There are various approaches in order to visualize and reduce the fractures of the condyles, these can be divided into two broad groups – extraoral and intraoral [11, 25, 60].

Extraoral approaches include preauricular, retroauricular, retromandibular, submandibular, and rhytidectomy (face-lift) incisions. These can also be used in different combinations [11, 25, 60].

Risdon described the submandibular approach; 4–5 cm skin incision, 2 cm below the angle of the mandible [60]. Access to the high condyle fractures with this approach is not as good as in preauricular and retromandibular approach, but the facial nerve, parotid gland, external carotid artery, and retromandibular vein are better avoided and kept out of the operation field. The scars are also more hidden in the submandibular approach. However, most surgeons prefer retromandibular approach described by Hinds and Girotti [60] because of better direct access, shorter working distance from the incision to the condyle, excellent exposure even in the presence of marked edema, easy retrieval of the medially displaced condyle, and less conspicuous facial scar [10–14, 25, 29, 41, 44, 53, 60].

Silverman first described the open reduction and internal fixation of the condyle via intraoral route [60]. The major problem with this approach is access to the condylar fragments with consequent difficulty in manipulating and reducing the fragments. The merit is no obvious scars [44, 60]. Intraoral approach is usually by the mandibular vestibular incision with or without the use of an endoscope [11, 43, 100]. In any case, a transbuccal trocar is often necessary to aid the placement of some or all of the screws through plates on the reduced fragment [29, 41, 44, 60]. The use of an endoscope to assist with visualization of the fracture has become popular, and is commonly done in some centers. New instrumentation is frequently being developed.

In some cases, 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 advantage in terms of outcome [43, 100]. The evidence in support of its use elucidates the fact that it minimizes the incision needed and enhances visualization of small fragments. However, manipulation can be difficult and operation time increased especially with inexperienced surgeons [43, 68, 100]. As the equipment improves and operators’ experience increases, operating times are expected to be reduced.

There are only few articles reporting outcomes with the use of endoscopes [43, 68, 100]. Hence, there is insufficient evidence to compare outcomes in terms of functional and aesthetic goals with properly performed and followed closed reduction, invasive intraoral, or extraoral approaches. In this regard, multidata based studies have to be conducted to answer the questions.

Generally speaking, most surgeons favor retromandibular approach, even though there are no conclusive evidences to suggest that outcome with one extraoral approach is better than the other or that extraoral approach is better than intraoral approach. In terms of scar perception, many patients prefer intraoral approach, even though access is better with the extraoral approach [11, 29, 41, 44, 60]. The approach used in each case would be determined by the surgeons’ and patients’ choice, amount of access obtainable, and the site of condyle fracture.

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 other issues of controversy. Some surgeons believe that fixation is not always required. In studies that looked at a series of patients who had condyles significantly displaced out of the fossa and open reduction without fixation was done, the surgeons argued that significant malunion was prevented while avoiding rigidly fixating the condyles in a nonphysiologic position [8–15, 19, 21, 26, 32, 33, 41]. In essence, each of these markedly displaced fractures was converted to an undisplaced fracture and then treated as such, with occlusal control and physical therapy. If the fracture segment is unilateral and small enough, some surgeons advocate condylectomy [53, 74] instead of ORIF. The procedure simply removes the proximal segment altogether, while controlling the occlusion; the patient participates in extensive physical therapy afterward.

On the contrary, some others advocate mandatory fixation once a fracture is opened up and different methods of fixation have been discussed. Wire fixation and intramedullary pins have been used to stabilize condylar fractures [26, 32, 104, 110]. Again, occlusal control and physiotherapy remain crucial to successful outcomes.

In some cases, external fixators (e.g., Joe Hall Morris-type appliances) have been used with good success. Once again, occlusal control and physiotherapy are crucial to successful outcomes [68–71, 73, 74]. Finally, miniplates and screws are discussed. Argument exists as to whether these constitute rigid fixation or not [23–26, 32, 33]. The conclusion is that stable fixation, either semirigid with transosseous wires or external fixators or rigid with miniplates, is necessary once open treatment is performed to keep the segments in physiologic position. Unstable fixation or fixation in a nonphysiologic position sets up the patient for pain, poor function, and degenerative joint disease [41, 53, 74, 91, 98, 99, 104, 110, 112, 120, 122, 123].

Of utmost importance for all patients, whether treated with closed or open techniques, is the general agreement that compliance with physical therapy regimens is highly essential [9–15]. 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 mouth opening exercises. There are commercially available devices such as the Therabite or EZ Flex jaw exercisers, which can be used by patients. An alternative and inexpensive method consists of a stack of tongue blades that can be increased in number each day [53, 74, 91, 98, 99]. Regardless of any device, during the first week posttreatment (i.e., non-IMF) or post-IMF, the patient should begin active movement of the jaws by attempting to open widely using their masticatory muscles. If sideward deviation is noted during this period, they are instructed to place a hand on the side of the face toward which the jaw deviates and apply gentle medial pressure as they open and close. By week 2, passive opening should begin with fingers, tongue blades, or exercise devices. 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 care providers do not remove hardwares until both goals have been achieved; the removal thus serves as an additional motivational factor for some patients [19, 21, 26, 32, 33]. The result of an appropriate physical therapy regimen is a functional joint and masticatory system with little or no deformity [21, 26, 32].

The conclusive evidence based on collective reports of experiences documented in the literature can be itemized as follows: