Condylar segment removal in the management of diacapitular mandibular fractures

Contemporary opinion strongly concurs that isolated intracapsular fractures, in almost every instance, should be treated solely with physical therapy. Based on the premise that although these fractures can result in significant anatomic/radiologic changes in the appearance of the condyle itself, most patients with these fractures recover very well if adequately rehabilitated. However, in our study four cases of high condylar head (diacapitular) fractures were managed by surgically removing the fractured condylar head as it was obstructing mandibular function.

The retrospective analytical study was carried out at the Division of Oral & Maxillofacial Surgery, Department of Dental Surgery, INHS Kalyani, Vishakhapatnam from Jul 2008 to Aug 2010. Patients who were clinically and radiologically diagnosed with high condylar head/neck fracture who did not respond to conservative management of active mouth opening exercises even after 2-3 weeks of physiotherapy and continued to have no improvement in mouth opening although the occlusion was stable were included in this study. The fractured condylar head was surgically removed and function restored.

A total of four cases, four males with high condylar head fractures were taken up for removal of the fractured condylar segment. In all cases satisfactory mouth opening was achieved intraoperatively. One case presented with troublesome intraoperative bleed.

The decision influencing open reduction and internal fixation versus closed reduction is based on the ability to restore function and esthetics. There are strong recommendations for conservatively managing the so called intracapsular or Neff's fractures. However, if the fracture segment is small and yet is causing restriction in mouth opening and inability to achieve desired occlusion we recommend removal of the fractured condylar segment. In this procedure the proximal segment is removed surgically and mouth opening is assessed. The occlusal discrepancy if any is managed subsequently using elastic traction on previously placed arch bars.

In our experience in those cases where the mouth opening continues to be restricted even after physiotherapy and a radiologically wedged segment is observed, removal of the fractured condylar segment to achieve mouth opening and subsequently managing the occlusion may prove to be beneficial to the patient.