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AOSurgeryReference

Diagnosis
Fracturesofthecondylarprocessandhead
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Options
Classification
Generalconsiderations
Imaging
Clinicalfindings
Bilateralcondylarprocessfracture
Subcondylarfracture
Neckfracture
Nondisplaced,nondislocatedfracture
Biomechanics
Classification

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Generalconsiderations
Controversyhassurroundedallaspectsoffracturesofthecondylarprocess.There
havebeenseveralproposedclassificationmethodsofthesetypesoffractures.
Following,theAOclassificationispresentedalongwithasimplifiedversion.TheAO
classificationallowsforbettercommunicationbetweenradiologistsandsurgeons.On
theotherhand,thesimplifiedversionbetterreflectstheclinicaltreatment
implications.

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AOClassification
Thecondylarprocessandheadisasubunitofthemandibleandisdefinedbyan
obliquelinerunningbackwardfromthesigmoidnotchtotheuppermasseteric
tuberosity.Thecondylarprocessisdifferedintothreesubregions:
Head
Neck
Subcondylar(caudal)area

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Frontalview.

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Threelinesareusedtodefinethesesubregions:
Thefirstlineparallelstheposteriorborderofthemandible
Thesigmoidnotchlinerunsperpendiculartothefirstlineatthedeepestportionof
thesigmoidnotch
Alinebelowthelateralpoleofthecondylarheadthatisalsoperpendiculartothe
firstline.
Clinicalpearl:theneckregioncanbedividedintohighandlowhalvesbyequally
dividingthedistancebetweenthesigmoidnotchlineandthelateralpoleline.

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Treatmentimplicationssimplifiedclassification
Incontrasttothedescriptive,previouslydefinedanatomicalclassification,amore
simplifiedoneisoutlinedandusedintheSurgeryReference.
Thesurgeondecidestotreatcondylarprocessfracturesinanopenorclosedmethod.
Toperformanopenreductionandinternalfixation,theremustberoominthe
superiorfragmentforatleasttwoscrewsfixingthesameplate.
Clinically,thisequatestoopentreatmentofcondylarneckfracturesorsubcondylar
(caudal)fractures(A).Thesurgeonmayelecttoplaceoneortwoplatesdepending
onthelocationandconfigurationofthefracture.
Fracturesatalevelwherethereisinadequatespacefortwoholestobedrilledfor
theplate(B)requirespecialtechniquesofosteosynthesis.Forthatreason,among
others,mostsurgeonschooseclosedtreatmentforthesejointfractures.
Generalconsiderations

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Fracturesofthecondylarprocess(unilateralorbilateral)canoccurinisolation.They
aremoreoftencombinedwithothermandibularfractures.
Imaging

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Routinediagnosisofthistypeoffractureshouldincluderadiographstakenintwo
planesat90toeachothertheminimumrequirementisaPAviewandapanoramic
view.
CTordigitalvolumetomography(DVT)imagingmaybeusedasanalternative.
Panoramicviewshowingleftcondylarprocessfractureinassociationwithananterior
bodyfracture.

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Townes(obliquePA)viewoftheabovepatient.Xraytakenat90toshow
displacementofleftcondylarprocessfracture.Verticalshorteningoftheleft
mandibleisnotedalongwiththerightanteriorbodyfracture.

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CTscansgivethesurgeonthebestinformationwithregardtofracturelocation,
morphology,fragmentation,andassociatedinjuries.
CTscan3Dreconstructionillustratesrightcondylarprocessfracture.
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Coronalviewoftheabovepatientshowsangulationandluxationofthecondylar
processfracture.
Clinicalfindings

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Thedentalocclusioncangiveorientationaboutthefracturelocation.Witha
unilateralcondylarprocessfractureandsubsequentreductionofheightintheramus
region,theclinicianwillseeanipsilateralprematureocclusionandcontralateralopen
bite.Thedentalmidlinewillshifttowardthesideoffracture.
Theocclusionshowsprematurecontactontherightwiththedeviationofthejawto
theaffectedsidethatiscommonlyseenwitharightmandibularcondylefracture.

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Bilateralfractureswithshorteninganddislocationresultinanterioropenbitewith
minimaldeviationofthemidline.

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Pitfall:wideningofthelowerface
Bilateralcondylefracturesassociatedwithfracturesofthesymphysisandbody
regionoftenproduceawideningofthemandibleandsubsequentmalocclusion.These
fracturesareverydifficulttotreat.Greatcaremustbetakenwhenperformingthe
openreductionandinternalfixationofthebodyfracturestoassurethemandibleis
narrowedtoitspreinjurystatus.Failuretorecognizeand/orcorrectthewideningof
thebodyfractureswillpreventanatomicreductionofthecondylarfracturesand
subsequentocclusalandfunctionalcomplications.
Bilateralcondylarprocessfracture

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CTand/ordigitalvolumetomography(DVT)isextremelyusefulespeciallyincasesof
highand/orintracapsularfracturesofthecondyle.
Thiscoronalviewdemonstratesbilateralcondylarprocessfracturewith
displacement.Onthepatientsrightsidethereisacondylarneckfracturewith
angulationandontheleftsidethereissagittalcondylarheadfracturemedialtothe
lateralpole.Ontherightside,theheightofthemandibleisnotreduced.
Theincreasedwidthofthemandibleinramus/condyleregionmayindicatethatthere
isanassociatedfractureintheanteriormandibulararch.
Subcondylarfracture

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Detailofapanoramicxrayshowingasubcondylarfracture.
Neckfracture

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Exampleof(low)neckfracture
Plainxraytakenat90todemonstratedisplacementofcondylarprocessfracture.
Townes

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andpanoramicviewsofa(low)neckfracture.

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Exampleofa(high)neckfracture
3Dreconstructionsareusefulinidentifyingfractureheight,directionandseverityof
displacement.
This3Dreconstructionillustratesa(high)neckfracturewithdisplacement.Notethe
associatedanteriorbodyfractureofthecontralateralside.
Nondisplaced,nondislocatedfracture

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Nondisplaced,nondislocatedfracturessuggestthepresenceofperiostealsupportfor
stabilityandmaynotrequireopentreatment.
XrayinthePAplaneshowsnoverticalshortening.

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Xrayshowsthatnodisplacementoccurred.
Biomechanics
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Huntingbowconcept
Themandibleissimilartoahuntingbowinshape,strongestinthemidline
(symphysis)andweakestatbothends(condyles).Themostcommonareaof
fractureinthemandibleisthereforethecondylarregion.
Ablowtotheanteriormandibularbodyisthemostcommonreasonforcondylar
fracture.Theforceistransmittedfromthebodyofthemandibletothecondyle.The
condyleistrappedintheglenoidfossa.Commonly,ablowtotheipsilateralmandible
causesacontralateralfractureinthecondylarregion.Iftheimpactisinthemidline
ofthemandible,fracturesofthebilateralcondylarregionareverycommon.

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Clinicalfindings
DirecttraumatotheTMJareaisunusualbutmaybeassociatedwithfracturesofthe
zygomaticcomplex.
Withacondylarfracture,thereisveryoftenshorteningoftheramusontheaffected
side.Thiswillresultinanipsilateralprematurecontactoftheteeth.Incaseof
bilateralfractures,thepatientmaypresentananterioropenbite.Thecondylar
fragmentmaybedisplaced(mostoftenlaterally)basedontheangulationofthe
fractureandpredominantmusclepull.

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