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Mandibular Condylar and Subcondylar

Fractures
Updated: Aug 31, 2015
Author: Kim E Goldman, DMD; Chief Editor: Arlen D Meyers, MD, MBA more...

OVERVIEW

Overview
Condylar and subcondylar fractures constitute 26-40% of all mandible fractures (see the image
below).

Sectional anatomy of the mandible with frequency of fractures.

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Given the unique geometry of the mandible and temporomandibular joints (TMJs), these
fractures can result in marked pain, dysfunction, and deformity if not recognized and treated
appropriately. These fractures may be associated with other injuries that alone have significant
morbidity. Examples of such injuries include but are not limited to facial nerve injuries, C-spine
injuries, displacement of the mandibular condyle into the middle cranial fossa, injuries to the
external auditory canal, and occlusion of the internal carotid artery.

A retrospective study by Vranis et al indicated that, compared with condylar head and condylar
neck fractures, extracapsular condylar base fractures are independently associated with a
nearly three-fold increase in the risk of a severe blunt carotid artery injury. The study included
605 patients with mandibular condyle fractures, including 316 with extracapsular condylar base
fractures. [1]

A thorough understanding of the anatomy and physiology of the masticatory system is therefore
essential in understanding and treating fractures of the condyle and subcondylar region.

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Anatomy
The first pharyngeal arch gives rise to the tissues that eventually form the mandible. Therefore,
this intramembranous bone develops around the ventral cartilage of the first branchial arch. The
mandible continues to grow and develop throughout childhood and adolescence. The eruption
of teeth promotes the formation of alveolar bone, but the condyle is a major growth center for
the mandible. The existence of panfacial deformities when the condyle is damaged before
complete growth and development is well documented.

The mandible, like the ribs, is curved and articulates at both ends, but unlike the synchondroses
that connect the ribs to the sternum and the vertebral column, TMJs are diarthrodial and allow
both rotational and translational movement (see the image below).

Movement of the temporomandibular joint (TMJ).

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The anatomy of the TMJ is well suited to its function. The articular eminence and the superior
portion of the mandibular condyle are covered with fibrocartilage, while the articular disc is
composed of dense collagenous connective tissue. The disc itself is without sensation, but the
retrodiscal tissue, a loose areolar connective tissue, is well innervated.

The jaw opens first by rotation of the condyle within the inferior joint space and then by
translation of the condyle and disc in a downward and forward direction; thus, while rotation
occurs in the inferior joint space, translation occurs in the superior joint space. Rotation alone
allows approximately 20-24 mm of interincisal opening, which is the distance between incisal
edges of the maxillary and mandibular incisors. Normal maximum interincisal opening meets or
exceeds 40 mm, and to accomplish this, translation is necessary.

The tooth-bearing facial skeleton, the dentition, and the TMJs together form an interdependent
tripartite complex where disruption of any single part can result in marked difficulties in the
others. As a corollary, considering all 3 parts in the reconstruction of an injury to any one part is
necessary. The significance of this concept is elucidated more clearly as treatment alternatives
and rationales are discussed.

Incidence, Etiology, Prevalence

Unilateral fractures occur approximately 3 times more frequently than bilateral fractures do, but
bilateral fractures are not uncommon. The frequency of these injuries does not seem to differ
significantly from location to location.

The etiology of these injuries varies in accordance with both sociologic and age factors. In the
Netherlands, for example, where bicycling is a common form of transportation, cycling accidents
are the primary cause of condylar/subcondylar injuries. In large American cities, the most
common etiology for the same injuries may be either motor vehicle accidents or interpersonal
violence, depending upon the characteristics of the city. In New York and San Francisco, for
example, where population density is high and traffic is congested, interpersonal violence is far
more common, while in the Midwest, where traffic moves faster and where land is available for

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all-terrain vehicle use, these fractures are more commonly a result of vehicular accidents.
Among children, falls and playground and bicycle accidents are the usual causes of these
injuries.

Presentation and Diagnosis

The clinical presentation of condylar/subcondylar injuries may be either straightforward or quite
subtle. An awareness of the mechanism of potential injury, as well as the specific signs and
symptoms that should raise the index of suspicion, is therefore helpful to the clinician. History,
physical examination, and radiographic studies form the mainstays of diagnosis (see the image
below).

Clinical presentations suspicious for condylar/subcondylar fracture.

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History and physical examination

Falls, blows to the contralateral face or ipsilateral preauricular area, or chin injuries should alert
the examiner to the possibility of a condylar/subcondylar injury. Because of the U-shaped
mandibular anatomy, patients thought to have a single mandibular fracture often have others.
Also, the patient with a subcondylar fracture often has another mandibular fracture.
Nevertheless, an isolated subcondylar or intracapsular fracture is quite possible.

Contusions over the chin or preauricular area, hemotympanum, and malocclusion are all
potential signs of a condylar or subcondylar fracture. Less commonly, a facial nerve deficit may
be associated with an injury to this area.

The examination must therefore include assessment of the patient's occlusion and facial nerve
function. For all practitioners, and especially for the practitioner not trained in dental anatomy,
ascertaining from patients whether or not they notice a change in their own occlusion may be
helpful. Of course, such evaluations are not fail-safe because the presence of multiple fractures
and/or injury to the inferior alveolar, lingual, and/or facial nerve may skew patients' perception of
their own clinical situation. Thus, all who intend to treat these types of injuries must become
cognizant of normal mandibular range of motion parameters, as well as normal occlusal
patterns and intraoral clues (eg, wear facets) that provide a guide to the patient's premorbid
occlusion and functional relationships. In the patient with multiple fractures, obtaining dental
study models may greatly facilitate treatment, while significantly decreasing intraoperative time.

Radiographic studies

Plain radiography (most commonly) and CT scanning help to ascertain the location of the
fracture, the degree and direction of displacement, and the presence or absence of associated
injuries. All of this information is integral to developing an appropriate treatment plan for the

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patient (see the image below).

Radiographic views of subcondylar fractures.

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Panoramic radiography is a useful study. Properly taken, this modality allows examination of the
entire mandible, both TMJs, the maxilla, and the maxillary sinuses. Unfortunately, the equipment
necessary to obtain radiographs is not available in every treatment facility. If panoramic
radiography is unavailable, bilateral lateral oblique views of the mandible can allow the surgeon
to view the condyles and subcondylar areas.

In 30 anteroposterior (AP) skull radiography (ie, Towne view), the head is positioned so that the
condyles and subcondylar area are not obscured by the base of the skull. By positioning the
head and film in this manner, the condyles and subcondylar area are visualized. This view is
particularly helpful for ascertaining the mediolateral position of the respective fractured
segments, information not readily available from a panoramic view.

CT scanning in axial and coronal planes can yield much information about this area provided
that the sections are sufficiently close to obtain images of the area and provided the practitioner
is intimately familiar with the pertinent anatomy. However, CT scanning is not the preferred
imaging modality for most mandible fractures, including those of the condyle. CT scanning does
provide the most information about intracapsular fractures.

For further reading, see Medscape.

Treatment Decision Making

Approach Considerations

The literature is rife with diametrically opposed opinions on the appropriate treatment for any
specific condylar/subcondylar fracture. Probably the only truism is that, for any given patient,
fracture, or incident, advantages and disadvantages are specific to each potential treatment
plan. The art and science of patient care encompasses learning how to choose optimal

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treatments and having an array of skills from which to choose. [2]

Isolated Intracapsular Fractures

Common medical opinion strongly agrees that isolated intracapsular fractures, in almost every
instance, should be treated solely with physical therapy. While these fractures can result in
significant anatomic/radiologic changes in the appearance of the condyle itself, most patients
with these fractures do well if properly rehabilitated. Late complications (eg, degenerative joint
disease) are possible, but again, with appropriate rehabilitation (in the absence of other
fractures and generalized joint disease), these patients tend to do well.

In the early rehabilitative phase, controlling the occlusion (usually by means of arch bars and
elastics) while emphasizing return of normal range of motion is important. The patient should
receive occlusion-guiding hardware and instruction in range-of-motion exercises immediately
postinjury. The patient must be carefully monitored. Not surprisingly, younger patients seem to
return more quickly to the premorbid state than do older patients, but even elderly patients, with
appropriate rehabilitation, tend to do well with these injuries.

The patients who encounter trouble are generally those in whom the fracture is undiagnosed
and those who, for reasons of pain, do not immediately resume a normal range of mandibular
motion. These patients then heal in anatomically incorrect and nonfunctional configurations.
Once a mandibular malunion has occurred, mandibular motion, in some cases, cannot be
reestablished without surgical intervention.

Patients with no Dentition

Patients who are edentulous entail special consideration. Certainly, preexisting dentures or
gunning splints may be wired in and adapted for interarch elastics. In most cases, however, an
equally good outcome can be obtained with careful physical therapy that trains patients to open
to a normal distance without deviation. Some patients require preexisting dentures to be remade
or relined. Often, the denture is broken in the same incident that caused the intracapsular
fracture. Some patients may be able to wear their preexisting prostheses during and after
rehabilitation.

Subcondylar Fractures

Closed reduction

The subcondylar fracture poses a different and more complicated set of questions. Most
practitioners agree that most subcondylar fractures can be treated in a closed fashion. Closed
treatment, as above, implies control of the occlusion, aggressive physical therapy, and close
follow-up. Additionally, most practitioners agree that children should generally be treated with
closed reduction. Often, children require only nonoperative management, ie, close follow-up of
occlusion and function and reassurance to the parents that it is not only acceptable but also
desirable for the children to resume normal range of motion activities.

Animal studies also confirm that closed reduction is an acceptable and successful form of
treatment for most of these fractures. In 1960, Walker studied unilateral fracture dislocations in
growing monkeys. [3] Two fractures were replaced in their normal position, and 4 were left
displaced, but all healed with normal shape and normal function. In 1967, Boyne replicated the
study, this time creating bilateral fractures and once again showing that all animals ended with
normal function and normal anatomy. [4] In 1991, Zhang et al performed a similar study with
adult rabbits and showed that, in this population, miniplate reduction provided a better final

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symmetry than closed reduction, but closed reduction was better than free condylar grafting. [5]
The reader should decide whether extrapolating this to humans, who are biologically different
and capable of undergoing goal-directed physical therapy, is reasonable.

According to Bradley, "The necessity for precise anatomical repositioning, so desirable in other
sites in the mandible, does not apply in the case of condylar fractures where the bony
displacement will be compensated by changes in the pattern of muscular activity, mediated by
proprioceptive impulses derived from the periodontal membranes and soft tissues surrounding
the joint."

Collective experience seems to support this opinion. An important corollary, however, is that
when rigid fixation is chosen as the treatment method it is an absolute necessity for the condyle
to be rigidly fixated in the appropriate position. The physician must avoid rigidly fixating the
condyle in a nonphysiologic position.

Long-term follow-up of subcondylar fracture dislocations that were treated with occlusal
guidance, physical therapy, and close supervision is important, but finding clinical records of
such practice is uncommon. Nevertheless, a few practitioners have records over 40 or more
years on some patients. Such records indicate that, in young patients, over time, function and
form is completely restored to normal. In older patients, less remodeling and less correction of
the radiologic picture may occur, but function is excellent and patients are free of pain. Others
have documented the same findings. Therefore, unless the fracture dislocation is in such a
place as to physically prohibit movement of the condyle, the simple fact of the dislocation may
not be an indication for an open surgical procedure. Furthermore, Walker, Alpert, and others
state that they have yet to see a closed fracture result in nonunion. [6, 7]

Open treatment

The landmark article by Kent and Zide gives absolute and relative indications for treating
subcondylar fractures in an open manner, [8] although a 2008 case report refutes at least one of
these indications as absolute. [9] Their absolute indications for open treatment of subcondylar
fractures are as follows:

Dislocation into the middle cranial fossa or external auditory canal

Lateral extracapsular displacement
Inability to obtain adequate occlusion
Open joint wound with foreign body or gross contamination

Few authorities would argue with any of these ideas. Note that the second criterion is lateral
extracapsular displacement and not just mild lateral displacement. The relative indications listed
by Kent and Zide are as follows:

Bilateral subcondylar fractures in a patient who has no dentition and where a splint is
unavailable or when splinting is impossible because of alveolar ridge atrophy
Bilateral or unilateral subcondylar fractures when splinting is not recommended for medical
reasons or where adequate physiotherapy is impossible
Bilateral condylar fractures associated with comminuted midfacial fractures
Bilateral subcondylar fractures with associated gnathologic problems, such as (1)
retrognathia or prognathism, (2) open bite with periodontal problems or lack of posterior
support, (3) loss of multiple teeth and later need for elaborate reconstruction, (4) bilateral
condylar fractures with unstable occlusion due to orthodontics, and (5) unilateral condylar
fracture with unstable fracture base

The authors themselves state that the "relative indications are arguable and patients may be

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treated differently by each surgeon." In fact, Zide further modified and expanded his absolute
and relative indications in a later article.

Edentulous Bilateral Fractures

Although edentulous bilateral fractures occur in which constructing a splint is difficult, the author
has yet to see a case in which it was impossible. Situations exist, however, in which a patient
does not easily tolerate such an appliance.

For cases of bilateral edentulous fractures, the second indication is the most common reason
for opening at least one side; however, in patients who are cooperative, dentate, and
nonmedically compromised, even bilateral fractures can often be managed with arch bars,
elastics, physical therapy, close supervision, and follow-up.

Open reduction and internal fixation

On the other hand, patients who are uncooperative, enfeebled, or in whom a stable AP
mandibular position cannot be maintained would certainly be considered (by most facial trauma
surgeons) as candidates for open reduction and rigid internal fixation (ORIF). Despite excellent
reduction and fixation, the overall outcome of a patient treated with ORIF alone (ie, without
physical therapy) is likely to be compromised.

Corollary principle: A patient with esthetic form and normal function as the final result is the goal
of treatment. The appearance of the radiograph is insignificant when these 2 goals have been
met. Open reduction does not by itself guarantee that these goals will be met, and, in most
cases, these can be met with closed reduction, meticulous postoperation physical therapy and
follow-up. Clinical judgment and consideration of other medical conditions must always
influence the treatment choice for any particular patient.

Condylar/Subcondylar Fractures With Other Associated Mandibular

Fractures

Finding subcondylar fractures in association with other mandibular fractures, usually in the
symphyseal/parasymphyseal region and sometimes more posteriorly, is not uncommon. In this
case, the standard principle of appropriately and anatomically reconstructing the tooth bearing
portion of the jaw first applies. Once this portion of the mandible has been rigidly fixed through
the practitioners method of choice appropriate for the patient at hand, the treatment algorithm
for the condylar/subcondylar fractures is unchanged from what has previously been discussed.

Corollary principle: Failure to correctly reconstruct the other mandibular fractures prior to
addressing management of the condylar/subcondylar fracture(s) will result in failure to
appropriately manage these fractures.

Bilateral Condylar and Midfacial Fractures

The patient who has both bilateral condylar fractures and comminuted midfacial fractures poses
a challenge for the reconstructive surgeon. Traditionally, such patients were reconstructed
bottom up, inside out. With the advent of rigid fixation, reconstructing from the outer facial frame
as described by Gruss is also possible. The surgeon thus takes into consideration the degree of
comminution, the associated injuries, and the state of the dentition when determining whether to
open one or both subcondylar fractures in such a patient.

ORIF can facilitate the care of the patient with an orthognathic problem that predates the

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fracture, but splints can be constructed to facilitate the care of these patients as well. Even if
such patients are to be treated in an open fashion, models should be made and splints should
be fabricated for intraoperative use. A millimeter of error at the fracture line may not be apparent
to the operator, but a millimeter of error at the occlusion may be apparent to the patient.

Complications

Of course, some complications may arise with any treatment modality, and many of these (eg,
pain, infection, edema, malocclusion, trismus, ankylosis, extrusion of the dentition, edema) can
occur with either closed or open treatment, especially if appropriate physical therapy is not part
of the treatment plan. However, some complications are associated more with open treatment.
These complications include avascular necrosis of the condylar head (particularly when the
condyle is removed, plated on the back table, and reinserted as a free graft), injury to the facial
nerve, hemorrhage during approaches to the condyle, and nonunion.

Remember that, according to Alpert, "in most cases open techniques prove no better than
closed techniques for most types of condylar fractures. As such, there are few indications to risk
the complications of open repair of the fractured condyle." [7] Nevertheless, some cases occur in
which, for a variety of reasons, surgeons and patients together choose open treatment.

The final choice of treatment modality for each individual patient takes into account a number of
factors, including position of the condyle, location of the fracture, age of the fracture, character
of the patient, age of the patient, presence or absence of other associated injuries, presence of
other systemic medical conditions, history of previous joint disease, cosmetic impact of the
surgery, and desires of the patient.

Finally, if the patient is to be treated with a closed procedure and has other mandibular (not
condylar or subcondylar) fractures, treatment of the patient is greatly facilitated if the other
fractures can be fixated rigidly so as to allow immediate commencement of physical therapy.
Four weeks of maxillomandibular fixation (MMF) to treat the other fractures is not optimal for
subcondylar fractures and is contraindicated for intracapsular fractures because risk of
ankylosis, adhesion, and/or hypomobility is increased with such treatment.

Treatment Procedures Closed Reduction

Remember that most often these subcondylar fractures are encased in a muscular sheath
between the masseter and the medial pterygoid; thus, they are splinted and well supplied with
blood. Correctly placed arch bars, Ivy loops, or other devices from which elastics can be
suspended to control and guide the occlusion are essential. In the edentulous patient, dentures
or gunning-type splints can be affixed to the maxilla and mandible via wires and/or screws and
serve the same purpose.

Instruct the patient to wear elastics 24 hours a day for the first several weeks, removing them
only to perform physical therapy exercises and oral hygiene. Remember that elastics stretch as
they absorb moisture from the oral cavity; therefore, teach the patient how to change the
elastics daily. For most patients, a single elastic at the canine/premolar region bilaterally
suffices.

Adjust diet for comfort; most patients eat a mechanical soft diet for the first few weeks. At
approximately week 3-4 (depending upon the individual), switch patients to elastics only at
night, with instructions to resume 24-hour wear if they notice their bite drifting during the day.
After 1-2 weeks with only nighttime elastics, the patient then switches to elastics every other
night. If the bite remains stable after a week of this, discontinue the elastics and keep the patient

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in appliances for 1 more week. Again, if no change occurs in the occlusion after 1 week, remove
the appliances (eg, arch bars, Ivy loops). The previous schedule can be compressed or
expanded depending upon the individual patient's response.

Of the utmost importance for all patients, whether treated with closed or open techniques, is
compliance with physical therapy regimens. These regimens do not require the patient to visit a
rehabilitation center or to have any outside personal assistance (except for patients who are
very young and/or some with physical or mental disabilities). Rather, physical therapy consists
of a series of opening exercises. Some devices on the market, such as the Therabite or EZ
Flex, can assist a patient with these exercises. An alternative and inexpensive method consists
of a stack of tongue blades that can be increased in number each day (see the image below).

Tongue blade physical therapy.

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Regardless of the device chosen, during week 1, the patient should begin active range of
motion. That is, patients should attempt to open widely using only their own masticatory
musculature. If sideward deviation is noted during this period, they are instructed to place a
hand on the side of the face toward which the deviation is occurring and place gentle medial
pressure as they open and close. In week 2, passive opening begins. Fingers, tongue blades, or
exercise devices may be used. Normal mandibular range of motion is 40 mm or more between
the incisal edges of the anterior maxillary and mandibular teeth. In most patients, this distance
should be achievable by week 2, if not sooner.

Once the patient has reached the minimum goal of 40 mm, continued work in the straight
opening plane is augmented with lateral and protrusive movements. The treatment is not
complete until the patient has both a stable occlusion and normal function. Many providers do
not remove hardware until both goals have been achieved; the removal thus serves as an
additional motivational factor for some patients.

The experienced provider realizes just how much work is involved in closed management of
these fractures. According to Walker, "Nonsurgical management is not easy because it requires
close supervision and attention by the therapist and compliance by the patient." [6] Poorly

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managed closed reductions may result in complications, such as pain, asymmetry and deviation
on opening, hypomobility, malocclusion, degenerative joint disease, adhesions, ankylosis, and
even maldevelopment if the patient still is growing. Nevertheless, closed reduction is most often
the treatment of choice. When correctly managed, closed reduction is excellent treatment for
most condylar/subcondylar fractures because, as Horswell wrote, "Approximately 15% of adult
patients treated with closed reduction have early post-fixation problems and the single
management component that leads to the resolution of these problems is joint physiotherapy,
which must be goal specific and interactive." [10]

The result of an appropriate physical therapy regimen is a functional joint and masticatory
system with little or no deformity.

Treatment Procedures Open Reduction

Remember that every patient who undergoes open reduction still needs to complete adequate
physical therapy as described in Treatment Procedures Closed Reduction. The goals here
also are the restoration of both normal range of motion and a stable occlusion. In all but a few
edentulous cases, occlusal control is established via arch bars, orthodontic brackets, Ivy loops,
or other hardware devices prior to approaching the fracture. These devices are then present for
use in guiding the occlusion and masticatory muscles after surgery.

Multiple approaches are possible in order to visualize and reduce these fractures. Extraoral
approaches include the preauricular, face-lift, retroauricular, retromandibular, and
submandibular incisions, often in combination. An excellent resource for understanding the
technical aspects of each of these approaches, as well as risks and benefits, is Approaches to
the Facial Skeleton by Ellis and Zide. [11]

Intraoral approaches (also discussed in the above-mentioned book) include the mandibular
vestibular incision with or without the use of an endoscope. In both cases, a transbuccal trocar
for the placement of some or all of the screws is usually necessary. In some centers, use of an
endoscope to assist with visualization of the fracture has become popular, and new
instrumentation is being developed daily. In many cases, however, the use of the endoscope
can add quite a bit to the length of the procedure and therefore to the anesthetic time and
hospital charges without adding a great deal of useful information except, perhaps, for research
and development purposes.

As equipment improves and operator experience is increased, operating times are expected to
be reduced. The next important issue to consider is whether endoscopic reduction actually
significantly improves functional and esthetic goals when compared with properly performed and
followed closed reduction or if it simply provides more attractive radiographs.

Whatever approach is chosen, once the fracture is exposed, it must be reduced. Whether the
fracture must be fixated and how stable that fixation should be are also topics of much debate.
A 1980 study looked at a series of patients who had condyles significantly displaced out of the
fossa who underwent open reduction without any fixation. The surgeons argued that this
prevented a significant malunion, while avoiding rigidly fixating the condyles in a nonphysiologic
position. In essence, each of these markedly displaced fractures was converted to a
nondisplaced fracture and then treated as such with occlusal control and physical therapy.

If the fracture segment is small enough, some surgeons advocate condylectomy. This procedure
simply removes the proximal segment altogether, while controlling the occlusion. The patient
participates in extensive physical therapy.

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Wire fixation and intramedullary pins have also been used to stabilize these fractures. Again,
occlusal control and physiotherapy remain crucial to successful outcomes.

In some cases, external fixators (eg, Joe Hall Morris-type appliances) have been used with
good success but poor esthetics. Once again, occlusal control and physiotherapy are crucial to
successful outcomes.

Finally, miniplates and screws are discussed. Argument exists as to whether these constitute
rigid fixation. Likely they do. Certainly, a miniplate that fixates the condylar segment in a
nonphysiologic position sets up the patient for pain, poor function, and degenerative joint
disease (see the image below).

The patient was compliant with postoperative physical therapy; however, the condyle was rigidly fixated
incorrectly, leading to marked deviation on opening.

View Media Gallery

As the use of various technologies progresses, the debate over open versus closed reduction
continues. For example, a study by Ho et al indicated that in patients with bilateral condylar
head fractures, open reduction results in better functional and radiographic outcomes than does
closed reduction. The study, which included 20 open-reduction and 18 closed-reduction
patients, found that postoperative chewing functions, malocclusion rates, TMJ pain, and
radiographic outcomes were better in the open-reduction group. [12]

Distinguished faculty members at the same institution often hold diametrically opposed opinions
on what is the "best" way to treat any individual case. Excellent discussions of the risks and
benefits of, as well as changing indications for, open versus closed reduction can be found in
the references from Haug and Assael. [13, 14, 15, 16]

Conclusion
Perhaps the collective experience of the many surgeons who treat these fractures can best be
characterized as follows:

Intracapsular fractures are best treated closed.

Fractures in children are best treated closed except when the fracture itself anatomically
prohibits jaw function.
Most fractures in adults can be treated closed.

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Physical therapy that 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 closed.
When open reduction is indicated, the procedure must be performed well, with an
appreciation for the patient's occlusal relationships, and it must be supported by an
appropriate physical therapy and follow-up regimen.

A particularly well-written and scientific review of the biologic factors involved in the treatment of
condylar fractures can be found in the article from Ellis and Throckmorton in the footnotes. [17]
For excellent patient education resources, see eMedicineHealth's patient education article
Broken Jaw.

References

1. Vranis NM, Mundinger GS, Bellamy JL, et al. Extracapsular Mandibular Condyle Fractures
Are Associated With Severe Blunt Internal Carotid Artery Injury: Analysis of 605 Patients.
Plast Reconstr Surg. 2015 Jun 15. [Medline].

2. Hackenberg B, Lee C, Caterson EJ. Management of subcondylar mandible fractures in the

adult patient. J Craniofac Surg. 2014 Jan. 25 (1):166-71. [Medline].

3. Walker RV. Traumatic mandibular condyle fracture dislocations. Am J Surg. 100:850-863.

4. Boyne PJ. Osseous repair and mandibular growth after subcondylar fractures. J Oral
Surg. 1967 Jul. 25(4):300-9. [Medline].

5. Zhang X, Obeid G. A comparative study of the treatment of unilateral fractured and

dislocated mandibular condyles in the rabbit. J Oral Maxillofac Surg. 1991 Nov.
49(11):1181-90. [Medline].

6. Walker RV. Condylar fractures: nonsurgical management. J Oral Maxillofac Surg. 1994
Nov. 52(11):1185-8. [Medline].

7. Alpert BA. Fractures, Mandible, Condylar and Subcondylar. Oral Maxillofac Surg Clin
North Am. 1999. 2(2):262.

8. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral
Maxillofac Surg. 1983 Feb. 41(2):89-98. [Medline].

9. Healy SM, Zwickey MR, Stamboulieh JN, Throndson RR. Closed reduction of an
intracranially displaced subcondylar fracture: a case report. J Oral Maxillofac Surg. 2008
Feb. 66(2):389-93. [Medline].

10. Horswell BB, Pospisil OA. Nasal symmetry after primary cleft lip repair: comparison
between Delaire cheilorhinoplasty and modified rotation-advancement. J Oral Maxillofac
Surg. 1995 Sep. 53(9):1025-30; discussion 1031-2. [Medline].

11. Ellis EE, Zide MF. Approaches to the Facial Skeleton. Philadelphia, Pa: Lippincott Williams
& Wilkins; 1995.

12. Ho SY, Liao HT, Chen CH, Chen YC, Chen YR, Chen CT. The radiographic and functional
outcome of bilateral mandibular condylar head fractures: a comparison between open and
closed treatment. Ann Plast Surg. 2015 May. 74 Suppl 2:S93-8. [Medline].

12 of 16 20/12/2016 19.33
Mandibular Condylar and Subcondylar Fractures: Overview, Anatomy,... http://emedicine.medscape.com/article/870075-overview

13. Assael LA. Open versus closed reduction of adult mandibular condyle fractures: an
alternative interpretation of the evidence. J Oral Maxillofac Surg. 2003 Nov. 61(11):1333-9.
[Medline].

14. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular
subcondylar fractures. J Oral Maxillofac Surg. 2001 Apr. 59(4):370-5; discussion 375-6.
[Medline].

15. Haug RH, Brandt MT. Traditional versus endoscope-assisted open reduction with rigid
internal fixation (ORIF) of adult mandibular condyle fractures: a review of the literature
regarding current thoughts on management. J Oral Maxillofac Surg. 2004 Oct.
62(10):1272-9. [Medline].

16. Haug, RH, Brandt, MT. Open versus closed reduction of adult mandibular condyle
fractures: A review of the literature regarding the evolution of current thoughts on
management. Journal of Oral and Maxillofacial Surgery. J Oral Maxillofac Surg. November
2003. 61:1324-1332.

17. Ellis E, Throckmorton GS. Treatment of mandibular condylar process fractures: biological
considerations. J Oral Maxillofac Surg. 2005 Jan. 63(1):115-34. [Medline].

18. Deleyiannis FW, Vecchione L, Martin B, Jiang S, Sotereanos G. Open reduction and
internal fixation of dislocated condylar fractures in children: long-term clinical and
radiologic outcomes. Ann Plast Surg. 2006 Nov. 57(5):495-501. [Medline].

19. Kanno T, Sukegawa S, Fujioka M, Takabatake K, Furuki Y. Transoral open reduction with
rigid internal fixation for subcondylar fractures of the mandible using a small angulated
screwdriver system: is endoscopic assistance necessary?. J Oral Maxillofac Surg. 2011
Nov. 69(11):e372-84. [Medline].

20. Lekven N, Neppelberg E, Tornes K. Long-term follow-up of mandibular condylar fractures

in children. J Oral Maxillofac Surg. 2011 Nov. 69(11):2853-9. [Medline].

21. Park JM, Jang YW, Kim SG, Park YW, Rotaru H, Baciut G, et al. Comparative study of the
prognosis of an extracorporeal reduction and a closed treatment in mandibular condyle
head and/or neck fractures. J Oral Maxillofac Surg. 2010 Dec. 68(12):2986-93. [Medline].

22. Sawazaki R, Lima Jnior SM, Asprino L, Moreira RW, de Moraes M. Incidence and
patterns of mandibular condyle fractures. J Oral Maxillofac Surg. 2010 Jun. 68(6):1252-9.
[Medline].

23. Schoen R, Fakler O, Metzger MC, Weyer N, Schmelzeisen R. Preliminary functional

results of endoscope-assisted transoral treatment of displaced bilateral condylar mandible
fractures. Int J Oral Maxillofac Surg. 2008 Feb. 37(2):111-6. [Medline].

24. Trost O, Kadlub N, Abu El-Naaj I, Danino A, Trouilloud P, Malka G. [Surgical management
of mandibular condylar fractures in adults in France, 2005]. Rev Stomatol Chir Maxillofac.
2007 Jun. 108(3):183-8. [Medline].

25. Zachariades N, Mezitis M, Mourouzis C, Papadakis D, Spanou A. Fractures of the

mandibular condyle: a review of 466 cases. Literature review, reflections on treatment and
proposals. J Craniomaxillofac Surg. 2006 Oct. 34(7):421-32. [Medline].

Media Gallery

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Mandibular Condylar and Subcondylar Fractures: Overview, Anatomy,... http://emedicine.medscape.com/article/870075-overview

Sectional anatomy of the mandible with frequency of fractures.

Movement of the temporomandibular joint (TMJ).
Clinical presentations suspicious for condylar/subcondylar fracture.
Radiographic views of subcondylar fractures.
Tongue blade physical therapy.
The patient was compliant with postoperative physical therapy; however, the condyle was
rigidly fixated incorrectly, leading to marked deviation on opening.
A tongue blade was placed across the molars as the patient bites down. The tongue blade
thus represents the occlusal plane. The lower picture shows the patient's occlusal
relationships in detail.
The panoramic radiograph and occlusal relationship depicted are found in an 18-year-old
man who is otherwise healthy. He reported jaw pain for the last 2 days, and his discomfort
began after he fell while running hurdles during track practice.
Pictured are the preoperative CT scan, final occlusion, and function for this 42-year-old
man. The CT scan reveals bilateral medial pole shear fractures of the condyles. This
patient was treated with guiding elastics and physical therapy alone. The medial pole
shears did not pose an impediment to function, and despite poor social conditions (ie,
homelessness, unemployment), the patient was motivated to cooperate with his physical
therapy regimen. As a result, at the end of treatment he was free of pain with excellent
function and without any discernible deformity. These results demonstrate the importance
of an appropriate supervised physical therapy regimen and prove that open treatment of at
least one of the condylar fractures is NOT always mandatory to re-establish facial height
and anteroposterior (AP) projection.

of 9

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Contributor Information and Disclosures

Author

Kim E Goldman, DMD Mt Sinai St Luke's/Roosevelt Hospitals

Kim E Goldman, DMD is a member of the following medical societies: American Association of
Oral and Maxillofacial Surgeons, American Academy of Oral and Maxillofacial Pathology,
American Trauma Society, International Association of Oral and Maxillofacial Surgeons,
Kentucky Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska

Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

14 of 16 20/12/2016 19.33
Mandibular Condylar and Subcondylar Fractures: Overview, Anatomy,... http://emedicine.medscape.com/article/870075-overview

Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of

Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership,
American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University
of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy
of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and
Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for:
Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or
greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board
membership; Received honoraria from RxRevu for chief medical editor; Received salary from
Medvoy for founder and president; Received consulting fee from Corvectra for senior medical
advisor; Received ownership interest from Cerescan for consulting; Received consulting fee
from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received
consulting fee from Covidien for consulting.

Additional Contributors

Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head

and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of
Medicine

Hassan H Ramadan, MD, MSc is a member of the following medical societies: American
Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery,
American College of Surgeons, American Rhinologic Society

Disclosure: Nothing to disclose.

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