Available online at www.sciencedirect.

com

British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526

Review
Fractures of the mandibular condyle: evidence base and
current concepts of management
Khalid Abdel-Galil ∗ , Richard Loukota 1
Oral & Maxillofacial Surgery, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, United Kingdom

Accepted 8 October 2009

Available online 8 November 2009

Abstract

Management of mandibular condylar fractures remains a source of ongoing controversy. While some condylar fractures can be managed
non-surgically, recognition of fracture patterns that require surgical intervention and selection of an appropriate operative procedure are
paramount to success in treating these injuries.The objective of this review is to appraise the current evidence regarding the effectiveness of
interventions that are used in the management of fractures of the mandibular condyle.
© 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Trauma; Mandibular fractures; Condylar injuries; Systematic review

Methods Fig. 1 summarises the literature search and selection

Search strategy
An electronic search of the literature directly relating to
condylar fracture management was conducted. The databases
examined were the Cochrane Controlled Trials Register,
Cochrane Database of Systematic Reviews, Database of
Abstracts of Reviews of Effects and the Health Technol-
ogy Assessment database. Electronic searches were also
conducted of the National Library of Medicine’s (NLM)
PubMed, Ovid Medline database, Embase, Cumulative Index
to Nursing & Allied Health Literature [CINAHL] and Biosis
databases up to 2009.
Of 1081 studies and publications identified on the initial
search of all databases, 858 were excluded as they were not
directly relevant to the subject matter studied. The remain-
ing 233 publications were examined and analysed for the
purposes of this review.
∗
Corresponding author. Tel.: +44 113 3436219; fax: +44 113 3436264.
E-mail addresses: khalidabdelgalil@doctors.org.uk (K. Abdel-Galil),
rloukota@doctors.org.uk (R. Loukota).
1 Tel.: +44 113 3436219; fax: +44 113 3436264.
process in the early stages of the review. The majority of
identified literature included case reports and series, descrip-
tions of osteosynthesis techniques, technical notes, letters and
editorials. Fig. 2 presents level I and II evidence identified in
this review.
Fracture classification as a guide to treatment selection
Classification systems for condylar fractures can offer insight
into which fractures might be best treated with open/closed
reduction; a usable classification system must be respon-
sive to the contemporary treatment options available to the
surgeon.
The lack of consistency in terminology relating to fracture
patterns, however, poses a problem associated with the man-
agement of these injuries among surgeons and researchers
and their reporting in the surgical literature.
Early attempts at fracture classification were rather sim-
plistic and did not help to direct surgical treatment of these
injuries beyond closed reduction and maxillo-mandibular
fixation.1–3
The Lindahl classification considers factors that include
the level of fracture, “dislocation” at the point of fracture,

0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.10.010
 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526
Fig. 1. Search strategy.
and the relationship of the condylar head to the articular
fossa. Although useful, this classification system is rather
complex.4
Similarly the Spiessl & Schroll classification divides
condylar fractures into subjectively assessed high and low
subtypes, with and without “dislocation”, but does not allow
easy visualisation of the fracture.5
The sub-classification reported by Loukota et al. (Fig. 3),
is also adopted by the Strasbourg Osteosynthesis Research
Group (SORG).6 This classification was analysed retrospec-
tively in a cohort of patients with condylar fractures and found
to be simple to use and can help predict treatment need and
outcome.7
The classification of condylar head fractures has
been further clarified recently.36 This should assist and
simplify both treatment decision making and standard-
isation of nomenclature in future work within this
field.
Indications for treatment/intervention
In an earlier review of the literature addressing the evolution
of treatment modalities, condylar displacement and ramus
521
height instability were considered the only indications for
open reduction and fixation of these injuries.
Open reduction and internal fixation (ORIF) was found
to provide better functional reconstruction of mandibular
condyle fractures than closed reduction (CR) and maxillo-
mandibular fixation.8 In current day practice, fractures with
a deviation of more than 10◦ , or a shortening of the ascend-
ing ramus of more than 2 mm, should be treated with open
reduction and fixation, irrespective of level of the fracture.
9
Operative techniques
Surgical techniques, including approaches to the mandibular
condyle and ramus have evolved over the last few decades.
This is evidenced by the substantial number of reports
identified in the searched literature describing the various
techniques, both open and endoscopic, used for rigid fixation
of condylar fractures.
No trial evidence exists comparing the various approaches
described for access to the ramus–condyle region.
Endoscope-assisted ORIF of condylar fractures is now
a viable alternative to traditional closed or open reduction
techniques and its acceptance continues to grow as more
surgeons gain experience. A recent prospective, randomised
controlled, multi-center trial concluded that the treatment of
condylar fractures with a transoral endoscopically assisted
technique is reliable and may offer advantages for selected
cases.19 This included a tendency towards lower occurrence
of facial nerve injury, although this was not supported by
comparative statistical analyses.
Figs. 4–8 illustrate some of the current osteosynthesis
techniques used in condylar fracture fixation.
Assessment scores and outcomes
Several methods, both objective and subjective, have been
described for the assessment of outcome following surgery
on the temporomandibular joint complex.10–15
The Helkimo dysfunction score consists of three indices
evaluating anamnestic and clinical dysfunction, occlusion
and articulation disturbance. It is an accepted valid and reli-
able tool used to determine the functional outcome after
surgery of mandibular and temporomandibular joint disor-
ders, as well as after orthognathic surgery.13–15
As in most surgical disciplines, clinicians managing
patients with condylar injuries are responsible for monitor-
ing and recording outcomes of treatment. This should include
functional assessments of jaw mobility and excursions (open-
ing, lateral excursion and protrusion), occlusal changes as
well as subjective pain and discomfort. This will facilitate
future clinical decision making and assist in the standardised
dissemination of treatment results.
Although outcome monitoring and reporting should be
encouraged using available validated indices/scores, this is
not common practice at present.
522 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526

Fig. 2. Existing level 1 and 2 evidence (ORIF: open reduction and internal fixation; CR: closed reduction; ENDO: endoscopic reduction and fixation).

Open reduction versus closed management – level 1
evidence
In an early trial, Worsaae and Thorn reported the complica-
tions associated with surgical versus non-surgical treatment
of unilateral low subcondylar fractures.30 Although both
groups underwent maxillo-mandibular immobilisation for 4
weeks, they reported complication rates of 4% and 39% in
the surgical and non-surgical groups respectively.
A randomised clinical trial assessing occlusal results
following open versus closed management of condylar
neck or subcondylar fractures found a significantly greater
percentage of malocclusion (22–28%) in the closed treat-
ment group.31 Earlier non-randomised longitudinal studies
from the same group confirmed decreased mandibular
motion and reduced posterior facial/ramus height in groups
of patients treated with closed reduction and maxillo-
mandibular fixation.32,33
An international prospective randomised trial involving
seven centres compared operative and conservative treatment
of displaced condylar fractures and yielded results which
were clearly in favour of the operative approach.16 This
reported on 66 patients treated for 79 fractures and followed
up for 6 months. Evaluation included radiographic assess-
ment, clinical, functional and subjective parameters including
visual analogue scales for pain and the Mandibular Function
Impairment Questionnaire index for dysfunction. Operative
treatment was found to be superior in all objective and all but
one subjective functional parameters.
In another prospective single-centre study 22 patients with
26 diacapitular condylar fractures were randomised to receive
either ORIF or closed treatment and followed up for 12

Fig. 3. SORG classification: (1) high/condylar neck fracture; (2) low/condylar base fracture; (3) diacapitular fracture (with permission from Loukota et al.6 ).
 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526 523

Fig. 4. Osteosynthesis configurations for condylar base fractures (with permission, from: Pilling E, Eckelt U, Loukota R, Schneider K, Stadlinger B. Comparative
evaluation of ten different condylar base fracture osteosynthesis techniques).
524 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526

Fig. 5. Headless bone screw fixation technique.

months.34 This failed to demonstrate a clear benefit to patients

of ORIF versus closed treatment and recommended closed
management in these cases. The cohort of patients studied
was small however, and only included undisplaced fractures,
a major weakness of the study.
The results of a recent meta-analysis were inconclusive
regarding whether open or closed treatment should be used
for the management of mandibular condylar fractures.17 This
was attributed to the relatively poor quality of the avail-
able data and the lack of other important information. The Fig. 7. Schematic illustrating ultrasound activated resorbable osteosynthesis
methodological quality of this study was weak, however, [SonicWeld RxTM KLSMartin].

and several deficiencies render its conclusions question-

able. These include incomplete database exploration, flawed
statistical analysis, and lack of adherence to QUOROM
standards.18
In a prospective, randomised controlled multicentre trial
invovlving centres from North America, Europe and Asia,
patients with condylar neck fractures were randomised to
receive either open reduction and internal fixation using
an extraoral (submandibular, preauricular, retromandibular)
approach or a transoral endoscopic procedure. The primary
functional outcome measure was investigated using the asym-
metric Helkimo dysfunction score at 8–12 weeks and 1
year after surgery.19 This showed that comparable functional
results were achieved after reduction and internal fixation
using either technique. A marginally better early cosmetic
outcome and fewer complications were the associated advan-
tages of the transoral approach. Although these included a
reduced occurrence of facial nerve damage, this was not
supported by comparative statistical analyses.

Who should provide care?

The increased focus on quality and efficiency improvement

within healthcare has put increasing pressure on surgeons to
improve outcomes.
Exisiting analyses from other surgical disciplines con-
Fig. 6. Preoperative radiograph of comminuted diacapitular fracture. firm learning curves in which complication rates, variance in
 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526
Fig. 8. Post-operative radiograph of comminuted diacapitular fracture fixa-
tion using ultrasound activated resorbable osteosynthesis.
operative time, and operative time all decrease with surgeon
experience.25 Similarly volume of work has been extensively
studied as a surrogate for surgical experience and improved
outcomes.26–28
Given the relatively high incidence of condylar
fractures,29 it is possible to achieve such a volume of work
and expertise by a nominated surgeon in most hospital units.
Post-operative morbidity to the facial nerve is often a
concern for surgeons performing open surgery for condy-
lar fractures. Published reports, including available level I
evidence, shows that permanent facial nerve palsy follow-
ing ORIF of condylar neck and base fractures is not a major
concern.16,20,21,34
The transoral approach is difficult to perform without
endoscopic assistance. Intensive training in endoscopic tech-
niques and the handling of relevant instruments is necessary
before the transoral approach for the treatment of condy-
lar fractures can be performed safely and competently.22–24
With increasing experience the technique can also be refined,
further improving outcomes.
525
Conclusion
A trend is emerging in the surgical literature confirming supe-
rior functional results following open reduction and internal
fixation of condylar fractures, where this is indicated. This
is supported by existing level I evidence. Endoscopic assis-
tance, performed transorally, may also provide an alternative
means for treating a subset of these injuries, reducing visible
scar formation and possibly facial nerve damage.
There are still areas of condylar trauma surgery which
some surgeons consider controversial: condylar head frac-
tures and displaced paediatric fractures. The use of resorbable
osteosynthesis techniques may be of benefit in both these
clinical settings; further research is needed in this field.
A SORG multicentre prospective randomised controlled
trial is planned to study the treatment of condylar head
fractures. Regarding paediatric injuries, promising outcomes
have been anecdotally reported following fixation of such
fractures in children as young as 6 years of age.
Conflict of interest
The authors have no conflict of interest to disclose.
References
1. MacLennan WD. Consideration of 180 cases of typical fractures of the
mandibular condylar process. Br J Plast Surg 1952;5:122–8.
2. Rowe NL, Killey HC. Fractures of the facial skeleton. Baltimore:
Williams & Silkins; 1955. p. 202–204.
3. Dingman RO, Natvig P. Surgery of facial fractures. Philadelphia: Saun-
ders; 1964. p. 177–184.
4. Lindahl L. Condylar fractures of the mandible. I. Classification and
relation to age, occlusion, and concomitant injuries of teeth and teeth-
supporting structures, and fractures of the mandibular body. Int J Oral
Surg 1977;6:12–21.
5. Spiessl B, Schroll K. Gelenkfortsatz und gelenkkopfchenfracturen. In:
Higst H, editor. Spezielle frakture und luxationslehre. Stuttgart: Thieme;
1972 [BD. I/I].
6. Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassification of frac-
tures of the condylar process of the mandible. Br J Oral Maxillofac Surg
2005;43:72–3.
7. Cenzi R, Burlini D, Arduin L, Zollino I, Guidi R, Carinci F. Mandibular
condyle fractures: evaluation of the Strasbourg Osteosynthesis Research
Group classification. J Craniofac Surg 2009;20:24–8.
8. Brandt MT, Haug RH. Open versus closed reduction of adult mandibular
condyle fractures: a review of the literature regarding the evolu-
tion of current thoughts on management. J Oral Maxillofac Surg
2003;61:1324–32.
9. Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota RA, Rasse
M. 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 eval-
uation of fracture level. J Oral Maxillofac Surg 2008;66:2537–44.
10. Clark GT, Seligman D, Solberg WK, Pullinger AG. Guidelines for the
examination and diagnosis of temporomandibular disorders. J Cran-
iomand Disord 1989;3:7–14.
11. Dworkin SF, LeResche L. Research diagnostic criteria for temporo-
mandibular disorders: review, criteria, examinations and specifications,
critique. J Craniomandib Disord 1992;6:301–55.
526 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526
12. Stegenga B, de Bont LG, de Leeuw R, Boering G. Assessment of
mandibular function impairment associated with temporomandibu-
lar joint osteoarthrosis and internal derangement. J Orofac Pain
1993;7:183–95.
13. Helkimo M. Studies on function and dysfunction of the masticatory
system. II. Index for anamnestic and clinical dysfunction and occlusal
state. Sven Tandlak Tidskr 1974;67:101–21.
14. Helkimo M. Studies on function and dysfunction of the masticatory
system. I. An epidemiological investigation of symptoms of dysfunction
in Lapps in the north of Finland. Proc Finn Dent Soc 1974;70:37–49.
15. Helkimo M. Studies on function and dysfunction of the masticatory
system. 3. Analyses of anamnestic and clinical recordings of dysfunction
with the aid of indices. Sven Tandlak Tidskr 1974;67:165–81.
16. Eckelt U, Schneider M, Erasmus F, Gerlach KL, Kuhlisch E, Loukota
R, et al. Open versus closed treatment of fractures of the mandibu-
lar condylar process—a prospective randomized multi-centre study. J
Craniomaxillofac Surg 2006;34:306–14.
17. Nussbaum ML, Laskin DM, Best AM. Closed versus open reduction
of mandibular condylar fractures in adults: a meta-analysis. J Oral
Maxillofac Surg 2008;66:1087–92.
18. Clarke M. The QUOROM statement. Lancet 2000;355:756.
19. Schmelzeisen R, Cienfuegos-Monroy R, Schön R, Chen CT, Cunning-
ham Jr L, Goldhahn S. Patient benefit from endoscopically assisted
fixation of condylar neck fractures—a randomized controlled trial. J
Oral Maxillofac Surg 2009;67:147–58.
20. Devlin MF, Hislop WS, Carton ATM. Open reduction and internal fix-
ation of fractured mandibular condyles by a retromandibular approach:
surgical morbidity and informed consent. Br J Oral Maxillofac Surg
2002;40:23–5.
21. Downie JJ, Devlin MF, Carton ATM, Hislop WS. Prospective study of
morbidity associated with open reduction and internal fixation of the
fractured condyle by the transparotid approach. Br J Oral Maxillofac
Surg 2009;47:370–3.
22. Schon R, Fakler O, Gellrich NC, Schmelzeisen R. Five-year
experience with the transoral endoscopically assisted treatment of dis-
placed condylar mandible fractures. Plast Reconstr Surg 2005;116:
44–50.
23. Loukota RA. Endoscopically assisted reduction and fixation of condy-
lar neck/base fractures—the learning curve. Br J Oral Maxillofac Surg
2006;44:480–1.
24. Mannion CJ, Loukota RA. Endoscopically-assisted treatment of condy-
lar fractures—experiences following an educational course. Br J Oral
Maxillofac Surg, doi:10.1016/j.bjoms.2009.08.022.
25. Carty MJ, Chan R, Huckman R, Snow D, Orgill DP. A detailed analysis
of the reduction mammaplasty learning curve: a statistical process model
for approaching surgical performance improvement. Plast Reconstr Surg
2009;124:706–14.
26. Eastham JA. Do high-volume hospitals and surgeons provide better care
in urologic oncology? Urol Oncol 2009;27:417–21.
27. Wang TS, Roman SA, Sosa JA. Predictors of outcomes following
pediatric thyroid and parathyroid surgery. Curr Opin Oncol 2009;21:
23–8.
28. Shervin N, Rubash HE, Katz JN. Orthopaedic procedure volume and
patient outcomes: a systematic literature review. Clin Orthop Relat Res
2007;457:35–41.
29. Ellis 3rd E, Moos KF, el-Attar A. Ten years of mandibular fractures:
an analysis of 2137 cases. Oral Surg Oral Med Oral Pathol 1985;59:
120–9.
30. Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral
low subcondylar fractures: a clinical study of 52 cases. J Oral Maxillofac
Surg 1994;52:353–60.
31. Ellis 3rd E, Simon P, Throckmorton GS. Occlusal results after open or
closed treatment of fractures of the mandibular condylar process. J Oral
Maxillofac Surg 2000;58:260–8.
32. Palmieri C, Ellis 3rd E, Throckmorton G. Mandibular motion after
closed and open treatment of unilateral mandibular condylar process
fractures. J Oral Maxillofac Surg 1999;57:764–75.
33. Ellis 3rd E, Throckmorton G. Facial symmetry after closed and open
treatment of fractures of the mandibular condylar process. J Oral Max-
illofac Surg 2000;58:729–30.
34. Landes CA, Day K, Lipphardt R, Sader R. Closed versus open opera-
tive treatment of nondisplaced diacapitular (Class VI) fractures. J Oral
Maxillofac Surg 2008;66:1586–94.
35. Nasser M, Fedorowicz Z, Ebadifar A. Management of the fractured eden-
tulous atrophic mandible. Cochrane Database Syst Rev 2007;4(January
(1)). CD006087.
36. Loukota RA, Neff A, Rasse M. Nomenclature/classification of frac-
tures of the mandibular condylar head. Br J Oral Maxillofac Surg,
doi:10.1016/j.bjoms.2009.08.036.