What is the treatment for a suspected condylar fracture of the mandible?

Treatment of Mandibular Condylar Fractures

CT maxillofacial without IV contrast is the most appropriate initial imaging for suspected mandibular condylar fractures, followed by treatment based on fracture characteristics, with most cases responding well to conservative management. 1

Diagnosis and Imaging

• CT maxillofacial without IV contrast provides superior delineation of osseous and soft-tissue structures with high image resolution, allowing detection of subtle nondisplaced fractures with nearly 100% sensitivity 2
• Orthopantomogram (OPG) may be appropriate in patients with low clinical suspicion, but has limitations including poor visualization of condyle and subcondylar fractures with anterior displacement 2
• Clinical signs suggesting condylar fracture include pain during jaw movement, malocclusion, facial asymmetry, limited mouth opening, and deviation of the jaw to the affected side when opening 3
• Anesthesia or paresthesia of the lower lip, chin, and mandibular teeth may occur if the fracture involves the mandibular canal 3

Treatment Algorithm

Conservative Management (First-line for most cases)

• Indicated for: 4, 5, 6

  • Non-displaced or minimally displaced fractures
  • Most intracapsular fractures
  • All condylar fractures in children
  • Unilateral fractures with minimal occlusal disturbance
  • Patients with medical contraindications to surgery

• Conservative approach includes:

  • Medication for symptomatic relief 5
  • Closed reduction with maxillomandibular fixation for 4-6 weeks in cases with occlusal disturbance 7
  • Early mobilization and physiotherapy after fixation period 4

Open Reduction with Internal Fixation

• Indicated for: 4, 5, 7

  • Severely displaced or dislocated fractures
  • Bilateral condylar fractures with occlusal disturbance
  • Loss of ramus height
  • Edentulous patients with displacement
  • Patients where maxillomandibular fixation is contraindicated

• Surgical approach considerations:

  • Facial nerve monitoring can mitigate risk of nerve damage during exposure 7
  • Semirigid fixation techniques provide stability while allowing early mobilization 5

Endoscopic-Assisted Reduction with Internal Fixation

• Best suited for: 7

  • Mildly displaced fractures
  • Patients with multiple injuries who cannot tolerate closed reduction
  • Cases where open approach carries high risk of complications

• Limitations:

  • Reduction can be difficult with significant medial displacement of proximal fragment 7

Outcomes and Complications

• Conservative treatment results in good outcomes with only 13% of patients having minor physical complaints after one year 6
• Only 3% experience pain in the joint or muscles and 2% have malocclusion after conservative management 6
• Risk of malocclusion is highest with bilateral fractures and dislocation of the condylar head from the fossa 6
• Early mobilization is key in preventing complications regardless of treatment approach 4

Associated Injuries to Consider

• 20-40% of patients with mandibular fractures have additional injuries 3
• Intracranial injuries occur in approximately 39% of mandibular fracture patients 3
• Cervical spine injuries are found in approximately 11% of patients with mandibular fractures 3
• Mandibular fractures often occur in pairs (67% of cases) due to the U-shaped configuration of the mandible 2