!ADVANCES IN OMFS .

1943-1993]
J Oral Maxillofac Surg
51:57-61,1993

Fractures of the Mandibular Condyle

JAMES R. HAYWARD, DDS, MS,* AND RICHARD F. SCOTT, DDS, MSt

Fifty years ago, the sixth article in the first issue of thors report acceptable function in all cases and
the Journal of Oral Surgery. entitled "Fracture of the conclude that although "surgical interference is occa-
Mandibular Condyle," by Bellinger, Henny, and Pe- sionally necessary, it is to be condemned for routine
terson, began "There has been much discussion in the cases. As long as results from simple immobilization
literature relative to the treatment of fractures of the are satisfactory, there can be no argument in support
mandibular condyle. Two schools of thought have ex- of needless surgical interference."!
isted, one advocating conservative treatment, the other, The limitations that existed in 1943 in regard to di-
open reduction. Both have backed up their opinions agnostic imaging by rudimentary radiographic tech-
with case histories, making it difficult for a neutral ob- niques, hazards of anesthesia, vulnerability to infection
server to properly assay the relative merits ofeach pro- in the preantibiotic days, and lack of rigid fixation
cedure."! Forty-nine years later in volume 50, number technology must be considered as background to this
4, of the Journal of Oral and Maxillofacial Surgery, article and its conclusions. Many of these limitations
the discussion of the sixth article begins: "The debate now have the appearance of historical footnotes. Ad-
continues about the best way to manage condylar pro- vances in these areas have led to better management
cess fractures; Is open reduction a superior method of of traumatic facial injuries with more accurate diag- '
treatment compared with closed reduction?"? It is ob- nosis, safer intraoperative anesthetic management, de-
vious that consensus has not been reached in regard creased risk of postoperative infection, and more pre-
to the proper management of this injury. But has pro- cise methods of fixation. Not addressed in this pioneer
gress been made toward resolution of the issue? article were the remodeling potentials of the mandib-
Ifprogress were judged solely on the amount of pub- ular condyle after initial "malunion," although all of
lished material, then there would be little question that the authors' cases were reported to have "acceptable
headway has been made. In the years that have followed function."
the 1943 publication, this journal and others have been The aversion to surgical methods in the era before
replete with articles devoted to this still debated subject. the advent of antibiotics was based chiefly on the threat
There have been 54 articles dealing specifically with of osteomyelitis and the technical problem of control-
fractures of the mandibular condylar process published ling a displaced condyle for reduction and fixation. In
between 1945 and 1965 and 20 between 1966 and 1990 1945, Dr Kurt H. Thoma published articles on "Func-
(74 in 45 years). Of course, there also have been dis- tional Disturbances Following Condylar Fractures"!
cussions of this problem in articles and texts about and "A Method for Treating Fractures and Dislocations
mandibular fractures, multiple facial injuries, and of the Mandibular Condyle"4 that advocated open re-
maxillofacial trauma in general. duction for subcondylar fractures and expressed con-
In the 1943 publication, I 100 consecutive cases of cern about malunion. The accumulated clinical ex-
subcondylar fracture were looked at retrospectively and perience of the Chalmers J. Lyons Academy suggested
classifiedaccording to degree ofdisplacement. All cases that these articles, which recommended open reduc-
were managed by closed reduction, elastic traction, and tion, were overstated, and that more conservative
immobilization. Two cases were treated by open re- closed reduction had resulted, with the help of remod-
duction only after complications developed. The au- eling, in satisfactory results. In the January 1947 issue
of the Journal of Oral Surgery.' the results of a series
of 120 carefully followed cases of condylar fractures
Received from the University of Michigan, Ann Arbor. with radiographic and clinical data were published. Al-
* Professor Emeritus, Department of Oral and Maxillofacial Sur- though this series supported closed reduction, the
gery.
t Assistant Professor, Department of Oral Medicine, Oral Pathol- choice of treatment has remained under debate in the
ogy, and Maxillofacial Surgery. literature.
Address correspondence and reprint requests to Dr Scott: 6360 As previously mentioned, there followed a wealth of
Jackson Rd, Suite A, Ann Arbor, M148103.
literature in regard to this question. In general, pro-
© 1993 American Association of Oral and Maxillofacial Surgeons ponents of the nonsurgical approach to these injuries
0278-2391/93/5101-0011$3.00/0 argue that the vast majority of these patients do well

57
58 FRACfURES OF THE MANDIBULAR CONDYLE 1943·1993

with a period of maxillomandibular fixation followed condylar fractures treated conservatively. They eval-
by a period of time using training elastics and other uated patients 15 years' postinjury with clinical and
forms of physiotherapy. In the opinion of this group, radiographic examinations and took into account the
the advantages that might be gained with an open patient's age at the time of injury, level of the fracture,
procedure do not offset the morbidity and risks in- and degree of displacement. Mandibular range ofmo-
volved.v'? Those advocating open reduction argue that tion also was recorded, as well as bite force using strain
condylar deformity, mandibular dysfunction, and gauge transducers in the region of the incisors and the
asymmetry will result with closed management of dis- premolars/molars bilaterally. Radiographic examina-
placed or dislocated fractures. I 1-13 What then have we tion included an orthopantomogram, posterior-ante-
learned over the intervening years from this work? First, rior and axial views ofthe skull, and oblique transcran-
we have learned that the question, "Should subcondylar ial projections of the temporomandibular joints. The
mandibular fractures be managed via a closed or open patients' opinions regarding their own chewing ability
technique?" is too broad. The question needs to be also was recorded using a standardized format. There
qualified by a list ofvariables that include 1) the degree were 14 patients who sustained their injuries as children
ofdisplacement of the fractured segments, particularly (ages 3 to I I years); 8 as teenagers (ages 12 to 19 years)
in relation to the articular fossa; 2) the level at which and 14 as adults (age> 20 years). The authors con-
the fracture has occurred; 3) the age of the patient; and cluded that no major growth disturbances were ob-
4) the presence ofconcomitant injuries, particularly in served in those injured as children, and function ofthe
regard to associated facial fractures (Table 1). masticatory system was good. In teenagers, the ana-
Also, to answer the above question, even in its qual- tomic and functional restitution of the temporoman-
ified form, we must accept two basic premises and then dibular joint was not as good as in the children but
answer an additional question. The basic premises are: hardly gave rise to objective symptoms. In the adult
1. Closed techniques for managing subcondylar group, signs of dysfunction were frequently observed,
fractures are simpler and easier to perform than but they were not considered serious by the patient.
open techniques. Dahlstrom et al noted that in cases ofcondylar fracture
2. When choosing between two surgical options, one without displacement, only mild signs and symptoms
simple and the other complex, the simpler of the of dysfunction may be expected irrespective of age.
two is the treatment of choice provided all else However, moderate signs of dysfunction can be ex-
is equal. pected after condylar displacement, especially in older
patients. They concluded, "One might speculate that
The obvious additional question one must then ask is
an open reduction in older patients could be useful in
What is meant by provided all else is equal? Certainly
preventing dysfunctional problems.v'" The results of
this condition refers to some of the previously men-
this study are consistent with those of a previously
tioned qualifiers; that is, age of patient, degree of dis-
published report by Lindahl and, in fact, use a subset
placement, and so forth. But given that these qualifiers
of his patients.":" This earlier article also shows that
are the same, one must still look at outcome and ask
masticatory dysfunction was rare in children treated
the question Will open reduction of this subcondylar
conservatively for condylar fracture, more frequent in
fracture offer significant long-term benefits in mandib-
teenagers, and frequent in adults. Similar results have
ular and temporomandibular joint function to warrant
been seen in other reports.F:"
its use over simpler, closed reduction?
Recently, the degree of condylar displacement and
Given this train of thought, we can return to the
the impact this has on treatment and outcome had
original question and look at what information has
received attention from Konstantinovic and Dimitri-
been accumulated in regard to the various qualifiers.
jevic.!? They reported on 80 patients with unilateral
In a well-designed study, Dahlstrom et al'" has supplied
condylar process fractures, 26 of whom were treated
information in regard to the long-term follow-up of
surgically with wire osteosynthesis via a submandibular
incision and 54 of whom were treated conservatively.
Table 1. Factors Affecting Decision of Closed Degree of displacement was determined by vigorous
vs Open Reduction analysis of standard posteroanterior views of the man-
Age of patient dible. Follow-up was for a minimum of 1.0 year, with
Level of fracture a mean of2.5 years. Clinical examination consisted of
Degree of displacement recording maximal opening and protrusive movements
Direction of displacement
Medical status of patient
and noting any deviation of the chin with these move-
Concomitant injuries ments. Complications of treatment also were noted.
Presence of dentition The results of the radiographic evaluation showed a
Status of existing dentition significantly better position of the condyle in the sur-
Ease in establishing adequate occlusion gically treated patients. Clinical examination, however,
Presence of foreign body
showed that there was no statistically significant dif-
HAYWARD AND scorr 59

ference between patients with surgically treated and white rabbits. Preoperative mandibular movements
those with conservatively treated unilateral condylar were recorded for each animal after which they received
process fractures. A shortcoming of this article, as a surgically induced subcondylar fracture of the left
pointed out by Stem,2 is the failure of the investigators mandible. The animals were then divided into three
to randomize the patient groups. This is particularly groups: The first received reduction and fixation with
evident in regard to patient age, where only one of the a titanium plate; the second group received complete
13 patients under the age of 20 underwent surgical detachment of the condyle with immediate replace-
treatment. ment as a free graft maintained with a plate similar to
Takenoshita et al also have recently presented a the first group; and the third group was treated by al-
comparative study of the open versus closed manage- lowing the displaced condyle to remain outside the gle-
ment of condylar fractures." Their report included 36 noid fossa. The first two groups received no maxillo-
cases; 16 that were treated open and 20 that were mandibular fixation (MMF), but the third group
treated closed. Maxillomandibular fixation was used received MMF for 7 days postsurgery. The results sug-
in both groups for 3 weeks postoperatively followed by gest that the group receiving open reduction and in-
active jaw movement with physiotherapy. They re- ternal fixation without disruption ofthe vascular supply
ported improved mouth opening in the unoperated had the most favorable result. The animals that were
group at I month and 1 year following release from treated with MMF without replacement ofthe condylar
fixation. However, all patients had maximal mouth process into its anatomic position had adequate func-
opening of more than 35 mm and maintained an ad- tional results. However, when compared to the first
equate interocclusal relation. No patient in either group group, there was a shorter condyle and ramus on the
complained of severe pain in the affected joints. This operated side and decreased lateral movement to the
study standardized the use ana length of maxilloman- unoperated side. Animals that had open reduction and
dibular fixation, as well as the use of active jaw phys- intemal fixation using the condylar process as a free
iotherapy, both of which are considered critical vari- graft did the poorest of the three groups. There was a
ables in patient management. Unfortunately, they did greater number of animals with facial asymmetry in
not randomize their cases in regard to degree of con- this group and the degree of asymmetry was greater,
dylar displacement; more severely displaced fractures as was the degree of malocclusion. Overall healing was
were more often treated by open reduction. Also, the slower in this group and it contained the only animal
methods of fragment fixation were not standardized. to develop a nonunion. Previous authors also have al-
As Hayward" has pointed out, these facts add to the luded to the tremendous remodeling processes in the .
difficulty in accurately assessing the results of this in- young developing animal and human and the capacity
vestigation. to form a new condylar process after displacement in-
The limitations of these studies, and the difficulties jury.14.15.22 Although Zang and Obeid caution against
encountered in adequately controlling all variables, are applying their results unequivocally to the human sub-
inherent in all clinical studies. This is particularly true ject, the findings indicate that returning the condyle to
of those done in a retrospective fashion. This has led its anatomic position in adult animals results in an
to the development ofother models in which to analyze improved morphologic outcome.
a particular problem. Several animal studies have been Many variations in surgical approach and fixation
used to look at the question of condylar fractures and methods have been proposed.2 8.33 Wire, pins 34-36
their management.P'" Walker22 used growing mon- screws,37,38 and plates39-43 all have been used to locate
keys and demonstrated normal symmetry and growth and hold the elusive condylar fragment in proper po-
as well as ramus height in nonsurgically treated uni- sition (Fig I). Better and more precise fixation of frag-
lateral fractured and dislocated condylar processes. ments with miniplates has solved some ofthe technical
Boyne'! also used the growing monkey but looked at control problems. However, one investigation reports
bilateral fractures of the condyle. He was able to dem- excessive bone resorption in conjunction with the use
onstrate normal growth and bony union at all sites
regardless of the type of treatment employed.
.
of miniplates." Others have advocated the open re-
duction of the fractured, dislocated condylar process
The use ofadult animal models to look at this prob- without the use of internal fixation.'? Rather a short
lem has received less attention." Heurlirr" looked at period of MMF is employed, followed by physiother-
two adult monkeys with unilateral subcondylar frac- apy. The degree and duration of mandibular immo-
tures in which the fractured segment was intentionally bilization also have been subject to differing views and
kept displaced. Six-month follow-up revealed facial each has its advocates. 1I,IO,13,34,45,46
asymmetry and a false temporomandibular joint. An The lack of consensus regarding the best method of
additional attempt to use an animal model to inves- treatment not only may stem from imprecise struc-
tigate the results of treatment on unilateral subcondylar turing of the question, as previously mentioned, but
fracture in the adult has recently been attempted by also from an overall lack ofdirection. As Walker points
Zhang and Obeid." They used 18 adult New Zealand out, "No standard has been agreed upon toward which
60 FRACfURES OF THE MANDIBULAR CONDYLE 1943-1993

nondisplaced condylar fracture in a child should be by

closed technique. On the other extreme, Zide and Kent
have attempted to enumerate the absolute indications
for open reduction. I I They list the following: 1) dis-
placement into the middle cranial fossa, 2) impossi-
bility of obtaining adequate occlusion by closed re-
duction, 3) lateral capsular displacement ofthe condyle,
and 4) invasion by a foreign body (eg, gunshot wound).
These authors also give a compelling list of relative
indications for open reduction pertaining primarily to
adults with condyles that are displaced out of the fossa
B and associated with a malocclusion. These relative in-
dications include 1) bilateral condylar fractures where
usc of a splint is not practical owing to ridge atrophy,
2) unilateral or bilateral condylar fractures when
splinting is not recommended for medical reasons (eg,
seizure disorders or alcoholism), 3) bilateral condylar
fractures associated with comminuted midface frac-
tures, and 4) bilateral condylar fractures and associated
gnathologic problems (eg, an unstable occlusion due
to skeletal deformity, missing teeth, or active ortho-
dontics). A possible algorithm ordecision tree for this
process is shown in Figure 2. If nothing else, it helps
delineate where additional energies may best be spent
in well-conceived research.
Certainly over the last 50 years we have made gains
in our ability to track various data and to analyze these
c D data statistically. We have also become more knowl-
edgeable in regard to what constitutes a well-controlled
FIGURE J. Methods of fracture reduct ion. A. Rigid internal fixation study and the need for randomization and control of
with bone plate . B. Wire osteosynthesis. C. Pin fixation secured with
variables. We must use these new skills, combined with
transosseous wires. D. Traction-screw osteosynthesis.
the various technologic advances that have enhanced
our diagnostic and treatment capabilities, to continue
we should all work in the management of mandibular to explore this issue with well-designed and well-con-
condyle fractures.t'f? He states that restoration offunc- trolled clinical and animal studies. In the meantime,
tion , and not necessarily anatomic restoration ofparts, the clinical variables of unilateral versus bilateral frac-
should be the main goal, and suggests the following
objectives: I) the mandible and temporomandibular
Condylar Fracture
joint should reach a reasonably normal, relatively pain
free range of motion soon after the injury, 2) the patient
should demonstrate a good occlusion, and 3) the patient Ch ild Adolesce,,1 Adult
should demonstrate symmetry of the mandible." Ad- IAge. (>.111 1"9.. '2 ·' 91 (Ages> 20)

ditional clarification of the term reasonably normal is

obviously required. For example, normal muscle func- I
tion before injury and function after injury, both short- ,.
co nditions anothers

I
conditions a.O others conditions
H
aUotnel'$

I
.
1"

term and long-term, should be documented. Some open

closed
redud iOll open
crcsed
reduction open
cIo$Od
reduction
work with electromyographic studies of the muscles of reduction reducOon reducbOn

mastication has already been done to add information seve re

displacement
to this important area ." The use of newly developed
se ver.
magnetic resonance imaging of the temporomandib- (SIsplacement
COnd ltiOOS
5-8
ular joint may also assist in determining reasonable c:on~e ,

ope n
outcome. reduction open consider
reduction open
Perhaps the day will arrive when an algorithm will 'eduction

exist that can aid the surgeon in the process of deter-

FIGURE 2. Possible decision tree for treatment of condylar fractures.
mining treatment for these injuries . Maybe the extreme Conditions 1-4 are those listed as absolute indications by Zide and
ends of the spectrum of this algorithm have already Kent." Conditions 5-8 are those listed as relative indications by Zide
been developed. For example, the management of a a nd Kent."
HAYWARD AND SCOTT 61

tures, stabilization ofocclusion versus treatment in ed- 22. Walker RV: Traumatic mand ibular condylar fracture disloca-
tions, Effect on growth in the Macaca rhesus monkey. Am J
entulism, degree of dislocation and displacement, extra Surg 100:850, 1960
or intra-articular involvement with threat ofankylosis, 23. Boyne PJ: Osseous repair and mandibular growth after subcon-
patient age, and expected acceptable outcome all re- dylar fractures. J Oral Surg 25:300, 1967
24. Choukas NC, Toto PD, Atsaves SJ: Effectsof surgically reduced
main variables requiring individual, case by case at- fracture dislocations of mandibular cond yles on facial growth
tention. As a consequence of these variables, the risk/ in Maraca rhesus monkeys. J Oral Surg 28:113, 1970
benefit ratio in the choice of treatment must be deter- 25. Heurl in RJ, Gans BJ, Stuteville OH : Skeletal changes following
fracture dislocation of the mandibular condyle in the adult
mined for each case. The burden still resides with the rhesus monkey . Oral Surg 14:1490,1961
surgeon as he or she attempts to evaluate every trauma 26. Markey RJ, Potter BE, Moffet BC: Cond ylar trauma and facial
victim with this specific condition. asymmetry: An experimental study, J Maxillofac Surg 8:38,
1980
27. Zhang X, Obeid G: A comparative study of the treatment of
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