Matching Surgical Approach to Condylar
Fracture Type
Hany A. Emam, BDS, MS , Courtney A. Jatana, DDS, MS , Gregory M. Ness, DDS*
KEYWORDS
 Surgical approaches  Condylar fractures  Open reduction of condylar fractures
KEY POINTS
 Head and neck trauma surgeons must have an acute knowledge of surgical principles to approach a condylar fracture with
an open surgical technique.
 An understanding of the classification of the fracture and the appropriate surgical access for visibility and reduction is
critical.
 Practicing good surgical principles to avoid vessel and nerve injury is equally important for successful reduction of these
fractures.
Introduction
Condylar fractures account for 25% to 35% of all mandibular
fractures. Because of their high incidence and frequent
complexity, several treatment options have been described for
these fractures. Broadly, the 2 main methods are defined as
either conservative (closed) or surgical (open) treatment.
Conservative therapy consists of 10 to 14 days of immobili-
zation, which is accomplished by the control of occlusion with
the use of arch bars and intermittent maxillomandibular fixa-
tion. Typically, this method is chosen because of the difficulty
in exposure of the condyle, the risk of facial nerve injury, and
the technical challenge in open reduction osteosynthesis of
condylar fractures. However, there are negative consequences
of conservative therapy, which can include malocclusion,
reduced facial height and asymmetry, chronic pain, and a
reduction in mobility.
In contrast, indications for surgical intervention are not
universally clear, with varying conclusions drawn from the
published evidence. Several studies comparing conservative
with surgical treatment have shown that open reduction and
rigid fixation leads to better results. Some studies report that
better functional outcome can occur with open treatment.
Identifying fractures by location
Regardless of method chosen, the means of access to the
fractured condyle is important in the initial treatment decision
process. A necessary prerequisite for choosing between con-
servative and surgical treatment and determining appropriate
access for treatment of condylar fracture is to identify the
Division of Oral and Maxillofacial Surgery and Dental Anesthesiology,
College of Dentistry, The Ohio State University, 305 West 12th Avenue,
Postle Hall, Columbus, OH 43210, USA
* Corresponding author.
E-mail address: ness.8@osu.edu
Atlas Oral Maxillofacial Surg Clin N Am - (2016) -e-
1061-3315/16/ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cxom.2016.10.004
location of the fracture. A fracture that is located above the
mandibular foramen and runs from the posterior edge of
the ramus into the sigmoid notch is classified as a fracture of
the condylar process. A fracture of the condylar head is
referred to either as intraarticular or diacapitular (Fig. 1).
However, within these broad definitions are many fine dis-
tinctions, and differing published classification schemes can
complicate injuries and the access needed to reach them.
Classification of condylar fractures is discussed in detail
elsewhere, but this article uses a basic well-known system for
determining appropriate access. Loukota developed this simple
nomenclature to minimize the difficulty of fracture visualiza-
tion and the confusion in the international terminology of the
widely cited 6 types in the Spiessl and Schroll classification.
Instead, Loukota suggested the following terms (Figs. 2 and 3):
1. Neck: fracture line is mostly above line A in the lateral view
(Fig. 2A), where line A is the perpendicular line through the
sigmoid notch to the tangent of the ramus
2. Base: fracture line runs behind the mandibular foramen and
mostly below line A (Fig. 2B)
3. Diacapitular (head): through the head of the condyle (Fig. 2C)
Surgical approaches
The decision on a particular approach to reach a fracture
depends on the location of the injury and the height, location,
and type of osteosynthesis being considered. Incisions
used to reach condylar and subcondylar fractures include
intraoral, periangular, retromandibular, preauricular, and
retroauricular. Approaches to the subcondylar base and neck
should be distinguished from head (diacapitular) fractures.
Diacapitular fractures can be accessed through the preaur-
icular or retroauricular approaches. Neck fractures can be
accessed through intraoral, periangular, retromandibular, and
preauricular and postauricular incisions. Base fractures can be
accessed through intraoral, periangular, and retromandibular
incisions (Fig. 4).
oralmaxsurgeryatlas.theclinics.com
2 Emam et al.

Submandibular/periangular

This approach is appropriate when access to the base and neck

are required for open reduction. To allow for full access a slight
extension of the classic submandibular incision in a backward
and upward direction to the periangular region allows full ac-
cess. The incision is marked 2 to 3 cm below the lower border
of the mandible and is approximately 3 to 4 cm in length
(Fig. 5). Anatomic planes transected include skin, subcutane-
ous fat tissue, and platysma. After division of the platysma,
meticulous dissection through the superficial layer of the deep
cervical fascia is performed to avoid injury to the mandibular
branch of the facial nerve and inadvertent bleeding of the
facial vein and artery, which may be divided to allow soft tissue
reflection. After reflection of the muscular sling and perios-
teum, careful retraction of the mandibular branch of the facial
nerve in a caudal direction is advised. With this access, mini-
plate and lag screw osteosynthesis can be achieved.

Retromandibular

This approach begins with a standard incision but, after the

skin and subcutaneous planes have been transected, 3 options
have been described for the final dissection to the condyle. In
all cases, the skin incision is marked 5 to 10 mm below the ear
lobe and should run parallel to the posterior border of the
Fig. 1 Black line indicating fracture line above mandibular fo-
mandible and be 3 to 4 cm long (Fig. 6).
ramen to the sigmoid notch (condylar process). Red line indicating
The first variation of the deeper dissection is termed the
fracture line of the condylar head (diacapitular).
transparotid approach. The parotid capsule is carefully iden-
tified and divided horizontally through the space between the

Fig. 2 Loukota classification. (A) Fracture of the condylar neck (above line A). (B) Fracture of the condylar base (below line A). (C)
Diacapitular fracture (through the head of the condyle). (From Loukota RA, Eckelt U, De Bont L, et al. Subclassification of fractures of the
condylar process of the mandible. Br J Oral Maxillofac Surg 2005;43(1):73; with permission.)
Surgical Approach for Condylar Fracture Types
Fig. 3 Loukota classification.
paths of the buccal and zygomatic branches of the facial nerve.
The parotid fascia and masseter muscle are dissected with final
exposure of the condylar fracture (Fig. 7).
The second variation is termed direct because it goes
straight through the parotid gland, posterior to the border of
the mandible. The facial nerve may require formal dissection
in this exposure to help with access to the lateral aspect of the
posterior border of the mandible.
Fig. 4 Matching fracture type to surgical access with the Loukota and Spiessl classifications.
3
Fig. 5 Skin marking of location of the classic submandibular
incision 2 cm below inferior border of mandible.
The third variation is described as the deep approach
because it involves dissection to the sternomastoid followed by
progression anteriorly toward the medial aspect of the poste-
rior border of the mandible. Despite this deeper dissection
4 Emam et al.

Fig. 6 Standard retromandibular skin incision. Fig. 8 Excellent visibility and access for osteosynthesis repair.

pathway, the retromandibular approach is an efficient and safe

way to expose the fracture site (Fig. 8). Disadvantages include
potential for formation of a sialocele or salivary fistula if the
parotid capsule is ineffectively closed.

Preauricular/endaural

This incision is most commonly used to access diacapitular

fractures. Regardless of the modification to the incision, the
result allows maximum lateral and anterior exposure of the
condyle. The skin incision is a 2.5-cm curvilinear line following
the tragus and helix of the ear with possible extension to the
temple (Fig. 9). This extension onto the temple can help
minimize unnecessary traction that may cause weakness of the
facial nerve. Once the superficial temporal fascia plane is
reached, it should be incised and carefully retracted while

Fig. 9 Preauricular skin incision line. The dotted line notes the
endaural skin incision line. (From Ness GM, Arthroplasty and dis-
cectomy of the temporomandibular joint. Atlas Oral Maxillofac
Fig. 7 Capsule of parotid gland. Surg Clin North Am 2011;19:177e87; with permission.)
Surgical Approach for Condylar Fracture Types 5

dissection proceeds deep until the anatomic separation of the Retroauricular

temporalis fascia (divided by fatty tissue) is seen (Figs. 10 and
11). Next, the dissection follows inferiorly between the su-
perficial and the fat pad above the deep temporal fascia, until
reaching the lateral aspect of the zygomatic arch and the
posterior root of the arch. Vertical incision through the peri-
osteum over the root of the zygomatic arch, which is contin-
uous with the parotidomasseteric fascia, exposes the
temporomandibular joint (TMJ) capsule and temporomandib-
ular ligament and protects the facial nerve (Fig. 12). Disad-
vantages of this approach are the potentially unaesthetic
preauricular crease scar along its entire length, as well as the
possibility of bleeding from the superficial temporal artery.
The endaural technique varies from this approach in that
most of the scar is camouflaged behind the tragus; however,
there is a slight risk of perichondritis with this technique (see
Fig. 9).
The postauricular approach was originally described by Bock-
enheimer and later modified by Axhausen (Kreutziger). This
incision has the best esthetic result because it is hidden in the
postauricular crease. The disadvantages of this approach
include possible stenosis of the auditory canal, infection that
can potentially lead to necrosis of the ear cartilage, and
anesthesia of the auricle. This approach is not advisable in
patients who must depend on wearing glasses in the early
postoperative period. Closure is more time consuming, and
must be meticulous to minimize complications. Using this
incision allows for good posterior and lateral joint exposure,
whereas anterior exposure can be limited. The incision is
parallel and approximately 3 mm posterior to the postauricular
flexure. The inferior portion of the incision curves over the
mastoid tip, whereas superiorly it stops at the attachment of

Fig. 10 The tissue planes superficial and slightly anterior to the TMJ. br., branch; m., muscle; SMAS, superficial muscular aponeurotic
system. (From Agarwal CA, Mendenhall SD, Foreman KB, et al. The course of the frontal branch of the facial nerve in relation to fascial
planes: an anatomic study. Plast Reconstr Surg 2010;125:536; with permission.)
6 Emam et al.

Fig. 11 Dissection to the superficial temporal fascia. (A) Exposure of the superficial temporal vein. (B) Clean white surface of the
superficial temporal fascia. (C) Senn retractors in each soft tissue pocket, delineating tissue to be sharply dissected. (D) Sharp dissection of
the remaining soft tissues. (From Ness GM, Arthroplasty and discectomy of the temporomandibular joint. Atlas Oral Maxillofac Surg Clin
North Am 2011;19:177e87; with permission.)

the pinna within the hairline. Once marked, the incision is
carried sharply down to the postauricular muscle to the fascia
overlying the mastoid bone and the temporalis fascia superi-
orly, dissecting anteriorly. The external auditory canal (EAC) is
a landmark, and is exposed on the superior and inferior aspects
through this approach. Next, a complete transaction of the EAC
is made at the bony cartilaginous junction. Similar to the
preauricular approach, the temporal fascia is incised at the
superior mark of the incision. This fascia is dissected above
the temporalis muscle in an anterior-inferior direction. At the
junction of the temporal fat pad, the same dissection plane is
developed as the superficial layer is elevated as it approaches
and attaches to the superior border of the zygomatic arch.
Anterior dissection is performed in a subperiosteal plane,
which protects the facial nerve. The anterior border of the
temporomandibular ligament and capsule are the most ante-
rior landmarks with this dissection. Inferior dissection stops at
the attachment of the temporomandibular ligament and
capsule to the condyle.
Transoral
This approach is used to avoid the risk of a skin incision scar, to
reduce the risk of facial nerve injury, as well as the potential
reduction of postoperative facial edema that may occur.
However, this access does limit visibility and has not been
popular for reduction of condylar fractures without additional
measures. Endoscopic-assisted fixation allows trauma surgeons
to avoid large skin incisions. The transoral incision is created

Fig. 12 Exposure of the lateral capsule. (A) Incision through the superficial temporal fascia. (B) Subperiosteal dissection along the
lateral surface of the zygomatic arch, identifying the parotidomasseteric fascia. (C) The lateral capsule following sharp release of the
parotidomasseteric fascia. (From Ness GM, Arthroplasty and discectomy of the temporomandibular joint. Atlas Oral Maxillofac Surg Clin
North Am 2011;19:177e87; with permission.)
Surgical Approach for Condylar Fracture Types
along the anterior aspect of the ascending mandibular ramus.
Fixation techniques for this approach require intensive
advanced surgical training, special instrumentation, and a
steep learning curve. Advantages have included excellent
functional results without the risk of facial nerve damage and
visible scars. However, despite allowing access to the condyle,
endoscopically assisted surgery may make repositioning a
medially dislocated or proximally rotated fracture fragment a
challenging exercise.
7
Summary
Head and neck trauma surgeons must have an acute knowledge
of surgical principles to approach a condylar fracture with an
open surgical technique. An understanding of the classification
of the fracture and the appropriate surgical access for visibility
and reduction is critical. Practicing good surgical principles to
avoid vessel and nerve injury is equally important for suc-
cessful reduction of these fractures.