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Clinical Follow-Up Examination of Surgically

Treated Fractures of the Condylar Process
Using the Transparotid Approach
Article in Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and
Maxillofacial Surgeons March 2010
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J Oral Maxillofac Surg

68:611-617, 2010

Clinical Follow-Up Examination of

Surgically Treated Fractures of the
Condylar Process Using the
Transparotid Approach
Jan Klatt, MD, DMD,* Philipp Pohlenz, MD, DMD, PhD,
Marco Blessmann, MD, DMD, Felix Blake, MD, DMD,
Wolfgang Eichhorn, MD, DMD, PhD,
Rainer Schmelzle, MD, DMD, PhD, and
Max Heiland, MD, DMD, PhD#
Purpose: The surgical approaches for the open treatment of condylar process fractures have been

controversial. In our study, we evaluated the morbidity of the transparotid approach during 2 years of
follow-up.
Patients and Methods: A total of 48 patients with condylar process Class II and IV fractures according
to classification of Spiessl and Schroll, were included in the present study. Of the 48 patients, 16 were
female and 32 male. The patient age range was 16 to 79 years (average 36.52). All patients were treated
using the transparotid approach, with rigid internal fixation using miniplates. Follow-up examinations
were performed for a minimum of 6.5 months and a maximum of 25 months (average 12.16) after
surgical treatment. At the follow-up examination, the patients completed the Mandibular Function
Impairment Questionnaire, and the examiner completed the Helkimo index. X-rays taken before, directly
after, and 6 months after surgery were compared.
Results: None of our patients had problems with wound healing; 2 patients developed a fistula of the
parotid gland; and 4 patients developed palsy of the facial nerve that was completely reversible after 6
weeks. The results of the Mandibular Function Impairment Questionnaire and the Helkimo index
revealed only a few subjective and objective problems after 6 months.
Conclusions: The transparotid approach to condylar process fractures is most appropriate for strongly
displaced Class II fractures. Especially for very old patients with dementia, for whom maxillomandibular
fixation is contraindicated, this approach is very appropriate. Another benefit to this type of patient is the
short operating time, with an average of 45 minutes.
2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:611-617, 2010

*Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Consultant, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Consultant, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Consultant, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Consultant, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Professor and Head, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany.

#Professor and Head, Department of Oral and Maxillofacial Surgery, Medical Center, Bremerhaven-Reinkenheide, Bremerhaven,
Germany.
Drs Klatt and Pohlenz contributed equally to this work.
Address correspondence and reprint requests to Dr. Klatt: Department of Oral and Maxillofacial Surgery (Nordwestdeutsche
Kieferklinik), University Medical Center Hamburg-Eppendorf, Martinistrae 52, Hamburg D-20246 Germany; e-mail: j.klatt@uke.unihamburg.de
2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/6803-0019$36.00/0
doi:10.1016/j.joms.2009.04.047

611

612

TREATMENT OF CONDYLAR PROCESS FRACTURES USING TRANSPAROTID APPROACH

Condylar fractures are the most common fractures of

the lower jaw, comprising approximately 30% of all
lower jaw fractures.1 Therefore, they play an important part in the trauma of the oral and maxillofacial
region. Apart from occurring as an isolated single or
double-sided fracture, they are often encountered in
combination with fractures of the lower jaw body and
alveolar ridge. The etiologic factors include falling on
the chin during sports injuries, vehicular accidents, or
assaults.
Because of the common occurrence of this fracture, various therapeutic options have been described. Currently, 2 main modalities can be defined:
conservative treatment with 10 to 14 days of immobilization of the lower jaw using dentally affixed splint
bandages; or surgical therapy, including the anatomically correct repositioning of the fragments and their
fixation with miniplates. For surgical therapy, different osteosynthesis procedures have been used. The
miniplate osteosynthesis of the condylar process using an extraoral approach is currently the most popular method, followed by the miniplate osteosynthesis using a transoral approach.
It is not only the type of osteosynthesis that determines the choice of the surgical approach. Other
factors, such as the anatomic positioning of the fracture of the condylar process, concomitance of additional jaw fractures, experience of the surgeon, possible complications, and, last but not least, cosmetic
considerations, are equally important.
Extraoral approaches such as preauricular, submandibular, or retromandibular approaches are frequently
used, because they facilitate better exposure of the operating field and thus simplify fracture repositioning
compared to the cosmetically more favorable transoral
approach and its endoscopically assisted modifications.2-4 Extraoral approaches, however, result in the

FIGURE 2. Intraoperative site of condylar process fracture.

Klatt et al. Treatment of Condylar Process Fractures Using
Transparotid Approach. J Oral Maxillofac Surg 2010.

risk of serious complications, especially those involving

the facial nerve. The pre- and postauricular approaches
are favored for intracapsular and more caudad fractures
of the condylar process, if, in these cases, osteosynthesis
is indicated.5 In contrast, submandibular and retromandibular approaches are mainly used for more caudad
fractures of the condylar process.6
For more caudad fractures for which surgical therapy
is indicated, a transparotid, retromandibular approach
according to Ellis and Zide7 is used at our institution (Fig
1). The main difference from extraoral approaches, such
as the submandibular approach, is the direct transparotid exposure of the condylar process region, respectively the fractured area, from the skin incision (Figs 2,
3). Hence, considerably less tissue needs to be displaced, especially compared with the submandibular
approach, allowing a clearer exposure of the mandibular branch and condylar region.
Because of these differences, a prospective study evaluating the morbidity of the retromandibular transparotid

FIGURE 1. Intraoperative site with transparotideal/retromandibular incision lines marked.

FIGURE 3. Condylar process fracture after rigid internal fixation

with Synthes 2.0 DCP plate.

Klatt et al. Treatment of Condylar Process Fractures Using

Transparotid Approach. J Oral Maxillofac Surg 2010.

Klatt et al. Treatment of Condylar Process Fractures Using

Transparotid Approach. J Oral Maxillofac Surg 2010.

613

KLATT ET AL

approach, with regard to nerve injury, wound healing,

and other surgical and functional complications was
completed.

Patients and Methods

A total of 48 patients treated using a transparotid
approach were included in the present study. The 48
patients had a total of 60 condylar process fractures.
The patients underwent follow-up examinations at
regular intervals at the University Medical Center
Hamburg-Eppendorf. The sutures were removed 7 to
10 days postoperatively. At 3 and 6 months postoperatively, the patients underwent radiologic assessment. After the 6-month x-ray examination and before
plate removal, clinical follow-up examinations com-

plemented the radiologic assessment. The follow-up

entailed analysis of the pre-, intra-, and postoperative
results of the patients, including the pre-, intra, and
postoperative x-ray diagnostics (pre- and postoperative panoramic view and Clementschitsch view).
The follow-up examinations were performed according to a fixed protocol. First, the patients underwent radiologic examination, including a panoramic
view and Clementschitsch view. On the basis of the
preoperative imaging findings, the fractures were
classified according to Spiessl and Schroll8 (Figs
4A,B). Furthermore, the angle of displacement of the
condylar process in relation to the ramus mandibulae
was determined in the preoperative, postoperative,
and 6-month postoperative images (Figs 5A,B). The
eventual existence of ramus shortening was analyzed

FIGURE 4. Right, Preoperative condylar process fracture and Left, corpus fracture. A, Panoramic view and B, Clementschitsch view.
Klatt et al. Treatment of Condylar Process Fractures Using Transparotid Approach. J Oral Maxillofac Surg 2010.

614

TREATMENT OF CONDYLAR PROCESS FRACTURES USING TRANSPAROTID APPROACH

FIGURE 5. Same fracture as in Figure 4 after open reduction and rigid internal fixation. A, Panoramic view and B, Clementschitsch view.
Klatt et al. Treatment of Condylar Process Fractures Using Transparotid Approach. J Oral Maxillofac Surg 2010.

using the preoperative images compared with the immediate postoperative images and the 6-month postoperative images. The x-ray images were evaluated according to the work of Eckelt9 and Hrle et al.10 An
additional classification of the postoperative fragment
positioning was performed using the classification of
Mokros and Erle11 of the repositioning results after joint
process fractures. Also, the data sets of the Arcadis Orbic
3D C-arm (Siemens Medical Solutions, Erlangen, Germany) were individually evaluated (Fig 6). The descriptive statistic showed how many patients did not require
an additional revision operation owing to the results of
intraoperative three-dimensional imaging.
Additionally, photographic documentation of the
functional mobility and photographic documentation
of extraoral scarring were performed. Patients completed the Mandibular Function Impairment Questionnaire (MFIQ).12,13 The clinical examination included the
parameters of nerve injury, mouth opening, wound

healing, scar length, salivary fistula, functional outcome,

permanent deflection of the lower jaw, asymmetry of
the face, scar pain, occlusional dysfunction, and temporomandibular joint disorders. Functional impairment
was measured using the Helkimo dysfunction index.14

Results
From January 2005 to April 2007, 48 patients with a
condylar process type II fracture according to Spiessl
and Schroll8 underwent surgery with the transparotid
approach at the University Medical Center, HamburgEppendorf. The 48 patients included 16 females and 32
males. Of the 48 patients, 17 did not return for the
follow-up examination at 6 months postoperatively and
29 did. The 48 patients had a total of 60 fractures. The
fractures were classified as 53 type II fractures, 5 type I
fractures, 1 type VI fracture, and 1 type III fracture,
using the system by Spiessl and Schroll.8 The average

615

KLATT ET AL

FIGURE 6. Intraoperative 3-dimensional reconstruction. SSD, surface-shaded design.

Klatt et al. Treatment of Condylar Process Fractures Using
Transparotid Approach. J Oral Maxillofac Surg 2010.

patient age was 36.52 years (range, 16 to 79). The

age-related classification of the patient groups revealed a
peak incidence in patients between 20 and 30 years old.
The main cause for mandibular fractures in this group
was associated with cycling (18 patients). A similar
quantity of fractures was caused by violence (16 patients) or when walking and stumbling or during a domestic accident (10 patients). Only a small number of
the patients were injured by a traffic accident, if we
excluded the cycling population (1 patient injured in a car
accident and 1 in a motorcycle accident). One case involved a drug addict who had jumped from the fourth floor
of a building, and another case, a patient who was trapped
between 2 panes of glass during an accident at work.
The analysis of the preoperative x-ray images showed
13 condylar process fractures with a dislocation of the
proximal fragment in a posterior medial direction. In
another 17 fractures, the proximal fragment was dislocated in an anterior-medial direction. Also, 12 fractures were posterior laterally displaced, 11 anterior
laterally, 3 medially, and 1 laterally. Of the 48 patients,
2 showed symptoms of a wound healing disorder in
the region of entry for the transparotid approach,
accompanied by the development of a salivary fistula.
These patients experienced spontaneous healing of
the salivary fistula, followed by a normal healing process. No patient showed signs of eminent hematoma
or seroma. Of the 48 patients, 4 showed temporary
facial atony; however, none of these 4 patients developed a permanent condition. The longest period until
complete recovery was 6 weeks.
The clinical examinations, using our clinical examination protocol, showed that the 29 patients had an
average internal space of 42.37 mm (range, 33 to 59).
Protrusion in the examined group was an average of
7.14 mm (range, 2 to 11.33). The mediotrusion analysis on the fractured side showed an average distance

of 8.32 mm (range, 2.66 to 15). The mediotrusion on

the nonfractured side was an average of 10.12 mm
(range, 7 to 15).
Five patients developed a permanent occlusion disorder. Two of these patients had had polytrauma with
multiple additional midfacial and lower jaw fractures.
One female patient had severe dislocated bilateral
collum fractures. Of the 29 patients, 2 had unilateral
ramus shortening, leading to facial asymmetry. Both
patients with ramus shortening had had polytrauma
with multiple additional mid-facial and lower jaw fractures. Five patients had lasting preauricular sensibility
disorders, including the 2 patients with polytrauma
and the patient with the dislocated bilateral fracture.
The evaluation of the Helkimo index revealed that
19 patients had no clinical dysfunction (D0), 8 had
slight clinical dysfunction (DI), and 2 had moderate
clinical dysfunction (DII). Of the 8 patients with slight
clinical dysfunction, 2 achieved 2 points and 6 patients achieved 1 point (range DI 1 to 4 points). The
evaluation of the MFIQ revealed that 19 patients experienced no functional limitation (grade 0), 5 had
slight functional impairment (grade I), 5 had moderate functional limitation (grade II), and none had
severe functional limitations (grade III).
Intraoperative imaging was performed after open
reduction and internal fixation on 34 patients, using
the Acardis Orbic 3D C-arm (Siemens Medical Solutions) under sterile conditions. Because of the results
of the intraoperative 3-dimensional imaging, a revision was performed in 4 patients (11.8%). The postoperative repositioning results were classified according to Mokros and Erle.11 One moderate reposition
result was evident. This was a lateral-anterior lengthening of the head of the bone, with postoperative
angular displacement of 30. The postoperative ramus
shortening was more than 10 mm. One patient had
satisfactory repositioning results, with an anterior angular displacement 42 and ramus shortening of 10
mm, postoperatively. However, the results using the
classification system of Mokros and Erle11 did not
correlate with our collected clinical results. The measuring technique must be criticized as being prone to
misinterpretation owing to the range differences in
the results produced from the x-ray images. In total,
26 of the 29 patients were satisfied with the operating
results and 3 were unsatisfied. The scar length was an
average of 17.05 mm (range, 10 to 25).

Discussion
The various types of surgical approaches to treat
the condylar process of the lower jaw are all associated with specific advantages and disadvantages. The
broad spectrum of approaches and the very different
surgical techniques make a comparison of the opera-

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TREATMENT OF CONDYLAR PROCESS FRACTURES USING TRANSPAROTID APPROACH

tional techniques for joint process fractures very difficult. For treatment of type II to IV fractures according to Spiessl and Schroll,8 the most commonly used
approaches are the submandibular (or Risdon) access,
periangular access, or the retromandibular/transparotid approaches.
Submandibular access is obtained by the surgeon
inserting 2 fingers laterally under the lower jaw,
through a 4 to 5-cm incision. Next, a large amount of
tissue must be moved and the masseter muscle and
glandula parotis prepared. Periangular access is obtained by incising the first skin flap below the mandibular angle.15 Access through the retromandibular/
transparotid is obtained 0.5 cm below the ear lobe
with direct preparation through the parotid gland and
masseter muscle on the fracture gap.16 All of these
techniques have the aim of treating the same type of
fracture. The differences in each technique make an
objective comparison of the complications difficult. Because of the direct access to the fracture, good visual
contact with the fracture, easy identification of the
facial nerve within the parotid gland, and the short
operative time made possible by the direct access, the
transparotid approach is our preferred method.
When considering the complications that can occur
after surgical treatment of fractures of the condylar process, only very small variations with respect to the incidence of complications have been found. In 1996, Chossegros and Cheynet17 examined 19 patients, all of
whom had undergone surgery with the retromandibular approach, for a 6-month period. The study found
no patient with permanent atony of the facial nerve,
although 1% experienced temporary atony; 11% of
the patients had a permanent occlusion disorder, 5%
a wound infection, 11% a temporary preauricular hypesthesia, and 5% extended scarring. A study by Ellis
and McFadden18 examined the complications after
extraoral osteosyntheses of the condylar process fractures. They examined 93 patients who had undergone
surgery using the retromandibular approach and 85
patients who had received conservative treatment.
During the 93 operations, contact with the facial
nerve was reported in 63. In no case was the nerve
severed. At 6 weeks postoperatively, 17.2% of the
patients still showed atony in the region of the facial
nerve. After 6 months, no patient reported facial atony. Manisali and Amin1 treated a condylar process
fracture using the retromandibular access route in 20
patients. Intraoperatively, they visualized the facial
nerve in 30% of the cases. Postoperatively, 30% of the
patients reported temporary atony of the facial nerve,
but none had permanent atony. Also, 10% reported
temporary atony of the major auricular nerve, and 5%
developed a salivary fistula, although the development stopped spontaneously. Devlin and Hislop19 reported on 40 patients, from 1991 to 1999, who were

examined at 3 weeks, 6 weeks, and 3 months after

treatment. All the patients had been treated using a
retromandibular approach; 7.5% of the patients had
developed facial atony, 5% had poor repositioning
results, and 5% had hypertrophic scarring. Vesnaver
and Gorjanc20 treated 34 patients with 36 fractures of
the condylar process. All patients were treated using
a transparotid facelift approach or extraoral retromandibular access. In their study group, 22% of the patients reported facial atony (duration 4 to 8 weeks).
One patient reported slight atony of the lower and
upper lip at 13 months postoperatively. Also, 14% of
the patients developed a fracture of the osteosynthetic plate (each with a 1.7 miniplate or smaller), and
14% developed a salivary fistula. A study by Vogt and
Roser21 reported on the possible advantages and disadvantages of extraoral treatment. They examined 48
patients with 42 fractures of the condylar process
type IIIV according to Spiessl and Schroll. All patients underwent surgery using the transparotidal approach. The following complications developed: 7.8%
developed a self-limiting salivary fistula, 19.6% developed temporary facial atony, 0% permanent facial
atony, 0% temporary occlusion disorder, and 6% (3
patients) a fracture of the osteosynthetic plate.
Our patients, who were treated using the transparotid
approach, had an overall low complication rate. Of our
patients, 10% had temporary atony of the facial nerve,
and no patient developed permanent atony of the facial
nerve. Five patients (16%) still had an occlusion disorder
6 months postoperatively (2 had had polytrauma and 1 a
double collum fracture). The 5 patients (16%) with persistent preauricular sensibility disorder were patients
who had experienced polytrauma or a double joint
process fracture. Finally, 4% of our patients developed a
self-limiting salivary fistula.
Apart from the different complications associated
with the different extraoral approaches, whether operative treatment of fractures of the condylar process
achieves better results than conservative therapy has
been discussed. Yang and Chen22 compared the results after conservative and operative therapy for this
fracture entity. The preoperative comparison showed
that patients who were treated using extraoral approaches had far greater dislocation in the frontal and
sagittal levels and ramus shortening compared with
patients treated conservatively. The results of their
study showed that the patients who had received
operative treatment, regardless of the severity of the
initial diagnosis, achieved the same level of function
as those who had been treated conservatively. A multicenter study by Eckelt and Schneider23 examined 66
patients with 79 condylar process fractures 6 weeks
and 6 months after the initial fracture. The final results
showed that both treatment methods produced acceptable results. However, Eckelt and Schneider23

KLATT ET AL

found operative treatment, regardless of the operative

method applied, to be in the ascendency compared
with conservative treatment.
Examination of intraorally treated condylar process
fractures has shown a wide range of results. Lee and
Young24 examined 40 patients, from 1995 to 1999,
who were treated transorally, with endoscopic assistance. Lee and Young24 found intraoral treatment of
condylar process fractures to be a valid therapeutic
option. A study by Jensen and Jensen25 came to a
different conclusion. They examined 15 patients with
24 condylar process fractures for a 23-month period.
They concluded that endoscopic intraoral treatment
of joint process fractures was technically a very difficult procedure and associated with a high rate of
complications. The main disadvantage of the intraoral
endoscopically assisted treatment was the long duration of the operation.3,26 Lee et al3 reported an average operative duration of 143 63 minutes.
The overview of complications reported during
clinical follow-up at the University Medical Center
Hamburg-Eppendorf showed similar results to those
of the previously cited studies. Most had good to
excellent reposition results, coupled with low levels
of patient problems. The analysis of the Helkimo
index confirmed the low level of clinical dysfunction
after extraoral treatment of condylar process fractures. The analysis of the patients MFIQ also confirmed the results. Additional studies that have used
the Helkimo index and MFIQ to collect data on clinical dysfunction showed that the operative treatment
of joint process fractures of the jaw leads to low levels
of dysfunction.23,27-30
Open reduction and rigid internal fixation of the condylar process using the transparotid approach is a recommended procedure for Class II fractures, as classified
according to Spiessl and Schroll.8 With the advantages of
minimal tissue alteration and rare complications and
sufficient exposure of the fracture site, this technique
has been proved to be a valid surgical alternative for the
treatment of condylar process fractures.

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