Condylar fractures

1. Contents (Part I)
• Introduction
• Incidence
• Embryology and Surgical Anatomy
• Etiology
• Mechanism of fracture
• Classification
• Clinical examination
– Extra oral
– Intra oral
• Imaging

2. Introduction
• Condylar and subcondylar fractures account for a large
number of all mandibular fractures and…
• The topic of mandibular condylar fracture has generated
more discussion and controversy than any other in the
field of maxillofacial trauma
• Given the unique geometry of the mandible and TMJ’s,
these fractures can result in marked pain, dysfunction,
and deformity if not recognized and treated appropriately
• Understanding of the anatomy and physiology of the
masticatory system is therefore essential in treating
fractures of the condyle and subcondylar region

3. Incidence
Series Year Condylar # in %

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

5. Incidence
Kim E.Goldman DMD, Assistant Clinical Professor,
Department of Oral and Maxillofacial Surgery,
University of Louisville (November 15, 2006)

6. Incidence
• Dharwad Unicentric Max-fax Trauma Study
Type No. of # Percent
Symphy
-sis
40 6.56%
Para-
Symphy
-sis
285 46.73%
Condyle 100 16.39%
Body 55 9.01%
Angle 130 21.31%
Total 610 100%

7. Embryology
• Arises from the 1st Pharyngeal Arch - develops around
the ventral cartilage of the 1st branchial arch
• Begins to develop by the 10th week of gestation
• Two separate blastemas – one for the temporal bone
component and one for the condyle
• Superior to the condylar blastema a band of
mesenchymal cell develops that will eventually
differentiate into the disc
• Temporal condylar mesenchymal cell differentiate into
osteoblasts which lay down membrane bone
• All the components of mature TMJ is formed by 14th
week of gestation
• 12 – 32 weeks of gestation there is a high degree of
calcification of the condylar head

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

9. Surgical Anatomy
• Primary blood supply to condyle:
– Branches of superficial temporal artery
– Transverse facial artery
– Posterior tympanic artery
– Posterior deep temporal artery
• Primary blood supply to lateral pterygoid muscle:
– Branches of deep temporal artery
• Neural structures of importance
– Sensory auriculotemporal nerve
– Motor branches of facial nerve

10. Pediatric vs. adult condyle
1 Cortical bone Thin Thick
2 Condylar neck Broad Thin
3 Articular surface Thin Thick
4 Capsule Highly vascular Less vascular
5 Periosteum Highly active – in osteogenic
phase
Less active in latent
stage
6 Intracapsular fracture &
hemarthrosis.
Very common Rare
7 Remodelling capacity following
trauma
Present Absent
8 Disturbance in growth Likely N.A

11. Pediatric vs. Adult condyle

12. Etiology
• In adults
– Motor vehicle accidents
– Interpersonal voilence
– Work related injuries
– Sporting accidents and
– Falls
• In children
– Falls and bicycle accidents
– Motor vehicle accidents
• In elderly
– Falls and
– Assault and motor vehicle accidents

13. Biomechanical considerations
Force along the mandibular arch
– fracture at weakest areas the
condylar necks

14. Mechanism of fracture
Factors influencing the fracture site, type and severity:
- Occlusion
- Whether mouth was open or closed during impact
- Direction of the force
- Magnitude of force applied
- Age of the patient

15. Mechanism of fracture
• Simplifies diagnosis
• Helps surgeon to look for parts of the mandible most
likely to fracture
• About two thirds of all temporomandibular joint fractures
are associated with other fractures of the mandible
• Condylar fractures are mainly due to an indirect injury
• They seldom arise from direct trauma, unless
accompanied by a zygomatic arch fracture

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

17. General nature of injury
- Rowe & Williams
Three main groups
1. Contusion of the soft tissues of the joint
2. Fracture of the condyle
3. Fracture - Dislocation of the condylar head from the
glenoid fossa
Combination of the above can also be seen and should
be ruled out before further treatment options are being
considered

18. Mechanisms of Injury

19. Mechanisms of Injury
• Kinetic energy imparted by a moving object through
the tissues of a static individual.
– Ex: by a fist, cricket bat or ball

20. Mechanisms of Injury
• Kinetic energy derived from the moving individual
striking a static object
– Ex: a child slipping and striking the pavement or a
fall during an epileptic fit or parade ground fracture

21. Classification
Killey’s
• Age
• Under 10yrs
• 10-17yrs
• Adults
• Surgical anatomy
• Involving joint surface – intracapsular
• Not involving joint surface – extracapsular
– High condylar neck
– Low condylar neck

22. Classification
• Site
• Unilateral
• Bilateral
• Occlusion
• Undisturbed
• Malocclusion

23. Classification
MacLennan Classification: 1952 –Clinical Classification
Type I: No displacement
Type II: Fracture deviation – simple angulation of the
fracture segments without overlap or separation. Ex.
Green stick fracture in children
Type III: Fracture displacement – when there is
overlap of fracture fragments. This overlap may be in an
anterior, posterior, lateral or medial. Medial is
commonest.
Type IV: Fracture dislocation – here the condylar head
is completely dislocated out of the articular fossa and out
of the capsular confines. Again dislocation can be medial
or lateral and rarely anterior or posterior.

25. Classification
Condylar neck fractures classification -
Spiessl & Schroll
Type I : Condylar neck fracture without serious
dislocation
Type II : Deep-seated condylar neck fracture with
dislocation
Type III : High condylar neck fracture with dislocation
Type IV : Deep-seated condylar neck fracture with
luxation
Type V : High condylar neck fracture with luxation
Type VI : Head or intracapsular fracture

26. Clinical examination- Extra oral
Inspection
• Swelling
• Preauricular depression
• Ecchymosis
• Lacerations
• Facial asymmetry
• Pain on jaw mobilization
• Deviation on opening
• Ear bleed
• CSF otorrhea

27. Clinical examination- Extra oral
PALPATION
• Inability to open jaws
• Tenderness associated with
crepitation
• A limited range of motion
• A significant deviation on opening
– (same side)
• Otoscopic evaluation
• Firm posterior pressure on the
chin will cause pain in the
preauricular region

28. Clinical examination –
Intra oral
• Malocclusion
• Fracture of the dentition
• Increase or decrease in inter-incisal opening
• Premature occlusal contacts
• Anterior open bite
• Posterior gagging of occlusion

29. Clinical examination
Summary
Clinical signs to look for and to rule out - Fonseca
1. Evidence of trauma – facial contusions, abrasions,
laceration of the chin, and /or ecchymosis or
hematoma in the TMJ region
2. Bleeding from the external auditory canal
3. A noticeable or palpable swelling over the TMJ
4. Facial asymmetry as a result of edema or ramal
shortening
5. Pain and tenderness
6. Crepitation
7. Malocclusion
8. Deviation of the mandible
9. Muscle spasm (“splinting”) with associated pain and
limited mouth opening
10. Dentoalveolar injuries

30. Imaging
Plain radiographs
View in two dimensions
• orthopantomogram
• posterior-anterior view
• lateral oblique view
• Towne’s view
Computed tomography
• To be able to exclude head or intracapsular fractures
and particularly if surgical treatment is planned, it is
imperative that the fracture line be demonstrated in a
coronal CT scan

31. Imaging
Magnetic resonance imaging
Disk position can be shown by means of MRI
Ultasonography
• Limited use – only can tell presence of fracture in TMJ
region
• Can be used to check position of condyle following
surgery

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

33. Plain Radiographs
• OPG

34. Plain Radiographs
• PA Mandible

35. Plain Radiographs
Lateral skull view Towne’s view

36. What is optimum imaging for condylar
fractures
Mandibular series -
PA view
Reverse towne’s view
R & L lateral oblique
Chayra and colleagues – J Oral Maxillofac Surg
1986;44:677–9
Initial screening - panoramic radiograph alone
92% of fractures panoramic radiograph alone
Whereas 66% on a routine radiographic series without a
panoramic view
Recommended - J Oral Maxillofac Surg 2003;61:668–72
OPG alone or with PA &/or Reverse Towne’s – Minimally
displaced green-stick kind of fractures
In multi trauma patients – CT

37. Contents (Part II)
• Treatment Modalities
– Closed Method
• Controversies in treatment of condylar fractures
• Open reduction
– Surgical approaches to condylar fractures
• Methods of reduction
• Complications
• Special considerations
– Children
– Geriatric
– Malunited condylar fractures
– Dislocation of condyle into middle cranial fossa
• Future
– TMJ implants
– Endoscopic repair of condylar #’s
• Conclusion
• References

38. Goals of treatment
1. Obtain stable & functional occlusion
2. Restore maximal inter incisal opening
3. Establish a full range of mandibular excursive
movements
4. Minimize deviation of the mandible
5. Produce a pain-free articular apparatus at rest and
during function
6. Avoid internal derangement of the TMJ on the injured
or the contralateral side
7. Avoid the long-term complications of growth
disturbance

39. Treatment options
• Conservative / Non surgical / Closed / Functional
• Surgical / Open

40. Treatment Modalities
Conservative-functional approach
• To produce an acceptable functional pseudo-arthrosis by
re-educating the neuromuscular pathways
“The main aim is to encourage active movement of the jaw
as early as possible”
Surgical approach
• Open reduction of fracture segment with osteosynthesis
“The main objective is to perform a repositioning of the
fractured condyle as near to its anatomical position as
possible”

41. Closed Method
• Range of treatment options available
– observation and soft diet, variable periods of
immobilization and / or intense physiotherapy
• Close supervision is mandatory
• Need for immobilization - when malocclusion, deviation
with function, & / or pain are present

42. Closed Method
• The period of immobilization - must be long enough to
allow initial union of the fracture segments but short
enough to prevent complications
• Active functional therapy allows a return of mandibular
range of motion and functional movements
• Guiding elastics should be used to direct the mandible to
its maximal intercuspation

43. Indications for closed reduction
• Non-displaced favorable fractures
• Grossly comminuted fractures
• Severely atrophic edentulous mandibles
• Fractures in children involving the developing dentition
• Coronoid fractures : usually require no treatment unless
impingement on the zygomatic arch is present

44. Closed Method
Treatment of condylar fractures:
• Condylar fractures can be treated with closed reduction
for a period of 2-3 weeks to allow for initial fibrous union
of the fracture segments
• Condylar fracture is in association with another fracture
of the mandible
– treat the non-condylar fracture with ORIF and
– treat the condylar fracture with closed reduction

45. Contraindications for -
Closed reduction
• Patients with poorly controlled seizure history
• Patients with compromised pulmonary function
(i.e., moderate-to-severe asthma, chronic obstructive
pulmonary disease)
• Patients with psychiatric or neurologic problems
• Patients with eating or GI disorders
These patients benefit from ORIF

46. Controversies in Treatment
Edward Ellis III & Gaylord Thockmorton - JOMS 2005
“Treatment of condylar process fractures”
Summary of current treatment options-
1. A period of MMF followed by functional therapy
2. Functional therapy without MMF
3. Open reduction & Internal fixation

47. SDMCDS-CRFU Protocol
Adults
• Closed or open method
• Inter-maxillary fixation for 7-10 days/4 weeks
• Soft diet
• Post-treatment early mobilization in the form of jaw
exercises / Physiotherapy
• Intermittent occlusion guide elastics

48. SDMCDS-CRFU Protocol
Children
• Nearly all cases - conservatively treat with immediate
function & analgesics
• In cases with pain & malocclusion – brief period of IMF –
7-10 days followed by active function
• Early mobilization & active physical therapy aimed at
increased range of mandibular motion & prevents
ankylosis & growth alteration

49. Open Method - Zide & Kent, Raveh et al
Absolute indications
1. Limitation of function secondary to the following:
- Fracture into middle cranial fossa
- Foreign body within the joint capsule
- Lateral extracapsular dislocation of condyle
2. Other fracture dislocations in which a mechanical
stop is present on opening which is confirmed
radiologically
3. Inability to bring the teeth into occlusion for closed
reduction
4. Open injury (penetrating, avulsive, lacerating) to the
TMJ that requires immediate treatment

50. Open Method - Zide & Kent, Raveh et al
Relative Indications
- Bilateral condylar fractures with comminuted mid-face
fractures in which rigid internal fixation of the mid-face is
not possible
- Situations when intermaxillary fixation is not feasible:
Medical restrictions
Poorly controlled seizure disorder
Psychiatric disorders
Severe mental retardation

51. Open Method - Zide & Kent, Raveh et al
- Concomitant injuries such as head injury or chest injury
- Displaced fractures where dentures or splints are not
feasible because of severe mandibular atrophy
- Bilateral fractures in which it is impossible to determine
what the proper occlusion is

52. Surgical Approaches
The various incisions to approach the condyle are :-
1. Submandibular
2. Preauricular
3. Endaural
4. Retromandibular
5. Face lift / Rhytidectomy
6. Intra oral

53. Surgical Approaches
Submandibular approach
• Most suitable for ramus fractures and for low fractures of
the condylar neck
• Can be combined with an endaural incision for total
reconstruction

54. Surgical Approaches
Preauricular / Auricular approach
• Appropriate for repositioning and fixing intracapsular and
very high temporomandibular joint fractures
• Under certain conditions it can also be used, together
with a submandibular access, for high TMJ fractures that
are difficult to reduce

55. Surgical Approaches
Endaural approach
• It starts from the ear lobule along the convexity of the
tragal helix and extends superiorly to the upper of part of
the auricle extending at a 45 degree angle into the
temporal region

56. Surgical Approaches
Retromandibular / Posterior mandible approach
• This approach is indicated for low and high condylar
fractures
• Incision begins 0.5 cm below the lobe of the
ear and continues inferiorly for 3-3.5 cm

57. Surgical Approaches
Intra oral approach
• Only for low fractures of the condyle
• It was initially proposed by Steinhauser
Advantage
• No visible scars but this is offset by the lack of good
vision

58. Surgical Approaches
• Face lift / Rhytidectomy approach

59. Methods of Reduction
Repositioning forceps Repositioning pin

60. Methods of Reduction

61. Methods of Osteosythesis –
Miniplate fixation

62. Lag screw - miniplate fixation

63. Fixation

64. Complications
EARLY COMPLICATIONS
Complications that occur concurrent with or early after
treatment of condylar fractures include the following:
1. Fracture of the tympanic plate - otorrhoea
2. Fracture of the glenoid fossa with or without
displacement of the condylar segment into the middle
cranial fossa – neurological signs
3. Damage to cranial nerves V and VII – traumatic/post op
4. Vascular injury

65. Complications
LATE COMPLICATIONS
Late complications of condylar fractures commonly
include the following:
1. Malocclusion
2. Growth disturbances
3. Temporomandibular joint dysfunction
(Internal derangement)
4. Ankylosis
5. Malunion
6. Scars

66. Special considerations
Children
• Clinically - difficult to detect
• Emotional & psychological factors – limit examination
• Inability to convey it’s symptoms
• Radiography made challenging – technically
• In such cases CT under sedation – ideally 24 hours post
injury to allow sufficient time to recover from shock
• Clinical findings – similar to adult- pain over fractured
joint, limited mouth opening & lateral excursions, jaw
deviation & malocclusion….

67. Special considerations
• Geriatric
Conservative - undisplaced/displaced condyle fractures
• Gunning-splint therapy/ immobilization/IMF
• Soft diet regimen, analgesics
• Anxiety - reduction protocols
• Active functional therapy/ Physiotherapy
• Close watch on progress mandatory
• Serial follow-up radiographs

68. MALUNITED CONDYLAR FRACTURES
•The functional status of the temporomandibular joint is an
important factor in the choice of technique adopted for
correction of the occlusal deformity
•If temporomandibular joint function is significantly
compromised, reduction of the dislocation may be
necessary, alongwith disc repositioning – Joint surgery
•If temporomandibular joint function is acceptable, ramus
osteotomy is indicated in order to avoid joint surgery and the
possibility of surgically induced limitation of mouth opening

69. Preoperative malocclusion
due to unilateral condylar
fracture
Preoperative radiographs
Bilateral sagittal split osteotomy to
correct post-traumatic
malocclusion:
MALUNITED CONDYLAR FRACTURES

70. Postoperative
occlusion following
osteotomy
MALUNITED CONDYLAR FRACTURES
Postoperative radiographs

71. Future
• Alloplastic TMJ implants have evolved rapidly over the
last 10yrs
• Used when autologous reconstruction is not medically
appropriate
• 2 stock TMJ replacement systems are in use
– Biomet prosthesis (Biomet, Fla.) and
– Christiansen prosthesis (TMJ Implants, Colo.)
• When gross anatomical destruction is present
• Custom fabricated CAD/CAM Total TMJ reconstruction
system (TMJ concepts, Calif) can be used

72. Future
Curved elevator
Pliers for retrieving and reduction of dislocated condylar fragment

73. Case 1
Pre op Post op

74. Case 2
• Pre op Post IMF

75. Case 3
• Pre op Post op

76. Conclusion
• Fractures of the mandibular condyles constitute a
notable portion of mandibular fractures
• The use of plain radiographs in multiple views usually
discloses most condylar fractures
• A number of classification systems have been devised
• Historically conservative management has been popular
• Recent literature supports open reduction and internal
fixation of condylar fractures
• Better knowledge of regional anatomy and improved
techniques for surgical access to the TMJ have greatly
reduced complication rates

77. Conclusion
• There are a number of different methods of reduction
and fixation of the fracture segments
• The simplest method with the least complications based
on the specifics of the fracture (location, type of fracture,
displacement of segments, age of the patient, and
concomitant medical conditions) should be used
• Children have a remarkable potential for healing &
regeneration
• Most serious of complications – Ankylosis & Growth
disturbance

78. References
• Killey’s Fractures of the Mandible
– Peter Banks
• Maxillofacial Injuries – Vol 1
– Rowe & Williams
• Maxillofacial Surgery –Vol 1
– Peter Ward Booth
• Atlas of Craniomaxillofacial Fixation
– Robert M. Kellman, Lawrence J. Marentette
• Maxillofacial Trauma
– Charles C. Alling III, Donald B. Obson
• Facial Trauma
– Seth R. Thaller, W.Scott McDonald
• Surgery of Facial Bone Fractures
– Craig A. Foster, John E. Sherman