1. - Dr. Dona Bhattacharya

2. 1. Introduction
2. Surgical anatomy
3. Classification
4. Etiology
5. Diagnosis
6. Management
7. Current concepts
8. Conclusion
9. References

3. Fractures of mandibular condyle
are common and account for 20-
30% of all mandibular fractures.
Forms imp component for TMJ

4. • Elliptical in shape, long axis
angled backwards between 15-
33 0 to frontal plane.
• Long axes of 2 condyle meet at
basion on anterior ligament of
foramen magnum forming an
angle 0f 145-160 degrees.

5. • Mediolateral width: 15-20 mm
• Anteroposterior width: 8-10mm
• Lateral pole: roughened, bluntly pointed,
projects from plane of ramus
• Medial pole: rounded, extends from
plane of ramus
• Fibrous layer thin on posterior aspect
and thick over convexity

6. Parameter Child Adult
Cortical bone Thin Thick
Condylar neck Broad Thin
Articular surface Thin Thick
Capsule Highly vascular Less vascular
Periosteum Highly active
osteogenic phase
Less active in latent
stage
Intracapsular fracture
& hemarthrosis
Very common Rare
Remodellin capacity
following trauma
Present Absent
Disturbance in growth Likely N.A.

7. Blood supply
TMJ area is highly vascular and innervated
Mainly from
• Superficial temporal artery
• Transverse facial artery
• Posterior tympanic artery
• Posterior deep temporal artery

8. Neural structures
• Facial nerve
• Auriculotemporal nerve

9. Al-Kayat& Bramley -> identifiable landmarks

10. Dingman & Grabb -> course
of marginal mandibular
nerve
• Posterior to facial artery it runs
above the inferior border of
mandible in 81%, in rest it coursed
in an arc with lowest border being
with in 1 cm from it.
• Anterior to the artery the nerve ran
above the inferior border in 100%
cases.

11. Incidence

13. ∏ Assault
∏ RTA
∏ Sport injuries
∏ Falls
∏ Work-related incidents
Less obvious causes are:
Orotracheal intubation
Whiplash injury(Royd house,1973)
Childbirth

14. ∏ Age
∏ Socioeconomic factors
∏ Geographic location
∏ Presence/absence of dentition
∏ Occlusion, mandibular position
∏ Dir & magnitude of force
∏ Muscle pull

16. Mechanism of injury

18. Given in 1915
Acc to location & direction of fracture:
• From above, downward & inward or reversed
• From above, backward & downward

19. Type I- The angle between the head and the long
axis of the ramus :10 to 45 degrees.
Type II- angle of 45 to 90 degrees, resulting in
tearing of the medial portion of the capsule.
Type III- the fragments are not in contact, and the
head is displaced mesially and forward owing to
traction of the lateral pterygoid muscle. confined
to within the glenoid fossa.
Type IV- fractures where the condylar head
articulates in an anterior position to the articular
eminence.
Type V- vertical or oblique fractures through the
head of the condyle.

20. Type I Non-displaced fracture
Type II Fracture deviation, where there is simple angulation of the condylar
process to the major fragment. (e.g. greenstick fracture)
Type III Fracture displacement, where there is simple overlap of the condylar
process and major mandibular fragments.
Type IV Fracture dislocation, where the head of the condyle is completely
disrupted from the articular fossa.

21. Intracapsular Fractures or High Condylar
i. Fractures involving the articular surface
ii. Fractures above or through the anatomical neck,
which do not involve the articular surface
Extracapsular or Low Condylar Fractures
Fractures associated with injury to the capsule, ligament and meniscus
Fractures involving adjacent bone

22. • Non-displaced fracture
• Low-neck fracture with
displacement, mostly with contact
between fragments
• High-neck fracture with
displacement, mostly without
contact between fragments
• Low-neck fracture with dislocation
• High-neck fracture with
dislocation
• Intracapsular fracture of condylar
head
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the
Canadian Dental Association December 2006, Vol. 68, No. 11

23. Type M: communited #; loss of vertical dimensions (Eckelt & Hlawitschaka)
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the
Canadian Dental Association December 2006, Vol. 68, No. 11

24. Anatomic location of the fracture
Condylar head
Condylar neck
Subcondylar
Relationship of condylar fragment to
mandible
Nondisplaced
Deviated
Displacement with medial or
lateral overlap
Displacement with anterior or
posterior overlap
No contact between fractured
segments
Relationship of condylar head & fossa
Nondisplaced
Displacement
Dislocation

25. Contusion of the TMJ
Fractures of the condylar process without displacement of the fragments
Fractures of the condyle
Transcapitular.
Subcapitular.
Fractures of the condylar neck
Basal fracture of the condylar process.
Fractures of the condylar process with displacement of the fragments.
Displacement of the small fragments
Ventrally
Dorsally
Medially
Laterally
Torsion of fragments

26. Sprains of the TMJ
Dislocation (subluxation) of the TMJ.
Dislocation of the condylar head (condyle).
Anteriorly
Posteriorly
Cranially (central dislocation)
Medially
Laterally
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the
Canadian Dental Association December 2006, Vol. 68, No. 11

27. Diacapitular fracture (through the head of
the condyle):
The fracture line starts in the articular surface
and may extend outside the capsule.
Fracture of the condylar neck:
The fracture line starts somewhere above line
A and in more than half runs above the line A
in the lateral view. Line A is the perpendicular
line through the sigmoid notch to the tangent
of the ramus.
Fracture of the condylar base:
The fracture line runs behind the mandibular
foramen and, in more than half, below line A
Classification of condylar process fractures;
M. Schneider, U. Eckelt; Journal of the
Canadian Dental Association December
2006, Vol. 68, No. 11

28. 1. History
2. Clinical examination
3. Radiological
examination

29. Evidence of trauma.
Bleeding from external auditory canal.
Noticeable or palpable swelling – haemotoma / edema.
Facial asymmetry – foreshortening of ramus.
Pain & tenderness.
Crepitation over the joint.
Malocclusion
Deviation of mandibular condyle.
Muscle spasm.
Dentoalveloar injuries.

30. Management of Traumatic Dislocation of the Mandibular Condyle into the Middle
Cranial Fossa; Robert P. Barron, J Can Dent Assoc 2002; 68(11):676–80

31. A. Conventional Radiography
a. P A- View
b. Lateral Oblique
c. Towne's Projection
d. Panoramic view
e. TMJ views
B. CT
C. MRI

32. Aims for surgery:
1. Relief from pain
2. Stable occlusion
3. Restoration of inter- incisal opening
4. Full range of mandibular movements
5. To minimize deviation
6. Avoid growth disturbances
7. Avoid Ankylosis

33. 2 schools of thought:
• Conservative-functional therapy
• Surgical treatment

34. Conservative-functional therapy
• Involves no surgical intervention of the fracture site
instead it reduces the fracture taking occlusion as a key
factor.
• Immobilization usually involves fixation with arch
bars, eyelet wires or splints.
• Period of immobilization varies from 7-17 days

35. Conservative management
• Exercise
• Increasing mouth opening
• Push the jaws laterally
• Diet: Soft diet
• Analgesics
• Anti-inflammatory
• Soft diet and mouth exercises-
• Teeth into normal occlusion
• Adequate ROM
• Elastic MMF for 2-3 weeks
• When occlusion is found to be altered
• Patient was unable to bring their teeth into normal occlusion presence
of pain or swelling

36. Physiotherapy
Elastic band – Class II light elastics
Review after 6
days
a) Normal occlusion: Remove when
brushing and replace immediately
b) Unable to achieve normal occlusion:
to be worn 24 hrs/day till next review
Review after
next 6 days
a) Occlusion maintainable: halt elastics
b) Occlusion difficult obtain: continue
elastics

37. Functional exercise:
• > 40 mm interincisal distance (adult)
• > 10 mm lateral excursion
• > 12 mm protrusion
Types of exercise:
• Maximal mouth opening
• Right lateral excursion
• Left lateral excursion
• Protrusive action

38. Indications:
• Condylar neck # with little or no displacement
• # occuring in child (10-12 yrs)
• Intracapsular #

39. Recently thermoforming plates is used for the same
Fixation strength is less than wiring so contraindicated in bilateral
fractures
Advantage:
• Smooth surface
• Transparent
Closed treatment of condylar fractures by intermaxillary fixation with
thermoforming plates; Haruhiko Terai et al, British Journal, 2004, Pg. 61-63

40. Advantage Disadvantage
• Relatively safe
• No injury of nerves and
blood vessels
• No postoperative
complications such as
infection or scar occurs.
• Fracture, loss, and
eruption delay of the
growing teeth can be
avoided in pediatric
patients as no tooth germ
injury occurs because of
no establishment of the
crown of the permanent
teeth
• Injury of the periodontal tissue and buccal
mucosa
• Poor oral hygiene,
• Pronunciation disorder
• Imbalanced nutrition
• Growth disorder and excessive growth of the
injured mandible may occur
• Facial asymmetry may occur in pediatric
patients aged 10 to 15 years due to growth disorder
or functional disorder, and that in particular, the
growth and functional disorders of the TMJ may
occur in 20% to 25% of pediatric patients aged 7
to 10 years
Closed reduction

43. New indications have slowly evolved with improvement in the surgical
techniques.
Zide’s 1989 indications
Absolute indications:
Fracture in to middle cranial fossa
Foreign body in to joint capsule
Lateral extracapsular deviation
Inability to open mouth or achieve occlusion after 1 week
Open fracture with potential for fibrosis
Possible indications:
Bilateral / unilateral fracture with crushed midface
Comminuted symphysis and condyle fracture with tooth loss
Displaced fracture with open bite or retrusion in mentally retarded or
medically compromised patients.
Displaced condyle in edentulous or partially edentulous mandible with
posterior bite collapse.

47. Blair’s Inverted
Hockey Stick
Incision
Thoma’s Angulated
Incision
Dingman’s
Incision
Popowich &
Crane Incision
Preauricular Incision

48. Preauricular Incision

49. End aural Incision

50. Post auricular Incision

51. Submandibular Incision

52. Transparotid Incision

53. Retroparotid Incision

54. Rhytidectomy Incision

55. Intraoral Incision
e
e

56. Approach Advantage Disadvantage
Preauricular
Endaural
• Exposure of lateral and
anterior part of condyle
• Cosmetic (Endaural)
• Injury to facial nerve
• Injury to auriculotemporal
• Damage to middle ear
• Hemorrhage
• Parotid fistula
Postauricular • Esthetic
• Minimum risk of facial
nerve injury
• Permits harvest of conchal
cartilage for grafting
• Infection
• Hematoma
• Cartilage necrosis
Intraoral • No visible scar
• Adequate access to condylar
neck
• Injury to buccal, IAN
• Injury to lingual vessels
• Damage to maxillary
artery
Submandibular
(Risdon)
• Adequate access to condylar
neck & subcondyle
• Injury to MMB
Retromandibular • Adequate access to condyle
• Less risk of injury to MMB
• Scar
• Parotid fistula
The risks & benefits of surgery for temporomandibular joint internal
derangements; Simon Weinberg et al

58. Fixation of fracture

59. Fixation of medially displaced fracture

60. Eckelt technique of lag screw osteosynthesis

61. CONDYLAR
TRAUMA?
Clinical Sign
Malocclusion
Deviation
Range of motion
Negative clinical
exam
(-) Malocclusion
Minimal pain
Normal range of motion
No deviation on opening
Observation
Radiographs
Lateral obliques
Panorex
CT scan
No radiographic
evidence of condylar #
R/O hemathrosis
Joint effusion
(+) Condylr fractre
Normal occlusion Malocclusion
ORIF?
ROM
Pain
Deviation
Conservative IMF (7-21 days)
ORIF Other # ?
IMF (7-21 days) Reduction/fixation
of other #
Follow up
Yes
Yes
No
No
No
Yes

63. Ellis and Throckmorton conducted study with open or closed treatment
for fractures of the mandibular condylar process, in one hundred forty-six
patients, 81 treated by closed and 65 by open methods. The patients treated by
closed methods developed asymmetries characterized by shortening of the face
on the side of injury.
In the study of the Santler et al. two hundred 34 patients with fractures
of the mandibular condylar process were treated by open or closed methods. No
significant difference in mobility, joint problems, occlusion, muscle pain, or nerve
disorders were observed when the surgically and non-surgically treated patients
were compared. Surgically treated patients showed significantly more weather
sensitivity and pain on maximum mouth opening.
Renato VALIATI, 2008, The treatment of condylar fractures: to open or not to open? A
critical review of this controversy

64. To compare the occlusal relationships after open or closed treatment for
fractures of the mandibular condylar process, a total of 137 patients with unilateral
fractures of the mandibular condylar process (neck or subcondylar), 77 treated
closed and 65 treated open, were included in the study of Ellis, Simon and
Throckmorton. The patients treated by closed techniques had a significantly
greater percentage of malocclusion compared with patients treated by open
reduction, in spite of the initial displacement of the fractures being greater in
patients treated by open reduction.
Renato VALIATI, 2008, The treatment of condylar fractures: to open or not
to open? A critical review of this controversy

65. Mini-retromandibular approach to condylar fractures ; Federico BIGLIOLI,
Giacomo COLLETTI; Journal of Cranio-Maxillofacial Surgery (2008) 36, 378e383
No visible scar
Less complication rate

66. Intraoral approach for treatment of displaced Condylar fractures: case report;
valfrido pereira-filho et al; craniomaxillofacial trauma & reconstruction/volume 4,
number 2 2011

67. Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment
Philosophy ;Reid V. Mueller et al, Facial Plast Surg Clin N Am 14 (2006) 1–9

68. Resorbable triangular plate for osteosynthesis of fractures of the condylar neck;
Günter Lauer et al; British Journal of Oral and Maxillofacial Surgery 48 (2010) 532–535

69. Transmasseteric Anteroparotid Approach for Mandibular Condylar Fractures-
Merits and Demerits; AHMAD MAHROUS MOHAMAD, Egypt, J. Plast. Reconstr.
Surg., Vol. 35, No. 2, July: 227-232, 2011

70. Early complications:
1. Fracture of the tympanic plate
2. Fracture of the glenoid fossa with or without displacement of the
condylar segment into the middle cranial fossa
3. Damage to cranial nerves V & VII
4. Vascular injury
Late complications:
1. Malocclusion
2. Growth disturbance
3. Temporomandibular joint dysfunction
4. Ankylosis
5. Asymmetry
6. Frey’s syndrome

71. Fractures of the mandibular condyle constitute a significant
portion of mandibular fractures. A number of clinical signs and symptoms
are characteristic of injury to the condylar apparatus. The use of plain
radiographs in multiple view, or CT scans discloses most condylar
fractures and displacements, if any. A number of classification systems are
available to help in treatment planning and record keeping.
Non-surgical treatment is adequate for a majority of condylar
fractures. A period of immobilisation followed by active functional
therapy is indicated for most cases. Surgical management has specific
indications, and can be accomplished through a wide variety of
techniques. In general, complications are not common following condylar
trauma. Important among the possible complications are ankylosis,
growth disturbances and internal derangement.

72. 1. Oral & maxillofacial trauma-Fonseca & walker vol 2
2. Oral & maxillofacial surgery-Fonseca vol 3
3. Oral & maxillofacial trauma-Rowe & Williams vol 2
4. Principles of Oral & maxillofacial surgery-Peterson
5. Fractures of middle third of face-Killey & Kay
6. Oral & maxillofacial surgery-Fragiskos
7. Maxillofacial trauma & facial reconstruction-Peter Ward Booth
8. Oral & maxillofacial surgery-Peter Ward Booth: vol 2
9. Chen Lee et al; Applications of the Endoscope in Facial fracture Management,
seminars in plastics surgery/volume 22, number 1 2008
10. Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of
the Canadian Dental Association December 2006, Vol. 68, No. 11
11. Management of Traumatic Dislocation of the Mandibular Condyle into the
Middle Cranial Fossa; Robert P. Barron, J Can Dent Assoc 2002; 68(11):676–80

73. 12. Closed treatment of condylar fractures by intermaxillary fixation with
thermoforming plates; Haruhiko Terai et al, British Journal, 2004, Pg. 61-63
13. The risks & benefits of surgery for temporomandibular joint internal
derangements; Simon Weinberg et al
14. Resorbable triangular plate for osteosynthesis of fractures of the condylar neck;
Günter Lauer et al; British Journal of Oral and Maxillofacial Surgery 48 (2010) 532–
535
15. Condylar Fracture Repair: Use of the Endoscope to Advance Traditional Treatment
Philosophy ;Reid V. Mueller et al, Facial Plast Surg Clin N Am 14 (2006) 1–9
16. Intraoral approach for treatment of displaced Condylar fractures: case report;
valfrido pereira-filho et al; craniomaxillofacial trauma & reconstruction/volume 4,
number 2 2011
17. Mini-retromandibular approach to condylar fractures; Federico BIGLIOLI,
Giacomo COLLETTI; Journal of Cranio-Maxillofacial Surgery (2008) 36, 378e383
18. Renato VALIATI, 2008, The treatment of condylar fractures: to open or not to
open? A critical review of this controversy
19. Transmasseteric Anteroparotid Approach for Mandibular Condylar Fractures-
Merits and Demerits; AHMAD MAHROUS MOHAMAD, Egypt, J. Plast. Reconstr.
Surg., Vol. 35, No. 2, July: 227-232, 2011