This document discusses fractures of the mandibular condyle. It notes that management principles and goals of treatment vary for these fractures compared to other mandibular fractures. The document covers the classification, clinical features, and management principles for condylar fractures. It discusses different surgical approaches for treating condylar fractures depending on the type and location of the fracture. Post-treatment, condylar remodeling can occur where a new temporomandibular joint articulation is established through bone adaptation processes.

2. Dr. Itrat Hussain

3.  Fractures of the mandibular condyle
warrant separate attention in view of
the fact that the management
principles and goals of treatment
vary from and its management has
been a issue of continued
controversy since >65yrs
Bellinger and Hollenger, 1943 JOS Review of 100 cases

4.  Aetiology
 Classification
 Clinical features
 Management principles
 Definitive management

5.  Zygomatic arch – gives protection to the
condyle from direct trauma
 Condylar # - Occur most commonly from
indirect trauma

6.  Highly variable – 8%-76%
 Onequarter-Onethird of all #’s of mandible

8.  M/F ratio – 2:1
 Mean age – 29 yrs [4-76 yrs]
 Most common cause of unilateral condylar # -
 Males
 RTA [40%]
 Assaults [37%]
 Females
 RTA [42%]
 Falls [36%]
 Most common cause of bilateral condylar # -
 Both M/F
 RTA
 Falls
Marker et al, BJOMS 2000, 348 pts

9.  Moving object – Static individual
 Moving individual – Static object
 Both Moving in opposite directions
 Maximum injury with -

13.  Fracture was more easily produced with the
teeth out of occlusion as the could act to
absorb and dissipate the forces of impact thus
shielding the condylar region
1974, Fonseca – experimentally produced fractures in cadaveric subjects

14.  Lindahl system – 1977 – classified on the basis
of –
 Anatomic location of the #
 Relationship of the condylar segment to the
mandibular segment
 Relationship of the condylar head to the glenoid
fossa

15.  Condylar head – usually defined as the portion
of the condyle superior to the narrow
constriction of the condylar neck
 Intracapsular # -
 Vertical
 Compression
 Comminuted

17.  Condylar neck – Thin constricted area located
immediately below the condylar head
 Extracapsular fractures – Anatomically the
region where the caudal portion of the joint
capsule attaches

18.  Subcondylar – Area below the condylar neck
 Extent – Deepest portion of the sigmoid notch
anteriorly to the concave posterior portion of
the mandibular ramus
 Level –
 High
 Low
 Depending on the level of surgical difficulty

19.  Non/Undisplaced [Fissure #]
 Deviated – single angulation of the condylar
fragment to the distal mandibular segment
 # ends remain in contact with no separarion or
overlap

20.  Displacement with –
 Medial overlap – MORE COMMON
 Lateral overlap
 Displacement with –
 Anterior overlap
 Posterior overlap
 No contact between the # ends

22.  Nondisplaced
 Displacement – Condylar head remains
within the fossa, alteration in the joint
space
 Slight
 Moderate

23.  Displacement – Condylar head lies completely
outside the confines of the fossa, requires
capsular rupture
 Generally occurs in ANTEROMEDIAL direction
 Inherently strong capsule on the lateral aspect
 Pull of LP muscle

24.  Muscle attached with articular disc and have role in
displacement in condylar fracture
a) Lateral pterygoid b) Medial pterygoid c) Masseter d)
Temporalis
[Ans. a) Lateral pterygoid Ref. Pg. 117 B.D. Chaurasia]
The fibres run backwards and laterally and converge to be inserted
into :
1. The pterygoid fovea on the anterior surface of the neck of
mandible.
2. The anterior margin of the articular disc and capsule of the
temporomandibular joint
So its lateral pterygoid which is attached with articular disc and it
has role in displacement of condylar fractures.

25.  Anterior displacement of fracture condyle is due to
a) Lateral pterygoid b) Buccinator c) Medial pterygoid d)
Temporalis
[Ans. (a) Ref-Neelima malik pg 351]
 The muscle, under the influence of which, the superior
fragment of condyle, in a condylar neck # is displaced anteriorly
& medially is:
A. Medial pterygoid B. Lateral pterygoid C. Masseter D.
Temporalis
Ans. (B) Lateral pterygoid (Ref: Neelima Malik- 1st Ed/Pg 370)

26.  An attempt to establish a more useful
classification scheme which helps in treatment
planning
 Based primarily on the relationship of proximal
to distal segment
 Type I – Undisplaced
 Type II – # Deviation
 Type III - # Displacement
 Type IV - # Dislocation

27.  Evidence of trauma
 Contusions, Abrasions, Lacerations over the chin
 Ecchymosis/Haematoma in the TMJ region
 Bleeding from EAC
 Noticeable or Palpable SWELLING over the
TMJ region
 Soft
 Hard

28.  Facial asymmetry
 Edema
 Foreshortening of ramus
 Pain
 Tenderness on palpation
 Crepitation over affected joint
 Deranged occlusion
 Unilateral condylar # - Ipsilateral premature
contact +/- Contralateral open bite
 Bilateral condylar # - Marked anterior open bite +
Retrognathia + Gagging of posterior teeth

29.  Deviated midline
 At rest and on excursive movements
 Bilateral condylar # - Minimal midline
deviation
 Muscle spasm – Splinting with associated
pain and limited opening
 Dentoalveolar injuries

32.  OPG
 Reverse Towne’s projection
 PA skull
 Two lateral oblique views
 CT
 MRI

33. Deviatian on right side

34. Displaced condylar fracture

35. Displaced subcondylar # of R side

36. # dislocation left side

37. Bilateral condylar # with telescoping on the right side

38. Fracture of the medial pole on the right side

39. Edentulous mandibular condyle and contralateral body #

40.  Restoration of FORM and FUNCTION with
the use of SIMPLEST MEANS
[Walker, JOMS 1988 Discussion: open reduction of condylar # of the mandible in conjunction with
repair of discal injury: a preliminary report]

41.  Observation with NO treatment + Soft diet
 Closed reduction with Immobilization
EE – Conservative Approach

42.  8 wks
[JOMS, 1987 – Amaratunga etal; IJOMS, 2000 – Ed Ellis, G.
Throckmorton]
 7-21 days –
 Age of patient
 Level of #
 Degree of displacement
 Presence of additional #

45.  ABSOLUTE
 Displacement of the condyle into the middle cranial
fossa
 Impossibility of obtaining adequate occlusion by
closed reduction techniques
 Lateral extracapsular dislocation of the condyle
 Foreign bodies within the capsule of TMJ
 Mechanical obstruction impending the function of
TMJ
 Open injury to the TMJ that requires immediate
treatment

46.  Bilateral condylar # in an edentulous patient
when splints are unavailable or impossible
because of severe ridge atrophy
 Uni/Bilateral condylar # when splinting is not
recommended because of concomitant medical
conditions or when physiotherapy is
imposssible
 Bilat. # associated with concomitant midfacial #
 Bilat. # associated with other gnathologic
problems

48.  Physical evidence of fracture
 Imaging evidence of fracture
 Malocclusion
 Mandibular dysfunction
 Abnormal relationship of jaw
 Presence of foreign bodies
 Lacerations and/or hemorrhage in external auditory canal
 Hemotympanum
 Cerebrospinal fluid otorrhea
 Effusion
 Hemarthrosis JOMS 2003 Brandt and Haug

51.  Useful in cases of high condylar fractures,
condylar head #
 Limitation –
 Limited view of the # joint

52.  First described [1934] – Risdon
 Dimensions
 Site
 Caution
 Approach of choice for subcondylar fractures

55.  Modification of conventional submandibular
incision
 Kruger [1990] discussed it

57.  Best access
 Transfacial trocars – rigidly fix high-level
condylar #

58. Mandibular Fractures

65.  Shorter working distance from the incision to
the condyle
 Greater access as the tissues can be retracted till
the level of the sigmoid notch
 Excellent exposure in face with marked edema
 Easy to retrieve the medially displaced condyle
 Facial scar is produced in a less conspicuous
location

66.  Rare
 Advantages
 Disadvantage
 Contraindications
 Technique
 Circum meatal approach

67.  Variant of the retromandibular approach
 Incision is more hidden as in facelift procedure
 Gives wider exposure to the ramus
 Incision, Dissection

73.  Advantage –
 Better visualisation
 Disadvantage –
 Visible scar
 Possible chances of damage to the branches of
facial nerve, MMN

74.  Steinhauser [1964] first described it
 Lacher – 1st
only for low subcondylar #
 Later, all extracapsular #
 Technique
 Incision
 Dissection
 Pitayama’s intraoral technique

75.  All approaches inadequate
 Eg.
 M/G

76.  Only reduction without fixation
[Rees, Weinberg, 1983 OOO]
 Suture ligatures
[Upton L]
 External fixation
 Use of K-wires
[Stephenson and Graham, 1952 and Lund and Takenoshita]
 Osteosynthesis Wires – transosseous wiring
[Henny, Thoma, Messer, Tasanen and Lamberg]
 Axial Anchorage screws
[Petzel and Kernel]
 Rigid plates and screws

77.  Use of moule pin
[Stewart and Bowerman, 1991]
 Use of extracoporeal fixation
[Mikkonen et al, Ellis and Dean, Boyne]
 Use of monocortical plate fixation
[Ellis E.

81.  Use of artery forceps
 Use of K-wire
 Use of moule pin [BJOMS 1991, Stewart and
Bowerman]
 Extracorpreal fixation
 Use of Petzel’ technique

82.  OPEN v/s CLOSED
 Evaluation of results and specific
recommendations -
 Occlusal results after open or closed t/t of
mandibular condylar process
 Surgical complications
 Patient’s wishes
 Interincisal opening
 Mandibular movements
 Facial symmetry

83.  Open reduction does not necessarily mean
rigid fixation
 It merely means that a fracture has been
anatomically reduced with verification via
direct visualization through an open approach
 Subsequent to reduction, some form of fixation
may be used to stabilize the fracture

88. Laskin and Abubaker – decision making

89.  A new TMJ articulation is established between
the mandible and base of the skull
 Condylar remodelling, condylar regeneration,
functional remodelling, restitutional
remodelling, etc.
EE – IJOMS 1998

90.  It is a skeletal adaptation that provides a new
articulation, restoring a Class III lever system
to the mandible and thus improving functional
efficiency.
 Gain of lost PVD
Lindahl and Hollender demonstrated radiologic findings in 67 pts. IJOMS 1977

91.  Re-establishment is maturation dependant
 Restitutional remodelling in children
 Functional remodelling in adults
 Morphologically abnormal but functionally normal
 New articulation more inferior at the base of
the articular eminence
 Joint may fill with bone and/or soft tissue –
quality and quantity of adaptation id related to
the biological age of an individual

92.  Immediate
 Late

93.  Fracture of the glenoid fossa with or without
displacement of the condylar segment into the
middle cranial fossa
 Fracture of the tympanic plate
 Damage to the cranial nerves V and VII
 Vascular injury

94.  Malocclusion
 Growth disturbances
 Temporomandibular joint dysfunction
 ankylosis

95.  Temporomandibular joint reconstruction v/s
Orthognathic surgery