Classification and Management of Mandibular Condyle Fractures in a Tertiary Health Center

doi:10.4236/ss.2013.48067

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Surgical Science, 2013, 4, 339-344

http://dx.doi.org/10.4236/ss.2013.48067 Published Online August 2013 (http://www.scirp.org/journal/ss)

Classification and Management of Mandibular Condyle

Fractures in a Tertiary Health Center

Babatunde O. Akinbami*, Oladimeji A. Akadiri

Department of Oral and Maxillofacial Surgery, Dental Center , Un iversity of Port Harcourt Teaching Hospital,

Port Harcourt, Nigeria

Email: *[email protected]

Received May 16, 2013; revised June 18, 2013; accepted June 26, 2013

Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original

work is properly cited.

ABSTRACT

Background: Condyle fractures are not common but could lead to detrimental effects of growth disturbance of the

mandible, ankylosis of temporomandibular joint and facial asymmetry especially in children, if not promptly and ade-

quately managed, the aim of this study was to document our experience in the management of mandibular condyle

fractures. Method: The fractures were classified based on the age of the patient, unilateral/bilateral, location on the

condyle, presence of displacement and dislocation, for those displaced, whether there was medial or lateral overlap, and

features presented. Treatment done for each patient was documented. Both clinical and radiological assessments were

done to ascertain the outcome of treatment. Result: 11 patients presented with 14 cond yle fractures, 3 patients w ith bi-

lateral and 8 with unilateral condyle fractures out of which 5 cases were on the right side. Age range of patients was

between 13 and 44 years with a mean (SD) of 25.3 (10.7) years. Nine (81.8%) of the patients were males and 2 (18.2%)

were females. Eight (72.7%) of the patients with condyle fracture had associated fractures affecting other sites of the

mandible while 3 (27.3%) patients had isolated condyle fractures. Intracapusular fractures recorded were 2 (14.2%),

while extracapsular accounted for 12 (85.8%) cases. Conservative treatment was not applied in any patient, 9 (81.8%)

patients had IMF and 2 (18.2%) patients had ORIF. Conclusion: Most fractures of the condyle were extracapsular and,

closed surgical treatment (IMF) was very useful to manage most of the cases.

Keywords: Classification; Management; Condyle; Fractures

1. Introduction

Fractures of the condyle of the mandible are rare [1].

Condyle fracture is a protective mechanism which pre-

vents fracture of the base of the skull [2]. It is commonly

an associated fracture with fractures of the body, sym-

physis or parasymphysis of the mandible due to trans-

mission of forces following impacts on these sites. It can

also occur in isolation as a consequence of direct impact.

These fractures have been classified as intracapsular or

extracapsular, un ilateral or bilateral and, head, neck (high

or low) subcondylar fractures based on the site [3]. In

addition, according to Lindahl, fractures of the condyles

can be classified into six, vertical slit of the head (type I),

horizontal break but mildly or not displaced (II), dis-

placement of the segments (III), there may be medial

overlap (IV) or lateral overlap (V) of the displaced

smaller proximal segment and a possible partial or com-

plete dislocation of the segment [3]. Rarely, fractures of

the condyle may also be communited (type VI) espe-

cially with gunshot injuries [3].

Aesthetics and restoration of function such as mouth

opening and mastication are important considerations in

the management of these fractures [4]. Others include

swallowing, occlusion, and control of symptoms like

pain, swelling and deviation [4]. Treatment ranges from

observation, jaw exercises to closed or open interven-

tions [5]. However in cases that require treatment many

surgeons have favored closed treatment to open treatment

in order to preven t some complications of open treatment

[6]. The purpose of this article wa s ther efo re to docu ment

our experience in the management of mandibular condyle

fractures.

2. Patients and Methods

All consecutive patients that presented with fractures of

*Corresponding a uthor.

B. O. AKINBAMI, O. A. AKADIRI

340

the condyle of the mandible to casualty or oral and max-

illofacial department of the University of Port Harcourt

Teaching hospital between May 2006 and December

2012 were included in the study. Informed consent was

obtained from the patients/relatives and the study was

approved by the hospital ethics and research committee.

The gender and age of the patients as well as the time of

presentation, site, side and associated symptoms like pain,

swelling, bleeding from the ear and deviation of the

mandible on opening or closing, restriction of mouth

opening and inability to close were retrieved from the

hospitals’ records and documented. Conventional Poste-

rior Anterior view, oblique lateral views of the mandible

or reversed Town’s view of the skull were taken to con-

firm the specific sites, degree of displacements, overlap

or dislocation. The fractures were classified based on age

of the patient, un ilateral/bilateral, lo cation on the condyle,

presence of displacement and dislocation, for those dis-

placed, whether there was medial or lateral overlap, and

features presented. Treatment done for each patient was

documented and was categorized as conservative treat-

ment, closed surgical and open surgical treatment. The

outcome of treatment was also documented. Both clinical

and radiological assessments were done to ascertain the

outcome of treatment. Favorable clinical outcome was

based on resolution of symptoms, restoration of occlu-

sion, unrestricted movements of the lower jaw, absence

of deviation or minimal deviation, facial symmetry and

improved inter-incisal distance. Radiographic outcome

was based on suitable alignment of the proximal and dis-

tal segments and reduced fracture gap.

3. Result

A total of 34 patients with mandibular fractures of vary-

ing sites were managed in our department out of which

11 (32.4%) patients presented w ith 14 condylar f ractures,

(Tables 1-3) 3 (27.3%) patients with bilateral and 8

(72.7%) with unilateral condylar fractures out of which 5

Table 1. Biodata and characteristics of the first consecutive patients.

S/No Sex/Age Side Site Displacement cause features Treatment Outcome

1. M/40 Both RT Sub

LT Low Neck Lateral overlap(V)

Displaced(III) RTA Anterior open biteClosed reduction

and IMF Satisfactory

2. M/33 RT Low Neck Medial overlap (IV) RTA Posterior open

bite/gagging Closed reduction and

IMF Satisfactory

3. M/15 RT Low Neck Medial overlap(IV) Fall Posterior open

bite/gagging Closed reduction and

IMF Satisfactory

4. M/16 RT Low Neck Medial overla p(IV) RTA Posterior open

bite/gagging ORIF Satisfactory

*Subco-subcondyle, LT-left, RT, right.

Table 2. Biodata and characteristics of the second consecutive patients.

S/No Sex/Age Side Site Displacement cause features Treatment Outcome

5. M/13 LT Head Mildly displaced(II)Fall

Posterior open

bite Closed reduction

and IMF Satisfactory

6. M/21 Both RT

Subco

LT Low Neck

Medial overlap (IV)

Displaced(III) RTA Posterior open

bite/gagging Closed reduction

and IMF Satisfactory

7. F/26 RT Low Neck Medial overlap(IV)RTA Posterior open

bite/gagging Closed reduction

and IMF Satisfactory

8. F/15 RT Low Neck Displaced(III) RTA

Posterior open

bite/gagging ORIF Satisfactory

*Subco-subcondyle, LT-left, RT, right.

Table 3. Biodata and Characteristics of the third consecutive patients.

S/No Sex/Age Side Site Displacement cause features Treatment Outcome

9. M/23 Both

LT Subc

RT Low

Neck

Lateral overlap(V)

Displaced (III) RTA Anterior open

bite Closed reduction

and IMF Satisfactory

10. M/44 RT Subco Medial overlap(IV)RTA

Posterior open

bite/gagging Closed reduction

and IMF Satisfactory

11. M/32 LT Low Neck Medial overlap (IV)Fall Posterior open

bite/gagging Closed reduction

and IMF Satisfactory

Subco-su bcondyle, LT-left, RT, right.

B. O. AKINBAMI, O. A. AKADIRI 341

(45.5%) cases were on the right side. Age range of pa-

tients was between 13 and 44 years with a mean (SD) of

25.3 (10.7) years. Nine (81.8%) of the patients were

males and 2 (18.2%) were females. Eight (72.7%) of the

patients with condyle fracture had associated fractures

affecting other sites of the mandible while 3 (27.3%)

patients had isolated condyle fractures. (Tables 1-3) In-

tracapusular fractures recorded were 2 (14.2%) {head

was 1 (7.1%) and upper neck was 17.1%)} while extra-

capsular accounted for 12 (85.8%) cases, the lower neck

of the condyle was the site most commonly involved

with 9 (64.3%) cases while the subcondyle was affected

in 3 (21.5%) cases respectively. All our patients pre-

sented within 24hrs of injury and 9 (81.8) % wer e due to

road traffic accident. Plain radiographs revealed gross

displacements with medial overlap (type IV) in 7 (50%)

of the 14 condylar fractures, lateral overlap (type V) in 2

(14.2%), there was moderate displacement (type III)

without overlap in 4 (28.6%), mild d isplacement (typ e II)

was present in 1 (7.1%) of the cases. When there was

bilateral fracture anterior open bite and gagging of occlu-

sion on both posterior sides were the prominent occlusal

derangements. All the unilateral cases with moderate to

gross displacements presented with features posterior

open bite on the normal side and gagging on the affected

side with deviation of the jaw to the affected side. Such

features were slightly altered when there were grossly

displaced fractures of other sites of the mandible. Con-

servative treatment (medication, jaw exercise and obser-

vation) was not indicated in any patient, while 9 (81.8%)

patients had closed treatment with intermaxillary fixation

using arch bars and 1 (9.2%) patient each had open re-

duction and internal fixation with bone plates and tran-

sosseous wires respectively. The submandibular ap-

proach was used for both patients. The patients were fol-

lowed-up for about 2 months postoperative and there was

satisfactory outcome in all the cases with complete re-

mission of pain, swelling and restriction in mouth open-

ings, correction of occlusal derangements and deviation

which was further improved with jaw exercise for at least

2 to 3 weeks. Alignment of the segments was satisfactory

in all the patients within 6 - 8 weeks following treatment.

4. Discussion

Fractures of the mandibular condyle account for 19% -

52% of all fractures of the mandible in the literature, in

our study [1-4], it was about 32.4%. Despite the fact that

the condyle is the weakest part of the mandible, fracture

of this portion of the mandible from direct impact is not

very common because of the protective and cushioning

effects of the muscles, meniscus, ligament, capsule and

surrounding bones [2]. However indirect impact as in

cases of contra-coup and parade ground fractures are

commoner. Such fractures to the condyle in most sce-

narios serve as a protective mechanism preventing trans-

mission of force and injury to the base of the skull [3].

Generally, bilateral cases which occur with impact on the

chin are much fewer than unilateral cases as observed

also in our study [4]. There is no side predilection in

condyle fractures as this is determined by the mechanics

of injury, the position of patient and impact direction.

Two classical features of intracapsular fracture involving

the head or upper neck of the condyle are bleeding from

the ear and supramastoid hematoma (Battle’s sign) [5-8],

however we did not study observe these features in our

study and this may be attributed to the fact that most of

our cases involved the extracapsular sites (lower neck

and subcondylar) of the condyle in contrast to other studies

with higher figures for intracapsular fractures [9,10]. In

addition, the few cases of fractures o f the head and upp er

neck may not be displaced backwards at the point of im-

pact; therefore the bony external acoustic meatus and

mastoid bone were not traumatized. Other features of

deranged occlusion an d deviation of the mandible in un i-

lateral fractures dominated our findings in this study and

this was similar in reports from other parts of the globe

[11-13]. Anterior open bite is classical in cases of bilat-

eral fractures that are moderately or grossly displaced

with either medial or lateral overlap (type III to VI)

based on Lindahl’s classification [14]. This is due to up-

ward pull of the lower segment by the muscles of masti-

cation and eventual telescoping of the upper condyle

segment. Based on the degree of displacement, half of

the fractures documented in this study are classified as

type IV with medial overlap of lower mandibular seg-

ment by the fragmented upper condylar segment. This is

not surprising, because the upper condyle segment is

usually pulled medially by the lateral pterygoid muscle.

The immediate objectives of treatment that must be

achieved include stabilization of the patient following

ABCDE protocol that is airway control, breathing, circu-

lation, CNS dysfunction, elimination of pain and swell-

ing, and achievement of close to normal occlusion [15].

There are controversies regarding the choice of treatment

amongst many surgeons but various factors such as the

age of the patient, duration of fracture, specific site of

fracture on the condyle, degree of displacement, time of

presentation and availability of funds and resources are

relevant considerations. Long-term objectives are aimed

at restoration of form and function of the jaw and facial

skeleton [16]. Definitive treatments to achieve these ob-

jectives are based on the principle of reduction, fixa-

tion/immobilization of the jaw/jaws. Broadly, treatment

can be closed reduction and IMF with arch bars if avail-

able or eyelet wires under GA or LA especially when

close to anatomical reduction is achievable [17]. It can

also be closed reduction and external fixation under GA

(frames and cap splint) if materials are available espe-

B. O. AKINBAMI, O. A. AKADIRI

342

cially for communited fractures which may be due to

gunshots. Open reduction and internal fixation (ORIF)

with plates (rigid) under GA offers the best option espe-

cially for gross displacements and patient who do not

want their mouth closed for a long period [18]. Open

reduction and transosseous wires (semi-rigid) are useful

when plates are not available [18].

Treatment should be done early enough to minimize

pain, swelling, prevent infection and enhance healing

with minimal callus, but it is better done when patients

are stable and respiration is not compromised [19]. Most

condylar fractures are treated with closed reduction and

intermaxillary fixation with arch bars using stainless steel

wires or elastic bands for immobilizing the jaws for

about 2 - 6 weeks depending on the age, time of presen-

tation, site/type of fracture, and severity of symptoms

[20].

Fresh cases unilateral or bilateral extracapsular frac-

tures in children or adults require IMF for 3 - 4 weeks

while cases of unilateral or bilateral extracapsular frac-

tures (lower neck and subcondylar) that have been left

untreated for sometime (>1 week) will need slow rubber

traction with a posterior bite plane to correct the contra-

lateral or anterior open bite caused by the marked overlap

of the fracture segments due to muscle spasms [21]. This

is placed on the teeth prior to intermaxillary fixation with

elastics bands around the hooks of th e arch bars.

When presentation is more than 1 month, consolida-

tion has begun and there will need for open reduction and

internal fixation. These were not applicable in our study

because all the patients presented within 24 hrs of injury.

Fractures affecting the head and upper neck are con-

fined within the capsule (intracapsular) and displace-

ments are usually minimal and most of these can be

treated with IMF in both children and adults [8,9,22].

However in longstanding cases that has malunited, ORIF

may be indicated to correct the deformities and asymme-

try especially in adults, most surgeons tend to avoid

ORIF in children to prevent ankylosis, facial nerve dam-

age and most importantly, growth disturbance [17,23].

Scar formation is another complication in Africans which

can be mitigated by endoscopic approach [24]. Dahlstrom

et al. [1] in their 15 years follow-up study on condylar

fractures treated by closed reduction, also documented

that there were no major growth disturbances amongst

the children and the function of their masticatory system

was good. There are no arguments against closed treat-

ment in children except that open treatment is preferred

for low level/subcondylar and dislocated fractures be-

cause of improved functional outcome associated with it.

Furthermore, for undisplaced intracapsular fractures

without symptoms like pain, swelling and deviation ch il-

dren and adults, conservative approach (no fixation) with

jaw exercises using tongue blades, acrylic or wooden

screws for 2 weeks may be sufficient. Frequently, be-

cause fracture to the head or high neck is intracapsular, it

is not usually displaced [8,9]. If there is no symptom,

observation of the patient and, assessment of mouth

opening and temporomandibular joint every 2 month

with serial TMJ X-rays [8,9].

If pain and swelling is present, recommended drugs

are (Augmentin 375 - 625 mg 8 hrly for 5 days and anal-

gesics like paracetamol 500 mg 8 hrly for 3 days or

tramadol 25 - 50 mg 8 hrly for 3 days for more severe

pains depending on the age. If there is restriction of

mouth opening and deviation then conservative therapy

with jaw exercise u sing tongue blades, acr ylic or wooden

screws for 2 weeks may be su fficient (no fixation), how-

ever this likely to be painful. So patient must be covered

with analgesics or done under relative analgesia if facil-

ity is available. If symptoms persist after 3 days, then

closed reduction and IMF with eyelets or acrylic cap

splints for 1 - 2 weeks fo llowed by jaw exercise is appli-

cable [25].

If there is displacement in head or high neck fractures,

especially when accompanied with other symptoms, then

the fracture is treated with closed reduction and IMF for

2 - 4 weeks followed by jaw exercise, analgesics, antibi-

otics for 1week and postoperative follow-up and review

with serial X-rays [26]. Open reduction and internal fixa-

tion is not indicated for undislocated fractures of condyle

head and upper neck in children because of reasons al-

ready mentioned and technical difficulties in manipulat-

ing the small upper condyle segments [27].

Absolute indications for ORIF include lateral overlap

displacements in extracapsular fractures, fractures asso-

ciated with dislocations of the condylar head, failure to

achieve satisfactory occlusion following closed reduction

and, presence of foreign bodies in the joint [28]. How-

ever ORIF can be done in a patient who has no dentitio n

and where a splint is unavailable or when splinting is

impossible because of alveolar ridge atrophy and when

splinting is not recommended for medical reasons or

where adequate physiotherapy is impossible in bilateral

or unilateral subcondylar fractures [28]. Also in bilateral

condylar fractures associated with comminuted mid-fa-

cial fractures and bilateral subcondylar fractures with

associated gnathologic problems, such as retrognathia or

prognathism, open bite with periodontal problems or lack

of posterior support, loss of multiple teeth and later need

for elaborate reconstruction, bilateral condylar fractures

with unstable occlusion due to orthodontics, and unilat-

eral condylar fracture with unstable fracture base [28].

Avulsion or gross communition of condyle bone seg-

ments will require costochondral or sternoclavicular joint

bone grafts and reconstruction plates for fixation [29].

The sternoclavicular graft does not have the demerit of

hyperplastic growth is seen in costochondral grafts. Bone

B. O. AKINBAMI, O. A. AKADIRI 343

morphogenenic proteins, hydroxyappatite blocks and

Beta TriCalcium phosphates, medpors (polyethelene)

with or without hyaluronic acid are now available as al-

loplasts to minimize donor site mobilities [30]. The

above treatment is also useful for old, malunited and non

united fractures. After refracturing, debriding and fresh-

ening the bony ends, it is necessary to fill gap with can-

cellous chips and apply reconstruction plates. Condyle

implants like the Lorenz or Christensens type are avail-

able for total joint replacements [29,30].

In conclusion, many of the fractures of the condyle of

the mandible documented in this study were extracapsu-

lar and with medial ov erlap and, 81.8 % of our cases were

managed by closed surgical treatment (IMF) while open

surgical treatment (ORIF) was indicated in two (18.2%)

cases. The first was based on surgeon’s choice and avail-

ability of funds to purchase the plates while the second

was based on the presence of lateral overlap of the seg-

ments which may not be easily corrected by closed re-

duction. Conservative management was not indicated in

any patient because there were obvious displacements

which could be worsened by either mastication or rigor-

ous jaw exercise without any form of fixation.

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