YIJOM-3265; No of Pages 5

Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2015.09.019, available online at http://www.sciencedirect.com

Clinical Paper
Trauma

Three-dimensional evaluation of Y. Yamashita, M. Inoue,

R.Aijima, A. Danjo, M. Goto
Department of Oral and Maxillofacial Surgery,

healing joint morphology after Faculty of Medicine, Saga University, Saga,

Japan

closed treatment of condylar

fractures
Y. Yamashita, M. Inoue, R. Aijima, A. Danjo, M. Goto: Three-dimensional evaluation
of healing joint morphology after closed treatment of condylar fractures. Int. J. Oral
Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Closed treatment for condylar fractures has long been widely accepted.
With closed treatment, the deviated bone fragments heal in their new positions, and
this may subsequently cause a range of functional impairments. The association
between healing morphology and post-treatment functional impairment is unclear.
In this study, computed tomography images of 26 patients (35 sides) who had
undergone closed treatment for condylar fractures were used to perform a
comparative investigation of three-dimensional (3D) bone morphology before and
after treatment. As a result, the morphology of the condylar process after treatment
was classified into four different patterns: unchanged, spherical, L-shaped, and
detached. In terms of the association between fracture types and healing
morphology, fractures of the condylar head healed in the spherical pattern, simple
fractures of the condylar neck healed in the spherical or L-shaped pattern, and
comminuted fractures of the condylar neck healed in the spherical, L-shaped, or
detached pattern. The association between mandibular deviation and healing
Key words: condylar fracture; closed treatment;
morphology was also investigated, and it was found that deviation was greater for three-dimensional evaluation; classification;
the spherical and detached patterns than for the L-shaped pattern. The present functional impairment.
findings indicate that 3D evaluation of the fractured condylar process is required to
elucidate the association with functional impairment after healing. Accepted for publication 23 September 2015

Fractures of the condylar process are
common fractures of the mandible,
occurring in approximately 25–35% of
cases,1–3 and their fracture patterns vary.4
MacLennan5 and Lindahl6 described dif-
ferent fracture patterns, and these pattern
differentiations are often used in practice
to select the method of treatment. Treat-
ment can broadly be divided into open or
closed, but there are no clear criteria to
determine the choice between them. Al-
though treatment also depends on the
morphological and functional character-
istics of the temporomandibular joint
(TMJ), the treatment strategy decision
is affected by many factors, including
the fracture site and pattern, as well as
patient-related factors.

0901-5027/000001+05 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Yamashita Y, et al. Three-dimensional evaluation of healing joint morphology after closed treatment
of condylar fractures, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.019
YIJOM-3265; No of Pages 5
2 Yamashita et al.
Closed treatment, chosen particularly for
intracapsular or complex fractures, is a
minimally invasive method of treatment.
This involves the use of intermaxillary fix-
ation or restrictions of jaw movement,
which encourages healing by keeping the
mandible still. However, if the jaw is immo-
bilized while the condyle is still dislocated
or deviated, the joint will be a different
shape after it has healed. Persistent sequelae
due to changes in bone morphology, such as
trismus, mandibular deviation, and maloc-
clusion, are not uncommon with this meth-
od, which may also cause TMJ disorders and
pseudarthrosis over the long term.7,8
In this study, the types of morphology
seen in healed bone after various fracture
patterns were investigated and classified,
with the aim of enabling the prediction of
post-healing functional impairment on the
basis of fracture site and pattern. Using
three-dimensional computed tomography
(3D-CT) images to carry out a three-di-
mensional (3D) rather than a conventional
two-dimensional (2D) evaluation, the
healing morphology of the condylar pro-
cess after closed treatment could be clas-
sified into four patterns. A further
investigation into the association of these
four patterns with post-healing functional
impairment was also performed.
Materials and methods
A retrospective study was conducted of 26
patients (16 men, 10 women) who
attended the department of oral and max-
illofacial surgery of the study hospital
between January 2010 and December
2014. These patients were diagnosed with
a fracture of the condylar process and were
treated conservatively. Those with a
temporomandibular disorder, facial bone
fracture, or who had undergone previous
orthognathic surgery were excluded from
the study, as were symptomatic patients.
The fracture site was on the right in seven
cases, the left in 10, and on both sides in
nine, for a total of 35 sides. Age at the time
of injury ranged from 17 to 86 years (mean
48.6 years). The causes of injury included
traffic accidents, falls, sports, and quarrels.
Conservative treatment
The basic treatment was intermaxillary fix-
ation with elastic or wire for approximately
2 weeks, using either an intramaxillary
splint or existing dentures. However, elder-
ly patients (>80 years old) either used a
chin cap or were instructed to consume a
soft diet. Active mouth-opening exercises
were encouraged soon after the intermax-
illary fixation was released.
Please cite this article in press as: Yamashita Y, et al. Three-dimensional evaluation of healing joint morphology after closed treatment
of condylar fractures, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.019
Assessment method
With each patient’s consent, CT images
were obtained at the time of injury and at 1
year post-treatment. These were converted
to 3D-CT images using an AZE Virtual-
Place medical image analysis workstation
(AZE, Tokyo, Japan). The 3D-CT images
produced were trimmed using the work-
station software to ensure that the condylar
process, coronoid process, and mandibular
ramus were clearly visible.
A post-healing functional assessment,
with the patient in the seated position, was
performed at 1 year after treatment during
an outpatient visit. The patient was asked
to open and close the lower jaw by him/
herself, and the deviation of the mandibu-
lar midline was checked.
Results
Fracture pattern at the time of injury
CT images scanned at the time of injury
were used to produce 3D-CT images.
Fractures were categorized into three
types according to the MacLennan classi-
fication,5 depending on whether the frac-
ture site was in the condylar head (three
sides), the condylar neck (24 sides), or the
condylar base (eight sides).
The great majority of fractures of
the condylar head involved deviation or
dislocation of small bone fragments. Frac-
tures of the condylar neck were catego-
rized as simple fractures with a single
fracture line (nine sides) or comminuted
fractures with multiple fracture lines (15
sides). Small bone fragments were deviat-
ed or dislocated medially in all cases in
which the fracture was located in the
condylar neck. The fractures on eight sides
Fig. 1. Unchanged. If there was no evident change in morphology on three-dimensional images
obtained before (A) and after (B) treatment, the pattern was classified as unchanged.
categorized as fractures of the condylar
base showed clear fracture lines but no
deviation of the bone fragments.
Classification of healing morphology
The 3D-CT images from 1 year after treat-
ment were used to classify the morphology
of the condylar process into four different
patterns: unchanged, spherical pattern, L-
shaped pattern, and detached pattern. If
there was no evident change in morphology
on 3D images before and after treatment,
the pattern was classified as unchanged
(Fig. 1). Cases in which small bone frag-
ments had been deviated or dislocated me-
dially and had fused with the fractured end
of the ramus in that position, healing in a
spherical shape, were classified as spherical
pattern (Fig. 2). Cases of simple fracture of
the condylar neck in which a small bone
fragment had been pulled by the lateral
pterygoid muscle so that it tilted sideways
in a medial direction, in which position
fusion occurred at its point of contact with
the fractured end of the ramus in the shape
of an L, were classified as L-shaped pattern
(Fig. 3). Cases of comminuted fracture
of the condylar neck in which most of
the crushed small bone fragments had
fused, but one or more fragments remained
individually detached, were classified as
detached pattern (Fig. 4).
Association between fracture pattern at
the time of injury and morphology after
healing
The association between the fracture pat-
tern at the time of injury and bone mor-
phology after healing is shown in Fig. 5.
The morphology of the condylar process
YIJOM-3265; No of Pages 5

3D evaluation of healing joint morphology 3

intracapsular fractures are basically trea-

Fig. 2. Spherical pattern. At the time of injury, there is a fracture of the condylar head that is
medially displaced and dislocated (A). At 1 year after treatment, the small bone fragment has
fused with the large bone fragment and has healed in a spherical morphology (B).
Fig. 3. L-shaped pattern. At the time of injury, there is a fracture of the condylar neck, and a
small bone fragment is tilted medially and dislocated (A). At 1 year after treatment, the small
bone fragment is still tilted, has fused with the large bone fragment, and in that position has
healed in an L-shape (B).
for the eight fractures of the condylar base
were all classified as unchanged 1 year later.
There were three fractures of the condylar
head and 11 of the condylar neck (five
simple, six comminuted) with the spherical
pattern after healing, for a total of 14. An-
other nine fractures of the condylar neck
(four simple, five comminuted) healed in an
L-shaped pattern, and four comminuted
fractures at this site had persistent detached
bone fragments after healing and were
therefore classified as detached pattern.
All fractures of the condylar head thus
exhibited the spherical pattern after heal-
ing. Fractures of the condylar neck were
categorized as simple, with a single frac-
ture line, or comminuted. Simple fractures
exhibited either the spherical or L-shaped
pattern after healing. Some comminuted
fractures also showed a detached morphol-
ogy after healing, meaning that three dif-
ferent types were evident.
Functional impairment after healing
The presence of mandibular deviation on
mouth opening was investigated at 1 year
after closed treatment (Table 1). Mandib-
ular deviation was 0% for all five patients
with fractures on one side and whose
morphology was unchanged after healing.
The spherical, L-shaped, and detached
patterns were investigated separately for
patients with a fracture on only one side
and those with fractures on both sides that
included one fracture of the condylar base.
Mandibular deviation was present in four
of nine patients (44.4%) who exhibited the
spherical pattern, one of four patients
(25%) who exhibited the L-shaped pat-
tern, and both patients (100%) who exhib-
ited the detached pattern. The deviation
was towards the fractured side in all cases.
Discussion
Treatment methods for fractures of the
condylar process can broadly be divided
into open reduction or closed treatment.
The first factor in determining the treat-
ment strategy is the position of the fracture
line. For low fractures of the condylar
base or neck, the authors actively perform
open reduction and fixation. However,
ted with closed treatment, because in the
case of open treatment, rigid fixation is
difficult, postoperative scarring of the tis-
sue occurs around the mandibular con-
dyle, including the articular capsule, and
joint movement may be impaired.9 Closed
treatment also offers the prospect of suffi-
cient osseous healing.10
Another important determining factor is
the fracture type. For extracapsular frac-
tures, open reduction and fixation should
be considered for patients with deviation,
displacement, and dislocation according
to the MacLennan classification.11–13
Patients with particularly large displace-
ment with the fractured end of the ramus
and those with deviation and dislocation or
displacement and dislocation, should pref-
erably undergo proactive reduction, be-
cause there is a risk of poor healing and
postoperative functional impairment.
Factors such as the patient’s age and
medical history also make a major contri-
bution to the decision on the method of
treatment. Children, for example, have a
powerful capacity to heal themselves,
which enables them to make an almost total
morphological and functional recovery
with closed treatment even in the event
of a dislocation fracture.14 In older patients,
previous medical history frequently makes
it difficult to perform open treatment.
Although closed treatment cannot result
in complete morphological recovery, it is
known that a certain level of functional
recovery can be achieved through the
ability of the TMJ to repair itself.10,15
The association between this type of heal-
ing morphology and functional impair-
ments, however, is unclear. In the past,
2D image evaluation was the main method
of evaluating the morphology of the TMJ,
but given the wide range of movement of
this joint, this method cannot be described
as adequate.16,17 In the present study, 3D
morphological evaluation of the healed
bone was performed, which identified four
different patterns of bone morphology
after healing.
An attempt was made to classify these
cases using conventional 2D evaluation,
but it was not possible to classify them in
the same way. The L-shaped pattern and
the presence of the detached bone frag-
ments seen in the detached pattern were
particularly difficult to identify in 2D. It is
highly likely that these types of healing
morphology would have been overlooked
in the previously used 2D evaluations.
In the present investigation, all patients
with fractures of the condylar base
were classified as unchanged. The authors’
basic treatment strategy for fractures of

Please cite this article in press as: Yamashita Y, et al. Three-dimensional evaluation of healing joint morphology after closed treatment
of condylar fractures, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.019
YIJOM-3265; No of Pages 5

4 Yamashita et al.

the condylar base is to carry out open

treatment if deviation is present. Patients
with fractures of the condylar base who
were selected to undergo closed treatment
showed almost no bone fragment devia-
tion when the injury occurred, and surgery
was therefore judged to be unnecessary;
thus their morphology was unchanged af-
ter healing in all cases. For these un-
changed patients, jaw movement was
also almost entirely unaffected after treat-
ment. The spherical pattern was seen in
healed simple fractures if there was a large
area of contact between the small bone
fragment and the fractured end of the
ramus, and the bone fused in this position.
Even for compound fractures, most of
these remained within the articular cap-
sule. The L-shaped pattern was seen in
healed simple fractures if the small bone
fragment was pulled by the lateral ptery-
goid muscle so that it tilted sideways in a
medial direction, in which position fusion
occurred at its point of contact with the
fractured end of the ramus. The detached
pattern arose in the event that a fracture
was comminuted at the time of the injury,
and neither the spherical pattern nor the L-
shaped pattern was completely formed
during the healing process.
The effect of age on the occurrence of
detached fragments was evaluated, but
Fig. 4. Detached pattern. At the time of injury, there is a comminuted fracture of the condylar since several of these patients were in
neck, resulting in numerous small bone fragments (A and A0 ). At 1 year after treatment, most of their 30s or 40s, it is inferred that fracture
the comminuted small bone fragments have fused with the fractured end of the ramus, but some pattern had a greater impact than did age.
detached bone fragments (arrows) are still present (B and B0 ). These detached fragments may cause im-
paired movement and pain in the TMJ at a
later date, and as such, must be investigat-
ed in the future.
Despite the small sample size, the asso-
ciation between morphology after healing
and mandibular movement at 1 year after
treatment was investigated. In patients
who exhibited the L-shaped pattern,
the left and right mandibular ramus had
different lengths after treatment, and de-
viation of the position of the mandible
during jaw movement was therefore an-
ticipated. However, greater deviation was
in fact evident in patients who showed the
detached or spherical patterns. Limitations
of this study include the small sample size.
A study with a large sample size should be
performed before definitive conclusions
can be drawn.
The present results suggest that the use
of 3D evaluation may enable the morphol-
ogy of the condylar process after healing
to be predicted to a certain extent accord-
ing to the fracture pattern at the time of
injury. Further studies are needed to elu-
cidate the association between functional
impairments after healing and the fracture
Fig. 5. Changes in morphology between the time of injury and after healing. pattern at the time of injury.

Please cite this article in press as: Yamashita Y, et al. Three-dimensional evaluation of healing joint morphology after closed treatment
of condylar fractures, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.019
YIJOM-3265; No of Pages 5
3D evaluation of healing joint morphology
Table 1. Mandibular deviation on mouth concomitant injuries. J Oral Maxillofac
opening. Surg 1990;48:926–32.
Pattern Number of cases 4. Silvennoinen U, Iizuka T, Lindqvist C,
Oikarinen K. Different patterns of condylar
Unchanged 0/5 (0%)
fractures: an analysis of 382 patients in a
Spherical 4/9 (44.4%)
3-year period. J Oral Maxillofac Surg
L-shaped 1/4 (25%)
1992;50:1032–7.
Detached 2/2 (100%)
5. MacLennan WD. Consideration of 180 cases
of typical fractures of the mandibular con-
dylar process. Br J Plast Surg 1952;5:122–8.
Funding
6. Lindahl L. Condylar fractures of the mandi-
None. ble. I. Classification and relation to age,
occlusion, and concomitant injuries of teeth
Competing interests and teeth-supporting structures, and frac-
tures of the mandibular body. Int J Oral
None declared. Surg 1977;6:12–21.
7. Smets LM, Van Damme PA, Stoelinga PJ.
Non-surgical treatment of condylar fractures
Ethical approval in adults: a retrospective analysis. J Cranio-
maxillofac Surg 2003;31:162–7.
The study was approved by the local
8. Silvennoinen U, Iizuka T, Oikarinen K,
committee on human research of Saga
Lindqvist C. Analysis of possible factors
University Hospital.
leading to problems after nonsurgical treat-
ment of condylar fractures. J Oral Maxillo-
fac Surg 1994;52:793–9.
Patient consent
9. Ellis III E, McFadden D, Simon P, Throck-
Not required. morton G. Surgical complications with open
treatment of mandibular condylar process
fractures. J Oral Maxillofac Surg 2000;58:
References
950–8.
1. Marciani RD, Hendler BH, Trauma.Fonseca 10. Lund K. Mandibular growth and remodelling
RJ, editor. Oral and maxillofacial surgery, processes after condylar fracture. A longitu-
vol. 2. St. Louis: W.B. Saunders; 2009 . p. dinal roentgencephalometric study. Acta
171–4. Odontol Scand Suppl 1974;32:3–117.
2. Ellis III E, Moos KF, el-Attar A. Ten years of 11. Manisali M, Amin M, Aghabeigi B, Newman
L. Retromandibular approach to the mandib-
mandibular fractures: an analysis of 2,137
cases. Oral Surg Oral Med Oral Pathol ular condyle: a clinical and cadaveric study.
1985;59:120–9. Int J Oral Maxillofac Surg 2003;32:253–6.
3. Haug RH, Prather J, Indresano A. An epi- 12. Narayanan V, Kannan R, Sreekumar K. Ret-
demiologic survey of facial fractures and romandibular approach for reduction and
Please cite this article in press as: Yamashita Y, et al. Three-dimensional evaluation of healing joint morphology after closed treatment
of condylar fractures, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.019
5
fixation of mandibular condylar fractures:
a clinical experience. Int J Oral Maxillofac
Surg 2009;38:835–9.
13. Biglioli F, Colletti G. Transmasseter ap-
proach to condylar fractures by mini-retro-
mandibular access. J Oral Maxillofac Surg
2009;67:2418–24.
14. Norholt SE, Krishnan V, Sindet-Pedersen
S, Jensen I. Pediatric condylar fractures:
a long-term follow-up study of 55 patients.
J Oral Maxillofac Surg 1993;51:
1302–10.
15. Ellis III E, Throckmorton G. Facial sym-
metry after closed and open treatment of
fractures of the mandibular condylar pro-
cess. J Oral Maxillofac Surg 2000;58:
719–28.
16. Nolte JW, Karssemakers LH, Grootendorst
DC, Tuinzing DB, Becking AG. Panoramic
imaging is not suitable for quantitative eval-
uation, classification, and follow up in uni-
lateral condylar hyperplasia. Br J Oral
Maxillofac Surg 2015;53:446–50.
17. Choi BH. Comparison of computed tomog-
raphy imaging before and after functional
treatment of bilateral condylar fractures in
adults. Int J Oral Maxillofac Surg 1996;25:
30–3.
Address:
Yoshio Yamashita
Department of Oral and Maxillofacial
Surgery
Faculty of Medicine
Saga University
5-1-1 Nabeshima
Saga 849-8501
Japan
Tel: +81 952 34 2397; Fax: +81 952 34 2044
E-mail: yamashy2@cc.saga-u.ac.jp