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British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526

Review
Fractures of the mandibular condyle: evidence base and
current concepts of management
Khalid Abdel-Galil ∗ , Richard Loukota 1
Oral & Maxillofacial Surgery, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, United Kingdom

Accepted 8 October 2009


Available online 8 November 2009

Abstract

Management of mandibular condylar fractures remains a source of ongoing controversy. While some condylar fractures can be managed
non-surgically, recognition of fracture patterns that require surgical intervention and selection of an appropriate operative procedure are
paramount to success in treating these injuries.The objective of this review is to appraise the current evidence regarding the effectiveness of
interventions that are used in the management of fractures of the mandibular condyle.
© 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Trauma; Mandibular fractures; Condylar injuries; Systematic review

Methods Fig. 1 summarises the literature search and selection


process in the early stages of the review. The majority of
Search strategy identified literature included case reports and series, descrip-
tions of osteosynthesis techniques, technical notes, letters and
An electronic search of the literature directly relating to editorials. Fig. 2 presents level I and II evidence identified in
condylar fracture management was conducted. The databases this review.
examined were the Cochrane Controlled Trials Register,
Cochrane Database of Systematic Reviews, Database of Fracture classification as a guide to treatment selection
Abstracts of Reviews of Effects and the Health Technol-
ogy Assessment database. Electronic searches were also Classification systems for condylar fractures can offer insight
conducted of the National Library of Medicine’s (NLM) into which fractures might be best treated with open/closed
PubMed, Ovid Medline database, Embase, Cumulative Index reduction; a usable classification system must be respon-
to Nursing & Allied Health Literature [CINAHL] and Biosis sive to the contemporary treatment options available to the
databases up to 2009. surgeon.
Of 1081 studies and publications identified on the initial The lack of consistency in terminology relating to fracture
search of all databases, 858 were excluded as they were not patterns, however, poses a problem associated with the man-
directly relevant to the subject matter studied. The remain- agement of these injuries among surgeons and researchers
ing 233 publications were examined and analysed for the and their reporting in the surgical literature.
purposes of this review. Early attempts at fracture classification were rather sim-
plistic and did not help to direct surgical treatment of these

injuries beyond closed reduction and maxillo-mandibular
Corresponding author. Tel.: +44 113 3436219; fax: +44 113 3436264.
E-mail addresses: khalidabdelgalil@doctors.org.uk (K. Abdel-Galil),
fixation.1–3
rloukota@doctors.org.uk (R. Loukota). The Lindahl classification considers factors that include
1 Tel.: +44 113 3436219; fax: +44 113 3436264. the level of fracture, “dislocation” at the point of fracture,

0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2009.10.010
K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526 521

height instability were considered the only indications for


open reduction and fixation of these injuries.
Open reduction and internal fixation (ORIF) was found
to provide better functional reconstruction of mandibular
condyle fractures than closed reduction (CR) and maxillo-
mandibular fixation.8 In current day practice, fractures with
a deviation of more than 10◦ , or a shortening of the ascend-
ing ramus of more than 2 mm, should be treated with open
reduction and fixation, irrespective of level of the fracture.
9

Operative techniques

Surgical techniques, including approaches to the mandibular


condyle and ramus have evolved over the last few decades.
This is evidenced by the substantial number of reports
identified in the searched literature describing the various
techniques, both open and endoscopic, used for rigid fixation
of condylar fractures.
No trial evidence exists comparing the various approaches
described for access to the ramus–condyle region.
Endoscope-assisted ORIF of condylar fractures is now
a viable alternative to traditional closed or open reduction
techniques and its acceptance continues to grow as more
surgeons gain experience. A recent prospective, randomised
controlled, multi-center trial concluded that the treatment of
condylar fractures with a transoral endoscopically assisted
technique is reliable and may offer advantages for selected
cases.19 This included a tendency towards lower occurrence
of facial nerve injury, although this was not supported by
comparative statistical analyses.
Fig. 1. Search strategy. Figs. 4–8 illustrate some of the current osteosynthesis
techniques used in condylar fracture fixation.
and the relationship of the condylar head to the articular
fossa. Although useful, this classification system is rather Assessment scores and outcomes
complex.4
Similarly the Spiessl & Schroll classification divides Several methods, both objective and subjective, have been
condylar fractures into subjectively assessed high and low described for the assessment of outcome following surgery
subtypes, with and without “dislocation”, but does not allow on the temporomandibular joint complex.10–15
easy visualisation of the fracture.5 The Helkimo dysfunction score consists of three indices
The sub-classification reported by Loukota et al. (Fig. 3), evaluating anamnestic and clinical dysfunction, occlusion
is also adopted by the Strasbourg Osteosynthesis Research and articulation disturbance. It is an accepted valid and reli-
Group (SORG).6 This classification was analysed retrospec- able tool used to determine the functional outcome after
tively in a cohort of patients with condylar fractures and found surgery of mandibular and temporomandibular joint disor-
to be simple to use and can help predict treatment need and ders, as well as after orthognathic surgery.13–15
outcome.7 As in most surgical disciplines, clinicians managing
The classification of condylar head fractures has patients with condylar injuries are responsible for monitor-
been further clarified recently.36 This should assist and ing and recording outcomes of treatment. This should include
simplify both treatment decision making and standard- functional assessments of jaw mobility and excursions (open-
isation of nomenclature in future work within this ing, lateral excursion and protrusion), occlusal changes as
field. well as subjective pain and discomfort. This will facilitate
future clinical decision making and assist in the standardised
Indications for treatment/intervention dissemination of treatment results.
Although outcome monitoring and reporting should be
In an earlier review of the literature addressing the evolution encouraged using available validated indices/scores, this is
of treatment modalities, condylar displacement and ramus not common practice at present.
522 K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526

Fig. 2. Existing level 1 and 2 evidence (ORIF: open reduction and internal fixation; CR: closed reduction; ENDO: endoscopic reduction and fixation).

Open reduction versus closed management – level 1 of patients treated with closed reduction and maxillo-
evidence mandibular fixation.32,33
An international prospective randomised trial involving
In an early trial, Worsaae and Thorn reported the complica- seven centres compared operative and conservative treatment
tions associated with surgical versus non-surgical treatment of displaced condylar fractures and yielded results which
of unilateral low subcondylar fractures.30 Although both were clearly in favour of the operative approach.16 This
groups underwent maxillo-mandibular immobilisation for 4 reported on 66 patients treated for 79 fractures and followed
weeks, they reported complication rates of 4% and 39% in up for 6 months. Evaluation included radiographic assess-
the surgical and non-surgical groups respectively. ment, clinical, functional and subjective parameters including
A randomised clinical trial assessing occlusal results visual analogue scales for pain and the Mandibular Function
following open versus closed management of condylar Impairment Questionnaire index for dysfunction. Operative
neck or subcondylar fractures found a significantly greater treatment was found to be superior in all objective and all but
percentage of malocclusion (22–28%) in the closed treat- one subjective functional parameters.
ment group.31 Earlier non-randomised longitudinal studies In another prospective single-centre study 22 patients with
from the same group confirmed decreased mandibular 26 diacapitular condylar fractures were randomised to receive
motion and reduced posterior facial/ramus height in groups either ORIF or closed treatment and followed up for 12

Fig. 3. SORG classification: (1) high/condylar neck fracture; (2) low/condylar base fracture; (3) diacapitular fracture (with permission from Loukota et al.6 ).
K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526 523

Fig. 4. Osteosynthesis configurations for condylar base fractures (with permission, from: Pilling E, Eckelt U, Loukota R, Schneider K, Stadlinger B. Comparative
evaluation of ten different condylar base fracture osteosynthesis techniques).
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Fig. 5. Headless bone screw fixation technique.

months.34 This failed to demonstrate a clear benefit to patients


of ORIF versus closed treatment and recommended closed
management in these cases. The cohort of patients studied
was small however, and only included undisplaced fractures,
a major weakness of the study.
The results of a recent meta-analysis were inconclusive
regarding whether open or closed treatment should be used
for the management of mandibular condylar fractures.17 This
was attributed to the relatively poor quality of the avail-
able data and the lack of other important information. The Fig. 7. Schematic illustrating ultrasound activated resorbable osteosynthesis
methodological quality of this study was weak, however, [SonicWeld RxTM KLSMartin].

and several deficiencies render its conclusions question-


able. These include incomplete database exploration, flawed
statistical analysis, and lack of adherence to QUOROM
standards.18
In a prospective, randomised controlled multicentre trial
invovlving centres from North America, Europe and Asia,
patients with condylar neck fractures were randomised to
receive either open reduction and internal fixation using
an extraoral (submandibular, preauricular, retromandibular)
approach or a transoral endoscopic procedure. The primary
functional outcome measure was investigated using the asym-
metric Helkimo dysfunction score at 8–12 weeks and 1
year after surgery.19 This showed that comparable functional
results were achieved after reduction and internal fixation
using either technique. A marginally better early cosmetic
outcome and fewer complications were the associated advan-
tages of the transoral approach. Although these included a
reduced occurrence of facial nerve damage, this was not
supported by comparative statistical analyses.

Who should provide care?

The increased focus on quality and efficiency improvement


within healthcare has put increasing pressure on surgeons to
improve outcomes.
Exisiting analyses from other surgical disciplines con-
Fig. 6. Preoperative radiograph of comminuted diacapitular fracture. firm learning curves in which complication rates, variance in
K. Abdel-Galil, R. Loukota / British Journal of Oral and Maxillofacial Surgery 48 (2010) 520–526 525

Conclusion

A trend is emerging in the surgical literature confirming supe-


rior functional results following open reduction and internal
fixation of condylar fractures, where this is indicated. This
is supported by existing level I evidence. Endoscopic assis-
tance, performed transorally, may also provide an alternative
means for treating a subset of these injuries, reducing visible
scar formation and possibly facial nerve damage.
There are still areas of condylar trauma surgery which
some surgeons consider controversial: condylar head frac-
tures and displaced paediatric fractures. The use of resorbable
osteosynthesis techniques may be of benefit in both these
clinical settings; further research is needed in this field.
A SORG multicentre prospective randomised controlled
trial is planned to study the treatment of condylar head
fractures. Regarding paediatric injuries, promising outcomes
have been anecdotally reported following fixation of such
fractures in children as young as 6 years of age.

Conflict of interest

The authors have no conflict of interest to disclose.

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