Original Article
PATTERNS AND CAUSES OF CONDYLAR FRACTURES — A STUDY
JAMEEL KIFAYATULLAH, BDS
2
FARRUKH JEHAN, BDS
3
FAHAD ASLAM, BDS
4
TANVEER HUSSAIN BANGASH, BDS
1
ABSTRACT
Mandibular condyle is one of the most common site of injury of the facial skeleton. It is also
the most commonly missed and least diagnosed fracture in the head and neck region. The condyle
forms the very corner stone of mandibular form and function. Therefore alterations in the anatomic
relationship and subsequently the function of this portion of the mandible due to its fracture may
significantly change occlusion and range of motion.
The objective of this study was to evaluate the patterns and causes of condylar fractures in patients seen in Maxillofacial Unit of Khyber College of Dentistry, Peshawar.
Detailed history, clinical and radiographic examination of 76 patients were performed. Data for
causes and patterns of condylar fracture were collected. Data analysis was done on SPSS 16.0.
Out of 76 patients with condylar fractures,58 (76.3%) were males and 18 (23.7%) were females.
The mean age was 17±1years with maximum number of patients belonged to the first decade of life
(42.1%) followed by second decade (26.3%). Most common cause of condylar fracture was Road traffic
accidents (44.7%) followed by fall (40.8%) and assault (6.6%). Extracapsular fracture was found in
46.1% patients followed by subcondylar fracture in 39.5% patients, and intracapsular condylar fractures in 13.2% patients. Condylar fracture in isolation was found in 17.1% patients while condylar
fracture in combination with other facial bones was found in 82.9% patients.
Key Words: Mandibular condyle fractures, facial bones, road traffic accidents.
INTRODUCTION
Maxillofacial trauma affects a significant percentage of trauma patients.1 Traumatic injury is identified
as a leading cause of reduced productivity, accounting
for the loss of more working years than heart disease
and cancer combined.2
Mandible performs an important role in mastication, phonetic and deglutition.3 It articulates at both
ends with the skull by temporomandibular joint (TMJ)
which is a diarthrodial joint and allows both rotational
and translational movements.4 The mandible is the
most commonly fractured bone of the face,5 and fracture of the condyle process is one of the most common
fractures of the mandible.6 The incidence of condylar
fracture varies from 25-36 %.7 Unilateral fractures are
Demonstrator in Oral Biology, Khyber College of Dentistry, Peshawar E-mail: [email protected] Cell: 0333-9287077
2
Trainee FCPS-II Oral & Maxillofacial Surgery
3
House Surgeon
4
Demonstrator in Oral & Maxillofacial Surgery, Foundation University Dental College, Rawalpindi
Received for Publication:
September 22, 2014
Revision Received:
October 30, 2014
Revision Accepted:
November 10, 2014
1
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
three times more common than bilateral one.8 In adults
Road Traffic Accident (RTA) is most common cause for
symphysis and condylar fracture of mandible.9 Other
causes comprise fall and aggression.10 Falls are the
most frequent cause of condylar fracture in children.11
Aetiology varies country wise and they can usually
be attributed to cultural, social, environmental and
economical factors.12
The prevalence of different types of condylar fractures is subcondylar (37.5%), intracapsular fractures
(35.6%) and condylar neck fractures (26.9%).13,14 In
children the three types of condylar fractures include
intracapsular crush fractures of the condylar head and
high condylar fractures through the neck above the
sigmoid notch. They are most common till six years of
age. The third type, which is most common, is a lower
subcondylar fracture associated with green stick fracture and is usually seen in children above six years of
age.15
The diagnosis of condylar fracture is based on clinical features and appropriate radiological investigations.
The clinical features include; pain and swelling in the
613
Patterns and causes of condylar fractures
preauricular region, trismus, malocclusion in the guise
of premature occlusal contact on the fractured side with
a slight posterior open bite on the non-fractured side,
an anterior open bite if there is fracture displacement
of both condyles, deviation on mandibular opening to
the fractured side. Definitive diagnosis of condylar
fractures is only possible with properradiological investigations.16
The radiographs used most commonly for diagnosis
of condylar fractures are orthopantogram (OPG) and
posteroanterior (PA) radiogram.17 The more advanced
imaging techniques such as CT- scans, CBCT and MRI
are usually reserved for complex injuries of the condyle
where surgical intervention is likely to be considered.18
Conservative management is the main stay of
treatment in the vast majority of condylar fractures
management.19 Closed reduction is the technique most
frequently employed to treat this type of fracture inspite
of all adversity of maxillomandibular fixation (MMF).20
Numerous methods of open reduction and plate fixation
fortreatment of condylar fracture have been developed
over the years to avoid MMF.21
The condylar fracture is documented to be a
leading cause of TMJ related complications such as
malocclusion, limitation of function, disc adhesion and
perforation, disc derangement, osteoarthritis, chronic
pain, mandibular growth alterations and ankylosis.22
In children the intracapsular compression fracture of
the condyle usually leads to masticatory disability and
temporomandibular joint ankylosis.23
The objective of this study was to evaluate the patterns and causes of condylar fractures in patients seen
in maxillofacial unit of Khyber College of Dentistry,
Peshawar.
METHODOLOGY
This descriptive cross-sectional study was done
in the department of Oral and Maxillofacial Surgery,
Khyber College of Dentistry, Peshawar from March
2012 to June 2014. Sample size of 76 patients was
calculated through computer based software named,
Sample Size determination in health studies by WHO
by Consecutive (non probability) sampling technique.
(Expected Prevalence of extracapsular (condylar neck)
fractures = 26.9%4, Expected error = 10%, Level of
confidence =95%,). The inclusion criteria consisted of;
(1) The patient presenting with fracture condyles due
to blunt trauma including RTA, fall, assault, sports
in isolation or in combination with other maxillofacial
injuries. (2) All age groups. (3) Both genders. The exclusion criteria comprised of condylar fractures resulting
from penetrating trauma incidents including fire arm
injuries and sharp blast injuries because these injuries are entirely different from blunt trauma and the
fracture line is distorted in these conditions.
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
The data were collected from patients who reported
to the Maxillofacial Unit of Khyber College of Dentistry, Peshawar with radiographically proved condylar
fractures. Study protocol and use of data for research
was explained to the patients and informed consent
was obtained. Approval of ethical committee was taken. All the necessary information about the variables
of the study (level/type, site and fracture event) were
collected by taking detailed history from the patients.
Extra oral and intraoral examination was performed.
In extra oral examination, facial asymmetry, swelling
and tenderness in the pre auricular region, chin abrasion or laceration, bleeding from the ears, crackling
sound upon palpation in auditory canals was noted.
In intraoral examination occlusion (contact of upper
and lower teeth) was assessed by asking the patient
to close the jaws, premature contact of the teeth (gagging) and open bite (no contact of teeth) was noted.
Any midline shift of the lower anterior teeth was also
noted. The definitive diagnosis of the patterns (type/
level, site, fracture event) was confirmed through Orthopantomogram (OPG) and Posteroanterior View Face
(PA-Face). CT scan was done in selected cases in case
of intracapsular fractures. The data were collected on
specially designed proforma and were analyzed using
SPSS version 16.0.
RESULTS
Out of 76 patients with condylar fractures, 58
(76.3%) were males and 18 (23.7%) were females. The
male to female ratio was 3:1. The mean age was 17±1
years with maximum number of patients presenting
in the first decade of life (42.1%) followed by second
decade of life (26.3%). The detail of age distribution is
given in the Table 1. Most common cause of condylar
fracture was Road traffic accidents (44.7%) followed by
fall (40.8%) and assault (6.6%). The detail of etiology
of condylar fracture is given in Fig 5.
On extraoral examination facial asymmetry was
noted in 44 (57.9%) patients. Tenderness in preauricular
area was noted in 63 (82.9%) patients. Chin abrasion
was present in 45(59.2%) patients. Bleeding from the
ear was noted in only 5(6.6%) patients. Crepitation in
pre-auricular area was found in 16 patients (21.1%)
(Table 2). On intraoral examination occlusion was disturbed in 82.9% patients. Anterior open bite was found
in 47.4% patients. Posterior open bite was observed
in 46.1% patients. Midline shift was found in 44.7%
patients (Table 3).
Extracapsular fracture was found in 46.1% patients
followed by subcondylar fracture in 39.5% patients, and
intracapsular condylar fractures in 13.2% patients. The
detail is given in Table 4. Unilateral condylar fracture
was seen in 68.4% cases while bilateral condylar fracture was seen in 31.6% cases (Table 5).
614
Patterns and causes of condylar fractures
TABLE 1: AGE DISTRIBUTION OF PATIENTS
Age
1-10
11-20
21-30
31-40
41-50
51.60
Total
Frequency
32
20
16
06
01
01
76
Percentage
42.1
26.3
21.1
7.9
1.3
1.3
100
TABLE 2: EXTRAORAL CLINICAL FEATURES
Clinical
features
Total No. of
patients
Affected
patients
Percentage
Facial
asymmetry
76
44
57.9
Tenderness
76
63
82.9
Chin
abrasio
76
45
59.2
Bleeding
from ear
76
05
6.6
Crepitation
76
16
21.4
TABLE 3: INTRAORAL FEATURES
Clinical
features
Total No.
of
patients
Affected
patients
Percentage
Disturbed
76
63
82.9
Anterior
ope bite
76
36
47.4
Posterior
open bite
76
35
46.1
Midline
shhift
76
34
44.7
TABLE 5: SITE OF MANDIBULAR CONDYLAR
FRACTURE
Site of
fracture
No of patients
(n)
Percentage
Unilateral fracture
52
68.4
Bilateral
24
31.6
Total
76
100.0
TABLE 6: FRACTURE EVENT
Site of
fracture
No of patients
(n)
Percentage
Isolated condylar
fracture
13
17.1
In combbinaton
with other facial
bones
63
82.9
Total
76
100.0
TABLE 7: CO-EXISTING FRACTURE OF
FACIAL BONES
Level of
fracture
No of patients
(n)
Percentage
Mandible fracture
43
68.25
Midfacial and mandible fracture
13
20.6
Midface fracture
7
11.11
Total
63
100.0
TABLE 4: LEVEL OF MANDIBULAR CONDYLE
FRACTURES
Level of
fracture
No of patients
(n)
Percentage
Extracapsular
fracture
35
46.1
Subcondylar
30
39.5
Intracapsular
(condylar hear)
10
13.2
Extracapsular
and subcondylar fracture
1
1.3
Total
76
100.0
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
Fig 1: Etiology of Condylar Fracture
Condylar fracture in isolation was found in 17.1%
patients while condylar fracture in combination
with other facial bones was found in 82.9% patients
(Table 6).
Condylar fracture in combination with mandibular fractures was found in 68.25% patients. Condylar
fracture in association with mandible and midfacial
fractures was found in 20.6% patients. Condylar fractures co-existing with midface fractures were found in
11.11% patients (Table 7).
615
Patterns and causes of condylar fractures
DISCUSSION
Mandibular condylar fractures are the most common fracture of facial bones.24 The increased incidence
of condylar fractures in the current in males may be
explained by the fact that males are more frequent
drivers and also tend to practice more physical contacts
and sports. In our setup social, economic and emotional
conflicts in males further increases the incidence of
condylar fractures. Also boys are more boisterous than
girls and spend more time outdoors. Sawazaki25 in his
study also reported that males were more commonly
affected than females with male to female ratio of 3:1.5.
In the present study the mean age of condylar
fracture was 17±1 years. The reason explained for
this is that the child is more enthusiastic to learn new
skills, and also more involved in outdoor activities. Also
this age group is the most active, careless and playing
period of life therefore making them prone to injuries.
Zachariades et al11 and Murad et al26 reported that
children have high proportion of condylar fracture.
While Sawazaki35 reported that greater prevalence
of condylar fracture was found in patients aged 10-30
years.
In this study the most common cause of condylar
fracture was Road traffic accident which accounted for
44.7% followed by fall 40.8%. This is because of careless
driving, ignorance of traffic rules, no vehicle safety
laws, overloading of vehicles, poor road infrastructure,
poor vehicle maintenance, lack of enforcement of traffic
rules, poor educational status of the drivers, inadequate
trauma care, lack of legislation and political will in
our part of the world. Marker et al27 in his study of
348 patients with condylar fracture found RTA as the
main cause followed by falls. While in another study
by Zachariades etal11 RTA is the most common cause of
condylar fracture which accounted for 57.8% of condylar
fracture.
In this study neck fracture was found in 46.1% cases
followed by subcondylar fracture which is 39.5% while
intracapsular fracture was found in 13.2% cases. The
reason is that condylar neck constitutes the weakest
region in the entire mandible and is therefore more
susceptible to fracture. Also as the mandible grows
and develops to structurally resemble that of adult
by age 7 or 8 years, most fractures are extracapsular
involving the condylar neck so in the neck portion it
become thin and more fragile and prone to fracture
whereas in children younger than 2 years of age, the
short , stout, and very vascular nature of condylar
head combined with its thin cortex makes this region
prone to intracapsular crush fractures. An increased
percentage of condylar neck fracture (46.1%) were seen
in this study because maximum number of children
were in mandibular growth phase. Thoren et al28 in
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
his study reported intracapsular fracture to be 14%.
In Lindhl studies29 condylar neck fractures presented
with 19.6% cases while subcondylar fracture presented
in 70.7% cases.
In our study unilateral condylar fracture was seen
in 68.4% cases while bilateral condylar fracture was
seen in 31.6% cases. Unilateral condylar fractures
are more common as compared to bilateral condylar
fractures in a study by Silvennoinen et al30, Murad
et al26, Smetset al31 and Khan32 68.5% unilateral condylar fractures were noted while bilateral condylar
fractures reported were 31.5% cases. This study is
consistent with the other national and international
studies when as far as the site distributionof condylar
fracture is concerned.
In this study condylar fracture in isolation was
found in 17.1% while condylar fracture co-existing
with other facial bones is 82.9%. Condyle fracture in
combination with other mandibular fracture was found
in 68.25%, in association with midfacial and other
mandibular regions was 20.6% while condylar fracture
co-existing with midface fractures was found in 11.11%.
The reason of this high association with other injuries
is due to elevated frequency of high energy impacts
in RTA and falls. Also one of the reason may be that
mandible is a U shaped bone which tends to fracture
at more than one points due to an impact. In a study
by Villareal14condylar fracture was associated with
other parts of fractured mandible in 54.8% cases while
condylar fracture co-existing with midface fracture was
found to be 8.3%. This finding correlates well with the
finding of the present study.
REFERENCES
1
Lida S, Kogo M, Sugiura T. Retrospective analysis of 1502
patients with facial fractures. Int J Oral Maxillofac Surg 2001;
30: 286-90.
2
Gassner R, Tuli T, Hach O. Craniomaxillofacial trauma: a
review of 9543 cases with 21,067 injuries. J Craniomaxillofac
Surg 2003; 31: 51-61.
3
Abbas I, Ali K, Mirza YB. Spectrum of mandibular fractures at
a tertiarycare dental hospital in Lahore. J Ayub Med coll 2003;
15(2): 12-4.
4
Annino DJ, Goguen LA. Pain from the oral cavity. Otolaryngol
Clin North Am 2003; 36(6): 1127-35.
5
Fasola AO, Nyako EA, Obiechina AE. Trends in the characteristics of maxillofacial fractures in Nigeria. J Oral Maxillofac
Surg 2003; 61; 1140-3.
6
Silvennoinen U, Raustia AM, Lindqvist C, Oikarinen K. Occlusal andtemporomandibular joint disorders in patients with
unilateral condylar fracture. A prospective one-year study. Int
J Oral Maxillofac Surg 1998; 27: 280-5.
7
Sverzut CE, Trivellato AE, Serra ECS, Ferraz EP, Sverzut AT.
Frey’s syndrome after condylar fracture: case report. Braz Dent
J 2004; 15(2): 159-62.
8
Eppley BL. Use of resorbable plates and screws in pediatric
facial fractures. J Oral Maxillofac Surg 2005; 63(3): 385-91.
616
Patterns and causes of condylar fractures
9
Martini MZ, Takahashi A, Neto HGO, Junior JPC, Curcio R,
ShinoharaEH. Epidemiology of mandibular fractures treated
in a Brazilian level I Trauma Public Hospital in the city of Sao
Paulo, Brazil. Braz Dent J 2006; 17(3): 243-8.
10 Valento ROH, Souza LCM, Antonini SV, Glock L, Nisa-Castro-Neto W. Epidemiology of mandibuar fracture assisted at
Santa Casa deMisericordia de Sao Paulo Hospital (HSCSP)
between 1996 and 1998. Revista Bras Cir Period 2003; 1: 141-6.
11 Zachariades N, Papavassiliou D, Koumoura F. Fractures of the
facialskeleton in children. J Craniomaxillofac Surg 1990; 18:
151-2.
12 Gilthorpe MS, Wilson RC, Moles DR, Bedi R. Variations in
admissions to hospital for head injury and assault to the head
Part 1: age and gender. Br J Oral Maxillofac Surg 1999; 37:
294-300.
13 Veras RB, Eckert AW, Schubert J, Maurer P. Long term outcomes after treatment of condylar fracture by intraoral access:
a functional and radiological assessment. J Oral Maxillofac
Surg 2007; 65: 1470-76.
14 Villareal PM, Monje F, Junquera LM, Mateo J, Morillo AJ,
Gonzalez C. Mandibular condyle fractures: determinants of
treatment and outcome. J Maxillofac Surg 2004; 62: 155-63.
15 Kalia V, Singh AP. Greenstick fractures of the mandible: a case
report. JIndian Soc Prev Dent 2008; 26: 32-5.
16 Dimitroulis G . Condylar injuries in growing patients. Australian
Dental Journal 1997; 42(6): 367-71.
17 Hlawitschka M, Eckelt U. Assessment of patients treated for
intracapsular fractures of the condyle by closed techniques. J
Oral Maxillofac Surg 2002; 60: 784-91.
18 Raustia AM, Pythinen J, Oikarinen KS. Conventional radiographic and computed tomographic findings in cases of fracture
of the mandibular condylar process. J Oral Maxillofac Surg
1990; 48: 1258-64.
19 Myall RWT. Condylar injuries in children: What is different
aboutthem. In: Worthington P, Evans JR. Controversies in oral
and maxillofacial surgery. 1st ed. Philadelphia: WB Saunders,
1994: 191-200.
21 Ellis E, Graham J. Use of 2mm locking plate/ screw system
formandibular fracture surgery. J Oral Maxillofac Surg 2002;
60: 642-6.
22 Long X, Li X, Cheng Y, Yang X, Qin L, Qiao Y, et al. Preservation ofdisc for treatment of traumatic TMJ ankylosis. J Oral
Maxillofac Surg 2005; 63: 897-902.
23 Guven O. A clinical study on temporomandibular joint ankylosis
in children. J Craniofac Surg 2008; 19(5): 1263-9.
24 Olson RA, Fonseca RJ, Zeitler DL. Fractures of the mandible:
a review of 580 cases. J Oral Maxillofac Surg 1993; 40: 23-8.
25 Sawazaki R, Junior SML, Asprino L. Incidence and pattern of
mandibular condyle fractures. J Oral Maxillofac Surg 2009;
68(6): 1252-9.
26 Murad N, Din Q, Khan M, Shah SMA. Condylar fractures in
children- a study. Pak Oral & Dent J 2010; 30(2): 291-4.
27 Buchbinder D. Treatment of fractures of the edentulous mandible,1943 to 1993: a review of the literature. J Oral Maxillofac
Surg 1993; 51: 1174-9.
28 Thoren H, Iizuka T, Hallikainen D, Nurminen M, Likndqvist
C. An epidemiologicalstudy of patterns of condylar fractures in
children. Br J Oral Maxillofac Surg 1997; 35: 306-11.
29 Lindahl L. Condylar fractures of the mandible. I: Classification
and relation to age, occlusion, and concomitant injuries of the
teeth and teeth-supporting structures, and fractures of the
mandibular body. Int J Oral Surg 1977; 6: 12-21.
30 Silvennoinen U, Iizuka T, Lindqvist C, Oikarinen K: different
patterns of condylar fractures: an analysis of 382 patients in a
3 year period. J Oral Maxillofac Surg 1992; 50: 1032-7.
31 Smets L, M, van Damme PA, Stoelinga PJW. Non-surgical treatment of condylar fractures in adults: a retrospective analysis.
J Craniomaxillofac Surg 2003; 31: 162-7.
32 Khan A, Khitab U, Khan MT, Salam A. A comparative analysis of rigid and non- rigid fixation in mandibular fractures: a
prospective study Pak Oral & Dent J 2010; 30(1): 62-27.
20 Walker RV. Condylar fracture. Non Surgical management. J
Oral Maxillofac Surg 1994; 52: 1185-7.
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
617