Condylar Fracture

Contents

 Introduction  Incidence  Anatomy  Etiology  Classification of Fracture  Clinical Examination  Treatment of the Fracture  Complications of the Fracture  Conclusion

Introduction

Condylar fractures are the most common overall fractures of the mandible. Condylar fractures account for 25% to 35% of all mandibular fractures. Fracture of the neck of the condyle can be regarded as a safety mechanism which protects the patient from the serious consequence of middle fossa fracture. Fractures involving the mandibular condyle are the only facial bone fractures which involve a synovial joint.

Fracture of condyle may be consequence of an indirect blow and direct blow. Indirect blow as when the external force, being applied in an anteroposterior direction and from below upwards upon the chin, the head of the condyle is forced against the prominent margins of the glenoid cavity. From a direct blow as when moving object strikes the region of the joint forcibly and impinges upon this part of the bone.

Incidence

The relative weakness of the mandible in the region of the neck would appear to make it the most vulnerable part of the whole jaw.

Incidence of condylar fractures may be as high as 35.6%. (Rowe & Killey, 1968) Tasanen et. al. 1975 -> 32.4%

Ekholm 1961 -> 27.7%

Schuchardt et.al. 1966 -> 25%.

Children under 15 years of age :

Hall et.al. (1983) reviewed 2194 maxillofacial injuries treated at the royal children's hospital, Melbourne, Australia from 1970-1979.

982 fractures of the facial bones were sustained, of which 242 (24.6%) occurred in the mandible.

98 of the mandibular fractures affected the condyle. 22 (22.4%) of which were located in the condylar head 76 (77.6%) were subcondylar fracture.

64 of the 98 fractures exhibited a displacement of 45° or less; 11 (11.2%) were displaced between 45° and 90°, 1(1.02%) was laterally displaced and 22 (22.4%) of cases sustained trauma to the articular head without displacement.

Lindane (1977) found that all types of condylar fracture occurred irrespective of occlusion and that the location of the most distal occlusal contact did not influence the type or magnitude of dislocation of the condylar fragment. In patient with unilateral fractures, injuries to the teeth were more often seen with intracapsular fractures than with subcondylar fractures.

Fonseca (1974) pointed out a relatively high incidence of condylar fractures in road traffic accidents, speculating that the mouth is likely to be open, either to scream or in fright at the moment of impact, and contrasted this with the low incidence in boxing where the boxer uses a mouth protector and has a tendency to keep the teeth clenched into the soft mouthpiece.

Anatomy

Anatomy of condyle is important to predict and manage the effect of trauma.

Muscles – Several muscles act upon the mandibular condyle, ramus and boyd. Lateral pterygoid muscle act upon the condyle. Lateral pterygoid muscle is often described as having a superior and inferior portion. The superior lateral pterygoid muscle originates from the inflatemporal surface of the greater wing of the sphenoid and inserts on the temporomandibular joint capsule and disk and the neck ofthe mandibular condyle. The insertion is primarily on the medial aspect of these structures. The superior portion of the lateral pterygoid muscle functions when the mandible is elevated against resistance. The inferior portion of the lateral pterygoid muscles originates from the lateral surface of the lateral pterygoid plate and inserts on the condylar neck. These muscles function during protrusion and lateral excursive movements of the mandible.

Blood Vessels – The temporomandibular joint itself is relatively a vascular the soft tissue surrounding the mandibular condyle and subcondylar region is highly vascular. End branches of the external carotid artery travel on both the medial (maxillary artery) and lateral (superficial temporal artery) aspects of the condylar head and neck. The external carotid artery bifurcates in the parotid gland region, developing into the maxillary and superficial temporal arteries.

Superficial Temporal Artery – This artery in the pre-auricular region runs in the temporoparietal fascia just beneath the subcutaneous fat layer. This artery crosses lateral to the zygomatic arch and forms a single branch, the transverse facial artery. After crossing over the zygomatic arch the superficial temporal artery divides into the frontal and parietal branches.

Maxillary Artery – The maxillary artery is the largest terminal branch of the external carotid artery. It originates from the external carotid medial to the condylar neck at the level of the sigmoid notch. It first travels through the parotid gland posterior and medial to the condylar neck and then runs along the inferior portion of the lateral pterygoid muscle. The first portion of the maxillary artery, termed the mandibular portion, travels through the infratemporal fossa in close proximity to the medial aspect of the mandibular condyle and neck. In this region the maxillary artery divided into several branches, including the deep auricular, anterior tympanic, middle meningeal, accessory meningeal and inferior alveolar arteries. The second portion of the maxillary artery also partitions into several branches. The masseteric artery detaches from the maxillary artery and travels through the sigmoid notch before entering the medial surface of the masseter muscle.

Retromandibular Vein – The superficial temporal vein and the maxillary vein unite, forming the retromandibular vein, within the body of the parotid gland medial to the mandibular condyle neck. This vein descends through the parotid gland superficial to the external carotid artery and deep to the facial nerve. It travels just posterior to the ramus of the mandible and divides into an anterior and a posterior portion. The anterior portion joins the facial vein and then empties into the internal jugular. The posterior portion joints the posterior auricular vein and then empties into the external jugular vein.

Nerves

Facial Nerve – The facial nerve emerges from the brain-stem and enters the internal auditory meatus. It travels through the petrous portion of the temporal bone in the

facial canal and exits the skull base at the stylomastoid foramen. The main trunk of the facial nerve is 2 cm deep to the skin surface at the middle of the anterior border of the mastoid process. The posterior auricular nerve and branches to the posterior digastric and stylohyoid muscle arise from the facial nerve as it exits the skull base. The nerve then courses forward toward the parotid gland. It crosses over the styloid process, retromandibular vein and external carotid artery before entering the parotid gland and dividing into the temporal facial and cervical facial branches. The mean distance from the lowest portion of the bony external auditory canal to the bifurcation of the facial nerve was 2.3 cm and that from the post glenoid tubercle was 3 cm. At kayat and branmley also found that distances from the most anterior portion of the bony external auditory canal to where the upper trunk crossed the zygomatic arch ranged from 0.8 cm – 3.5 cm. This defined the 8 mm 'safe zone' for preauricular incisions. In the body of the parotid gland the temporal facial and cervical facial branches further divide into the nerve's terminal branches (temporal, zygomatic, buccal, mandibular and cervical). The temporal branch travels in, or just deep to, the temporal parietal fascia. It innervates the frontalis, corrugator and orbicularis oculi muscles.

Trigeminal Nerve – The third division of the trigeminal nerve exists the skull base through the foramen ovale. At this point the nerve is 4 cm from the skin surface and just anterior and deep to the condyle neck. The motor root of the third division of trigeminal nerve supplies motor innervation of the muscle of mastication. The auricular temporal nerve (branch of the third division of trigeminal nerve) courses laterally behind the condyle neck and supplies sensation to skin in the temporal and pre-auricular region, the external auditory meatus and the tympanic membrane. The

lingual nerve (next branch) travels in an anterior direction deep to the lateral pterygoid muscle. The nerve continues laterally, emerges from under the lateral pterygoid and runs between the mandibular ramus and medial pterygoid muscle. The inferior alveolar nerve is initially deep to the lateral pterygoid muscle. It emerges below the inferior surface of the muscle, crosses the spheno-mandibular ligament and enters the mandibular foramen.

Etiology

A etiological factors leading to condylar fractures may be grouped as – 1) Intentional Trauma – Interpersonal violence/fish fight, etc.

2) Unintentional Trauma – Motor vehicular accidents, fall on the chin, sports injuries, industrial mishaps etc.

Mechanism of Injury

Lindanl (1977) divided trauma causing condylar injury into three groups.

1) Kinetic energy imparted by a moving object through the tissues of static individual. This commonly results from trauma sustained from a fist during sporting activities, or in the course of some industrial accidents.

2) Kinetic energy derived from the movement of the individual and expended upon a static object. This type of injury is more often seen in an epileptic patients or soldiers who fall on the face during parade.

3) Kinetic energy which is a summation of forces derived from a combination of 1 and 2 and, therefore, generally produces a more severe type of injury such as typically occurs in a road traffic accident.

The position of the fractured condyle in relation to the other fractured segment will depend on certain factors :

1) The direction and degree of the forces resulting from impact. 2) The precise point of application of force.

3) Whether the teeth were in occlusion or not at the time of injury. 4) Whether the patient is partially or fully edentulous.

In case of patient is wearing a denture or is having the posterior teeth in occlusion at the time of injury, the contact between the upper and lower teeth would minimize the consequences of the impact, but if such protection is not possible, then the patient may sustain a severe fracture dislocation of one or both the condyles.

If the patient receives a blow on the chin, the force of the impact is transmitted upwards and backwards direction along the length of the mandible. If the blow is delivered with great force, it would force the condylar head through the glenoid fossa, into the middle cranial fossa.

The vector force to the symphysis can determine where condylar injury will occur. The most common cause of condylar fracture is blunt trauma delivered directly to symphysis, parallel to the inferior border. For example in most case of vehicular trauma, the mouth is open at the point of impach, which allow majority of the force to be delivered to the weakest part of the mandible. A force directed perpendicular to the inferior border is likely to result in dental trauma and less likely to cause condylar fracture or intracapsular trauma.

When the blow is received in the centre of the chin, the distribution of force is equal to both the condyles, resulting in a bilateral indirect fracture of the condylar neck along with the direct fracture of the symphysis.

This type of injury is more often seen in an epileptic patients or soldiers who fall on the face during parade. If the force is received from the lateral direction or if the teeth are out of occlusion, then the fracture of the condyle will be with little or without displacement.

Classification of Condylar Fractures

1) Unilateral or bilateral condylar fractures 2) Rowe and Killey's classification

a) Simple fractures of condyle b) Compound fractures of condyle

c) Comminuted fracture associated with zygomatic arch fractures 3) Rowe and Killey's Classification (1968)

a) Intracapsular fractures or high condylar fractures i) fractures involving the articular surface

ii) fractures above or through the anatomical neck, which do not involve the articular surfaces.

b) Extra capsular or low condylar or subcondylar fractures. Here the fracture runs from the lowest point of cunature of the sigmoid notch, obliquely downward and backward below the surgical neck of the condyle to the posterior aspect of the upper part of the ramus.

c) Fractures associated with injury to the capsule, ligaments and meniscus.

d) Fractures involving the adjacent bone – eg. fracture of the roof of the glenoid fossa or the tympanic plate of the external auditory meatus.

4) Clinical classification by Maclennan (1952)

a) No displacement : A crack fracture is seen without alteration of the normal relationship of the condylar head to the glenoid fossa or of the neck of the condyle to the ramus.

c) Displacement : Overlap occurs between the condylar process and the ramus. The obliquely fractured condylar fragment lies lateral to the ramus.

d) Dislocation : Disruption takes place between the condylar head and the glenoid fossa. The condylar fragment gets pulled anteriorly and medially by the lateral pterygoid muscle.

5) Wassmund's Classification (1934)

a) Type I : Fracture of the neck of the condyle with slight displacement of the head. The angle between the head and axis of the ramus varies from 10-45°. These type of fractures tend to reduce spontaneously.

b) Type II : An angle of 45-90° is seen between the head and the ramus. There is tearing of the medial portion of the joint capsule.

c) Type III : The fragments are not in contact. Head is displaced medially and forward due to the pull of lateral pterygoid muscle and spasm. The fragment is generally confined within the area of the glenoid fossa. The capsule is turn and head is outside the capsule open reduction is advocated.

d) Type IV – Fractured head articulates on or forward to the articular eminence. e) Type V – Vertical or oblique fracture through the head of the condyle (rare). 6) Comprehensive Classification

Proposed by Lindhal (1977), which required radiographs in two planes at right angles to each other.

a) Fracture level : This may be as follows :

i) Condylar head fracture, intracapsular : They are divided into : - vertical (anterioposterior sagittal split)

- compression (producing a mushroom type of expansion) - comminuted

ii) Condylar neck – The radiographic constriction representing the condylar neck corresponds anatomically to the region of the inferior attachment of joint capsule.

iii) Sub condylar –

b) Relationship of condylar fragment to mandible – This may be as follows : i) Undisplaced (or fissure fracture)

ii) Deviated – This is a simple angulation of the condylar process in relation to main mandibular fragment without overlap.

iii) Displaced with medial overlap of the condylar fragment. iv) Displaced with lateral overlap of the condylar fragment. v) Anteroposterior overlap is possible, but intraquent. vi) Without contact between the fragments.

c) Relationship of condylar head to fossa – The following relationship may be observed : i) No displacement : joint space appears normal.

ii) Displacement : joint space is increased, but condyle is still related to the glenoid fossa. Lindhal subdivided this into slight displacement and moderate displacement but quantification is difficult.

iii) Dislocation : Condylar fragment is completely out of the fossa. The actual location of the fragment to the fossa is usually antero-medial.

d) Injury to meniscus – It may be turn, ruptured/herniated in forward/backward direction.

7) Thoma (1945) classified fractures in a simple way taking into consideration the direction of displacement.

A) Condylar fracture

1. Without displacement of condyle

 Greenstick fracture

 Intracapsular

 Extra capsular

2. With displacement of condyle

 Lateral

 Medial

 Forward

 Backward

3. With overriding of fragments

4. With dislocation in lateral or medial direction

 Intracapsular

 Complete fracture dislocation

 Complete dislodgement of the condyle

 Dislocation of the fractured part of the head of the condyle. 5. With dislocation in forward direction

 Anteriorly from the articular eminence

 Posteriorly from the articular eminence

 With dislocation and displacement of the meniscus

 With comminution

 Old fracture with o Pseudoarthrosis o Ankylosis

B) Sub condylar fracture

1. Without displacement of fragment 2. With displacement of fragment

C) Spiessel and Schroll classification (1972) 1. Non displaced fracture

2. Low neck fracture with displacement 3. High neck fracture with displacement 4. Low neck fracture with dislocation 5. High neck fracture with dislocation. 6. Head fracture

Clinical Examination

Condylar fracture are the most common overall fractures of the mandible and are the ones most commonly missed on clinical examination.

They may be unilateral or bilateral and they may be intra capsular or extra capsular. The most common displacement is anteromedial owing to the direction of pull of the lateral pterygoid muscle, which is attached to the anteromedial aspect of the condylar head and to the meniscus of the tempromandibular joint.

Unilateral Condylar Fractures Sign and Symptoms

 There is often swelling and tenderness over the temporomandibular area.

 There may be haemorrhage from the ear on that side results from laceration of the anterior wall of the external auditory meatus.

 Ecchymosis of the skin just below the mastoid process on the same side. This particular physical sign also occurs with fractures of the base of the skull when it is known as 'Battle's sign'.

 If the condylar head is dislocated medially and all oedema has subsided due to passage of time, a characteristic hollow over the region of the condylar head is observed.

 Deviation of the mandible on opening toward the involved side.

 Unilateral posterior crossbite and retrognathic occlusion also be associated.

 Paraesthesia of the lower lip in the absence of a fracture of the body or angle of mandible on that side.

 Displacement of the condyle from the fossa or overriding of the fractured condylar neck shortens the ramus on that side and produces gagging of the occlusion on the ipsilateral molar teeth.

 Painful limitation of protrusion and lateral excursion to the opposite side.

 Tenderness over the condylar area on palpation. Bilateral Condylar fractures

 The signs and symptoms for unilateral fracture may be present on both sides.

 Overall mandibular movement is usually more restricted than in unilateral fracture.

 Swelling over both fracture sites.

 If both fractures have resulted in displacement of the condyles from the glenoid fossa or overriding of the fractured bone ends, an anterior open bite is present.

 There is pain and limitation of opening and restricted protrusion and lateral excursions.

 They are frequently associated with fracture of the symphysis or parasymphysis.

Principles of treatment of condylar fracture

Condylar fracture depends upon the patient's age, can be treated either conservatively or radically by open reduction.

In recent years, open treatment of condylar fractures has become more common, probably because of the introduction of plate and screw fixation devices that allow stabilization of such injuries.

1. Conservative :- This involves immobilization by intermaxillary fixation. The time duration for this treatment may range from 7-10 days as in case of unilateral fracture to 4 weeks or more as in bilateral fracture with anterior open bite.

2. Functional :- The emphasis here is given on active movement. The principle is that the risk of ankylosis can be prevented by active movement.

3. Surgical :- A variety of surgical approaches have been devised using miniature bone plates to provide from fixation.

The first two are forms of closed treatment and the third one is an open method.

Treatment of Condylar Fractures

Closed Technique (Conservative Treatment)

This term is utilized for all kind of the fractures other then surgical intervention. The closed technique is applied to all kinds of unilateral of bilateral fractures other than those with gross displacement. Primary goal of conservative and functional treatment is to facilitate active jaw movement as early as possible and as long as the patient can bring his/her teeth into occlusion. When excessive pain or gross malocclusion is present, intermaxillary fixation is recommended which would not exceed a period of two weeks.

Indications

 Condylar fracture with minimum displacement and minimum occlusal disturbance.

 In cases of slight deviation of the mandible on opening the mouth. Open reduction

The objective of surgical treatment is achieved by exposure of the condylar fragment, reduction to the normal relationship and fiaxation in that position.

Zide and Kent (1983) have outlined the indications for open reduction. Zide and Kent's indication of open reduction

1. Absolute Indications

 Displacement of condyle into middle cranial fossa.

 Impossibility of restoring occlusion by closed reduction.

 Lateral extra capsular displacement.

2. Relative indications

 Unilateral or bilateral condylar fractures where in intermaxillary fixation is not recommended for medical reasons.

 Bilateral condylar fractures in case of edentulous patients where splinting is not recommended for reason like atrophic residual alveolar ridge.

 Bilateral condylar fractures with comminuted mid face fractures.

 Bilateral condylar fractures in patients with orthognathic problems such as retrognathia or prognathia, lack of teeth in the posterior segment, mandible requiring reconstruction and open bite with periodontal support.

Surgical Approaches

There are three principal approaches to a fractured condyle. 1. Preauricular approach

2. Submandibular approach 3. Intraoral approach

1. Preauricular approach – This is the most direct approach in high subcondylar and neck fractures and also in fracture dislocations where medial exploration is facilitated.

2. Submandibular approach – This gives good access in cases of low subcondylar fractures.

3. Intra oral approach – An incision is made from high on the anterior border of the ramus downwards to the retromolar region. The tendinous attachment of the temporalis is exposed. Medial dissection is carried out to identify the inferior alveolar nerve at the mandibular foramen. With intra and extra oral

digital manipulation the medially dislocated condylar fragment is repositioned in the glenoid fossa.

Methods of fixation of Condyler Fractures

There are a variety of methods of fixation of condylar fractures.

1. Transosseous wiring – This is occasionally used in low subcondylar fractures, particularly those extending through the sigmoid notch, access being obtained through the submandibular incision. It may be possible to drill and wire across the fracture at one or even two sites in a conventional manner. It is best to pass the wire through the hole in the major fragment first so that this may be used for downward traction to improve access to the condylar fragment. A pull through wire will be needed for passing the wire through a hole drilled in the minor fragment.

For higher level fracture approaches through a preauricular incision Thoma (1954) advocates a special sequence. The fragments are drilled obliquely from the external surface to the fracture surface. This facilitates insertion of the wire and decreases the danger of injuring the blood vessels on the medial aspect, particularly the maxillary artery. If there is lateral overlap of the condylar fragment, this fragment is drilled first. Since this is more accessible. When this has been done an instrument, such as a small bone elevator, is inserted between the bone ends and is used to reverse the overlap so that the mandibular fragment becomes accessible for drilling. A pull through wire is again needed for the second insertion. Where there is medial overlap the sequence is reversed.

2. Bone pins – Archer (1975) describes the insertion of pins into the condylar head and neck which are connected with an external bar and universal joints. 3. Plating – A small monocortical non-compression bone plate may be used for

rigid fixation, which usually requires contouring to compensate for the outward flaring of the condyle.

4. Gut Suture – Wassmund (1934) describes drilling a small hole through the lateral edge of the glenoid fossa and the related edge of the condylar articulating surface. A chronic catgut suture can be looped through and tied. It may, however, resorb or loosen prematurely with unpredictable results, as reported by Herfert (1961).

5. Kirschner wire – A Kirschner wire may be drilled vertically through the main mandibular fragment from the angle, avoiding the inferior alveolar bundle, so that it enters the fracture interface and can be further inserted into the condyle which has previously been reduced. Petzel (1982) describes a technique using self tapping intramedullary screw pins inserted from a submandibular incision. The lower end is secured to a countersunk nut which, when tightened, exerts a degree of compression at the fracture site.

Surgical Technique (Endoural modification of preauricular approach)

 Scalp is shaved and head prepared and draped for sterile surgery.

 General anaesthesia is administrated through nasoendotracheal intubation.

 Injection of local anaesthetic solution containing vaso-constrictor beneath the line of incision not only reduces bleeding but can be useful in defining tissue planes.

 Once the preauricular incision is made, it is carefully deepened in layers following the plane superficial to the perichondrium of the external auditory meatus.

 Care should be not to inure the temporal branch of facial nerve.

 Now carefully blunt dissection is done to locate the proximal fractured segment, which is likely to be displaced in forward and medial direction. Here care should be taken not to injure the parotid gland, facial nerve and its branches.

 After identifying the proximal segment. It should be reduced to its anatomical position. For this purpose we can use a bone pin near the neck of the condyle to manipulate it more conveniently into the correct anatomical position.

 To get a correct relationship between the fractured segments one must do IMF prior to the surgery.

 Once the fractured segments are reduced four miniature holes are made using a drill to stabilize the attained result.

 Care is taken to preserve the insertion of the pterygoid muscles.

 Intermaxillary fixation is removed to verify the opening, closing, protrusive, retrusive and excursive movements of the mandible.

 Finally, haematosis is secured before closing the wound in layers.

 No drains are used.

 Patients should be informed not to perform any physical jaw exercise in the immediate postoperative period.

 Mouth opening, overbite, overjet, mandibular mobility and Temporomandibular joint function are evaluated.

Treatment protocol for different types of condylar fracture 1. For children under 10 years of age

This age group is more likely to develop ankylosis and growth disturbance due to the condylar fracture. The treatment is completely functional for both unilateral and bilateral condylar fractures. Intermaxillary fixation may be required for a period of 9-10 days in case of extreme pain.

2. Adolescents 10-17 years of age

The treatment protocol is same for this group. If malocclusion is present the capacity for spontaneous correction is less than in the younger group. Therefore intermaxillary fixation is indicated for a period of 2-3 weeks in such cases.

3. Unilateral intracapsular fractures in adults

The occlusion is usually undisturbed and the fracture should be treated conservatively without immobilization of the mandible.

In one of malocclusion, intermaxillary fixation is indicated for a period of 2-3 weeks.

4. Unilateral extracapsular fractures is adults

A low condylar neck fracture is treated by open reduction method in case of severe malocclusion caused by the fracture or dislocation.

No effective treatment is necessary if the fractured segments are not displaced, and there is no disturbance to the occlusion.

5. Bilateral intracapsular fractures in adults

These fractures represent the slightly deranged occlusion. The degree of displacement of the two condyles may be different therefore an intermaxillary

fixation required for a period of 3-4 weeks for stable union. Physiotherapy after intermaxillary fixation prevents any restriction of the mouth opening. 6. Bilateral extracapsular fracture in adults

These fractures present the major problem in treatment. Usually this fracture results in instability and gross displacement of the mandible.

Although the intermaxillary fixation will establish the occlusion, it will not reliably reduce the fracture on both sides. Open reduction of at least one side to establish the normal height is recommended and then the treatment protocol is same that for unilateral extra capsular fracture. If bilateral extra capsular fracture is associated with other gross mid facial fracture, open reduction of the both the sides should be considered.

In case of bilateral high condylar neck fractures where open reduction is likely to be difficult, intermaxillary fixation should be applied for upto 6 weeks.

Complications of Condylar Fracture

In considering any treatment the two most important complications of condylar injury must be considered which are ankylosis and disturbance of mandibular growth in children.

A) Ankylosis – Ankylosis is the development of significant or complete limitation of movement of the temporomandibular joint by bone or fibrous tissue.

According to Laskin, the factors predisposing to ankylosis are:

1. Age of the patient – The predisposition is greater in younger patients (below 10 years) than the older patients.

2. Site and type of fracture – Intracapsular fractures are associated with high risk of ankylosis. Laskin considers that the most important feature in a fracture encouraging ankylosis is close contact between the glenoid fossa and the condylar stump and that this is more likely to occur with intracapsular fractures than with extra capsular fractures.

3. Duration of immobilization – According to some authors, prolonged immobilization may be a contributory cause for ankylosis.

4. Damage to meniscus – Laskin has suggested that the position and state of the meniscus may be the key factor in determining whether post traumatic ankylosis will develop. The meniscus acts as a barrier between the glenoid fossa and the condylar head. Therefore bony union does not occur in a condylar fracture wherein the meniscus is intact, but If meniscus is damaged or misplaced then ankylosis may occur.

Disturbance of mandibulr growth in children

Disturbance of growth is seen in small proportion of children in whom the fracture involves condylar cartilage and the articular surface. In some cases fibrous or bony ankylosis of the tempromandibular joint in an additional complication. This reduces the normal functional movement of the jaw which further inhibits growth. The effect of damage to this area will cause failure of development of condylar process as well as retarded growth of the mandible on the affected side.

Conclusion

Condylar fractures are most common fractures of the mandible. Because of relative weakness of mandible in this region, neck of mandible is the most vulnerable part of the whole jaw.

It is unfortunate that there are still no clear guide lines for the treatment of mandibular condylar fracture. Fractures can be treated by conservative treatment using closed reduction and by surgical treatment using open reduction. Treatment type should be selected considering patient's age, fracture type. Patient's systemic status, other fracture and existence of foreign materials.

If these fractured are not recognized and treated appropriately, these fractures can result in marked pain, dysfunction and deformity.

References

 Textbook of Oral and Maxillofacial Surgery

 Neelima Anil Malik (2nd

Edition)

 Textbook of Oral and Maxillofacial Injuries

 N.L. Rowe and J.L.L. Williams (Volume One)

 Textbook of Oral and Maxillofacial Surgery

 Fonseca (Volume One)

 Textbook of Oral and Maxillofacial Surgery  S.M. Balaji