This document reviews the evolution of treatment approaches for adult mandibular condyle fractures. It summarizes literature comparing outcomes of open reduction with internal fixation (ORIF) versus closed reduction with maxillomandibular fixation (CRMMF). While CRMMF was traditionally preferred, more recent studies show higher complication rates with CRMMF, including malocclusion, asymmetry and limited mobility. ORIF is associated with better anatomic reconstruction and outcomes. The document outlines classification systems for condyle fractures and indications for different treatment methods based on displacement and stability. It also reviews techniques used for ORIF and concludes that based on reviewed literature, ORIF provides better outcomes and is the preferred approach for treating condyle fractures.

1. OpenVersus Closed Reduction of Adult
Mandibular Condyle Fractures: A Review
of the Literature Regarding the Evolution
of CurrentThoughts on Management
Presented by: Sailesh Kumar
PGTrainee

2. Incidence of Condylar fracture
• The one of most common area of
fracture in the mandible is the condylar
region.
• The mandible is similar to a hunting bow
in shape, strongest in the midline
(symphysis) and weakest at both ends
(condyles). (Hunting bow concept)
• A blow to the anterior mandibular body -
force is transmitted from the body of the
mandible to the condyle and fracturing
it.

3. Methods of Management of Condylar fractures
Open Reduction with internal
fixation
Closed Reduction with
maxillomandibular fixation

4. AIM
•To determine the best method of condylar fracture
management with better outcomes by reviewing articles

5. •It has been suggested that closed reduction of
mandibular condyle fractures has been the preferred
approach to treatment
•Based on recent advancements in treatment based on
the classification of fracture reveals completely different
interpretations.

6. Classification of Mandibular Condyle
Fractures
• Brophy (1915)
• Wassmund (1927
&1934)
• Thoma
• MacLennan (1952)
• Rowe and Killey (1955)
• Dingman & Natvig
(1964)
•Spiessl & Schroll
(1972)
•Lindahl (1977)
•Ellis (1999)
•Loukota (2005)
•AOCMF
Classification (2014)

7. •Other systems were rather simplistic and did not help to
direct management alternatives beyond CRMMF.
•As radiographic techniques improved, so did the
classification systems..

8. •The Lindahl Classification system was based on
prospective investigation of 123 patients with 138
mandibular condyle fractures

9. HEAD
NECK
SUB CONDYLAR

10. 1. Based on Fracture level
• Condylar head — at or above the ligamentous attachment
• Horizontal — may be difficult to differentiate between
condylar neck
• Vertical
• Compression
• Condylar neck — thin, constricted region below head of
condyle
• Subcondylar — from the sigmoid notch to the posterior
mandible just below the neck of the condyle

11. 2. Dislocation at fracture level of condylar neck,
subcondylar
•Angulation with medial override
•Angulation with lateral override
•Angulation without override
•Fissure

12. 3. Position of condylar head to articular fossa
•No displacement
•Slight displacement
•Moderate displacement
•Dislocation

14. Indications for Management

17. *According to the guideline, open reduction is recommended for the cases of mandibular
condyle fracture suspected in clinical and radiologic examinations to prevent complications
such as functional or growth disorders (AAOMS 2003)

18. •Indications for management suggest that if a patient has
an acceptable range of motion, good occlusion, and
minimal pain, observation or CRMMF is preferred, no
matter what the level of fracture.
•Condylar head fractures (intracapsular); whether single
fragment, medial pole or comminuted, should be
managed in the same fashion.
To summarize the Indications

19. •Zide’s discussion points out that condylar displacement
and ramus height instability are the only indications for
the ORIF of mandibular condyle fractures.
• Thus, for displaced or unstable low condylar neck or
subcondylar fractures, ORIF is indicated
To Summarize the Indications

20. Review of Outcomes = ORIFVersus CRMMF
• Konstantinovic and Dimitrijevic et al (1992)- No difference in
deviation or MIIO (2.5 yrs) (26 ORIF/54 CRMMF)
• Worsae and Thorn et al (1994) - 39% Complication rate in
CRMMF—asymmetry, malocclusion, reduced MIIO, headaches,
pain. 4% Complication rate in ORIF—maloccusion, impaired
mastication, pain (2yrs) (61 CRMMF/40 ORIF)
• Hidding et al (1999)- Deviation seen in 64% CRMMF versus 10%
ORIF. Anatomic reconstruction in 93% ORIF versus 7% CRMMF. No
difference in headaches, mastication, or MIIO (follow up- 5 year)
(20 ORIF/14 CRMMF)

21. • Throckmorton et al (1999) - No perceivable differences noted
between CRMMF versus ORIF for mandibular motion or muscle
activity (3yrs) (14 CRMMF/6 ORIF)
• Palmieri et al (1999)- ORIF patients had greater condylar mobility
(3yrs) (74 CRMMF/62 ORIF)
• Oezmen et al (2001) - MRI revealed 30% disc displacement in
CRMMF and 10% in ORIF MRI revealed 80% of CRMMF with
malaligned or deformed condyles(2 yrs) (20 ORIF/10 CRMMF)

22. •Ellis et al (1999)- Position of the condylar process is not
static (6wk) (65 CRMMF)
•Ellis et al (2000)- Anatomic reduction possible, but
changes in the condylar process position may result from
a loss of fixation (6 month) (61 ORIF)
•Ellis et al (2000)-CRMMF had significantly greater
percentage of malocclusion (3 yr ) (77 ORIF/65 CRMMF)

23. •Ellis andThrockmorton (2000)- CRMMF had shorter
posterior facial and ramus heights on the side of injury (3
yr) (81 CRMMF/65 ORIF)
•Ellis et al (2000)- ORIF—17.2% facial nerve weakness at 6
weeks with 0% at 6 months and 7.5% scarring judged as
hypertrophic (3 yr ) (93 ORIF/85 CRMMF)
•Ellis andThrockmorton (2005)- No difference noted
betweenORIF versus CRMMF for maximum bite forces(3
yr ) (91 CRMMF/64 ORIF)

24. Summarizing
• Literature regarding the closed approach versus ORIF, ORIF has
been associated with scar development and temporary (6 months)
paralysis of facial nerve branches.
• For CRMMF - include chronic pain, malocclusion, asymmetry,
limited mobility, and gross radiographic abnormalities.
• These results suggest that under similar indications and conditions,
ORIF is the preferred approach.

25. METHODS ORTECHNIQUESTHAT HAVE
BEEN USEDTO STABILIZE MANDIBULAR CONDYLE
FRACTURES IN OPEN REDUCTION
• Use of a urethral sound
• Condylectomy
• Intraosseous or transosseous wire fixation
• Intramedullary pins
• Traction screw osteosynthesis with combination nut at angle
• Long screw placement
• Onlay-inlay splint

26. • Miniaturized dynamic compression plates designed for zygoma
fractures
• Extraoral pinning with biphasic connector
• Free graft with wire fixation after extracorporeal avulsion
• Disk repair with silicone rubber implantation
• Axial anchor screw
• Rigid plates and screws
• Bioabsorbable plates and screws
METHODS ORTECHNIQUESTHAT HAVE
BEEN USEDTO STABILIZE MANDIBULAR CONDYLE
FRACTURES IN OPEN REDUCTION

27. • ORIF is the preferred approach – as suggested by the
author based on the outcomes from reviewed articles
• ORIF - Stabilization is better while using minidynamic
compression plates compared to adaptation plates
• Future – Endoscopic approach to do ORIF for condylar
fracture fixation with advancement in instrumentation
Conclusion

28. Critical analysis
• Positives:
• Author has reviewed mostly large sample size studies
• Had chosen both long series and short series of follow ups to
compare immediate and delayed results
• He has reviewed about the complications arising from both
the methods and suggested ORIF as the best method with
better outcome

29. • Positives:
• He has given suggested the better classification for treatment
planning
• Explained about the changing concepts in indication for open
reduction
• Author has highlighted the importance of endoscopic approach
and modification of instrumentation for better fixation in
future.

30. Critical Analysis
•Negatives:
• Selection criteria for the articles reviewed was not mentioned
• Reviewed articles didn’t state whether the treatment is done
in unilateral or bilateral condylar fracture cases
• Article didn’t not include the treatment protocol followed by
each authors
• The classification followed in planning the treatment in the reviewed
articles - not mentioned
• Approaches used to access the respective condylar fracture was not
mentioned

31. Negatives:
• Which Level of fracture to be addressed with ORIF /
CRMMF - not stated
• CRMMF techniques wasn’t mentioned (about the rigid and
functional treatment) in most of the reviewed articles
• Parameters didn’t include infection rate following ORIF
• Osteosynthesis technique used by all authors were not
reviewed

32. Articles to Counter
• Nitzan DW, Palla S, “Closed reduction” principles can manage diverse
conditions of temporomandibular joint vertical height loss: from displaced
condylar fractures to idiopathic condylar resorption, Journal of Oral and
Maxillofacial Surgery (2017), doi: 10.1016/j.joms.2017.01.037.

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