CLlNlCAl.

ARTICLES

J Oral Maxillofac Surg

41~89-98, 1983

Indications for Open Reduction of

Mandibular Condyle Fractures
MICHAEL F. ZIDE, DDS,* AND JOHN N. KENT, DDSt

Most condylar fractures of the mandible may be treated by closed reduc-

tion and appropriate physiotherapy. Some, however, absolutely should be
opened and reduced anatomically; with others, good arguments for open
reduction may be offered. This article reviews the possible indications for
open reduction and presents an approach that conceals the scar.

The majority of mandibular condyle fractures are
treated by closed reduction, and the long-term re-
sults have proved the procedure to be satisfactory
in most instances. Review of the literature generally
supports this concept. WeHowever, several factors
may influence the treatment plan because unfavor-
able results of closed reduction are known to occur.
This paper discusses (1) the rationale for open re-
duction, (2) the absolute and relative indications for
open reduction, (3) selection of the appropriate
open reduction technique, and (4) a description of a
new surgical approach.
Rationale for Open Reduction
The mandibular condyle fracture almost always
has been treated by closed reduction for four rea-
sons. First, experience has shown good results in
most patients after such a procedure. Second, sur-
gical procedures in the temporomandibular joint
(TMJ) area may result in complications involving
the facial nerve, as well as other problems. Third,
technical problems may exist in manipulating the
fracture segments into good anatomic position, be-
cause of comminution, fragment size, or fracture
characteristics. Lastly, open reduction leaves a scar
on the face.
The longest reported follow-up of mandibular
fractures treated by closed reduction is around
twenty years. The length of follow-up is important
if decisions about therapy are to be made. The
* Associate Professor, Oral and Maxillofacial Surgery, Loui-
siana State University; Clinic Director, Charity Hospital. New
Orleans.
: Professor and Head, Oral and Maxillofacial Surgery,
Louisiana State University Medical Center.
Address correspondence and reprint requests to Dr. Zide:
LSU Medical Center, School of Dentistry, 1100 Florida Avenue.
Box 220. New Orleans. LA 70119.
027%2391/83/0200/0089 $02.50 @;: American
major problems resulting from treatment of dis-
placed articular fractures by closed reduction are
not only early dysfunctions but late arthritic changes
occurring 10 to 50 years later in a joint that is not
in its appropriate anatomic position.7 Most litera-
ture reviews on closed reduction of mandibular
condyle fracture are inadequate because of lack
of long-term follow-up. During the periods studied,
however, collective data (Table I) show good re-
sults in most cases. In only about 15% are there short-
term problems such as pain, dysfunction, limitation
of opening, or deformity (e.g., retrognathia, asym-
metry, or open bite). Although there is no long-term
follow-up of a large series of open reduction cases,
it is to be hoped that such treatment would eliminate
many cases of dysfunction or deformity. On the
other hand, long-term sequelae associated with
closed reduction techniques (pain, arthritis, limita-
tion of motion) may also occur with open reduction.
Obviously, not all mandibular condyle fractures
should be treated by closed reduction regardless of
pre-existing or traumatically induced problems:
each fracture is unique. For this reason, decisions
on how to treat most fractures should not be based
on the radiograph alone. It is the essence of good
treatment to ascertain the patients age, medical and
dental history, the pathogenesis and severity of the
injury, and behavior patterns that might modify the
treatment expectations. With these ideas in mind,
treatment modalities, which include open reduction
techniques, may be chosen on the basis of sound
surgical judgement and experience.
At our institution approximately 300 patients with
mandibular fractures are treated each year; of
these, slightly less than one third have condylar
fractures.8 With this volume and the experience of
past problems, we have decided upon a rationale
for open reduction of condylar fractures.
Association of Oral and Maxillofacial Surgeons
89
90 MANDIBULAR CONDYLE FRACTURES

Table 1. Closed ReductiowLarge Case Series

Muscle or Joint
No. of Tenderness,
Dysfunction/ Time of Either Side or Click or
Author Total Cases Follow-up Both Sides POP Asymmetry Comments

Lindahl et al, 1977 12119 24-36 mo 10 8 16119 All patients had

molar and bicuspid
occlusion (adult
only)
Blevins and Gores, 1961 13190 lM- 12 yr 20 Children and
(responded adults
to study)
MacLennan, 1952 291180 14-37 mo 2 ND 29: deviation 73 with radiographic
7: deformity deformity (children
and adults)
Kromer, 1953 121154 Not recorded ND* ND* 14 Child and adult
Chalmers J. Lyons Club, 1947 71120 8 mo- 19 yr ND ND ND Children and
adults in study

Total 731563

* ND = not determined.

Indications for Open Reduction of lems, alcoholism, refractory behavior, or mental

Condyle Fractures
The absolute indications for open reduction are
(1) displacement into the middle cranial fossa, (2)
impossibility of obtaining adequate occlusion by
closed reduction, (3) lateral extracapsular displace-
ment of the condyle, and (4) invasion by a foreign
body (e.g., gunshot wound). These indications per-
tain to children as well as to adults.
Displacement of fractured condyles into the mid-
dle cranial fossa is rare, but it has been reporteds~10
and has been treated by us. If good occlusion is
impossible to achieve at the time of open reduction
of a fractured condyle, a wait of one week is sug-
gested to allow for resolution of edema or hemar-
throsis. Lateral extracapsular displacement of a
fractured condyle is rare, but it does occur. Inva-
sion of a foreign body into the joint area can cause
severe destruction, fibrosis, and erosion into the
ear canal. Foreign bodies should be removed from
any joint; a waiting period of approximately one to
two weeks is recommended to allow resolution of
edema, so that some fibrosis will occur around the
foreign body. This will assist in its isolation and
retrieval.
The relative indications for open reduction per-
tain primarily to adults with condyles displaced out
of the fossa and associated malocclusion. They in-
clude (1) bilateral condylar fractures in an edentu-
lous patient when a splint is unavailable or when
splinting is impossible because of alveolar ridge at-
rophy, (2) unilateral or bilateral condylar fractures
when splinting is not recommended for medical rea-
sons or where adequate physiotherapy is impossible
(patients with seizure disorders, psychiatric prob-
retardation or retardation secondary to neurologic
injury), (3) bilateral condylar fractures associated
with cornminuted midfacial fractures, (4) bilateral
condylar fractures and associated gnathologic
problems, such as retrognathia or prognathism,
open bite with periodontal problems or lack of pos-
terior support, loss of multiple teeth and later need
for elaborate reconstruction (possibly applicable in
cases of unilateral fracture), and bilateral condylar
fractures and unstable occlusion due to orthodon-
tics, and unilateral condylar fracture with an unsta-
ble fracture base. The relative indications are argu-
able, and patients may be treated differently by
each surgeon.
Selection of Surgical Technique
The following factors influence the selection of a
method for open reduction: (1) position of condyle,
(2) location of fracture, (3) age of fracture, (4)
character of patient, (5) amount of edema, (6) loca-
tion of incision, and (7) type of fixation. Condylar
fractures have been classified according to their po-
sition. These classifications are a burden in making
the decision whether a condylar fracture should be
opened. It is preferable to determine whether the
condyle is in the articular fossa. If it is in the fossa,
the fracture will probably heal in a fairly good func-
tional position after the occlusion is accurately se-
cured and physiotherapy is performed. Therefore,
an open reduction is not contemplated, unless abso-
lute and a few relative factors influence the decision
to perform open reduction. When the condyle is
severely displaced, and open reduction is con-
ZIDE AND KENT
templated, the approach should allow as direct ac-
cess as possible to the segment. A low condylar
neck fracture may be accessible by a submandibular
or retromandibular approach. A higher fracture may
necessitate an approach that combines subman-
dibular and periauricular approaches or uses only a
periauricular approach.
The position of the fracture should also be ascer-
tained by a posteroanterior (PA) radiograph. During
impact, fracture segments separate widely and are
then drawn back into closer approximation by mus-
cle and soft tissue. It is possible for muscle to be
entrapped between the fracture segments. Under
such circumstances, a fracture that appears similar
to a vertical subcondylar osteotomy on the panoram-
ic radiograph may not have bony approximation when
seen in a PA view. Bony union is jeopardized under
such conditions.
The age of a fracture affects ease of manipulation
of the condylar fragment and also influences the
approach to the fracture. If the fracture is two or
three weeks old (which is near the maximum limit
for operability), a combined submandibular and
periauricular approach may be needed to mobilize
the condyle. regardless of where the fracture is.
The character of the patient also influences the
surgical approach. At our teaching institutions there
are many patients who are refractory to good con-
servative therapy. Alcoholics, imprisoned patients,
or patients with compromised neurologic or respi-
ratory function will do better without maxillo-
mandibular fixation: closed reduction is therefore
eliminated in favor of open techniques.
The amount of edema may affect the approach
and the size of the incision as well. If massive
edema is present, the approach through the parotid
gland is difficult and other techniques should be
used. The submandibular incision may be extended.
The facial nerve may be dissected out to allow
further access through the parotid gland. Whenever
possible, it is better to operate early or to allow
resolution of edema.
The location of the incision is a cosmetic consid-
eration that can influence the approach used. The
submandibular incision leaves a scar, even though
small. The preauricular, postauricular, and sub-
mandibular or retromandibular approaches are well
known and do not need to be described. If the pa-
tient cannot emotionally accept a scar, a face-lift
approach is used after the edema is resolved so that
transparotid surgery is easier.
Facedift Approach
The preauricular aspect of the face-lift approach
is in the natural crease anterior to the pinna. Under
91
I temporal branches
CN VII, traqion
FIGURE 1. Diagram showing methods of locating the facial
nerve.
the lobe of the ear, the incision continues in the
lobular fold and extends postauricularly on the
posterior surface of this auricle. This modification
prevents a noticeable scar that during maturation
would otherwise migrate posteriorly and inferiorly
onto the neck or mastoid bone. The undermining of
the face is accomplished in the subdermal fatty
layer.
In the face-lift approach, a decision must be made
whether to dissect out the facial nerve first, as is
sometimes easier, or merely to dissect bluntly
through the parotid and the masseter muscle. If the
patient is heavy or edematous, the facial nerve trunk
and branches may need to be dissected out. This
can be done under direct vision or with operating
glasses. One of three methods is recommended to
find the facial nerve. All methods rely on cutaneous
anatomic landmarks. The first method relies on the
observation by ReissneV of a consistent relation-
ship of the temporal branch of the facial nerve to the
zygomatic arch. This relationship formed the basis
for his use of a peripheral branch in doing parotid-
ectomy, and also serves well in determining the
approach for open condylar reduction. A line is
drawn from the lateral canthus of the eye to the
tragion point. The temporal nerve branches, usually
two, cross the superior border of the zygomatic
arch 3 and 4 cm posterior to the lateral aspect of the
bony orbital wall at the canthal level (Fig. I). I3 The
second method of finding the facial nerve involves
exposure of the main trunk.14 A line is drawn from
the mastoid process to the corner of the mouth (Fig.
1). After the superficial dissection, the parotid gland
is dissected off the auricular cartilage, mastoid pro-
cess, and sternocleidomastoid muscle. Care is
taken not to enter the parotid capsule. At the
mastoid process a curved clamp against bone is
used to separate tissues and to dissect forward and
medially in the retromandibular fossa. The nerve is
92
FIGURE 2. (Case I) Anterior displacement of right condyle.
glistening white when exposed. A third method of
finding the nerve in relation to the joint, recently
described, may also aid in surgical dissection.15
Once the condylar fracture has been exposed,
methods of stabilization have involved avulsion16
with complete removal and replacement of the seg-
ment, bone plating, direct wiring,lsals K-wire or
pinzo2* wiring via drill-guide,* and other methods
of plating or pinning. Our experiences have shown
that the only method of stabilization that routinely
allows immediate postoperative mobilization is
plating with at least two screws in the condylar
segment and two screws in the stable mandible. All
other techniques allow some rotation and the man-
dible should probably be immobilized for four to six
MANDIBULAR CONDYLE FRACTURES
weeks, after which physiotherapy is performed. If
the fracture is recent, it is also acceptable to simply
replace the segments in as anatomic a position as
possible without wiring, provided maxillomandib-
ular fixation is used.
The following cases illustrate some of the indica-
tions for open reduction of condylar fractures.
Report of Six Cases
Case I. A 3%year-old man came to Charity Hospital
Accident Room approximately five hours after being hit
on the left side of the face with a fist. He complained of
pain on the right side of his face, inability to put his teeth
together, and swelling in front of his right ear. The
neurologic functions were intact. The patients medical
history and physical examination results were otherwise
unremarkable. Radiographic examination revealed a right
subcondylar fracture with a proximal segment anterome-
dially displaced from the glenoid fossa (Fig. 21.
The patient was sedated, and arch bars were placed on
his maxillary and mandibular teeth. It was not possible to
manipulate the mandible into appropriate occlusion.
Elastic traction was applied, and the patient was seen
daily. After one week, adequate occlusion had not yet
been obtained. It was believed that the teeth could not be
brought into occlusion because of mechanical obstruction
by the condylar fragment.
The patient was taken to the operating room nine days
after his injury. A modified face-lift incision was used
FIGURE 3. (Case 1) A, Modified
face-lift incision. B, Undermining of
the skin and subcutaneous tissue over
the parotid, leaving a layer of fat with
the skin. C, Blunt dissection through
the parotid gland with incision through
the masseter muscle, allowing a wire
to be inserted in the distal segment.
D, Postoperative scar at seven months.
Notice the widening of the scar in the
postauricular area where the drain was
removed. (Placement of this incision
is now done higher.)
ZIDE AND KENT
(Fig. 3, A and B). Superiorly, a standard preauricular dis-
section was extended down to the capsule of the TMJ.
Inferiorly, over the fracture site and below the main trunk
of the facial nerve, blunt dissection was accomplished
parallel to the course of the facial nerve through the
parotid gland. An incision was then made through the
masseter muscle in this region down to the ramus of the
mandible. After the ramus was exposed, a wire was
placed through a bur hole to allow inferior distraction on
the mandible and to permit uprighting of the condylar
segment into normal anatomic position in the glenoid
fossa (Fig. 3. C). Maxillomandibular fixation was then
applied, appropriate occlusion being easily obtained. The
condylar segment was then wired to the stable portion of
the mandible. To prevent hematoma a small penrose drain
was placed, which exited in the postauricular area.
No evidence of injury to the facial nerve was seen post-
operatively, and healing was uneventful (Fig. 3, D). Fixa-
tion was left in place for six weeks, at which time the
radiograph revealed good bone position (Fig. 4). Occlu-
sion was good, and opening was wide and without devia-
tion. Physiotherapy was not given, and the patient was
lost to clinic follow-up until several months later, when he
presented with asymmetry and slight open bite. A radio-
graph showed the condyle to be collapsed, but the head
was still in the fossa (Fig. 5). Standard orthognathic
surgery corrected the problem.
Comment: Long-term observation and physiotherapy
are advisable following open as well as closed reduction,
although they may not need to be as vigorous. Also, at six
weeks osteoid is still present in healing fractures. Remod-
eling and calcification occur for many more weeks,
necessitating continued observation.
Case 2. A 19-year-old man presented to the Charity
Hospital Emergency Room after a motor vehicle acci-
dent. The medical history was unremarkable. The dental
history revealed maxillary first premolar extractions to
correct a Class II malocclusion. The patients appearance
was retrognathic and microgenic. A bony prominence
could be felt in front of his left ear. A laceration was
FIGURE 4. Above. Six-week postoperative radiograph
tient in Case 1.
FIGURE 5. BP/OW, Condyle in collapsed position several
months later.
93
FIGURE 6. (Case 2) Preoperative occlusion showing retrog-
nathia and open bite.
present under the chin. Examination of his injury re-
vealed an open bite and severe retrognathia (Fig. 6).
Radiographic examination revealed bilateral displaced
condylar fractures, (one medial, one lateral) and a sym-
physis fracture (Fig. 7). All fracture sites were opened
and reduced. The symphysis was wired through the
existing laceration. The condylar fractures were exposed
and reduced via posterior mandibular incisions (Fig. 8). A
preauricular approach was also used on the left to ascer-
tain the position of the laterally displaced condyle and to
repair the joint capsule. Physiotherapy was performed.
Two and a half years postoperatively the patients occlu-
sion is stable (Fig. 9): he opens his mouth without devia-
tion or pain.
Ctrse 3. A 25-year-old man was brought to the Charity
Hospital Emergency Room after being shot once at close
range. The bullet entered 1 cm to the left of the right
commissure of the lip, causing a fracture of the right
maxillary alveolus, laceration of the right buccal mucosa,
obliteration of Stensens papilla, fractures of the right
mandibular coronoid and angle, and a comminuted, me-
dially displaced condylar fracture. Two large segments of
bullet lodged close to or within the temporomandibular
joint area (Fig. 10). Shortly after admission, the following
procedures were performed: (1) soft tissue debridement
and conservative closure, (2) closed reduction of the
maxillary and mandibular fractures, with application of a
prefabricated acrylic interocclusal splint, and (3) ligation
of the right external carotid artery in the retromandibular
fossa and the facial artery to control severe postdebride-
ment bleeding not controllable by conservative measures.
The patient was discharged approximately two weeks
after admission and was advised to return shortly for re-
moval of the bullet fragments.
Unfortunately, the patient was noncompliant to post-
operative care and came to the clinic more than two
months after discharge, with a painful fluctuant swelling
over the right preauricular region. Pus was seen in the
right ear canal. The infection was drained preauricularly.
The patient was given antibiotics appropriate to the cul-
ture and sensitivity test results. Three days later, he was
brought to the operating room. Through a preauricular
of pa- approach. the right temporomandibular joint area was
explored to remove the necrotic condylar fragments. A
large bullet fragment, located in the glenoid fossa and
extending through the external auditory canal, was re-
94 MANDIBULAR CONDYLE FRACTURES

The patients neurologic state deteriorated, and a

neurosurgical team took the patient to the operating
room, where a craniotomy was performed to repair small
dural tears and to insure the patency of the sagittal sinus.
An oral and maxillofacial surgical team subsequently
explored the parotid duct through the existing facial lac-
eration and found no wound in the duct but a crushed
parotid gland. Because the neurosurgeon believed that
the patient had an excellent prognosis for recovery, an
open reduction of his severely displaced left subcondylar
fracture was performed through a submandibular ap-
proach. The left condyle was stabilized in a normal an-
atomic position with a four-hole finger plate. The
symphysis was opened and wired. Further stabilization
FIGURE 7. Leff, Preoperative radiograph of patient in Case 2,
of the patients mandible was then performed in the clinic
showing one medially and one laterally displaced condyle.
ten days after surgery by insertion of prefabricated max-
FIGURE 8. Right, One-week postoperative radiograph. illary and mandibular acrylic splints constructed on
plaster models (Fig. 13). Appropriate positioning of the
maxilla to the mandible was more easily accomplished
because of the stability of the left condyle.
The patient was followed up regularly, and the maxil-
lomandibular fixation was discontinued about one month
after reduction. He opened his mouth 30 mm without sig-
nificant deviation or pain. Physiotherapy was performed
regularly. Four months postoperatively the patient com-

FIGURE 9. (Case 2) One-year postoperative panoramic radio-

graph.

moved. The area was packed open. Resolution of the

swelling occurred slowly.
Follow-up in the clinic one month after the debridement
of the temporomandibular joint revealed an opening of 25
mm with deviation to the right. Because physiotherapy
did not alter the occlusion, six months after the first ad-
mission a TMCK chrome cobalt condyle prosthesis* was
inserted on the right side via a combined preauricular and
submandibular approach (Fig. 11). The patient was able
to open 35 mm one month postoperatively with minimal
deviation and has maintained an adequate interocclusal
opening and good occlusion during one year postopera-
tive follow-up.
Case 4. A 48-year-old man was involved in a domestic
altercation and was hit over the back of the head and on
the face with a hatchet. He subsequently fell on his chin.
The medical history was unremarkable with the exception
of heavy ethanol use. Physical examination revealed a
decreased sensorium but appropriate response to com-
mand. There was a 15 cm laceration over the occiput,
with a depressed skull fracture. There was a 5 cm superfi-
cial jagged laceration over the right parotid gland, ex-
tending through the right ear lobe, and a 1 cm jagged
laceration on the left cheek. Blood was expressed from
the left Stensens duct. The facial nerve was intact. The
patient was edentulous except for the three periodontally
involved upper left maxillary molars. Radiographic ex-
amination confirmed the depressed skull fracture and
showed bilateral mandibular subcondylar fractures, with
the left condyle medially displaced and the right commi-
nuted around the glenoid fossa, and a mandibular sym- FIGURE IO. Above, posteroanterior radiograph of patient in
physis fracture. Case 3. showing large bullet fragment in the right condylar area.
Below~. Panoramic radiograph showing bullet fragment in right
* Dow Corning, Midland, Michigan. condylar area, and fractures of the ramus and the body.
ZIDE AND KENT 95

plained of increasing pain on mastication in the left tem-

poromandibular region and directly over the bone plate.
There was radiographic evidence of condylar erosion,
with a clinical correlation of traumatic degenerative
joint disease. The patient was taken to the operating
room, where a high condylar shave was performed with
placement of a Proplast Teflon implant. It was observed
at this time that the meniscus had been severely injured
during the initial trauma. The bone piate was removed via
blunt dissection through the parotid. These procedures
were performed through a single incision by use of a
modified face-lift approach. The patient was discharged
able to open to 35 mm without discomfort and without
facial nerve injury.
Two months later the patient came to the neurosurgery
clinic with complaints of decreasing alertness, decreasing
memory, and increased lethargy. A chronic subdural
hematoma was evacuated several days later without
complications. The patient has been well for two years
after the original hatchet injury and continues to maintain
opening to 35 mm without pain or deviation.
Cuse 5. A 20-year-old man presented to the Charity
Hospital Emergency Room 12 hours after being hit on the
side of the face with a board. He complained of pain.
inability to bite, and deviation of his jaw to the right. He
also complained of palpitations in his chest. His
neurologic functions were intact. The medical history was
unremarkable, except for shortness of breath and a feel-
ing that his heart skipped a beat when he was excited. He FIGURE 12. (Case 4) Above, Extended submandibular ap-
had never seen a physician for this problem because of proach used to reposition severely displaced fragment
fear.
FIGURE 13. Below, Postoperative radiograph with splints in
Radiographic examination revealed a right antero-
place after six weeks. The comminuted fracture is healing well.

medially displaced subcondylar fracture of the mandible.

FIGURE Il. Above, Panoramic radiograph showing condylar
prosthesis of patient in Case 3. Below, Posteroanterior view of
TMCK condylar prosthesis in place.
The result of cardiovascular examination was remarkable
for unifocal premature ventricular contractions, five to six
per minute. The patient also had a grade I/6 systolic ejec-
tion murmur and an S4 murmur. He stated that he had
great facial pain. After admission, the patient was sedated
in the outpatient clinic under cardiac monitoring, and
maxillomandibular fixation was applied (Fig. 14). The
cardiology service was consulted to evaluate his arrhyth-
mia and noted a significant incipient cardiomyopathy of
unknown origin. It was the cardiologists opinion that the
patients condition would worsen in the future. Also, it
was recommended that future surgery to relieve TMJ
problems secondary to the present injury be avoided and
that surgery to correct that problem be attempted imme-
diately, while the patient was young and cardiologically
fairly stable. For that reason, an open reduction of his
displaced subcondylar fracture was performed. A mod-
ified face-lift approach was used because of the high posi-
tion of the fracture. The facial nerve was identified as its
posterior temporal branch crossed over the zygomatic
arch. Because of edema and the position of the fracture,
the nerve was then dissected out proximally to this
branch, and the entire pes anserinus was exposed and
retracted to allow adequate transparotid exposure for vi-
sualization of the fracture. The fracture was anatomically
positioned and wired (Fig. 15). During the procedure,
premature ventricular contractions, three to eight per mi-
nute, occurred. Lidocaine drip was used and controlled
the arrhythmia. The patient was placed into maxillo-
mandibular fixation for four weeks (Fig. 16). Postopera-
tively, he was given physiotherapy. He has maintained a
45 mm opening without deviation or pain for 18 months.
 MANDIBULAR CONDYLE FRACTURES

ables: orthodontic care and actual fracture treatment.

First, if the patient is receiving active orthodontic ther-
apy, true occlusal stability is probably not possible with-
out skeletally fixed splints to ensure some stable founda-
tion. Physiotherapy with training elastics causes extru-
sion of teeth that are already mobile. Second, bilateral
condylar fractures that are displaced should probably not
be placed into maxillomandibular fixation for six weeks.
Two to three weeks of intermittent fixation, and active
physiotherapy, sometimes for three to six months, are
needed in conservative therapy. A new pseudoarthrosis
may form, which maintains a reproducible occlusion but
no reproduction of centric relation (a real problem for
future prosthetics and orthodontics). Mandibular ad-
vancement osteotomies are still frequently needed.
This type of malocclusion may occur in patients with
perfect preoperative occlusion who are placed in maxil-
lomandibular fixation for six weeks. For this reason. we
reserve such treatment for adults with low condylar frac-
tures (which are really ramus fractures).

Discussion

The age of the patient, concurrent traumatic in-

juries, medical and dental history, current dental
treatment, the pathogenesis and severity of the in-
jury, the position of the fracture, and concomitant
facial fractures all influence treatment of the con-
dylar fracture. The age of the patient has a bearing

FIGURE 14. Above, Radiograph showing anteromedially dis-

placed right condyle of patient in Case 5.
FIGURE 15. Center, Insertion of wire for stabilization of
proximal fragment. Notice relation to facial nerve.
FIGURE 16. B&W. Four-week postoperative radiograph.

Case 6. A 25-year-old man had an automobile acci-

dent in which he incurred bilateral condylar fractures with
displacement. He was undergoing active orthodontia at
the time of injury. He was treated by maxillomandibular
fixation for six weeks. Severe retrognathia and open bite
ensued, and training elastics were unsuccessful in restor-
ing correct jaw position. Four months after treatment the
patient was referred for evaluation of his skeletal defor-
mity (Fig. 17). These problems were treated by standard
orthognathic surgery principles via mandibular sagittal FIGURE 17. Cephalometric radiograph showing retrognathia
split and posterior maxillary osteotomies. and open bite.
Comment: This case and others in which fractures FIGURE 18. Temporomandibularjoint views four months after
occur during orthodontic treatment have two major vari- closed reduction of condylar fractures.
ZIDE AND KENT 97

on treatment, because growth potential influences Table 2. Open Reductions, Charity

long-term results. When a fracture condyle occurs Hospital, 1980
in a child under 3 years old, the fracture is usually of FACE-LIFT APPROACH
the compression type because of the stubbiness of Indicatiom
the condyle. In children over 3, most fractures are Displaced high condylar fracture ................... .12
linear. In a child between 3 and 11, the malposed Occlusion impossible ............................... 3
Invasion foreign body .............................. 2
fractured condylar segment tends to resorb after
Bilateral edentulous fracture
successful therapy. Remodeling of the distal stump No splint available ............................... 2
may occur with formation of an architecturally Alcoholism or other medical problem .............. 5
normal condyle in fairly normal anatomic position. Unstable fracture base ........................... 1
Fractures in teenagers show remodeling, which is Loss of multiple teeth. unstable
dentalbase .................................... 2
neither complete nor predictable in all cases.
Removal bone plate, high condylar
Growth disturbances may cause asymmetry when shave, degenerative arthritis .................... 1
fractures occur prior to completion of growth.23 In Total number of cases 12
adults, fractures show remodeling only as a func- Complicntions (Rhytidectom_v)
tional adjustment. Because growth of the skeleton is Transientneuropraxia .............................. 5
complete, the capacity to remodel according to the 4 temporal branch; I temporal and zygomatic branch.
functional matrix theory is greatly diminished.Z4 Deviation on opening .............................. 2
Pain .............................................. 1
The need for open reductions therefore, is evidently Infection .......................................... 0
greater in the postpubertal patient, so that optimal Loss of condylar bulk .............................. 2
anatomic alignment can be achieved. There are, SUBMANIXBULAR APPROACH
however, occasional reports of almost complete res- Indicatiorts
titution of a radiographically normal condyle sub- Low condylar neck fractures. ....................... 9
Displaced condylar head medially ................... 7
sequent to displaced condylar fractures in adults.
Vertical dimension established
A patients medical and dental condition affect for LeFort II-III, edentulous bilateral ........... 2
treatment in an often unpredictable manner. The Bilateral edentulous fractures-
alcoholic patient and the psychiatric patient are alveolar ridge insufficiency ..................... 2
likely to cut wires and to refuse elastic fixation. Total number of cases 9
Open reduction techniques may avoid these prob- Compliccrtion.~ (Submandibular)
lems. The patient with a seizure disorder may have Transient neuropraxia-marginal mandibular
branch ........................................ 1
difficulty because of inability to take medication Deviation on opening .............................. 0
properly. The dental history may reveal that the Myofdcial pain dysfunction ......................... 1
patient has no interest in maintaining dental health, Infection .......................................... 0
no matter what the outcome, or, conversely, a pa- Loss of condylar bulk .............................. 0

tient who wants precise prosthetic rehabilitation.

The pathogenesis and severity of the injury are
the most significant factors influencing the outcome patients with condylar fractures, approximately one
of treatment. Penetrating missile injuries and frac- fifth of all condylar fracture patients, were treated
tures that are severe enough to cause meniscal dis- with open reduction. The results have been gratify-
ruption. perforations, or tears are the wounds that ing in almost all cases (Table 21, although follow-up
result in dysfunction with hypomobility and asym- does not exceed two years.
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