Controversies in

Mandibular Condyle
Fracture Repair 
Frederick Mars Untalan MD
Baguio General Hospital & Medical Center
  “Concerning the treatment of
condylarfractures, it seems that the battle
will rage forever between the extremists
who urge nonoperative treatment in
practically every case and the other
extremists who advocate open reduction in
almost every case.”


Malkin et al..



 Objectives
• To mention condyle fracture
treatment controversies (OPEN vs
CLOSE Treatment)
• To become aware of landmark
studies with regards treatment of
Condyle fracture
• To discuss possible future directions
to settle these controversies
Main treatments advocated for adults
with
condylar process fractures
 NONSURGICAL  SURGICAL



 1. a period of  3. open reduction

maxillomandibul with or without
ar fixation (MMF)
followed by internal
functional fixation.
therapy



 2. functional
therapy without
a period of MMF
 Conflicting Terminology

“closed “closed
reduction treatment”
” 

(misnome  “nonsurgical
r) treatment”
 

•
 CONDYLE fractures
 Type A: Type C :
fractures through the
 Intracapsular
lateral condylar
fractures of the
pole w/ loss of
mandibular vertical height of the
condyle mandibular ramus
Type B: Type M :


fractures multiple
through the fragments
medial condylar comminuted
pole fractures.
 Mandibular Condyle Fractures:
Evaluation of the Strasbourg
Osteosynthesis Research Group
sim p le m e th Classification o d to d e fin e C F s a n d ca n
• Journal of Craniofacial Surgery: January 2009 - Volume 20 - Issue 1 - pp 24-28
g• ivCenzi,
e so m eMD;eBurlini,
Roberto le m Dante
e n ts a b o Laura
MD; Arduin, u t MD;th Zollino,
e p ro g MD;
Ilaria n oGuidi,
sis .
Riccardo DDS; Carinci, Francesco MD

3 • m aAbstract
in typ e s o f C Fs:
• Condylar fractures (CFs) are about 30% of mandibular fractures. Condylar fractures are
1. d ia catreated
p itu lwith
a r fra ctuprotocols,
several re ( ie
. .,and thunsatisfying
ro u g h thoutcome
e h e aisd achieved
o f th einco n dcases.
some yle A
[ DF ]staging
) system for classifying CFs is of paramount importance to plan therapy, to define
prognosis, and to exchange information among trauma centers. The Strasbourg
Osteosynthesis Research Group proposed a classification system for CFs, but no report
2. fra ctufocusing
re o ftothitseeffectiveness
co n d yla ris nstill
e ckavailable. Thus, we performed a retrospective study
on a series of patients affected by CFs.
3. fra ctu re o f th e co n d yla r b a se ( C B F ).
• The Strasbourg Osteosynthesis Research Group classification defines 3 main types of CFs:
Fra ctu re s o f th e co n d yla r b a se a re th e m o st
diacapitular fracture (i.e., through the head of the condyle [DF]), fracture of the condylar
neck, and fracture of the condylar base (CBF). A series of 66 patients (and 84 CFs) was
evaluated, and age, sex, clinical diagnosis at admission, treatment, and outcome were
( 52 . 4 % )
considered.
• Fractures of the condylar base and DFs are the most (52.4%) and the least (4.8%) frequent
D Fs lfractures,
e a strespectively.
( 4 . 8 %Conversely,
) fre q associated
u e n t fractures
fra ctu refacial
of the s skeleton are found
in most cases of DFs (75%) and in few cases of CBFs (20.5%). Surgery was performed in
about 15% of all cases: no DF was operated, whereas fractures of the condylar neck and
CBFs have an open reduction and an internal rigid fixation in 57% and 43%, respectively.
Postsurgical and late sequelae were 22.3% and 19%. Temporomandibular joint
Te m p o ro m a n d ib u la r jo in t sym p to m s a n d
symptoms and malocclusion cover about 80% and 90% of postsurgical and late
sequelae.

m • a lThe
o ccl u sio n co ve r a b o u t 8 0 % a n d 9 0 % o f
new classification is a simple method to define CFs and can give some elements about
the prognosis.

p o• stsu rg ica la n d la te se q u e la e .
The treatment of condylar fractures: to
open or not to open? A critical review
of this controversy
• techniques must be chosen taking into consideration the
•
presence of teeth, fracture height, patient's adaptation,
Renato VALIATI,1* Danilo IBRAHIM,1* Marcelo Emir Requia ABREU,1* Claiton HEITZ,2* Rogério Belle de
OLIVEIRA,2* Rogério Miranda PAGNONCELLI,2* and Daniela Nascimento SILVA2*

• Thepatient's
treatmentmasticatory system, fractures
of condylar process disturbance of occlusal
has generated a great
function
deal of discussion and controversy in oral and maxillofacial of
, deviation of the mandible , internal derangements
the trauma
temporomandibular
and there areJoint
many(TMJ ) and methods
different ankylosistoof thethis
treat joint
injury. with resultant inability to move the jaw
• For each type of condylar fracture, the techniques must be chosen
taking into consideration the presence of teeth, fracture height,
in recent
patient's years
adaptation, open
patient's
, treatment
masticatory system, of
disturbance
of occlusal function, deviation of the mandible, internal
condylar
derangements fractures with rigid
of the temporomandibular Jointinternal
(TMJ) and
ankylosis of the joint with resultant inability to move the jaw, all
fixation
of (RIF) of
which are sequelae hasthisbecome more
injury. Many common
surgeons seem to
favor closed treatment with maxillomandibular fixation (MMF),
but in recent years, open treatment of condylar fractures with
rigid internal fixation (RIF) has become more common.
• The objective of this review was to evaluate the main variables
that determine the choice of method for treatment of condylar
fractures: open or closed, pointing out their indications, contra-
indications, advantages and disadvantages.
 Interventions for the
treatment of fractures of the
mandibular condyle
Sharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R
• Fractures of the condylar process of the mandible (lower
closed approach
jaw) are common. the complications
include disturbances
• Two treatment in the either
options are available: way the teeth
closed
treatment (withoutasymmetry
meet, facial surgery) or open reduction
, chronic (involving
pain and
surgery).
reduced mobility of the lower jaw.
• Complications are associated with both treatment
modalities.
– With a closed approach the complications include
open approach
disturbances in the way the theteeth
complications
meet, facial
includeasymmetry,
a scar chronic
on the pain and reduced
overlying mobility
skin and of the
also
lower jaw.
the possibility
– With of temporary
an open approach paralysis
the complications of athe
include scar on
nervethesupplying some
overlying skin and ofalsothe facial muscles
the possibility of temporary
paralysis
involved in of the nerve
smiling andsupplying
eye some of/closing
opening the facial.
muscles involved in smiling and eye opening/closing.
• Currently there is much controversy regarding the most
appropriate method for the management of fractured
mandibular condyles.
• This review revealed that there is a lack of high quality
evidence for the effectiveness of either approach, and
Fractures of the mandibular
condyle. Therapeutic
controversies
• ActaMed Port. 1999 Apr-Jun;12(4-6):209-15. Martins JS,
T h e m a in g o a lo f tre a tm e n t is
Frage ZB.
restoration of function and not
• Serviço de Cirúrgia Plástica e Reconstrutiva, Hospital Egas
Moniz, Lisboa.
anatomic restoration of parts.
• Abstract
• The condylar mandibular fractures are important because
its incidence, possible complications and controversial
treatment. The treatment of condylar fractures has
Despite
generated several clinical
more controversy andand anatomical
discussion than any
other in still
studies the fieldlack
of maxillofacial
consensus trauma.regarding
The main goal
of treatment is restoration of function and not anatomic
the best
restoration method
of parts. Despiteof treatment
several .
clinical and
anatomical studies still lack consensus regarding the
best method of treatment. This review article focus on
the controversy that surrounds treatment of the condylar
fractures, trying to supply consensus about questions
like: Should condylar mandibular fractures be managed
via a closed or open technique? What is the best surgical
approach? Surgical timing? What is the degree and
duration of mandibular immobilization? Is or not
The majority of surgeons seem to favor
non surgical treatment of
condylar fractures.

3 main factors.



 Is MMF
Necessary/Desirable?
 2 main treatments advocated when
performing closed treatment:
1) a 2)


 period of functional
MMF therapy
followed without a
by period of
functiona tradition MMF.
l therapy and
experience
 MMF is instituted for 3 main
reasons:

• to make the patient more

comfortable
• to promote osseous union
• to help reduce the fractured
fragment
•
? ? ?
 Unilateral mandibular
condylarfractures: 31-year
follow-up of non-surgical treatment
• 1National Dental Service, Söndrum, Getinge, Sweden
•
• 3
87 %
2National
of patients reported no pain from
Dental Service, Örebro, Sweden
Department of Oral and Maxillofacial Surgery, University Hospital MAS, Malmö, Sweden
• 4 the jaws
Department of Oral Surgery and Oral Medicine, Faculty of Odontology, University of Malmö,

•
83% no problems chewing
Malmö, Sweden
Accepted 8 November 2006. 
• 91%onlinereported
Available 18 January 2007. no impact of the fracture
•
•
on daily activities.
Abstract
At the University Hospital of Malmö, Sweden, standardized trauma charts were used for
registration of all jaw fractures from 1972 to 1976.
• During the year 2005 the aim was to interview all patients treated non-surgically for
Neck and shoulder symptoms were reported
unilateral mandibular condylar fractures during this period.
•
by 39% and back pain by 30%.
In total, 49 patients with unilateral condylar fractures were treated non-surgically in 1972–
1976.
• Of these, 23 patients were available for follow-up, 17 were dead, 7 were not found and 2 did
not answer letters or phone calls.
• The follow-up was a telephone interview according to a standardized questionnaire
concerning occurrence of pain and headache, function of the jaw and joint sounds.
• Information from original records, radiographic reports and the standardized trauma charts
revealed fracture site, type of fracture and intermaxillary fixation if any.
• Eighty-seven percent of the patients reported no pain from the jaws, 83% had no problems
chewing and 91% reported no impact of the fracture on daily activities.
• Neck and shoulder symptoms were reported by 39% and back pain by 30%.
• The 31-year results of non-surgical treatment of unilateral non-dislocated and minor
 Botulinum toxin in closed
treatment of mandibular
C lo se d tre a tm e n t w a s a p p lie d th ro u g h :
1. in je ctio n condylar
o f 1 0 0 u n its o f b o tufracture
lin u m to x in A , diluted to a
• Ann Plast Surg. 2007 May;58(5):474-8. Canter HI, Kayikcioglu A, Aksu M, Mavili ME.
coHacettepe
n ce n traUniversity,
tio n o fFaculty
2 0 IUof/ mMedicine,
L , in to th e m uofscl
Department e s and
Plastic o f Reconstructive
m a stica tio n
o f th e fra ctu re d sid e . M a sse te r a n d a n te rio r fib e rs o f
Surgery, Ankara, Turkey. hicanter@gmail.com
• Abstract
•
te m p o ra lis m u scle s w e re re a ch e d th ro u g h p e rcu ta n e o u s
BACKGROUND: The topic of condylar injury in adults has generated more discussion and
extra o ra lro
controversy u te
than anyaother
n d 3in0theIUfield
o fofth e toxin trauma.
maxillofacial
fractures in adults is still a highly debated theme.
w a s inThe
je treatment
cte d toofecondylar
a ch
• m u sclePatients
METHODS: . with unilateral subcondylar or condylar neck fractures of the mandibula
2. A d dtreatment
itio n a lprotocol.
without any 4 0 IUClosed
significant oangulation
f th e to x incondylar
of the w a s head
in je were
cte dmanaged
a ro u nwith
d th e
closed-
treatment was applied through the injection of 100 units of
frabotulinum
ctu re toxin
d b A,
o ndiluted
e fra to g m e n ts thofro20u IU/mL,
a concentration g h tra n sm
into u co saofl mastication
the muscles
of the fractured side. Masseter and anterior fibers of temporalis muscles were reached
in tra o rapercutaneous
through lro u te toextraoral
p a ra lyze m e30
route and d iIU
a la n dtoxin
of the la tewas
rainjected
lp te ryg o idmuscle.
to each
Additional 40 IU of the toxin was injected around the fractured bone fragments through
m utransmucosal
scle s a s intraoral
m u chroute a s ptooparalyze
ssib lemedial
. and lateral pterygoid muscles as much
as possible. An asymmetric occlusal splint was applied for maxillomandibular fixation to
3. A n restore
a sy mthem vertical
e tricheight
o cclu sadays.
for 10
elastics was advocated for 2 months.
l spFunctional
lin t w therapy
a s a pwith
p lieintermaxillary
d fo r guiding

• m a xillThere
RESULTS: o m awere
n d ibnoucomplications
la r fixa tiorelated
n to to reeither
sto re thinjections
toxin e ve rtior casplint
lh eapplication
ig h t fo r
1 0procedures.
d a ys. The toxin was effective on all occasions. Fractured condylar process and
ramus of the mandibula were in good approximation and remained in reduced positions.
4 . F u None
n ctio n apatients
of the l th e rahadpanyy occlusal
with intermaxillary
dysfunction in the follow-up period.
disturbance, mandibular guiding
asymmetry,elastics
or joint

w a s a d vo ca We te d fothat
r 2 modification
m o n th s.of treatment options concerning the clinical
•
to relieve the spasm of muscles of
CONCLUSIONS: believe
situation of the patients is the best method for condylar injury. The purpose of this study
mastication, along with special splint
is to present and discuss the results achieved in closed treatment of a selected group of
patients with mandibular condylar fractures to whom botulinum toxin A was injected to
relieve the spasm of muscles of mastication, along with special splint application.
application.
 OPEN TREATMENT
becoming more common, probably
because of the introduction of plate
and screw fixation devices that allow
stabilization of such injuries.
no definitive study performed that has

shown the superiority of open

versus closed reduction
Unfortunately, the type of study

needed to clarify this question may

never be possible.
 Is Open Reduction and Internal Fixation of
Condylar Process Fracture Biologically Sound?

a v a ila b ility o f SA FE
p la te &
scre w fix a tio n ??
• To determine
sy ste m s whether or not open
treatment of condylar process
fractures is biologically sound:
– 1) the blood supply to the condyle,
– 2) whether or not the blood supply is
essential to open treatment.
condyle blood supply is mostly
derived
from 3 sources
 Indications for open reduction and rigid
internal fixation of mandibular condyle
fractures
(MITCHELL, 19971; HAUG and ASSAEL, 200119; BRANDT and HAUG, 200330)

Absolute Indications:
 Relative Indications:


• Patient preference (when no • Edentulous jaws

absolute or relative
contraindications co-exist)
• When manipulation and closed
treatment cannot re-
establish the pretraumatic
occlusion;
• mutliple facial fractures
• When stability of the occlusion
is limited
• Displacement into the middle
cranial fossa
• Lateral extracapsular deviation
• Open fracture with potential for
fibrosis
• Invasion by foreign body.
• Periodontal problems
• Bilateral condylar fractures in an
edentulous patient without a splint
• Unilateral or bilateral condylar fractures
where splinting cannot be
accomplished for medical reasons or
because physiotherapy is impossible
• Bilateral condylar fractures with
comminuted midfacial fractures,
prognathia or retrognathia;
• Unilateral condylar fracture with unstable
base;
• Displaced condyle with edentulous or
partially edentulous mandible with
posterior bite collapse;
• Noncompliance
• Uncontrolled seizure disorders
• Status asthmaticus
• Obtunded neurologic status with
documentation of predicted
improvement
• Psychologic compromise (e.g., mental
 Contraindications to open reduction and rigid
internal fixation of mandibular condyle
fractures
(MITCHELL, 19971; HAUG and ASSAEL, 200119; BRANDT and HAUG, 200330).
Absolute
 Relative


Contraindications: Contraindications:
• Condylar head fractures • When a simpler
(at or above the method is as
ligamentous
attachment—single effective
fragment,
comminuted, or • Condylar neck
medial pole) fractures (the thin,
• When medical illness or constricted region
systemic injury add inferior to the
undue risk to an
extended general condylar head)
anesthetic • Obtunded neurologic
• Good occlusion status when there is
• Minimal pain no documented
• Acceptable mandibular hope for
movement.
 Surgical versus conservative
treatment of unilateral condylar
process fractures: Clinical and
radiographic evaluation of 80
U sin g clin ica l p a patients
• Volume 50, Issue 4, Pages 349-352 (April 1992)
ra m e te rs ( m a x im a l m o u th
• Vitomir S. Konstantinović, DDS, Branislav Dimitrijević, DDD,
o p e n in g , d e v ia tio n , p ro tru sio n ) , n o
PhD
sta tistica l d iffe re n ce s b e tw e e n su rg ica lly
• Abstract 
• aTreatment
n d co n se rv a tiv
results e lysurgically
of 26 tre a te d and
fra ctu
54 re s w e re
conservatively treated unilateral condylar process
fo u n d by
fractures were investigated . standardized clinical
examination and by evaluation of computer-simulated
graphic presentations of posteroanterior (PA) radiographs
However , the radiographic examinations
of the mandible.
• showed a statistically
The radiographic better
evaluation compared position
the relation ofof
actual
reduction of the condylar process fractures with ideally
the surgically
reduced reduced oncondylar
fractures produced process
the computer.
• Using clinical parameters fractures
(maximal . mouth opening,
deviation, protrusion), no statistical differences between
surgically and conservatively treated fractures were
found.
• However, the radiographic examinations showed a
statistically better position of the surgically reduced
 Functional Results of Unilateral
Mandibular Condylar Process
Fractures after Open and Closed
Treatment
Journal of Trauma-Injury Infection & Critical Care: March 2002 - Volume 52 -
• 66 patients with unilateral mandibular condylar process fractures
Issue 3 - pp 498-503
were reviewed. 36 patients received open reduction
• 30 Yang, Wen-Guei
underwent MD;
closed Chen, Chien-Tzung
treatment MMF only MD; Tsay, Pei-Kwei PhD; Chen,
Yu-Ray MD
• Abstract
Backgroundsubgroup
• condylar : This retrospective
with study
opencompared
reductionthe functional results ofless
presented
unilateral mandibular condylar process fractures treated either by open
chin reduction
deviation ( 21 . 43
or by closed %) compared with those with
treatment.
• closed
Methodstreatment ( 56 .with
: Sixty-six patients 25 %)unilateral mandibular condylar process
fractures were reviewed. Thirty-six patients received open reduction, and
the other
condylar 30 underwent
neck or head closed treatment
fractures (intermaxillary
gained fixation only).
more benefits fromEach
group was further divided into condylar and subcondylar subgroups
open to
according reduction in The
fracture level. terms of chin
functional deviation
outcome and by
was evaluated
posttreatment temporomandibular
occlusion status, maximal joint
mouth painopening,
. facial symmetry,
chin deviation, and temporomandibular joint symptoms.
For subcondylar fractures, open reduction provides
• Results : Patients undergoing closed treatment exhibited more condylar motility
satisfactory functional
than those treated results Patients
by open reduction. in patients with severely
in the condylar subgroup with
open reduction presenteddisplaced
less chinfractures .
deviation (21.43%) compared with those
with closed treatment (56.25%;p = 0.072). Although a greater severity of
subcondylar fractures existed in patients treated with open reduction,
patients treated with open reduction or closed treatment did not reveal a
significantly functional difference.
• Conclusion : The present study revealed that patients with condylar neck or
head fractures gained more benefits from open reduction in terms of chin
deviation and temporomandibular joint pain. For subcondylar fractures, open
reduction provides satisfactory functional results in patients with severely
 Open Reduction and Internal Fixation Versus Closed
Treatment and Mandibulomaxillary Fixation of
Fractures of the Mandibular Condylar Process: A Randomized,
Prospective, Multicenter Study With Special Evaluation of
Fracture Level
• TheThe difference
average
J Oral Maxillofac in;66average
painDec
Surg. 2008 level mouth0
(VAS from
(12):2537-2544 opening
to 100) 25 wasafter
12 mmCRMMF
(P ,
• Matthias Schneider</=. 001
and
Francois between
)Erasmus,
1 after both
Louistreatment
ORIF
Klaus P </=.001
(Gerlach, groups
).
Eberhard .
Kuhlisch, Richard A
Loukota, Michael Rasse, Johannes Schubert, Hendrik Terheyden, Uwe Eckelt
• Consultant, Department of Oral and Maxillofacial Surgery, Technical University of Dresden,
In 53
Dresden, unilateral fractures, better functional
Germany.
•
results were observed
and whetherfor ORIFfracture
compared
level was awith
PURPOSE: This randomized, clinical multicenter trial investigated the treatment outcomes of
displaced condylar fractures, radiographic prognostic
factorCRMMF , irrespective
in therapeutic of
decision-making fracture
between level
open reduction (
andcondylar
internal fixation
(ORIF) versus closed reduction and mandibulomaxillary fixation (CRMMF).
•
base, neck, or intracapsular head).
PATIENTS AND METHODS: Sixty-six patients with 79 displaced fractures (deviation of 10
degrees to 45 degrees , or shortening of the ascending ramus >/=2 mm) of the condylar
process of the mandible at 7 clinical centers were enrolled. Patients were randomly
In patients
allocated to CRMMFwith
(n = 30bilateral
patients) or ORIFcondylar fractures
(n = 36 patients) treatment. The, following
parameters ORIF was especially
were measured 6 months after theadvantageous
trauma. Clinical parameters
. included
mouth opening, protrusion, and laterotrusion. Radiographic parameters included level of
the fracture, deviation of the fragment, and shortening of the ascending ramus.
Subjective parameters included pain (according to a visual analogue scale), discomfort,
and subjective functional impairment with a mandibular functional impairment
questionnaire.
•
Fractures with a deviation of 10
CONCLUSION:
RESULTS: The difference in average mouth opening was 12 mm (P </=.001) between both
degrees to 45 degrees or a shortening of the
treatment groups. The average pain level (visual analogue scale from 0 to 100) was 25
after CRMMF, and 1 after ORIF (P </=.001). In 53 unilateral fractures, better functional
ascending ramus >/= 2 mm , should be treated
results were observed for ORIF compared with CRMMF, irrespective of fracture level
(condylar base, neck, or intracapsular head). Unexpectedly, the subjective discomfort
with ORIF , irrespective of level of the
level decreased with ascending level of the fracture. In patients with bilateral condylar
fractures, ORIF was especially advantageous. CONCLUSION: Fractures with a deviation of
fracture .
10 degrees to 45 degrees , or a shortening of the ascending ramus >/=2 mm, should be
treated with ORIF, irrespective of level of the fracture.
 Intracapsular condylar fracture of the
mandible: our classification and open
treatment experience
• J Oral Maxillofac Surg. 2009 Aug ;67 (8):1672-9  19615581  Cit:1
• treatment
Dongmei protocol
He, Chi Yang, is Bin
Minjie Chen, open
Jiang,reduction
Baoli Wang for a fracture
• in which
Department theandsuperolaterally
of Oral dislocated
Maxillofacial Surgery, Ninth ramus
People's Hospital, stump
Shanghai Jiao Tong
isChina.
out of the glenoid fossa or any type of fracture
University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai,

• PURPOSE: We studied the classification of intracapsular condylar fracture (ICF) of the

mandible based on coronal computed tomography (CT) scans and present our open
type A : treatment
fracture line
experience thru
at the lateral joint
temporomandibular third of condylar
(TMJ) division of Shanghai's Ninth
head w / reduction of ramus height
People's Hospital (Shanghai, China).

type
•
B : our
fracture
division. Amonglinethem,through middle
195 patients (269 third
joints) had CT scans of condylarWe
MATERIALS AND METHODS: From 1999 to 2008, 229 patients with 312 ICFs were treated in
for classification.
head modified the classification of Neff et al, adding a new fracture type according to our
experience: type A, fracture line through lateral third of condylar head with reduction of
type C : ramus
fracture line
height; type through
B, fracture medial
line through third
middle third of head;
of condylar condylar
type C,
head fracture line through medial third of condylar head; and type M, comminuted fracture of
condylar head. There was no ramus height reduction in fracture types B and C. Our
type postoperative
M : treatment
comminuted protocol isfracture
dislocated ramus stumpCTopen reduction of
isscans
out of theshowed
condylar
for a fracture
glenoid fossa
in whichhead
that
or any 95
type. 6
of%
. of with displaced
the superolaterally
fracture
these had absolute
or dislocated fragments that anatomic or nearly
may cause TMJ dysfunction later. anatomic
• reduction
RESULT: Among. the 269 joints, 116 had type A fractures (43.1%), 81 had type B fractures
(30.1%), 11 had type C fractures (4.1%), and 58 had type M fractures (21.6%); 3 joints
In all
(1.1%) of them that
had fractures normal
were notmouth
displaced.opening andhad open reduction-
Of the joints, 173
internal fixation; postoperative CT scans showed that 95.6% of these had absolute
occlusion wereanatomic
anatomic or nearly restoredreduction. In all of them normal mouth opening and
occlusion were restored. No or little deviation was found during mouth opening.
Complications were pain in the joint (n = 1), crepitations (n = 2), and facial nerve
(temporal branch) paralysis (n = 1). Two patients had the plate removed because of
these complications.
• CONCLUSION: Our new classification based on CT scans can better guide clinical treatment.
Open reduction for ICF can restore the anatomic position for both the condyle and TMJ
Mini-retromandibularapproach to
condylar fractures
• Journal of cranio-maxillo-facial surgery : official publication of the European Association for
Cranio-Maxillo-Facial Surgery. 01/08/2008; Authors: Federico Biglioli, Giacomo Colletti
• INTRODUCTION: Among maxillofacial surgeons, a general agreement exists that the

fixation and healing can be managed

therapeutic strategy for intracapsular condylar fractures is conservative, while the
treatment of extracapsular fractures of the mandibular condyle is extremely
controversial. The indications and choice of treatment are less than uniform, often
comfortably using a limited
relying on the surgeon's personal experience and beliefs. The literature increasingly
suggests that the surgical management of these fractures is superior to conservative
retromandibular approach.
management in functional terms. Nonetheless, the indications for surgically treating
condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral

Moreover, the risk of facial nerve injury

routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral
access is free from these pitfalls but is demanding technically, especially for higher neck
fractures. In our experience, a 2-cm-long retromandibular access allows straightforward
is limited as the nerve fibres are viewed
management of condylar fractures, providing as a result a well concealed scar.

directlyaccess.
• MATERIALS AND METHODS: From 2006 to 2007, 21 patients with 25 condylar fractures were
treated surgically using the mini-retromandibular . The mean operating time was
32min (range 17-55min). No facial nerve injuries were observed. The first two patients
developed postoperative infections. One patient, in whom the first intervention resulted
in malreduction of the fracture because the access was insufficient (15mm incision),
required a second operation to achieve correct reduction and rigid fixation of the
condyle.
• RESULTS: In all cases, good anatomical stump reduction was achieved. All the patients
obtained good articular function, since the access was exclusively extra-articular.
• CONCLUSIONS: Condylar fracture reduction, fixation and healing can be managed
comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve
injury is limited as the nerve fibres are viewed directly.
 Endoscopic-assisted repair
of subcondylar fractures
• Volume 96 Issue 4 Pages 387-391 (October 2003) Michael Miloro DMD, Md
• Abstract 
• EObjective
n d o sco p ic a p p ro a cvh
• MTo evaluate
Mendoscopic
F w outcomes
a sreduction
u seofdaand
infixation.
tra
series o p e ra ti
of mandibular ve ly tofractures
subcondylar a id irepaired
n frawith
ctu re
• re d udesign
Study ctio n .
•
MSixoconsecutive
d ifi
was e dintraoperatively
used R isd o n itonaidcisi o n reduction. A modified Risdon incision was
subcondylar fractures were treated endoscopically. Intermaxillary fixation
in fracture
used to gain access to the lateral ramus, and a modified retractor and endoscope were
used for retraction and visualization. Fracture fixation was achieved with a 2-mm
titanium plate and screws. Patients were evaluated clinically and radiographically for 6
months and functional, radiographic, and esthetic parameters were assessed at each
E n d o sco p ic - a ssiste d re p a ir o f
time period (1, 2, 4, 12, and 24 weeks).
•
•
su b co n d y la r fra ctu re s is a n a d d itio n a l
Results
All patients demonstrated a stable occlusion in the postoperative period and anatomic
toalignment
waso 42.2
l fo±ofr5.7themmm.
a There
n aradiographically.
condyle gwas
e mno joint
e nnoise
t Byo or
fmonth,
1 su bmaximum
co n d interincisal
y joint
temporomandibular la r(TMJ)opening
pain
fra ctu re s cases. There was minimal transient facial nerve paresis following
postoperatively. Radiographs at each follow-up visit indicated the ramus height was
maintained in most
surgery. Scar perception was considered acceptable by all patients. Operative times
were acceptable as well.
• Conclusion
• Endoscopic-assisted repair of subcondylar fractures is an additional tool for management of
subcondylar fractures, however there is a steep learning curve based on this study. The
technique allows good visualization of the fracture site for reduction through an incision
with an acceptable cosmetic result.
 Endoscopically Assisted
Mandibular Subcondylar
•
Fracture Repair
Plastic & Reconstructive Surgery: January 1999 - Volume 103 - Issue 1 - pp 60-
65
• Chen, Chien-Tzung M.D.; Lai, Jui-Ping M.D.; Tung, Tung-Chain M.D.;
Chen, Yu-Ray M.D.
• Abstract b e tte r v isu a liza tio n
•
p re cise a n a to m ic a lig n m e n t o f b o n y
The endoscope has been widely used in aesthetic surgery in recent years, but
rarely has it been used in cases of facial trauma. From July of 1996 to
December of 1996, the endoscope was used successfully to assist in the
se g m e n ts th e a v o id a n ce o f la rg e fa cia l
repair of mandibular subcondylar fractures in eight patients (five men and
three women). Their ages ranged from 15 to 60 years with an average age
sca rs a n d fa cia l n e rv e in ju rie s
of 31 years. Six of the patients had other associated mandibular fractures
including angular, parasymphyseal, and contralateral subcondylar fractures.
A 4.0-mm, 30-degree telescope was introduced to visualize the fracture site
by means of an intraoral incision over the ascending ramus. A miniplate was
used to stabilize the fracture site with the help of a percutaneous trocar.
Intermaxillary fixation was applied for 3 to 6 days. Functionally, all patients
returned to normal range of motion within 8 weeks. A slight deviation to the
trauma site was noted on maximal opening in three patients, but this
condition returned to normal 3 months after surgery. There was no facial
palsy or lip numbness. The benefits of the endoscopic approach include not
only the provision of better visualization and precise anatomic alignment of
bony segments but also the avoidance of large facial scars and facial nerve
injuries.

•
 Open reduction and internal rigid
fixation of subcondylar fractures via an
intraoral approach
• Oral
A n Surgery,
in tra o raOral
l a pMedicine,
p ro a ch Oral
w ithPathology
a p e rcu ta n e o u s
Volume 71, Issue 3, March 1991, Pages 257-261
tro ca r a n d m in ip la te s d e m o n stra te d
• Joachim Lachner D.M.D., M.D.a, a, Jerald T. Clanton
saD.M.D.,
tisfa ctoM.D.ryb, re d u ctio
a and Petern .D. Waite D.D.S., M.D., ( a
p re a,uc,ricu
M.P.H. a la r o r su b m a n d ib u la r in cisio n )
• aDepartment of Oral and Maxillofacial Surgery,
E a rly of
University fu Alabama
n ctio n watith p ro p e r v Birmingham,
Birmingham e rtica l
Ala.,
d imUSA
e n sio n w a s re sto re d w ith m in im a l
• Extraoral open reduction
p o sto and
p e ra tiv e rigid fixation
m o rb id ity . of
mandibular subcondylar fractures is controversial
among surgeons. An intraoral approach with a
percutaneous trocar and miniplates demonstrated
satisfactory reduction. This technique can be more
easily performed than a preauricular or
submandibular incision, and risk of facial nerve
damage is diminished. Early function with proper
vertical dimension was restored with minimal
postoperative morbidity.
 Closed versus open reduction of
mandibular condylar fractures in
adults: a meta-analysis
Medline
• Journalsearch
of oral and maxillofacial surgery : official journal of the American
"mandibular condyleoffractures"
Association Oral and Maxillofacial Surgeons. 01/07/2008; 66(6):1087-92.
Authors: Marcy L Nussbaum,
"mandibular condyle fracture surgery" Daniel M Laskin, Al M Best
• PURPOSE: A review of the literature shows a difference of opinion regarding
whether open or closed reduction of condylar fractures produces the best
results. It would be beneficial, therefore, to critically analyze past studies
1. lack of patient randomization
that have directly compared the 2 methods in an attempt to answer this
question.
2• . failure to classify the type of
MATERIALS AND METHODS: A Medline search for articles using the key words
condylar
"mandibular condyle fractures" and "mandibular condyle fracture surgery"
was performed. Articles that compared open and closed reduction were
3. fracture variability within the
selected for further evaluation. Additional articles were obtained from
reference lists in the Medline-selected articles. Of the 32 articles identified,
surgical protocols,
13 met the final selection criteria. These contained data on at least one of
the following: postoperative maximum mouth opening, deviation on
4• . inconsistencies in choice of
opening, lateral excursion, protrusion, asymmetry, and joint or muscle pain.
RESULTS: Numerous problems were found with the information presented in the
variables and how they were reported.
various articles. These included lack of patient randomization, failure to
classify the type of condylar fracture, variability within the surgical
not possible to perform a reliable meta-analysis.
protocols, and inconsistencies in choice of variables and how they were
There is a need for better standardization of data
reported. However, the results from the meta-analyses were explored in a
general sense.
• collection
CONCLUSIONS: Because of the great variation in the manner in which the
various study parameters were reported, it was not possible to perform a
reliable meta-analysis. There is a need for better standardization of data
collection as well as randomization of the patients treated in future studies
to accurately compare the 2 methods.
 Closed reduction , open reduction , and
endoscopic assistance :
current thoughts on the management of

mandibular condyle fractures

Plasticmanagement
• The and reconstructive of surgery.
fractures01/01/2008; of 120(7
the Suppl
2):90S-102S.
• mandibular
Authors: Richardcondyle H Haug, M Todd continues
Brandt to be
• controversial
The management of.fractures of the mandibular condyle
continues to be controversial. This is in part attributable
1. a tom aisi n te rp re ta tio n of
misinterpretation o fthe
th eliterature
lite ra tu from
re frodecades
m
prior, a lack of uniformity of classification of the various
danatomical
e ca d e s p ri or
components of the mandibular condyle, and
2. a alaperceived
ck o f u npotential
ifo rm ity too fcause
cla ssi fica ti
harm o n o f th
through thee open
approach based in part on the surgeon's lack of a critical
va rio u s a n a of
examination to mtheica lco m p oThis
literature. n e nreview
ts o f th e
explores the
mkeya nhistorical
d ib u la r co n d ylethat deal with the management of
articles
mandibular condyle fractures, and those modern-day
3. a contributions
p e rce ive d pthato terepresent
n tia lto ca theu se
stateh aof
rmthe
thart.
ro uThe
g h th e
oauthors'
p e n a p intention
p ro a ch bwas a seto
d provide
in p a rttheo n reader
th e suwith
rg e oann 's
objective summary of the management of this form of
lainjury,
ck o ftoa place
criticaitslexa m in a tio ninto
management o fathmodern-day
e lite ra tu re .
perspective, and perhaps to minimize the perception of
controversy.

•
 Interventions for the
treatment of fractures of the
mandibular condyle
• Sharif
Abstract MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, Oliver R
Cochrane
• Background Oral Health Group's Trials Register (to

12th
•
March 2010
fractures of the CENTRAL
),consist
condyles (The
of either the closed Cochrane
method Library
or by open reduction 2010, may
Fractures of the condylar process account for between 25% and 35% of all mandibular fractures. Treatment options for
with fixation. Complications
be associated with either treatment option; for the closed approach these can include malocclusion, particularly
Issue open2 ), MEDLINE (from 1950 to are12th March 2010 ), and
bites, reduced posterior facial height and facial asymmetry in addition to chronic pain and reduced mobility. A
cutaneous scar and temporary paralysis of the facial nerve not infrequent complications associated with the

EMBASEtreatment
(from 1980 to 12th March 2010).
open approach. There is a lack of consensus currently surrounding the indications for either surgical or non-surgical
of fractures of the mandibular condyle.
• Objectives
• To evaluate the effectiveness of interventions that can be used in the treatment of fractures of the mandibular condyle.
• Search strategy
• The databases searched were: the Cochrane Oral Health Group's Trials Register (to 12th March 2010), CENTRAL (The
Cochrane Library 2010, Issue 2), MEDLINE (from 1950 to 12th March 2010), and EMBASE (from 1980 to 12th March
2010). The reference lists of all trials identified were cross checked for additional trials. Authors were contacted by
electronic mail to ask for details of additional published and unpublished trials. There were no language restrictions
and several articles were translated.
•
•
No high quality evidence
Selection criteria
Randomised controlled trials (RCTs) which included adults, over 18 years of age, with unilateral or bilateral fractures of

is available
the mandibular condyles. Any form of open or closed method of reduction and fixation was considered.
• Data collection and analysis
• Review authors screened trials for inclusion. Extracted data were to be synthesised using the fixed-effect model but if
substantial clinical diversity was identified between the studies we planned to use the random-effects model with
studies grouped by action and we would explore the heterogeneity between the included studies. Mean differences
were to be calculated for continuous outcomes and risk ratios for dichotomous outcomes together with their 95%
confidence intervals.

• Main results
• No high quality evidence matching the inclusion criteria was identified.
• Authors' conclusions
 CONCLUSION
The final choice of treatment modality


for each individual patient takes into

account a number of factors
• position of the condyle • presence or absence
• location of the fracture of other associated
injuries
• age of the fracture • presence of other
character of the systemic medical
patient conditions
• age of the patient • history of previous
joint disease,
• cosmetic impact of the
surgery
• desires of the patient.
 CONCLUSION
Perhaps the collective experience of the many


surgeons who treat these fractures can best be

characterized as follows:

• Intracapsular fractures • Most fractures in

are best treated
closed.
• When open reduction • Physical therapy that
is indicated, the
procedure must be
performed well,
– appreciate patient's
occlusal
relationships
– must be supported
by an appropriate
physical therapy
adults can be
treated closed.
is goal-directed and
specific to each
patient is integral to
good patient care
and is the primary
factor influencing
successful outcomes
whether the patient
is treated open or
 Controversies in
Mandibular Condyle
Fracture Repair 
Frederick Mars Untalan MD
Baguio General Hospital & Medical Center