Int. J. Oral Maxillofac. Surg.

2007; 36: 310314

doi:10.1016/j.ijom.2006.11.001, available online at http://www.sciencedirect.com

Clinical paper
Trauma

Unilateral mandibular condylar

fractures: a 31-year follow-up of
non-surgical treatment

J. Andersson1,4,a, F. Hallmer2,4,a,
L. Eriksson3,4
1

National Dental Service, Sondrum, Getinge,

rebro,
Sweden; 2National Dental Service, O
Sweden; 3Department of Oral and
Maxillofacial Surgery, University Hospital
MAS, Malmo, Sweden; 4Department of Oral
Surgery and Oral Medicine, Faculty of
Odontology, University of Malmo, Malmo,
Sweden

J. Andersson, F. Hallmer, L. Eriksson: Unilateral mandibular condylar fractures: a

31-year follow-up of non-surgical treatment. Int. J. Oral Maxillofac. Surg. 2007; 36:
310314. # 2006 International Association of Oral and Maxillofacial surgeons.
Published by Elsevier Ltd. All rights reserved.
Abstract. At the University Hospital of Malmo, Sweden, standardized trauma charts
were used for registration of all jaw fractures from 1972 to 1976. During the year
2005 the aim was to interview all patients treated non-surgically for unilateral
mandibular condylar fractures during this period. In total, 49 patients with unilateral
condylar fractures were treated non-surgically in 19721976. Of these, 23 patients
were available for follow-up, 17 were dead, 7 were not found and 2 did not answer
letters or phone calls. The follow-up was a telephone interview according to a
standardized questionnaire concerning occurrence of pain and headache, function of
the jaw and joint sounds. Information from original records, radiographic reports
and the standardized trauma charts revealed fracture site, type of fracture and
intermaxillary fixation if any. Eighty-seven percent of the patients reported no pain
from the jaws, 83% had no problems chewing and 91% reported no impact of the
fracture on daily activities. Neck and shoulder symptoms were reported by 39% and
back pain by 30%. The 31-year results of non-surgical treatment of unilateral nondislocated and minor dislocated condylar fractures seem favourable concerning
function, occurrence of pain and impact on daily life.

Condylar fractures account for between

25% and 35% of all mandibular fractures.
Concerning condylar fractures in children
there is a consensus of opinion for a nonsurgical approach4,5,10,11. In adults it is
still a highly debated theme, and MALKIN
et al.12 already in 1964 stated that: Concerning the treatment of condylar fractures, it seems that the battle will rage
forever between the extremists who urge
nonoperative treatment in practically
every case and the other extremists who
advocate open reduction in almost every
0901-5027/040310 + 05 $30.00/0

case. According to ELLIS & THROCKMOR5

TON the topic of mandibular condylar
fractures has generated more discussion
and controversy than any other in the field
of trauma.
At the University Hospital of Malmo,
Sweden, standardized trauma forms were
used for registration of all jaw fractures
between 1972 and 1976. This hospital was
the only location for treatment of jaw
fractures in Malmo at that time. The
aim of this study was to interview all
patients treated non-surgically for unilat-

Key words: condylar fractures; non-surgical

treatment; long-term results.
Accepted for publication 8 November 2006
Available online 18 January 2007

eral mandibular condylar fractures during

this period, giving a follow-up of 31 years
as a mean.
Patients and methods

In total, 49 patients, 37 men and 12

women (mean age 32.4 years, SD =
19.5, median age 27 years, range 583),
with unilateral condylar fractures were
a

These authors contributed equally to the

present work.

# 2006 International Association of Oral and Maxillofacial surgeons. Published by Elsevier Ltd. All rights reserved.

Condylar fractures: a 31-year follow up

treated non-surgically during 19721976.
The patients had no other jaw fractures
diagnosed clinically or radiologically.
When treatment of the fractures was finished, data from the records were collected
on all patients by the same person, according to a standardized form. In 2005 a followup was performed based on these forms.
From the register of national registration
numbers at the national registration authority current addresses were found. Fourteen
men and three women (mean age 49.8
years, SD = 20.6, median age 49.0 years,
range 1683) were dead at the time of the
follow up, and four men and three women
(mean age 32.1 years, standard deviation
SD = 8.1, median age 34 years, range 18
42) could not be found in the national
register. Two men did not answer letters
or phone calls. Thus a total of 23 patients, 17
men and 6 women (mean age at follow-up
50.4 years, SD = 8.9, median age 49 years,
range 3775), were available for a 31-year
follow-up (range 2933). At the time of the
fracture 15 of the patients were between 17
and 44 years old and 8 patients between 5
and 15 years (infant group).
In the infant group four patients had
fractures on the left side and four on the
right side. None or only minor dislocation
of the fractured condyle was seen in two of
these patients at the time of injury. In three
patients the condyles were severely tilted
medially and anteriorly. Information on
the occurrence of dislocation was not
available for three patients. In the adult
group seven patients had fractures on the
left side and eight on the right side. None
or only minor dislocation of the fractured
condyle was seen in 10 of these 15 patients
at the time of the injury. One of these
fractures was classified as intracapsular. In
three patients the condyles were severely
tilted medially and anteriorly. Information
on any dislocation could not be gained for
two patients.
In the infant group none of the patients
had intermaxillary fixation. In the adult
group (15 patients) 4 patients were intermaxillary fixated, 3 of whom had dislocated
condyles, for 26 weeks with elastics, while

9 patients only were recommended a soft

diet for 2 weeks. Information on two
patients was not available. At the time of
the last consultation, according to the
records, 17 patients had an occlusion identical to the pretrauma occlusion. One patient
had a minor bite opening in the cuspid and
premolar region on the contralateral side to
the fracture. This patient reported at the
long-term follow-up moderate problems
with chewing. Information on occlusion
at the last consultation was missing for five
patients. The reason for the missing information on some parameters is that most of
the records and forms were stored on CD,
and scanning had in some cases resulted in
parts of the text not being readable.
The 23 patients available at follow-up
were informed by letter that they would be
contacted by telephone in a couple of
weeks to hear if they were willing to
participate in a telephone interview concerning the current status of their earlier
fractured jaw. A standardized questionnaire was used to record occurrence of
pain, headache, problems in functioning of
the jaw, joint sounds and disturbed sleep
because of joint pain according to Table 1.
A 10-grade visual analogue scale (VAS)
was used for evaluation of intensity of
pain (no pain intolerable pain), ability
to chew (no problem very severe problems) and impact on daily life (not at all
very great impact).
The patients were asked if they had all
their teeth, partial loss of teeth or total loss
of teeth, and if they had a removable
prosthesis. There was no question on
any disturbance in occlusion, as the
patients evaluation was thought to be
too uncertain, especially as major prosthetic reconstructions might have been done
during the 30 years since the fracture. Joint
and muscle disease, neck and shoulder
problems, back pain and migraine were
recorded, as well as occurrence of further
jaw fractures after the initial fracture.
Regular use of pain medication, muscle
relaxants and tranquilizers was recorded.
Information from the original records,
radiographic reports and the standardized

311

summary revealed fracture site, appearance

of the fracture and any intermaxillary fixation. The fractures were classified as intracapsular or fracture of the condylar neck.
Fractures without dislocation or with only
minor dislocation, according to the radiographic report, were classified as non-dislocated. The others were classified as
dislocated. Panoramic radiographs and postero-anterior projections were used on all
patients at the initial examination. The
examinations were done at the Department
of Oral Radiology, Dental School, Malmo,
Sweden. Owing to the long interval
between the initial examination and the
follow-up no radiographs were available,
as they were discarded after 10 years
according to official regulations.
Results

At the time of follow-up, 18 patients had

all their teeth, 4 patients were partially
edentulous and 1 patient had upper and
lower full dentures. None of the patients
had suffered any further jaw fractures.
History of pain, headache, function of
the jaw, joint sounds and disturbed sleep
because of joint pain is shown in Table 1.
As some of the data concerning pain,
disturbed ability to chew and impact on
daily activities seemed to be contradictory, those who had made positive indications received a second phone call.
Twenty out of 23 patients reported no
pain from the jaws and/or face. Three out
of 23 patients reported pain, one daily and
two more sporadically. The patient with
daily pain, estimated as VAS 1, would
according to the second phone call rather
classify the pain as spasm and fatigue. The
sensation was the same also on movement
of the lower jaw. This patient was in the
infant group at the time of fracture and had
no dislocation of the condyle. The second
patient estimated the pain as VAS 4 when
she was opening her mouth maximally, for
example when yawning. This patient was
in the adult group at the time of fracture
and had only minor dislocation of the
condyle. The third patient estimated his

Table 1. History according to telephone interview 31 years after non-surgical treatment of unilateral condylar fractures (n = 23)
Pain in the face and jaws
Headache
Pain on jaw movements
Restricted opening
Feeling of fatigue in the jaws
Clicking
Crepitation
Locking
Disturbed sleep because of joint pain

Never

12 times a month

Once a week

Several times a week

20
15
21
22
15
15
22
22
23

1
5
1

1
1
1

3
4
1
1

Daily
1
1
3
4

312

Andersson et al.

pain as VAS 2 once or twice a month, and

related to a feeling of numbness in a scar
on the lip following the trauma. This
patient had an intracapsular fracture and
was adult at the time of fracture.
Nineteen patients out of 23 reported that
they had no problems chewing. One patient
marked VAS 1 on the ability to chew. She
was in the adult group at the time of trauma
with minor dislocation of the condyle. Two
patients marked VAS 4. One of them was
the same patient as mentioned above, who
reported pain as VAS 4 on maximal opening. During the second phone call the
patient revealed that the problem with
chewing was that the bite did not fit correctly. The other patient with VAS 4 was
also in the adult group at the time of trauma
and had a dislocated condyle. The problem
in chewing was a feeling of fatigue in the
cheeks. Similar fatigue was also reported
by the patient with the intracapsular fracture mentioned above, who estimated the
problems with chewing as VAS 6.
No impact on daily activities was
reported by 21/23 patients. One patient
in the adult group with a dislocated condyle at time of fracture reported VAS 3
concerning impact on daily activities. This
patient was the same one who experienced
fatigue on chewing, estimated as VAS 4.
The second patient with impact on daily
activities was the one with the intracapsular fracture, who also reported fatigue
on chewing estimated as VAS 6.
History of joint and muscle disease,
neck and shoulder symptoms, back pain
and migraine is shown in Table 2. Pain
medication was used regularly by two
patients, one of whom reported joint and
muscle disease. This patient also used
muscle relaxants and a tranquilizer regularly. The patient was the same one who
reported pain at maximal opening of the
mouth and a non-fitting bite on chewing.
The other patient taking pain medication
regularly because of neck and shoulder
problems was the one with the intracapsular condylar fracture.
Discussion

A disadvantage of long-term follow-ups is

the difficulty of finding all the patients.
Table 2. History according to telephone interview 31 years after non-surgical treatment of
unilateral condylar fractures (n = 23)
Joint and muscle disease
Neck and shoulder symptoms
Back pain
Migraine

Yes

No

1
9
7
3

22
14
16
20

The national registration numbers used for

all Swedes nowadays were not in use in
hospital records 30 years ago. In spite of
this, current addresses, and also information on those patients who had died, were
acquired by the aid of the national registration and taxation authorities. On seven
of the initial 49 patients it was not possible
to get any information, as they might have
moved abroad or changed identity. A
comparison of the 23 patients found with
the data of the missing patients did not
indicate any major differences concerning
type of fracture, age at the time of trauma
and treatment. These results may be
looked upon as representative of all the
patients in spite of the major loss (53%) at
follow-up.
According to this 31-year follow-up of
non-surgically treated unilateral mandibular condylar fractures, the results seem to be
acceptable. Eighty-seven percent reported
no pain from the jaws, 83% had no problems when chewing and 91% had no
problems maintaining their daily activities,
when those who were children and those
who were adults at the time of fracture were
looked upon as one group. From earlier
studies it is well known that fractures in
children usually have a good prognosis2,7,10,19. The fact that in the present
study 35% of the patients were children at
the time of fracture might have had a
positive influence on the results.
Concerning the age of the patients it
seemed reasonable to classify patients 15
years or younger as children. Only one out
of eight patients who were children at the
time of the fracture reported minor pain on
movement of the jaw 31 years later. This
patient had a non-dislocated fracture.
None of the other patients in this group
experienced any problems with pain,
chewing or impact on daily activities, in
spite of the fact that at least three of them
had initially displaced condyles. When
those who were adult at the time of the
fracture were looked upon as one group,
20% (3/15 patients) reported minor to
moderate problems (VAS 14) and 7%
(1/15 patients) more severe problems
(VAS 510), with either pain on movement of the lower jaw, problems chewing
or impact on daily life. One of the patients
in the first group had a dislocated fracture
and the patient in the second group had an
intracapsular fracture, while the other two
patients had non-dislocated fractures. The
number of dislocated condyles or intracapsular fractures was small, which is why
the impact of findings on pain and function
in this group should be interpreted with
caution. SANTLER et al.14 reported that
dislocation often led to a reduction in

mouth opening and higher incidence of

subjective discomfort during heavy chewing. High-grade dislocation or luxation
has been reported to cause frequent pathological changes in function19 as well as
altered occlusion or ability to bite only
unilaterally16.
Frequent consumption of pain medication, muscle relaxants and tranquilizers for
other reasons than jaw problems might
also have an influence on the results. As
only two patients reported such medication, it should not have a major impact on
the findings. In spite of more than 30% of
the patients reporting neck and shoulder
symptoms and/or back pain, referred pain
does not seem to have a major effect on the
results, as the majority of the patients
reported that they had no pain in the face
and jaws. Thirty-five percent of the
patients experienced headache and 13%
reported migraine, most often sporadically. As the prevalence of tension headache has been reported to be 86% among
women and 63% among men, while the
corresponding figures for migraine are
15% and 6%, respectively, headache does
not appear to be a consequence of condylar fracture6. Thirty-nine percent of the
patients reported clicking or crepitation
daily or sporadically from the temporomandibular joints. This is in accordance
with observations on the prevalence of
awareness of undefined TMJ sounds in
the population, estimated to be 648%1,
and thus fractured condyles did not seem
to have a major influence on the occurrence of joint sounds.
The treatment philosophy for the
patients in this study was to mobilize
the jaw early and use rubber bands for
fixation, if the occlusion was not spontaneously normalized, within the first 3 days
after the fracture (five patients). This is
principally in agreement with treatment
regimes used at other centers4,7,22. Concerning fractures in children, THOREN
et al.20 concluded that conservative treatment of dislocated condylar process fractures results in satisfactory long-term
outcome of jaw function despite a high
frequency of radiologically noted aberrations. Similar observations were made by
CHOI et al.2. There seem to be different
opinions concerning such long-term radiological findings in children, as LINDAHL &
HOLLENDER11 found that children until they
were teenagers had a good capacity to
completely return to normal skeletal relations. They concluded that remodelling
processes of the condylar process in a
clinical sense may be looked upon as
restitutional in children, and adjusting
and functional in adults.

Condylar fractures: a 31-year follow up

Recently, KONDOH et al.8 reported that
intra-articular irrigation and corticosteroid
injection into a fractured joint is a more
effective and faster acting method than
conventional closed reduction with intermaxillary fixation for functional recovery
and control of clinical symptoms of patients
with unilateral fresh condylar fractures.
This method may have an initial beneficial
effect, but the present study indicates that
irrigation and steroids are not necessary to
achieve acceptable long-term results. In a
follow-up of 348 patients with condylar
fractures MARKER et al.13 concluded that
conservative treatment of condylar fractures is non-traumatic, safe and reliable,
and in only a few cases may cause disturbance of function and malocclusion.
The indications for surgical treatment
are still under debate. According to a study
by THROCKMORTON & ELLIS21 in general
patients with unilateral fractures of the
condylar process had maximum excursions that returned to normal values within
3 years of fracture regardless of treatment,
but patients treated surgically exhibited a
faster rate of improvement in maximum
interincisal opening than patients treated
closed. Patients treated open also exhibited a faster rate of improvement in maximum excursion toward the fracture side
than patients treated closed. Based upon
the same study, patients with unilateral
fractures of the condylar process who were
treated closed and not put into maxillomandibular fixation but instructed in physical therapy could be expected to achieve
normal maximum excursions within 3
years of the end of treatment. According
to STIESCH-SCHOLZ et al.18 open as well as
closed treatment gave clinically acceptable functional results, although they found
that condylar mobility was markedly
greater after open treatment than after
closed treatment.
Using radiographic examinations KON9
STANTINOVIC & DIMITRIJEVIC found statistically better position of surgically
reduced condylar fractures but according
to clinical parameters, no statistical differences between surgically and conservatively treated fractures were found.
Similar results have been reported by
SANTLER et al.14 who did not find any
significant differences in mobility, joint
problems, occlusion, muscle pain or nerve
disorders when surgically and non-surgically treated patients were compared.
They concluded that, because of its disadvantages, open surgery is only indicated
in patients with severely dislocated condylar process fractures.
A more aggressive treatment philosophy is supported by WORSAAE & THORN23,

who found that malocclusion, mandibular

asymmetry, impaired masticatory function, and pain located to the affected joint
or masticatory muscles were seen significantly more frequently in patients treated
with closed reduction compared to those
treated surgically. Neither the degree of
dislocation of the proximal fragment, concomitant mandibular fractures, nor the
absence of posterior occlusal support
seemed to influence the results.
SILVENNOINEN et al.15,16 stressed the
importance of observing the ramus height
in patients with persistent malocclusion.
The height was significantly reduced in
patients with persistent malocclusion irrespective of degree or direction of the
angulations between the fragments. They
concluded that condylar fractures with the
potential for future problems can often be
identified preoperatively by means of simple radiographic measurements, and those
cases with reduced height should probably
be treated surgically. A similar treatment
philosophy has been proposed by SMETS
et al.17, that only in selected patients with
shortening of the ascending ramus of
8 mm or more and/or considerable displacement of the condylar fragment should
surgical repositioning and rigid internal
fixation be considered.
Although the topic of mandibular condylar fractures is still controversial, for
non-dislocated or only minor dislocated
condylar fractures several studies seem to
support non-surgical treatment. DAHL M et al.3 in a prospective 15-year
STRO
follow-up concluded that condylar fractures without dislocation showed minimal
signs of dysfunction that were independent of age. This is in accordance with the
present observations, which show results
to be favourable up to 31 years after the
fracture.

References
1. Carlsson GE. Epidemiological studies
of signs and symptoms of temporomandibular joint-pain-dysfunction. A literature review. Aust Prosthodont Soc Bull
1984: 14: 712.
2. Choi J, Oh N, Kim IK. A follow-up study
of condyle fracture in children. Int J Oral
Maxillofac Surg 2005: 34: 851858.
3. Dahlstrom L, Kahnberg KE, Lindahl
L. 15 years follow-up on condylar fractures. Int J Oral Maxillofac Surg 1989:
18: 1823.
4. Ellis III E. Condylar process fractures of
the mandible. Facial Plast Surg 2000: 16:
193205.
5. Ellis III E, Throckmorton GS. Treatment of mandibular condylar process

6.

7.

8.

9.

10.
11.

12.

13.

14.

15.

16.

17.

18.

19.

313

fractures: Biological considerations. J

Oral Maxillofac Surg 2005: 63: 115134.
Hindfelt B, Kahn R, Traff P. Huvudvark. The Drug Book. Stockholm: The
National Corporation of Swedish Pharmacies 2001/2002: pp. 716726 [Headache
(in Swedish)].
Hovinga J, Boering G, Stegenga B.
Long-term results of nonsurgical management of condylar fractures in children. Int J
Oral Maxillofac Surg 1999: 28: 429440.
Kondoh T, Hamada Y, Kamei K,
Kobayakawa M, Horie A, Iino M,
Kobayashi K, Seto K. Comparative
study of intra-articular irrigation and corticosteroid injection versus closed reduction with intermaxillary fixation for the
management of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2004: 98: 651656.
Konstantinovic VS, Dimitrijevic B.
Surgical versus conservative treatment
of unilateral condylar process fractures:
clinical and radiographic evaluation of 80
patients. J Oral Maxillofac Surg 1992: 50:
352353.
Lindahl L. Condylar fractures of the
mandible. IV. Function of the masticatory
system. Int J Oral Surg 1977: 6: 195203.
Lindahl L, Hollender L. Condylar
fractures of the mandible. II. A radiographic study of remodelling processes
in the temporomandibular joint. Int J Oral
Surg 1977: 6: 153165.
Malkin M, Kresberg H, Mandel L.
Submandibular approach for open reduction of condylar fractures. Oral Surg Oral
Med Oral Pathol 1964: 17: 152157.
Marker P, Nielsen A, Bastian HL.
Fractures of the mandibular condyle. Part
2: results of treatment of 348 patients. Br J
Oral Maxillofac Surg 2000: 38: 422426.
Santler G, Karcher H, Ruda C, Kole
E. Fractures of the condylar process: surgical versus nonsurgical treatment. J Oral
Maxillofac Surg 1999: 57: 392397.
Silvennoinen U, Iizuka T, Oikarinen
K, Lindqvist C. Analysis of possible
factors leading to problems after nonsurgical treatment of condylar fractures. J
Oral Maxillofac Surg 1994: 52: 793799.
Silvennoinen U, Raustia AM, Lindquist C, Oikarinen K. Occlusal and
temporomandibular joint disorders in
patients with unilateral condylar fracture.
A prospective one-year study. Int J Oral
Maxillofac Surg 1998: 27: 280285.
Smets LM, Van Damme PA, Stoelinga
PJ. Non-surgical treatment of condylar
fractures in adults: a retrospective analysis. J Craniomaxillofac Surg 2003: 31:
162167.
Stiesch-Scholz M, Schmidt S, Eckardt A. Condylar motion after open
and closed treatment of mandibular condylar fractures. J Oral Maxillofac Surg
2005: 63: 13041309.
Stoll P, Waechter R, Schlotthauer
U, Tuerp J. Late results of 15 years
and longer after mandibular condyle

314

Andersson et al.

fractures. Fortschr Kiefer Gesichtschir

1996: 41: 127130.
20. Thoren H, Hallikainen D, Iizuka T,
Lindquist C. Condylar process fractures
in children: a follow-up study of fractures
with total dislocation of the condyle from
the glenoid fossa. J Oral Maxillofac Surg
2001: 59: 768773.
21. Throckmorton GS, Ellis 3rd E. Recovery of mandibular motion after closed and
open treatment of unilateral mandibular

condylar process fractures. Int J Oral

Maxillofac Surg 2000: 29: 421427.
22. Walker RV. Condylar fractures: nonsurgical management. J Oral Maxillofac
Surg 1994: 52: 11851188.
23. Worsaae N, Thorn JJ. Surgical
versus non-surgical treatment of unilateral dislocated low subcondylar fractures: a clinical study of 52 cases. J
Oral Maxillofac Surg 1994: 52: 353
360.

Address:
Lars Eriksson
Department of Oral and Maxillofacial
Surgery
Malmo University Hospital
SE 205 02
Malmo
Sweden
Tel: +46 40 33 31 09
Fax: +46 40 33 62 05
E-mail: lars.o.eriksson@skane.se