Journal of Cranio-Maxillofacial Surgery (2006) 34, 421–432 r 2006 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2006.07.854, available online at http://www.sciencedirect.com Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals Nicholas ZACHARIADES, Michael MEZITIS, Constintine MOUROUZIS, Demetrius PAPADAKIS, Athena SPANOU Oral and Maxillofacial Department, KAT (Trauma Rehabilitation Center), General District Hospital of Attica (formerly: ‘‘Apostle Paul’s’’ Trauma Hospital) Kifissia, Athens, Greece SUMMARY. Introduction: The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) or intracapsular, undisplaced, deviated, displaced or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and the dental occlusion, and the surgeon’s experience. Purpose: This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment. Material and methods: The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted. Results: Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively. Conclusions: Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with ‘medical problems’ where intermaxillary fixation is not recommended. r 2006 European Association for Cranio- Maxillofacial Surgery Keywords: condylar fractures with/without displacement; dislocation INTRODUCTION The proportion of condylar fractures among all mandibular fractures is between 17.5% and 52% (Zachariades et al., 1983; Bochlogyros, 1985; Zachar- iades & Papavassiliou, 1990; Stylogianni et al., 1991; Silvennoinen et al., 1992; Newman, 1998; Marker et al., 2000a; de Riu et al., 2001; Miloro, 2003; Villarreal et al., 2004). Indeed, according to Killey (1974), the most common unilateral fracture is of the condyle, and the most common bilateral fracture is of the condylar heads. According to Villarreal et al. (2004) they are the most controversial fractures regarding diagnosis and management. Most are not caused by direct trauma, but follow indirect forces transmitted to the condyle from a blow elsewhere. Consequently condylar fractures are those most commonly missed (Silvennoinen et al., 1992; Lee et al., 1993 Pereira et al., 1995). Their displacement is determined by the direction, degree, magnitude and precise point of application of the force, as well as the state of dentition and the occlusial position. With adequate molar support and the teeth in occlusion, little or no displacement is likely to be sustained, while with the mouth widely open the full force will be transmitted to the condyles (Rowe and Killey, 1968). Direct impact leads to a unilateral fracture (MacLennan, 1969) as the weak condylar neck breaks easily and there is no intracranial displacement; thus the condyle protects the brain in mandibular frac- tures (Oikarinen, 1994). There are two types of fracture, intracapsular and extracapsular (MacLennan, 1969), but for practical purposes, the anatomical level of the fracture is divided into three sites: the condylar head (intracap- sular), the condylar neck (extracapsular) and the subcondylar region (Lindahl, 1977; Laskin,1991; Zhang and Obeid, 1991; Silvennoinen et al., 1992; Newman, 1998; editorial, 1999). The fracture is classified as: undisplaced, deviated, displaced (with medial or lateral overlap, or complete separation), and dislocated (outside the glenoid fossa) (MacLen- nan, 1969; Lindahl, 1977; Zhang and Obeid, 1991; Silvennoinen et al., 1992; Newman, 1998; Hyde et al., 2002). Lindahl (1977) also classifies condylar head fractures into horizontal, vertical, and compression types. According to Lindahl, (1977) condylar head dislocation is more frequent in children. Four elements determine articular function following condylar fracture, the fracture site and ARTICLE IN PRESS 421