The document provides information on mandibular condyle fractures, including: 1. It discusses the historical background, development, surgical anatomy, incidence, etiology, clinical findings, investigations, and management strategies for mandibular condyle fractures. 2. Management strategies include conservative/functional treatment using elastics and exercises or surgical treatment via open reduction and internal fixation depending on the type and severity of the fracture. 3. Classification systems for condylar fractures are presented based on location, direction of fracture, and anatomical relationships.

1. PRESENTED BY
MAROTI WADEWALE
POSTGRADUATE STUDENT
DEPARTMENT OF ORALAND MAXILLOFACIAL SURGERY,
GDC& H Mumbai.
MANDIBULAR CONDYLE
FRACTURE

2. CONTENTS
• Introduction
• Historical review
• Development
• Surgical anatomy
• Incidence & pattern
• etiology
• Clinical findings and investigations
• Management strategies
• Surgical approaches
• Fixation
• Management of Condylar fractures in children
• Management of condylar fracture in Panfacial injury
• Complications
• Conclusion

3. 3
• constitute 24% of all mandible
fractures.
• 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.
1. Lee KH. Epidemiology of mandibular fractures in a tertiary trauma centre. Emergency Medicine Journal 2008;25:565-568.
2. Barde D, Mudhol A, Madan R. Prevalence and pattern of mandibular fracture in Central India. National journal of maxillofacial surgery. 2014 Jul;5(2):153.
INTRODUCTION

4. Mukerji R, Mukerji G, McGurk M. Mandibular fractures: Historical perspective. British Journal of Oral and Maxillofacial Surgery. 2006 Jun 1;44(3):222-8.
Chopart F. Traité des maladies chirurgicales et des opérations qui leur conviennent. Villier; 1796.
HISTORICAL REVIEW
1.Hippocrate
s
• digital manupaltion of fracture segment for reduction & use of bandage.
1650
• Egyptians was the first who described mandible fracture in 1650 B.C
1.1779
2.Chopart and
Desault
• external fixation for management of mandible fracture
1.1805
Desault
• gave an excellent account on management of condylar fracture
1.Malgaigne
1856
• digital reduction of condyle fracture through introral.
1.Silverman
(1925)
• advocated open reduction for displaced fracture of mandibular subcondyle.
8.Zemsky in
1926
• advocated active movement of the jaw (functional treatment)

5. 5
• Meckel’s cartilage.
• Intramembranous ossification
• Bone formation : secretion of bone matrix
directly within the connective tissue;
without any intermediate cartilage
formation.
• Condensation of mesenchyme just lateral to
the Meckel’s cartilage.
• Cartilage then disappears as the bony
mandible
develops.
Parada C, Chai Y. Mandible and tongue development. InCurrent topics in developmental biology 2015 Jan 1 (Vol. 115, pp. 31-58). Academic Press.
DEVELOPMENT

6. • Condyle is a strong upward projection from
the posterosuperior part of the ramus.
• Upper end : Head
• TMJ
• Pterygoid fovea
SURGICAL ANATOMY

7. Any fracture that is located above the mandibular foramen and that runs from the posterior
edge of the ramus into the sigmoid notch or the condylar head, is classified as a fracture of the
condylar process- Eckelt, Scheinder
Choi KY, Yang JD, Chung HY, Cho BC. Current concepts in the mandibular condyle fracture management part I: overview of condylar fracture. Archives of Plastic Surgery. 2012 Jul;39(4):291.

8. • Elliptical in shape, long axis angled backwards
between 15-330 to frontal plane.
• Long axis of 2 condyles meet at basion on
anterior ligament of foramen magnum forming
an angle 0f 145-160 degrees.

9. width: 15-20• Mediolateral
mm
width: 8 -
roughened,
• Anteroposterior
10mm
• Lateral pole:
bluntly pointed.
• Medial pole: rounded,
extends from plane of ramus
9

10. Blood Supply
10
• Superficial temporal artery
• Transverse facial artery
• Posterior tympanic artery
• Posterior deep temporal artery

11. Condylar head – primarily through TMJ capsule
Condylar process

12. • Facial nerve
• Auriculotemporal nerve
Nerve Supply
12

13. Muscle Attachments
13
• Lateral pterygoid muscle

15. Posterior to the facial artery it runs above
the inferior border of the mandible in 81
percent. In others it is coursed like an arc
upto 1cm below the inferior border of the
mandible.
Anterior to the artery the nerve runs below
the inferior border.

16. CHILD V/S ADULT CONDYLE
CHILD ADULT
Cortical Bone Thin Thick
Condylar neck Broad, short Thin, long
Articular surface Thin Thick
Capsule Highly Vascular less vascular
Periosteum Highly active less active in latent
phase
Intracapsular
Fracture/
Hemarthrosis
Very common rare
Remodelling capacity Higher capacity lower

17. INCIDENCE & PATTERN

18. ETIOLOGY
Shah SA, Bangash ZQ, Khan TU, Yunas M, Raza M, et al. (2016) The Pattern of Maxillofacial Trauma & its Management. J Dent Oral Disord Ther 4(4): 1-6. DOI:

19. PREDISPOSING FACTORS
Status of
dentition
Socio-
economic
status
Age
Direction
of force
Muscle
pull

20. Does the position of the
most distal occlusal
contact influence
dislocation of the
condylar fragment?
did not influence
What kind of injuries to
teeth and teeth
supporting structures
occur in patients with
condylar fractures?
One-third of the patients with condylar
fractures also sustained teeth injuries such
as crown, crown/root fractures, luxation,
or fractures of the alveolar process
Is there any relationship
between the type
of condylar fracture and
concomitant mandibular
body fracture?
Concomitant fractures of the mandibular body
were more frequent in bilateral. In cases of
unilateral fractures concomitant fractures were
more closely related to the subcondylar fractures
than to the condylar head and neck fractures.
Lindahl, L. (1977). Condylar fractures of the mandible. International Journal of Oral Surgery, 6(1), 12–21. doi:10.1016/s0300-9785(77)80067-7

21. Is there any relationship
between the type
of condylar fracture and
concomitant injuries to
teeth and teeth-
supporting structures?
Teeth injuries were more frequent in cases
of bilateral, unilateral fractures, teeth
injuries were more often seen with the
condylar head and neck fractures than with
the subcondylar fractures.
Does a specific type of
trauma cause a
specific type of condylar
fracture?
Condylar fractures with medial override at
the fracture level were associated with
accidents in which the trauma to the chin
was judged to have been severe.
Is there any relationship
between the type of
condylar fracture and
age?
Condylar fractures with lateral override at
the fracture level were specific for adults
and fractures without override were
specific for children. Condylar head
dislocation was more frequent in children
than in adults.
Lindahl, L. (1977). Condylar fractures of the mandible. International Journal of Oral Surgery, 6(1), 12–21. doi:10.1016/s0300-9785(77)80067-7

22. presence of a mandibular third molar decreases the chance
of condylar fracture
most favourable for condylar fracture are classes A and I
classes B and II acting as protective factors.

23. 23
Lindahl, L. (1977). Condylar fractures of the mandible. International Journal of Oral Surgery, 6(1), 12–21. doi:10.1016/s0300-9785(77)80067-7
MECHANISM OF INJURY
Kinetic energy imparted by a
moving object through the tissue of
static individual
Kinetic energy derived from the
movement of the individual and
extednded upon a static object
Combination of above 1 & 2

24. Contra-coup injury -Injury site parasymphysis and Condyle on
opposite side
Parade-ground/ Guardsman Injury- Symphysis & Bilateral Condyle
Dashboard Injury- Bilateral Condyle & Parasymphysis
Hunting Bow Concept
TYPES OF INJURY

25. 25
CLASSIFICATION OF CONDYLAR FRACTURES
General
classification
Unilateral
Bilateral

26. As per location & direction of fracture
From above, downward or inward or
reverse
From above, backward & downward
Park SS, Lee KC, Kim SK. Overview of mandibular condyle fracture. Archives of plastic surgery. 2012 Jul;39(4):281.

27. Type 1- The angle between the head and the long axis of ramus
10-45 degree
Type II - Angle of 45-90 degree results in tearing of the medial
portion of the capsule
Type III Fragments not in contact, but confined to glenoid
fossa
Type IV where condylar head articulates in anterior position to
the articular eminence
Type V Vertical or oblique fractures through the head
of the condyle

28. MacLennan WD. Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 1952;5(2):122e8.
•Intracapsular fractures
•Extracapsular fractures
•Fractures involving the adjacent
bone

29. Dingman RO, Natvig P. Surgery of the facial fracture. Philadelphia: Saunders; 1964. p. 177e84.
Ellis E 3rd, Palmieri C, Throckmorton GS. Further displacement of condylar process fractures after closed treatment. J Oral Max- illofac Surg 1999;59(2):120e9.
•High condylar neck fracture:
•Intermediate condylar neck
fracture
•Low condylar neck fracture
the insertion of the lateral pterygoid
muscle at the condylar neck

30. Spiessl B, Schroll K. Spezielle frakturen- und luxationslehre. Ein kurzes handbuch in fu ̈nf ba ̈nden. Band I/1 Gesichtsscha ̈del. H. Ningst. Stuttgart (West Germany): Georg Thieme Verlag; 1972.

31. Anatomic Fracture Level
Relation with ramal
segment
Relation of condylar head &
fossa
Lindahl L. Condylar fractures of the mandible. I: classification and relation to age, occlusion and concomitant injuries of the teeth and teeth-supporting structures and fractures of the mandibular

33. 20
Neff And Rasse’s Modification (2006)
• Type A(VI A): Displacement of medial
condylar pole with preservation of the
vertical dimension
• Type B (VI B): The lateral condylar pole
is involved with loss of the vertical
dimension
• Type C (V): dislocation of the entire
condylar head
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian
Dental Association December 2006, Vol. 68, No. 11

34. STRASBOURG OSTEOSYNTHESIS RESEARCH GROUP
R.A loukotaa et al subclassification (2005)
Based on anatomical and clinical significance
1. Diacapitular fracture- through head of condyle
2. Fracture of neck of condyle
3. Fracture of condylar base
4. Displacement
Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassification of fractures of the condylar process of the mandible. British Journal of Oral and Maxillofacial Surgery. 2005 Feb 1;43(1):72-3.

35. DIAGNOSTIC
TECHNIQUE

36. •Clinical
examination
•Radiographic
examination
•History

37. • How did the patient sustain the injury?
-Area of impact
-Direction of impact
-degree of force

38. UNILATERAL CONDYLAR FRACTURE
38
A. Inspection

39. B. Palpation :
• Tenderness over the condylar area.
• Mandibular movements:
- Protrusion
- Lateral excursion
• Determine the displacement of
the condylar head.
39

40. Bilateral Condylar Fractures

41. • Signs & symptoms :
41

42. Radiographic Imaging
• Conventional radiography
-Orthopantomogram and Lateral oblique
mandible.
–Reverse Towne’s and PA mandible.
–Transcranial views of
Temporomandibular joint
• CBCT
• CT scan
• MRI

44. TREATMENT
MODALITIES

45. Aims for surgery:
1. Relief from pain
2. Stable occlusion
3. Stable TMJs
4. Restoration of interincisal opening beyond 40 mm
5. Full range of mandibular movements
6. Tominimize deviation
7. Avoid growth disturbances
8. Avoid Ankylosis
Walker R V : Discussion. J Oral Maxillofacial Surg 46:262, 1988

46. SURGICAL
FUNCTIONAL
CONSERVATIVE

47. FUNCTIONAL THERAPY
Elastics & jaw exercises
Light elastics given
Weekly review done

48. Conservative Therapy

49. 49
• no surgical intervention of the fracture site instead it reduces
the fracture taking occlusion as a key factor.
• Immobilization usually involves fixation with arch bars,
eyelet wires or splints.
• Period of immobilization varies from 1-6 weeks
 INDICATIONS
 Nondisplaced or incomplete fractures
 Condylar neck fractures in children <12 years (except for absolute
indications)
 Very high condylar neck fractures without dislocation
 Intra-capsular fractures.
 Grossly comminuted fractures and gun shot.

50. Elastic band – Class II light elastics
Review after 1
week
a) Normal occlusion: Remove when
brushing and replace immediately
b) Unable to achieve normal occlusion: to be
worn 24 hrs/day till next review
Review after next
week
a) Occlusion maintainable: halt elastics
b) Occlusion difficult obtain: continue
elastics (as long as 3 months)
Intermittent elastics traction at night and release at day time –
stretching of soft tissue.

51. Research showed that bony union occurs in condylar fractures , whether
IMF is applied or not but restoration of occlusion by IMF provides
satisfactory functional outcome.
For unilateral=7-10days
For bilateral =3-4weeks
Closed treatment followed by 3 months rehabilitation by guiding
elastics and mobilization regimes.
Rationale: Adult muscles are stronger , commonly causes jaw shift
leading to malocclusion. The application of elastics to guide the
occlusion will allow some degree of remodeling and articulation in new
position.

52. Advantage Disadvantage
• Relatively safe
• No injury of nerves and
blood vessels
• No postoperative
complications such as
infection or scar occurs.
• Fracture, loss, and
eruption delay of the
growing teeth can be
avoided in pediatric
patients as no tooth germ
injury occurs
• Injury of the periodontal tissue and buccal mucosa
• Poor oral hygiene,
• Pronunciation disorder
• Imbalanced nutrition
• Growth disorder and excessive growth of the
injured mandible may occur
• Facial asymmetry may occur in pediatric patients
aged 10 to 15 years due to growth disorder or
functional disorder
• Growth and functional disorders of the TMJ may
occur in 20% to 25% of pediatric patients aged 7
to 10 years

53. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. Journal of Oral and Maxillofacial Surgery. 1983 Feb 1;41(2):89-98.
Open Reduction

54. Treatment Protocol- Mathes

55. AAOMS Special Committee On Parameters of Care
Indications F. Or ORIF 2003
Physical evidence of fracture
Imaging evidence of fracture Malocclusion
Mandibular dysfunction
Abnormal relationship pf jaw Presence of foreign
bodies
Lacerations and/or haemorrhage in EAC Haemotympanum
CSF Otorrhea Effusion

56. ABSOLUTE CONTRAINDICATIONS-
 Condylar head fractures at or above the ligamentous attachment- single fragment,
comminuted or medial pole
 Medical risk to GA Good occlusion
 Minimal pain
 Acceptable mandibular movement
RELATIVE CONTRAINDICATIONS-
 When a simpler method is effective
 Condylar neck fractures( thin, constricted region inferior to the condylar head)
 Obtunded neurologic status when there is no documented hope for improvement
Contraindications of ORIF

57. 57
Advantage
• direct approach to the facture
site.
• prevent complications such as
respiration disorder,
pronunciation disorder, and
severe nutritional imbalance by
shortening intermaxillary fixation
period via rigid fixation.
Disadvatage
• injury of nerves or blood vessels
during operation, and
postoperative complications
including infection.
• permanent scar

58. SURGICAL APPROACHES

59. Surgical Approaches
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

60. Timeline

61. Esmaeelinejad M, Sohrabi M. Surgical Approaches to the Temporomandibular Joint. Temporomandibular Joint Pathology: Current Approaches and Understanding. 2018 Feb 10:185.

62. Submandibular Approach/ Risdon's Approach
• Indications-
 axial anchor screw fixation
 low subcondylar factures.
• Advantages –
 ability to distract the mandibular ramus
 direct access of the gonial angle
• Disadvantages-
 limited surgical site exposure
 difficult to reduce medially displaced condyle
 Plate and screw fixation restricted without a transfacial trocar

63. PERTINENT ANATOMY
63
• Marginal mandibular branch of the facial nerve
• Facial artery and vein

64. Incision
Richards AT. Chapter 14 - Surgical Exposures for the Nerves of the Neck A2 - Tubbs, R. Shane. In: Rizk E, Shoja MM, Loukas M, Barbaro N, Spinner RJ, editors. Nerves and Nerve Injuries. San Diego:
Academic Press; 2015. p. 201-213
According to the Hayes-Martin maneuver, ligation and upward retraction of facial vessels protect
the marginal mandibular nerve from injury

65. Retromandibular Approach
• Indications
 large fractures which requires plates and screws
 low condylar fracture
• Advantages
 short distance between incision and fracture site
 Better access to the fracture site
 Scar is less noticeable than that of a submandibular incision
 Effective in patients with oedema
 Access for an osteotomy if required to reach the condyle
• Disadvantage-
 scar is more visible than that of a preauricular incision
 access to the joint spaces and anteromedially displaced
condyle is limited

66. 55
PERTINENT ANATOMY
• Facial nerve
• Retromandibular
vein

67. INCISION
• 0.5 cm below the ear lobe
• 2cm behind ramus
• Carry inferiorly for 3 to 3.5 cm
• Placed posterior to the posterior
border of the mandible
• Hind's incision

68. • 12.7% were associated with FNP
• RMA for subcondylar fractures is feasible and safe.
• Dislocated condylar neck fractures are associated
with a highly increased risk of temporary
postoperative FNP

69. Rhytidectomy Approach
• provides the same exposure as the retromandibular
accesses.
• The only difference is that the skin incision is placed in a
more cosmetically acceptable location.
• It exposes the entire ramus from behind the posterior border.
• It therefore may be useful for procedures involving the
condylar neck/head, or the ramus itself.

71. Transmassetric - anteroparotid Approach
• Indications
 high and low subcondylar and ramus fractures
• Advantages –
 Quick and direct access to the fractured site
 Access to the gonial angle
 Ramus can be distracted
• Disadvantages
 Visible scar
 Potential damage to the facial nerve

72. PERTINENT ANATOMY
• Marginal mandibular and the buccal branches of the facial
nerve
• Layers of the parotid-massetric region- skin, subcutaneous fat,
parotid-massetric fascia,superficial and the deep bellies of the
masseter and lastly the periostium of the mandible

73. INCISION
• Line through bottom of ear lobe till the
gonial angle in the posterior border
• 2nd line from gonial angle (same length) in
the inferior border
• Incision in the intersection 3rd

74. Preauricular Approach
• Indications
 Whenever wire fixation of a high anteromedially displaced proximal fragment
• Advantages
 Provides access to the posterior most segment of the jaw
• Disadvantages
 Not ideal for plate and screw fixation
 No access to the angle of the mandible to distract the ramus inferiorly
 Limited ramus exposure makes the plate placement difficult
 condyle fracture is difficult in this approach, if fracture site is positioned
inferiorly to the mandibular condyle neck.
Jayavelu P, Riaz R, Tariq Salam AR, Saravanan B, Karthick R. Difficulties encountered in preauricular approach over retromandibular approach in condylar fracture. Journal of Pharmacy & Bioallied
Sciences. 2016;8:S175-S1s8

76. INCISION
76
• In the skin fold in the
entire length of the
ear
• Superiorly to the top
of the helix
• Incise to the depth of
the superficial layer
of the temporalis
fascia

77. Intraoral Approach
• Indications
 Low subcondyar fractures,
 Axial anchor screws or mini plates can be used
• Adantages
 No visible scar
 No damage to the facial nerve
• Disadvantages-
 Intraoral approach without endoscope- very limited access, poorest access
among all the approaches
 Endoscope assisted intraoral approach- steep learning curve, difficulty in
reducing the fracture segments

78. INCISION
78

79. Endoscopic Assisted Osteosynthesis
• Advantages- access high condylar fractures, better visualization,
lesser complications
• Instruments required- angled drills, a 30 degree angled 4mm
endoscope, screwdrivers, illuminating hooks and retractors

80. Aboelatta YA, Elbarbary AS, Abdelazeem S, Massoud KS, Safe II. Minimizing the Submandibular Incision in Endoscopic Subcondylar Fracture Repair. Craniomaxillofac Trauma Reconstr.
2015;8(4):315-320. doi:10.1055/s-0035-1549010
Intraoral versus Extraoral- Extraoral more
preferable by many surgeon, transoral is ideal

81. FIXATION TECHNIQUE OF
FRACTURE

82. Trans osseous Wiring
• in low subcondylar fractures extending through the sigmoid
notch
• Access is possible through a submandibular approach
• Higher level fractures are approached through the pre
auricular incision
• Damage to the maxillary artery
• 0.4 mm or 0.5 mm soft stainless steelwire
Tasanen A, Lamberg MA. Transosseous wiring in the treatment of condylar fractures of the mandible. J Maxillofac Surg. 1976;4(4):200-206. doi:10.1016/s0301-0503(76)80036-7

83. Bone Pins
• Archer (1975)
• ex-fix allows for minimal movement of
reduced bone fragments, thereby
decreasing bone resorption seen with
rigid internal fixation.
• condylar head segment that is severely
telescoped medially can be more
easily reduced.
• applied for approximately 2 weeks
Cascone P, Spallaccia F, Arangio P, Vellone V, Gualtieri M. A Modified External Fixator System in Treatment of Mandibular Condylar Fractures. J Craniofac Surg. 2017;28(5):1230-1235.
doi:10.1097/SCS.0000000000003669

84. 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 catgut suture was looped through it and tied
• Disadvantage – resorb prematurely, loosen

85. Kirschner Wire
• A k-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
• Brown and obeid modified this technique
in 1984, in which they used two
interosseous wires to fix the k wire
Haghighi K, Manolakakis MG, Balog C. Open Reduction With K-Wire Stabilization of Fracture Dislocations of the Mandibular Condyle: A Retrospective Review. J Oral Maxillofac Surg.
2017;75(6):1238.e1-1238.e7. doi:10.1016/j.joms.2017.01.038
K-wire stabilization can achieve satisfactory outcomes

86. Intramedullary Screws
• Petzel (1982) described the use of an
intramedullary screw fixing the
fracture segments, through a
submandibular approach
• kitayama(1989) described the same
through an intraoral approach
• This technique requires special
instrumentation(tapping drills), a
variety of length of screws of correct
diameter and specialised forceps

87. Bone Plating
• This the method of choice as it gives higher
stability and is relatively easy to apply
• Robinson and yoon (1960) described the use
of a 2-hole plate
• Koberg and momma (1978) advocated the
use of a 4-hole plate, which has become
standard

88. • one plate below the sigmoid notch and one plate along the
posterior border.
• placed along the long axis of the condylar process.
Drill hole for the first screw in condylar fracture fragment
• anterior plate is applied first.

90. Axial Anchor Screw
• Generally approached by the submandibular or intraoral incision
• This restores the vertical ramus height and may be more effective
than mini plates
• Direct fixation- a groove is made in the lateral cortex ( 1cm anterior
to the posterior border) and 1.5 to 2cm inferior to the fracture line

91. • Most common pediatric mandibular fracture (21-72%).
• male-to-female ratio of 4:1.
• most common mechanism was falls.
• Prior to age 6, most fractures are intracapsular, whereas after that age they occur
most frequently in the neck of the mandible.
• When normal occlusion is present, fractures of the condylar region are treated
conservatively with close observation, soft diet, and pain medication.
• When there is malocclusion, a short course of maxillary–mandibular fixation is
warranted.
• Limiting fixation to 7 to 10 days helps limit the chance of joint ankylosis, although
postoperative physiotherapy may still be beneficial.
PEDIATRIC CONDYLAR FRACTURES
Posnick JC, Goldstein JA. Surgical management of temporomandibular joint ankylosis in the pediatric population. Plast Reconstr Surg. 1993;91(5):791-798. doi:10.1097/00006534-199304001-
00006
Steed, M. B., & Schadel, C. M. (2017). Management of Pediatric and Adolescent Condylar Fractures. Atlas of the Oral and Maxillofacial Surgery Clinics, 25(1), 75–83.
doi:10.1016/j.cxom.2016.10.005

92. Mu ̈ller-Richter UD, Reuther T, Bo ̈hm H, et al. Treatment of intra- capsular condylar fractures with resorbable pins. J Oral Maxillofac Surg 2011;69(12):3019e25.
Bae, S. S., & Aronovich, S. (2018). Trauma to the Pediatric Temporomandibular Joint. Oral and Maxillofacial Surgery Clinics of North America, 30(1), 47–60. doi:10.1016/j.coms.2017.08.004

93. • Choice of technique is largely dependent on the age of the child and, more
importantly, the quality and quantity of dentition.
• Due to the possibility of injuring nonerupted teeth, intermaxillary fixation screws
should not be placed.
• It is important to discuss chin deviation during chewing and the possibility of long-
term growth abnormalities of the jaw with patients’ parents.

94. CONDYLAR
TRAUMA?
Clinical Sign
Malocclusion
Deviation
Range of motion
Negative clinical exam
(-)Malocclusion
Minimal pain
Normal range of motion
No deviation on opening
Observation
Radiographs
Lateral obliques
opg
CT scan
No radiographic
evidence of condylar #
hemathrosis
Joint effusion
(+) Condylr fractre
Normal occlusion Malocclusion
ORIF?
ROM
Pain
Deviation
Conservative IMF (7-21 days)
ORIF Other # ?
IMF (7-21 days)
Yes
89
Follow up
YesNo
No
No
Yes
Reduction/fixation of
other #

95. Arya, V., & Chigurupati, R. (2016). Treatment Algorithm for Intracranial Intrusion Injuries of the Mandibular Condyle. Journal of Oral and Maxillofacial Surgery, 74(3), 569–
581.doi:10.1016/j.joms.2015.09.033
TREATMENT ALGORITHM FOR INTRACRANIAL INTRUSION INJURIES OF THE
MANDIBULAR CONDYLE

96. OPEN
VS
CLOSED REDUCTION

97. ORIF provides superior functional
clinical outcomes (subjective and
objective) compared with CT

98. Ellis III E, Throckmorton GS. Facial Symmetry After Closed And
Open Treatment Of Fractures Of The Mandibular Condylar
Process. J Oral Maxillofac Surg 2000; 58:719-728
• 146 patients, 81 treated by closed and 65 by open methods.
• The patients treated by closed methods had significantly shorter
posterior facial and ramus heights on the side of injury, and more
tilting of the occlusal and bigonial planes toward the fractured
side, than patients whose fractures were treated by open
methods.
• The patients treated by closed methods developed
asymmetries characterized by shortening of the face on the
side of injury.

99. Santler G, Kärcher H, Ruda C, Köle E. Fractures of the condylarprocess:
surgical versus nonsurgical treatment. J Oral Maxillofac Surg 1999;
• 234 patients
• In the follow-up study, 150 patients with a mean follow-up time of 2.5 years
were analyzed using radiologic and objective and subjective clinical
examinations.
• No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve
disorders were observed
• The only significant difference was in subjective discomfort.
• Surgically treated patients showed significantly more weather sensitivity and pain
on maximum mouth opening.
• Because of these disadvantages, open surgery is only indicated in patients with
severely dislocated condylar process fractures.

100. Marker P, Nielsen A, Lehmann Bastian H. Fractures of the mandibular
condyle. Part 2: results of treatment of 348 patients. British Journal of
Oral and Maxillofacial Surgery 2000
• The ability to open the mouth, deviation and occlusion were recorded
• After one year 45 of the 348 patients (13%) had minor physical complaints such as
reduced ability to open the mouth, deviation, or dysfunction.
• Ten of them (3%) had pain in the joint or muscles or both.
• Eight patients (2%) had malocclusion
• They concluded that closed treatment of condylar fractures is non-traumatic, safe,
and reliable and in only a few cases may cause disturbances of function and
malocclusion

101. • 89% of the patients had no
occlusal disturbances
• some form of malocclusion
ranged from 0% to 24%
• incidence of pain at rest
ranged from 0% to 16%.
• good opening’ of the mouth
was reported in 86% of the
cases
• No cases of ankylosis were
reported.
• 72.7–100% of the
patients had no occlusal
disturbances
• presence of some form
of malocclusion ranged
from 0% to 27.3%.
• limited mouth opening
in 0–27.3%
• No cases of ankylosis
were reported.
• incidences of persistent
pain ranged from 0 to
42.1%.

104. Early 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 facial nerve (0-24%)
4. Vascular injury
Late complications:
1. Malocclusion
2. Growth disturbance
3. Facial scar (7.5%)
4. Temporomandibular joint dysfunction
5. Ankylosis
6. Asymmetry
7. Frey’s syndrome
COMPLICATIONS
Ellis E 3rd, McFadden D, Simon P, Throckmorton G. Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg. 2000;58(9):950-958.
doi:10.1053/joms.2000.8734

105. • Intracapsular fractures are best treated closed.
• Fractures in children are best treated closed except when the fracture itself
anatomically prohibits jaw function.
• Physical therapy is integral to good patient care and is the primary factor
influencing successful outcomes, whether the patient is treated open or
closed.
• When open reduction is indicated, the procedure must be performed well,
with an appreciation for the patient's occlusal relationships, and must be
supported by an appropriate physical therapy and follow-up regimen
CONCLUSION

106. 1. Oral & maxillofacial trauma-Fonseca & walker
2. Oral & maxillofacial trauma-Rowe & Williams vol 2
3. Principles of Oral & maxillofacial surgery-Peterson
4. Maxillofacial trauma & facial reconstruction-Peter Ward Booth
5. Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian
Dental Association December 2006, Vol. 68, No. 11
6. Ellis III E, Throckmorton GS. Facial Symmetry After Closed and Open Treatment of Fractures of
the Mandibular Condylar Process.Journal Of Oral Maxillofacial Surgery 2000;58 : 719 -728
7. Santler G, Kärcher H, Ruda C, Köle E. Fractures of the condylarprocess: surgical versus
nonsurgical treatment. J Oral MaxillofacialSurg1999
8. Marker P,Nielsen A, Lehmann Bastian H. Fractures of the mandibular condyle. Part 2: results of
treatment of 348 patients.British Journal of Oral and Maxillofacial Surgery 2000
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