Mandibular condyle fractures are among the most common mandibular injuries, and management is a subject of debate. The most common classification systems are highlighted. Algorithm-based clinical decision making may help practitioners in their management. This review focuses on the history and management strategies, including non-surgical, closed treatment, and open reduction and internal fixation (ORIF). ORIF has been increasing in favor over the past decade owing to reduced complications compared with nonsurgical treatment. The surgical approaches and plating techniques have continued to evolve to minimize complications.
Key points
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Mandibular condyle fractures are among the most common facial fractures, representing up to 45% of all mandibular injuries.
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Classification systems are inconsistent in use across the literature, limiting comparability between studies; recent proposals for algorithm-based decision making may help standardize management.
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Nonsurgical management leads to satisfactory results and requires close follow-up. Open reduction and internal fixation (ORIF) has shown favorable results, especially in significant displacement, dislocation, and malocclusion.
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The decision of surgical approach and the plating method can be adapted to reduce risk of facial nerve injury, hardware failure, malocclusion, and so forth.
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Development of standardized protocols, especially in nonsurgical treatment, will allow improvement in interstudy comparability.
Abbreviations
| IMF | intermaxillary fixation |
| MMF | maxillomandibular fixation |
| ORIF | open reduction and internal fixation |
| TMJ | temporomandibular joint |
Introduction
Fractures of the mandibular condyle represent a significant portion of mandibular fractures. The unique anatomy of the mandible and surrounding structures can make management of these fractures challenging and unique from management of fractures of other portions of the mandible. Successful management of these fractures requires detailed knowledge of the anatomy, of the functional goals, and of the treatment modalities available.
Cause
Facial fractures have been reported to be present in around 7% of all patients, with the mandible involved in 47% to 65% of all facial traumas. , The condyle is uniquely susceptible to fracture owing to indirect forces transmitted through direct traumas to the angle and body of the mandible. Studies reveal the mandibular condyle accounts for 32% to 45% of all mandible fractures. , Men and people less than 40 years of age are more likely to have these fractures. , Common mechanisms of injury are motor vehicle accidents, interpersonal violence, and falls. ,,,, Appropriate management of mandibular condyle fractures is of great value to restore the form and function of the mandibular complex.
History
Certain goals must be met when managing adult mandibular condylar fractures, such as obtaining stable occlusion, jaw opening and functional movements, and pain reduction, while reducing surgical complications, particularly facial nerve damage. Table 1 gives a list of definitions of terms for fracture management commonly used when discussing treatment options, although the terms are inconsistently used in the literature. These fractures were traditionally managed with functional limitations with or without maxillomandibular fixation (MMF). Currently, there has been greater use of open reduction and internal fixation (ORIF) owing to improvements in plate and screw fixation. Literature on the topic of open versus closed treatment has increased dramatically over recent years, guiding the conversation on how to best manage these fractures. Many centers often choose conservative management with fewer fractures being managed with ORIF. There is strong evidence for acceptable outcomes with nonsurgical treatments, ,,,,,,,,, but recent studies have demonstrated decreased complications with ORIF. ,,,,,,,,,,,
Table 1
Definitions of important terms regarding management of mandibular condyle fractures
| Type of Management | Definition |
|---|---|
| Conservative (nonsurgical treatment) |
Patient follow-up
Diet modification Range-of-motion exercises |
|
Closed treatment
Closed reduction (nonsurgical treatment) |
Conservative management with additional:
Placement of an intraoral MMF technique to manage occlusion with fixation vs elastics |
| Open reduction internal fixation (surgical treatment) |
Closed treatment management with additional:
Surgical application of plates and fixation screws |
Additional synonyms are listed in italics.
Classification
Classification systems have been developed to describe and communicate the types of mandibular condyle fractures. In a review by McLeod and Keenan, recent studies of condylar fractures found that many use no classification system, a custom paper-specific classification, or other previously published different classification systems. Here, the authors discuss briefly the 3 most common classification systems used in recent years.
The most common published classification system is by Loukota and colleagues, where figures are used to demonstrate 3 different fractures: diacapitular (head), condylar neck, and condylar base fractures ( Fig. 1 ). This system is simplified and usually easier to communicate, but the differentiation between a neck and a base fracture remains vague.
( A ) Condylar head fracture; ( B ) Condylar neck fracture; ( C ) Condylar base fracture.
( Adapted from figures 1–3 from Loukota et al. (2005) ; with permission.)
The second most common classification used is by Lindahl, which includes fracture by level (head, neck, or subcondylar), dislocation (lateral, medial, fissure, or none), and condylar head positioning compared with the articular fossa graded from 0 to 3 ( Fig. 2 ).
Classification of condylar fractures with respect to fracture level, dislocation at the fracture level, and condylar head relation to articular fossa. Dotted lines in condylar head (CH) indicate compression (c), vertical (v), and horizontal (h) fractures. CN, condylar neck; SC, subcondylar fractures.
( From Lindahl (1977) ; with permission.)
The third most frequently used classification, by Neff and colleagues, is one of the most recent and the most comprehensive. This incorporates location fragmentation, vertical apposition, sideward displacement, angulation, head fragment displacement, caudal fragment displacement, distortion of the condylar head, and loss of ramus height. Each of these has associated numerical or alphabetical values to categorize the fractures. It may be difficult to implement clinically and functions best in standardizing a descriptive method of communication between research articles about fracture patterns.
There is no single classification that is universally accepted. The system from Neff and colleagues may be beneficial for research consistency, but a simpler method is preferred for clinical practice. Alyahya and colleagues performed a systematic review on the subjective data of condylar fractures and proposed the algorithm shown in Fig. 3 . Although the authors do not specifically recommended this method, a method such as this may be used by a surgical team to systematically evaluate the patient with a mandibular condyle fracture.
Algorithm for management of condylar fractures.
( From Alyahya et al. (2020) ; with permission.)
Conservative and Closed Treatment
Nonsurgical management, either conservative or closed treatment, is appropriate for cases without significant displacement, malocclusion, or dislocation. Conservative management typically involves range-of-motion exercises, diet modification, and consistent patient follow-up. ,,, Closed treatment, often called closed reduction, involves an MMF technique (arch bars or intermaxillary fixation [IMF] screws), a short period of MMF (<3 weeks to avoid ankylosis), up to 6 weeks of guiding elastics, soft diet, and physiotherapy. ,, A provider should have a plan for each of the following key considerations:
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Follow-up schedule : Often weeks 1, 2, 4, and 6 to monitor occlusion and maximum interincisal opening. ,
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MMF technique (if any): Erich arch bars, hybrid arch bars, IMF screws, and so forth.
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Duration of MMF: Ideally less than 3 weeks to decrease ankylosis risk. ,,,,
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Functional elastics (if any): Often between 2 and 6 weeks depending on the stability of occlusion. ,,
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Diet: No chewing, but liquids or soft diet for 4 to 6 weeks. ,
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Functional therapy: Jaw-opening exercises (with or without adjuncts, such as digital pressure, bite stick, or tongue depressors), as well as lateral excursions and jaw protrusion. ,,,,
Methods of maxillomandibular fixation
More common MMF techniques are Erich arch bars, IMF screws, hybrid arch bars, and dental occlusion ties ( Fig. 4 ). Wire-based methods, such as Ernst ligature, Risdon cables, ivy loops, and embrasure wires, are less frequently used. The article by McGinn and Fedok demonstrates great photographic representation for several of these methods in a stepwise fashion.
Application of dental occlusion ties.
Johnson and colleagues developed an algorithm in their study to guide practitioners in the best option to select between the more common MMF techniques and gave recommendations on which should be used based on surgery or fracture. Although several of the products cost more, reduced operative time is argued to offset the cost. Table 2 lists the common methods of MMF, their complications, benefits, and general cost.
Table 2
Most common methods of maxillomandibular fixation with typical uses, costs, complications, and benefits
| Use with Functional Elastics | Only MMF | Only Intraoperative | Need Stable Dentition | Cost | Complication | Benefits | |
|---|---|---|---|---|---|---|---|
| Ernst Ligature | X | X | + | Self-stick or intraoral trauma with wires | Inexpensive | ||
| Risdon cables | X | X | + | Self-stick or intraoral trauma |
Inexpensive
Pediatrics |
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| Ivy loops | X | X | + | Self-stick or intraoral trauma |
Inexpensive
Pediatrics |
||
| Embrasure wires | X | X | + | Self-stick or intraoral trauma |
Inexpensive
Fast placement |
||
| Erich arch bars | X | X | + |
Self-stick or intraoral trauma
,
Longer duration |
Tension band | ||
| IMF screws | X | X | ++ |
Root damage
,
Screw loosening/damage ,, Mucosal covering |
Fast placement , | ||
| Hybrid arch bars | X | +++ |
Root damage
No tension band |
Fast placement , | |||
| Dental occlusion ties | X | X | +++ | Loosening |
No wire stick risk
,
Fast placement , |
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| Orthodontic lugs | X | X | +++ | Use if patient already in orthodontics | Removal of lugs |
+, cost between $0 and 100; ++, cost between $100 and 1000; +++, cost >$2000.
Indications for open treatment
A surgeon must decide when a condylar fracture should be managed with open treatment. Traditional indications include displacement of the condyle into the middle cranial fossa, lateral extracapsular displacement, an occlusion that is not amenable to closed treatment, and a foreign body being present in the line of the fracture. Although these remain valid, recent literature had expanded indications owing to the benefits of ORIF compared with nonsurgical treatment. ,,,,,,,,,,,,,,
Traditional Indications
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Condyle in the middle cranial fossa
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Lateral extracapsular displacement ,
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Occlusion that is not amenable to closed treatment ,,
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Foreign body being present in the line of the fracture
Newer Indications
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Any malocclusion ,,,
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Bilateral condylar fractures ,
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Loss of ramus height greater than 2 to 5 mm ,,,
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Angulation of the condylar head greater than 10 to 45° ,,,,
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Significant fracture displacement ,,,
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Condylar dislocation ,
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Temporomandibular joint (TMJ) symptoms
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Health conditions/situations where ORIF is beneficial, such as inability to tolerate MMF, such as in the developmentally delayed patient
Surgical approach
The decision of which surgical approach to use is determined by fracture location, surgeon experience, available instrumentation, and avoidance of injury to the facial nerve. Many surgeons have elected nonsurgical management for condylar head and neck fractures, but open techniques, including endoscopic approaches, are increasingly used. , Some common surgical approaches include transoral with or without trocar or endoscope, low submandibular, high submandibular, and retromandibular, including anteroparotid, transparotid, preauricular, retroauricular, and deep retroparotid. Many practitioners choose a transparotid approach with a permanent nerve injury rate of 1.7% and malocclusion rate of 18%.
The choice of approach should be tailored to the fracture type and patient needs. For condylar head fractures, a preauricular approach is commonly used, offering good access while minimizing facial nerve risk. Condylar neck fractures are often treated via extraoral approaches, such as retromandibular (transparotid or retroparotid) and high cervical transmasseteric anteroparotid approaches. For condylar base or subcondylar fractures, the previously mentioned incisions for condylar necks may be used as well as high submandibular incisions. In some cases, even intraoral approaches (with or without endoscopic assistance) can be used. Thoughtful consideration of the involved anatomy, personal familiarity with techniques, and the risks and benefits associated with each approach should guide the surgeon’s choice.
Plating Methods
Plating method significantly impacts condylar fracture repair outcomes. Because of the anterosuperior pull of the masseter and medial pterygoid, the posterosuperior pull of the temporalis, and the anteromedial pull of the lateral pterygoid, the lines of compression lie along the posterior condyle, and the lines of tension lie along the anterior near the mandibular notch. Plates range from unique geometric plates, such as minidynamic compression, trapezoidal, delta, or strut plate, a single plate, or use of multiple plates. A two-miniplate method is commonly used with a low complication rate to achieve compression and tension while minimizing rotational forces , ( Fig. 5 ). Table 3 summarizes the findings between outcomes from the different types of plates.
