Background
During the last 2 decades, many studies on the treatment of mandibular condyle fracture have been published. However, the timing and methodology of treatment are still widely debated, despite the advent of new technologies, such as advanced computed tomography (CT), and new materials such as titanium fixation devices.
The incidence of mandibular condyle fracture is variable, ranging from 17.5 to 52% of all mandibular fractures. The main causes of this type of fracture are road traffic accidents (approximately 50%), falls (30%), and personal violence (20%). In addition, age, gender, and the cause of fractures show a statistically significant association with the incidence of mandibular condyle fractures, with bicycle accidents (24.61%), car accidents (23.07%), and falls (23.07%) being the most common causes of such fractures among women.
Mandibular condyle fractures are categorized into 2 groups: intra- or extra-capsular fracture; this categorization is based on the anatomical aspects such as the condylar head, condylar neck, and subcondylar region. Another classification method is based on the condyle position, i.e., undisplaced, deviated, displaced (with medial or lateral overlap or complete separation), or dislocated (outside the glenoid fossa) condyle fractures.
Further, sagittal or diacapitular mandibular condylar fractures are very rare and difficult to identify via conventional radiography. These fractures do not require any surgical treatment but require early mobilization. Therefore, these cases were excluded, as they do not fall under the scope of this study.
A variety of treatment options are available according to the clinical symptoms and diagnostic findings of the fracture, e.g., unilateral or bilateral fracture, displacement, dislocation, size and position of the condylar segment, dental malocclusion, mandibular dysfunction, and patient's willingness to receive surgical treatment. Other important parameters that may affect the final treatment choice are the surgeon's experience, patient's age, and general health status.
Skin surgical approaches as well as fixation methods are still highly debated although the number of proponents of surgical treatment has been gradually increasing throughout the last decade. The majority of the papers published in a recent 5-year period (2006–2011) have discussed and recommended the surgical treatment of condylar fractures rather than using conservative approaches.
Several studies have focused on the absolute and relative indications for the open reduction of mandibular condylar fractures. Zide and Kent described what was considered the "gold standard" treatment during the early 1980s (see the Zide and Kent's indications for open reduction section). Obviously, the indications for surgery versus conservative treatment were based on the materials and surgical techniques available at that time.
Zide and Kent's Indications for Open Reduction (1983)
Absolute
Displacement into middle cranial fossa
Impossibility of obtaining adequate occlusion by closed reduction
Lateral extracapsular displacement
Invasion by foreign body
Relative
Bilateral condylar fractures in an edentulous patient without a splint
Unilateral or bilateral condylar fractures where splinting cannot be accomplished for medical reasons or because physiotherapy is impossible
Bilateral condylar fractures with comminuted midfacial fractures, prognathia or retrognathia
Periodontal problems
Loss of teeth
Unilateral condylar fracture with unstable base
With the application of rigid internal fixation (RIF) techniques to the cranio-maxillofacial skeleton in the mid-1980s, new indications and contraindications have slowly evolved on the basis of perceived advantages or disadvantages of one technique over another. This transition can be observed through the numerous attempts by various authors to formulate clear indications for the surgical treatment of mandibular condylar fractures. Several approaches have been proposed: the preauricular approach followed by retroauricular, submandibular, coronal, or intraoral incision or a combination of these approaches.
In the last few years, some authors have considered another method: transoral endoscopic-assisted open reduction. This method is a valid alternative to the transcutaneous approach for the reduction and fixation of extracapsular condyle fractures in selected cases. With regard to fracture fixation, the use of numerous devices and methods has been reported, ranging from external fixation to rigid internal fixation. Only a few authors have reported the long-term clinical and radiological follow-up details exclusively after surgical treatment of mandibular condylar fractures. After performing routine surgical treatment of mandibular condylar fractures for several years, we reviewed our case series and performed a retrospective study to present our long-term clinical and radiological findings.