Surgical Science, 2013, 4, 339-344
http://dx.doi.org/10.4236/ss.2013.48067 Published Online August 2013 (http://www.scirp.org/journal/ss)
Classification and Management of Mandibular Condyle
Fractures in a Tertiary Health Center
Babatunde O. Akinbami*, Oladimeji A. Akadiri
Department of Oral and Maxillofacial Surgery, Dental Center , Un iversity of Port Harcourt Teaching Hospital,
Port Harcourt, Nigeria
Received May 16, 2013; revised June 18, 2013; accepted June 26, 2013
Copyright © 2013 Babatunde O. Akinbami, Oladimeji A. Akadiri. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original
work is properly cited.
ABSTRACT
Background: Condyle fractures are not common but could lead to detrimental effects of growth disturbance of the
mandible, ankylosis of temporomandibular joint and facial asymmetry especially in children, if not promptly and ade-
quately managed, the aim of this study was to document our experience in the management of mandibular condyle
fractures. Method: The fractures were classified based on the age of the patient, unilateral/bilateral, location on the
condyle, presence of displacement and dislocation, for those displaced, whether there was medial or lateral overlap, and
features presented. Treatment done for each patient was documented. Both clinical and radiological assessments were
done to ascertain the outcome of treatment. Result: 11 patients presented with 14 cond yle fractures, 3 patients w ith bi-
lateral and 8 with unilateral condyle fractures out of which 5 cases were on the right side. Age range of patients was
between 13 and 44 years with a mean (SD) of 25.3 (10.7) years. Nine (81.8%) of the patients were males and 2 (18.2%)
were females. Eight (72.7%) of the patients with condyle fracture had associated fractures affecting other sites of the
mandible while 3 (27.3%) patients had isolated condyle fractures. Intracapusular fractures recorded were 2 (14.2%),
while extracapsular accounted for 12 (85.8%) cases. Conservative treatment was not applied in any patient, 9 (81.8%)
patients had IMF and 2 (18.2%) patients had ORIF. Conclusion: Most fractures of the condyle were extracapsular and,
closed surgical treatment (IMF) was very useful to manage most of the cases.
Keywords: Classification; Management; Condyle; Fractures
1. Introduction
Fractures of the condyle of the mandible are rare [1].
Condyle fracture is a protective mechanism which pre-
vents fracture of the base of the skull [2]. It is commonly
an associated fracture with fractures of the body, sym-
physis or parasymphysis of the mandible due to trans-
mission of forces following impacts on these sites. It can
also occur in isolation as a consequence of direct impact.
These fractures have been classified as intracapsular or
extracapsular, un ilateral or bilateral and, head, neck (high
or low) subcondylar fractures based on the site [3]. In
addition, according to Lindahl, fractures of the condyles
can be classified into six, vertical slit of the head (type I),
horizontal break but mildly or not displaced (II), dis-
placement of the segments (III), there may be medial
overlap (IV) or lateral overlap (V) of the displaced
smaller proximal segment and a possible partial or com-
plete dislocation of the segment [3]. Rarely, fractures of
the condyle may also be communited (type VI) espe-
cially with gunshot injuries [3].
Aesthetics and restoration of function such as mouth
opening and mastication are important considerations in
the management of these fractures [4]. Others include
swallowing, occlusion, and control of symptoms like
pain, swelling and deviation [4]. Treatment ranges from
observation, jaw exercises to closed or open interven-
tions [5]. However in cases that require treatment many
surgeons have favored closed treatment to open treatment
in order to preven t some complications of open treatment
[6]. The purpose of this article wa s ther efo re to docu ment
our experience in the management of mandibular condyle
fractures.
2. Patients and Methods
All consecutive patients that presented with fractures of
*Corresponding a uthor.
C
opyright © 2013 SciRes. SS

B. O. AKINBAMI, O. A. AKADIRI 340
the condyle of the mandible to casualty or oral and max-
illofacial department of the University of Port Harcourt
Teaching hospital between May 2006 and December
2012 were included in the study. Informed consent was
obtained from the patients/relatives and the study was
approved by the hospital ethics and research committee.
The gender and age of the patients as well as the time of
presentation, site, side and associated symptoms like pain,
swelling, bleeding from the ear and deviation of the
mandible on opening or closing, restriction of mouth
opening and inability to close were retrieved from the
hospitals’ records and documented. Conventional Poste-
rior Anterior view, oblique lateral views of the mandible
or reversed Town’s view of the skull were taken to con-
firm the specific sites, degree of displacements, overlap
or dislocation. The fractures were classified based on age
of the patient, un ilateral/bilateral, lo cation on the condyle,
presence of displacement and dislocation, for those dis-
placed, whether there was medial or lateral overlap, and
features presented. Treatment done for each patient was
documented and was categorized as conservative treat-
ment, closed surgical and open surgical treatment. The
outcome of treatment was also documented. Both clinical
and radiological assessments were done to ascertain the
outcome of treatment. Favorable clinical outcome was
based on resolution of symptoms, restoration of occlu-
sion, unrestricted movements of the lower jaw, absence
of deviation or minimal deviation, facial symmetry and
improved inter-incisal distance. Radiographic outcome
was based on suitable alignment of the proximal and dis-
tal segments and reduced fracture gap.
3. Result
A total of 34 patients with mandibular fractures of vary-
ing sites were managed in our department out of which
11 (32.4%) patients presented w ith 14 condylar f ractures,
(Tables 1-3) 3 (27.3%) patients with bilateral and 8
(72.7%) with unilateral condylar fractures out of which 5
Table 1. Biodata and characteristics of the first consecutive patients.
S/No Sex/Age Side Site Displacement cause features Treatment Outcome
1. M/40 Both RT Sub
LT Low Neck Lateral overlap(V) Displaced(III) RTA Anterior open biteClosed reduction and IMF Satisfactory
2. M/33 RT Low Neck Medial overlap (IV) RTA Posterior open
bite/gagging Closed reduction and IMF Satisfactory
3. M/15 RT Low Neck Medial overlap(IV) Fall Posterior open
bite/gagging Closed reduction and IMF Satisfactory
4. M/16 RT Low Neck Medial overla p(IV) RTA Posterior open
bite/gagging ORIF Satisfactory
*Subco-subcondyle, LT-left, RT, right.
Table 2. Biodata and characteristics of the second consecutive patients.
S/No Sex/Age Side Site Displacement cause features Treatment Outcome
5. M/13 LT Head Mildly displaced(II)Fall
Posterior open
bite Closed reduction and IMF Satisfactory
6. M/21 Both RT Subco
LT Low Neck
Medial overlap (IV)
Displaced(III) RTA Posterior open
bite/gagging Closed reduction and IMF Satisfactory
7. F/26 RT Low Neck Medial overlap(IV)RTA Posterior open
bite/gagging Closed reduction and IMF Satisfactory
8. F/15 RT Low Neck Displaced(III) RTA
Posterior open
bite/gagging ORIF Satisfactory
*Subco-subcondyle, LT-left, RT, right.
Table 3. Biodata and Characteristics of the third consecutive patients.
S/No Sex/Age Side Site Displacement cause features Treatment Outcome
9. M/23 Both
LT Subc
RT Low
Neck
Lateral overlap(V)
Displaced (III) RTA Anterior open bite Closed reduction and IMF Satisfactory
10. M/44 RT Subco Medial overlap(IV)RTA
Posterior open
bite/gagging Closed reduction and IMF Satisfactory
11. M/32 LT Low Neck Medial overlap (IV)Fall Posterior open
bite/gagging Closed reduction and IMF Satisfactory
*
Subco-su bcondyle, LT-left, RT, right.

B. O. AKINBAMI, O. A. AKADIRI 341
(45.5%) cases were on the right side. Age range of pa-
tients was between 13 and 44 years with a mean (SD) of
25.3 (10.7) years. Nine (81.8%) of the patients were
males and 2 (18.2%) were females. Eight (72.7%) of the
patients with condyle fracture had associated fractures
affecting other sites of the mandible while 3 (27.3%)
patients had isolated condyle fractures. (Tables 1-3) In-
tracapusular fractures recorded were 2 (14.2%) {head
was 1 (7.1%) and upper neck was 17.1%)} while extra-
capsular accounted for 12 (85.8%) cases, the lower neck
of the condyle was the site most commonly involved
with 9 (64.3%) cases while the subcondyle was affected
in 3 (21.5%) cases respectively. All our patients pre-
sented within 24hrs of injury and 9 (81.8) % wer e due to
road traffic accident. Plain radiographs revealed gross
displacements with medial overlap (type IV) in 7 (50%)
of the 14 condylar fractures, lateral overlap (type V) in 2
(14.2%), there was moderate displacement (type III)
without overlap in 4 (28.6%), mild d isplacement (typ e II)
was present in 1 (7.1%) of the cases. When there was
bilateral fracture anterior open bite and gagging of occlu-
sion on both posterior sides were the prominent occlusal
derangements. All the unilateral cases with moderate to
gross displacements presented with features posterior
open bite on the normal side and gagging on the affected
side with deviation of the jaw to the affected side. Such
features were slightly altered when there were grossly
displaced fractures of other sites of the mandible. Con-
servative treatment (medication, jaw exercise and obser-
vation) was not indicated in any patient, while 9 (81.8%)
patients had closed treatment with intermaxillary fixation
using arch bars and 1 (9.2%) patient each had open re-
duction and internal fixation with bone plates and tran-
sosseous wires respectively. The submandibular ap-
proach was used for both patients. The patients were fol-
lowed-up for about 2 months postoperative and there was
satisfactory outcome in all the cases with complete re-
mission of pain, swelling and restriction in mouth open-
ings, correction of occlusal derangements and deviation
which was further improved with jaw exercise for at least
2 to 3 weeks. Alignment of the segments was satisfactory
in all the patients within 6 - 8 weeks following treatment.
4. Discussion
Fractures of the mandibular condyle account for 19% -
52% of all fractures of the mandible in the literature, in
our study [1-4], it was about 32.4%. Despite the fact that
the condyle is the weakest part of the mandible, fracture
of this portion of the mandible from direct impact is not
very common because of the protective and cushioning
effects of the muscles, meniscus, ligament, capsule and
surrounding bones [2]. However indirect impact as in
cases of contra-coup and parade ground fractures are
commoner. Such fractures to the condyle in most sce-
narios serve as a protective mechanism preventing trans-
mission of force and injury to the base of the skull [3].
Generally, bilateral cases which occur with impact on the
chin are much fewer than unilateral cases as observed
also in our study [4]. There is no side predilection in
condyle fractures as this is determined by the mechanics
of injury, the position of patient and impact direction.
Two classical features of intracapsular fracture involving
the head or upper neck of the condyle are bleeding from
the ear and supramastoid hematoma (Battle’s sign) [5-8],
however we did not study observe these features in our
study and this may be attributed to the fact that most of
our cases involved the extracapsular sites (lower neck
and subcondylar) of the condyle in contrast to other studies
with higher figures for intracapsular fractures [9,10]. In
addition, the few cases of fractures o f the head and upp er
neck may not be displaced backwards at the point of im-
pact; therefore the bony external acoustic meatus and
mastoid bone were not traumatized. Other features of
deranged occlusion an d deviation of the mandible in un i-
lateral fractures dominated our findings in this study and
this was similar in reports from other parts of the globe
[11-13]. Anterior open bite is classical in cases of bilat-
eral fractures that are moderately or grossly displaced
with either medial or lateral overlap (type III to VI)
based on Lindahl’s classification [14]. This is due to up-
ward pull of the lower segment by the muscles of masti-
cation and eventual telescoping of the upper condyle
segment. Based on the degree of displacement, half of
the fractures documented in this study are classified as
type IV with medial overlap of lower mandibular seg-
ment by the fragmented upper condylar segment. This is
not surprising, because the upper condyle segment is
usually pulled medially by the lateral pterygoid muscle.
The immediate objectives of treatment that must be
achieved include stabilization of the patient following
ABCDE protocol that is airway control, breathing, circu-
lation, CNS dysfunction, elimination of pain and swell-
ing, and achievement of close to normal occlusion [15].
There are controversies regarding the choice of treatment
amongst many surgeons but various factors such as the
age of the patient, duration of fracture, specific site of
fracture on the condyle, degree of displacement, time of
presentation and availability of funds and resources are
relevant considerations. Long-term objectives are aimed
at restoration of form and function of the jaw and facial
skeleton [16]. Definitive treatments to achieve these ob-
jectives are based on the principle of reduction, fixa-
tion/immobilization of the jaw/jaws. Broadly, treatment
can be closed reduction and IMF with arch bars if avail-
able or eyelet wires under GA or LA especially when
close to anatomical reduction is achievable [17]. It can
also be closed reduction and external fixation under GA
(frames and cap splint) if materials are available espe-

B. O. AKINBAMI, O. A. AKADIRI 342
cially for communited fractures which may be due to
gunshots. Open reduction and internal fixation (ORIF)
with plates (rigid) under GA offers the best option espe-
cially for gross displacements and patient who do not
want their mouth closed for a long period [18]. Open
reduction and transosseous wires (semi-rigid) are useful
when plates are not available [18].
Treatment should be done early enough to minimize
pain, swelling, prevent infection and enhance healing
with minimal callus, but it is better done when patients
are stable and respiration is not compromised [19]. Most
condylar fractures are treated with closed reduction and
intermaxillary fixation with arch bars using stainless steel
wires or elastic bands for immobilizing the jaws for
about 2 - 6 weeks depending on the age, time of presen-
tation, site/type of fracture, and severity of symptoms
[20].
Fresh cases unilateral or bilateral extracapsular frac-
tures in children or adults require IMF for 3 - 4 weeks
while cases of unilateral or bilateral extracapsular frac-
tures (lower neck and subcondylar) that have been left
untreated for sometime (>1 week) will need slow rubber
traction with a posterior bite plane to correct the contra-
lateral or anterior open bite caused by the marked overlap
of the fracture segments due to muscle spasms [21]. This
is placed on the teeth prior to intermaxillary fixation with
elastics bands around the hooks of th e arch bars.
When presentation is more than 1 month, consolida-
tion has begun and there will need for open reduction and
internal fixation. These were not applicable in our study
because all the patients presented within 24 hrs of injury.
Fractures affecting the head and upper neck are con-
fined within the capsule (intracapsular) and displace-
ments are usually minimal and most of these can be
treated with IMF in both children and adults [8,9,22].
However in longstanding cases that has malunited, ORIF
may be indicated to correct the deformities and asymme-
try especially in adults, most surgeons tend to avoid
ORIF in children to prevent ankylosis, facial nerve dam-
age and most importantly, growth disturbance [17,23].
Scar formation is another complication in Africans which
can be mitigated by endoscopic approach [24]. Dahlstrom
et al. [1] in their 15 years follow-up study on condylar
fractures treated by closed reduction, also documented
that there were no major growth disturbances amongst
the children and the function of their masticatory system
was good. There are no arguments against closed treat-
ment in children except that open treatment is preferred
for low level/subcondylar and dislocated fractures be-
cause of improved functional outcome associated with it.
Furthermore, for undisplaced intracapsular fractures
without symptoms like pain, swelling and deviation ch il-
dren and adults, conservative approach (no fixation) with
jaw exercises using tongue blades, acrylic or wooden
screws for 2 weeks may be sufficient. Frequently, be-
cause fracture to the head or high neck is intracapsular, it
is not usually displaced [8,9]. If there is no symptom,
observation of the patient and, assessment of mouth
opening and temporomandibular joint every 2 month
with serial TMJ X-rays [8,9].
If pain and swelling is present, recommended drugs
are (Augmentin 375 - 625 mg 8 hrly for 5 days and anal-
gesics like paracetamol 500 mg 8 hrly for 3 days or
tramadol 25 - 50 mg 8 hrly for 3 days for more severe
pains depending on the age. If there is restriction of
mouth opening and deviation then conservative therapy
with jaw exercise u sing tongue blades, acr ylic or wooden
screws for 2 weeks may be su fficient (no fixation), how-
ever this likely to be painful. So patient must be covered
with analgesics or done under relative analgesia if facil-
ity is available. If symptoms persist after 3 days, then
closed reduction and IMF with eyelets or acrylic cap
splints for 1 - 2 weeks fo llowed by jaw exercise is appli-
cable [25].
If there is displacement in head or high neck fractures,
especially when accompanied with other symptoms, then
the fracture is treated with closed reduction and IMF for
2 - 4 weeks followed by jaw exercise, analgesics, antibi-
otics for 1week and postoperative follow-up and review
with serial X-rays [26]. Open reduction and internal fixa-
tion is not indicated for undislocated fractures of condyle
head and upper neck in children because of reasons al-
ready mentioned and technical difficulties in manipulat-
ing the small upper condyle segments [27].
Absolute indications for ORIF include lateral overlap
displacements in extracapsular fractures, fractures asso-
ciated with dislocations of the condylar head, failure to
achieve satisfactory occlusion following closed reduction
and, presence of foreign bodies in the joint [28]. How-
ever ORIF can be done in a patient who has no dentitio n
and where a splint is unavailable or when splinting is
impossible because of alveolar ridge atrophy and when
splinting is not recommended for medical reasons or
where adequate physiotherapy is impossible in bilateral
or unilateral subcondylar fractures [28]. Also in bilateral
condylar fractures associated with comminuted mid-fa-
cial fractures and bilateral subcondylar fractures with
associated gnathologic problems, such as retrognathia or
prognathism, open bite with periodontal problems or lack
of posterior support, loss of multiple teeth and later need
for elaborate reconstruction, bilateral condylar fractures
with unstable occlusion due to orthodontics, and unilat-
eral condylar fracture with unstable fracture base [28].
Avulsion or gross communition of condyle bone seg-
ments will require costochondral or sternoclavicular joint
bone grafts and reconstruction plates for fixation [29].
The sternoclavicular graft does not have the demerit of
hyperplastic growth is seen in costochondral grafts. Bone

B. O. AKINBAMI, O. A. AKADIRI 343
morphogenenic proteins, hydroxyappatite blocks and
Beta TriCalcium phosphates, medpors (polyethelene)
with or without hyaluronic acid are now available as al-
loplasts to minimize donor site mobilities [30]. The
above treatment is also useful for old, malunited and non
united fractures. After refracturing, debriding and fresh-
ening the bony ends, it is necessary to fill gap with can-
cellous chips and apply reconstruction plates. Condyle
implants like the Lorenz or Christensens type are avail-
able for total joint replacements [29,30].
In conclusion, many of the fractures of the condyle of
the mandible documented in this study were extracapsu-
lar and with medial ov erlap and, 81.8 % of our cases were
managed by closed surgical treatment (IMF) while open
surgical treatment (ORIF) was indicated in two (18.2%)
cases. The first was based on surgeon’s choice and avail-
ability of funds to purchase the plates while the second
was based on the presence of lateral overlap of the seg-
ments which may not be easily corrected by closed re-
duction. Conservative management was not indicated in
any patient because there were obvious displacements
which could be worsened by either mastication or rigor-
ous jaw exercise without any form of fixation.
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