This document provides an overview of condylar fractures, including: - The surgical anatomy of the temporomandibular joint region. - Common mechanisms of injury that can cause condylar fractures. - Several classification systems used to describe different types of condylar fractures. - Clinical examination findings and various radiologic imaging modalities useful for diagnosing condylar fractures. - Considerations for treatment and complications that can arise from condylar fractures.

1. CONDYLAR FRACTURES
MALIK ASHIM
FINAL YEAR
SDS, SHARDA UNIVERSITY

2. CONTENTS
Introduction
Surgical anatomy
Mechanism of injury & biomechanical
considerations
Classification of Condylar fractures
Clinical features - examination
Radiologic imaging modalities
Treatment considerations
The controversies in treatment
Special considerations
Complications
Summary & conclusion
References

3. INTRODUCTION
“Fracture of the condyle can sometimes be the
consequence of an indirect blow…. the head of the
condyle is forced against the prominent margins
of the glenoid cavity; and sometimes from a direct
blow …..and impinges upon this part of the
bone…… it is usually observed to occur in the
narrow section which supports the condyle, and
below the insertion of the external pterygoid”
Desault, Oeuvres Chirurgicales (1830)

4. INCIDENCE
1.3%1.3%
33.4%33.4%
17.4%17.4%
33.6%33.6%
Oikarinen & Malmstrom- Percentage occurrence of
fracture based on site of occurrence -1969

5. INCIDENCE
Luyk NH - 1992Luyk NH - 1992

6. FORCE REQUIRED
Nahum et al 1975,
Line of force through the symphysis and TMJ
A single subcondylar fracture at 193 kg(425 lb)
A bilateral subcondylar fracture at 250 kg (550 lb)
Symphyseal fractures – b/w 250 and 408 kg (800-900lb)

7. SURGICAL ANATOMY

8. SURGICAL ANATOMY - RELATIONS
CoronalCoronal AxialAxial

9. SURGICAL ANATOMY

10. SURGICAL ANATOMY
In 1979, studies were conducted on 56 cadaveric facial halves by
Al-Kayat and Bramley - the temporal branches lie within 0.8 – 3.5
cm (average of 2 cm) anterior to the greatest anterior concavity of
the external auditory canal

11. SPECIAL ANATOMIC FEATURES
The blood supply of the mandibular condyle –
Joint Capsule:
Terminal branches of:
Superficial temporal artery
Deep temporal artery
Posterior tympanic artery
Transverse facial artery
Lateral pterygoid muscle:
Branches of the deep temporal artery along the lateral pterygoid muscle

12. SPECIAL ANATOMIC FEATURES
The position of the mandibular foramen
Lingula orAnte lingula - anatomic guide
11.2 mmaway fromthe posterioredge of the mandibularramus
21.3 mmbelow the lowest point of the sigmoid notch
Point for surgical repositioning
The vascularsupply to the lateral dorsal edge is relatively less
The structure of the mandibular bone
 Structural analyses of fractured mandibularfragments - great variationin
the condylarneck
 On rare occasions the condylarneckis so thinthat thereis no cancellous
bonebetweenthe cortical plates
 The narrowest place of the condylarneckis 4.9 mm ( avg)

13. DIFFERENCES IN ADULT AND PEDIATRIC
CONDYLES

15. ParameterParameter ChildChild AdultAdult
11 Cortical boneCortical bone ThinThin ThickThick
22 Condylar neckCondylar neck BroadBroad ThinThin
33 Articular surfaceArticular surface ThinThin ThickThick
44 CapsuleCapsule Highly vascularHighly vascular Less vascularLess vascular
55 PeriosteumPeriosteum Highly active– inHighly active– in
osteogenic phaseosteogenic phase
Less active inLess active in
latent stagelatent stage
66 Intracapsular fracture &Intracapsular fracture &
hemarthrosis.hemarthrosis.
Very commonVery common RareRare
77 Remodelling capacityRemodelling capacity
following traumafollowing trauma
PresentPresent AbsentAbsent
88 Disturbance in growthDisturbance in growth LikelyLikely N.AN.A

16. MECHANISM OF FRACTURE
Whyshouldweknow this?
Simplifies diagnosis
Helps surgeon to lookforparts of the mandible most likely to
fracture
About two thirds of all temporomandibular joint fractures' are
associated with otherfractures of the mandible
Condylarfractures are mainly due to an indirect injury
They seldom arise from direct trauma, unless accompanied by a
zygomatic arch fracture.

17. MECHANISM OF
FRACTURES
Factors influencing the fracture sites
Occlusion
Whethermouth was open orclosed during
impact
Direction of the impact
Amount of force applied

18. MECHANISM OF FRACTURES
Afew commoninjurypatterns
 A direct blow to the TMJregion – fracture of condyle
 A blow to the mandibularbody in a horizontal direction –
ipsilateral body & contralateral condyle fracture
 A force on the parasymphysis region can cause ipsilateral or
bilateral condylarfracture as well as localized parasymphysis
fracture
 An axially directed force to the parasymphysis – bilateral
Condylarfracture with symphyseal orparasymphyseal fracture
It can furtherbe associated with fracture of the glenoid fossa
with penetration into the middle cranial fossa orfracture of
the tympanic plate causing damage to the external acoustic
meatus

19. BIOMECHANICAL
CONSIDERATIONS
Force along the mandibular arch –fracture at weakest areas
the condylar necks

20. GENERAL NATURE OF INJURY - ROWE
& WILLIAMS
Three main groups
1. Contusion of the soft tissues of
the joint
2. Fractureof the condyle
3. Fracture-Dislocationof the
condylarhead fromthe glenoid
fossa
Combination of the above can
also be seen and should be ruled
out before furthertreatment
options are being considered

21. MECHANISM OF INJURY
According toLindahl, the forces causing damage to the
joint are of three main types
1. Kinetic energy imparted by a moving object through the
tissues of a static individual. Ex by a fist, cricket bat orball

22. MECHANISM OF INJURY
2. Kinetic energy derived fromthe moving individual striking a static object
E.g. A child slipping and striking the pavement ora fall during an epileptic fit
orparade ground fracture

23. MECHANISM OF INJURY
3. Kinetic energy, which is the sumof, forces due to
combination of factors 1 and 2
Ex RTA where a person in a moving carstrikes his chin
across the dashboard

24. CLASSIFICATION OF CONDYLAR
FRACTURES
Rowe & Killey’s classification (1968)
1. Intracapsularfracture - high condylarfracture
Involving the articularsurface
Fracture through the neck
2. Extracapsularfracture - low condylarfracture
3. With injury to the capsule, ligament and meniscus
4. Involving the adjacent bone

25. CLASSIFICATION OF CONDYLAR
FRACTURES
McLennan Classification: 1952 – Clinical Classification
Type I: No displacement
Type II: Fracture deviation – simple angulation of the fracture segments
without overlap or separation. Ex. Green stick fracture in children
Type III: Fracture displacement –when there is overlap of fracture
fragments. This overlap may be in an anterior, posterior, lateral or medial.
Medial is commonest.
Type IV: 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.
Type V: High condylar fracture with luxation
Type VI: Head fracture or intracapsular fracture

26. FRACTURE
DISLOCATION
5mm
30 deg

27. CLASSIFICATION OF CONDYLAR
FRACTURES
Condylarneckfractures classification - Spiessl & Schroll
Type I Condylarneckfracture without serious dislocation
Type II Deep-seated Condylar neck fracture with
dislocation
Type III High Condylarneckfracture with dislocation
Type IV Deep-seated Condylarneckfracture with luxation
Type V High Condylarneckfracture with luxation
Type VI Head orintracapsularfracture

28. CLASSIFICATION OF CONDYLAR FRACTURES
Lindhal’s classification: Comprehensive classification (1977)
Lindahl proposed a classification based on several factors namely
Theanatomic locationof thefracture
Therelationof thecondylarsegment to themandibularsegment
Therelationof thecondylarheadtothearticularfossa
1. Depending on fracture level
i. Condylarhead #
ii. Condylarneck#
iii. Subcondylar#

29. CLASSIFICATION OF CONDYLAR
FRACTURES
i.i. Undisplaced (fissure fracture) (B)Undisplaced (fissure fracture) (B)
ii.ii. Deviated –Deviated – simple angulations of the condylar process in i.r.tsimple angulations of the condylar process in i.r.t
distal mandibular segment without overlap.distal mandibular segment without overlap.((C)C)
iii. Displaced with medial overlap (D)iii. Displaced with medial overlap (D)
iv. Displaced with lateral overlap (E)iv. Displaced with lateral overlap (E)
v. Antero-posterior overlapv. Antero-posterior overlap – possible but are seldom seen.– possible but are seldom seen. (F)(F)
vi. Without contact between fragments (G)vi. Without contact between fragments (G)
2.. The relation of the condylar segment to the mandibular segmentThe relation of the condylar segment to the mandibular segment

30. CLASSIFICATION OF CONDYLAR FRACTURES
3.The relation of the condylar
head to the articular fossa
i. No displacement- condylar head appears
in normal relation with fossa
ii. Displacement- condylar head is in fossa
but there is alteration of joint space. Joint
space is increased
iii.Dislocation- the condylar process is
completely out of the fossa.

31. CLINICAL EXAMINATION- EXTRA ORAL
Inspection
Swelling
Preauriculardepression
Ecchymosis
Lacerations
Facial asymmetry
Pain on jaw mobilization
Deviation on opening
Earbleed
CSF otorrhoea
Battle sign
Patient interview regarding pain and disturbedPatient interview regarding pain and disturbed
masticationmastication..

32. CLINICAL EXAMINATION- EXTRA ORAL
Position : The clinician begins the examination from
behind the seated orsupine patient
Inability to open jaws
Tenderness associated with crepitation
A limited range of motion
A significant deviation on opening –
(same side)
Otoscopic evaluation
Firm posteriorpressure on the chin will
cause pain in the preauricularregion
PalpationPalpation

33. CLINICAL EXAMINATION – INTRA
ORAL
Malocclusion
Fracture of the dentition
▲ or in inter-incisal▼
opening
Premature occlusal
contacts
Anterioropen bite
Posteriorgagging of
occlusion
Lateral deviation of
more than 2 mm
when opening the
mouth
Effusion/ Hemarthrosis of left joint space

34. Bilateral condylar fracture
Anterior open bite with
disto-occlusion
Unilateral condylar
fracture
Posterior open bite with
jaw deviation to affected
side.

35. CLINICAL EXAMINATION – SUMMARY
Clinical signs to look for and to rule out -
Fonseca
• Evidence of trauma
• Bleeding from the external auditory canal
• A noticeable or palpable swelling over the TMJ
• Facial asymmetry as a result of edema or ramal shortening
• Pain and tenderness
• Crepitation
• Malocclusion
• Deviation of the mandible
• Muscle spasm (“splinting”) with associated pain and limited
mouth opening
• Dentoalveolar injuries

36. RADIOLOGIC DIAGNOSIS: AVAILABLE
OPTIONS
1. Plain radiographs
View in two dimensions
Orthopantomogram view
Posterior-anteriorview
2. Computed tomography
To be able to exclude head orintracapsularfractures and particularly if
surgical treatment is planned, it is imperative that the fracture line be
demonstrated in a coronal CT scan
3. Magnetic resonance imaging
Diskposition can be shown by means of MRI
GRASS
4. Ultrasonography
Limited use – only can tell presence of fracture in TMJregion

37. PLAIN RADIOGRAPHS
At least two views at right angles to each other are
necessary – OPG & Reverse Towne’s view
In the multiple-trauma patient for whom OPG not
possible, lateral oblique views may be substituted
Other radiographic views that may be useful
depending on the circumstances are
posteroanterior mandibular
mandibular occlusal
periapical
Limitation
Intracapsular fractures of the condylar head are
often difficult to visualize accurately on plain films

38. ORTHOPANTOMPOGRAPH & LATERAL
OBLIQUE VIEWS
Antero-posterior planeAntero-posterior plane
Centered on condylesCentered on condyles
Open mouth – if possibleOpen mouth – if possible
Low sub-condylar #
High sub-condylar #/ condylar
neck #

39. Lateral skull radiograph
shows condylar head lying horizontally with
its
articulating surface directed anteriorly
(arrows).

40. TRANSCRANIAL & TRANSORBITAL
VIEWS
Mouth closed
Mouth open
Mainly TMJ pathologiesMainly TMJ pathologies
Intracapsular fractures orIntracapsular fractures or
dislocation ofdislocation of fracturedfractured
fragmentfragment

41. Reverse Towne’sReverse Towne’s
Mediolateral planeMediolateral plane
RT’s view- better visualizationRT’s view- better visualization
DO NOT confuse marginal process of frontal bone for condyleDO NOT confuse marginal process of frontal bone for condyle
Towne view of the
left condylar fracture.
Towne view shows that the left
condylar fracture is comminuted and

42. POSTERO-ANTERIOR VIEW

43. COMPUTED TOMOGRAPHY
Indications forCT scans
1. Significant displacement ordislocation
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 otherprocesses, such as
previous internal derangement orTMJ
surgery, to the degree that a
pretreatment baseline is necessary
4. Inability to position the multi- trauma
patient forconventional radiographs
Coronal CT scan demonstrating
bilateral high condylar fractures.

44. Three-dimensional computed tomography
reconstruction of a triple mandibular fracture
with intracapsular fractures of the mandibular
condyles, as well as an oblique fracture in the
right mandibular body.

45. Coronal computed tomography scans depicting
unilateral diacapitular fractures of the condylar head
with concomitant fractures of the condylar neck on the
contralateral side (A and B).