University of Medicine and Dentistry of New Jersey
Department of Oral and Maxillofacial Surgery
110 Bergen Street
Room B-854
Newark, NJ 07103-2400
(973) 972-7462
ziccarvb@umdnj.edu

Abstract
Management of condylar fractures in adults is a controversial topic. This paper will discuss the treatment options available in managing this common maxillofacial injury. Some of the advances in the armamentarium used for treating these fractures will also be presented. Inherent in all treatment algorithms for condylar fractures in adults, is the rigorous postoperative physical therapy which must be utilized to retain adequate function. The different approaches to this complex injury will be illustrated with a variety of case examples.

Introduction
The condyle is involved in up to one third of all mandibular fractures in adults. Condylar fractures differ from fractures in other regions of the mandible in that they usually result from a force applied at the body or symphyseal region which is transmitted to the more susceptible condylar process. Fractures of the dentate portion of the mandible can generally be reduced and stabilized with maxillomandibular fixation (MMF), whereas condylar fractures can seldom be anatomically reduced by this technique alone.¹ In spite of the lack of reduction of these fractures, immobilization with MMF remains the most frequently employed treatment modality. (figures 1 through 4) Conservative treatment modalities including guided elastic therapy, opening exercises in front of a mirror to minimize deviation and reproduce occlusion, as well as dietary restrictions are all useful adjuncts.² Surgical management of condylar fractures is complicated by the limited surgical access and difficulty in restoring normal function. There are cases, however, which do not lend themselves to surgical treatment such as the severely comminuted or intracapsular condylar fractures (figures 5 through 8).³

Zide and Kent⁴ suggested a protocol of absolute and relative indications for open reduction of condylar fractures which still holds true today. Their protocol of absolute indications for open reduction included:

 
1. displacement of the condyle into the middle cranial fossa
2. the inability to obtain adequate occlusion by MMF
3. lateral extracapsular displacement of the condyle with concomitant esthetic deformity
4. the presence of a foreign body in the joint space.

 
1. bilateral condylar fractures when there is no available splint or severe alveolar ridge atrophy precludes its use
2. unilateral or bilateral fractures where MMF would not be tolerated or recommended for medical or psychological reasons such as seizure disorder, alcohol abuse or severe mental retardation
3. bilateral condylar fractures associated with unstable midface fractures where vertical support buttresses cannot be reconstructed
4. bilateral fractures associated with gnathological problems such as apertognathia, prognathism, retrognathism or dental abnormalities such as loss of periodontal support, loss of posterior teeth or partial anodontia. (figures 9 through 14)

Complications of trauma to the temporomandibular joint (TMJ) are not always immediately apparent. Disturbances of occlusion, deviation of the mandible when opening, internal derangements, ankylosis are all possible sequelae of this injury.⁵ Intracapsular fractures may result in a hemarthrosis which can lead to synovial hypertrophy and an acute inflammatory response which has been implicated in the pathogenesis of intra-articular ankylosis. However, experimentally induced hemarthrosis has not been shown to result in ankylosis.⁶

The rapid clearance of blood from the joint space is through extravasation via gaps between synovial intimal cells and phagocytosis by subintimal macrophages. The driving force behind joint clearance is joint mobility and intra-articular pressure generation, hence the impetus for early joint mobilization. Arthroscopic examination of post-traumatic joints has demonstrated adhesions between the disc and glenoid fossa. Recently injured joints have been shown to demonstrate hyperemia of the capsule as well as hemarthrosis. These injuries, however, usually resolve spontaneously as borne out by clinical experience in the management of condylar fractures.⁷

Bony destruction, osteophyte formation, and flattening of the condylar head have been shown to result from the application of rigid fixation to osteotomies on condylar necks in sheep. Stable fixation may lead to degenerative changes in the articular surface depending upon the amount of dissection and manipulation required. Improper condylar head positioning or vascular injury may also contribute to the condylar degeneration.⁸ It has been demonstrated that non-physiological loading in condylar fractures treated with MMF that were not anatomically reduced also developed degeneration.⁹ Inadequate restoration of ramal height may create a malocclusion or force the contralateral condyle into a position which bears a greater load during mastication with resultant occlusal and adaptive changes.¹⁰

The goals of treatment in the management of condylar fractures should be the restoration of pain-free function, proper occlusion, normal facial contour and symmetry of motion. Pain and hypomobility, however, may result from either open or closed procedures. Early mobilization with physiotherapy may prevent complications such as ankylosis and functional disorders. Ankylosis does not usually develop in a moving jaw with active physiotherapy. Physiotherapy should be initiated with the goal of maximal interincisal opening of greater than 35mm with a full range of excursions and protrusive function. The cornerstone to a satisfactory outcome is early mobilization, active jaw movement, and strict follow-up.¹¹

Conservative management alone in children with emphasis on early guided function generally yields clinically acceptable results. In adults, however, deviation on opening and reduced movements in lateral and protrusive function occur more frequently. Symptoms such as clicking and tenderness within the temporomandibular joint are less predictable based upon the initial clinical presentation and form part of the basis for the controversy in the management of condylar fractures in adults.^12-15

Condylar fractures may be classified according to whether they are intracapsular or extracapsular. Within the extracapsular division are the condylar neck and subcondylar fractures. It is this division of condylar fractures which may be amendable to surgical reduction and rigid internal fixation. The degree of condylar displacement has been radiographically classified by MacLennan¹⁶ into four classes: class I is non-displaced, class II demonstrates deviation at the fracture line, class III is moderate displacement of the condylar fragment so that the bony ends are not in contact but the condyle remains within the glenoid fossa and class IV is dislocation of the condyle from the glenoid fossa. Many surgeons consider class IV fractures appropriate for surgical intervention, although, they may still be managed by closed techniques in certain circumstances.

The degree of dislocation of the condylar process is often a factor in deciding surgical versus closed technique. Other factors to be considered include the position of the condyle relative to the glenoid fossa, as well as medial or lateral telescoping with a shortening of the ramal height and vertical dimension. If a condyle is in the fossa, the fracture will probably heal in a good functional position once the occlusion is re-established and active physiotherapy is initiated.³

Condylar Fracture Imaging
The panoramic radiograph is an excellent screening film demonstrating displacement of fractured condylar segments in the anterior-posterior direction, but not in the medial-lateral dimension. Advantages of the panoramic film include its broad image, low radiation dose, and ability to be performed on patients who are unable to open their mouths. Other radiographic views and clinical acumen are necessary to spatially reconstruct a three dimensional image for diagnostic and therapeutic purposes.¹⁷ The open mouth Reverse Towne's view is a useful adjunctive film since it prevents the mastoid air cells and petrous portion of the temporal bone from obstructing the condylar image.¹⁸ Computed tomography (CT) is yet another useful modality for evaluating fractures of the mandibular condylar process since both bony and soft tissue windows are available. An additional advantage of the CT is in the evaluation of sagittal fractures of the condylar head which can not be identified on plain radiographs because of overlapping images. However, the use of CT scans can not be routinely recommended in the evaluation of condylar fractures because of its cost and non-availability such as in an office setting.^{19, 20}

Surgical Techniques
When open reduction of a condylar fracture is indicated, a number of surgical approaches and fixation techniques are available (table 1). An intraoral approach is possible through a vestibular incision similar to that used for intraoral vertical ramus osteotomies. The condyle can be manipulated with a clamp and traction applied to the mandible with a percutaneously placed towel clamp. Traction allows for further manipulation of the displaced condylar segment. The advantages of an intraoral approach is the absence of a visible scar, avoidance of facial nerve injury, minimal incidence of vascular injury, and elimination of parotid parenchymal injury with subsequent fistula formation. It is, however, more technically difficult and should be reserved for select low subcondylar fractures.²¹ A variation of this technique has been described which includes a sub-sigmoid osteotomy or coronoidectomy that is replaced and fixated with a lag screw after reduction and fixation of the condylar fracture. The advantage is the enhanced visualization of the condylar process, although, there is a greater likelihood of inferior alveolar nerve injury from the osteotomy.²²

Combinations of preauricular, endaural, submandibular, retromandibular, and rhytidectomy approaches may be used to surgically approach condylar fractures. A retromandibular or submandibular approach alone is suitable for most subcondylar fractures to achieve direct access for wiring or plating. Since these fractures are usually oblique in orientation, compression is generally not necessary and the plates are secured in the neutral mode.²³ Control of the proximal condylar fragment may be difficult to achieve, particularly if significant displacement of the condylar segment has occurred. Use of a Moule pin has been described to facilitate retrieval of the condylar head and allow alignment of bone fragments for accurate anatomic reduction and application of rigid fixation.²⁴ Ellis²⁵ and Mikkonen²⁶ described a technique when the condyle can not be retrieved or stabilized by other methods. In this approach, a vertical osteotomy is created to allow removal of the posterior mandibular border and condylar fragment which are plated extracorpeally. The entire posterior border with attached condyle are fixed to the distal mandible with plates as a free graft. It has been demonstrated in monkeys that re-implanted mandibular condylar grafts heal and incorporate to function normally.²⁷ This, technique, therefore, may be indicated in those cases in which the condylar segment could not be reduced and stabilized by other means. Boyne²⁸ has advocated this technique for access in vascular surgery when approaching carotid aneurysms. He also states that when a condyle is so deformed that it could not be functional, the distal segment may be reshaped and moved superiorly into the glenoid fossa to maintain the posterior mandibular ramal height. However, a number of cases of condylar resorption have been reported after extracorpeal reduction and fixation of condylar fractures limiting the usefulness of this procedure as has also been experienced by the authors of this paper.

It has been postulated that fractured condyles which are displaced out of the fossa require anatomic repositioning of the disc and condyle to avoid future problems with occlusion and TMJ dysfunction. Raveh²⁹ has reported the use of open reduction of displaced condylar segments with no fixation. Patients are placed into MMF for ten days with subsequent physiotherapy. The correct physiological relation of the condyle in the glenoid fossa is described as being more important than exact reduction of bony fragments. Chuong³⁰ described a more physiologic approach to the management of condylar fractures in which the disc is surgically repositioned under the operating microscope in addition to rigid fixation of the bony segments. Bony reduction alone re-establishes ramal height and serves to reposition the condyle away from the displaced disc. The medial and lateral pole attachments are disrupted by the trauma which is thought to preclude spontaneous disc repositioning by fracture reduction alone. This technique, however, has been described for small series of patients with limited follow-up and is not practiced by many surgeons.

In spite of these surgical approaches, optimal access for reduction and placement of plates can be difficult and a number of "work around" procedures have been described. Postoperative MMF may be combined with Kirschner wires or intraosseous wires.^{11, 13} A technique³² using either a K-wire or Steinmann pin has been described where the condylar segment is reduced and the distal pin or wire is recessed into a superficial trough created on the posterior mandible which is secured with posterior border wires. Axial anchor lag screws are an alternative to plate fixation of condylar fractures. A lag screw has threads only on the distal portion so they can engage the proximal condylar fragment and provide interfragmentary compression upon tightening. Lag screw techniques in which a cortical screw is used by enlarging the hole in the near cortex so that the threads do not engage is the technique most frequently used in maxillofacial surgery. Advantages of lag screw fixation include rapid application and minimal hardware (figures 19 and 20). Contraindication to the use of lag screws include comminution or loss of bone in the fracture gap which precludes application of compression or bony interdigitation. In these instances, a bone plate may be applied in the neutral mode without affecting occlusion.²⁵ Lag screws have also been placed intraorally through the mandibular crest. Poor visibility, the need for special instrumentation and utility for only low subcondylar fractures, limits the applicability of this technique.³³

With lag screw osteosynthesis, the spherical head of the screw acts as a wedge. This may be overcome by combining the screw with a washer which transforms the crushing forces into pressure forces which are better tolerated. The addition of a washer prevents the screw head from penetrating the medullary bone or cortical fragments from breaking off. Lag screws with washers have been reported to be able to be turned twice as tight as lag screws without washers before the surface bone begins to crack.³⁴ Fracture or osteolysis and resorption of the overlying bone may occur in the axial anchor screw technique.³⁵ A related technique is the Wurzburg lag screw plate® (Leibinger, L.P., Dallas, Texas) which incorporates a collum lag screw and miniplate for high condylar fractures. Preliminary data indicates that this is a stable means of condylar fracture fixation.³⁶

Conclusion
This article has attempted to review the contemporary management of condylar fractures in adults based upon anatomic location and degree of displacement. Support for conservative therapy, closed reduction, and surgical intervention have been presented as well as reported long term sequelae of each treatment modality. An algorithm for the management of these fractures has been developed for assistance to the surgeon in determining optimal therapy for their patient. Multiple factors play a role in determining which treatment is best for each patient and the specific clinical scenario.

References

 
1. Silvennoinen U, Iizuka T, Lindqvist C, et al: Different patterns of condylar fractures: an analysis of 382 patients in a 3 year period. J Oral Maxillofac Surg 50:1032-1037, 1992. 
2. Ziccardi VB, Ochs MW, Braun TW, et al: Management of condylar fractures in children: review of the literature and case presentations. Compend Contin Dent Educ XVI(9):874-888, 1995. 
3. Konstantinovic VS and Dimitrijevic B: Surgical versus conservative treatment of unilateral condylar process fractures: clinical and radiographic evaluation of 80 patients. J Oral Maxillofac Surg 50:349-352, 1992. 
4. Zide MF and Kent JN: Indications for open reductions of mandibular condyle fractures. J Oral Maxillofac Surg 41:89-98, 1983. 
5. Ellis E and Dean J: Rigid fixation of mandibular condyle fractures. Oral Surg Oral Med Oral Path 76:6-15, 1993. 
6. Jones JK and Van Sickles JE: A preliminary report of arthroscopic findings following acute condylar trauma. J Oral Maxillofac Surg 49:55-60, 1991. 
7. Goss AN and Bosanquet AG:The arthroscopic appearance of acute temporomandibular joint trauma. J Oral Maxillofac Surg 48:780-783, 1990. 
8. Suuronen R, Vainionpaa S, Hietanen J, et al: The effect of osteotomy and osteosynthesis in the mandibular condyle. A radiologic and histologic study in sheep. Int J Oral Maxillofac Surg 23:174-179, 1994. 
9. Hidding J, Wolf R, Pingel D: Surgical versus non-surgical treatment of fractures of the articular process of the mandible. J Craniomaxillofac Surg 20:345-347, 1992. 
10. Silvennoinen U, Iizuka T, Oikarinen K, et al: Analysis of possible factors leading to problems after nonsurgical treatment of condylar fractures. J Oral Maxillofac Surg 52:793-799, 1994. 
11. Takenoshita Y, Oka M, Tashiro H: Surgical treatment of fractures of the mandibular condylar neck. J Craniomaxillofac Surg 17:119-124, 1989. 
12. Walker RV: Discussion: Open reduction of condylar fractures of the mandible in conjunction with repair of discal injury: a preliminary report. J Oral Maxillofac Surg 46:262, 1988. 
13. Lindahl L: Condylar fractures of the mandible. IV. Int J Oral Surg 6:195-203, 1977. 
14. Walker RV: Condylar fractures: Nonsurgical management. J Oral Maxillofac Surg 52:1185, 1994. 
15. Hall MB: Condylar fractures: Surgical Management. J Oral Maxillofac Surg 52:1189, 1994. 
16. MacLennan WD: Consideration of 180 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 5:122, 1952. 
17. Ziccardi VB and Ochs MW: Fracture of titanium rigid fixation plate not clearly discernable on panoramic radiograph. Am J Emer Med 11:315-316, 1993. 
18. Ziccardi VB and Ochs MW: Assessment of mandibular condylar fracture displacement. Am J Emer Med 13:474-476, 1995. 
19. Raustia AM, Pyhtinen J, Oikarinen KS, et al: Conventional radiographic and computed tomographic findings in cases of fracture of the mandibular condylar process. J Oral Maxillofac Surg 48:1258-1262, 1990. 
20. Yamaoka M, Furusawa K, Iguchi K, et al: The assessment of fracture of the mandibular condyle by use of computerized tomography. Incidence of sagittal split fracture. Br J Oral Maxillofac Surg 32:77-79, 1994. 
21. Jeter TS, Van Sickels JE, Nishioka GJ: Intraoral open reduction with rigid internal fixation of mandibular subcondylar fractures. J Oral Maxillofac Surg 46:1113-1116, 1988. 
22. 22. Habel G, O'Regan B, Hidding J, et al: A transcoronoidal approach of fractures of the condylar neck. J Craniomaxillofac Surg 18:348-351, 1990. 
23. Sargent LA and Green JF: Plate and screw fixation of selected condylar fractures of the mandible. Ann Plast Surg 28:235-241, 1992. 
24. Stewart A and Bowerman JE: A technique for control of the condylar head during open reduction of the fractured mandibular condyle. Br J Oral Maxillofac Surg 29:312-315, 1991. 
25. Ellis E, Reynolds ST, Park HS: A method to rigidly fix high condylar fractures. Oral Surg Oral Med Oral Path 68:369-373, 1989. 
26. Mikkonen P, Lindqvist C, Pihakari A, et al: Osteotomy-osteosynthesis in displaced condylar fractures. Int J Oral Maxillofac Surg 18:267-270, 1989. 
27. Daniels S, Ellis E, Carlson DS: Histologic analysis of costochondral and sternoclavicular grafts in the TMJ of the juvenile monkey. J Oral Maxillofac Surg 45:675-682, 1987. 
28. Boyne PJ: Free grafting of traumatically displaced or resected mandibular condyles. J Oral Maxillofac Surg 47:228-232, 1989. 
29. Raveh J, Vuillemin T, Ladrach K: Open reduction of the dislocated fractured condylar process. Indications and surgical procedures. J Oral Maxillofac Surg 47:120-126, 1989. 
30. Chuong R and Piper MA: Open reduction of condylar fractures of the mandible in conjunction with repair of discal injury. A preliminary report. J Oral Maxillofac Surg 46:257-263, 1988. 
31. Kallela I, Soderholm AL, Pau KKU, Lindqvist C: Lag screw osteosynthesis of mandibular condyle fractures: a clinical and radiological study. J Oral Maxillofac Surg 53:1397, 1995. 
32. Kitayama S: A method of intraoral open reduction using a screw applied through the mandibular crest of condylar fractures. J Craniomaxillofac Surg 17:16-23, 1989. 
33. Wennogle CF and Delo RI: A pin in groove technique for reduction of displaced subcondylar fractures of the mandible. J Oral Maxillofac Surg 43:659-665, 1985. 
34. Krenkel C: Axial anchor screw (lag screw with biconcave washer) or slanted-screw plate for osteosynthesis of fractures of the mandibular condylar process. J Craniomaxillofac Surg 20:348-353, 1992. 
35. Silvennoinen U, Iizuka T, Pernu H, et al: Surgical treatment of condylar process fractures using axial anchor screw fixation: a preliminary report. J Oral Maxillofac Surg 53:884-893, 1995. 
36. Ziccardi VB, Schneider RE, Kummer F: Wurzburg lag screw plate versus four hole miniplate in the treatment of condylar fractures. J Oral Maxillofac Surg. 1997;55:602-607. 

1. Which of the following is not true regarding the surgical management of condylar fractures in adults?

a. limited surgical access
b. potential morbidity of surgery
c. not useful in intracapsular fractures
d. useful in comminuted fractures

2. Absolute indications for the open reduction of condylar fractures in adults include all the following except?

a. displacement into the middle cranial fossa
b. inability to obtain adequate occlusion
c. patient desires
d. lateral extracapsular displacement

3. Relative indications for the surgical management of condylar fractures in adults include all the following except?

a. bilateral condylar fractures
b. Non-displaced fracture of the condylar neck
c. bilateral condylar fractures with unstable midface fractures preventing adequate vertical buttresses
d. bilateral fractures with gnathological problems such as apertognathia or prognathism

4. Complications of trauma to the temporomandibular joint include all the following except?

a. disturbances of occlusion
b. deviation of the mandible when opening
c. hypertrophy of adenoid masses
d. internal derangements

5. The goals of treatment in the management of condylar fractures should include all of the following except?

a. restoration of painful function
b. proper occlusion
c. symmetry of motion
d. adequate amount of opening and excursive function

6. In experimentally induced hemarthrosis, which of the following statements is not true?

a. Rapid clearance of blood is via gaps between synovial cells
b. A postulated driving force for this clearance is joint immobility
c. Intra-articular joint pressure assists in blood clearance
d. Ankylosis does not occur

7. Factors which influence whether or not to surgically treat a condylar fracture include all the following except?

a. Age of the patient
b. Shortened ramal height from telescoping of the distal segment
c. Degree of condylar dislocation
d. Subcondylar fracture location

8. Which of the following surgical approaches may be used independently or in combination for the management of condylar fractures in adults?

a. retromandibular
b. intraoral
c. rhytidectomy
d. preauricular
e. all the above are correct

9. Anatomic repositioning of a condyle which has been displaced out of the fossa may be repositioned by all the following methods except?

a. Moule pin
b. Kirshner pin (k wire)
c. intraosseous wire
d. endodontic file

10. Which of the following statements are false regarding the use of lag screws?

a. They are an alternative form of fixation in the fixation of fractures
b. They are useful in comminuted fractures
c. use minimal hardware
d. create compression between bone surfaces
 
 

Answers to the above questions
 

Question #1:	Correct answer is D
Question #2:	Correct answer is C
Question #3:	Correct answer is B
Question #4:	Correct answer is C
Question #5:	Correct answer is A
Question #6:	Correct answer is B
Question #7:	Correct answer is D
Question #8:	Correct answer is E
Question #9:	Correct answer is D
Question #10:	Correct answer is B