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British Journal of Oral and Maxillofacial Surgery 48 (2010) 520526

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
Search strategy
An electronic search of the literature directly relating to
condylar fracture management was conducted. The databases
examined were the Cochrane Controlled Trials Register,
Cochrane Database of Systematic Reviews, Database of
Abstracts of Reviews of Effects and the Health Technology Assessment database. Electronic searches were also
conducted of the National Library of Medicines (NLM)
PubMed, Ovid Medline database, Embase, Cumulative Index
to Nursing & Allied Health Literature [CINAHL] and Biosis
databases up to 2009.
Of 1081 studies and publications identified on the initial
search of all databases, 858 were excluded as they were not
directly relevant to the subject matter studied. The remaining 233 publications were examined and analysed for the
purposes of this review.

Corresponding author. Tel.: +44 113 3436219; fax: +44 113 3436264.
E-mail addresses: khalidabdelgalil@doctors.org.uk (K. Abdel-Galil),
rloukota@doctors.org.uk (R. Loukota).
1 Tel.: +44 113 3436219; fax: +44 113 3436264.

Fig. 1 summarises the literature search and selection

process in the early stages of the review. The majority of
identified literature included case reports and series, descriptions of osteosynthesis techniques, technical notes, letters and
editorials. Fig. 2 presents level I and II evidence identified in
this review.
Fracture classication as a guide to treatment selection
Classification systems for condylar fractures can offer insight
into which fractures might be best treated with open/closed
reduction; a usable classification system must be responsive to the contemporary treatment options available to the
surgeon.
The lack of consistency in terminology relating to fracture
patterns, however, poses a problem associated with the management of these injuries among surgeons and researchers
and their reporting in the surgical literature.
Early attempts at fracture classification were rather simplistic and did not help to direct surgical treatment of these
injuries beyond closed reduction and maxillo-mandibular
fixation.13
The Lindahl classification considers factors that include
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

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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 maxillomandibular fixation.8 In current day practice, fractures with
a deviation of more than 10 , or a shortening of the ascending ramus of more than 2 mm, should be treated with open
reduction and fixation, irrespective of level of the fracture.
9

Operative techniques

Fig. 1. Search strategy.

and the relationship of the condylar head to the articular

fossa. Although useful, this classification system is rather
complex.4
Similarly the Spiessl & Schroll classification divides
condylar fractures into subjectively assessed high and low
subtypes, with and without dislocation, but does not allow
easy visualisation of the fracture.5
The sub-classification reported by Loukota et al. (Fig. 3),
is also adopted by the Strasbourg Osteosynthesis Research
Group (SORG).6 This classification was analysed retrospectively in a cohort of patients with condylar fractures and found
to be simple to use and can help predict treatment need and
outcome.7
The classification of condylar head fractures has
been further clarified recently.36 This should assist and
simplify both treatment decision making and standardisation of nomenclature in future work within this
field.
Indications for treatment/intervention
In an earlier review of the literature addressing the evolution
of treatment modalities, condylar displacement and ramus

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 ramuscondyle 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.
Figs. 48 illustrate some of the current osteosynthesis
techniques used in condylar fracture fixation.
Assessment scores and outcomes
Several methods, both objective and subjective, have been
described for the assessment of outcome following surgery
on the temporomandibular joint complex.1015
The Helkimo dysfunction score consists of three indices
evaluating anamnestic and clinical dysfunction, occlusion
and articulation disturbance. It is an accepted valid and reliable tool used to determine the functional outcome after
surgery of mandibular and temporomandibular joint disorders, as well as after orthognathic surgery.1315
As in most surgical disciplines, clinicians managing
patients with condylar injuries are responsible for monitoring and recording outcomes of treatment. This should include
functional assessments of jaw mobility and excursions (opening, lateral excursion and protrusion), occlusal changes as
well as subjective pain and discomfort. This will facilitate
future clinical decision making and assist in the standardised
dissemination of treatment results.
Although outcome monitoring and reporting should be
encouraged using available validated indices/scores, this is
not common practice at present.

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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

evidence
In an early trial, Worsaae and Thorn reported the complications associated with surgical versus non-surgical treatment
of unilateral low subcondylar fractures.30 Although both
groups underwent maxillo-mandibular immobilisation for 4
weeks, they reported complication rates of 4% and 39% in
the surgical and non-surgical groups respectively.
A randomised clinical trial assessing occlusal results
following open versus closed management of condylar
neck or subcondylar fractures found a significantly greater
percentage of malocclusion (2228%) in the closed treatment group.31 Earlier non-randomised longitudinal studies
from the same group confirmed decreased mandibular
motion and reduced posterior facial/ramus height in groups

of patients treated with closed reduction and maxillomandibular fixation.32,33

An international prospective randomised trial involving
seven centres compared operative and conservative treatment
of displaced condylar fractures and yielded results which
were clearly in favour of the operative approach.16 This
reported on 66 patients treated for 79 fractures and followed
up for 6 months. Evaluation included radiographic assessment, clinical, functional and subjective parameters including
visual analogue scales for pain and the Mandibular Function
Impairment Questionnaire index for dysfunction. Operative
treatment was found to be superior in all objective and all but
one subjective functional parameters.
In another prospective single-centre study 22 patients with
26 diacapitular condylar fractures were randomised to receive
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 ).

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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 available data and the lack of other important information. The
methodological quality of this study was weak, however,

Fig. 7. Schematic illustrating ultrasound activated resorbable osteosynthesis

[SonicWeld RxTM KLSMartin].

and several deficiencies render its conclusions questionable. 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 asymmetric Helkimo dysfunction score at 812 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 advantages 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?

Fig. 6. Preoperative radiograph of comminuted diacapitular fracture.

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 confirm learning curves in which complication rates, variance in

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525

Conclusion
A trend is emerging in the surgical literature confirming superior functional results following open reduction and internal
fixation of condylar fractures, where this is indicated. This
is supported by existing level I evidence. Endoscopic assistance, 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 fractures 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.
Conict of interest
The authors have no conflict of interest to disclose.

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Fig. 8. Post-operative radiograph of comminuted diacapitular fracture fixation using ultrasound activated resorbable osteosynthesis.

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concern.16,20,21,34
The transoral approach is difficult to perform without
endoscopic assistance. Intensive training in endoscopic techniques and the handling of relevant instruments is necessary
before the transoral approach for the treatment of condylar fractures can be performed safely and competently.2224
With increasing experience the technique can also be refined,
further improving outcomes.

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