ORIGINAL ARTICLE

Mandibular Condyle Fractures: Evaluation of the

Strasbourg Osteosynthesis Research Group Classification
Roberto Cenzi, MD,* Dante Burlini, MD,Þ Laura Arduin, MD,þ Ilaria Zollino, MD,þ
Riccardo Guidi, DDS,þ and Francesco Carinci, MDþ

growth disturbances of the face and disorders of the temporoman-

Abstract: Condylar fractures (CFs) are about 30% of mandibular
fractures. Condylar fractures are treated with several protocols, and
unsatisfying outcome is achieved in some cases. A staging system
for classifying CFs is of paramount importance to plan therapy, to
define prognosis, and to exchange information among trauma
centers. The Strasbourg Osteosynthesis Research Group proposed
a classification system for CFs, but no report focusing to its
effectiveness is still available. Thus, we performed a retrospective
study on a series of patients affected by CFs.
The Strasbourg Osteosynthesis Research Group classification
defines 3 main types of CFs: diacapitular fracture (i.e., through the
head of the condyle [DF]), fracture of the condylar neck, and
fracture of the condylar base (CBF). A series of 66 patients (and 84
CFs) was evaluated, and age, sex, clinical diagnosis at admission,
treatment, and outcome were considered.
Fractures of the condylar base and DFs are the most (52.4%) and
the least (4.8%) frequent fractures, respectively. Conversely, as-
sociated fractures of the facial skeleton are found in most cases of
DFs (75%) and in few cases of CBFs (20.5%). Surgery was
performed in about 15% of all cases: no DF was operated, whereas
fractures of the condylar neck and CBFs have an open reduction and
an internal rigid fixation in 57% and 43%, respectively. Postsurgical
and late sequelae were 22.3% and 19%. Temporomandibular joint
symptoms and malocclusion cover about 80% and 90% of post-
surgical and late sequelae.
The new classification is a simple method to define CFs and can
give some elements about the prognosis.
Key Words: Classification, staging, fracture, trauma, condyle
(J Craniofac Surg 2009;20: 24Y28)
dibular joint (TMJ).1
The incidence of condylar fractures (CFs) is high (26% to
40% of all mandible fractures). Unilateral fractures occur approx-
imately 3 times more frequently than do bilateral fractures.2
Condylar fractures are associated with impaired translational
movement of the condyle along the articular eminence. Although
limited rotation can occur, this lack of translation produces a
characteristic deviation of the chin on opening toward the side of
such a fracture. Fractures of the neck of the condyle tend to be
displaced anteromedially in response to the action of the lateral
pterygoid muscle. This displacement produces a loss in the func-
tional height of the ramus, which allows premature contact of the
ipsilateral molar teeth. The point of contact acts as a fulcrum and
produces a characteristic open bite on the side opposite the fracture.
Bilaterally displaced fractures of the necks of the condyles produce a
symmetric anterior open bite.3,4
The clinical presentation of CF may be either straightforward
or quite subtle. An awareness of the mechanism of potential injury,
as well as the specific signs and symptoms that should raise the index
of suspicion, is therefore helpful to the clinician. History, physical
examination, and radiographic studies form the mainstays of
diagnosis. Contusions over the chin or preauricular area, hemotym-
panum, and malocclusion are all potential signs of a CF. The
examination must therefore include assessment of the patient’s

T raumas to the mandible, due to falls or traffic accidents, can

involve fractures in the condylar area. Without timely and proper
diagnosis, such fractures may give rise to serious problems, such as

From the *Department of Maxillofacial Surgery, Civil Hospital, Rovigo,

†Department of Maxillofacial Surgery, Civil Hospital, Brescia, and
‡Department of Maxillofacial Surgery, University of Ferrara, Ferrara, Italy.
Received for publication April 14, 2008.
Accepted April 25, 2008.
Address correspondence and reprint requests to Francesco Carinci, MD,
Department of Maxillofacial Surgery, University of Ferrara, Arcispedale
S. Anna, Corso Giovecca, 203, 44100 Ferrara, Italy; E-mail: crc@unife.it
This study was supported by a grant from FAR (to F.C.), University of
Ferrara, Ferrara, Italy.
Copyright * 2009 by Mutaz B. Habal, MD
ISSN: 1049-2276 FIGURE 1. Diacapitular fracture (through the head of the
DOI: 10.1097/scs.0b013e31819032a3 condyle).

24 The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009 Sorg Classification in Condyle Fractures

condylar neck (CNF), and fracture of the condylar base (CBF). To

verify if the SORG classification relates CFs to surrounding
structure affection, treatment modalities, and prognosis, we analyzed
a series of patients affected by CF.

MATERIALS AND METHODS

Patients
The case series is composed of 10 patients affected by CFs
consecutively treated at the Department of Maxillofacial Surgery of
the Civil Hospital in Brescia from January to December 2007 and
56 patients treated at the Department of Maxillofacial Surgery of the
Civil Hospital in Rovigo from August 1992 to December 2007.
There were 41 males and 25 females. The mean age at
presentation was 28 years, ranging from 3 to 75 years. Forty-eight
patients have single CF, and 18 have bilateral CFs.
Condylar fractures were classified as proposed by SORG11
(Figs. 1Y3). There were 4 DFs (through the head of condyle, i.e., the
fracture line starts in the articular surface and may extend outside the
capsule), 36 CNFs (i.e., the fracture line starts somewhere above a
line, the so-called line A, running tangentially to the lower point of
FIGURE 2. Fracture of the condylar neck. the sigmoid nock and perpendicular to a line tangent to the posterior
border of the mandibular ramus; in case of CNF, more than half of
the fracture runs above line A), and 44 CBFs (i.e., the fracture line
occlusion and facial nerve function (less commonly, a facial nerve runs behind the mandibular foramen, and in more than half, it is
deficit may be associated with an injury to this area).5 below line A). Sixty-two fractures (73.8%) were displaced.
Plain radiography (most commonly) and computed tomo- Associated fractures were in 50 CFs: 38 of the mandible, 8 of
graphic scanning help to ascertain the location of the fracture, the the midfacial region, and 4 panfacial fractures.
degree and direction of displacement, and the presence or absence of
associated injuries. All of these pieces of information are integral to
developing an appropriate treatment plan for the patient. Treatment Therapy
depends on the age of the patient, the coexistence of other man- Condylar fractures were treated as reported in Table 1. The
dibular or maxillary fractures, whether the CF is unilateral or intermaxillary elastic and rigid fixations were applied for an average
bilateral, the level and displacement of the fracture, the state of period of 20 and 15 days, respectively. The traction at the
dentition and the dental occlusion, and the surgeon’s experience.6 mandibular angle was applied for an average period of 15 days.
Early mobilization is the key in treating CFs. Although rigid The approach for the traction at the mandibular angle was performed
internal fixation provides stabilization and allows early mobilization, with an incision 2 cm under the mandibular angle, then after smooth
conservative treatment is the treatment of choice for most fractures.7 dissection of soft tissues, the bone was drilled bicortically; a
Closed treatment, as above, implies control of the occlusion, ag- transcutaneous wire was inserted. It was connected to an extraoral
gressive physical therapy, and close follow-up. Children and traction. This treatment has been performed since the 1990s and then
intracapsular fractures are treated conservatively with or without
maxillomandibular fixation (MMF).8
Open reduction is recommended in selected cases to restore
the occlusion, in severely dislocated fractures, and in cases of loss of
ramus height. It may be considered in those with Bmedical prob-
lems[ where intermaxillary fixation is not recommended.7,9
Some complications may arise with any treatment modality,
and many of these (e.g., pain, edema, malocclusion, trismus, in-
fection, ankylosis, extrusion of the dentition) can occur with either
closed or open treatment, especially if appropriate physical therapy
is not part of the treatment plan. However, some complications are
associated more with open treatment. These complications include
avascular necrosis of the condylar head (particularly when the
condyle is removed, plated on the back table, and reinserted as a free
graft), injury to the facial nerve, hemorrhage during approaches to
the condyle, nonunion, and Frey syndrome.10
Condylar fractures can be (a) single or multiple fractures
(from 1 linear fracture to comminute CF), (b) intracapsular,
extracapsular, or mixed CF, and (c) undisplaced or displaced (also
named dislocated or luxated).7
In 2004, Loukota et al11 reported a simple and precise method
to classify CF as proposed by the Strasbourg Osteosynthesis
Research Group (SORG). There are 3 main types of CF: diacapitular
fracture (i.e., through the head of the condyle [DF]), fracture of the FIGURE 3. Fracture of the condylar base.

* 2009 Mutaz B. Habal, MD 25

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Cenzi et al The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009

sequelae. Table 5 describes those fractures associated with a partial

TABLE 1. Types of CFs and Associated Fractures malocclusion at the end of the follow-up period.
DFs CNFs CBFs Total
(n = 4) (n = 36) (n = 44) (N = 84)
DISCUSSION
Displaced or 1 (25%*) 26 (72.2%*) 35 (79.5%*) 62 (73.8%) Condylar fractures are a frequently admitted presentation at
dislocated maxillofacial surgery departments, have several treatment modali-
Associated 3 (75%*) 10 (27.8%*) 9 (20.5%*) 22 (26.2%) ties, and have to be followed up to avoid possible insufficient results.
fractures In our series, CNFs and CBFs cover most cases (95.2%) but
were rarely associated with other fractures of the facial skeleton
In displaced fractures, the axes of the 2 bone fragments are not allineated;
(23.7%). It seems that most severe facial fractures are associated
dislocated is equivalent to luxated (i.e., there is no correct anatomic relation
between the 2 surface of the temporal joint articulation). Associated fractures with DFs, whereas CNFs and CBFs are mostly isolated, and they
can be mandibular or midfacial ones. In parenthesis without asterisk is the have a protective effect to glenoid and medial temporal fossae.
percentage of the total number of condylar fractures (i.e., 84), whereas with Treatment for CF is an ongoing controversy and has remained
the asterisk is the percentage of the specific group of condylar fractures. one of the most complex and controversial issues in mandibular
fracture management.12 Both conservative treatment and open
reduction are currently used: each method has advantages and
with closed treatment with intraoral elastic fixation. Surgical disadvantages, depending on the level of the fracture and the degree
approach used the preauricular incision. of displacement.13
Closed reduction and MMF may be indicated in cases
where condylar displacement is minimal and the height of the
Clinical Outcome ramus is almost normal,14 but open reduction and internal fixation
Most CFs had a good recovery of function and occlusion. of CFs may be indicated for bilateral injuries or considerably
There were 3 major complications: 1 patient with a basal CF and displaced CFs.9
treated with open reduction and internal rigid fixation had a Frey The final choice of treatment modality for each individual
syndrome (that was completely resolved at 4 years’ control); patient takes into account a number of factors, including position of
1 patient had a persistent TMJ dysfunction (clicking and mandibular the condyle, location of the fracture, age of the fracture, character of
deviation, but the patient has a pre-existing malocclusion); 1 patient the patient, age of the patient, presence or absence of other
had a fixation plate fracture (but at 16 months’ follow-up, the associated injuries, presence of other systemic medical conditions,
occlusion was normal, the median line centered, and there was no history of previous joint disease, cosmetic impact of the surgery, and
sign of TMJ dysfunction, so the fractured fixation device was not desire of the patient.15
removed). The mean follow-up period was 9 months (range, 1Y90 The standard treatment for most unilateral condylar neck
months). fractures used to be conservative and aimed at a stable occlusion
after a short period of MMF (10Y14 days)16 followed by progressive
RESULTS mobilization and placement of elastics at night for an additional 2
Types of fractures are summarized in Table 1. Fractures of the weeks. If rigid internal fixation is not used on major CFs, thus
condylar base and DFs are the most (52.4%) and the least (4.8%) necessitating a 6-week period of MMF, the MMF should be briefly
frequent fractures, respectively. Conversely, associated fractures of released every 2 weeks to allow for jaw-opening exercises. This
the facial skeleton are found in most cases of DFs (75%) and in few helps to reduce intracapsular and pericapsular fibrosis that
cases of CBFs (20.5%). Surgery was performed in about 15% of all accompanies any CF, particularly those with an intracapsular
cases (Table 2). No DF was operated, whereas CNFs and CBFs have component.13
an open reduction and an internal rigid fixation in 57% and 43%, In our series, elastic and rigid MMFs were used alone or in
respectively (Table 3). Postsurgical and late sequelae were 22.3% combination (sequence) with surgical or orthopedic technique (i.e.,
and 19% (Table 4). Temporomandibular joint symptoms and traction at the mandibular angle [Table 2]). Traction at the
malocclusion cover about 80% and 90% of postsurgical and late mandibular angle has an incomplete recovery at the end of the
follow-up period in several cases (12 of 44, i.e., about 27%), and
thus, it is not used any more (Table 5).
TABLE 2. Types of Treatment Indications for consideration of open reduction and internal
fixation of condylar neck fractures might include displacement of
Open the condylar head from the glenoid fossa, mechanical obstruction of
Reduction
and Internal Traction
No Rigid of the TABLE 3. Types of Condylar Fractures and Types of Treatment
Surgical Fixation of Mandibular
Treatment the Fracture Angle Total DF CNF CBF
(n = 4) (n = 36) (n = 44) Total
No MMF 0 9 55 64 (76.2%)
Elastic MMF 8 2 3 13 (15.5%) Open reduction 0 8 6 14 (16.7%)
Rigid MMF 2 3 2 7 (8.3%) and rigid fixation
Total 10 (9.5%) 14 (16.7%) 60 (73.8%) 84 Traction of the 2 25 33 60 (73.8%)
mandibular angle
The surgical procedures are reported in the columns, whereas the MMF 2 3 5 10 (11.9%)
orthopedic therapies are reported in the rows. In parenthesis is the percentage
of the total number of condylar fractures (i.e., 84). MMF is referred to those fractures treated only with this technique.

26 * 2009 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009 Sorg Classification in Condyle Fractures

TABLE 4. Types of Condylar Fractures Matched With Early and Late Complications
Type of Complication DF (n = 4) CNF (n = 36) CBF (n = 44) Total (N = 84)
Postsurgical outcome Frey syndrome V V 1 18 (21.4%)
Malocclusion TMJ symptoms V 8 6
Facial asymmetry V 2 V
Broken plate V 1 V
Total V 11 (30.5%*) 7 (16%*)
Final outcome Frey syndrome V V V 16 (17.8%)
Malocclusion TMJ symptoms V 8 6
Facial asymmetry V V V
Broken plate V 1 V
Total V 9 (25%*) 6 (13.6%*)
In parenthesis without asterisk is the percentage of the total number of condylar fractures (i.e., 84), whereas with the asterisk is the percentage of the specific
group of condylar fractures.

jaw opening caused by a displaced condylar head, telescoping of the Although the decision on the type of treatment must depend
proximal and distal fragments with the loss of vertical ramus height on a number of factors, MMF gave good results in most of the
resulting in malocclusion, displaced bilateral subcondylar fractures patients without complications and technical difficulties encoun-
with malocclusion, and a unilateral or bilateral CF with severely tered during the surgical procedures.20 Of course, some complica-
comminuted midfacial fractures.17 tions may arise with any treatment modality, and many of these (e.g.,
The approach to the condylar neck, when indicated, is pain, infection, edema, malocclusion, trismus, ankylosis, extrusion
through the incision in the preauricular region, but also, an approach of the dentition, edema) can occur with either closed or open
from the mandibular angle can be used.18 Plate-and- (2.0 mm) treatment, especially if appropriate physical therapy is not part of the
fixation offers the most effective method of holding an anatomic treatment plan.10
reduction, and the patient should be able to mobilize the mandible In conclusion, the new classification is a simple method to
immediately. In our series, 14 cases were treated, and 2 had an define CFs and can give some elements about the severity of fracture
insufficient occlusal recovery (14% [Table 5]). and risk of associated fractures. It is our understanding, however,
The disadvantages of internal fixation are the limited access that a multicenter study should be performed before the effective-
to the fracture, the risk of damage to the facial nerve, unsightly ness of SORG classification can be clearly stated especially as
scarring, and condylar resorption.19 On the other hand, internal regards treatment modality and clinical outcome.
fixation is advantageous in substantially displaced CFs for which
anatomical reduction is advantageous.10
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