1.
15 
Fractures of the Condylar Process
of the Mandible
Edward Ellis III, Daniel Perez
BACKGROUND
Approximately 11%–50% of all facial fractures and 30%–40%% of all
mandibular fractures (MFs) are fractures of the mandibular condyle.1,2
Most are not caused by direct trauma, but follow indirect forces trans-
mitted to the condyle from a blow elsewhere, usually in the body or
symphysis region. They are often the result of rapid deceleration injuries
such as when the chin of an unrestrained passenger in a car strikes the
dashboard, the bicycle rider who lands on their chin, or a patient who
falls on their face.
SURGICAL ANATOMY AND
CLINICAL PRESENTATION
The four main components of the temporomandibular joint that are
important when considering condylar process fractures are the condylar
process itself, the glenoid fossa of the temporal bone, including the
articular eminence, the intraarticular disk, and the lateral pterygoid
muscle. For purposes of this chapter, it will be assumed that the glenoid
fossa and temporal articulations are uninjured.
Because the lateral pterygoid muscle inserts mostly onto the ptery-
goid fovea of the condyle, when a fracture occurs below this level,
contraction of the muscle causes the condylar fragment to be displaced
anteromedially. For the same reason, condylar fractures are associated
with impaired translational movement of the condyle along the articular
eminence because the lateral pterygoid muscle is no longer connected
to the distal portion of the mandible (Fig. 1.15.1). Although rotation
can occur, lack of translation produces a characteristic deviation of the
chin on opening toward the side of a unilateral condylar fracture (Fig.
1.15.2). Displacement of the condylar process produces a loss in the
anatomic height of the ramus, which allows premature contact of the
ipsilateral most distal tooth (Fig. 1.15.3). The point of contact acts as a
fulcrum and produces a characteristic open-bite on the side opposite of
a unilateral fracture (Fig. 1.15.3). Bilaterally displaced fractures of the
condylar processes produce a symmetric anterior open-bite (Fig. 1.15.4).3,4
Some patients who sustain mandibular injury may present with
pain in the joint and a malocclusion where the mandible comes forward
on the side of the injury or they may not be able to bring the teeth
together on that side and yet a fracture of the condylar process cannot
be identified on imaging. In such instances, one should suspect a
contusion/hematoma within the affected joint.
RADIOLOGICAL EVALUATION
The vast majority of condylar process fractures in adults can be identi-
fied using plain radiographs. It is important to get at least two radio-
graphs 90° to the other. For instance, the combination of panoramic and
Towne’s projections offer most of what might be needed to prescribe
treatment in the vast majority of patients (Fig. 1.15.5). Plain films
186
are not as useful for pediatric condylar process fractures because the
bone is less dense, the condylar neck is much shorter, and often the
fractures are through the condylar head, which are not revealed well
with plain films. On the other hand, if the surgeon routinely treats
condylar process fractures in children closed, the need for more detailed
imaging (CT) may not be warranted given the need for more radiation to
do so.
The main limitation of plain radiographs is that they do not give
three-dimensional details of the fracture. Computed tomography (CT)
is almost universally available today and most patients will already have
a scan performed by the emergency department before a surgical con-
sultation is made. CT gives extremely good detail of the position of the
fracture(s) and the displacement of the segments. It is especially good
for intraarticular fractures (Fig. 1.15.6). CT scans cannot show the
position of the intraarticular disk but the need to have that information
available for treatment planning purposes is a hotly debated topic (dis-
cussed later). Should one desire more information on the position of
the disk, a magnetic resonance imaging (MRI) scan would be needed
as this is the imaging modality that provides the best view of the disk
and other soft tissues within the joint.
TERMINOLOGY
Controversy exists with respect to terminology and classification of
condylar process fractures. Practitioners in Europe and North America
may refer to the same entity with different words. For the purpose of
this chapter and to clarify the vocabulary, it is important to make a
distinction between the following terms:
Displacement. Displacement refers to the relationship of the fractured
ends of the bones to one another. Often arbitrarily broken down
into mild, moderate and severe displacement, it can be used for
fractures throughout the skeleton whereas “dislocation” and “luxa-
tion” (see below) can be used only for fractures that involve a joint.
The amount of displacement and its direction can be quantified by
measuring the angle the condylar process makes with the ramus of
the mandible in both the sagittal and coronal planes (Fig. 1.15.5).
A fracture that is displaced 90 degrees medially is one that is also
dislocated because the articular surfaces will no longer have much
contact. The relationship of the fractured ends can be further clas-
sified as those with medial and those with lateral override (displace-
ment) of the segments (Fig. 1.15.7).
Dislocation (aka Luxation). Dislocation refers to the lack of relationship
of the articular surfaces to one another. It usually indicates that the
articulating surface of the mandibular condyle is mostly not contact-
ing the articulating surface of the glenoid fossa (Fig. 1.15.8). To be
dislocated, the fracture would have to be severely displaced (see
above).
Subluxation. Sometimes the term subluxation is used to describe a
partial separation of the articular surfaces but the condyle is not
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible 187

completely dislodged outside of the glenoid fossa. The difference
between subluxation and dislocation (and luxation) is a matter of
degree in that the articulating surfaces are not contacting.
Diacapitular (fractures). This is another European term that is used
when the fracture line starts at the articular surface, goes through
the head of the condyle and may extend outside the capsule. So it
extends from within the capsule to outside the capsule (Fig. 1.15.9).
These types of fractures are also known as intracapsular fractures,
especially in North America. However, it has been shown that in a
large number of “intracapsular” fractures, the fracture extends inferior
to the capsule on the medial aspect. The name “intracapsular” there-
fore may be anatomically incorrect in such cases.5
CLASSIFICATION OF CONDYLAR
PROCESS FRACTURES
There are many classification systems in the literature.6–10 Classification
systems are used for two main purposes. One is to categorize injuries
so their treatment may be studied. For this purpose, the classification
system must be very complete (Table 1.15.1). Unfortunately, most clas-
sification systems used to adequately classify condylar process fractures
for purposes of research are complex, cumbersome, and have very little
clinical usefulness. The other purpose of a classification system is to
help decide between the possibilities for treatment. Such systems do
not have to be as complex and the ones that are used the most today
by clinicians to classify condylar process fractures are based on the level
or anatomic position of the fracture(s) (i.e., head, neck, subcondylar)
(Fig. 1.15.10) and the magnitude and direction of displacement of the
fragments (Fig. 1.15.5).

Fig. 1.15.1  Illustration showing fractured mandibular condyle on the

right side. Note how the contraction of the lateral pterygoid muscle,
which is attached at the pterygoid fovea of the condyle, displaces the
condylar head anteromedially. This illustration also shows why the man-
dible deviates toward the side of a unilateral condylar fracture when a
patient opens their mouth. Contraction of the lateral pterygoid muscle
on the nonfractured side moves the condyle anteriorly. Because the
lateral pterygoid muscle on the fractured side is no longer connected
to the distal portion of the mandible, the fractured side mandible cannot Fig. 1.15.2  Photograph of a patient with deviation to the right side when
move anteriorly, so the unbalanced asymmetric action of the lateral opening their mouth. This patient was treated for a right mandibular
pterygoid muscle on the nonfractured side causes the mandible to deviate condylar process fracture and has a good occlusion but persistent devia-
toward the fractured side. tion on opening toward the side of the fracture.

Premature
contact on
fractured Open
side bite

A B
Deviation of mandible toward fractured side (rt)
Fig. 1.15.3  (A) Occlusion of a patient with a fresh condylar process fracture on the right. Note the premature
occlusion on the right side, deviation of the mandible to the right, and a left open-bite. (B) Illustration showing
how a right condylar process fracture allows the right ramus to move upward causing the premature contact
of teeth on that side, deviation of the mandible to that side, and the contralateral open-bite.
188 SECTION 1  Primary Injury

A B
Anterior open bite
Fig. 1.15.4  (A) Occlusion of a patient with fresh bilateral condylar process fractures. Note the premature
occlusion on the terminal molars and the anterior open-bite. (B) Illustration showing how bilateral condylar
process fractures allow the mandibular rami to move upward, causing premature occlusion on the posterior
teeth and an anterior open-bite.

B
Fig. 1.15.5  Panoramic and Towne’s radiographs of condylar process fractures. Note that the angle between
the ramus and the condylar process can be quantified in both views.
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible 189

Lateral displacement Medial displacement

Fig. 1.15.7  Illustration showing lateral and medial displacement (over-

Fig. 1.15.6  CT scan of a patient with bilateral condylar process fractures. ride) of the fractured ends of a condylar process fracture.
The condyle on the right is comminuted whereas the condyle on the
left is luxated 90 degrees medially. Plain radiographs would not show
this degree of detail.

B
Fig. 1.15.8  CT scans of two completely dislocated condylar process fractures. Note that the articulating
surface of the condyle is not in contact with the articulating surface of the glenoid fossa.

Level of the Fracture
The “level” or anatomical position of the fracture is a method of broadly
classifying fractures. Although a debated issue is the exact anatomic
position of the divisions, a simple method is to divide condylar process
fracture into three types: condylar head, condylar neck, and subcondylar
region (Fig. 1.15.10). A condylar head fracture is one at the level of the
joint capsule, so the fracture is essentially intracapsular or possibly
diacapitular. The neck of the condylar process is from the joint capsule
above to the level of the sigmoid notch below. Anything lower than
that is considered a subcondylar fracture. The main usefulness of such
a classification is that it directly correlates with the possibility of placing
190 SECTION 1  Primary Injury

TABLE 1.15.1  The AO/ASIF Classification

SPECIFIC LEVEL 3 CONDYLAR PROCESS SYSTEM SUBREGIONS
Parameters Code and Description Process Head Neck Base
Location M 1
4 Medial to the pole zone/P 1
4 within or lateral to the pole zone x
Fragmentation 0 1
4 None/1 1
4 fragmented minor/2 1
4 fragmented major x x x
Vertical apposition 0 1
4 Complete/1 1
4 partial/2 1
4 lost x
Sideward displacement 0 14 None/1 14 partial/2 14 full x x
Direction a 14 anterior/p 14 posterior and m 1
4 medial/l 1
4 lateral x x
Angulation 0 14 None (up to 5 degrees)/1 14 > 5–45 degrees/2 14 > 45 degrees x x
Direction a 14 anterior/p 14 posterior and m 14 medial/l 14 lateral x x
Displacement head fragment/fossa 0 14 No displacement/1 14 displacement/2 14 dislocation x
Direction a 14 anterior/p 14 posterior and m 14 medial/l 14 lateral x
Displacement caudal fragment/fossa 0 14 No displacement/1 14 displacement xa
Direction a 14 anterior/p 14 posterior and l 1
4 lateral xa
Distortion of condylar head 0 1
4 orthotopic/1 1
4 dystopic x
Overall loss of ramus height 0 1
4 No change of height/1 1
4 loss of height/2 1
4 increase of height x
a
Only in case of neck or base fracture.
From Neff A, Cornelius CP, Rasse M, et al. The comprehensive AOCMF classification system: condylar process fractures – level 3 tutorial.
Craniomaxillofac Trauma Reconstr 2014;7(Suppl 1):S44–S58).

Condylar head

Condylar neck

Subcondylar
region

Fig. 1.15.10  Classification of condylar process fractures by location

(head, neck, subcondylar).

TREATMENT OF CONDYLAR PROCESS FRACTURES

Fig. 1.15.9  CT of a diacapitular fracture. Note that the fracture line
begins on the articular surface, goes through the head of the condyle
and may extend outside the joint capsule on the medial side.
stable bone plate osteosynthesis across the fracture. For example, most
condylar neck and all subcondylar fractures are amenable to stabiliza-
tion with standard 2.0 mm bone plate osteosynthesis whereas intra-
capsular fractures through the condylar head are often not treated open
by most surgeons except those skilled in temporomandibular joint
surgery.
Most condylar process fractures require treatment. There are some cases,
however, where observation may be indicated, for instance, a patient
with a condylar process fracture that is nondisplaced or minimally
displaced, but who can bring their teeth into a normal occlusion. Such
patients can be placed on a soft diet and monitored. When treatment
is deemed necessary, there are options that have to be considered. The
main decision is whether to treat the fracture open or closed.
Deciding on Open or Closed Treatment
The age-old question is whether or not condylar fractures should be
treated open or closed. This question will never be answered because
it is the wrong question. What we should instead be asking is whether
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible
there are some condylar fractures that would obtain predictably better
outcomes when treated open. And if that is the case, how do we identify
them?
In selecting open or closed treatment, one must first understand
the goals of treatment. The outcomes that are sought when treating
patients with condylar fractures are the following11:
1. Maintenance of pretrauma occlusion
2. Pain-free function
3. Normal range of mandibular motion (interincisal opening > 40 mm,
9–12 mm lateral and protrusive excursions)
4. Maintenance of facial symmetry
If the clinician feels that closed treatment can achieve the above out-
comes, it would make no sense to perform open surgery because all
surgical procedures have known risks (i.e., bleeding, infection, nerve
damage, facial scars, etc.). On the other hand, if the clinician feels that
they can better achieve the above outcomes with open treatment than
with closed treatment, then they should consider open treatment.
However, they have to weigh the risks of open treatment against the
potential benefits of that treatment. This is often an experiential ques-
tion because some surgeons are very facile in safely performing open
treatment whereas others may do so very infrequently and are not as
sure of their abilities to safely do so.
The literature is not very useful in helping an individual surgeon
decide about what treatment to provide an individual patient. A fair
synthesis of the entire world literature on the topic of condylar fracture
treatment would be: While objective measures of outcomes vary with
the level of the fracture (head, neck, subcondylar), the amount of dis-
placement and/or dislocation, the presence of bilateral vs. unilateral
condylar fractures, and whether or not they were treated open or closed,
most patients with condylar fractures have few subjective complaints
after treatment, irrespective of the above factors. One must keep this
in mind when making treatment decisions for patients who present
with condylar fractures. But knowing this may not be useful in making
individual treatment decisions because each fracture, patient, and surgeon
is different.
There are prerequisites to closed treatment that are important to
understand.12
1. The patient must have a good complement of teeth, especially pos-
terior teeth on the side(s) of the fracture(s). Without them, there
will be a significant loss of posterior vertical dimension and an
increase in the mandibular plane angle. The loss of posterior vertical
dimension can also make future prosthetic reconstruction difficult
because there will be no room between the retromolar pad and the
maxillary tuberosity to accommodate the thickness of a denture
base. Open treatment in patients without good posterior teeth will
be better able to maintain the posterior vertical dimension and
interarch space.
2. The patient must be cooperative. They must wear their elastics,
frequently verify their occlusion, do their functional exercises, and
return often for follow-up. If one does not feel that a patient will
be cooperative, then closed treatment may fail to achieve the above
outcomes; open treatment might be more favored.
3. The surgeon must be willing to see the patient often to assess treat-
ment and alter functional therapy as necessary. There is no question
that patients treated closed require more visits to assure the occlusion
is being maintained and the physiotherapy is being performed
adequately. If the surgeon is unwilling to see the patient more often,
open treatment might be a more favorable option.
There are also pre-requisites to open treatment that are important
to understand.
1. The surgeon must be capable of safely performing open reduction
and internal fixation (ORIF) of a condylar process fracture.
191
2. Stable internal fixation must be applied to the fragments to assure
no loss of stability during the postoperative healing period. If the
fixation fails, loose hardware in this area will likely cause inflammation/
infection for which more surgery will be needed. Therefore, one
should only perform open surgery when the fragments are large
enough to adequately stabilize with internal fixation devices and
when the quality of the bone is adequate to maintain a stable screw–
bone interface. The very young and the osteoporotic elderly female
may have bone that is not capable of maintaining screw–bone interface
stability.
Considerations for Open Reduction and
Internal Fixation
Most condylar process fractures can be treated closed with satisfactory
outcomes. This is especially true of unilateral condylar fractures that
satisfy the prerequisites for closed treatment listed above. This is also
true of severely displaced unilateral fractures, high or low. However,
there are some conditions where open treatment facilitates the overall
care of the patient. These conditions include the following:
1. Bilateral condylar process fractures. When a patient has both condylar
processes fractured, especially when they are displaced, it will be
difficult to predictably achieve the above desirable outcomes using
closed techniques. The reason for this is that the biomechanics become
unfavorable.13 If one considers that under the power stroke of mas-
tication the mandible functions as a Class III lever system (Fig.
1.15.11A), when the fulcrum (condyle) is removed (by displacing
the condyles), contraction of the elevator muscles causes premature
contact of the terminal molars, resulting in an anterior open-bite
(Fig. 1.15.11B). While closed treatment can often achieve the pre-
trauma occlusion and does so in the majority of patients, it is not
predictable. Some patients obtain good outcomes, some do not. It
is not possible to determine which patients will have a good outcome
with closed treatment of bilateral condylar fractures and which will
not. Therefore, ORIF of at least one of the condylar fractures will
greatly increase the predictability of a favorable outcome.
2. Associated maxillary fracture(s). When a patient has condylar
fracture(s) associated with a free-floating maxilla from fractures
superior to the maxillary dentition, especially when there is com-
minution of the articulations of the maxilla with the zygomas along
the Le Fort I level, ORIF of the condyle(s) will facilitate repositioning
the maxilla. By performing open treatment of the condylar fractures,
as well as any other mandibular fracture(s), the case becomes an
isolated midface fracture. The treatment then is simplified by simply
mobilizing the maxilla, placing it into maxillomandibular fixation
(MMF) with the mandible, and rotating the maxillomandibular
complex until first bone contact, followed by passive fixation across
the Le Fort I level. When both condyles are fractured, both must be
treated open or there might be deviation of the entire maxilloman-
dibular complex (maxilla and mandible) to the side of the nontreated
condyle fracture.
3. Edentulous condylar fractures. Edentulous patients who do not wear
a prosthesis (dentures) and are unconcerned that their chin has
shifted to one side of the face do not require any treatment at all.
But for those who do wear a dental prosthesis, treatment will be
needed for most condylar fractures, especially those with displace-
ment. If not treated, the mandibular retromolar area will collapse
vertically against the maxillary tuberosity, eliminating any recon-
structive space for a dental prosthesis. As noted above, one of the
prerequisites for a good outcome with closed treatment is posterior
teeth to maintain the vertical dimension of the ramus. With patients
who have no teeth, maintaining the position of the mandible is
difficult when there is/are condylar fracture(s). Using the patient’s
192 SECTION 1  Primary Injury
Class III lever
Resultant
force
Fulcrum
Load
Force
Fulcrum Load
A
Fig. 1.15.11  Illustration of the biomechanics involved with bilateral condylar process fractures. (A) A Class
III lever system where the resultant muscle force from the elevator muscles is between the fulcrum (TMJ)
and the load (teeth). (B) A fractured mandibular condyle removes the fulcrum (TMJ), allowing the elevator
muscles to move the ramus upward, causing premature contact on the terminal molars and a resultant
anterior open-bite.
dental prosthesis may help but the jaws must be wired into MMF
with the prostheses in place because functional therapy is not pos-
sible without a “handle” on the jaws that teeth usually provide. It
has never been demonstrated whether closed treatment using remov-
able dental prostheses can truly maintain the posterior vertical
dimension. Open reduction and internal fixation of condylar fractures
in the edentulous patient immediately reconstructs the vertical
dimension of the ramus and maintains it.
Method of Closed Treatment
The literature is full of closed techniques that can be used to treat
condylar fractures. They include periods of MMF, functional therapy,
or most frequently a combination of both. For those advocating a
period of MMF, the duration ranges from a day or two all the way to
6 weeks. A method that has worked well for us over the years is the
following14:
1. Application of arch bars. It is much more predictable in achieving a
successful occlusal outcome when arch bars are used instead of bone
fixation appliances. The reason for this is that orthodontic adapta-
tions such as extrusion of some teeth and intrusion of others are
often required to maintain the pretrauma occlusion while the skeletal
adaptations, like forming a new articulation, are progressing.15 Using
elastics with appliances attached directly to the teeth facilitates the
needed orthodontic adaptations.
2. Open reduction and internal fixation of all other noncondylar fractures.
It is important that any noncondylar fracture(s) be treated with
rigid internal fixation so that no motion across them will occur
during the functional therapy of the condylar process fracture.
3. Removal of MMF and examining the occlusion. Typically, the mandible
will deviate toward the side of the condylar fracture (Fig. 1.15.12A).
Temporalis
Masseter
B Suprahyoids
This is of no consequence and occlusal guidance commences the
following day.
4. Placement of elastics p.r.n. The next day, assessment of the occlusion
is performed. Most commonly, there will be a premature contact
posteriorly on the side of the condylar process fracture with devia-
tion to that side and possibly a contralateral open-bite (Fig. 1.15.3).
If there is a malocclusion, elastics are applied to assist the neuro-
musculature in obtaining the proper occlusion. For unilateral frac-
tures, this is typically one elastic on the side of the condylar fracture
applied in a Class II manner, to help draw the mandible anteriorly
when the patient closes the mouth. Occasionally, a second one is
necessary (Fig. 1.15.12B). One should apply as much elastic guidance
as is necessary to allow the patient to obtain their normal occlusal
relationship when they occlude. The goal, however, is to use as little
as necessary to facilitate active use of the mandible. For bilateral
fractures, elastics are usually required bilaterally in a Class II vector,
and often supplementation with vertical elastics in the anterior.
While the patient sleeps, they should apply sufficient elastics to
maintain MMF throughout the night.
5. Postsurgical physiotherapy. Patients are encouraged to use their jaws
as much as possible beginning on the first postoperative day. They
are instructed in physiotherapeutic exercises to increase range of
mandibular motion, which they should employ at least four times
a day. Exercises consist of maximum opening of the mouth, attempt-
ing to do so without deviation toward the side of fracture. The
patient should also be shown how to use lateral excursive exercises
to both the right and left sides. Finally, protrusive excursions should
be practiced, again attempting to do so without deviation of the
mandible to one side or the other. During the exercises, eating, and
oral hygiene procedures, the patient can remove the elastics. The
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible 193

A B
Fig. 1.15.12  Intraoperative photographs of a patient who is being treated for a right unilateral condylar process
fracture. Note the premature occlusion on the right, the deviation of the mandible to the right, and the left
anterior open-bite. This patient required two Class II elastics to bring the mandible into the proper occlusion.

elastics are then reapplied, and the patient is shown how to determine
they are biting in the proper occlusal relationship in a mirror, using
as few elastics as possible. Patients with unilateral fractures may
always have some degree of deviation toward the side of fracture
on wide opening or protrusion (Fig. 1.15.2). Typically, patients will
be able to obtain the above treatment goals in 4–5 weeks.
6. Weaning the patient from the elastics. After 2 or 3 weeks of this treat-
ment, the patient should be able to obtain their pretraumatic occlu-
sion without the constant use of elastics. The elastics are withdrawn
more and more over the next 2–3 weeks so that they are used only
while sleeping for another 2–3 weeks. Once the use of elastics is no
longer necessary for the patient to obtain their pretraumatic occlu-
sion, they can be discontinued (Fig. 1.15.13). The arch bars should
be left in place, however, for a few weeks beyond that time so that
if the patient has some difficulty with occlusion later, elastics can
be easily reapplied.
Fig. 1.15.13  Photographs of a patient 6 weeks after closed treatment
7. Removal of arch bars. Most commonly, arch bars are left in place for of a right condylar process fracture using one Class II elastic on the
6–8 weeks for unilateral and 3–4 months for bilateral condylar process right side. She has been able to obtain a normal occlusion without
fractures. Once the patient can consistently assume their normal elastics for 2 weeks so the arch bars are no longer required.
occlusion without the use of elastics, the arch bars can be removed.

Method for Open Treatment
When the decision is made to treat the patient’s condylar process fracture
with ORIF, the following steps are followed14:
1. Application of arch bars.
2. Open reduction and internal fixation of all other non-condylar
fractures.
3. Removal of MMF and examining the occlusion. Typically, the man-
dible will deviate toward the side of the condylar fracture.
4. Placement of interarch elastics. If using a transfacial approach to
the condylar fracture, elastics are placed between the upper and
lower arch bars to provide the proper occlusal relationship. Elastics
are used instead of wires during open treatment of the condylar
process fractures because the mandibular ramus must frequently
be distracted inferiorly to retrieve a medially displaced condylar
process. When using a transoral approach to the condylar fracture,
elastics are unnecessary because one will have direct visualization
of the occlusion.
5. Open reduction and stable internal fixation of condylar process
fracture. The surgeon should use whichever surgical approach they
prefer (see below). The condylar process should be properly reduced
and stabilized. The use of either a single strong bone plate employ-
ing 2.0 mm self-threading screws or two standard miniplates that
employ 2.0 mm screws is adequate fixation (Fig. 1.15.14).
6. Occlusal verification. The occlusion is checked to assure the man-
dible rotates properly into occlusion with the maxilla.
7. Closure. If a transfacial approach has been used, the incision is
closed in layers, taking care to hermetically close the parotid capsule
if the surgical approach violates the gland.
8. Occlusal guidance. The next day, assessment of the occlusion is
performed. Most commonly there will be a slight posterior open-
bite on the side of the condylar process fracture secondary to edema
in the TMJ. This will resolve within a week. If the posterior open-
bite is still present at the end of one week, light vertical elastics are
applied to close the bite. Elastics should be placed only if there is
a malocclusion, and as few as necessary are employed. The goal is
to use as few as required to facilitate active use of the mandible.
9. Postsurgical physiotherapy. Same as described above for closed
treatment.
10. Removal of arch bars. Once the patient can consistently assume
their normal occlusion without the use of elastics, the arch bars
194 SECTION 1  Primary Injury
A B
Fig. 1.15.14  Photographs of sufficient fixation of a condylar process fracture. (A) A single 4-hole plate employ-
ing 2.0 mm screws. Note that the plate is wider than a standard miniplate. (B) A small mandibular compres-
sion plate using 2.0 mm screws. (C) Two standard miniplates using 2.0 mm screws.
can be removed. Most commonly, arch bars are left in place for
4–6 weeks for condylar process fractures treated open.
Surgical Approaches for ORIF of Condylar
Process Fractures
Like most fractures, there are different surgical approaches that can be
used. The choice depends as much on experience of the surgeon or
other factors but the position of the fracture and the choice of fixation
scheme may also help direct the surgical approach.
Retromandibular Approach
The retromandibular technique has the advantage that it is a direct
dissection to the condylar neck region. This facilitates the reduction of
condylar neck and subcondylar fractures and the application of bone
plate fixation to them. The disadvantages are that the dissection is
thought to be difficult because it is a dissection through the parotid
gland with the branching VII nerve. Once mastered, it is a safe and
relatively fast surgical approach.
The incision for the retromandibular approach begins 0.5 cm below
the lobe of the ear and continues inferiorly 2.5–3 cm (Fig. 1.15.15A).
Another incision is then made through the scant platysma muscle found
in this location and the parotid capsule (Fig. 1.15.15B). At this point,
blunt dissection begins in an anteromedial direction towards the pos-
terior border of the mandible (Fig. 1.15.15C). The marginal mandibular
and cervical branches of the facial nerve will frequently be encountered
during this dissection. When the buccal and/or marginal mandibular
branches are located, they should be dissected free. Once the nerves
are retracted, one can readily expose the pterygomasseteric sling at the
posterior border of the mandible. The periosteum along the posterior
border of the mandible and partially around the mandibular angle is
incised from as far superiorly as is reachable to as far inferiorly around
the gonial angle as is possible (Fig. 1.15.15D). The masseter muscle is
then stripped from the ramus. The fractured condylar fragment is then
identified (Fig. 1.15.15E), reduced and stabilized. The wound is closed
in layers.
C
Submandibular Approach
The submandibular approach to the condylar process has the advantage
that most surgeons are familiar with the approach because it is used
for many other problems besides condylar fractures. The disadvantage,
when treating condylar process fractures, is that one is distant from
the area of injury. This makes it difficult to reduce condylar fractures,
especially those that are medially displaced. Plating them requires a
transcutaneous trocar for instrumentation.
The incision is 1.5–2 cm inferior to the mandibular border. The
initial incision is carried through skin and subcutaneous tissues to the
level of the platysma muscle. Retraction of the skin edges reveals the
underlying platysma muscle. Division of the fibers (Fig. 1.15.16A) is
performed and reveals the white superficial layer of deep cervical fascia.
The submandibular salivary gland can also be visualized through the
fascia, which helps form its capsule. Dissection through the superficial
layer of deep cervical fascia is the step that requires the most care
because the facial vein and artery are usually encountered when approach-
ing the area of the premasseteric notch of the mandible, as may the
marginal mandibular branch of the facial nerve (Fig. 1.15.16B). If the
facial vessels are in the way, they can be isolated, clamped, divided, and
ligated. Dissection continues until the only tissue remaining on the
inferior border of the mandible is the pterygomasseteric sling. The
pterygomasseteric sling is sharply incised with a scalpel along the inferior
border (Fig. 1.15.16C) and the lateral surface of the mandibular ramus
is stripped of the masseter muscle in a subperiosteal plane. Further
dissection superiorly should reveal the fractured condylar process (Fig.
1.15.16D). After ORIF of the condylar fracture, a layered closure is
performed.
Preauricular Approach
The preauricular approach to the temporomandibular joint (TMJ) is
relatively easy to expose surgically, although the amount of exposure
obtained is not great. The structure that limits the amount of exposure
is the branching facial nerve. The advantage of the preauricular approach
is that most surgeons who do TMJ surgery are familiar with it. The
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible 195

A B C

D E
Fig. 1.15.15  The retromandibular approach to the condylar process. (A) Incision through skin and subcutane-
ous tissues. (B) Incision through SMAS and parotid capsule. (C) Blunt dissection through the parotid gland.
(D) Incision through the pterygomasseteric sling along the posterior border. (E) Exposure of the fracture.
(Adapted from Ellis E, Zide MF. Surgical approaches to the facial skeleton. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.)

disadvantage is that it only provides good access to intracapsular and
condylar neck fractures. Fractures below the neck of the condyle are
difficult to stabilize because exposure of the subcondylar region is poor
with this approach.
The incision is made through skin and subcutaneous connective
tissues (including temporoparietal fascia) to the depth of the temporalis
fascia (superficial layer) (Fig. 1.15.17A). Dissection with sharp scissors
commences along the cartilaginous auditory canal below the zygomatic
arch and to the glistening outer layer of temporalis fascia above the
zygomatic arch (Fig. 1.15.17B). The tissue is dissected and retracted
anteriorly at the depth of the superficial (outer) layer of temporalis
fascia. The superficial temporal vessels and auriculotemporal nerve are
retracted anteriorly in the flap. The entire flap is retracted anteriorly,
and blunt dissection at this depth (just superficial to the capsule of the
TMJ) proceeds anteriorly until the articular eminence is exposed. The
entire TMJ capsule should then be revealed. The temporal branches of
the facial nerve are located within the substance of the retracted flap
(Fig. 1.15.17C). If a condylar neck fracture is being treated, dissection
proceeds inferiorly until just below the capsule (Fig. 1.15.17C) at which
point an incision is made through the periosteum and dissection of
the condyle neck proceeds (Fig. 1.15.17D). The distal fragment is then
identified and a subperiosteal dissection of the masseter muscle inferiorly
exposes the posterior border and lateral surface of the ramus. If an
intraarticular fracture is being treated, the capsule is opened and entrance
into the lower joint space is performed. The condylar head is identified
and the fragment stripped of as much capsule as needed to perform
the reduction and fixation. One should take care to maintain the attach-
ment of the lateral pterygoid muscle as it may be the only blood supply
remaining on the condylar fragment. The fracture is then reduced and
stabilized. A layered closure is then performed.
Intraoral Approach
The intraoral approach is the easiest approach to perform because there
are no tissue layers to dissect in approaching the bone. There is only
the fusion of the oral mucosa, buccinator muscle, and the periosteum
through which one incises. The scar will remain hidden within the oral
cavity, which is very important for many patients. The other advantage
is that there are no major anatomic structures that have to be negoti-
ated. The main disadvantage is the limited amount of visibility provided
and the technical difficulties of reducing and stabilizing the condylar
196 SECTION 1  Primary Injury

ZA

MM

Mand

VII

PM FA
SG

SLDCF

A B

C D
Fig. 1.15.16  The submandibular approach to the condylar process. (A) Incision through platysma. (B) Cross-
sectional anatomy in the area. (C) Incision through pterygomasseteric sling. (D) Exposure of the fracture.
(Adapted from Ellis E, Zide MF. Surgical approaches to the facial skeleton. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.)

process. The use of an endoscope can greatly facilitate visibility and
instruments designed for this approach facilitate reduction and fixation.
A right-angle drill and screwdriver make the application of fixation
devices easier than using a transbuccal trocar.
After instillation of local anesthetic with a vasoconstrictor along the
incision line as well as between the masseter muscle and the ramus, an
incision is made through mucosa, buccinator muscle, and periosteum
from the depth of the coronoid notch along the external oblique ridge
to the second molar. Subperiosteal dissection exposes the entire lateral
surface of the ramus (Fig. 1.15.18A). The condylar process is located
and the soft tissues inferior to the joint capsule are dissected off the
fragment to facilitate reduction. If the fragment is displaced medially,
downward traction on the posterior mandible can help pull the frag-
ment into a more vertical position. Once the fragment is clearly visible
and dissected, it is reduced into position and held there by using an
instrument. If using an endoscope for assistance, it can be placed through
the same intraoral incision (Fig. 1.15.18B) or alternately through a
small incision in the submandibular region (Fig. 1.15.18C). Once the
fracture is plated, a single-layered closure of the oral mucosa is then
performed.
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible 197

VII

A B C

D
Fig. 1.15.17  The preauricular approach to the condylar process. (A) Incision through skin and subcutaneous
tissues. (B) Dissection along the superficial layer of the temporalis fascia. (C) Cross-sectional anatomy in the
area. Note that branches of the facial nerve should be lateral to the path of dissection. (D) Exposure of the
fracture. (Adapted from Ellis E, Zide MF. Surgical approaches to the facial skeleton. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins; 2006.)

What About the Articular Disk?
The articular disk is an important component of normal TMJ anatomy.
Several questions might be asked about the relationship between a
condylar fracture and the articular disk. The answers to these questions
are important because they may provide some information about what
treatment should be provided to patients with condylar fractures and/
or intraarticular injuries.
The first question that should be asked is whether or not the articular
disk or its attachments are injured when a patient sustains a condylar
process fracture. Studies using MRI and TMJ arthroscopy have shown
that injuries to the intraarticular structures can occur not just in patients
who sustain condylar process fractures but also to those who have
sustained noncondylar mandibular fractures.16–26 These studies have
shown effusions, hemarthroses, perforations of the disc, displacement
of the disc, and tears to the capsular attachments of the disc in some
patients with condylar fractures – especially those with gross displacement/
dislocation and those with intracapsular fractures. When the condylar
process is fractured and grossly displaced and/or dislocated, the articular
disc tends to become displaced in the same direction with the condylar
head.21–23,26
The second question that should be asked is, given that intra-articular
injuries can occur with condylar process fractures, should our treatment
address the intra-articular injuries? For instance, should the articular
disc be repositioned when performing open treatment of the condylar
process fracture? There are advocates of such treatment,22,26,27 especially
for displaced intracapsular fractures. However, most surgeons do not
surgically address the intraarticular injuries and instead confine their
treatment to closed treatment or open treatment of the condylar process
without entering the joint capsule. Open reduction and internal fixation
has been shown to bring the articular disk into a more normal position
in most cases.22,23,26
Treating the intraarticular injuries with benign neglect has been
done for centuries and overall most patients recover quite well. There
are good reasons to not address the intraarticular injuries. First, iden-
tification of such injuries requires MRI scans, which are not routinely
obtained with the treatment of condylar process fractures. Second, if
198 SECTION 1  Primary Injury

A B

C
Fig. 1.15.18  The intraoral approach to the condylar process. (A) Exposure after subperiosteal dissection. (B)
Use of an endoscope inserted through the transoral incision and insertion of a transbuccal trochar. (C) Expo-
sure of a condylar process fracture as viewed through an endoscope. (Panels A and C adapted from Ellis E,
Zide MF. Surgical approaches to the facial skeleton. 2nd ed. Philadelphia: Lippincott Williams & Wilkins;
2006.)

MRIs showed displacement of the disc, it is not always possible to know
if this was a consequence of the injury or a preexisting problem. Studies
have shown a high incidence of displaced TMJ discs in the general
population (approximately one-third).28–30 Third, performing disc repo-
sitioning surgery requires an intraarticular operation which can disrupt
the remaining blood supply to the head of the condyle which after
fracture only comes from the TMJ capsule and the lateral pterygoid
muscle.15 Last, repositioning the disc assumes that patients will do better
than those who do not have disc repositioning. There is not much
evidence to support this assumption. For the average surgeon, especially
those who do not routinely perform TMJ surgery, addressing any intraar-
ticular injuries will likely not occur with any frequency when treating
condylar process fractures.
TRAUMA-DERIVED
TEMPOROMANDIBULAR DISORDERS
Temporomandibular disorders (TMD) are very common in developed
countries and are multifactorial in cause.31,32 Stress, anxiety, malocclu-
sion, internal derangements, muscle spasms, eating and functional habits
among others have been identified as important factors in TMD. Such
factors can be considered as causing microtrauma to the joint. Condylar
or noncondylar mandibular fractures would be considered forms of
macrotrauma to the TMJ and have been implicated as an important
factor with intraarticular TMDs.33,34
Animal studies have shown condylar trauma results in biochemical
changes within the TMJ, cartilage degeneration and intraarticular adhe-
sions.35,36 The long-term effect of such TMJ changes on jaw function
is not clear and although most clinicians are aware of the association
between mandibular trauma and the later development of TMD there
have been few systematic studies. When one considers how common
TMDs are in the general population and how relatively rare macrotrauma
to the TMJ is, it is hard to implicate trauma as a major cause of TMDs.32
The majority of patients respond well to TMJ trauma and adapt
with very few complaints long term. However, it is important to realize
that trauma may play an important role in the onset of acute TMDs
or may exacerbate an already preexistent and perhaps dormant TMD.
TMJ trauma has been implicated as an important etiological factor
in TMJ ankylosis, especially in untreated or poorly treated patient
populations.37–40 While the most common cause of TMJ ankylosis is
condylar fracture, the incidence of TMJ ankylosis from condylar fracture
is very low (<.05%).41,42
 CHAPTER 1.15  Fractures of the Condylar Process of the Mandible
EXPERT COMMENTARY
This chapter, whose senior author is the master of principlization and problem
solving in the mandible as well as other facial injuries, is my favorite literature
on the subject. Clearly, briefly written and well organized, the chapter distills
an overwhelming volume of literature into a minimal number of well-defined
principles. What one learns quickly is that picking the treatment is as much
about picking the complications as the results. The condyle also is a more brittle
piece of bone, has more consistent microfractures than the literature would
indicate, making it a poor candidate for stability after open reduction, and is
prone therefore to screw loosening and repeat displacement following open
reduction, especially in non-cooperative patients. These problems are far more
frequent than in other mandibular locations treated with internal fixation. Resorp-
tion is also frequent, especially if the head is stripped to accomplish the reduction,
and I have several patients in whom the head has entirely resorbed over 1 year,
leaving the plate sticking up by itself. Personally, I went to immediate replace-
ment with a costochrondral bone graft [1–3] in situations of high comminution
like gunshot wounds, or when the head was replaced as a free graft, as it is
better bone, and more likely to survive.
I have not seen closed treatment maintain the vertical height of the ramus as
well as open techniques, and occlusal adjustments are frequently necessary but
well tolerated. Whether they are better than occlusal adjustments is a subject
for discussion. The idea of treating one condyle alone in bilateral fractures with
fractures of the horizontal mandible has never made much sense to me.
In patients who require anterior elastics, some support for the arch bar to bone
with skeletal wires prevents/minimizes extrusion of anterior teeth, which without
them is inevitable.
There ought to be patient instructions available on diet, exercise of the mandible,
occlusion and elastics and the goals and self-monitoring of the occlusion. At
Shock Trauma, we had a book for patients which covered: “Let’s Face this Together”
by P. Azman and P. Manson.
Note Ellis’s advice on the superiority of arch bars, and how they do orthodontics
to help restore occlusion, and especially how long the bars must stay on after
the initial perception of stability. Personally, I have had far more problems with
malocclusion from early discontinuance of IMF with loss of control of the
Evidence-based medicine (EBM) content available in Appendix 1
(online only)
REFERENCES
1. Chrcanovic BR. Surgical versus non-surgical treatment of mandibular
condylar fractures: a metaanalysis. Int J Oral Maxillofac Surg.
2015;44:158–179.
2. Zachariades N, Mezitis M, Mourouzis C, et al. Fractures of the
mandibular condyle: a review of 466 cases. Literature review, reflections
on treatment and proposals. J Craniomaxillofac Surg. 2006;34:421–432.
3. Walker RV. Traumatic mandibular condyle fracture dislocations. Am J
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4. Rudderman RH, Mullen RL. Biomechanics of the facial skeleton. Clin
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199
occlusion, than I have had stiffness, and I firmly believe in a period of rest for
both the bone and the soft tissue immediately after treatment in IMF. Poor
application of arch bars or poorly setting up the occlusion are some of the most
frequent causes of problems I have seen, especially in those who infrequently
treat fractures of the mandible. I use a Penrose drain in areas where I have
transected the parotid, and in the retromandibular incision I do not go through
the parotid but mobilize it anteriorly and superiorly.
One of the best mandible surgeons I know is Anthony Tufaro, who trained in
three specialties and who does condylar open reductions like a head and neck
surgeon, with two approaches – a simultaneous preauricular and a retromandibular
exposure with visualization and protection of the facial nerve – allowing him to
generate the inferior distraction which facilitates the reduction, and which gives
him precise control of all of the variables that haunt the more limited approaches
to the condyle [4].
Finally, precise application and management of Erich arch bars, the addition
of skeletal wires where necessary especially anteriorly, occlusal monitoring
weekly, patient education, and rigid supervision of the patient will improve the
results dramatically, as will obtaining dental records and old models in challeng-
ing cases. At the end of the case, and often after placing one screw on each
side of the plate, I will frequently take the patient out of occlusion and, with the
condyles clearly and solidly seated into its proper position in the fossa, check
the occlusion and thus the accuracy of the temporary reduction. The sound of
the “click” as all of the teeth come together precisely at once cannot be mimicked
by any other sound.
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