What is the appropriate management for a non‑displaced fracture of the mandibular ramus and condyle?

Treatment of Non-Displaced Mandibular Ramus and Condyle Fractures

Non-displaced fractures of the mandibular ramus and condyle should be managed conservatively with medication for symptomatic relief and early functional physiotherapy, without any invasive treatment or maxillomandibular fixation. 1

Diagnostic Confirmation

Before finalizing treatment, confirm the non-displaced nature of the fracture with appropriate imaging:

• Obtain CT maxillofacial with multiplanar and 3-D reconstructions as the primary diagnostic modality, which provides nearly 100% sensitivity for detecting subtle displacement in the ramus and condyle that may be missed on conventional radiography. 2
• CT is specifically critical for ramus and condyle fractures because the degree of displacement in these areas can be subtle and underestimated on plain films. 3
• Do not rely on panoramic radiographs alone, as they have only 86-92% sensitivity and notable limitations for detecting anteriorly displaced condylar fractures. 2

Screen for Associated Injuries

Given the high incidence of concomitant injuries, systematically evaluate for:

• Obtain CT head imaging, as coexisting intracranial injuries occur in approximately 39% of patients with mandibular fractures. 2
• Screen for blunt cerebrovascular injury (BCVI) in patients with condylar or extracapsular subcondylar fractures, as these constitute a recognized risk factor for BCVI with high morbidity and mortality if missed. 2
• Assess for cervical spine injury, which occurs in approximately 11% of patients with mandibular fractures. 2
• Examine for inferior alveolar nerve damage by testing for anesthesia or paresthesia of the lower lip, chin, anterior tongue, and mandibular teeth. 2

Conservative Management Protocol

For truly non-displaced fractures without occlusal derangement:

• Provide medication for symptomatic pain relief without any invasive treatment, maxillomandibular fixation, or surgical intervention. 1
• This approach is supported by evidence showing no significant difference in occlusion, trismus index, mandibular movements, or masticatory efficiency between conservative and invasive treatments for non-displaced fractures. 1
• Initiate early functional physiotherapy to prevent long-term complications such as chronic pain, mobility limitation, and temporomandibular joint dysfunction. 4

When to Escalate Treatment

The conservative approach is appropriate only when specific criteria are met. Escalate to closed or open reduction if:

• Any displacement of fractured fragments is present, even if subtle, as this requires closed reduction with maxillomandibular fixation. 1
• Occlusal derangement exists, particularly malocclusion or open bite. 1, 4
• The condylar process is dislocated out of the glenoid fossa, especially in bilateral cases, which requires open reduction with internal fixation. 1
• Bilateral condylar fractures with symphyseal fracture (flail mandible) are present, as this pattern threatens airway patency. 3

Critical Pitfalls to Avoid

• Do not miss a second fracture after identifying the first one—67% of mandibular fractures occur in pairs due to the U-shaped configuration of the mandible. 2
• Do not underestimate displacement by relying on conventional radiography, which will miss subtle displacement that changes management from conservative to operative. 2
• Do not overlook the 20-40% incidence of additional injuries beyond the mandible. 3
• Recognize that condylar fractures can cause long-term complications including malocclusion, reduced posterior facial height, facial asymmetry, and chronic temporomandibular joint dysfunction if not properly managed. 4

Arrange Follow-Up

• Obtain immediate oral and maxillofacial surgery consultation for definitive management planning and to confirm the appropriateness of conservative management. 2
• Schedule close follow-up to monitor for delayed displacement, occlusal changes, or development of temporomandibular joint dysfunction. 5