Condylar fractures

CONDYLAR FRACTURES
PRESENTED BY –
DR. SWATI SAHU, OMFS
1

CONTENTS
 Introduction
 Surgical anatomy of condyle
 Blood supply
 Nerve supply
 Child vs adult condyle
 Aetiology of condylar fractures
 Predisposing factors
 General nature of injury
2

 Mechanism of injury
 Incidence of fracture
 Classification of condylar fractures
 Clinical examination in diagnosis
 Imaging techniques in diagnosis
 Clinical features
 Management
 Specific treatment of condylar fractures
 Complications of condylar injuries
3

INTRODUCTION
 Condylar and subcondylar fractures constitute
26-40% of all mandible fractures
 Given the unique geometry of the mandible and
temporomandibular joints (TMJs), these
fractures can result in marked pain, dysfunction,
and deformity if not recognized and treated
appropriately.
 Condyle is a major growth center for the
mandible
4

SURGICAL ANATOMY OF
CONDYLE
 Elliptical in shape, long axis angled backwards between 15-
33 degree to frontal plane.
 Long axis of 2 condyles meet at basion on anterior ligament
of foramen magnum forming an angle 0f 145-160 degrees.
 Mediolateral width: 15-20 mm
 Anteroposterior width: 8 - 10mm
 Lateral pole: roughened, bluntly pointed.
 Medial pole: rounded, extends from plane of ramus
 Fibrous layer thin on posterior aspect and thick over convexity
5

BLOOD SUPPLY
 Superficial temporal artery
 Transverse facial artery
 Posterior tympanic artery
 Posterior deep temporal artery
6

NERVE SUPPLY
 Facial nerve
 Auriculotemporal nerve
7

THREE LINES ARE USED TO DEFINE THE
SUBREGIONS (AO)
1. The first line parallels the posterior border
of the mandible
2. The sigmoid notch line runs perpendicular
to the first line at the deepest portion of the
sigmoid notch
3. A line below the lateral pole of the condylar
head that is also perpendicular to the first
line.
9

The neckregion can be divided intohigh andlow halves by equallydividingthe distance
betweenthe sigmoid notch line and thelateral pole line. 10

AETIOLOGY OF CONDYLAR
FRACTURES
1. Intentional trauma —
interpersonal violence/fist fight, etc.
2. Unintentional trauma —
motor vehicular accidents, fall on the chin, sports injuries, industrial mishaps,
etc.
11

GENERAL NATURE OF INJURY
 Type of injuries in the TMJ can be separated into 3 main groups –
1. Contusion -
Contusion of the soft tissues of the joint, which may involve either an avulsion of soft
tissues, such as the ligaments, the synovium and the muscular attachment of the lateral
pterygoid; or an effusion causing the formation of an inflammatory exudate or a
haemarthrosis. Rarely, such an effusion may be complicated by an infection resulting in
pyarthrosis.
The meniscus acts as a cushion or barrier between the articular surfaces and, in the adult,
where this structure has been torn, osteoarthritic changes may ensue.
13

2. Dislocation of the condylar head from the glenoid fossa is usually in an
anterior direction, but the displacement can be central, posterior or on rare
occasions, lateral.
3. Fracture of the condyle itself, either within the capsule involving the head
or neck or outside the capsule in the subcondylar region.
14

MECHANISM OF INJURY
Lindahl (1977) divided trauma causing condylar injury
into three main groups
1. Kinetic energy imparted by a moving object through
the tissues of a static individual. This commonly results
from trauma sustained from a fist, during sporting
activities or in the course of some industrial accidents.
15

2. Kinetic energy derived from the movement of the
individual and expended upon a static object. This is
exemplified by a fall during an epileptic fit or
following a faint when the patient is unable to
protect the face with an outstretched hand as in the
case of the so-called 'parade-ground' fracture .
16

3. Kinetic energy which is a summation of forces
derived from a combination of (1) and (2) and,
therefore, generally produces a more severe type of
injury such as typically occurs in a road traffic
accident.
17

INCIDENCE OF FRACTURE
 According to most large series reported in the literature, fractures of the mandibular condyle account for 26% to
57% of all mandibular fractures.
 The male-to female sex ratio ranges from 3 : 1 to 2 : 1 depending on which population is studied.
 Between 48% and 66% of patients with condylar fractures also have a fracture of the mandible body or angle.
 Approximately 84% of condylar fractures are unilateral, and the most common causes are interpersonal violence,
sports injury, falls, and road traffic accidents.
 According to Silvennoinen et al., approximately 14% are intracapsular, 24% condylar neck, 62% subcondylar, and
16% associated with severe displacement.
 The highest incidence of fractures is seen in patients between 20 and 39 years of age.
19

CLASSIFICATION OF
CONDYLAR FRACTURES
20

I. GENERAL CLASSIFICATION
I. Unilateral or bilateral condylar fractures
21

II. ROWE’S & KILLEY CLASSIFICATION
a. Simple fractures of condyle
b. Compound fractures of condyle
c. Comminuted fracture associated with zygomatic arch fractures
22

III. BROPHY CLASSIFICATION (1915)
ACCORDING to Location &Direction of fracture:
• From above, downward &inward or reversed
• From above, backward &downward
23

IV. WASSMUND’S CLASSIFICATION (1934)
a. Type I: Fracture of the neck of the condyle with slight displacement
of the head. The angle between the head and the axis of the ramus
varies from 10 to 45 degrees. These type of fractures tend to reduce
spontaneously.
b. Type II: An angle of 45 to 90 degrees is seen between the head and
the ramus. There is tearing of the medial portion of the joint capsule.
c. Type III: The fragments are not in contact. Head is displaced
medially and forward due to the pull of lateral pterygoid muscle and
spasm. The fragment is generally confined within the area of the
glenoid fossa. The capsule is torn and head is outside the capsule. Open
reduction is advocated.
d. Type IV: Fractured head articulates on or forward to the articular
DISLOCATED FRACTURE
24

V. THOMA CLASSIFICATION (1948)
A. Condylar fractures
i. Without displacement of condyle
• Greenstick fracture
• Intracapsular
• Extracapsular
ii. With displacement of condyle
• Lateral
• Medial
• Forward
• Backward
iii. With overriding of fragments
DIRECTION OF DISPLACEMENT
25

iv. With dislocation in lateral or medial direction
• Intracapsular
• Complete fracture dislocation
• Complete dislodgement of the condyle
• Dislocation of the fractured part of the head of the condyle
v. With dislocation in forward direction
• Anteriorly from the articular eminence
• Posteriorly from the articular eminence
• With dislocation and displacement of the meniscus
• With comminution
• Old fracture with deformities
— Pseudoarthrosis
— Ankylosis 26

B. Subcondylar fractures
i. Without displacement of fragment
ii. With displacement of fragment
 Fracture line either extending through head or base of the condyle or neck
has been called condylar fracture by Thoma, whereas in subcondylar
fracture, the line runs transversely over ascending ramus.
27

VI. MACLENNAN CLASSIFICATION
(1952)
a. No displacement: A crack fracture is seen without alteration of the
normal relationship of the condylar head to the glenoid fossa or of the neck
of the condyle to the ramus.
b. Deviation: Simple angulation exists between the condylar neck and the
ramus.
c. Displacement: Overlap occurs between the condylar process and the
ramus. The obliquely fractured condylar fragment lies lateral to the ramus.
d. Dislocation: Disruption takes place between the condylar head and the
glenoid fossa. The condylar fragment gets pulled anteriorly and medially by
the lateral pterygoid muscle.
CLINICAL CLASSIFICATION
28

VII. 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
INCORPORATES THE INSERTION OF THE LATERAL PTERYGOID MUSCLE AT THE CONDYLAR NECK
30

VIII. ROWE AND KILLEY’S CLASSIFICATION
(1968)
a. Intracapsular fractures or high condylar fractures
i. Fractures involving the articular surface (rare).
ii. Fractures above or through the anatomical neck, which do not involve the articular surfaces
b. Extracapsular or low condylar or subcondylar fractures:
 Here the fracture runs from the lowest point of curvature of the sigmoid notch, obliquely
downward and backward below the surgical neck of the condyle to the posterior aspect of the
upper part of the ramus.
c. Fractures associated with injury to the capsule, ligaments and meniscus.
d. Fractures involving the adjacent bone, e.g. fracture of the roof of the glenoid fossa or the tympanic
BASED ON THE ANATOMIC DIMENSIONS OF THE TMJ
CAPSULE AND THE SURROUNDING STRUCTURES OF THE TMJ
31

Rowe and Killey’s classification for condylar fractures: (A) 1—Intracapsular or high condylar fracture, 2—
Extracapsular or low or subcondylar fracture, (B) First fracture line is above the attachment of lateral
pterygoid muscle. Second fracture line is at or below the attachment of lateral pterygoid muscle, where
condylar head is always prone to displacement due to the contraction of the muscle
32

IX. SPIESSEL AND SCHROLL
CLASSIFICATION (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
 Type IV: low condylar neck fracture with dislocation
 Type V: high condylar neck fracture with dislocation
 Type VI: intracapsular fracture of the condylar head
LOCATION OF THE CONDYLAR NECK
FRACTURES
33

X. LINDAHL CLASSIFICATION (1977) –
COMPREHENSIVE CLASSIFICATION
a. Fracture level: This may be as follows :
i. Condylar head fracture, intracapsular: By definition a
condylar head fracture is within the capsule and is therefore termed
intracapsular.
• Vertical (anteroposterior sagittal split)
• Compression (producing a mushroom type of expansion)
• Comminuted
A horizontal subdivision would be difficult to differentiate from next
category.
ii Condylar neck: The radioconstriction representing the condylar
neck corresponds anatomically to region of inferior attachment of
Lindhal’s classification: CH—
condylar head-intracapsular
fracture, CN—condylar neck
fracture, SC—subcondylar
fracture
DESCRIBES THE LOCATION OF THE FRACTURE, DEVIATION, AND/OR DISPLACEMENT AND POSITION OF THE CONDYLAR
HEAD WITHIN THE ARTICULATING FOSSA
35

iii. Subcondylar: This is the region below the neck, extending down to the
most inferior part of the sigmoid notch anteriorly while its posterior limits
situated more inferiorly corresponding to the point of maximum curvature of
natural concavity of posterior border of the mandible in that region.
36

b. Relationship of condylar fragment to mandible : This
may be as follows:
i. Undisplaced (or fissure fracture)
ii. Deviated: This is a simple angulation of the condylar process in
relation to main mandibular
fragment without overlap
iii. Displaced with medial overlap of the condylar fragment
iv. Displaced with lateral overlap of the condylar fragment
v. Anteroposterior overlap is possible, but infrequent
vi. Without contact between the fragments 37

c. Relationship of condylar head to fossa -
The following relationship may be observed:
i. No displacement—joint space appears normal.
ii. Displacement—joint space is increased, but condyle is still related to the
glenoid
fossa. Lindhal subdivided this into slight displacement and moderate
displacement,
but quantification is difficult.
d. Injury to meniscus: It may be torn, ruptured/ herniated in
forward/backward direction.
38

XI. MODIFICATION OF SPIESSL
AND SCHROLL
 Type A: continuous bony contact within the articular fossa, with a
component of the condylar head remaining and the fracture supported
without loss of ramus height
 Type B: loss of support within the articulating fossa and subsequent loss of
mandibular ramus height
 Type C: the uppermost portion of the fracture is below the level of the
lateral ligament, resulting in a loss of ramus height
39

Diacapitular fractures, type
A. Continuous bony
contact
within the articular fossa.
No loss of ramus height.
Diacapitular fractures, type B. Loss
of support within the
articular fossa and loss of height of
the mandibular ramus.
Diacapitular fractures, type C. The
most superior portion
of the fracture is below the level of
the lateral ligament. Loss of
ramus height is appreciated due to
involvement of the entirety of
the condylar head.40

XII. ELLIS AND COWORKERS
(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
LOCATION OF THE FRACTURE AND THE DEGREE OF DISLOCATION AND/OR DISPLACEMENT
41

CLASSIFICATION ADOPTED BY THE STRASBOURG OSTEOSYNTHESIS
RESEARCH GROUP (SORG)
42

XIII. LOUKOTA AND COWORKERS
(2005)
CLASSIFICATION
 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
THIS PROTOCOL DESCRIBED “LINE A,” WHICH IS A PERPENDICULAR LINE THAT EXTENDS THROUGH THE LOWEST EXTENSION OF THE
SIGMOID NOTCH TO THE MANDIBULAR RAMUS. THE PURPOSE OF THE LINE IS TO IDENTIFY A COMPONENT OF THE STRUCTURAL
ANATOMY OF THE MANDIBLE THAT IS EASILY REPRODUCIBLE EVEN IN CASES OF SIGNIFICANT CONDYLAR TRAUMA. ADDITIONALLY,
CLARIFICATION OF THE CONDYLAR HEAD FRACTURE (DIACAPITULAR FRACTURE) WAS NOTED, AND PRESENTED A DEFINITION FOR THE
TERM “MINIMAL DISPLACEMENT”
43

Strausbourg Osteosynthesis Research Group
classification.
The key landmark in the Strausbourg Osteosynthesis
Research
Group classification is Line A, a perpendicular line
through the
sigmoid notch to the tangent of the ramus.
Diacapitular fracture extending
outside the temporomandibular
joint capsule without
displacement of the articulating
surface of the condylar head.
44

Condylar neck fracture. The fracture
line starts above Line A, and more than
half of the fracture is above Line A in
the
lateral view.
Condylar base (subcondylar) fracture. The
fracture line runs posterior to the
mandibular foramen, and more than half
the
length of the fracture extends below Line
A. 45

XIV. AO CLASSIFICATION (2010)
 The first line parallels the posterior border of the mandible
 The sigmoid notch line runs perpendicular to the first line
at the deepest portion of the sigmoid notch
 There is a line below the lateral pole of the condylar head
that is also perpendicular to the first line
 A line is drawn half way between the lateral pole line and
the sigmoid notch line
 A “high-neck” fracture is above this line, whereas a “low-
neck” fracture is below
AOFoundationclassification of “high-neck” and
“low-neck” mandibular condylar fractures.46

XV. COMPREHENSIVE AOCMF
CLASSIFICATION SYSTEM: CONDYLAR
PROCESS FRACTURES
 Condylar head: the condylar head reference line runs perpendicular to the
posterior ramus below the lateral pole of the condylar head
 Condylar neck: the sigmoid notch line running through the deepest point of
the sigmoid notch perpendicular to the ramus line extending superiorly to
the condylar head
 Base of the condylar process: the sigmoid notch line running through the
deepest point of the sigmoid notch perpendicular to the ramus line
extending inferiorly
47

CLINICAL
EXAMINATION IN
DIAGNOSIS
48

UNILATERAL CONDYLAR FRACTURE
A. Inspection
• Swelling over the TMJ area.
• Heamorrhage from ear on that side.
- bleeding from external auditory canal
- middle ear haemorrhage
• Haematoma on the involved side
• Ecchymosis of skin just below the mastoid process
• Characteristic hollow over the region of condylar head
49

B. Palpation :
• Tenderness over the condylar area.
• Mandibular movements:
- Protrusion
- Lateral excursion
• Determine the displacement of the condylar head.
50

Intra – orally :
• Mandible deviates on opening towards the
side of fracture.
• Painful protrusion or lateral excursion to
the opposite side.
• Premature contact of the molar teeth on
the side of fracture.
51

BILATERAL CONDYLAR FRACTURES
• Inspection & palpation are same as unilateral
• Overall mandibular movement is usually more restricted than in case of
unilateral.
• Mandible may not be deviated.
• The midlines are often coincident, and premature contact is present
bilaterally on the posterior dentition with an anterior open bite.
52

IMAGING TECHNIQUES
IN DIAGNOSIS
53

CONVENTIONAL RADIOGRAPHY
A. Orthopantomogram and lateral oblique View of mandible
–
 Either of these two views will give information on the overall relationship of proximal
and distal fragments in the antero-posterior plane.
 Sagittal displacement can be determined with a panoramic radiograph.
 The orthopantomogram has now become the more standard view providing, as it does,
an all-in-one view of the mandible.
 It is useful to supplement the standard view with a high OPG centred on the condyles
and this is best taken in the mouth open position if the patient is able to move the lower
jaw to any significant degree.
54

To evaluate the loss of ramus height,18,23,25 a panoramic radiograph is used.
The measurement technique is as follows -
• Line drawn between gonial angles across Panorex
• Perpendicular lines to most superior aspect of condylar heads
• The difference between the nonfractured and fractured side equals the
change in ramus height.
55

B. Reverse Towne's view and PA mandible –
 The reverse Towne's view gives a good representation of the proximal and distal
fragments in a medio-lateral plane.
 For the measurement of condylar process displacement, coronal displacement is
evaluated with Towne’s radiograph
 It shows the condylar heads much better than the more conventional PA or AP
views of the mandible where these structures tend to be superimposed on the image
of the base of the skull, although the latter views are still useful in the overall
assessment of the injury.
58

C. Transcranial views of temporomandibular joints –
 These coned down views may occasionally be helpful in defining the
relationship of the condylar proximal fragment to the glenoid fossa and also
in delineating the pattern of high intracapsular fractures.
 The view is not a true lateral one but taken obliquely from above;
judgements of changes in joint space must take this into account.
61

E. CT SCAN –
INDICATIONS –
Significant displacement or dislocation, particularly if open reduction
is contemplated
 Limited range of motion with a suspicion of mechanical obstruction
caused By the position of the condylar segment
 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
Inability to position the multiple-trauma patient for conventional
radiographs (CT scans may be the only useful radiograph that can be
obtained)
64

F. Magnetic Resonance Imaging (MRI) –
Prospective MR imaging in the early post-traumatic period, if the condition of
the patient allows this, provides the possibility of a much fuller understanding
of the internal derangements of the joint and muscular injuries which
accompany condylar fractures.
65

ARTHROGRAPHY
 Arthrography, by introducing a contrast medium into the upper and lower
joint spaces, provided the first feasible method of visualising the position of
the meniscus in internal derangement (Wilkes 1978).
 It is not a suitable method for use in the acutely injured patient as it involves
considerable subject co-operation during the examination.
66

GOOD AFTERNOON
SEMINAR PRESENTATION ON
CONDYLAR FRACTURES –
PART II
67

1. Evidence of facial trauma, especially in the area of the mandible
and symphysis.
2. Localized pain and swelling in the region of the TMJ.
3. Limitation in mouth opening.
4. Deviation, upon opening, towards the involved side.
5. Posterior open bite on the contralateral side.
6. Shift of occlusion towards the ipsilateral side with possible cross
bite.
7. Blood in the external auditory canal. 69

8. Pain on palpation over the fracture site.
9. Lack of condylar movement upon palpation.
10. Difficulty in lateral excursions as well as protrusion.
11. The occurrence of anterior open bite with bilateral subcondylar fractures.
This is associated with posterior gagging of the occlusion.
12. Persistent cerebrospinal fluid leak through the ear is indicative of an
associated fracture of the middle cranial fossa (otorrhea).
70

 Clinically, it will be noted that there is asymmetry of the face on the involved side due to,
shifting of the mandible posteriorly and laterally towards the affected side (deviation of the
mandible).
 Premature occlusion on the involved side is caused by upward pull of the elevator muscles of
the mandible.
 This results in a class I lever with the fulcrum on the molar teeth on the involved side.
71

 An open bite deformity anteriorly and on the opposite side of the mandible is noted.
 In case of bilateral fracture condyles, the patient will have anterior open bite
deformity with premature contact only on the posterior teeth.
 This is caused by upward displacement of ramus and telescoping of the fractured
fragments, due to contractions of the lateral pterygoid muscles.
 In bilateral condylar fracture, which occurs below the attachment of the lateral
pterygoid muscles, the patient is unable to protrude the mandible.
 In unilateral fractures at the same level, the patient is unable to perform lateral
movements to the opposite side, as the lateral pterygoid muscle is out of function on
72

(A)Diagram—bilateral condylar fractures with anterior open bite,
(B) OPG showing R parasymphysis and L unilateral condylar fracture,
(C) 3D CT scan with posterior rotational view, showing bilateral condylar fractures with overriding and
symphysis fracture mandible (countercoup fractures)
74

 Fractures above the level of the lateral pterygoid muscle insertion do not exhibit
displacement, as there is absence of contracting muscle attached to the proximal
segment.
 The patient may complain of severe pain in the TM joint and the teeth are
separated and do not come into the occlusion on the affected side, because of the
hemarthrosis in the joint, which forces the condyles downwards. It may be few
weeks before the teeth come into their normal occlusal relationship.
75

MANAGEMENT OF
CONDYLAR
FRACTURES
76

“Concerning the treatment of condylar fractures, it seems that
the battle will rage forever between the extremists who urge
nonoperative treatment in practically every case and the other
extremists who advocate open reduction in almost every case.”
- Malkin
77

The main controversies in relationship to condylar fractures relate to the
basic philosophy of management.
Three main schools of treatment have evolved, namely:
CONSERVATIVE FUNCTIONAL SURGICAL
78

1. Conservative.
This relies on the use of a period of rest and immobilisation by intermaxillary
fixation, which may be for a short period of 7-10 days to allow muscle spasm
and telescoping to settle down, as in a unilateral fracture dislocation, or
alternatively, it may be for 4 weeks or more in bilateral ,fracture dislocations
with an anterior open bite.
79

2. Functional.
 Here the accent is on active movement.
 This may be important in fractures which are at risk of causing ankylosis
since movement can prevent bony union.
 There is also a school of thought which favours traction devices attached to
the mandible to remedy disto-occlusion particularly combined with active
movement.
80

Elastic band–Class II light elastics
Review after 6 days
a)Normal occlusion: Remove when brushing and replace immediately
b)Unable to achieve normal occlusion: to be worn 24hrs/day till next review
Review after next 6days
a)Occlusion maintainable: halt elastics
b)Occlusion difficult obtain : continue elastics
81

Functional exercise:
• > 40 mm interincisal distance (adult)
• > 10 mm lateral excursion
• > 12 mm protrusion
Types of exercise:
•Maximal mouth opening
•Right lateral excursion
•Left lateral excursion
•Protrusive action
82

3. Surgical.
 Surgery may be considered for a fracture dislocation of the condyle.
although bony union always appears to take place.
 Surgical access is difficult as the condyle tend's to be pulled forward and
medially by the lateral pterygoid muscle and there is a risk of damage to
branches of the facial nerve.
83

PHYSICAL THERAPY FOR
CONDYLAR FRACTURES
84

MANUAL THERAPY TECHNIQUES
Manual therapy techniques include joint distraction for general mobility, anterior glide to restore
translation during mandibular depression greater than 20 to 25 mm and protrusion, and lateral or medial
glides to restore lateral deviation required for chewing 85

ACTIVE RANGE OF MOTION
EXERCISES
Following manual therapy, the patient is taught to perform active range of motion exercises. Visual
feedback with a mirror is critical to enable the patient to perform early exercises properly. A tongue
depressor can be used to facilitate straight opening and symmetrical lateral deviation 86

When the fracture site is healed enough to
handle stress, active-assisted opening is
performed by the patient by placing her or his
thumbs on the maxillary canines and/or
premolars and the middle fingers on the
central mandibular incisors .
87

MUSCLE STRENGTHENING AND ENDURANCE THERAPY
The patient is encouraged to chew on both sides of the mouth equally. In addition, isometric exercises can
be performed in a progressive manner. The physical therapist demonstrates the amount of pressure to be
applied manually to restrict mandibular movement in various planes and the patient performs the
exercises as a home program.
88

When the patient demonstrates good control without
pain, the exercises are repeated with 1 to 2 cm of
mandibular depression.
89

CLOSED REDUCTION
INDICATIONS FOR NONSURGICAL TREATMENT
 Nondisplaced or incomplete fractures
 Isolated intracapsular fractures
 Condylar fractures in children (except for absolute indications)
 Reproducible occlusion without dropback or with dropback that returns to midline on
release of posterior force
 Medical illness or injury that inhibits ability to receive extended general anesthesia
90

DEFINITION OF CLOSED TREATMENT
Closed treatment is treatment of condylar fractures by means other than surgical exploration,
reduction, and fixation of the fracture line (i.e., not involving an open surgical exposure of the
fracture).
Traditionally, this has been achieved by arch bars, splints fitted over the remaining dentition, IMF,
screws, or bonded brackets.
Once reduction of the occlusion has been achieved, a period of immobilization may be required to
encourage bony healing.
Early mobilization is advised to minimize the risk of fibrous and bony TMJ ankylosis.
This method of treatment is based on the principle that condylar nonunion is unlikely despite
mobilization.
92

DEFINITION OF CLOSED FUNCTIONAL
TREATMENT
 Closed functional treatment involves the principles of closed treatment but is
followed by at least 3 months of rehabilitation, including guiding elastics and
mobilization regimens.
 It was found that when a full range of jaw movement is attained, normal jaw growth
is not hindered.
 Adult muscles are more powerful than children’s and commonly cause jaw shift,
leading to malocclusion.
 The application of elastics to guide the occlusion allows some degree of remodeling
and articulation in its new position.
94

 Early mobilization reduces the development of soft tissue scarring and promotes
increased mobility.
 Use of intermittent maxillomandibular elastic traction each night, followed by release in
the morning for full daytime use, results in daily stretching of the soft tissues.
 The motion enables linear and circumarticular healing of these tissues sufficient to allow
a full range of joint and jaw movement.
 Scarring and tethering are inevitable, but this treatment may allow full jaw mobility.
 Repeated holding of the jaw in occlusion at night results in a balance between
remodeling of the condylar fracture and firm extension of the soft tissue healing.
95

Absolute indications for open reduction
1. Fracture dislocation of the condyle into the middle cranial fossa
2. Impossibility of obtaining adequate occlusion by closed reduction due to locking by
the condylar fragment
3. Lateral fracture dislocation of the condyle
4. Invasion by a foreign body (e.g. gunshot wound). This category would include most
compound fractures of the condyle where some degree of debridement and surgical
toilet is indicated.
OPEN REDUCTION
98

Relative indications
1. Bilateral condylar fractures in an edentulous patient where a splint is unavailable
(e.g. the patient's dentures have been lost and the condition is too painful to allow
prosthetic manipulations) or when splinting is impossible because of alveolar ridge
atrophy.
2. Unilateral or bilateral condylar fractures where splinting is not recommended for
medical reasons like, seizure disorders, psychiatric problems, alcoholism, refractory
behaviour or mental retardation or retardation secondary to neurologic injury.
99

3. Bilateral condylar fractures associated with comminuted mid-face fractures. This is to
allow the reconstitution of a mandibular platform as a starting point in facial
reconstitution in very complex injuries.
4. Bilateral condylar fractures with associated gnathologic problems such as retrognathia
or prognathism, open bite with periodontal problems or lack of posterior support, loss of
multiple teeth and later need for elaborate reconstruction (possibly applicable to cases of
unilateral fracture). They also mention bilateral condylar fractures with an unstable
occlusion · due to current orthodontic treatment.
100

SURGICAL VERSUS NONSURGICAL
TREATMENT
The surgical goals enumerated decades ago by Walker include the following five
features :
1. Pain-free mouth opening, with an interincisal distance beyond 40 mm
2. Good movement of the jaw in all excursive movements
3. Preinjury occlusion of teeth
4. Stable TMJs
5. Good facial and jaw symmetry
105

REHABILITATION IN PATIENTS TREATED
BY CLOSED OR OPEN REDUCTION
OCCLUSAL GUIDANCE
• Place arch bars
• Class 2 elastics on ipsilateral side of fracture
• Have patient discontinue guiding elastics 24 hours prior to clinic appointment. If
occlusion stable and opens symmetrically, there is no need to continue with elastic
guidance.
• Remove arch bars during 6- to 12-wk period postoperatively after rehabilitation
goals are achieved. 106

FUNCTIONAL EXERCISE: REHABILITATION TARGETS
• Maximal incisal opening > 40 mm
• Lateral excursive movements > 10 mm
• Protrusive excursive movements > 12 mm
• Full use of TMJ throughout the day (diet as indicated by pain and coexisting
injuries)
• Close supervision by surgeon to evaluate occlusion, adjust regimen as necessary
107

GOOD AFTERNOON
SURGICAL APPROACHES TO
THE CONDYLAR AND
SUBCONDYLAR REGIONS
109

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 and plated with more than one
screw on the proximal segment.
110

SUBMANDIBULAR APPROACH
 This is also known as the Risdon approach
 Indications. axial anchor screw fixation.
 Advantages. ability to distract the 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, and plate and
screw fixation restricted without a transfacial trocar.
111

PERTINENT ANATOMY
Marginal Mandibular Branch of the Facial Nerve-
 Posterior to the facial artery, the marginal branch passes
inferior to the border of the mandible .
 The maximum inferior extent of the mandibular branch is 1.2
1.2 cm below the mandible.
 Anterior to the facial artery, the marginal branch passes
inferior to the border of the mandible in 0% to 6% of
specimens studied.
 It passes immediately deep to the superficial layer of the
deep cervical fascia, which is immediately deep to the 112

Facial Artery and Vein.
 This passes through or along the superficial surface of the
submandibular gland and approximates the inferior border of the
the mandible just anterior to the pterygomasseteric sling .
 The artery then rounds the inferior border of the mandible and
becomes superficial to the mandible.
 Generally, the anterior facial vein runs posterior to the facial
artery above the inferior border of the mandible.
 The facial vein is just deep to the platysma.
113

SURGICAL TECHNIQUE -
Exposure
 The corners of the mouth and lower lip are exposed anteriorly and the entire ear, posteriorly.
Incision
 Using arch bars and elastics or wires prior to facial incision, place the patient in MMF.
 These are 1.5 to 2 cm below the inferior border of the mandible in or parallel to a skin crease.
 In patients with ramus height shortening, place the incision 1.5 to 2 cm below where the
anticipated reduced mandible would be.
 The initial incision is placed to the depth of the platysma, with extensive undermining in all
directions.
114

Dissection -
• Through the platysma
Undermine and sharply dissect, being careful to stay superficial to the superficial layer of the deep cervical fascia.
fascia.
• From the platysma to pterygomasseteric sling
Make a small incision through the superficial layer of the deep cervical fascia at the level of the skin incision (1.5
(1.5 to 2 cm inferior to the mandible).
The facial artery and vein may be retracted anteriorly or divided and ligated if necessary.
Continue the dissection superiorly until the pterygomasseteric sling is encountered.
115

Division of the pterygomasseteric sling
 Sharply incise the pterygomasseteric sling with a scalpel along the inferior border of the
mandible.
 Use a periosteal elevator to expose the ramus up to the level of the TMJ capsule and coronoid
process.
116

OSTEOSYNTHESIS: AXIAL ANCHOR SCREW
Visibility and Reduction.
 Distract the distal segment using ligature wire at the gonial angle.
 Use a sigmoid notch retractor and condylar neck retractor to reflect soft
tissues. Stabilize and reduce the proximal segment using a curved hemostat.
118

Direct Fixation
 Place a groove in the lateral cortex approximately 1 cm anterior to the posterior border
border and 1.5 to 2 cm inferior to the fracture line.
 A centering instrument is used to place the screw hole; a 2-mm drill is used to drill the
the pilot hole to the fracture line.
 The drill guide is placed and a 1.5-mm drill is used to penetrate beyond the fracture
line into the proximal segment an additional 1 to 2 cm.
 Measure length and place and tighten titanium screw with biconcave washer.
119

Direct fixation using lag screw technique
120

Indirect Fixation
 This alternative method is indicated when the proximal condylar fragment is difficult to
difficult to reduce.
 First, place the positioning screw into the proximal segment.
 Then reduce the proximal segment using a biomechanically advantageous screw.
 Place a groove through the lateral cortex to the fracture line.
 Lock the screw into place using a two-hole miniplate locked against the proximal screw
screw shaft.
121

Indirect fixation using lag screw technique
122

Closure
• Pterygomasseteric sling. Suture together the masseter and medial pterygoid
using interrupted resorbable sutures.
• Platysma. Suture using resorbable sutures in a running fashion.
• Subcutaneous tissue. Use resorbable sutures.
• Skin. Use nonresorbable suture material.
123

RETROMANDIBULAR APPROACH
 Indications. This is used for any fracture that is large enough to be reduced and stabilized by ORIF
using plates and screws.
 Advantages.
1. There is a short distance between the incision and the fracture site
2. There is best access to the fracture site
3. There is no need for a transfacial trocar
4. The facial scar is less noticeable than with a submandibular incision
5. It is effective in patients with edema;
6. There is access for an osteotomy if required to reach the condyle.
 Disadvantages. The facial scar is more noticeable than with a preauricular incision. 124

PERTINENT ANATOMY
Facial Nerve
However, between the superior and
inferior divisions of the facial nerve, the
posterior ramus of the mandible can be
safely accessed
Retromandibular Vein
This is formed deep to the neck of the
mandible from the superficial temporal
vein and maxillary vein, superficial to the
external carotid and crossed by the facial
nerve.
125

SURGICAL TECHNIQUE
Exposure
Anteriorly, this should be at the corner of the mouth and lower lip and posteriorly, at the entire ear.
Incision
 Place the incision 0.5 cm below the earlobe and carry inferiorly for 3 to 3.5 cm.
 Place it just posterior to the posterior border of the mandible.
 Incise to the depth of the scant platysma overlying the superficial musculoaponeurotic system
(SMAS) and the parotid capsule.
 Undermine extensively in all directions for maximal exposure.
126

Dissection
 Dissection to the pterygomasseteric sling.
 Sharply incise the platysma, underlying SMAS, and parotid capsule.
 Continue the dissection bluntly in the substance of the parotid parallel to the
the expected direction of the facial nerve.
 Carry the dissection to the periosteum of the posterior border of the mandible,
mandible, avoiding injury to the branches of the facial nerve and
retromandibular vein.
127

Position of facial nerveExposure of ramus.
128

Division of the pterygomasseteric sling
 To divide the pterygomasseteric sling, sharply incise, starting as superiorly and
posteriorly on the ramus as possible.
 Carry the incision around the gonial angle as far anteriorly and inferiorly as possible.
129

Osteosynthesis
• Distract the proximal fragment inferiorly using an Allis clamp.
clamp. Place the hole superior to fracture line in the second
screw hole from the top of the plate.
• Place 24-gauge wire through the inferior hole of the plate.
Distract the condylar head inferiorly to enable the placement of a
of a drill hole in the superior hole of the plate, and apply a screw.
screw.
• Drill and place the screws in the inferior holes in the distal
segment.
130

Closure
 For the pterygomasseteric sling, suture together the masseter and medial pterygoid
using interrupted resorbable sutures.
 For the parotid capsule, platysma, and SMAS layer, use slowly resorbable horizontal
mattress sutures in a running fashion.
 This step is vital for avoiding a salivary fistula.
 For subcutaneous tissue, use resorbable sutures and, for the skin, use nonresorbable
131

RHYTIDECTOMY APPROACH
 This uses the same access as that of the retromandibular approach, with better
cosmesis.
 This approach must be drained with closed suction drainage postoperatively.
132

TRANSMASSETERIC-
ANTEROPAROTID APPROACH
 Indications. This is done to provide access to high and low subcondylar
and ramus fractures.
 Advantages. These include 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, and has the
best access of all the approaches.
 Disadvantages. There is a visible scar that is more noticeable than with
the other approaches and there is potential damage to the facial nerve.
133

PERTINENT ANATOMY
Marginal Mandibular and Buccal Branches of the Facial Nerve.
 Posterior to the facial artery, the marginal mandibular branch is above the inferior border of the
mandible.
 There is a single buccal branch of the facial nerve in 85% of specimens studied, which is inferior to the
parotid duct.
 In 15% of cases, there are two branches, one above and one below the parotid duct. Both are
immediately deep to the SMAS layer of the parotidomasseteric fascia.
Layers of the Parotidomasseteric Region.
 These are the skin, subcutaneous fat, parotidomasseteric fascia–SMAS layer, masseter superficial and
deep bellies, and periosteum of the mandible.
134

SURGICAL TECHNIQUE
Exposure
Anteriorly, this is at the border of the mouth and lower lip and lateral nose and cheek; posteriorly, the entire ear. The patient is
in wire MMF for the entire procedure.
Incision
 Draw a line from the bottom of the earlobe at the posterior border of the ramus to the gonial angle.
 Divide the distance of this line into thirds. Draw a line the same distance as above, anteriorly along the inferior border of the
mandible from the gonial angle forward. Divide this distance into thirds.
 Make the incision at the line connecting the intersections of the last third on the posterior ramus line and the 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). Then, there is extensive subcutaneous
undermining in all directions to allow for maximal exposure.
135

Dissection to the Pterygomasseteric Sling
 Undermine the parotidomasseteric fascia (SMAS) in the horizontal direction (parallel
(parallel to the facial nerves).
 If no facial nerve branches are identified by testing or visualization, then sharply incise
incise and expose the pterygomasseteric sling.
 If the facial nerve is identified by testing or visualization and unavoidable in the
horizontal approach, bluntly dissect through the parotidomasseteric fascia (SMAS) in
in the vertical direction to displace the facial nerve(s) away in the superior or inferior
inferior direction.
136

Division of the Masseteric Sling
 Bluntly dissect (using hemostats or scissors) in a
vertical plane, with access through the masseter
muscle until the mandible is identified .
 The direction of dissection is parallel to the
masseter muscle fibers.
Division of the masseter
137

Exposure of the Mandible and Fracture
 Use a periosteal elevator to strip the masseter muscle and periosteum to
expose the angle of the mandible first and then the lateral mandible along the
the ascending ramus.
 Identify the sigmoid notch and place a retractor (e.g., channel retractor) in the
the sigmoid notch for orientation.
 Finally, expose the posterior ramus of the mandible superiorly to the fracture
fracture site.
138

Osteosynthesis
 Once the proximal segment is positioned properly,
release the inferiorly displaced mandible. Repeat
until the fracture is reduced.
 Place the plates (variable, straight, H, U, X, modified
modified Y-shaped) and screws with direct
visualization.
139

Closure
 Closure of the periosteum or masseter muscle sling is necessary.
 Suture the parotidomasseteric fascia (SMAS) using slowly resorbable sutures
sutures in running fashion (necessary to avoid salivary fistula).
 Suture the subcutaneous tissue using resorbable sutures. Suture the skin using
using nonresorbable sutures.
140

PREAURICULAR APPROACH
 Indications. These include wire fixation of a high, anteromedially
displaced proximal fragment.
 Advantages. This provides access to the superiormost portion of the joint.
 Disadvantages. This is not indicated for placement of the plate and screw
fixation. There is no access to the angle of the mandible to distract the
ramus inferiorly; towel clip placed transcutaneously may be a reasonable
substitute. Limited ramus exposure makes osteosynthesis plate placement
extremely difficult. This results in more proximal segment stripping, leading
to an increased risk of necrosis. 141

PERTINENT ANATOMY
Ginglymoarthrodial Joint
 This allows for rotation and translation.
 The capsular ligament surrounds the
condylar head, superiorly attaches to the
temporal bone, and inferiorly attaches to the
condylar neck.
 For the collateral discal ligaments, attach the
articular disc to the condylar head.
142

Blood Vessels
 These include the superficial temporal artery, lateral and posterior to the
condylar head and neck.
 It runs within the temporoparietal fascia accompanied by the
auriculotemporal nerve.
 As it crosses over the zygomatic arch, a temporal branch is given off, which
frequently causes bleeding when using the preauricular approach.
 The retromandibular vein is formed from the maxillary and superficial
temporal veins. It travels just posterior to the mandibular ramus and is
superficial to the external carotid and deep to the facial nerve.
143

Nerves
 The main trunk of the facial nerve is 2 cm deep to the
skin at the middle of the anterior border of the mastoid
mastoid process.
 The temporal branches are the most susceptible to
injury; 8 to 35 mm (average, 20 mm) is the range of
distances from the anteriormost portion of the bony
external auditory canal (EAC) to where the upper trunk
trunk crosses zygomatic arch, under the surface of the
temporoparietal (superficial layer of temporalis fascia)
144

Trigeminal Nerve: Auriculotemporal Nerve
 This courses laterally behind the condylar neck and
and supplies skin in the temporal and preauricular
145

Layers of the Temporal Region
 These include the skin, subcutaneous fat,
temporoparietal fascia (i.e., superficial temporal
fascia or suprazygomatic SMAS).
 Extension of the galea is continuous with the SMAS.
146

PREAURICULAR INCISION
Blair’s Inverted
Hockey Stick
Incision
Thoma’s
angulated
incision
DIncision
ingman’s
Popowich &
Crane Incision
147

SURGICAL TECHNIQUE
 Exposure. Expose the entire ear and lateral
canthus of the eye.
 Incision. This is made in the skin fold along
the entire length of the ear. It extends
superiorly to the top of the helix and may
include the anterior extension. Incise to the
depth of the superficial layer of the temporalis
fascia.
 Dissection to the Joint Capsule. Dissect
along the anterior portion of the external
auditory cartilage to avoid damage to the
superficial temporal vessels and 148

 Exposing the Superior Joint Space. Distract the condyle inferiorly and sharply
dissect along the posterior slope of the articular eminence until the joint space
space unites with the retrodiscal tissues.
 Exposing the Inferior Joint Space. Incise the disc along the lateral recess of the
superior joint space. This allows exposure to the inferior joint space.
150

Closure
• Inferior joint space. Use slow resorbing or permanent suture material to reconnect the
reconnect the lateral disc attachments (medial) to the joint capsule (lateral).
• Superior joint space. Use slow resorbing sutures to attach the remnants of the TMJ
TMJ capsule from the zygomatic arch to the remainder of the joint capsule.
• Subcutaneous tissues. Close using resorbable sutures.
• Skin. Monocryl subcuticular sutures with a pressure dressing is used.
151

INTRAORAL APPROACH
 Indications. This approach is indicated for low subcondylar fractures. Axial anchor screws or
miniplate fixation may be used.
 Advantages. A visible scar avoided and damage to the facial nerve is minimized.
 Disadvantages
 Intraoral Approach without Endoscope. There is limited access, the poorest access of all
the approaches, it is difficult to ascertain the adequacy of reduction and fixation, and there is a
high rate of complications.
 Endoscope-Assisted Intraoral Approach. This is more time-consuming, with a steep
learning curve, poor visibility of the posterior ramus, and difficulty in reducing certain fracture
types
154

PERTINENT ANATOMY
 This is an anatomically safe approach, with minimal risks.
155

SURGICAL TECHNIQUE
 Incision. Incise at the anterior border of the ramus, extending to the lower
buccal sulcus. This is similar to the surgical approach for a sagittal split
osteotomy.The incision is made through the periosteum.
 Dissection and Exposure. Use a notch retractor to reflect soft tissues so the
sigmoid notch can be visualized. Strip the masseter and temporalis muscles
using a subperiosteal dissection. If inferior distraction of the ramus is needed,
perform transcutaneously with a towel clamp.
156

Osteosynthesis: Miniplate and Screw Fixation
• Preauricular transcutaneous trocar insertion. Insert the drill and screwdriver
screwdriver through a trocar incision with the first drill hole placed in the
proximal fragment. Insert the screw and plate via a transoral incision.
• Other screws and drill holes are placed through a trocar incision.
157

Osteosynthesis: Axial Anchor
Screw
Position the screw just superior
and parallel to the occlusal plane,
plane, superior to the
mandibular foramen. Place the
groove in the medial cortex
approximately 1.5 to 2 cm
anterior to the fracture line
158

Closure
• Oral mucosa. Resorbable sutures
• Skin. If trocar site is present, nonresorbable sutures
159

FACE-LIFT INCISION
This comprises a pre-auricular component together with an in-
continuity post-auricular component much of which may be in the
hairline.
 This approach has been suggested by Zide & Kent (1983). It
combines the advantages of the pre-auricular and submandibular
approaches but with better aesthetics.
 The post-auricular component allows lifting of the masseter muscle
from the lower part of the ramus to give access for low subcondylar
fractures.
 In particularly difficult cases the facial nerve may need to be
dissected as a prophylaxis against damage and this is possible with
this incision.
160

COMPLICATIONS OF
CONDYLAR FRACTURE
TREATMENT
161

MALOCCLUSION
 This is often implied secondary to improper treatment, such as inadequate
use of occlusal guidance or closed reduction when open reduction is
indicated.
 Older patients (>50 years) with preexisting locked-in occlusion and
definitive wear facets often complain of occlusal disharmony, even after
proper physiotherapy.
 Malocclusion is also common when patients have prolonged hospitalizations
, other complex injuries, or any medical limitation to adaptive
physiotherapy.
162

MANDIBULAR HYPOMOBILITY
 This is related to delayed physiotherapy of the joint and has been shown to
increase the longer the patient is subjected to MMF.
 Children are more susceptible to hypomobility, as are those subjected to
high-energy injuries with capsular disruption.
163

ANKYLOSIS
 In children, ankylosis is related to severe meniscal disruption with
inappropriate physiotherapy.
 In adults, ankylosis usually results from a widened mandible, which leads to
superior lateral displacement of the condyle.
 This may be mitigated by proper reduction of the fractures restricting
mandibular widening.
164

ASYMMETRY
 In children, approximately 25% of condylar fractures will produce some
facial asymmetry, whether it is hypoplasia or hyperplasia.
 In adults, deviation on opening has been noted in up to 50% of individuals
following fracture of the condyle.
165

DYSFUNCTION OR
DEGENERATION
 All injured joints are more susceptible to arthritis, and the TMJ is no
different.
 Risk factors include increased age, displaced condyle, longer periods of
MMF, and hypomobility secondary to capsular or meniscal injuries.
166

CONDYLAR RESORPTION
 This is somewhat avoidable by limiting the total denudation of the blood
supply and proper anatomic reduction.
167

IATROGENIC INJURY
 Following surgical repair of condylar fractures, up to 15% of patients may
experience transient facial nerve weakness; however, permanent injury is rare.
168

CHRONIC PAIN
 This occurs more commonly when condylar fractures are treated with closed
reduction.
169

SIMPLE REPAIR OF SOFT TISSUES
WITHOUT FIXATION
 This was described by Silverman in 1925
 It is combined with a period of intermaxillary fixation of approximately 10 days in the latter report. There must
be a significant risk of redisplacement due to the action of the lateral pteiygoid muscle
 Methods of immobilisation of the Condyle –
1. Transosseous wiring
2. Bone pins
3. Glenoid Fossa-Condyle Suture
4. Kirschner wire
5. Intramedullary screws
6. Bone plating Silverman (1925)171

TRANSOSSEOUS WIRING
 This is occasionally used in low subcondylar fractures,
particularly those extending through the sigmoid notch,
access being obtained through a submandibular incision.
 It may be possible to drill and wire across the fracture at
one or even two sites in the conventional manner.
 It is best to pass the wire through the hole in the major
fragment first so that this may be used for a downward
traction to improve access to the condylar fragment.
 A pull-through wire may be needed for passing the wire
through a hole drilled in the minor fragment.
172

 For higher level fractures, approached through a preauricular incision, Thoma (1945) advocates a
special sequence.
 The fragments are drilled obliquely from the external surface to the fracture surface.
 This facilitates insertion of the wire and decreases the danger of injuring the blood vessels on the
medial side, particularly the maxillary artery.
 If there is lateral overlap of the condylar fragment, this is drilled first since it is more accessible.
 When this has been done an instrument such as a small bone elevator is inserted between the bone
ends and is used to reverse the overlap so that the mandibular fragment becomes accessible for drilling.
 A pull-through wire is again needed for the second insertion. Where there is medial overlap the
sequence is reversed .
 An alternative lassooing type technique has been described by Messer (1972) which is claimed to give Thoma (1945)173

BONE PINS
 Archer (1975) described the insertion of pins into the
condylar head and neck which were connected with an
external bar and universal joints.
 This technique is rarely indicated and this seems to be
borne out in practice.
 Thoma (1945) had previously described a similar
technique but placed the pins in the condylar neck and
the zygomatic bone; this would need to be combined with
a period of intermaxillary fixation.
Thoma (1945)175

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 cat-gut suture was looped through and tied.
 It may, however, resorb and loosen prematurely with unpredictable results
as reported by Herfert ( 1961).
176

KIRSCHNER WIRE
 A Kirschner wire may 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 which has previously been
reduced (Lund 1972) (Vero 1968).
 This technique has been modified by Brown & Obeid (1984)
whereby the Kirschner wire is inserted into the proximal condylar
fragment and after this a groove is cut for its base in the main
distal mandibular fragment; two interosseous wires are then used
to secure the basal part of the pin.
Brown & Obeid (1984)177

INTRAMEDULLARY SCREWS
 Petzel (1982) described the use of an intramedullary screw transfixing
the distal and proximal fragments; this was inserted through a
submandibular approach.
 Kitayama (1989) described the use of a similar type of screw via an
intraoral approach.
 Both techniques require specialised instrumentation in the form of
tapping drills, a variety of lengths of screws of correct diameter and
specialised forceps, etc.
 Considerable expertise is required, particularly with the intraoral
technique. Petzel (1982)
178

BONE PLATING
 The use of small compact bone plates has
tended to evolutionise practice in relation
to stabilising the fractured proximal
condylar fragment and should be regarded
as the method of choice in view of its
rigidity and relative ease of application.
 Robinson & Yoon (1960) mentioned two-
hole plates while Koberg & Momma
(1978) advocate a four-hole plate, which
has tended to become standard.
Robinson & Yoon (1960) Koberg & Momma (1978)
180

DELAYED SURGERY
 There is an alternative 'wait and see' policy which can be used in doubtful
cases whereby conservative treatment is given and function assessed after
an interval of approximately 8 weeks to allow an initial union.
 At this stage it should still be possible to carry out refracture and reduction
if necessary, although there is little precise data on the technique.
 Hinds & Parnes (1966) relate three cases where such late management of
condylar fractures was carried out by means of an elective subcondylar
osteotomy.
181

 This particular approach involved sectioning the mandible at a chosen level,
which simplified the surgical access and allowed easier bone wiring (plating
could of course be used here with advantage).
 However, in this series, satisfactory condylar repositioning in the fossa was
only obtained in one of the cases - the use of semi-rigid plate fixation may
have offered the possibility of improvement on this type of result.
182

SPECIFIC TREATMENT OF
CONDYLAR FRACTURES
183

YOUNG PATIENTS WITH A MAXIMUM
REMODELLING POTENTIAL
 In patients under the age of 12 years bony union and adaptive remodelling will restore a functional
condyle regardless of treatment .
 Conservative mobilisation regimes can be undertaken unless there is a major degree of
malocclusion or there are other fractures to be considered which may necessitate intermaxillary
fixation.
 Surgical reduction, is contra-indicated in children in view of the excellent remodelling potential
and the increased hazard to the 7th cranial nerve.
 Those children at risk from ankylosis and/or defective development must be identified and
function must be resumed within 10 days in order to prevent bony union. Such patients should be
kept under careful review to detect any development of ankylosis or defective development.
184

ADULT DENTATE PATIENTS WITH
UNILATERAL FRACTURE
 If the patient is able to attain a normal centric occlusion in a unilateral fracture or
fracture dislocation, a conservative non-immobilisation regime can usually be
undertaken.
 This comprises:
1. Advocating a soft diet for a period of 2-3 weeks
2. Using analgesics as required in the early period. A non-steroidal anti-inflammatory
agent such as ibuprofen may be chosen providing that the patient does not have a
history of a tendency to dyspepsia
3. Taking great care to avoid another impact to the area. This will entail advising the
patient to avoid crowded environments or work if unexpected trauma to the region 185

Exceptions to this pattern of conservative nonimmobilisation treatment
would be the following:
1. If this regime is accompanied by excessive pain then a short period of
immobilisation by intermaxillary fixation for 7-10 days should be advised.
2. In fractures with no displacement or minimal deviation/displacement
consideration should be given to instituting 4 weeks immobilisation to ensure
union in the good position already exsisting.
186

 If a patient with a unilateral fracture is not able to attain their normal
occlusion then a period of 7-1O days immobilisation will have to be
undertaken.
 This can often be provided very simply by eyelet wiring on either side placed
as an outpatient under local analgesia.
 If the patient is not in a great deal of pain, it is sensible to delay making a
decision as to the necessity for intermaxillary fixation for 48 hours; during
this time spasm of the pterygomasseteric sling will often settle and allow a
minor occlusal discrepancy to remedy itself. 187

 Once intermaxillary fixation has been removed, the patient should be
encouraged in a gentle regime of steadily improving function.
 If there is a tendency to deviation on opening to the affected side, this
should be pointed out to the patient and he or she should be encouraged to
open in a straight line while looking in a mirror.
 If difficulty is experienced in achieving straight opening, the subject's hand
can be applied to the ipsilateral side of the chin while undertaking the
exercises to ensure centr'alisation.
188

 In intracapsular fractures, even in the adult, there is a possible, albeit slight, risk of
ankylosis.
 Functional opening should be restored as soon as possible; any immobilisation
deemed necessary for the fractured condyle or other maxillofacial injuries should
ideally not involve intermaxillary fixation for more than a maximum of 7-10 days.
 If there are other jaw fractures in this situation, these should be treated in such a
way as to avoid the necessity for lntermaxillary fixation for more than 10 days.
 The use of mini-plating may be very appropriate in these circumstances.
189

 Surgical reduction and fixation by bone plating for unilateral fractures is
only absolutely indicated in the rare circumstance of fracture dislocation of
the condyle into the middle cranial fossa, impossibility of obtaining
adequate occlusion by closed reduction due to locking of the condylar
fragment or true lateral fracture dislocation of the condyle.
190

ADULT DENTATE PATIENTS WITH
BILATERAL FRACTURES
 If the occlusion is normal for the individual, it is usually wise to institute a medium period of
immobilisation (3-4 weeks) as the risk of converting a deviated or displaced fracture to a
dislocation is significantly greater with bilateral fractures than with unilateral.
 Occlusal derangement is likely to occur with bilateral fracture dislocations and the typical anomaly
is the anterior open bite.
 In such cases a full 4 weeks of intermaxillary fixation is indicated.
 After this period the patient can be taken out of fixation but should be watched carefully for several
days while still maintaining the means of fixation, e.g. arch bars.
 Not infrequently, slight relapse is found to occur which necessitates a further 2 weeks of fixation
followed by further reassessment.
191

 If the degree of anterior open bite is severe from the outset or treatment has
been delayed, posterior distraction by gagging open the molar regions may
be considered. This overdistraction tends to stretch any developing scar
tissue and reduce the tendency to relapse.
 Overdistraction
192

Overdistraction in the molar regions may be achieved by one of the following
methods:
1. Thickening of the molar regions of cap splints. This can be achieved by the
maxillofacial technician opening the bite evenly in the molar regions while keeping
the incisors, canines and the first premolars in contact.
2. Small gutta-percha blocks may be fashioned to be placed between the posterior
molar teeth in combination with arch bars. It is suggested that a short length of wire
be incorporated io each gutta-percha block; this can then be twisted on to one of the
cleats of the arch bars to prevent dislodgement of the block and possible aspiration.
193

 In general, where a form of intermaxillary fixation is indicated because of an
anterior open bite, it is best to utilise a method in which cleats are available such as
arch bars or cap splints.
 This means that if there is a persistent tendency towards recurrence of an anterior
open bite after an adequate period of immobilisation, mild elastic traction by bands
can be put in place for a further period of 2-4 weeks.
 The absolute indications for surgical reduction and fixation are the same as those
for unilateral fracture. In bilateral fractures there is a tendency for more relative
indications for surgery to be relevant.
194

EDENTULOUS PATIENTS
 UNILATERAL CASES –
There is a reduced need for treatment in unilateral cases as a slight discrepancy in
bite can be compensated for by prosthetic means in the future.
 BILATERAL CASES –
In bilateral cases the treatment needs are as for the dentate patient.
Gunning-type splints may be employed for establishing the vertical dimension.
Alternatively the patient's own dentures may be modified to be used as splints by
provision of cleats and some means of attaching the dentures to the underlying
skeletal bases.
195

 In cases of anterior open bite, unless the alveolar process is well formed, the
use of peralveolar wires is generally unsatisfactory since the force of elastic
traction required to correct the occlusion may well cause wires to cut
through the one during the fixation period.
 In such circumstances splints are best secured by either piriform aperture /
wires or circumzygomatic wires (secured to a loop or eye in the premolar
regions).
 These are best combined with a single peralveolar wire in the midline,
otherwise the anterior region of the denture may still swing away from the 196

 Indications for surgical reduction and fixation are essentially the same as for dentate patients.
 Respiratory medical conditions may be less of a relative indication as it is possible to leave splints
open in the anterior region to provide a reasonable oral airway; contact will need to be maintained,
however, in the canine regions if there is an anterior open bite.
 There may be a relative indication in the situation of bilateral condylar fractures in an edentulous
patient where a splint is unavailable, as for example when the patient's dentures have been lost
and the condition is too painful to allow prosthetic manipulations yet there is an extreme degree of
fracture dislocation.
 Occasionally the use of splints is also impossible because of extreme alveolar ridge atrophy;
alternatively it is possible in such patients to combat a tendency to extreme open bite by
combining upper piriform fossa wires with lower circum-mandibular wires in the anterior region.
197

COMPOUND FRACTURES
 In compound fractures there is an undoubted risk of post-operative infection,
ensuing fibrosis and the development of a fibrous ankylosis.
 Any lacerations in the condylar area should be carefully explored, subjected to
lavage and the site drained if there is a dead space to prevent haematoma
formation.
 Prophylactic antibiotics are indicated. If there is comminution of the condylar bone
in such compound cases removal of non-viable bone fragments (those detached
from a good periosteal covering) is indicated at the time of exploration and closure.
 This may even necessitate a condylectomy in grossly contaminated and
comminuted cases. 198

 In the case of compound fractures, early function is encouraged to reduce
the tendency to fibrous ankylosis; exercising devices may be indicated.
 If, however, a condylectomy has proved to be necessary, there will. be a
tendency for premature posterior contact on tht side so that a short period
of intermaxillary fixation of not more than 10 days may be necessary to
allow spasm of the pterygomaxillary sling to settle.
199

Condylar fractures

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