This is a presentation on clinical management of condylar fractures

1. CONDYLAR FRACTURES
BDS/07/18

2. ETIOLOGY
• Whenever a blow is received on the lateral side of face, the zygomatic
arch protects the condyle and coronoid process.
• Under these circumstances, the arch may fracture and may be
associated with fracture or dislocation of the condyle

3. • When a blow is given on the face resulting in fracture
of the mandibular condyle, the position of the
fractured condyle in relation to the remainder of the
ramal stump will depend on certain factors:
1. The direction and degree of force.
2. The precise point of application of force.
3. Whether the teeth were in occlusion at the time of
injury.
4. Whether the patient is partially or fully edentulous

4. MECHANISM OF INJURY
Trauma Causing Condylar Injury, Lindahl 1977
 Kinetic Energy imparted by moving object on static individual:
 Assault(fist)
 Industrial accidents
 Kinetic Energy derived from movement of individual and expended on
a static object:
 Parade Ground Fracture - Fall of victim without attempt to shield face due to
sudden loss of consciousness
 Fall during epileptic attack
 Kinetic energy summation of forces from combination of the above
which produces more severe injury:
 RTA

5. Mechanism of injury to the condyles:
(1) Blow,
(2) Ground fall,
(3) Dashboard RTA injury

6. CLASSIFICATION
1. Unilateral or Bilateral Fracture
2. Intracapsular(High Condylar) or Extracapsular (Low Condylar)
fractures
 Intracapsular: Fractures involving articular surfaces, condylar neck just below
articular surface
 Extracapsular: Fractures running deepest concavity of sigmoid notch to
posterior direction

7. Anatomical Classification

8. Other Classifications
• Wassmund’s classification (1934)
• MacLennan System (1952) - based on relationship of the proximal and
distal fracture segments to each other
• Spiessl and Scholl - based on displacement severity
• Lindahl’s classification - considered comprehensive
• Requires radiograph taken in two planes at right angles to each other

9. LINDAHL CLASSIFICATION, 1977
1. ANATOMICAL LOCATION OF FRACTURE
• Condylar Head
• Condylar Neck
• Subcondylar
2. Relationship of the Condylar Fragment to the mandible
• Nondisplaced
• Deviated
• Displacement with medial or lateral overlap
• Displacement with anterior or lateral overlap
• No contact between fractured segments
3. Relationship of Condylar Head and Fossa
• Nondisplaced
• Deviated
• Dislocation

10. (A) Relationship of condylar fragment to mandible (B) Relationship of
condylar fragment to glenoid fossa
Anatomic Location of Fracture

11. • Fracture with little or no displacement occurs when adequate natural
or artificial molar support exists and the teeth are in occlusion at the
time of impact.
• A variable degree of displacement will take place , if the teeth are
separated or the force is received from a lateral direction.
• Full force of impact will be transmitted to the condyles, resulting in a
variable degree of fracture dislocation, if the mouth is widely open or
there is inadequate molar support at the time of injury

12. • When the blow is received in the center of the chin, the distribution
of force is equal to both the condyles,
-resulting in a bilateral indirect fracture through the necks,
accompanied by a direct fracture at the symphysis (countercoup type
of fractures).
• This type more often is seen in an epileptic patients or soldiers who
fall on the face during parade.

13. DIAGNOSIS
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, toward the involved side.
5. Posterior open bite on the contralateral side.
6. Shift of occlusion toward the ipsilateral side with possible cross bite.
• Occlusion: Unilateral posterior crossbite or contralateral open bite
(gagging of the occlusion on the ipsilateral molar teeth) and
retrognathic occlusion may also be associated. Displacement of the
condyle from the fossa or overriding of the fractured condylar neck
shortens the ramus on that side producing the malocclusion.

14. 7. Blood in the external auditory canal. It is important to distinguish
bleeding originating in the external auditory canal from the middle ear
haemorrhage. The latter signifies a fracture of the petrous temporal
bone
8. Pain on palpation over the fracture site
9. Lack of condylar movement upon palpation
• If the condylar head is dislocated medially, a characteristic hollow
over the region of the condylar head may occur
10. Difficulty in lateral excursions as well as protrusion
11. Persistent cerebrospinal fluid leak through the ear is indicative of an
associated fracture of the middle cranial fossa (otorrhoea)

15. Bilateral Condylar Fracture
1. Signs and symptoms of unilateral condylar fractures present on
both sides
2. Swelling over both fracture sites
3. Overall mandibular movement more restricted than in unilateral
4. Anterior open bite present if there is displacement of the condyles
from glenoid fossa, or overriding of the fracture ends with posterior
gagging of occlusion
5. Elongated face appearance
6. Pain and limitation on opening and restricted protrusion and lateral
excursions
7. Frequent association with fracture of the symphysis or
parasymphysis

16. Significant midline
deviation towards the
fracture side

17. Anterior Open Bite
present in a bilateral
condyle fracture
Anterior and right lateral open bite
associated with left mandibular
condyle fracture

18. • 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.
• 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

19. • 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 the affected side
• 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.

20. • The patient may complain of severe pain in the TM joint and it will be
noted that the teeth are separated and do not come into the
occlusion on the affected side, because of the haemarthrosis in the
joint, which forces the condyles downwards.
• It may be few weeks before the teeth come into their normal occlusal
relationship.
• In this type of fractures, especially in children, active early
mobilization of the joint is a must, the parents should be warned
about the possibility of the development of ankylosis of the TMJ, if
proper treatment is not initiated.

21. Radiology and Imaging
• OPG-shows empty fossa and increase in joint space.
• Reverse Towne’s view-showing elongated condylar fracture
• PA mandible
• CT scan(coronal)-important in sagittal fracture of the condyle.

23. Reverse Towne’s View

25. Goals of therapy
1. To get stable occlusion
2. Restoration of interincisal opening
3. Restore Full range of mandibular excursive movement
4. Decrease deviation
5. Eliminate pain
6. Avoid internal derangement
7. Avoid growth disturbance

26. TREATMENT OF CONDYLAR FRACTURES
 The management of condylar fractures is divided into:
(a) Non-surgical -
• Conservative -Immobilization by Intermaxillary fixation
• Functional - Active movement
(b) Surgical
 The decision will vary depending on the age of the patient, the type
of fracture, concomitant injuries and associated anatomical findings.

27. Treatment of condylar fractures in infants and
young children
Unique anatomical features of infants condyle
1. Short thick necks with a less pronounced head.
2. Thin cortical bone with large marrow rich in undifferentiated
pluripotent cells.
3. Trauma often leads to intra-capsular fractures.
4. Release of marrow and blood into the joint space readily predispose
to ankylosis.
Unless severely displaced, the fractures are treated by closed reduction
with a short period of fixation not exceeding 10 days followed by
mouth opening exercises to minimize the risk of ankylosis.

28. Treatment Protocol
0-2 years - Encouragement of active jaw function + analgesics
3-12years - Functional Treatment for both unilateral and bilateral
condylar fractures. IMF for 7-10 days in case of extreme pain
• With significant displacement and ST injury, myofunctional interocclusal
appliances may be used.
13-18years -Relatively decreased remodelling capacity. May result in
abnormally shaped condylar head, shortened ramus heights. IMF for
2-3 weeks. Can be considered for surgery based on severity

29. In Adults:
Unilateral Intracapsular Fracture
• Does not cause much deformity
• Conservative treatment (usual IMF for 7-10days)
• IMF for 2-3 weeks incase of malocclusion
Bilateral Intracapsular Fracture
• IMF for 3-4weeks
• Physiotherapy afterwards to prevent restriction in mouth opening

30. Unilateral Extracapsular Fracture
• No displacement, no disturbance to occlusion - no effective treatment
• Displacement or severe malocclusion - Open reduction
Bilateral Extracapsular Fracture
• Results in instability and gross displacement of mandible
• Open reduction of at least one side is recommended to establish normal
height
• If there is association with gross midfacial fractures, open reduction of both
sides should be done

31. Nonsurgical Management of Condylar Fractures
• Most cases of the condylar fractures are best managed through nonsurgical
means. The obvious advantage is the avoidance of morbidity and
complications associated with surgery.
• Conservative method varies from no fixation to employing various devices.
1. Condylar fractures without displacement or with minimum
displacement, without much occlusal disturbance and functional range of
motion do not require any active treatment.
• Patient is asked to restrict the movements and semisolid soft diet intake
for 10 to 15 days followed by active movements.

32. 2. In case of deviation on mouth opening without much occlusal
discrepancy, a simple muscle training in front of a mirror is adequate. On the
involved side, class II elastic traction and on the normal side, vertical elastic
forces may be beneficial.
3. In cases, where condylar fragment overriding is seen with alteration in
ramus height, producing malocclusion, initially elastic traction is given to
correct the malocclusion, followed by IMF for 2 to 3 weeks.
• Early mobilization is advocated in cases of young
children to avoid ankylosis of TMJ.

33. Surgical Correction of Condylar Fractures
• Many a times, ankylosis, malocclusion, continued pain,
dysfunction are examples of residual difficulties associated
with the conservative management with condylar fractures
Absolute Indications for Open Surgery
1. Fracture dislocations in the auditory canal or middle
cranial fossa (rare)
2. Anterior dislocation with restricted mandibular
movements
3. Bilateral condylar fractures associated with a
comminuted LeFort III type with craniofacial
dysjunction.

34. Zide and Kent indications for open reduction
of condylar fractures
Absolute indications:
1. Displacement of the condyle into the middle cranial fossa.
2. Inability to obtain adequate occlusion by closed techniques
3. Lateral extra-capsular dislocation of the condyle
4. Invasion by foreign body in the joint capsule

35. Relative Indications
1. Subcondylar fractures with overriding of the fragments with anterior
open bite.
2. Anterior and medial displacement of the condylar fragment.
3. In case of delayed treatment, where there is pain and dysfunction
associated with malunited fracture.
4. Unilateral or bilateral fractures with loss of the posterior teeth, in
either upper jaw or both the jaws.
5. Cases in which position of the condylar fragment interferes with
normal function of the jaws.

36. Surgical Approaches to the Condyle
• Preauricular approach
• Retromandibular approach
• Submandibular approach
• Intraoral approach
• Bicoronal (bilateral condylar fracture along with frontal bone fracture)

38. Surgical Approach to the Condyle
• The preauricular approach historically has had a relatively high
incidence of facial nerve involvement.
• Modifications of this approach include an approach to the joint region
through a subtemporal fascial-periosteal envelope. Such an
approach allows avoidance of the facial nerve branches by staying
first posterior and then deep to the nerve.
• Postramal approach is better for subcondylar fractures.

39. Methods of Fxixation of the Condyle
• Transosseous wiring
• Kirschner wire
• Intramedullary screw
• Bone pins
• Bone plating

40. Preparation of the patient
• The temporal region is shaved preferably the day before surgery.
• The skin of the preauricular region and the ear are prepared in the
usual manner.
• The patient should be placed on the table so that the sagittal plane of
the head is parallel with the table.
• This often requires that the shoulder be raised with a flat sandbag.
Sandbags are also used to maintain the head in the correct position.

41. Operative Procedure
• Operative procedure Access to the TMJ is done for high condylar fracture
via modified preauricular incision and for subcondylar through postramal
approach.
• Blunt retractors are inserted and the zygomatic arch is located. The
depression in the inferior border of the arch denotes the location of the
mandibular joint.
• The mandible at this point may be moved by the assistant, which may
produce movement of the fragments and so helps in locating them.
• As one proceeds, the transverse facial artery and vein may be
encountered, cut and tied. Inverted L-shaped incision is taken from
• the lower border of the zygomatic arch to the outer surface of the ramus.

42. • The procedure from here, depends on whether the condyle is
displaced laterally or medially, which is already determined from the
radiographs.
• If the condyle is laterally displaced, then the periosteum of the neck
of the condyle is stripped off with a periosteal elevator.
• The condylar retractor is now inserted from the posterior border
going medially to protect the vital structures. The hole is drilled
through the outer cortex till the inner cortex.
• The 26 gauge double wire is passed through the hole and grasped
with the haemostat from the medial aspect

43. • The mandibular fragment is located next, since the fragment is under
the condyle. If submandibular or postramal approach is taken, then
small hole is made at the angle at the inferior border of the mandible,
through which double wire is passed and grasped with a haemostat
• This wire is pulled downward, so that there is better access for
grasping the condylar fragment as well as ramus.
• By using periosteal elevator and special condylar retractor, another
hole is drilled in the ramal fragment. The wire, previously placed in
the condylar fragment is now drawn through from the fracture
surface by inserting a looped wire in the hole from the outer surface
of the ramus.

44. • The fracture is then reduced under direct vision and temporary IMF is
done intraorally by the assistant.
• After that the wire ends are twisted together and cut off and the ends
are bent over close to the bone. In cases, where condyles are medially
displaced, the procedure is reversed.
• First the mandibular fragment is located by manipulation and same
procedure can be repeated as described. After fixation by the wires,
the wound is closed in layers and dressing is given.
• At the end of the operation, temporary IMF should be removed to
facilitate extubation and it should be replaced next day.
• Immobilization is kept for 15 to 20 days.

45. • Minibone plating can also be done instead of intraosseous wiring
• Here, the fracture should be reduced as described and then the small
four hole or two hole bone plate should be adapted to the external
cortex and fixed with monocortical selftapping screws.
• If the high condylar fractured fragment is displaced too
anteromedially, then it should be located by depressing the ramal
fragment and catching it with the haemostat.
• Then if it can be fixed back as a free graft to the ramal stump, the
attempt should be done. But many times condylectomy is
recommended, because replantation is not possible.

48. Complications of condylar fractures
1. Permanent TMJ derangement e.g., osteoarthritis or internal joint
derangement due to injury to the meniscus.
2. Facial asymmetry esp. in children due to growth interference. This
may require osteotomy,bone grafting or distraction osteogenesis to
correct the deformity.
3. Trismus
4. Ankylosis esp. following intra-capsular fracture in children. Shown
in the radiograph as a mushrooming head of the affected condyle,
also a prominent antegonion notch.
5. Lateral open bite.

49. Early/concurrent complications
1. Fracture of the tympanic plate
2. Fracture of the glenoid fossa with or without displacement of the
condylar segment into the middle cranial fossa.
3. Damage to the trigeminal and facial nerves
4. Vascular injury
5. infection

50. Late complications
• Delayed union
• Non-union
• Malunion
• Malocclusion
• Growth disturbances
• Tmj dysfunction
• Ankylosis
• Scars