Operative Technique in Plastic Surgery – Kevin C.Chung

■ Full intraoral and dental examination
• Evaluate for anterior or posterior open bite in centric occlusion.
• Evaluate for dental trauma and overall state of dental health.
• Evaluate areas of wear on the teeth (“wear facets”) to determine which teeth
and where teeth made daily contact prior to the injury. These wear patterns
can give an idea of preinjury occlusion, as the occlusion may not have been
normal.
FIG 1 • Normal occlusion.
■ Tips
• Use tongue blade intraorally for complete soft tissue and dental evaluation.
• Previous dental imaging and molds can be used to determine preinjury
occlusion.
IMAGING
■ Panorex plain films may be used to diagnose mandible fractures and can be
used easily for postfracture follow-up.
■ CT imaging is superior to plain films for diagnosing and evaluating
mandibular fractures.
■ Noncontrast maxillofacial CT, with 3D reconstruction if available, is useful for

determining fracture patterns, identifying concomitant injuries, and planning
repair.1,2
SURGICAL MANAGEMENT
■ Indications for MMF3:
■ Temporary fragment stabilization as bridge to ORIF
■ Conservative treatment
■ Alveolar crest fractures
■ Tension band in conjunction with rigid internal fixation
■ Control of occlusion in the posttraumatic/postoperative period
Preoperative Planning
■ Nutrition optimization is important for postoperative healing.
■ For edentulous patients, consider intraoral prosthesis to maintain maxillary-
mandibular relation.
■ Appropriate preoperative evaluation of cardiopulmonary status is always
indicated prior to any surgical procedure.
■ Equipment
■ Erich arch bars and either 24- or 26-gauge dental wire (surgeon preference).
■ MMF set should include heavy needle drivers, wire cutting scissors, a pickle
fork, and intraoral retractors (ie, Weider adult cheek tongue retractor,
Minnesota, etc.).
■ Optional: MMF screws
■ Anesthesia
■ General anesthesia via nasotracheal intubation is preferred.
■ Orotracheal intubation with ETT posterior to the retromolar trigone and
submental intubation are other alternatives if nasotracheal intubation is not
possible.
■ Tracheostomy should be performed if there are contraindications to the
above-mentioned methods of anesthesia.
Positioning
■ The patient is placed in the supine position with a shoulder roll and arms
tucked.
T E C H N I Q U E S

■ Arch Bars
■ Check occlusion, paying attention to avulsed teeth and wear facets, to obtain
preinjury occlusion.
■ If possible, obtain prior dental records; however, this is often not possible in
the acute trauma setting.
■ Measure and cut appropriate length of arch bar required to span left second
molar to right second molar.
■ The arch bar should sit occlusal to the gingiva along the dental equator so as
to avoid damage to the gingiva. Furthermore, the arch bar hooks should lie
apical and symmetrical in the mandible and maxilla (TECH FIG 1A).
■ A 24- or 26-gauge dental wire is passed around each side of the most distal
molar with one end of the wire above and one end below the arch bar so that
when the wire is twisted down it will secure the arch bar in place (TECH
FIG 1B,C).
■ Make sure the arch bar is correctly positioned prior to twisting the ends of
the wire in a clockwise direction with a heavy needle driver:
■ Gently, pull up on the wire in a perpendicular direction to the arch bar
during the twisting process to remove all slack from the wire. This is
necessary to ensure the wire is tightened adequately.
■ Cut the wire, leaving 8 to 10 mm of the length to allow fold of the wire
inward away from the gingiva, and place it along the arch bar to avoid
gingival irritation.

TECH FIG 1 • A. Arch bar relationship to the teeth and
gingiva. B. First step in application of arch bars. C.
Completed application of arch bars.
■ Apply wires to the next tooth in a sequential fashion to span the arch bar
from left second molar to right second molar to prevent redundancy and
possible malocclusion:
■ Wires are placed in the interproximal spaces and apical to the widest
diameter of the crown.
■ Wires are placed around all molar and premolars due to stability of tooth
roots.
■ Wires can be placed around the canines and incisors; however,
recommendations are to include two teeth in each wire pass to disperse the
force of the MMF over both teeth.
■ After all wires are placed, check the stability of the arch bar by grabbing it
with an empty needle driver and seeing if it can be mobilized in any
direction:

■ If the arch bar is mobile, check all wires for tightness, and add additional
clockwise twisting as needed until the arch bar is immobile.
■ MMF is achieved by taking a looped wire and placing it along a minimum of
two hooks on each arch bar (upper and lower) and securing it in place with a
twist knot in the clockwise direction. Tight dental elastics can be wrapped
around upper and lower hooks and utilized for MMF instead of wire loops:
■ The benefit of elastics is ease of removal in case of emergent airway issues.
■ Their disadvantage is less rigid MMF, but this can be overcome with tight
placement.
■ MMF Screws (TECH FIG 2)
■ Primarily indicated in emergency cases, simple fracture patterns, and when
standard arch bars cannot be applied.
■ Contraindications include comminuted/displaced/unstable, mobile teeth, and
children, if tooth buds are present at the planned location of screw placement.
■ Check occlusion, paying attention to avulsed teeth and wear facets, to obtain
preinjury occlusion. If possible, obtain prior dental records.
■ The self-drilling and self-tapping screws are placed apical and in between
the canine tooth roots of the maxilla and mandible bilaterally.
■ Ensure screw head grooves are lying in same line to pass wire for MMF.
■ A total of four screws are used, with two located on the mandible and two on
the maxilla.
■ MMF is achieved with 0.4 mm wires passed through head grooves on the
screws in the maxilla and mandible and tightened in a clockwise direction
with a heavy needle driver:
■ Repeat for contralateral side.

TECH FIG 2 • A,B. Placement of MMF wires. C. MMF
screw in the mandible with wire loop to MMF screw in
the maxilla (upper screw not shown). Wire is passed
through channel in the screw head.
■ Rapid Fixation Hybrid MMF Systems
■ Multiple rapid fixation hybrid MMF systems are available for use.
■ These systems combine elements of both arch bars and MMF screws and can
be used to secure patients in MMF.
■ These systems are an additional option in patients with poor dentition.
■ Special Considerations in Edentulous Patients
■ Fracture stabilization with existing dentures, Gunning splints, or MMF
screws can be used in patients with edentulous mandibles.1
PEARLS AND PITFALLS
Wire
application
■ Proper occlusion and fracture reduction must be established before
complete tightening of the circumdental wires in the area of the
fracture in order to prevent malreduction by the arch bar.
■ When applying wires for arch bars, start in a sequential fashion from
distal molar to distal molar. An alternative is to start mesial and work
distally. This sequence prevents redundancy and possible
malocclusion.
■ When twisting wires to arch bar, start each strand length equidistant
from the twist to the crown. This helps reduce wire fracture due to
overtwisting.
■ Wires generally change from shiny to dull color just prior to
breakage. Learning to recognize the color change helps reduce wire
fracture.
■ While passing wires through the interproximal space during arch bar
application, pay careful attention not to injure the gingiva. Also, care
must be taken to prevent inadvertent needle injury to the surgeon.

POSTOPERATIVE CARE
■ Patients will be on a full liquid diet and should have nutrition counseling and
close monitoring of nutritional intake, with supplementation as needed.4
■ Oral hygiene can be poor during MMF, and, therefore, Peridex mouth rinse is
imperative in maintaining good oral hygiene.4
■ Dental wax can be used to protect oral mucosa from injury by wires and arch
bar hooks.
■ Routine follow-up at 2 and 4 weeks after surgery to evaluate healing and
assess occlusion.
■ Wire fixation can be released at 2 weeks after surgery, and the patient can be
transitioned to dental elastic band fixation for the remainder of MMF to permit
early motion of the TMJ joint.2,4 If there is a concern for adequate healing, a
panorex film can be obtained prior to switching from wire to dental elastic
fixation.
■ Fixation should be removed intraoperatively or 4 to 8 weeks postoperatively
pending fracture healing.
COMPLICATIONS
■ Overall, there is an increased risk of anesthetic complications in patients with
mandible fractures who are treated with MMF compared to those who are not.5
■ Additional complications include1,2,5
■ Aspiration
■ Gingival trauma and recession
■ Difficulty with oral hygiene
■ Delayed temporomandibular joint mobility
■ Malocclusion6–8
ACKNOWLEDGMENTS
We would like to acknowledge Paul Mittermiller and Peter Lorenz in
preparing this chapter.
REFERENCES
1. Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-based
medicine: mandible fractures. Plast Reconstr Surg. 2014;134(6):1381-1390.
2. Stacey DH, Doyle JF, Mount DL, et al. Management of mandible fractures.
Plast Reconstr Surg. 2006;117(3):48e-60e.
3. Cienfuegos R, Cornelius CP, Ellis E, Kushner G. Mandibulomaxillary

fixation. AO Foundation. December 1, 2008. Web. November 20, 2016.
4. Koshy JC, Feldman EM, Chike-Obi CJ, Bullocks JM. Pearls of mandibular
trauma management. Semin Plast Surg. 2010;24(4):357-374.
5. Saman M, Kadakia S, Ducic Y. Postoperative maxillomandibular fixation after
open reduction of mandible fractures. JAMA Facial Plast Surg.
2014;16(6):410-413.
6. Goth S, Sawatari Y, Peleg M. Management of pediatric mandible fractures. J
Craniofac Surg. 2012;23(1):47-58.
7. Allred LJ, Crantford JC, Reynolds MF, David LR. Analysis of pediatric
maxillofacial fractures requiring operative treatment: characteristics,
management, and outcomes. J Craniofac Surg. 2015;26(8):2368-2374.
8. Farber SJ, Nguyen DC, Harvey AA, Patel KB. An alternative method of
intermaxillary fixation for simple pediatric mandible fractures. J Oral
Maxillofac Surg. 2016;72(3):582.e1-582.e8.

69
CHAPTER
Open Treatment of Mandible
Fractures
Joseph Baylan and H. Peter Lorenz
DEFINITION
■ Mandible fractures are one of the most common facial bone fractures.
■ Without adequate treatment, fractures of the mandible can lead to
malocclusion, condylar resorption, and poor functional and cosmetic
outcomes.1
ANATOMY2,3
■ The mandible is a U-shaped bone composed of thick buccal and lingual
cortices with a thin medullary canal.
■ The mandible is divided into paired condyle, coronoid, ramus, angle, body,
parasymphysis areas with a single midline symphysis, and tooth-bearing
alveolus (FIG 1).
■ Blood supply to the mandible comes from the inferior alveolar artery and
direct muscular attachments.
■ The inferior alveolar nerve traverses the mandible in the medullary canal,
exiting at the mental foramen which is located inferior to the second premolar.
■ Muscles inserting on the mandible (FIG 2):
■ Muscles of mastication
• Masseter
• Temporalis
• Medial pterygoid
• Lateral pterygoid:
■ Suprahyoid muscles
• Digastric

• Stylohyoid
• Mylohyoid
• Geniohyoid
PATHOGENESIS
■ Two most common causes of mandible fractures are assault and motor vehicle
collisions.
■ Additional causes include gunshot wounds, falls, and sports injuries.
■ Most common location of fractures2,3:
■ Condylar (36%)
■ Body (21%)
■ Angle (20%)
■ Symphysis (14%)
■ Alveolar ridge (3%)
■ Ramus (3%)
■ Coronoid fractures (2%)
■ Displacement of fracture segments commonly occurs from differing forces of
inserting muscles3:
■ Muscles of mastication displace posterior segments superiorly.
■ Suprahyoid muscles displace anterior segment inferiorly.
■ The lateral pterygoid displaces condylar head medially.
■ Favorable mandible fractures3:
■ Nondisplaced by muscular pull.
■ Most rami fractures.

FIG 1 • Bony anatomy of the mandible.

FIG 2 • Muscle attachments of the mandible.
■ Unfavorable mandible fractures3:

■ Horizontal angle fractures that extend posteriorly and downward tend to be
displaced by muscles of mastication.
■ Vertical symphyseal and parasymphyseal fractures are displaced downward
by suprahyoid muscles.
■ High condylar fractures are displaced medially by the lateral pterygoid
muscle.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Focused history and physical exam:
■ Mechanism of injury.
■ Full intraoral and dental examination.
• Evaluate for anterior or posterior open bite in centric occlusion.
• Evaluate for deviation of the mandible upon opening.
• Palpate condyles in preauricular area and external auditory canal during
opening to assess translation and tenderness.
■ Evaluate for mental nerve paresthesias.
■ Tips.
• Use tongue blade intraorally for complete soft tissue evaluation.
• Gingival lacerations are typically present at fracture sites.
• Ecchymosis on the floor of the mouth is indicative of mandible fracture.
• Chin deviation suggests condylar fracture.
■ Concomitant injury evaluation:
• 2.6% of patients with facial fractures will have cervical spine injury.3
IMAGING
■ Panorex plain films may be used to diagnose mandible fractures.
■ CT imaging is superior to plain films for diagnosing and evaluating
mandibular fractures.
■ Noncontrast maxillofacial CT, with three-dimensional (3D) reconstruction if
available, is useful for determining fracture patterns, identifying concomitant
injuries, and planning repair.2,3
NONOPERATIVE MANAGEMENT
■ The majority of mandible fractures will require operative intervention.
■ Nondisplaced, stable fractures with normal occlusion can be treated with soft
diet and close follow-up.

■ Greenstick-type fractures or minimally displaced fractures in children with
normal occlusion can also be treated nonsurgically.3,4
■ In the case of edentulous mandibles, minimally displaced fractures can be
treated nonoperatively.3
SURGICAL MANAGEMENT
■ The main goal of operative intervention for mandible fractures is to restore
preinjury occlusion and restore mandibular form and function.2
■ Timing of surgery has no correlation to complication rates.2,5
■ Antibiotics:
■ All patients with mandible fractures should receive prophylactic antibiotics
from the time of injury until the fracture is treated.
• This practice has been shown to reduce postoperative infection from 50% to
6%.2
• Penicillin-based antibiotic is preferred or clindamycin for patients with
penicillin allergy.
■ Postoperative antibiotics have been shown to have no effect on infection
rates.2
■ Fracture patterns to consider:
■ Symphysis and parasymphysis: fracture is located in the anterior mandibular
portion between the canine teeth.
■ Body: fracture is located between canine and distal last molar.
■ Angle or ramus: fracture is located posterior to the second molar and triangle
between the horizontal and ascending ramus and often involving the third
molar.
■ Condylar and subcondylar fracture: fracture is located superior to the ramus
and is classified according to levels.
■ Indications for open reduction and internal fixation (ORIF):
■ Severely displaced fractures
■ Bilateral fractures
■ Open fractures
■ Comminuted fractures
■ Multiple fracture sites
■ Panfacial fractures
■ Infected fractures
■ Uncooperative patients

■ Patients with relative contraindication to MMF secondary to medical
conditions (seizures, malnutrition, etc.)
■ Indications for external fixation6:
■ Bridge until ORIF
■ Large segmental defect
■ Severe comminution
■ Infection present
■ Indications for removal of the teeth:
■ Grossly mobile teeth with periapical pathology or advanced periodontal
disease
■ Teeth preventing fracture reduction
■ Fractured tooth root
■ Exposed root apices
Preoperative Planning
■ Nutrition optimization is important for postoperative healing.
■ For patients with edentulous mandibles, consider the creation of an intraoral
prosthesis to help establish maxillary-mandibular relation.2,3
■ Appropriate preoperative evaluation of cardiopulmonary status is always
indicated prior to any surgical procedure.
■ Equipment:
■ MMF: Erich arch bars, 22- to 26-gauge wire.
■ Craniofacial mandibular plating system of preference. Different
manufacturer’s systems are similar, and venders include Stryker, DePuy
Synthes, and KLS Martin mandible plating sets. Choosing between systems is
by surgeon preference, which is generally based on comfort/familiarity of use
and availability at institution.
■ Power bur and drill system.
■ Anesthesia:
■ General anesthesia via nasotracheal intubation is preferred.
■ Orotracheal intubation with endotracheal tube (ETT) posterior to the
retromolar trigone and submental intubation are other alternatives if
nasotracheal intubation is not possible.
■ Tracheostomy should be performed if there are contraindications to the
above-mentioned methods of anesthesia.

Positioning
■ The patient is placed in the supine position with a shoulder roll and arms
tucked.
T E C H N I Q U E S
■ General Considerations
Fracture Exposure
■ Local anesthetic with epinephrine should be injected into incision sites prior
to making incisions.
■ Begin with lower buccal sulcus incision over the area of the fracture leaving
at least 10 to 15 mm gingival cuff at the unattached gingiva.
■ Use existing extraoral lacerations for additional exposure if needed.
■ Submental and submandibular approaches are alternatives to improve
reduction and access for complex fractures of the body and angle.
■ Expose fracture site in a subperiosteal plane paying careful attention to avoid
injury to the mental nerve with wide exposure (TECH FIG 1).
TECH FIG 1 • Incisions for access.

Initial Approaches to Fracture Reduction
■ Place patient in temporary MMF to help obtain preinjury occlusion.
■ If fracture is displaced, manipulate segments until anatomic reduction is
achieved.
■ Consider the use of bone hooks or screws as adjuncts to achieve reduction.
■ For comminuted fractures:
■ Realign fragments in a systematic fashion; superior to inferior, anterior to
posterior, etc.
■ Temporary miniplates can be used to help hold reduction during
realignment of fragments, but ensure plate location does not interfere with
placement of reconstruction plate.
■ Confirm mandibular condyles are seated.
■ Ensure reduction is held with predrilled holes and reduction forceps placing
clamps perpendicular to fracture line.
■ Alternative options include suture, wire, forceps, and an assistant.
■ The tendency is for splaying of the inner cortex of the mandible. Thus
reduction is often applied with a medial force on the gonial angle in
addition to a cephlad force to achieve reduction.
Plate Application (TECH FIG 2)
■ Ensure the length of plate is adequate to span the fracture site and allow for a
minimum of two screws on each side of the fracture site.
■ Prior to plate application, confirm reduction is held appropriately and
anatomically.
■ Ensure mandibular condyles are well seated to prevent an anterior open bite.
■ Plates should be contoured with plate bending pliers to fit flush with the
underlying bone.
■ Drill and insert the first screw without completely tightening it down for
adjustment of plate position.
■ Place the second screw on the other side of the fracture site, and then tighten
the first screw completely.
■ Fill remaining plate holes with screws.
■ Consideration of a reconstruction plate may be necessary in cases of
panfacial fractures or concomitant subcondylar fractures.
■ The superior border plate (tension band) will be monocortical to avoid

damage to the tooth roots.
■ The inferior border plate (compression band) will be bicortical and often
requires the use of a depth gauge to determine length of screw required.
■ For comminuted fractures:
■ Contour template to span the fracture and for flush placement of inferior
mandibular border, paying careful attention to avoid injury to the mental
nerve.
■ Contour reconstruction plate using the template as a guide by torqueing, in-
plane bending, and out-of-plane bending, as necessary.
■ Release MMF and ensure occlusion is appropriate. If concern for stability of
fracture fixation is present, replace the patient in MMF with wires or dental
rubber bands.
TECH FIG 2 • General plating technique.

■ Symphysis/Parasymphysis
Nondisplaced and Simple Displaced Fractures
■ The fracture should be stabilized with a minimum of two points of fixation.
■ See general considerations for initial approaches to fracture reduction.
■ After contouring, place two four-hole miniplates, 2.0 mm, at the fracture
site, superiorly and inferiorly at the mandibular border.
■ Apply monocortical screws below the apices of the tooth roots.
■ Apply bicortical screws a few millimeters superior to the inferior border.
■ See general considerations for plate application.
Comminuted Fractures
■ The fracture should be stabilized with a minimum of two points of fixation.
■ See general considerations for initial approaches to fracture reduction.
■ Length of plate is dictated by a minimum of two screws on each side of the
fracture to ensure load-bearing fixation.
■ Mobile fragments can be held in place by screws through the reconstruction
plate.
■ Remove temporary plates if interference with reconstruction plate is present.
■ Apply appropriate screws to reconstruction plate ensuring plate is flush with
the mandible.
■ See general considerations for plate application.
■ Body Fractures
Nondisplaced, Simple Displaced, and Oblique Fractures
■ The fracture should be stabilized with a minimum of two points of fixation.
■ See general considerations for initial approaches to fracture reduction.
■ For nondisplaced fractures, place two four-hole 2.0-mm miniplates at the
fracture site, superiorly and inferiorly at the mandibular border.
■ For displaced and oblique fractures, place a 2.0-mm miniplate superiorly and
a 2.4-mm compression plate inferiorly. An overbend of the compression plate
is typically useful to ensure lingual cortex approximation at the fracture site.
■ Apply monocortical screws below the apices of the tooth roots.
■ Apply bicortical screws a few millimeters superior to the inferior border. To

protect the mental nerve, the plate must lie below the mental foramen. The
use of retractors or transbuccal approach can ensure proper screw orientation.
■ See general considerations for plate application.
Comminuted Fractures
■ The fracture should be stabilized with a minimum of two points of fixation.
■ See general considerations for initial approaches to fracture reduction
■ Length of plate is dictated by a minimum of two screws on each side of the
fracture to ensure load-bearing fixation.
■ Mobile fragments can be held in place by screws through the reconstruction
plate.
■ Remove temporary plates if interference with reconstruction plate is present.
■ Apply appropriate screws to reconstruction plate ensuring plate is flush with
the mandible.
■ See general considerations for plate application.
■ Angle and Ramus Fractures
Nondisplaced, Simple Displaced, and Oblique Fractures
■ Consideration of plate placement should be either a plate along the external
oblique ridge (Champy plate) or two miniplates along the superior and
inferior border of the mandible.
■ See general considerations for initial approaches to fracture reduction.
■ Champy plate placement (TECH FIG 3):

TECH FIG 3 • Champy plate placed on the external
oblique ridge of the mandible through intraoral
approach.
■ Plate should be twisted 90 degrees to sit flush with the superior border of
the mandibular angle along the external oblique ridge.
■ Apply monocortical screws below the apices of the tooth roots and place
plate to sit flush against the underlying bone.
■ Two miniplate placement (TECH FIG 4):
■ The superior miniplate can be contoured to sit along the external oblique
ridge or along the superior border of the fracture.
■ After contouring, place a 2.0-mm miniplate superiorly with monocortical
screws.
■ A stab incision is made on the skin overlying the fracture to allow for

transbuccal trocar devices.
■ Apply bicortical screws a few millimeters superior to the inferior border.
■ The first screw should be placed posterior to the fracture site through the
transbuccal trocar.
■ The second screw is then placed anterior to the fracture site through the
transbuccal trocar ensuring adequate reduction.
■ Remaining screws are then placed.
■ See general considerations for plate application.
■ Do not hesitate to make an additional skin incision to aid in fixation.
Comminuted Fractures
■ See general considerations for initial approaches to fracture reduction.
■ To fully realign fragments, transbuccal trocar devices can be used.
■ Due to difficult location, a submandibular incision can be utilized by
avoiding injury to the marginal mandibular branch of the facial nerve.
■ Incision is made 2 to 3 cm below the inferior border of the mandible.
■ Divide platysma muscle 2 to 3 cm below mandibular border, and dissect in
a subplatysmal plane.
■ Below the mandibular border, the marginal mandibular branch lies anterior
to the facial vessels in subplatysmal plane. Identify with the nerve
stimulator or other nerve identification system.

TECH FIG 4 • Transbuccal trocar approach for inferior
border plate.
■ Identify and ligate facial vein, and retract vessel superiorly to also retract
marginal mandibular branch.
■ Divide pterygomasseteric sling, and incise the periosteum over the fracture
site.
■ Use temporary miniplates to help hold reduction during realignment of
fragments, but ensure plate location does not interfere with placement of
reconstruction plate.
■ Mobile fragments can be held in place by screws through the reconstruction
plate.
■ Remove temporary plates if interference with reconstruction plate is present.
■ Apply appropriate screws to reconstruction plate ensuring plate is flush with
the mandible.
■ Close pterygomasseteric sling and remaining layers of the wound.
■ See general considerations for plate application.
■ Condylar and Subcondylar Fractures
■ Condylar fracture lines are within the temporomandibular joint and capsule.
Subcondylar fractures are located below the temporomandibular joint
capsule.
■ Subcondylar fractures are generally treated conservatively due to potential
risk of necrosis of the condylar head from disruption of blood supply during
open reduction repair. Furthermore, because of the location, application of
plates and screws is difficult.
■ Treatment primarily consists of MMF for a minimum of 2 weeks when
nondislocated.
ORIF
■ Absolute indications for ORIF: (a) displacement of the condyle into the
middle cranial fossa; (b) difficulty in obtaining adequate occlusion by closed
reduction; (c) lateral capsular displacement of the condyle; or (d) invasion of
the condylar neck by a foreign body.7

■ An intraoral approach can be considered with incision over ascending ramus,
but this exposure can often be difficult to expose the fracture.
■ A retromandibular, retroparotid approach is advocated for exposure of the
condylar/subcondylar process. An alternative is a retromandibular,
transparotid approach (TECH FIGS 1 and 5).
TECH FIG 5 • Retromandibular, retroparotid approach
for exposure of the condylar/subcondylar process. An
incision has been made through the SMAS and the
parotid gland dissected off the masseter. The
pterygomasseteric sling has been incised for
subperiosteal access to the condylar/subcondylar
process posteriorly.
■ Incision is made from the mastoid process to the angle of the mandible. The
use of local anesthetic with epinephrine may impair facial nerve function and
limit the use of a nerve stimulator and nerve identification.

■ An incision is made through the superficial musculoaponeurotic system, and
the parotid gland is identified.
■ Dissection is carried posteriorly, and the masseter is identified behind the
parotid gland.
■ The pterygomasseteric sling is incised, and a subperiosteal dissection is
carried out to expose the area of fracture.
■ See general considerations for initial approaches to fracture reduction.
■ Manipulation of the fragment for reduction may also be achieved with the
jaw open.
■ Due to the lateral pterygoid forces, medialization of the condylar fragment
occurs. This must be overcome by lateralizing the segment.
■ A plate is then placed along the long axis of the fragment to hold the
condylar segment in place, but the screw is not completely tightened.
■ The mandible is pulled out to length in an anterior/inferior direction with
reduction held by an assistant or bite block.
■ With anterior traction applied to the plate, secure the remainder of the plate
ensuring it is flush with the underlying bone.
■ If possible, apply the second plate for fixation. However, this is often
difficult due to limited exposure of the fracture.
■ Close the pterygomasseteric sling and remaining layers of the wound.
■ Special Considerations
Fractures of Atrophic/Edentulous Mandible2,3
■ Often seen in patient with poor hygiene, malnutrition, immunosuppressed,
and elderly.
■ Closed reduction: achieved with wiring patients in dentures or Gunning-style
splints, which are acrylic splints that take form of modified dentures.
■ ORIF for displaced or comminuted fractures:
■ The procedure is often performed with a reconstruction plate through either
a submandibular or intraoral approach. The extraoral approach is
technically easier.
■ A locking plate must span from angle to angle with a minimum of two
screws in all bone fragments. Generally, three or more screws are placed in
all fragments, and all plate screw holes over intact bone are utilized due to

the poor bone stock.
■ Screws are generally placed in the symphysis and angle due to better bone
quality.
■ Autogenous bone graft may be added to fracture site to facilitate healing as
malunion/nonunion is common in these patients.
■ External fixation: can be considered for temporary stabilization as a bridge
until ORIF is possible.
External Fixation
■ Approach considerations:
■ Observation indicated with significant comorbid medical conditions
■ Closed reduction achieved by wiring
■ Application (TECH FIG 6):
■ Safe zones are located along lower and posterior portions of the mandible.
Avoid the condylar neck so as to prevent damage to the facial nerve trunk.
Other areas to avoid are the mental foramen and mandibular canal
containing the inferior alveolar nerve.
■ Place patient in MMF to help align major fragments.
■ Via small stab incisions, blunt dissection to bone is performed.
■ Through a trocar, bicortical pins are placed with two pins through each
major fragment.
■ Rods are placed at the two pins for each fragment followed by rod-to-rod
clamps.
■ Achieve reduction and tighten rod-to-rod clamps.
■ Alternatively, a bow-shaped rod can attach directly to the pins.
■ Release MMF and check occlusion.
Coronoid Fractures
■ Coronoid fractures account for less than 1% of all mandible fractures.
■ They are often associated with zygomaticomaxillary fractures and can
present as trismus.
■ Fractures are often observed and managed with soft diet only.
■ If persistent trismus or interference with mouth opening is present, coronoid
removal is considered without significant sequelae.
■ Consider ORIF vs removal in cases of panfacial fractures.

TECH FIG 6 • External fixation application technique.
PEARLS AND PITFALLS
Reduction
■ Insufficient reduction can lead to a higher rate of postoperative
complications.
Fixation
■ Number of plates and screws should be limited, and avoid temptation
to over treat with too large or too many plates.
■ Poor screw positioning can result in nerve or root damage.
■ Compression in comminuted areas should be avoided, and
reconstruction plate should be used.
■ At least two screws should be placed on each side of defect for
comminuted fractures.
POSTOPERATIVE CARE
■ Adult patients who have undergone ORIF will be on a soft, nonchew diet for 4

weeks minimum.
■ Patients who have been placed in MMF will be on a full liquid diet and should
have nutrition counseling and close monitoring of nutritional intake, with
supplementation as needed.6
■ Peridex mouth rinse is imperative for maintaining good oral hygiene.6
■ Routine follow-up at 2 and 4 weeks after surgery to evaluate healing and
assess occlusion is recommended.
■ Normal bony union takes 4 to 8 weeks, depending on the age of the patient.3
■ Arch bars should be removed 4 to 6 weeks after surgery.
COMPLICATIONS
■ Complication rates are directly related to the type of injury and location of
fracture.1,3
■ Angle fractures have the highest rate of complications.1,3
■ Infection is the most common complication after repair of mandible
fractures.1–3
■ Less common complications include3:
■ Nonunion.
■ Malunion.
■ Malocclusion.
■ Tooth loss.
■ Trismus.
■ Ankylosis.
■ Broadening of the face especially with condylar and subcondylar fractures.
■ Paralysis of marginal mandibular and/or mental nerves is generally transient.1
ACKNOWLEDGMENTS
Dana Johns, MD
Paul Mittermiller, MD
REFERENCES
1. Oruc M, Isik VM, Kankaya Y, et al. Analysis of fractured mandible over two
decades. J Craniofac Surg. 2016;27(6):1457-1461.
2. Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-based
medicine: Mandible fractures. Plast Reconstr Surg. 2014;134(6):1381-1390.
3. Stacey DH, Doyle JF, Mount DL, et al. Management of mandible fractures.

Plast Reconstr Surg. 2006;117(3):48e-60e.
4. Goth S, Sawatari Y, Peleg M. Management of pediatric mandible fractures. J
Craniofac Surg. 2012;23(1):47-58.
5. Barker DA, Oo KK, Allak A, Park SS. Timing for repair of mandible
fractures. Laryngoscope. 2011;121:1160-1163.
6. Koshy JC, Feldman EM, Chike-Obi CJ, Bullocks JM. Pearls of mandibular
trauma management. Semin Plast Surg. 2010;24(4):357-374.
7. Zide MF, Kent JN. Indications for open reduction of mandibular condyle
fractures. J Oral Maxillofac Surg. 1983;41(2):89-98.
8. Saylam C, Ucerler H, Orhan M, et al. Localization of the marginal mandibular
branch of the facial nerve. J Craniofac Surg. 2007;18(1):137-142.

70
CHAPTER
Open Treatment of Condyle
Fractures
Michael A. Lypka
DEFINITION
■ Condyle fractures of the mandible refer to a group of fractures involving the
condylar head, neck, and base (FIG 1).1
■ There have been many classification schemes for mandibular condyle
fractures; which classification system is best is debatable.
■ Important concepts relating to complexity of surgical repair would be the
cranial-caudal position of the fracture (condylar head fractures are
complicated), medial or lateral displacement of the proximal segment relative
to the ramus (medially displaced are more difficult), and degree of
displacement of the proximal segment from the mandibular fossa.
ANATOMY
■ Knowledge of the anatomy of the temporomandibular joint (TMJ) and
surrounding structures is critical if open treatment of condyle fractures is
entertained. The decision to operate must be balanced with the potential risks
of surgery, most importantly the risk to the facial nerve (FIG 2).
■ Temporomandibular joint (TMJ)
■ The TMJ is a symmetrically paired synovial articulation, which is the
interface between the mandible and the base of skull.
■ The condylar head, with a lateral and medial pole, rests in the mandibular
fossa, separated from the middle cranial fossa cephalad by a thin margin
(approximately 1 mm) of bone. Anteriorly, the TMJ rests on the articular
eminence of the zygomatic arch and translates along its slope with oral
opening.
■ An ovoid biconcave avascular disk is interposed between the mandibular

condyle and temporal bone, separating the TMJ into superior and inferior
joint spaces, in which translation and rotation occur, respectively. The
superior head of the lateral pterygoid muscle inserts into the anterior aspect of
the disk, whereas the inferior head inserts onto the mandibular condyle. The
disk transitions into an innervated network of connective tissue and blood
vessels posteriorly, known as the bilaminar zone.
FIG 1 • Classification of mandibular condyle fractures.
The sigmoid notch line (Loukota’s line) differentiates
neck and base fractures. A. Condylar head fracture:
fracture of the medial or lateral pole of the condyle. B.
Condylar neck fracture: the fracture runs above the line
for greater than half its length. C. Condylar base
fracture runs below the line for greater than half its
length.
■ The joint capsule that surrounds the eminence and fossa blends with the
periosteum of the zygomatic arch and condylar neck. It is thickened laterally
to form the temporomandibular ligament or lateral ligament.
■ Vascular/nerve supply
■ The external carotid artery bifurcates into two terminal branches within the
parotid gland; the superficial temporal artery, which ascends vertically along
the posterior border of the condyle and forms anterior and posterior branches
above the zygomatic arch, and the maxillary artery, which traverses the
condylar neck on its deep surface toward the pterygopalatine fossa.
■ The auriculotemporal nerve provides sensory innervation to portions of the
auricle, external auditory canal, tympanic membrane, and temporal skin, and

runs parallel and posterior to the superficial temporal artery.
■ The superficial temporal vein lies superficial and posterior to the artery and
then drains into the retromandibular vein, which runs posterior to the ramus
of the mandible.
FIG 2 • Complex anatomy overlying mandibular
condyle.
■ Parotid gland
■ The parotid gland, encapsulated by the parotidomasseteric fascia (parotid
capsule), lies directly over the TMJ capsule.
■ The gland contains facial nerve branches coursing through it, as well as the
superficial temporal artery and retromandibular vein.
■ Relevant fascial layers (FIG 3).
■ Deep to the skin, in the temporal region, lies the temporoparietal fascia (TPF)
or superficial temporal fascia. Anteriorly, this layer is continuous with
galea/frontalis. The TPF is continuous caudally in the parotid region with the
superficial musculoaponeurotic system (SMAS). In the neck, the SMAS is
continuous with the platysma muscle.

■ A layer deeper, in the temporal region, is the innominate or subgaleal fascia.
The temporal branch of the facial nerve lies in this plane, deep to the TPF.
The parotidomasseteric fascia in the parotid region is continuous with the
innominate fascia above and the superficial layer of the deep cervical fascia in
the neck. The marginal mandibular branch lies within or just deep to this
cervical fascia.
■ The temporalis fascia overlying the temporalis muscle, splits into superficial
and deep layers above the zygomatic arch, containing the superficial
temporal fat pad, before inserting onto the zygomatic arch.
■ Facial nerve
■ The facial nerve emerges from the stylomastoid foramen and curves
anteriorly into the parotid gland. It bifurcates within the parotid gland into
temporofacial and cervicofacial branches, ultimately giving rise to five
terminal branches: temporal, zygomatic, buccal, marginal mandibular, and
cervical. There are many interconnections between buccal and zygomatic
branches but not the temporal and marginal mandibular branches, thus
requiring special attention during surgical exposures involving these branches.

FIG 3 • Relevant fascial layers in the area of the
mandibular condyle.
■ The temporal branch runs deep to the TPF, crosses the zygomatic arch, and
lies anywhere from 8 to 35 mm anterior to the external auditory canal.2
■ The marginal mandibular branch, of significance in the Risdon approach, lies
in or deep to the superficial layer of the deep cervical fascia. It may course
below the angle of the mandible (upwards of 1.2 cm). Anterior to the facial
vessels, the marginal mandibular nerve is almost always above the inferior
border.3,4
PATHOGENESIS
■ Condyle fractures are sustained from either an axial load or a lateral impact.
■ A patient who sustains an impact to the chin transmits forces to the base of

the skull resulting in bilateral condyle fractures, often with a concurrent
symphysis fracture.
■ A lateral impact results in ipsilateral condyle fracture and concurrent
contralateral body fractures.
NATURAL HISTORY
■ Untreated condyle fractures typically will heal without treatment (meaning
that bony union will occur), but sequelae such as malocclusion, TMJ pain, or
rarely ankylosis (less than 0.5 per 1000)5 can occur.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The mechanism of injury should be ascertained. An impact to the chin, as in a
fall directly onto the chin, should elicit suspicion for bilateral condylar
fractures with possible symphyseal fracture. A lateral impact (punch to the
face) may result in a condyle fracture on the side of impact.
■ Change in occlusion, preauricular pain, concussive symptoms, and limitations
of mouth opening are important historical data.
■ Physical findings
■ Limited mouth opening: deviation to the side of fracture on opening
■ Change in occlusion
• Premature molar contacts on the side of fracture or lateral open bite on the
opposite side.
• Anterior open bite in bilateral condyle fractures due to loss of vertical height
• Occlusal canting
■ Facial asymmetry due to loss of height on the fractured side
■ Tenderness to palpation over the fracture sites in preauricular area

FIG 4 • A. Orthopantomogram of left condylar base
fracture. B. Towne’s view showing laterally displaced
fracture. Coronal (C) and axial (D) CT scans of condylar
head fractures in two different patients. (The author
would not approach these surgically, although some
would.) E,F. Sagittal CT sections of right and left
condylar neck and base fractures. G. 3D CT scan of
condylar base fracture.
■ Blood in external auditory canal—signifies fracture of cartilaginous wall of
EAC
■ Submental lacerations
■ Cervical spine tenderness (concomitant injury in approximately 5% of
mandible fractures)

IMAGING
■ Orthopantomogram is a useful x-ray that identifies most condyle fractures and
provides an overview of teeth and bony structures, often giving additional
information about occlusion (FIG 4A).
■ Reverse Towne’s view: This plain film, taken from posterior to anterior with
the neck flexed, is a useful adjunct to the panorex to identify condyle fractures
(FIG 4B).
■ CT scans have become the standard for imaging of the maxillofacial skeleton
in facial trauma and are indispensable in diagnosing and treatment planning for
various types of condyle fractures.
■ Coronal, axial, and sagittal views (FIG 4C–F), in addition to the 3D
reconstruction (FIG 4G), will identify and characterize any fracture.
NONOPERATIVE MANAGEMENT
■ In select cases with nondisplaced fractures on one or both sides, with a stable
occlusion and limited pain, nonoperative management with a soft diet and
progressive range of motion is appropriate.
SURGICAL MANAGEMENT
Indications/Contraindications
■ According to Zide and Kent,6 absolute indications for open treatment include
the following:
■ Displacement into the middle cranial fossa
■ Impossibility of obtaining adequate occlusion by closed reduction
■ Lateral extracapsular displacement
■ Invasion by foreign body
■ The indications for open treatment of condyle fractures are relative, given the
satisfactory outcomes of most fractures by closed means. Nonetheless, the
decision to open condyle fractures is based on identifiable factors, including
patient age, general health and mental state, concomitant panfacial fractures,
and most importantly the surgeon’s comfort level with opening condyle
fractures. Common reasons for open treatment include the following:
■ Unilateral condylar fractures (fractures of the neck and base) with significant
displacement or loss of vertical height
■ Bilateral condylar fractures (fractures of the neck and base) with significant
displacement—to restore vertical height and projection

■ Contraindications to open treatment include the following:
■ Condyle fractures in children
■ Fractures of the condylar head, including bilateral fractures. Although
controversial, the author prefers managing postoperative malocclusions with
orthognathic surgery rather than permanently disrupting the vascular supply to
the condylar head, which often results in unsatisfactory results.
Preoperative Planning
■ Combining history and physical findings, with a detailed radiographic
evaluation, a decision is made to perform open reduction of the condyle
fracture with the optimal surgical approach.
Positioning
■ The patient should be positioned supine with the head in a horseshoe, allowing
head rotation during surgery.
Approach
■ There are three standard extraoral approaches to the mandibular ramus and
condyle.
■ Retromandibular approach7 is the most used approach.
• For fractures either just above, at, or below the sigmoid notch, this
transparotid approach allows direct access to the fracture for efficient
reduction and application of rigid fixation.

FIG 5 • Retromandibular incision relative to facial nerve
branches.
• This approach is positioned between the buccal branches and the marginal
mandibular branch, resulting in less traction on the nerve (FIG 5).
• Access is limited, however, because typically, only a small “window” can
be created through the parotid gland.
■ Risdon (submandibular)8 approach is the standard approach to the mandible.
• This approach “from below” gives access to the entire ramus and condyle
but requires significant soft tissue retraction, potentially resulting in traction
injury to the marginal mandibular branch. A limited Risdon approach with
the aid of an endoscope limits the need for extensive soft tissue retraction.9
• Useful for fractures below the sigmoid notch or condylar head fractures in
which a vertical ramus osteotomy is performed, and the condylar head
disarticulated, with fixation of the segments on the back table and
replacement with rigid fixation of the devascularized ramus/condylar unit
(not advocated by this author).

■ Preauricular approach allows access for condylar head fractures.
• Access given by this approach is often too cephalad for most fractures and
must be combined with another more inferior approach.
• Useful to reduce a condyle fracture displaced into the middle cranial fossa.
■ An intraoral approach to the condyle through a mandibular vestibular incision
with or without endoscopic assistance, with extraoral trochar stabs or a special
angled drill to apply fixation, is well described but will not be discussed here.10
■ Open treatment of condyle fractures from an extraoral approach is already
technically difficult, and it is the author’s opinion that the intraoral-
endoscopic technique, requiring special equipment and significant skill and
training, should not be used by novice surgeons.
T E C H N I Q U E S
■ Retromandibular Approach
Markings and Exposure
■ Marking is made approximately a half centimeter below the earlobe
paralleling the posterior border of the mandible, extending toward the angle
(TECH FIG 1).
■ The incision can usually be limited to 2 to 3 cm.
■ Local anesthetic with vasoconstrictor is administered. Avoid paralytic agents
at this point so facial nerve monitoring is possible.
■ The skin incision extends through the subcutaneous tissues and superficial
musculoaponeurotic sling (platysma is thin in this region) to the parotid
capsule.
■ Vertical incision is made in the parotid capsule, entering the substance of the
gland.
■ Blunt dissection is then performed through the gland, spreading in the
direction of the facial nerve branches, in a horizontal or slightly oblique
direction.
■ Toe-in retractors can be used to create a “window,” through the gland down
to the mandible. Space is limited and will increase slightly with retraction.
Typically, the window is between the buccal and marginal mandibular
branches of the facial nerve. No attempt is made to isolate these branches,

but they may be encountered during dissection through the gland.
■ Dissection through the pterygomasseteric sling is performed, with either a
scalpel blade or Bovie cautery along the posterior border of the ramus.
Subperiosteal dissection of the ramus, including the sigmoid notch and angle,
then ensues, exposing the fracture cephalad.
■ A toe-out retractor is placed behind the posterior ramus, protecting the
retromandibular vein.
■ A toe-in retractor is placed cephalad to locate the fracture line and
displaced proximal segment.
Reduction and Fixation
■ Fracture reduction is the difficult part.
■ Laterally displaced proximal segments, and those below the sigmoid notch,
are the easiest to locate and reduce, whereas medially displaced, high
condylar neck fractures are the most difficult.
■ Although not always feasible, it is best not to strip all the periosteal
attachments from the proximal segment (dissect only the parts closest to the
fracture site as necessary); otherwise, the segment will be devascularized,
but more importantly, will become a floating target, making successful
reduction difficult.
■ Typically, the ramus has lost vertical height due to overlap of fracture
segments. To re-establish height and achieve reduction, the angle of the
mandible needs to be pulled caudally, thus stretching the sling. Paralytic
agents may now be useful to accomplish this task.

TECH FIG 1 • Retromandibular incision preoperative
marking (with mandible overlay).
■ Two options exist to pull the angle caudally. A wire can be used to lasso a
screw placed at the angle by using a spinal needle to enter the dissection
pocket from below percutaneously. Another option is to open the posterior
occlusion with a bite block. This may contaminate a sterile approach;
however, external approach to the condyle is often combined with an
intraoral approach if other fractures require reduction and fixation.
■ Ideally, the fracture is reduced, and if stable, fixation is applied, with any one
of three options: a four-hole plate at the posterior border; two plates, one at
the posterior border and the other at the sigmoid notch; or a specifically
designed plate for the condyle (TECH FIG 2A–E).
■ Stable reduction prior to fixation is rarely achieved. Often, it is useful to
apply the fixation plate with one screw in the proximal segment and use it as
a handle to control the segment and reduce the fracture.
■ With the fracture reduced, another screw is placed in the distal segment,
followed by the remaining screws.
■ Alternatively, a K-wire can be used as a joystick for the proximal segment
to control its movement.

■ After fracture reduction and fixation, the posterior border of the ramus
should naturally flare posteriorly.
■ If it does not, re-evaluate fixation.
■ Check occlusion after reduction.
■ Irrigate surgical site and begin closure.
■ Repair of the pterygomasseteric sling can be attempted but is not performed
by the author.
■ The key to this approach is a watertight closure of the parotid capsule, to
prevent sialocele formation.
■ Skin closure is accomplished according to surgeon preference (TECH FIG
2F).
TECH FIG 2 • Three different options for fixation of the
reduced condyle fracture: one four-hole plate (A), two
plates (B), custom plate (C). D,E. Plate fixation
through retromandibular approach. F. Typical
postoperative appearance of scar.

■ Submandibular (Risdon) Approach
■ Marking is made 1.5 to 2 cm below the inferior border of the mandible,
either paralleling the inferior border of the mandible or following a natural
skin crease of the neck (TECH FIG 3).
■ If a natural skin crease is used, the incision will tend to diverge from the
mandible anteriorly, requiring a longer incision for the same access relative to
an incision paralleling the inferior border.
■ Local anesthetic with vasoconstrictor is administered. Avoid paralytic agents
so facial nerve monitoring is possible.
■ Skin incision is made and dissection continues through the platysma muscle
to the superficial layer of the deep cervical fascia. The marginal mandibular
nerve is in this layer, or just deep to it.
■ Blunt dissection continues through the deep cervical fascia over the
submandibular gland but inferior to the inferior border of the mandible. A
prominent lymph node (Node of Stahr) will be encountered, heralding the
location of the facial artery and vein (artery lies anterior and deep to the
vein).
■ The artery and vein may be ligated at this time if exposure of the body of the
mandible is necessary. The marginal mandibular nerve lies superficial to the
vessels; if dissection ensues deep to them, the nerve is protected.
■ With retraction of the soft tissue cephalad, an incision is made in the
pterygomasseteric sling. Subperiosteal dissection of the ramus and condyle is
performed with this approach.
■ Fracture reduction and fixation ensues as described in the retromandibular
approach. Direct access to the angle allows the mandible to be tractioned
inferiorly by this approach. The fracture segments can be lag screwed via this
approach.
■ The pterygomasseteric sling is approximated, followed by the platysma, and
skin layers.

TECH FIG 3 • Preoperative markings for preauricular
and Risdon (submandibular approaches).
■ Preauricular Approach
Exposure
■ The simplest approach is through the preauricular crease, extending from the
superior helix to the lobule.
■ A cephalad extension can be made for improved access, either straight
vertically into the hairline or anteriorly, in a hockey stick fashion, either at
the anterior hairline junction or just above the junction.
■ Modification: Transitioning the marking along the margin of the tragus
(endaural) is a common modification to conceal the incision. A
retroauricular crease incision has been described but requires transection of
the external auditory canal with later reapproximation (see TECH FIG 3).
■ Local anesthetic is injected. Paralytic agents should be avoided, so facial
nerve monitoring is possible.
■ The skin incision proceeds through the TPF (cephalad) and SMAS

(caudally). If an endaural incision is used, avoid transecting the tragal
cartilage after skin incision.
■ The superficial temporal vein will be encountered first and ideally retracted
anteriorly.
■ Below the zygomatic arch, dissection proceeds along the border of the
tragal cartilage or external auditory canal, in this avascular plane.
■ If dissection proceeds too far anteriorly, away from the cartilage, the
superficial temporal artery will be encountered.
■ Bleeding from this source may be difficult to control.
■ Above the zygomatic arch, dissection proceeds to the temporalis fascia.
■ An oblique incision is made in the temporalis fascia, extending from the root
of the zygomatic arch, exposing the superficial temporal fat pad.
■ Veins within the fat pad, close to the area of dissection, may be cauterized
with bipolar cautery.
■ Inferiorly from this oblique incision, a periosteal incision is made on the
root of the zygomatic arch, which transitions into the caudal dissection
along the border of the external auditory canal.
■ The zygomatic arch is exposed in a subperiosteal plane, unveiling the TMJ
capsule below.
■ The soft tissues are retracted anteriorly, protecting the temporal branch of
the facial nerve, which is contained within the flap.
■ A periosteal incision is made on the posterior border of the condylar neck;
the joint space is not entered.
■ A tunneling-type subperiosteal approach is then employed from above to
access the condylar head and neck, exposing the sigmoid notch anteriorly.
Remember that the main trunk of the facial nerve is just caudal to this area
of dissection.
■ This dissection can be connected with a subperiosteal dissection from an
alternative approach (Risdon or retromandibular) from below (TECH FIG
4).
Reduction and Fixation
■ The displaced fracture segments are located, reduced, and fixated. Hooks can
be used to stabilize small fragments. Overly aggressive stripping of the
periosteal attachments will devascularize bony segments and make fracture
reduction more challenging.
■ Condylar head fractures are usually fixated with small lag screws or

miniplates (1.5 or 2.0).
■ Deep layer closure is not necessary in this approach, and skin closure can be
performed based on surgeon preference.
TECH FIG 4 • Intraoperative view of exposure to TMJ.
PEARLS AND PITFALLS
Decision-
making
■ Select appropriate cases (evaluate CT scan carefully).
■ Fractures of the condylar neck and below
■ Avoid fractures in children and condylar head fractures.
■ If not comfortable with regional anatomy, do not use an open
approach.
Anesthesia
■ Avoid paralytic agents in order to monitor facial nerve during
dissection.
■ Use paralytic agents after dissection is complete to facilitate
fracture reduction.

Technique
■ The posterior border of the ramus/condylar unit should curve
gently posteriorly after reduction.
■ Avoid excessive periosteal stripping to maintain blood supply and
facilitate fracture reduction.
■ Check occlusion after reduction and fixation.
■ Assure good closure of parotid capsule to avoid sialocele
formation in the retromandibular approach.
Postoperative
care
■ A short period of MMF or guiding elastics is a good idea to
prevent occlusal disharmonies and avoid discomfort.
FIG 6 • A, B. Slight lateral posterior open bite due to
loss of vertical height on the side of the fracture in a
patient treated with a short period of maxillomandibular
fixation. Patient refused open reduction.
POSTOPERATIVE CARE
■ To avoid subtle occlusal discrepancies in the postoperative period (a result of
swelling in the TMJ fossa from manipulation of the condyle), a short period (1
to 2 weeks) of maxillomandibular fixation or rubber band guidance is
warranted.
OUTCOMES
■ Most patients with condyle fractures, with either appropriate open or closed
therapy, have excellent outcomes.
■ The ability of the condyle to remodel and the stomatognathic system to adapt
explain these good outcomes, even when the fracture is not reduced in closed
treatment and when anatomic reduction is not precisely achieved in open

treatment.
■ When treated ineffectively, however, certain sequelae may develop:
■ Malocclusion (most common) (FIG 6)
■ Long-term degenerative changes in the TMJ, with or without pain.
■ TMJ ankylosis (uncommon)—especially in the pediatric population when a
fracture is unrecognized and range of motion is not established after the
injury.
■ Iatrogenic facial nerve injury from open treatment approaches.
COMPLICATIONS
■ Facial nerve injury. Typically, a traction injury resolves with time, but will be
permanent if the nerve branches are transected or tractioned too aggressively.
■ Poor scarring. Hypertrophic or unaesthetic scars are possible sequelae of
extraoral approaches.
■ Malocclusion. May be the result of:
■ Incorrect occlusion at fracture reduction
■ Improper fracture reduction (malunion)
■ Early failure of fixation
■ Loss of vertical height from resorption of the condylar head, leading to
contralateral posterior open bite.
■ Sialocele: Leakage of salivary fluid from parotid gland after the
retromandibular approach. Prevented by careful closure of the parotid capsule.
Treated with compression and antisialagogues.
■ Malunion/nonunion
■ Failure of fixation
■ Facial widening/asymmetry
REFERENCES
1. Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassification of fractures of
the condylar process of the mandible. Br J Oral Maxillofac Surg. 2005;43:72-
73.
2. Al-Kayat A, Bramley P. A modified pre-auricular approach to the
temporomandibular joint and malar arch. Br J Oral Surg. 1979;17:91.
3. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the
facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg
Transplant Bull. 1962;29:66.
4. Ziarah HA, Atkinson ME. The surgical anatomy of the cervical distribution of