S u b c o n d y l a r F r a c t u re s

Edward Ellis III, DDS, MSa,*, Robert M. Kellman, MDc,*,

Emre Vural, MDb,*

KEYWORDS
 Subcondylar fracture  Mandible fracture  Facial fracture  Surgical techniques
 Open surgical technique  Closed surgical technique  Mandible maxilla

Subcondylar Fractures
Edward Ellis III, Robert M. Kellman, and Emre Vural address questions for discussion and debate:
1. Are there specific indications for open versus closed treatment of subcondylar fractures? Are there
any contraindications to open treatment, and do they supersede the indications for open treatment?
2. Does the presence of other fractures (mandible and/or midface) affect your choice of open versus
closed treatment? (Is the selection of closed vs open treatment the same for unilateral vs bilateral
fractures?)
3. If one chooses to perform closed treatment, how long a period of maxillomandibular fixation is
required?
4. What are the most important factors for success when closed treatment is used?
5. What is the best surgical approach to open reduction and internal fixation of subcondylar fractures?
6. Analysis: Over the past 5 years, how has your technique or approach evolved and what is the most
important thing you have learned/observed in working with subcondylar fractures?

Are there specific indications for open versus closed treatment of

subcondylar fractures? Are there any contraindications to open treatment,
and do they supersede the indications for open treatment?
ELLIS
I applaud this debate because I believe it is time I find it pejorative to come up with specific “indi-
we stopped arguing about whether condylar frac- cations” for open or closed treatment. I prefer to
tures should be treated open or closed, and use the term “considerations,” for which there
instead ask which condylar fractures might have are many. I can think of only 1 situation in which I
better outcomes when treated open. believe open treatment should almost always be
facialplastic.theclinics.com

a
Department of Oral and Maxillofacial Surgery, The University of Texas Health Science Center at San Antonio,
San Antonio, TX, USA
b
Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301
West Markham, Slot 543, Little Rock, AR 72205, USA
c
Department of Otolaryngology and Communication Sciences, State University of New York – Upstate Medical
University, 750 East Adams Street, Syracuse, NY 13210, USA
* Corresponding authors.
E-mail addresses: ellise3@uthscsa.edu; kellmanr@upstate.edu; vuralemrea@uams.edu

Facial Plast Surg Clin N Am 20 (2012) 365–382

doi:10.1016/j.fsc.2012.05.002
1064-7406/12/$ – see front matter Ó 2012 Published by Elsevier Inc.
366 Ellis, Kellman, Vural

used, and it is addressed later (condylar fractures

associated with comminuted maxillary fracture[s]).
However, there are other considerations that may
push one toward one treatment or the other and I
address these now.
However, to fully understand condylar fractures,
one has to understand the adaptations in the
masticatory system that occur when these injuries
are treated closed or open. I refer readers to an
article on this topic by Ellis and Throckmorton.2
First, I believe that any unilateral condylar frac-
ture can be treated closed, with the following
prerequisites:
1. The patient must have a good complement of
teeth, especially posterior teeth. Without
them, there is a significant loss of posterior
vertical dimension and an increase in the
mandibular and occlusal plane angles. The
loss of posterior vertical dimension makes
future prosthetic reconstruction difficult.
2. The patient must be cooperative. They must
wear their elastics, do their functional exer-
cises, and return often for follow-up.
3. The surgeon must be willing to see the patient
Fig. 1. A patient treated closed for a left condylar
often to assess treatment and alter functional process fracture. Note the deviation toward the side
therapy as necessary. of fracture.
It does not matter to me whether the unilateral
condylar fracture is intracapsular, condylar neck,
or subcondylar. Nor does the degree of displace- occlusion, good facial symmetry, and pain-free
ment matter to me. (It does not matter to me if there function by treating someone closed, why should
is a condyle. Unilateral condylectomy patients can they risk the potential intraoperative and postoper-
readily be treated nonsurgically with excellent ative complications that are associated with open
outcomes.) They can all be managed effectively if treatment?1
the criteria listed earlier are met. However, one Unlike the unilateral condylar fracture, I do not
must understand completely that, when one choo- believe that I can satisfactorily treat all bilateral
ses closed treatment, especially those with large condylar fractures closed. Some have good
displacements, the neoarticulation does not trans- outcomes; some do not. The problem is that I
late as much as the nonfractured side. The conse- cannot predict which ones will do well with closed
quence of this situation in the skeletally mature treatment and which will not. The bilateral condylar
patient is that they often deviate toward the side fracture, especially those that are displaced,
of fracture when the mouth is opened (see creates a biomechanical alteration that is a chal-
Fig. 1A in the techniques section) and they have lenge to the masticatory system. Bilateral loss of
limited lateral excursion away from the side of frac- vertical and horizontal support from disruption of
ture (Fig. 1).3–5 When they protrude their mandible, the craniomandibular articulation means that the
they also deviate toward the side of fracture. mandible is essentially a free-floating bone, posi-
This deviation is not a failure of treatment; it is tioned only by the muscles and ligaments attached
a consequence of the alteration in biomechanics to it, and the dentition.1,6,7 Some patients have the
secondary to the displaced condyle and the altered neuromuscular ability to adapt to the alteration in
lateral pterygoid function. It is of no clinical conse- biomechanics and others do not. A successful
quence to the patient. That is not to say that outcome requires the muscle coordination to be
patients treated open for unilateral condylar frac- such that the patient can carry the mandible in
tures do not do well. They usually do well, the proper position while a new craniomandibular
assuming that no injuries occur from the surgery articulation is established. The reestablishment of
to reduce and stabilize the condyle. However, a new articulation always occurs. The only ques-
one has to consider the risk/benefit ratio when tion is whether the mandible will be in a favorable
deciding on treatment. If one can obtain a good position at the conclusion of the process by which
 Subcondylar Fractures 367

the neoarticulation is established. Because I superiorly during the formation of the neoarticula-
cannot predict who will and will not readily adapt, tion. Even with insertion of the patient’s dentures,
I tend to treat bilateral condylar fractures, espe- there is no evidence that they can prevent the
cially those that are displaced, by open reduction tendency for loss of posterior vertical dimension.
and internal fixation (ORIF) of at least one of the The consequence of that loss is difficulty in future
fractured condylar processes. However, the litera- prosthetic reconstruction. Treating condylar frac-
ture shows that perhaps only 10% of patients with ture(s) closed in such patients not only requires
bilateral condylar fractures develop malocclusions that they wear their dentures but that the dentures
that are beyond the capability of orthodontic or be secured to the jaws. Otherwise, there is no way
prosthetic reconstruction, requiring orthognathic to control the tendency for deviation of the
surgery.8 It is always hard to recommend that mandible toward the side of a unilateral condylar
100% of patients should undergo open treatment fracture or the anterior open bite tendency in bilat-
of their condylar fractures when 90% of them do eral fractures. Performing open treatment in these
not need it. The clinicians need to keep this in patients allows them to go back to wearing the
mind. Again, it is the risk/benefit ratio of open dentures immediately.
versus closed treatment that must be considered. A discussion on this topic is not complete
When a patient has the combination of a very without discussing the skeletal maturation of the
mobile, very comminuted maxillary fracture and patient. This is another major consideration for
condylar fracture(s), I usually perform ORIF of the me. Every study in the literature that has studied
condylar process fracture(s). I do this because this topic suggests that skeletally immature
with a panfacial fracture, I choose to reconstruct patients have a better ability to adapt to a condylar
the mandible first. This procedure requires that fracture than skeletally mature patients when
all fractures of the mandible undergo open reduc- treated closed (Fig. 2).9–14 Therefore, there is
tion and stable internal fixation. I essentially turn less need to perform open treatment of condylar
a panfacial fracture into an isolated midfacial frac- process fractures in young patients. That is not
ture. When one has an isolated midface fracture, to say that open treatment is not also effective.
the nonfractured mandible serves as a platform However, it comes back to the risk/benefit ratio.
on which the maxillary arch can be positioned The bone in the young does not always allow
through maxillomandibular fixation (MMF). secure purchase for the bone screws. The last
Because the mandible still maintains its position thing one would like is loose hardware in the
with respect to the cranium through the cranio- wound. Therefore, before performing ORIF, one
mandibular articulation, using the mandible has to be able to convince oneself that open treat-
provides the proper mediolateral and anteroposte- ment provides better outcomes than closed
rior position of the maxilla. The only dimension one treatment.
needs to obtain at surgery is the vertical dimen- Several considerations must be entertained
sion, rotating the maxillomandibular complex before open treatment is planned. First is the
around the temporomandibular joint (TMJ). When ability of the surgeon to obtain an anatomic
the mandibular condyle is also fractured and the
mandible is used to position the maxilla, one
must reestablish the continuity of the mandible.
Otherwise, the midface is positioned off-midline
because of the tendency of the mandible to
deviate to the side of the condylar fracture. That
is not to say that one must always treat a panfacial
fracture in this manner. The other way is to stabi-
lize the midfacial bones, including the maxilla,
using bony interfaces as guides. Once stabilized,
the condylar fracture could even be treated
closed. However, in my experience, it is difficult
to properly position the maxilla in all 3 planes of
space when the bony articulations, especially
those along the anterior maxilla, are comminuted.
Another injury for which one might consider the Fig. 2. Posteroanterior radiographs of a fractured
open treatment of condylar fracture(s) is the eden- mandibular condylar process in a 6-year-old child
tulous patient. As noted earlier, if the patient has before (A) and 6 months after closed treatment (B).
no teeth, especially posterior teeth, it is difficult Note that it is almost impossible to determine that
to prevent the posterior mandible from moving fracture had occurred.
368 Ellis, Kellman, Vural

reduction and stable internal fixation. If one cannot use a transfacial approach, cervical spine frac-
assure oneself that one is likely to be successful in tures may therefore become a contraindication to
this procedure, then closed treatment might be open treatment. For those surgeons who use an
a better option. For instance, intracapsular or diac- approach that does not require the head to be
apitular fractures of the condyle are difficult to turned (ie, the transoral approach), a cervical spine
treat open. Those surgeons who are skilled in fracture is not a contraindication.
TMJ surgery may be able to predictably perform Another consideration for me is the patient with
open reduction and internal derangement of such a condylar fracture who can still maintain a good
fractures, but many surgeons find this a chal- occlusion, even when a posteriorly directed force
lenging exercise. Therefore, for most surgeons is applied to the chin.15 If, after application of
who treat maxillofacial injuries, a relative contrain- arch bars and ORIF of other fractures of the
dication is the intracapsular or diacapitular mandible, the occlusion is stable and reproduc-
fracture. ible to manual manipulation with posteriorly
Another consideration hinges on the surgical directed force applied to the chin, I see no
approach that one might use to perform ORIF. reason to perform ORIF of the condylar process
For those surgeons who use a transfacial fracture. Although fractured, the fragments
approach, the ability to turn the head is critical to provide good support to the anterior mandible.15
exposing the fracture. For patients with unstable These are the easiest cases to treat closed. For
cervical spine fractures or those in halo frames, me, this is a relative contraindication to open
the head cannot be turned. For surgeons who treatment.

KELLMAN
The question assumes that the diagnosis of a sub- a shift in the chin point to one side or the other
condylar fracture (or of bilateral subcondylar frac- or if there is visible foreshortening of one side of
tures) has been made. However, if that diagnosis is the mandible (and therefore an alteration in facial
made, one must still return to the issue of diag- appearance), or widening of the face because of
nosis. One of the first controversies that we face malposition of the bone, then additional options
as clinicians is how to evaluate these injuries. should be discussed with the patient. Similarly, if
Whereas some surgeons are satisfied with a pano- the patient has difficulty bringing the teeth into
ramic tomographic radiograph (orthopantomo- a premorbid occlusal relationship, additional inter-
gram), others suggest the benefit of plain films of vention is warranted.
the mandible, because the Towne view provides Experience has shown that most subcondylar
an excellent view of the vertical rami of the fractures of the mandible can be successfully
mandible, allowing assessment of angulation of managed using nonopen techniques. This state-
the condylar segment, as well as assessment of ment does not mean that so-called closed tech-
the vertical height of the ramus-condyle unit. niques reduce subcondylar fractures. They do
Schubert and colleagues have found that the not. However, they do manage the occlusion,
combination of computed tomography (CT) scans and most patients achieve what have long been
and orthopantomograms provides the most considered satisfactory results using this ap-
complete diagnostic evaluation of mandibular proach. For me, closed management (I am not
fractures, and Lee and colleagues advocate ob- saying closed reduction) entails the application of
taining both axial and coronal CT views of the arch bars to the upper and lower dentition followed
ramus/condyle unit when subcondylar fractures by the use of limited elastic traction (commonly
are suspected.1,2 These views show alterations referred to as training elastics) to gently pull the
in vertical height and angulation as well as rotation dentition into a premorbid relationship and permit
of the condylar segment. CT also provides for function, so that the patient can open and close
better assessment of comminution, although it the mouth. This strategy also allows for early phys-
often underestimates the extent of comminution. iotherapy. The elastics are left in place until the
Although the various radiographs provide for patient can maintain their premorbid occlusal rela-
excellent analysis of the fracture, the most impor- tionship without them. This procedure requires
tant assessment is clinical. If the patient is able to close follow-up, particularly because the option
open and close normally or near-normally and of reconsidering open reduction for those patients
achieve their normal occlusal relationship easily, for whom this approach is not working well should
then limited intervention is generally warranted. A be considered earlier rather than later (preferably
soft diet along with early physiotherapy usually within 1 to 2 weeks). Probably the single biggest
provides a satisfactory result. However, if there is controversy in the management of these fractures
 Subcondylar Fractures 369

is the question of when open reduction should be reduction and repair are used,4,5 although there
used, because some surgeons perform open are conflicting data as well.6 The study by Eckelt
reduction freely on most if not all fractures, and colleagues4 is particularly worthy of careful
whereas others use open reduction rarely if ever, review, because the randomization was impres-
and most fall somewhere between. sive, so that severity of injury was not used to
Open reduction should be performed when determine the treatment, unlike the situation with
a reasonable occlusal relationship cannot be almost all of the retrospective studies, which
achieved, even under general anesthesia with showed little difference regardless of treatment
muscle relaxation. It should also be considered category. (In most of these reviews, the results of
for those patients who are bothered by the alter- the open and closed treatments were similar
ation (or, in discussion with the patient, the poten- despite the fact that the more severe fractures
tial alteration) in their cosmetic appearance that with more severe displacement/dysfunction were
results from the change in the mandibular shape. generally in the open groups.)
The presence of edema can make this alteration Cosmetic deformity is also an important consid-
difficult to determine early on, and sometimes eration. When there is significant foreshortening on
the likelihood or potential of these changes devel- radiograph (>1 cm) (Fig. 3), the change in the
oping is part of the discussion with the patient, patient’s appearance may be apparent, although
because the final appearance with and without the amount of overlap that correlates with a notice-
surgery may be difficult to predict precisely in able cosmetic deformity has to my knowledge
a timely fashion that allows for timely repair. The never been studied. However, it may be necessary
surgical repair of subcondylar fractures becomes to discuss the risk of cosmetic deformity with the
more difficult as time passes, so it is often neces- patient, even when it is not yet apparent because
sary to make a surgical decision before the of swelling. Because open reduction is not without
swelling has gone down sufficiently for the patient its own attendant risks, the surgeon needs to be
to decide based on the appearance. careful to inform rather than lead the patient.
Open reduction can be performed transcutane- The presence of midfacial fractures, particularly
ously with direct exposure of the fractured frag- when severe enough to make determination of
ments, or it can be performed via a transoral facial height challenging, should be considered
approach, typically with the aid of an angled endo- an indication for open reduction. In this situation,
scope for better visualization of the fragments the reestablishment of the vertical height of the
when using the transoral approach. The choice ramus of the mandible serves as a guide to the
of surgical approach is yet another controversy.3 midfacial position.7 This situation leads directly to
Once the bone fragments are reduced, 1 or 2 tita- the next question.
nium miniplates are generally applied across the
fracture, although the size, strength, and number
of plates required to obtain a good result are not
clear and may even vary from patient to patient.
When open reduction is used, I still prefer to apply
arch bars and use the same postoperative
approach that I use with closed management (ie,
loose training elastics and physiotherapy).
As noted earlier, the foremost reason to perform
open reduction of a subcondylar fracture of the
mandible is the inability to reduce the occlusion,
particularly if this inability persists under general
anesthesia with muscle relaxation. If the patient
cannot come into occlusion themselves, the
surgeon may still be able to compensate for this
under anesthesia, and if preferred by either the
patient or the surgeon, closed management with
training elastics and physiotherapy may still be at-
tempted. However, when the occlusion cannot be
reduced under anesthesia, a poor outcome is
almost assured, and therefore open reduction is Fig. 3. A coronal CT scan showing a typical subcondy-
warranted to try to achieve a better functional lar fracture with lateral displacement of the proximal
result. Two recent prospective studies have sug- fragment and significant loss of vertical ramus height
gested better outcomes when open surgical caused by overlap of the fragments.
370 Ellis, Kellman, Vural

When considering contraindications to open progressing, the same might be said for fractures
repair, any other medical condition that would of the condylar head. Most surgeons, particularly
contraindicate proceeding with anything other in the United States, see few if any indications for
than life-or-death surgery should similarly be repairing condylar head fractures, but there is
considered a contraindication. However, in terms a small but increasing group of European surgeons
of maxillofacial contraindications, I would expec- who believe that open reduction of condylar head
ted failure, such as might be predicted with very fractures yields better outcomes.8,9 The absence
high or severely comminuted fractures would be of dentition makes closed management difficult,
in this category. These are relative contraindica- so if there is displacement or foreshortening that
tions, though, and if there is a particular clinical necessitates treatment, an open approach should
indication for open reduction, it should probably be entertained. Although most surgeons rarely
supersede a contraindication in this category. open subcondylar fractures in children younger
However, just as the evolution of treatment from than 14 years, age younger than this is not consid-
closed to open repair of subcondylar fractures is ered an absolute contraindication.

VURAL
Although there is almost universal consensus on as lack of uniformity in patient populations, bias in
the management of pediatric subcondylar frac- the selection of approach, and subjective evalua-
tures, which are almost exclusively treated with tion of certain parameters. When we present
a closed approach, treatment of subcondylar data on occlusion for open and closed
mandibular fractures in the adult population prob- approaches, do we really know how the occlusion
ably forms one of the most controversial topics of was for any given patient before the event causing
discussion in maxillofacial trauma. Therefore, it is the fracture? Do we pick and choose what we
difficult to establish absolute indications or contra- plate and what we do not plate? And, do we really
indications for open versus closed management of know if one particular patient treated with one
these fractures. Use of an endoscopic approach in approach would do the same, better, or worse if
the treatment of subcondylar fractures is an the other approach was used?
exciting recent advance.1,2 However, the question An exhaustive literature review in this topic
of whether these fractures need to be managed reveals both significant and nonsignificant differ-
closed or open still exists. I believe that both ences between open and closed approaches, for
approaches have a role in the management of sub- almost all parameters, such as occlusion, excur-
condylar fractures and each of these approaches sion, pain, interincisal opening, protrusion, or devi-
may serve better than the other in certain ation.5–12 Considering all these, it is impossible to
conditions. establish absolute indications for each treatment
The goal in the treatment of subcondylar frac- approach. Fracture of the subcondylar region is
tures should be providing the patient with a satis- an unfortunate event, and both good and bad
factory occlusion with the least possible outcomes are possibilities regardless of the
discomfort and limitation of movement in the approach chosen. Multiple other factors are
mandible. However, the jury is still out on deciding involved in obtaining the final outcome (satisfac-
which approach is the best to accomplish this tory or unsatisfactory) in any given patient, in addi-
goal, because there are no high-quality published tion to the selected management approach. The
data comparing of the outcomes of closed, status of the patient’s dentition, compliance,
open, or endoscopic management of subcondylar bone stock quality, age, comorbid conditions,
fractures. A recent Cochrane review performed by occlusal relationship before the event causing
Sharif and colleagues3 indicates that the decision fracture, and presence of additional maxillofacial
of which is the best approach in subcondylar frac- fractures, infection, or other accompanying life-
tures may not be made based on current evidence. threatening issues such as intracranial injuries
Another recent study performed by Nussbaum are just a few. Therefore, it is more appropriate
and colleagues,4 which involved a meta-analysis to talk about personal preferences rather than indi-
of published data on condylar fractures in adults, cations/contraindications of open versus closed
revealed that most of the parameters showed no treatment.
difference between open and closed approaches, Nonetheless, performing open or endoscopic
although some parameters favored one approach reduction/fixation in a subcondylar fracture may
over another. As stated in these 2 articles,3,4 there be contraindicated if the patient is not a candi-
are numerous shortcomings in the presentation of date for general anesthesia, does not wish to
the published data on subcondylar fractures; such undergo open or endoscopic surgery, or has
 Subcondylar Fractures 371

other life-threatening issues to be resolved. The head fractures are questionable and may not
benefits of attempting rigid fixation of high frac- outweigh the risks. Therefore, rigid fixation may
tures such as intracapsular fractures or condylar be considered contraindicated in these fractures.

Does the presence of other fractures (mandible or midface) affect your

choice of open versus closed treatment? (Is the selection of closed vs open
treatment the same for unilateral vs bilateral fractures?)
ELLIS
I addressed these issues fully in my first response. cannot predict which ones will do well with closed
To summarize, I believe that any unilateral condylar treatment and which will not. It is always difficult
fracture can be treated closed, with several prereq- to recommend that 100% of patients should
uisites. Unlike the unilateral condylar fracture, I do undergo open treatment of their condylar fractures
not believe that I can satisfactorily treat all bilateral when 90% of them do not need it. Clinicians need to
condylar fractures closed. Some have good keep this in mind. Again, the risk/benefit ratio of
outcomes; some do not. The problem is that I open versus closed treatment must be considered.

KELLMAN
As noted earlier, the presence of severe midfacial the combination of these fractures is a setup
fractures usually requires direct (open) repair of for widening of the mandible with lingual splaying
displaced subcondylar fractures. When the mid- of the symphyseal fracture(s). It is difficult to
face is comminuted, the mandible serves as adequately reduce the symphyseal region first,
a template for positioning of the alveolus, thereby and therefore, I prefer to open and repair the
determining the relationship of the maxillary dental subcondylar fracture(s) first, before applying the
arches to the remainder of the face and skull. Fore- final fixation to the symphysis (Fig. 4). For this
shortening of the mandibular height as a result type of combination, bilateral subcondylar frac-
of loss of continuity of the ramus-condyle unit tures are more difficult than unilateral, although
positions the maxillary dental arches superiorly, widening can result with a unilateral fracture as
with resultant foreshortening of the midface (in well.
essence, an accidental maxillary intrusion). On the other hand, the presence of bilateral sub-
One should also consider the presence of condylar fractures in isolation does not mandate
other mandible fractures. In particular, the pres- an open repair, and this situation can often be
ence of symphyseal/parasymphyseal fractures managed with the same approach as a unilateral
of the mandible should be considered, because fracture.

VURAL
Presence of other fractures in the mandible or in to operate. On the other hand, if the patient has
the midface does not affect my choice of treat- multiple fractures, which need to be managed by
ment of the subcondylar fracture(s). I do not feel ORIF, and if I believe that the subcondylar compo-
obliged to plate one fracture (if it is suitable to be nent could also benefit from an internal fixation;
managed by conservative approach), just because then I try to plate them all. Sometimes I apply
I plate the other. The condition of the other frac- arch bars with elastic bands for the subcondylar
tures, rather than their presence, is important, component in combination with applying plates
because some midface fractures or selected frac- and screws for the other fractures in the face.
tures of other sites of the mandible could easily be Therefore, a patient may have ORIF or closed
managed by a conservative approach in the form management in all facial fracture components, as
of a soft diet. For example, if a nondisplaced tripod well as ORIF in some and closed management
fracture is managed by soft diet only, an accompa- for others.
nying nondisplaced subcondylar fracture with Similarly, having a unilateral or bilateral subcon-
unaffected occlusion can also be managed by dylar fracture should not affect the decision-
soft diet and should not be considered as a reason making process in the management of
372 Ellis, Kellman, Vural

Fig. 4. (A) Axial CT scan of the anterior mandibular body showing a symphyseal fracture with lingual diastasis.
What is not apparent is that this patient has had an attempt at repair (see B). (B) Same CT scan as in (A), but
the CT cut shows that a plate has been placed. However, bilateral subcondylar fractures have not been addressed
(see C). (C) Coronal CT scan showing bilateral subcondylar fractures with the distal ramus segments directed later-
ally out of the glenoid fossae. (D) Three-dimensional (3D) CT scan reconstruction after secondary repair, including
plating of both subcondylar fractures, allowing better control of the symphyseal fracture. (E) Same 3D CT scan
rotated to show the mandible from the inferior view, showing closure of the lingual cortex of the symphyseal
fracture.

subcondylar fractures. Whereas nondisplaced is best treated with an elastic MMF or open
bilateral subcondylar fractures can be managed approach. Therefore, occlusal status plays
by soft diet only if the occlusion is not affected, a more important role in decision making, rather
a displaced unilateral fracture with malocclusion than the fracture being unilateral versus bilateral.

If one chooses to perform closed treatment, how long a period of

maxillomandibular fixation is required?
ELLIS
I do not use postoperative MMF for patients who range of mandibular motion faster, and their
are treated closed for fractures of the mandibular speech, diet, and oral hygiene are facilitated.
condylar process. Although doing so is not contra- Instead, I use aggressive physiotherapy and
indicated, there is no convincing evidence that it is control of the occlusion by 1 or 2 interarch elastics
helpful. There is good evidence that it is more in a class II direction on the side of fracture. The
useful to allow the patient to function immedi- patient is weaned off the elastics over the 4 to 6
ately.16–18 Patients allowed to do so increase their weeks after arch bars have been applied.1
 Subcondylar Fractures 373

KELLMAN
I generally no longer use rigid MMF in the manage- I like the idea of early functioning of the mandible
ment of subcondylar fractures. The exception is to improve the likelihood of better functional
the rare situation in which I have performed an outcomes, although the belief that poor function is
open reduction, but for some technical reason, I caused by prolonged MMF has never been proved
have been unable to apply any rigid fixation hard- either. It is likely that the joint injury that occurs as
ware. In this situation, I place the patient in rigid a result of the initial trauma is the most meaningful
MMF for 10 days to discourage displacement of predictor of later joint dysfunction. Nonetheless,
the now reduced but not fixated fracture frag- because there is no evidence that early functioning
ments. However, despite the logic of this interferes with the outcome, this approach at least
approach, there is no good evidence that it is makes intuitive sense. Early physiotherapy should
successful. Raveh and colleagues10,11 reported be able to increase range of motion of the mandible
success with this technique, but it seems that in all directions, whereas the elastics provide the
the proximal fragment likely displaces secondary guidance to train the muscles to bring the dentition
to muscle pull, even with the jaws immobilized in into the best occlusal relationship, despite the
MMF. malposition of unreduced bone fragments.

VURAL
I believe that there is a consensus on keeping the next 3 to 4 weeks. If the patient fell into a correct
MMF as short as possible.13 Long-term rigid MMF occlusal relationship without elastic bands and
can cause ankylosis in the TMJ, which can cause maintains this relationship, I would remove the
limitation in the range of motion. If I could bring arch bars. If I could bring the patient into satisfac-
the patient into satisfactory occlusion with elastic tory occlusion only by using rigid MMF using wires,
bands, I would choose not to use rigid MMF using I would keep these wires for only 1 or 2 weeks and
wires. In this case, I would closely follow the switch to training elastics, as I mentioned in my
patient and try to eliminate elastic bands over the second response.

What are the most important factors for success when closed treatment
is used?
ELLIS
My full response to this is within the first question; 2. The patient must be cooperative. They must
however, it bears repeating, I believe that any wear their elastics, do their functional exer-
unilateral condylar fracture can be treated closed cises, and return often for follow-up.
with prerequisites: 3. The surgeon must be willing to see the patient
often to assess treatment and alter functional
1. The patient must have a good complement of therapy as necessary.
teeth, especially posterior teeth. Without
them, there is a significant loss of posterior For a successful outcome for bilateral condylar
vertical dimension and an increase in the fractures treated closed, the risk/benefit ratio
mandibular and occlusal plane angles. The of open versus closed treatment must be
loss of posterior vertical dimension makes considered.
future prosthetic reconstruction difficult.
Patient muscle coordination
Patient muscle coordination requires that the comminuted maxillary fracture and condylar frac-
muscle coordination is such that patients can ture(s), the condylar fracture could even be treated
carry the mandible in the proper position while closed. However, in my experience, it is difficult to
a new craniomandibular articulation is established. properly position the maxilla in all 3 planes of
Once midfacial bones and maxilla are stabilized space when the bony articulations, especially
in patients with combination of a very mobile, very those along the anterior maxilla, are comminuted.
374 Ellis, Kellman, Vural

Dentition
Without teeth, especially posterior teeth, it is difficult Performing open treatment in edentulous patients
to prevent the posterior mandible from moving supe- allows them to go back to wearing dentures
riorly during the formation of the neoarticulation. immediately.

Skeletal maturity
There is less need to perform open treatment of is not to say that open treatment is not also effective.
condylar process fractures in young patients. That However, it comes back to the risk/benefit ratio.

KELLMAN
First, it is important to define success when approach is to mention the risk of facial fore-
closed management is chosen as the treatment shortening (in general terms as a risk of this
of subcondylar fractures. If there is foreshorten- type of fracture) during my initial discussion
ing of the mandible on the side of a subcondylar with the patient and then be guided by the level
fracture, the use of closed management is not of concern that the patient then expresses. If
likely to resolve this. However, that statement to the patient finds this to be a concern, and there
some extent begs an important question: how is significant overlap (foreshortening) on the
often is foreshortening significant, and the radiograph, then I think the option of reestablish-
obvious corollary question is that when it is ing ramus height via open reduction must be
significant, to whom is it significant: the patient candidly discussed with the patient.
or the astute cosmetically oriented surgeon (or Another key factor in obtaining a good result is
both)? Like so many issues in medicine, many patient compliance. It is difficult to expect
examples of facial foreshortening are not noticed a good functional outcome when the patient is
by the patient until the surgeon points it out. This not willing to be an active partner in their care. A
is a difficult situation, because it is unclear patient who removes the elastics (possibly even
whether it is more ethical to point it out to the the arch bars) and fails to comply with exercises
patient in the interest of full disclosure and risk or physiotherapy sessions is less likely to obtain
creating dissatisfaction with the self-image where the best possible outcome. There is no way to
none existed, or whether ethics suggest that we ensure patient compliance with our treatment regi-
should not create concern when the patient mens, and we have to do our best to educate
does not independently raise the issue. I do not patients as to how important their participation is
know how to resolve this issue, but my personal in the final result.

VURAL
In my opinion, one of the most important factors if the subcondylar component is appropriately
in successful management of subcondylar frac- managed.
tures is the presence or absence of malocclusion. Another important factor is the patient’s compli-
I believe that patients with unilateral or bilateral ance. A nondisplaced or minimally displaced sub-
subcondylar fracture(s) with normal occlusal rela- condylar fracture can be easily and optimally
tionship may do better than the ones who present managed by keeping the patient on a soft diet
with malocclusion; and the ones with malocclu- only, if the patient is compliant with the regimen.
sion that can be easily corrected with elastics Conversely, a patient who was kept on excellent
do better than the ones with malocclusion that occlusion on elastic MMF may lose this occlusal
cannot be corrected with elastics and necessi- relationship easily and quickly, for example, if
tates rigid MMF. Some patients may have maloc- broken elastics are not replaced in a timely
clusion as a result of fractures of other mandibular fashion.
sites or midface. If normal occlusion is obtained One other important factor is the level of the
by performing ORIF on those other fracture sites fracture, because I believe that the outcome
in the presence of 1 or 2 subcondylar fractures, becomes worse as the level of fracture gets higher
these patients may still do well in the long term, (ie, low subcondylar vs intracapsular fractures).
 Subcondylar Fractures 375

What is the best surgical approach to open reduction internal fixation of

subcondylar fractures?
ELLIS
I prefer the retromandibular approach.19 It from the fractured condylar process. One there-
provides direct access to the entire posterior fore must work down a long tunnel. Placing screws
ramus and condylar neck, and can be performed may therefore require a transcutaneous trochar,
rapidly. The problem with the preauricular especially for the screws above the fracture. I
approach is that it gives good exposure of the occasionally use a transoral approach with endo-
TMJ but poor exposure of the subcondylar region. scopic assistance, but I am not expert in this
Placing a bone plate through this approach is diffi- approach so I cannot predictably attain a good
cult because insertion of the screws below the reduction and stable internal fixation. For surgeons
fracture requires some inferior retraction of the skilled in the transoral approach, it is ideal because
facial nerve. The problem with the submandibular the scar is hidden and the anatomic hazards (ie,
approach is that it is positioned a long way away nerves and vessels) are largely avoided.

KELLMAN
There are several approaches to the ramus/sub- proximal fragment, which is more commonly later-
condylar region of the mandible, and each surgeon ally displaced. Once the elevation is completed,
should use the approach with which they are most fracture reduction is accomplished by applying
comfortable. Most surgeons articulate the reasons inferior traction on the posterior mandible, thereby
that they prefer their particular approach. allowing reduction of the proximal fragment into
My favorite surgical approach is the endoscope- the space superior to the ramus. After reduction
assisted transoral approach, with the use of is accomplished, fixation may be applied. When I
a transbuccal stab incision for placement of am unable to successfully perform the ORIF via
screws into the plate or plates that are used to this approach I either convert to a transcutaneous
fixate the fracture. Although it takes longer to approach or I see if open reduction without fixation
perform this approach when one is less experi- allows reduction of the occlusion and use of
enced, there is good evidence that the duration closed management. When I do convert to a trans-
of these procedures decreases as experience is cutaneous open procedure, I prefer the subman-
gained.12 The advantages include minimizing the dibular approach, which allows for visualization
external scar (the procedure can be performed of the mandibular ramus of the facial nerve to
completely transorally using a right-angled drill protect it, and avoidance of the parotid gland,
and screwdriver, in which case there is not even which is sectioned when using the retromandibular
the tiny scar associated with the transbuccal approach. However, for high subcondylar frac-
stab incision), and the risk of facial nerve injury tures, the submandibular approach does require
seems to be less.3,12 The incision for this approach some retraction, which can be a source of stretch
is made along the anterior ramus of the mandible injury to the main trunk of the facial nerve.
by feeling the bone and cutting directly down to The transoral approach may be helpful in
it with an electrocautery wand. For greater visual- reducing medially displaced proximal fragments,
ization of the vertical ramus when needed, the inci- because it is possible to perform an elevation on
sion can be extended inferiorly along the oblique the medial (lingual) side of the ramus of the
line, as might be done for intraoral management mandible. The medially displaced proximal frag-
of mandibular angle fractures. The elevation is per- ment can then be directly visualized or the endo-
formed in the subperiosteal plane, between the scope may be used. Once it is exposed, an
masseter muscle and the bone. As the elevation instrument or a finger may be used to carry out the
is performed, care must be taken not to elevate lateral repositioning and reduction of the fragment.
superiorly into the joint space, medial to the Care should be taken when dissecting in this area.

VURAL
I believe that the endoscopic approach is prob- fracture is low enough to accommodate
ably the best open approach for subcondylar a 2-mm plate with at least 2 screw holes on
fractures. I believe that most subcondylar frac- each side of the fracture and the fracture is fresh
tures can be plated with the endoscopic enough to allow manipulation of the proximal
approach, if they are suitable for plating. If the segment (ie, a maximum of 7–10 days old), the
376 Ellis, Kellman, Vural

preauricular approach is not indicated most of fixation can be performed with endoscopic
the time, and equally satisfactory reduction and approach.

Analysis: Over the past 5 years, how has your technique or approach
evolved and what is the most important thing you have learned/observed
in working with subcondylar fractures?
ELLIS
I have not changed my technique for closed or feel for which cases can be treated closed, which
open treatment of condylar process fractures in might do better treated open, and how to provide
more than 20 years. I believe that I have a good that treatment.

KELLMAN
Over the last decade, my approach has changed with open reduction. Other factors probably
significantly, both in regard to closed management played a role as well. However, with better surgical
as well as my approach to ORIF. A decade ago, I techniques, the incidence of facial nerve injury
was still leaning toward more closed treatments seems to be less of a concern, and more surgeons
and fewer open reductions. Furthermore, the are advocating ORIF.
closed treatments were more generally referred The other major evolution has been in how I
to as closed reductions, although most surgeons manage my closed management patients. When
were aware that it was the occlusion rather than I trained, we were using rigid MMF with wire for 6
the fracture that was being reduced. I now make weeks, probably because of the mistaken belief
a point of clarifying that difference, both to patients at the time that we were reducing the fractures
as well as to other members of the health care by this effort, and therefore we needed to put the
delivery team. Having become involved early in jaw at rest so that it could heal. Over time, I found
the use of the endoscopic-assisted open reduc- myself using shorter and shorter periods of rigid
tion approaches, I overcame my initial reluctance MMF, until the last 5 to 10 years, when I pro-
to accept the possibility of frequent open reduc- gressed to the approach indicated earlier, using
tion for a fracture that I had almost always treated training elastics and physiotherapy, with few re-
with closed management, with what at the time maining indications for rigid MMF.
had seemed like satisfactory results. Although for I would like to close by mentioning again what I
me, it may have been the use of the endoscope believe is going to be the next frontier in this area.
that led to this shift, it was also a timely shift, For years, even those who advocated ORIF of sub-
because more and more surgeons seem to be condylar fractures7 advocated avoiding direct
recognizing that reducing the fractures, rather repair of the condylar head. Most recently, a small
than accepting forced adaptation of the occlusion but increasing group of surgeons are performing
despite nonreduced fractures, may provide better ORIF on many condylar head fractures.8,9
outcomes in many cases. Perhaps the reluctance Although this is probably the newest area of
to open these fractures in previous years13 was controversy in the management of mandible frac-
partly because of unacceptably high complica- tures, it is not unlikely that the trend toward
tions, particularly the dreaded seventh nerve opening many of these fractures will increase in
palsy, which probably led to surgeons’ discomfort the future.

VURAL
My approach was almost exclusively closed at the or not) can easily be managed by close observation
beginning. Then, I did have a transition period, with the patient on a soft diet. If the fracture is
when I used endoscopic ORIF as much as causing malocclusion and seems to be suitable
possible. I finally settled on a blend of endoscopic for an endoscopic ORIF, this may serve as an indi-
and closed management. cation to operate, with the patient consenting to
I do not think that plating is required in every sub- both open and closed management. If the proximal
condylar fracture, regardless of how suitable the segment is large enough to accommodate at least 2
fracture is for plating. A nondisplaced or minimally screws and the occlusion can be restored easily
displaced subcondylar fracture with unaffected under general anesthesia by manual MMF, then
occlusion (ie, occlusion that did not change after an endoscopic ORIF should be attempted. In my
trauma regardless of whether the occlusion is ideal opinion, providing correct occlusion easily by
 Subcondylar Fractures 377

performing manual MMF under general anesthesia have shortening of the posterior facial length;
is a good predictor of maintenance of correct however, I have not seen such a patient in my prac-
occlusion with elastic MMF (either with MMF tice, probably because of masking of facial soft
screws or arch bars) during endoscopic ORIF.14 If tissues of such skeletal deformities, unless the
the occlusion can be restored with elastics, but patient has significant anterior open bite.
the fracture is not suitable for plating or rigid fixation If the patient is edentulous, but the occlusion is
cannot be accomplished; then the patient is left on maintained when the dentures are in place,
arch bars and training elastics. If the patient has a nondisplaced or minimally displaced subcondylar
malocclusion and the correct occlusion can be fracture can be managed by a soft diet. If the
maintained only by applying rigid MMF, I typically denture-based occlusion is shifted because of
avoid rigid fixation because rigid MMF may not significant displacement, and the fracture is suitable
allow manipulation of the distal fragment, which to be plated with the endoscopic approach, the best
may be necessary for optimal reduction in the frac- possible fracture reduction should be attempted by
ture line. An exception to this situation is the cases using endoscopic assistance. The patient can then
in which the proximal fragment can be reduced be referred for new dentures or for adjustment of
optimally, without the need for any manipulation their old dentures. When the patient is edentulous
of the distal mandible; I find this condition to be and there is also senile atrophy in the mandible,
rare. In cases in which malocclusion can be cor- the surgeon and the patient should be aware that
rected only with rigid MMF, I keep MMF wires for the bone stock quality might not be good enough
a week or 2 and replace these MMF wires with to maintain rigid fixation in the subcondylar region.
elastic bands as soon as possible. Furthermore, stripping off the periosteum to obtain
If the patient has bilateral subcondylar fractures, I rigid fixation may cause disruption of the vascular
follow the same approach that has been explained supply to the bony fragments. Because the subcon-
earlier. It may be better to provide rigid fixation to at dylar region bears a significant amount of load
least 1 side, if it is possible, to prevent chronic ante- because of the short distance of the fracture line
rior open bite as a result of premature contact of to the fulcrum point (TMJ), loose hardware can be
molar regions in bilateral fractures, if the patient a complication in such patients.
has malocclusion. Some practitioners consider Considering all of my past experiences, I can still
bilateral subcondylar fractures as an indication for say that most subcondylar fractures can be and
open approach, with the fear that the patient will should be managed with a closed approach.

Surgical techniques for subcondylar fracture

Edward Ellis’ technique for closed treatment1

When the decision is made to treat the patient’s condylar process fracture closed, the following steps are
used:
1. Arch bars are applied.
2. Other (noncondylar) fractures are exposed.
3. Other (noncondylar) fractures are reduced and MMF is applied.
4. Stable internal fixation is applied to noncondylar fractures.
5. MMF is removed and the occlusion is examined. Typically, the mandible deviates toward the side of
the condylar fracture (see Fig. 1A, B). This is of no consequence, and occlusal guidance commences
the next day.
6. Placement of elastics as needed: the next day, the occlusion is assessed. Most commonly, there is
a premature contact posteriorly on the side of the condylar process fracture. The mandible deviates
to that side to varying degrees, with a resulting malocclusion. Occasionally, the patient is able to
occlude normally without the use of guiding elastics. In this instance, they should be allowed to
do so. If there is a malocclusion, elastics are applied to assist their neuromusculature to obtain the
proper occlusion. For most unilateral fractures, this process is typically 1 elastic on the side of the
condylar process fracture applied in a class II manner, to help draw the mandible anteriorly. Occasion-
ally, a second one is necessary (see Fig. 1C). One should apply as much elastic guidance as is necessary
to allow the patient to obtain their normal occlusal relationship when they occlude. However, the
goal is to use as little as necessary to promote active use of the mandible. For bilateral fractures, elas-
tics are usually required bilaterally in a class II vector, and often supplementation with vertical elastics
in the anterior is necessary.
378 Ellis, Kellman, Vural

Fig. 1. Patient treated closed for right condylar neck fracture. (A) Posteroanterior radiograph showing frac-
ture. (B) Preoperative occlusion with deviation to the side of the fracture (right). (C) Class II elastics placed on
the side of the fracture (right), allowing establishment of the proper occlusal relationship. (D) 4 weeks after
treatment, the patient can open widely. However, notice that the mandible deviates toward the side of frac-
ture (right). (E) At 4 weeks, the patient’s pretrauma occlusion is reestablished without the need for elastics.
The arch bars can now be removed.
7. Postsurgical physiotherapy: patients are encouraged to use their jaws as much as possible beginning
on the first postoperative day. They are instructed in physiotherapeutic exercises to increase range of
mandibular motion, which they should perform at least 4 times a day. Exercises consist of maximum
opening of the mouth, attempting to do so without deviation toward the side of fracture. This exer-
cise can be facilitated by observing themselves in a mirror. The patient should also be shown how to
use lateral excursive exercises to both the right and left sides. Protrusive excursions should be prac-
ticed, again attempting to do so without deviation of the mandible. During the exercises, eating, and
oral hygiene procedures, the patient can remove the elastics. The elastics are then reapplied, and the
 Subcondylar Fractures 379

patient is shown how to determine that they are biting in the proper occlusal relationship in a mirror
using as few elastics as possible. At bedtime, more elastics are used so that mandibular immobiliza-
tion (MMF) is firmly established while sleeping. The elastics are removed in the morning for oral
hygiene, breakfast, and exercises, and the patient then reapplies the minimum number of elastics
as necessary to help them establish their proper occlusion when their teeth are occluded. The goal
of physiotherapy should be an interincisal opening of greater than 40 mm, lateral excursions greater
than 10 mm, and protrusive excursions greater than 5 mm. Patients with unilateral fractures may
always have some degree of deviation toward the side of fracture on wide opening or protrusion
(see Fig. 1D). Typically, patients are able to obtain the above treatment goals in 4 to 5 weeks.
8. Weaning the patient from use of elastics: after 2 or 3 weeks of this treatment, the patient should be
able to obtain their pretraumatic occlusion without the constant use of elastics. The elastics are with-
drawn more and more over the next 2 to 3 weeks so that they are used only while sleeping for
another 2 to 3 weeks. Once the use of elastics is no longer necessary for the patient to obtain their
pretraumatic occlusion, they can be discontinued (see Fig. 1E). However, the arch bars should be left
in place for a few weeks beyond that time so that if the patient has some difficulty with occlusion
later, elastics can be reapplied.
9. Removal of arch bars: most commonly, arch bars are left in place for 6 to 8 weeks for unilateral and 3
to 4 months for bilateral condylar process fractures. Once the patient can consistently assume their
normal occlusion without the use of elastics, and they are no longer necessary for the patient to
obtain their pretraumatic occlusion, the arch bars can be removed.

Edward Ellis’ technique for open treatment1

When the decision is made to treat the patient’s condylar process fracture with ORIF, the following steps
are used:
1. Arch bars are applied.
2. Other (noncondylar) fractures are exposed.
3. Other (noncondylar) fractures are reduced and MMF is applied.
4. Stable internal fixation is applied to noncondylar fractures.
5. Placement of interarch elastics: before opening the condylar process fracture, the wire MMF is re-
placed with elastics. Enough elastics are placed between the upper and lower arch bars to provide
the proper occlusal relationship. Elastics are used instead of wires during open treatment of the
condylar process fractures because the mandibular ramus must frequently be distracted inferiorly
to retrieve a medially displaced condylar process. The elastics allow this procedure, and on release
of the distracting force, the proper occlusal relationship is again reestablished by the elastic force
(Fig. 2).

Fig. 2. Intraoperative photographs of a patient who will undergo ORIF of a left condylar process fracture. (A)
Elastics are placed that have sufficient strength to allow reestablishment of the proper occlusion on release of
the mandible (B) after forceful opening.

6. Open reduction of the condylar process fracture: the technique I describe uses a retromandibular,
transparotid dissection to the posterior ramus. The incision for the retromandibular approach begins
0.5 cm below the lobe of the ear and continues inferiorly 2.5 to 3 cm (Fig. 3A). It is placed just behind
the posterior border of the mandible and usually does not extend inferiorly below the level of the
380 Ellis, Kellman, Vural

mandibular angle. The skin is undermined to facilitate closure. Another incision is then made
through the scant platysma muscle found in this location and the parotid capsule. At this point, blunt
dissection begins in an anteromedial direction toward the posterior border of the mandible. The
marginal mandibular and cervical branches of the facial nerve are frequently encountered during
this dissection. A nerve stimulator can be used to identify branches of the facial nerve. When the
buccal or marginal mandibular branches are located, they should be dissected free from surrounding
tissues proximally for 1 cm and distally for 1.5 to 2 cm. Once the nerves are retracted, one can readily
expose the pterygomasseteric sling at the posterior border of the mandible. One should also be
cognizant of the retromandibular vein, which runs vertically in the same plane of dissection and is
commonly exposed along its entire retromandibular course. This vein rarely requires ligation unless
inadvertently transected. The periosteum along the posterior border of the mandible and partially
around the mandibular angle is incised from as far superiorly as is reachable to as far inferiorly
around the gonial angle as is possible. The masseter muscle is then stripped from the ramus. The frac-
tured condylar fragment is then identified (see Fig. 3B) and reduced. This procedure may be more
difficult for medially displaced fragments. A wire placed around a bone screw in the gonial angle
may be useful to distract the mandibular ramus inferiorly during the dissection and retrieval of
the fragment (see Fig. 3C).

Fig. 3. The retromandibular approach to the condylar region. (A) The incision drawn on the face. (B) Exposure
of the fracture. (C) A wire is inserted through the skin below the angle of the mandible and attached to
a bone screw in the angle region to allow distraction of the ramus inferiorly to help retrieve a displaced
condylar fragment. (D) Bone plate applied.

7. Reduction and stable internal fixation of condylar process fracture: the technique I routinely use is
the application of a single strong bone plate using 2.0-mm self-threading screws (see Fig. 3D). One
should use a bone plate of sufficient thickness because the standard miniplates using 2.0-mm screws
readily fracture under function.
8. Occlusal verification: the occlusion is checked to ensure the mandible rotates properly into occlu-
sion with the maxilla.
9. Closure: the incision is closed in layers, taking care to hermetically close the parotid capsule.
 Subcondylar Fractures 381

10. Occlusal guidance: the next day, assessment of the occlusion is performed. Most commonly, there is
a slight posterior open bite on the side of the condylar process fracture. This open bite is usually
secondary to edema in the TMJ and usually resolves within a week. If the posterior open bite is still
present at the end of 1 week, light vertical elastics are applied to close the bite. Most commonly, the
patient is able to occlude normally without the use of guiding elastics. In this instance, they should
be allowed to do so. Elastics should be placed only if there is a malocclusion, and as few as necessary
are used. The goal is to use as few as necessary to promote active use of the mandible.
11. Postsurgical physiotherapy: same as for closed treatment.
12. Removal of arch bars: once the patient can consistently assume their normal occlusion without the
use of elastics, and they are no longer necessary for the patient to obtain their pretraumatic occlu-
sion, the arch bars can be removed. Most commonly, arch bars are left in place for 4 to 6 weeks for
condylar process fractures.

REFERENCES (ELLIS)
1. Ellis E. Condylar process fractures of the mandible. 62 patients injured in the growth period. In:
Facial Plast Surg 2000;16:193–205. Walker RV, editor. Oral surgery–transactions of the
2. Ellis E, Throckmorton GS. Treatment of mandibular 3rd International Conference on Oral Surgery. Edin-
condylar process fractures: biological consider- burgh (Scotland): E&S Livingstone; 1970. p. 121–9.
ations. J Oral Maxillofac Surg 2005;63:115–34. 11. Lund K. Mandibular growth and remodeling
3. Amaratunga NA. A study of condylar fractures in Sri processes after condylar fracture. Acta Odontol
Lankan patients with special reference to the recent Scand Suppl 1974;32(64):75.
views on treatment, healing and sequelae. Br J Oral 12. Lindahl L, Hollender L. Condylar fractures of the
Maxillofac Surg 1987;25:391. mandible. II. Radiographic study of remodeling
4. Palmieri C, Ellis E, Throckmorton GS. Mandibular processes in the temporomandibular joint. Int J
motion after closed and open treatment of unilateral Oral Surg 1977;6:153.
condylar process fractures. J Oral Maxillofac Surg 13. Bjuggren G. Fem fall av Käkortopediskt behand-
1999;57:764–75. lade, enkelsidiga frakturer av collum mandibulae
5. Throckmorton GS, Ellis E, Hayasaki H. Masticatory hos barn. Svenst Tandlaek T 1950;43:21 [in
motion after surgical or non-surgical treatment for Swedish].
unilateral fractures of the mandibular condylar 14. Kivimäki J, Ekholm A. Nachuntersuchungen von Brü-
process. J Oral Maxillofac Surg 2004;62:127–38. chen des Kiefergelenkfortsatzes. Dtsch Zahn Mund
6. Choi BH. Comparison of computed tomography Kierferheilkd Zentralbl 1959;31:139 [in German].
imaging before and after functional treatment of 15. Ellis E. Method to determine when open treatment of
bilateral condylar fractures in adults. Int J Oral Max- condylar process fractures is not necessary. J Oral
illofac Surg 1996;25:30–3. Maxillofac Surg 2009;67:1685–90.
7. Talwar RW, Ellis E, Throckmorton GS. Adaptations of 16. Amaratunga NA. Mouth opening after release of
the masticatory system after bilateral fractures of the MMF in fracture patients. J Oral Maxillofac Surg
mandibular condylar process. J Oral Maxillofac Surg 1987;45:383.
1998;56:430–9. 17. Oikarinen KS, Raustia AM, Lahti J. Signs and symp-
8. Newman L. A clinical evaluation of the long-term toms of TMJ dysfunction in patients with mandibular
outcome of patients treated for bilateral fracture of condyle fractures. Cranio 1991;9:58.
the mandibular condyles. Br J Oral Maxillofac Surg 18. Throckmorton GS, Ellis E. Recovery of mandibular
1998;36:176–9. motion after closed and open treatment of unilateral
9. Gilhuus-Möe O. Fractures of mandibular condyle in mandibular condylar process fractures. Int J Oral
the growth period. Oslo (Norway): Universitetförla- Maxillofac Surg 2000;29:421–7.
get; 1969. 19. Ellis E, Dean J. Rigid fixation of mandibular condyle
10. Gilhuus-Möe O. Fractures of the mandibular fractures. Oral Surg Oral Med Oral Pathol 1993;76:
condyle: a clinical and radiographic examination of 6–15.

REFERENCES (VURAL)
1. Kellman RM, Cienfuegos R. Endoscopic approaches 2. Vural E. Treatment of adult subcondylar mandibular
to subcondylar fractures of the mandible. Facial Plast fractures. Closed vs open vs endoscopic approach.
Surg 2009;25(1):23–8. Arch Otolaryngol Head Neck Surg 2004;130:1228–30.
382 Ellis, Kellman, Vural

3. Sharif MO, Fedorowicz Z, Drews P, et al. Intervention for 9. Haug RH, Assael LA. Outcomes of open versus
the treatment of fractures of the mandibular condyle. closed treatment of mandibular subcondylar frac-
Cochrane Database Syst Rev 2010;4:CD006538. tures. J Oral Maxillofac Surg 2001;59(4):370–5.
4. Nussbaum ML, Laskin DM, Best AM. Closed versus 10. Ellis E 3rd, Throckmorton GS. Bite forces after open
open reduction of mandibular condylar fractures in or closed treatment of mandibular condylar process
adults: a meta analysis. J Oral Maxillofac Surg fractures. J Oral Maxillofac Surg 2001;59(4):389–95.
2008;66:1087–92. 11. Yang WG, Chen CT, Tsay PK, et al. Functional results
5. Singh V, Bhagol A, Goel M, et al. Outcomes of open of unilateral mandibular condylar process fractures
versus closed treatment of mandibular subcondylar after open and closed treatment. J Trauma 2002;
fractures: a prospective randomized study. J Oral 52(3):498–503.
Maxillofac Surg 2010;68(6):1304–9. 12. Ellis E 3rd, Simon P, Throckmorton GS. Occlusal
6. Danda AK, Muthusekhar MR, Narayanan V, et al. results after open or closed treatment of fractures
Open versus closed treatment of unilateral subcondy- of the mandibular condylar process. J Oral Maxillo-
lar and condylar neck fractures: a prospective, fac Surg 2000;58(3):260–8.
randomized clinical study. J Oral Maxillofac Surg 13. Zachariades N, Mezitis M, Mourouzis C, et al. Frac-
2010;68(6):1238–41. tures of the mandibular condyle: a review of 466
7. Villareal PM, Monje F, Junguera LM, et al. Mandibular cases. Literature review, reflections on treatment
condyle fractures: determinants of treatment and and proposals. J Craniomaxillofac Surg 2006;
outcome. J Oral Maxillofac Surg 2004;62(2):155–63. 34(7):421–32.
8. MacArthur CJ, Donald PJ, Knowles J, et al. Open 14. Vural E, Ragland J, Key JM. Manually provided
reduction-fixation of mandibular subcondylar frac- temporary maxillomandibular fixation in the treat-
tures. A review. Arch Otolaryngol Head Neck Surg ment of selected mandibular fractures. Otolaryngol
1993;119(4):403–6. Head Neck Surg 2008;138:528–30.

REFERENCES (KELLMAN)
1. Wilson IF, Lokeh A, Benjamin CI, et al. Prospective 7. Kellman RM. Maxillofacial Trauma. In: Cummings
comparison of panoramic tomography (zonogra- otolaryngology head and neck surgery. 5th edition.
phy) and helical computed tomography in the Philadelphia: Mosby; 2010. p. 318–41.
diagnosis and operative management of mandib- 8. Schneider M, Erasmus F, Gerlach KL, et al. Open
ular fractures. Plast Reconstr Surg 2001;107: reduction and internal fixation v. closed treatment
1369–75. and mandibulomaxillary fixation of fractures of the
2. Lee C, Mankani MH, Kellman RM, et al. Mini- mandible condylar process: a randomized, prospec-
mally invasive approaches to mandibular frac- tive, multicenter study with special evaluation of frac-
tures. Facial Plast Surg Clin North Am 2001;9: ture level. J Oral Maxillofac Surg 2008;66:2337–44.
475–87. 9. Kerner CH, Undt G, Rasse M. Surgical reduction and
3. Kellman RM. Endoscopically assisted repair of sub- fixation of intracapsular condylar fracture: a follow-up
condylar fractures of the mandible. Arch Facial Plast study. Int J Oral Maxillofac Surg 1998;27:191–4.
Surg 2003;5:244–50. 10. Raveh J, Redli M, Markwalder TM. Operative
4. Eckelt U, Schneider M, Erasmus F, et al. Open v. management of 194 cases of combined maxillofa-
closed treatment of mandibular condylar process– cial-frontobasal fractures: principles and surgical
a prospective randomized multi-center study. J Cra- modifications. J Oral Maxillofac Surg 1984;42:555–64.
niomaxillofac Surg 2006;34:306–14. 11. Raveh J. Open reduction of the dislocated fixed
5. Singh V, Bhagol A, Goel M, et al. Outcomes of open condylar process: indications and surgical proce-
versus closed treatment of mandibular subcondylar dures. J Oral Maxillofac Surg 1989;47:120–6.
fractures: a prospective randomized study. J Oral 12. Mueller RV, Czerwinski M, Lee C, et al. Condylar
Maxillofac Surg 2010;68(6):1304–9. fracture repair: use of the endoscope to advance
6. Danda AK, Muthusekhar MR, Narayanan V, et al. traditional treatment philosophy. Facial Plast Surg
Open versus closed treatment of unilateral subcondy- Clin North Am 2006;14:1–9.
lar and condylar neck fractures: a prospective, 13. Zide MF, Kent JN. Indications for open reduction of
randomized clinical study. J Oral Maxillofac Surg mandibular condyle fractures. J Oral Maxillofac
2010;68(6):1238–41. Surg 1983;41:89–98.