Executive Editor: Marcelo Figari, Gregorio Sánchez Aniceto General Editor: Daniel Buchbinder

Authors: Ricardo Cienfuegos, Carl-Peter Cornelius, Edward Ellis III, George Kushner

Mandible - Condylar process and head, simple and complex

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Glossary

General considerations

The indications for condylar process fracture treatment are controversial, even among expert surgeons. At this point in time, consensus has not been reached. The surgeon must take into account the following considerations:

  • Location of the fracture
  • Amount of vertical reduction in height of the ramus
  • Degree of angulation
  • Degree of luxation of the condylar head out of the glenoid fossa
  • Fragmentation pattern (simple versus complex)
  • Association with other mandibular injuries
  • Dental occlusion/status of dentition
  • Association with other facial bone injuries
  • Association with systemic injuries
  • Association with the condition of the patient (comorbidity factors)
  • Foreign body in temporomandibular joint (TMJ)
Observation
Main indication Skill Equipment
Non- or minimally displaced fractures in compliant patient. Basic surgical experience, no specialized skills Basic equipment only

Requirements

  • Minimally or nondisplaced fracture
  • Dentate patients should have a stable occlusion over time
  • Acceptable level of pain
  • Patient compliance

Patient must be advised that additional treatment may be required if complications arise during the observation period.

Closed treatment
Main indication Skill Equipment
Standard method of treatment for non-dislocated or minimally displaced fractures in compliant patients with good dentition and amenable for MMF. Basic surgical experience, no specialized skills Basic equipment only

Closed reduction is a misnomer. Often there is no anatomic reduction of the fracture. Closed treatment results in a functional adaptation by the patient to achieve a repeatable occlusion.

Advantages

  • Minimally invasive technique
  • Can be performed under local anesthesia at the surgeon’s practice.
  • Many patients favor nonoperative techniques for management of their fractures where possible.
ORIF, one/two plate(s) - extraoral approach
Main indication Skill Equipment
Displaced fractures resulting in shortening of the ramus height or when the fracture segment interferes with normal mandibular function. Highly experienced and skilled surgeon Simple surgical and imaging resources

The main advantage of an extraoral approach is the direct access and improved visualization of the fracture for reduction and fixation.

ORIF, one/two plate(s) - intraoral approach
Main indication Skill Equipment
Low condylar process fractures. Some specialized surgical experience Full specialized surgical and imaging resources

Advantages:

  • Avoidance of injury to the facial nerve
  • No need for cutaneous access with the consequent scar.

It is more difficult to treat higher condylar process fractures using this surgical approach.

Note: intraoral approaches require formal specialist training and specialized equipment.

ORIF, one/two plate(s) - endoscopically assisted
Main indication Skill Equipment
Higher condylar process fractures amenable to an intraoral approach with endoscopic assistance. Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Note: intraoral approaches and endoscopic assistance require formal training of the surgical team and specialized equipment. Endoscopic equipment can be very expensive and difficult to maintain.

Be prepared for a back-up strategy.

 

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2008-12-01