Nat. Volatiles & Essent.

Oils, 2021; 8(5): 450 – 459

Condylar fracture – a review

Dr.Wasim Ahamed (1),Dr.S.Ishwarya2,Dr.Bhagya mathivanan A3
1 Reader, Dept of oral and maxillofacial surgery, Sree Balaji dental college and hospital, BHARATH
UNIVERSITY,Chennai-600100, Tamil nadu ,India
2 Postgraduate student ,Dept od oral and maxillofacial surgery,Sree Balaji dental college and
hospital,BHARATH UNIVERSITY,Chennai-600100, Tamil nadu ,India
3 Postgraduate student,Dept od oral and maxillofacial surgery,Sree Balaji dental college and hospital,
BHARATH UNIVERSITY,Chennai-600100, Tamil nadu ,India
Email address sgwasimahamed@yahoo.com

Abstract
Condylar and choronoid fractures constitutes 26 -40%of all mandibular fracture. Condyle is the
major growth centre of mandible.This article acts a small summarization of the views and thoughts
of various surgeons and anatomists over the ages and tr ies to condense the vastly available
information into a meaningful format applicable to current genre of maxillofacial surgeons.

Fractures of the condyle and joint represent 20 -30% of all mandibular fractures,
and are thus among the commonest facial fractures1. The pattern of the fracture can be extremely
variable and may occur anywhere down a line from the sigmoid notch to the mandibular angle.
Condylar neck fractures are clearly different from other mandibular frac tures in as much as they
are always located behind and above the lingula. They also differ from mandibular body fractures
because they are more difficult to diagnose, both clinically and radiologically. Different treatment
methods must also be employed; this is due on the one hand to the a natomically more difficult
access to the joint and on the other to the fact that the articular region is a growth region, thus
requiring a different approach to fractures that occur during childhood.
Introduction
Condylar and choronoid fractures co nstitutes 26 -40%of all mandibular fracture .
Condyle is the major growth centre of mandible.This article acts a small
summarization of the views and thoughts of various surgeo ns and anatomists over
the ages and tries to condense the vastly avail able information into a meaningful
format applicable to current genre of maxillofacial surgeons.

Fractures of the condyle and joint represent 20 -30% of all mandibular

fractures, and are thus among the commonest facial fractures 1 . The pattern of the
fracture can be extremely variable and may occur anywhere down a line from the
sigmoid notch to the mandibular angle. Condylar neck fractures are clearly different
from other mandibular frac tures in as much as they are always located behind and
above the li ngula. They also differ from mandibular body fractures because they are
more difficult to diagnose, both clinically and radiolo gically. Different treatment
methods must also be employed; this is due on the one hand to the anatomically
more difficult access to the joint and on the other to the fact that the articular
region is a growth region, thus requiring a different approach to fractures that occur
during childhood.

Classification of Condylar Fractur es

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Rowe & Killey’s classi fication (1968)

• Intra-capsular fracture - high co ndylar fracture

o Involving the articular surface
o Fracture through the neck
• Extracapsular fracture - low condylar fracture
• Injury to the capsule, meniscus and ligament
• Involving the adjacent bone

McLennan Classification (1 952)–Clinical Classification

• Type I: No displ acement

• Type II: Fracture devi ation – simple angulation of the fracture d segments
without overlap or separation.
• Type III: Fracture displ acement – when there is overlap o fracture fragments.
This overlap may be in an anterior, posterior, lateral or medial. Medial is
commonest.
• Type IV: Fracture dislocation –The head o f the condyle gets completely
dislocated out of the articular fossa this dislocation can be medial or lateral
and rarely anterior or posterior.

• Type V: High condyl ar fractur e with luxati on

• Type VI: Head fractur e or i ntracapsul ar fr acture

Lindhal’s classification: Comprehensive classification (1977)

a. The anatomic location of the fracture.

b. The relation of the condylar segment to the mandibular segment.
c. The relation of the condylar head to the articular fossa.

This system necessitates that radiographs be obtained in atleast two views

at right angles to each other. He suggested the following views to allow optimum
localizatio n
1. Orthopantompograph
2. Postero-anterior projection of the skull
3. Profile projection of the skull
4. Axial projection of the skull
5. Oblique trans-cranial views of the TMJ

To obtain proper classification, the following factors m ust be noted 2 .

A. Dependi ng on fr acture lev el

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CH- condylar head / CN – Condylar neck / SC – Sub condylar

1. Condylar head fr actur e - intr a-c apsular –

The exact anatomic co nfines of the head of the condyle:

GRAYS ANATOMY describes the head as extending a short distance down the
anterior aspect of the process, covering the entirety of the superior portio n, and
extending at least 5 mm down the posterior aspect. Radiographically noting the
neck constriction as the head lies above the neck serves as an indicator to locate
the head. The fractures of the head are necessarily intra -capsular as the capsule
attaches to the neck. The head of condyle fractures can be further classified as
a. Vertical fractures
b. Compression fractures
c. Comminuted fractures
d. Condylar neck fracture –
These are fractures at the thin constricted part of the condyle. These are fairly
easy to identify radiologically. The neck is caudal to the attachment of the capsule
and thus makes it an extracapsular fracture.

Subcondylar fractur e
These fractures are located below the co ndylar neck and extends from
concave surface of the sigmoid notch anteriorly to the deepest point along the
concave posterior aspect of the mandibular

Ramus. These ca n be described as “high” or “low” fractures.

B. Relationship of c ondylar fr agment to mandibl e

1. Undisplaced (fissure fracture) (B)

2. Deviated – this is simple angulatio n of the co ndylar process in relation to
the distal mandibular segment without overlap. (C)
3. Displaced with medial overlap (D)
4. Displaced with lateral overlap (E)
5. Antero-posterior overlap – possible but are seldom seen. (F)
6. Without contact between fragments (G)

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C. Relationshi p of condylar head to fossa:

1. No displ acement - co ndylar head appears in normal relation with fossa .(H)
2. Displacement – co ndy lar head is in fossa but there is alteration of joint space.
Joint space is increased.
3. Dislocation – The condylar process is completely out of the fossa. For this to
occur there must be rupture of the capsule. The lateral capsule is usually quite
thick whereas the medial joint capsule is thin and weak. As a result of this as
well as the attachment of the lateral pterygoid muscle, dislocation is usually
antero-medial. ( J)

Classification - Eckelt (Peter War d Booth)

For a 'classification' to be useful it must be easy to use and have both
therapeutic and prognostic value. The main therapeutic and prognostic factors are
the height and direction of the fracture line and the degree of displacement.

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Classification of temporomandibular joi nt fractures according to the height of the

fractur e

a) Intra-c apsular fr actur es

These fractures run v ery irregularly, usually diagonally through the head.
Because of the anato mic variation of the capsule attachment, they can lie within
the capsule as well as outside it.

b) High tempor omandi bular joi nt fr actures

These fractures run below the capsule and always below the attachment of
the lateral pterygo id muscle and the capsule attachment and above the sigmoi d
notch
c) Low tempor omandi bular joint fractures
These fractures run from the sigmoid no tch to the back edge of the
mandibular ramus. The fracture line can run variably at the posterior site, following
a horizontal line in some cases, but also running at an angle do wnwards, almost
reaching to the mandibular angle, in other cases. The fracture line is dorsal to the
lingual. There arc numerous classifications o f joint fractures.

A classification that takes both the height of the fracture and the dislocation
and luxation of the small fragment into account has been suggested by Spiessl &
Schroll. They differentiate 6 different fracture types

Classification of condylar neck fractur es ac cording to Spiessl & S chroll

• Type 1-Condylar neck fracture without serious di slocation

• Type II Condylar neck fracture with dislocation
• Type III-High Co ndylar neck fracture with dislocation
• Type IV-Deep-seated Condylar neck fracture with luxatio n
• Type V-High Condylar neck fracture with luxation
• Type VI-Head or intra-capsular fracture

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Severely dislocated fr actures of the articul ar pr ocess

The higher the fracture is located and the greater the degree of dislocatio n
of the fragments, the less favorable are the expected functional results. Seen from
a therapeutic point of view, a further differentiation of the degree of dis locatio n is
meaningful. Ap functional-conservative treatment is worth considering in less
severely dislocated fractures. Dislocation of fr actures must always be distinguished
between those with deviation and those with deviatio n without bo ny contact.
Fractures occurring among juvenile patients with an intact perio steum, as at the
mandibular body, are considered to be greenstick fractures. Th e most common form
of luxation by far is the medio -ventral luxation 3 .
Diagnostic criteria
• History of external violence. The rare occurrence of a pathological fracture
may not be preceded by external violence.
• tenderness on mouth opening, closing, excursion and protrusion.
• Restrictio n of mandibular movement.
• Deviation of mandibular movement.
• Alteration of the occlusion.
• Laceration of the anterior wall of the external auditory meatus with blood in
the canal.
• Imaging evidence of condylar head/neck fracture.
➢ P-A view
➢ Lateral oblique
➢ Panoramic view
➢ Reverse Townes projection
➢ TMJ view
➢ CT
➢ MRI

Principles of treatment of condylar fractur es

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Concerning the treatment of condylar fracture, it seems that the battle will rage
forever between the extremists who urge non -operative treatment in practically
every case and the oth er extremiti es who advocate open reduction in almost every
cases-MALKIN

Goals of Therapy
1. Obtain stable occlusio n.
2. Restore interincisal opening and mandibular excursive movements.
3. To Establish a full range of mandibular movements.
4. Minimize deviation of the mandible.
5. Avoid internal derangement of the temporomandibular joint on the injured
or the contralateral side.
6. Avoid the long-term complication of growth disturbance 4 . Condylar fractures,
particularly if it must be done at the expense of other more important goals.
A malunio n or fibro us union that functions normally witho ut pain is
preferable to a radiographically excellent reduction that does not eliminate
pain or limits motion.

The treatment modalities avail able ar e:

Surgical approach
Open reduction of the fracture with osteosythesis.

Conserv ative - functional approach

Treatment other than surgical intervention is termed as conservative approach . Its
objective is to allow bony union to occur when there is no significant displacement
of the condyle or, in case of a fracture dislocatio n, to produce an acceptable
functional pseudo -arthrosis by re -educating the neuromuscular pathways.

Indicati ons for conser vative functional ther apy

• Condylar neck fractures with little or no dislocation.
• Fractures occurring during childhood (up to the age of 10 -12 years).
• Intracapsular fractures, depending on the line of the fracture.

Indicati ons for Open Reducti on

Absolute indicati ons
1. Limitation of function secondary to the follo wing:
• Fracture into middle cranial fossa
• Foreign body within the joint capsule
• Lateral extracapsular dislocation of condylar head 5
2. Inability to acheive occlusion by closed reduction
3. Open injury (penetrating, avulsive, and lacerating) to the TMJ that requires
immediate treatment.

Relative Indicati ons

1. Bilateral condylar fractures

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2. Situations when intermaxillary fixation is not feasible as a result of the

following:
• Medical restrictions
• Poorly controlled seizure disorder
• Psychiatric disorders
• Severe mental retardation
3. Concomitant injuries
4. Displaced fractures
5. Bilateral fracture s in which it is impossible to determine what the proper
occlusion is as a result of loss of posterior teeth or the presence of a pre injury
skeletal malocclusion
6. In fracture dislocatio n in adults to restore the positio n and function of the
meniscus 6 , 7 (co ntroversial)

AGE:12-20

AGE:20+

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CONCLUSION:
Fractures of the mandibular condyles co nstitute a notable portion of mandibular
fractures. A number o f clinical signs and symptoms should alert the clinician to the
possibility of such injuries. The use of plain radio graphs in multiple views usually
discloses most condy lar fractures, although the advent of the CT scan has made a
more definitive and detailed evaluatio n and description of these injuries possible.
A number of classification systems have been devised to group co ndylar fractures,
but in most instances these systems have little utility in the clinical management of
these injuries.
With regard to treatment, most of the published data before t he advent of rigid
fixatio n on both animals and humans suppo rt the use of conservative therapy for
the management of condylar fractures except in a specific subset of fractures in
which movement is limited, adequate occlusio n cannot be obtained, or inter -
maxillary fixation is contraindicated. However, recently there has been resurgence
in literature supporting open reduction and internal fixa tion of co ndylar fractures,
citing improved condylar stability and occlusal results, earlier return of jo int
funct ion, and improv ed cosmesis. Knowl edge of regio nal anatomy and improved
techniques for surgical access to the TMJ have greatly reduced complication rates.
There are a number of surgical approaches to the condylar fracture and an equal
number of different m ethods of reduction and fixation of the fracture segments.
The simplest metho d with the least complications based on the specifics of the
fracture (location, type of fracture, displacement of segments, age of the patient
and co ncomitant medical conditio ns) should be used.

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Ethical clearance – Not needed as it is a review article

Source of funding- Nil

Conflict of interest- Nil

REFERENCES:
1. Sharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, et al. Interventions for the
treatment of fractures of the mandibular condyle.
2. Loukota R A, Neff A, Rasse M. Nomenclature/classification of fractures of the mandibular
condylar head. Br J Oral Maxillofac Surg. 2010;48(6):477–478.
3. He D, Yang C, Chen M, Jiang B, Wang B. Intracapsular condylar fracture of the mandible: our
classification and open treatment experience. J Oral Maxillofac Surg. 2009;67(8):1672–1679.
4. Sharif MO, Fedorowicz Z, Drews P, Nasser M, Dorri M, Newton T, et al. Interventions for the
treatment of fractures of the mandibular condyle. Cochrane Database Syst Rev. 2010
5. Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN. 1,454 mandibular fractures: A 3-year study
in a hospital in Belo Horizonte, Brazil. J Craniomaxillofac Surg. 2012;40:116–23.
6. Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassification of fractures of the condylar process
of the mandible. Br J Oral Maxillofac Surg. 2005;43:72–3
7. Neff A, Kolk A, Deppe H, Horch H H. New aspects for indications of surgical management of
intra-articular and high temporomandibular dislocation fracture
8.

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