Craniomax
Trauma Recon
2009
> 3 to 6
months
Sub-condylar osteotomy Chenn, Ann
Plast Surg
2013
> 9 months Normal Ramus Orthognathic
Surgery
Ellis E, Walker
RV 2009
Comminuted
ramal # or
Shortening of
Ramus height
TMJ
Reconstruction
79. Objectives of Sialocele management
1. Reduce secretion
To facilitate rapid healing
• Nil per oral
• Avoid tangy food
• Local injections
• Hypertonic saline
• Botox
• Systemic drugs
• Scopolamine patch
2. Reduce dead space &
approximate tissues
To eliminate space for saliva
collection
• Repeated aspirations
• Pressure dressing
3. Induce Fibrosis
• To strengthen tissues around
salivary pool
• To block outflow through
subcutaneous tissues -
Sclerosants
4. Divert secretions into oral
cavity
• Surgical procedures
80. Conclusion
• Paradigm shift in century old tradition of non surgical
treatment of condylar #
• Improvement in
CT Diagnostics
Indication specific Osteosynthesis – 3D plates & resorbable
systems
Newer approaches
• Recent consensus on improved evidence
IBRA 2012
AAOMS Parameters of Care 2017
• ORIF – Gold standard in base & neck # in adults
• Endoscopic approach for base with lateral lateral displacement
• Growing tendency to open Head #
• ORIF displaced/ dislocated # in children with mixed dentition
