Hassan El-Abdin, BDS, FDSRCPS
College of Dentistry, Kihg Saud University, P.O.Box 60169, Riyadh 11545, Saudi Arabia.

Due to the increased incidence of road traffic accidents, fractures of the facial skeleton are on the rise with condylar fracture being almost 50% in some societies. The latter is usually treated either surgically or conservatively. Advocates of the conservative approach believe that the only indication for surgical intervention is displacement of the fractured condyle with a magnitude and direction such that occlusion is impossible and function is deranged. This paper presents findings in eight patients with history of fractured condyle, who were managed conservatively but presented later with serious and late complications.

Fracture of the mandibular condyle has been rec­ ognized and treated since the beginning of the 19th century.1 The treatment has provided many chal­ lenges to the oral and maxillofacial surgeons and is still a controversial subject. Each surgeon determines the basis for his preferred line of treatment and, with periodic review of treatment methods and results in condylar fractures, assessment and
re-evaluation of treatment methods and standard of results could be made.

Two main approaches are available for the practicing surgeons; the surgical one, by means of direct visualization and open reductions, and the conservative approach through dental fixation gui­ dance of occlusion and physiotherapy. The advocates of the second approach believe that the objective is either to allow bony union, if displace­ ment is not significant, or to produce an acceptable pseudoarthrosis by reducation of the neuromuscular pathways.2 The main indication for surgery is
believed to be a displaced fragment of a magnitude and direction that renders repositioning of teeth in occlusion impossible.3

In a developing country with inadequate clinical facilities, a conservative method of management is often the only rational approach. This policy was adopted in the management of eight patients with fractured condyles at different hospitals in Saudi
Arabia. We have prospectively reviewed the cases with late and even serious complication in the non­ surgical management approach.

A total of eight patients, each with a history of fractured condyle and who were previously treated at different hospitals in Saudi Arabia, were seen at the Oral and Maxillofacial Surgery unit of the King Saud University College of Dentistry. All cases
were managed conservatively relying on limited intermaxillary fixation in four of the cases, and functional therapy in the other four cases. Three of the patients were males and five were females. The youngest was eight years old and the oldest was thirty-four years of age. All eight patients had only fractured condyles. Those with history of fractures at other sites in the mandible were excluded. Condylar fracture was bilateral in one case, on the left side in three cases, and on the right side in the remaining four cases. One patient sustained his fracture during road traffic accident (RTA); the rest were due to falling down from a height, a tree or a building. One patient was managed 4 years previously. Previous management periods for the other patients, before coming to our clinics, varied between 10 and 15 years.

All patients were seen between October 1985 and October 1987 with varied late complications, ranging from minor to severe (Table I).

The patient with bilateral fracture of the condyle developed severe bony ankylosis with typical bird­ like face, complete limitation of opening, lock jaw, and arrested growth of the lower face. Severe den­ tal complication and facial appearance were quite evident fifteen years after the trauma (Figs. 1 & 2).

  Six patients (75%) suffered from severe limitation of opening, although mouth openings were reported to be normal at the time of the accidents but worsened with time. Mouth opening measured between 1.5 cm. and 2.0 cm., with some comp­ laining of inability to clean their teeth properly. Two patients were referred by their attending dentists because they could not treat the patients (Fig. 3). Radiographicaliy, enlarged and elongated coronoid processes were evident in some of these cases (Fig. 4). Gross deviation and displacement toward the affected side was a major finding in five cases (63%). This was disturbing, especially in

Fracture of the mandibular condyle is receiving greater attention because the current incidence rate is at 30 to 40%.4 These fractures in a develop­ ing country differ, in some respect, from those seen in developed countries of the world. The difference

is emphasized in the aetiology, clinical facilities, and methods of management. Falling down from heights is a more common cause than R.T.A., although the latter is a bit predominant because of the phenomenal increase in automobile usage.

Most of the patients failed to reach the hospital because of poor transport at the time, and those who were able to reach were usually managed on an outpatient basis due to lack of hospital beds and specialized personnel. Therefore, a more conser­ vative approach to the management was usually adopted in all cases.

To adopt a conservative approach for the treat­ ment of fractured condyle, even if it is undisplaced or undislocated, will require an experienced personnel in diagnosis and management. Strict follow-up of the patient, especially for the first year, is very essential. Limited information in the literature is related to the residual or late complication of frac­ tured condyle.

1. Madennan WD. Consideration of 180 cases of typical fracture of the mandibular condylar process. BrJ  PlastSurg 1952;122-128.
2. McGregor AB, Fordyce GB. Treatment of fracture of the neck of the mandibular condyle. Brit Dent J 1957,102:351.
3. Rees A, Weinberg S. Number of the mandibular condyle: Review of the literature and presentation of 5 cases with late complications. Oral Health 1983;73(7):37-41.
4. Olson RA, Fonseca Rj, ZeitlerOL, Osbon DD. Fracture of the mandible: Review of 580 Cases. J Oral and Maxillofac Surg1982;40.