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ORIGINAL ARTICLE

A Modified External Fixator System in Treatment

of Mandibular Condylar Fractures
Piero Cascone, MD, PhD, Fabrizio Spallaccia, MD,y Paolo Arangio, MD,
Valentino Vellone, MD, and Matteo Gualtieri, MD
factors include osteomyelitis, benign or malignant tumor, and
Abstract: The purpose of this study is to evaluate patient’s out- muscular spasm during electric shock treatment.
comes after condylar fractures treated with the modified external Their displacement is determined by the direction, degree,
fixation system from 2008 to 2012. magnitude, and precise point of application of the force, as well
A group of 58 patients with unilateral and bilateral fractures of as the state of dentition and the occlusial position.4
mandibular condyle was admitted in the authors’ study. Most are not caused by directed trauma, but follow indirect
The final sample included a total of 44 patients, 24 males forces transmitted to the condyle from a blow elsewhere. With
(54.6%) and 20 females (45.4%). adequate molar support and the teeth in occlusion, little or no
displacement is likely to be sustained, while with the mouth widely
The remaining 14 (24%) patients were excluded because they
open the full force will be transmitted to the condyles. Direct impact
did not fulfill all the criteria requested. leads to a unilateral fracture5 as the weak condylar neck breaks
After 12 months from surgery, the functional-clinical evaluation easily and there is no intracranial displacement; thus the condyle
of mouth’s maximum opening and mostly extent of lateral excur- protects the brain in mandibular fractures.6
sion and of protrusion showed the following results: 8% of the Mandibular condyle fracture may cause long-term compli-
sample showed a maximum mouth opening <30 mm, 72% of the cations such as malocclusion, particularly open bite, reduced
sample showed a maximum mouth opening between 30 and 40 mm, posterior facial height, and facial asymmetry in addition to chronic
20% of the sample showed a maximum mouth opening >40 mm pain and mobility limitation, so great caution should be taken.
lateral excursion (contralateral to fracture) and protrusion was Accurate diagnosis, appropriate management, and complication
respectively of 9.5 and 3.9 mm. prevention are required.7
About treatment, in the 2nd International Bone Research Associ-
Only 2 (4.5%) of the 44 evaluated patients reported headaches.
ation (IBRA) Symposium for Condylar Fracture Osteosynthesis
86.5% of the patients showed no postoperative temporomandibular 2012,8 it was found that most surgeons preferred to perform open
joint dysfunction; 9% of them reported occasional clicking, while reduction internal fixation (ORIF) for condylar base and neck
4.5% reported recurrent disorders. The average satisfaction score of fractures in both adults and growing patients (age >12–13 years),
surgery outcome reported by patients was 94.5/100, and it ranged especially in displaced and dislocated fractures.
between 50/100 and 100/100. In 2010, Singh et al9 demonstrated that ORIF is superior in all
objective and subjective functional parameters; in that study, the
improvement obtained by open treatment was greater than that
Key Words: Condylar external fixator, condylar fracture, pediatric obtained by closed methods.
fractures The purpose of this study is to evaluate patient’s outcomes after
(J Craniofac Surg 2017;00: 00–00) condylar fractures treated with a modified external fixation system
from 2008 to 2012.
The advantages of application of condylar external fixator (CEF)
C ondylar fractures are very common, with an incidence of 29%
to 52% of mandibular fractures1 and 11% to 16% of all
facial fractures2 but their diagnosis and management remain
are as follows: immediate joint mobilization that promotes a fast
functional recovery; the use of pins that allow an easy fracture
reduction, especially when the small fragment is dislocated out of
controversial.3 the glenoid cavity; total removal of the device in an outpatient setting
Patients between 25 and 34 years old account for one third of all without anesthesia (this characteristic makes it the elective device for
the patients. the surgical treatment of growing patients); short fixation period of
The most common external factor is physical trauma and car time, varying from 15 to 25 days; the semirigidity of the system based
accident, violence, industrial hazard, fall, sports, and gunshot on three-dimensional (3D) characteristics; the possibility of changing
wound are also included in the external causative factors. Internal condyle position, even if condyle reduction is not perfect, through
early removal of the fixator, using occlusal elastic forces that provide
From the Maxillo-Facial Surgery Department, ‘‘Sapienza’’ Università di a repositioning of the condyle as physiological as possible.
Roma, Roma; and yMaxillo-Facial Surgery Department, ‘‘S. Maria’’ An important disadvantage is quite high learning curve..
Hospital, Terni, Italy.
Received June 30, 2016.
Accepted for publication January 7, 2017. METHODS
Address correspondence and reprint requests to Valentino Vellone, MD, A retrospective study was performed to assess the use of a modified
Maxillo-Facial Surgery Department, ‘‘Sapienza’’ Università di Roma, external fixator for condyle fractures in patients treated at Diparti-
Via Teano 35, Latina, Italy; E-mail: [email protected] mento di Scienze Odontostomatologiche e Maxillo-Facciali,
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
Sapienza Università di Roma from 2008 to 2012.
ISSN: 1049-2275 Condyle fractures were classified according to Loukota et al10
DOI: 10.1097/SCS.0000000000003669 in diacapitular, neck or condylar base fractures and in fractures

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TABLE 1. Questionnaire Administered to Patients

Questionnaire Part 1 Yes, Continuously Yes, Often Yes, Occasionally No

Do you feel pain in the treated area? 0 2.20% 6.80% 91%

Do you suffer from headaches? If yes, 0 0 0 100%
please indicate where.
Do you hear noise or feel pain in the 0 4.50% 9% 86.50%
TMJ area that you did not hear/feel
before surgery? If yes, please
indicate whether unilateral or
bilateral.
Is your occlusion is the same as it was 100% 0
before surgery?

Questionnarire No, I Only Drink No, I Do Not Eat No, I Do Not

‘Part 2 Liquids Medium Consistency Food Eat Solid Food Yes

Can you eat anything? 0 4.5% 15.9% 79.6%

How much are you satisfied with your surgery results? (0–100) 94.5 (average)

TMJ, temporomandibular joint.

without dislocation, displaced without dislocation and displaced A follow-up at 1, 6, and 12 months after surgery was assessed.
with dislocation.
The surgical indication for condylar fractures was a fractured Condylar External Fixator
fragment dislocation of 108 to 458, or a shortening of the ascending Condylar external fixator is a modified external fixation system
ramus  2 mm11 on the basis of orthopantomography according to for the treatment of mandibular condyle fractures that were patented
Clementschitsch12 and 3D computed tomography scans, in most by the research support area of ‘‘Sapienza’’ Università di Roma. The
complicated cases, by means of OsiriX software program. patent number is RM2012A000574, ownership of ‘‘Sapienza’’
Data were collected directly from the medical records of the Università. The complete original set is packaged in a special
hospital, including name, sex, medical history, patient’s symptoms, container, also suitable for device sterilization. The package shows
clinical signs and the radiological findings, cause, and type the symbol of ‘‘Sapienza’’ Università di Roma and manufacturer
of fracture. (Cizeta Surgical) symbol (Fig. 1).
A group of 58 patients with unilateral and bilateral fractures of The external fixation system consists of a device that is com-
mandibular condyle was admitted in our study. posed of the following steel instruments:
Condylar head fractures (also called ‘‘intracapsular’’ or ‘‘diaca-
pitular’’ fractures) were excluded due to the impossibility to be  titanium pins with self-drilling, self-tapping tip; pin diameter
treated with external fixator. is 2.0 mm;
Only 44 (76%) of 58 interventions performed in this period were  4.5 mm distance unit pinholder straight and curved titanium
included in the study. pinholder (linear or curved clamps with a size of 4.5 mm for
The remaining 14 (24%) patients were excluded because they the connection of closed pins);
did not fulfill all the criteria requested.  4.5 mm distance unit joining threaded pins/connecting rod
The final sample included a total of 44 patients, 24 males (swivel fittings having size of 4.5 mm and a hole for bar insertion);
(54.6%) and 20 females (45.4%).  standard unit pinholder joining/connecting titanium rod
All the patients underwent a clinical examination (maximum (fittings used for bar locking): the connecting bar is inserted
mouth opening, pain and/or articular noises/rumors, chewing and through a hole; pins are secured using a clamp;
speech difficulties, facial nerve injuries) and morpho-structural
evaluation (orthopantomography or computed tomography scans),
to assess the complete condylar condition. Last, patients underwent
gnatography evaluations with BioPAK (Bioresearch Inc, Brown
Deer, WI) after surgery, to assess their mandibular function.
To fully involve patients who agreed to participate in this
research project, they have been asked to complete a questionnaire
12 months after surgery, to evaluate clinical parameters and their
evolution in detail. The questionnaire consisted of a general part in
which patients were asked to provide their personal data and a
specific part containing 6 questions (Table 1).
All the patients followed the same surgical protocol with the
modified external fixator. Surgeries were performed under general
anesthesia with nasotracheal intubation.
The device has been removed after 15 days on outpatient
without anaesthesia.
Short-term elastic maxillomandibular immobilization applied to
arch bars for 10 to 20 days was performed when condyle reduction FIGURE 1. Condylar external fixator, the modified external fixation system for
was not perfect, to provide a repositioning of the condyle as the treatment of mandibular condyle fractures, patented (RM2012A000574) by
physiological as possible. the research support area of ‘‘Sapienza’’ Università di Roma.

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 Modified External Fixator System

 connecting titanium rods (connecting bar used for the

connection of the 2 units);
 screwdriver handle rotating type (screwdriver for pin insertion
and junction adjustment);
 repositioning forceps;
 pin spacing.

Surgical Technique
Surgical access for the correct positioning of the device is a
minimally invasive preauricular pretragic access.13 Through this
access, after the exposure of the deep temporal fascia and ligation
of superficial temporal vessels you will reach the condylar
fragment. The first pin is placed on the condylar head, when it
is not dislocated, or on condylar neck, when it is dislocated. If the
first pin was applied on the condylar head (eg, in fractures
without dislocation), the position is considered favorable and
so it is possible to proceed with the next steps of surgery.
Otherwise, if the first pin was applied on the condylar neck, it
is necessary to apply a second pin on the condylar head to keep FIGURE 2. Gender distribution.
the fragment in place and then remove the first pin and apply it to
the condylar head. The 2 pins must be parallel to each other using
the dedicated instrument and so it is possible restoring the Eleven (55%) of low-neck fractures showed displacement but no
correct position of the fractured condylar fragment handling dislocation, while 9 (45%) of them showed dislocation.
the pinholder. Twenty-one (51.2%) were classified as high condylar fractures.
Later, 2 more transcutaneous pins are applied to the mandibular Five (23.8%) of high-neck fracture were displaced but showed
angle, below the course of the inferior alveolar nerve; these pins are no dislocation while 16 (76.2%) were displaced and dislocated.
set and made parallel to each other through the dedicated pinholder. Among condylar base fractures, 5 (62.5%) were displaced without
For intraoperative evaluation, the following 3 checkpoints must be dislocation and 3 (37.5%) were displaced and dislocated (Fig. 4).
taken into account: The questionnaire was proposed after 12 months from surgery,
 Contact between fractured surfaces: it is not viewable but you 91% of patients reported no pain in the treated area; in less than 9%
can detect it by moving the upper and lower pins; the greater of the patients they reported occasional pain (6.8%) or frequent
bone fragment must be aligned with the smaller bone pain (2.2%), while continuous pain was not reported in the
fragment. postoperative period.
 Repositioning of the small fragment in all the 3 planes, inside All the patients recovered their pretrauma occlusion after
the glenoid cavity; in few patients a small intraoral approach surgery. With regards to chewing activity recovery, 79.6% of the
was performed to evaluate endoscopically the correct sample claimed they were able to eat any kind of food, regardless of
fragments position. food consistency. 15.9% of the sample reported they were able to
 Proper occlusion: it can be verified only if you temporarily eat any food except for very hard food, while only 4.5% reported
remove the intermaxillary fixation. they were not able to eat medium consistency food. After surgery,
 After you can stabilize the system using a connecting no patient had a liquid diet.
bar, which is connected to the 4 pins through swivel Only 2 (4.5%) of the 44 evaluated patients reported headaches;
clamps.14 however, we found that these patients suffered from chronic
headaches before surgery yet and the headache was related to
neurological events (Table 1).
RESULTS At follow-up, after 12 months, 86.5% of the patients showed no
The final sample included a total of 44 patients, 24 males (54.6%) postoperative temporomandibular joint (TMJ) dysfunction; 9% of
and 20 females (45.4%) (Fig. 2). them reported occasional clicking, while 4.5% reported recurrent
Twelve patients were excluded from the sample because their disorders.
documentation was incomplete; 2 more patients were excluded
because they refused to give consent to participate in the
research project.
Mean age at the time of surgery was 24.5 years, with patient’s
age varying from 8 to 70 years old.
Thirty-five (79.5%) patients were diagnosed with a unilateral
condylar fracture and 9 (20.5%) patients were diagnosed with a
bilateral condylar fracture, for a total of 53 condylar fractures
(Fig. 3).
Four condylar fractures on 53 were compound but included in
the study because associated with a contralateral displaced fracture.
Forty-one condylar fractures (83.7%) occurred in the neck and 8
(16.3%) in the condilar base region.
Among neck fractures, 20 (48.8%) were classified as low-
neck fractures. FIGURE 3. Affected side.

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FIGURE 4. Pattern of condylar fractures.

Only 1 single patient was not satisfied due to the formation of a

hypertrophic scar in the preauricular region. The average satisfac-
tion score of surgery outcome reported by patients was 94.5/100,
and it ranged between 50/100 and 100/100.
The analysis of gnatographic functional parameters showed that
all the patients had regained the ability to move the jaw (opening,
protrusion, and laterality movements) already during the short-term
follow-up after surgery. In particular, the functional-clinical evalu-
ation of mouth’s maximum opening and mostly extent of lateral
excursion and of protrusion showed the following results:
 8% of the sample showed a maximum mouth opening
< 30 mm.
 72% of the sample showed a maximum mouth opening
between 30 and 40 mm.
 20% of the sample showed a maximum mouth opening
> 40 mm.
 Lateral excursion (contralateral to fracture) and protrusion
was respectively of 9.5 and 3.9 mm.
 Evaluation of morphostructural parameters obtained from
diagnostic images showed the following results, 12 months
after surgery.
 Vertical height recovery of the bony structures was good in 73.4%
of patients (Figs. 5 and 6), sufficient (shortening of the ascending
ramus 1 mm) in 24.3% of patients and insufficient (shortening of
the ascending ramus 2 mm) in only 1 patient (2.3%).
 Regarding bilateral condylar fractures, vertical height
recovery was similar in both sides for all patients.
 Bone contact has been achieved in all patients.
FIGURE 5. (A-C) A clinical patient showing a patient with a left condylar fracture
Less than 7% of patients showed a temporary partial paralysis, treated with condylar external fixator. The clinical and radiological restoring of
involving the temporozygomatic branch, resolved in few weeks. the pretrauma morphology and function is shown after 1-year follow-up.
No permanent paralysis of the facial nerve as postoperative
complication occurred among all patients. Less than 3% of
patients developed postoperative infections in the surgical Various authors maintain surgical indication in cases of mono-
area, resolved with appropriate antibiotic therapy; no patients condylar fractures in adults or adolescents, where it is impossible to
developed systemic infections. achieve normal occlusion and where there is a noteworthy dis-
location, with an angle of the small fragment greater than 458 or
simply where the condylar head has dislocated from the glenoid
DISCUSSION cavity.17 In fact, in these patients, conservative therapy although
The treatment of mandibular condylar fractures remained contro- assures good dental occlusion often does not allow complete
versial over the past due to the lack of unanimous agreement on it. recovery of the mandibular movements.
In the past, the 2 main therapeutic directions were on one Eckelt et al18 clearly demonstrated, on the basis of statistically
hand orthopaedic-functional treatment and on the other surgical proven data in their prospective randomized multicentre study, the
treatment. better results for open (operative) treatment and fixation of fractures
Surgical therapy is generally adopted when it is not possible to of the mandibular condylar process.
use a conservative treatment or when this would not guarantee an Singh et al,9 in their prospective randomized study, confirmed
adequate functional recovery. that today open approaches are considered the treatment of choice in
In 1983, Zide and Kent schematized the indications for surgical subcondylar mandibular fractures with deviation (108–358), and/or
treatment in absolute and relative and claimed surgery mandatory to fractures with shortening of the ascending ramus (>2 mm).
recover the reduction of posterior facial height, giving an adequate There are 2 main options in the treatment of surgical mandibular
guide for successive 3D reconstruction of the face.15,16 condylar fractures.

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possible, especially in growing patients for which osteocartilagi-

nous development is not completed yet.
In these patients, plates’ removal may be difficult and dangerous
for relation between scar tissue and facial nerve. Moreover, a
second surgery under general anesthesia may cause a heavy psy-
cho-physical stress to the patient and in subjects with decreased
functional reserve it can influence patient general conditions. To
reduce the disadvantages related to rigid internal fixation and
endoscopic treatment, ‘‘Sapienza" University of Rome developed,
since many years, a protocol based on external fixation system for
the treatment of surgical mandibular condylar fracture.
The external fixation system is made of steel, a biocompatible
material that provides a high resistance;13 the elastic properties of
the system are intrinsic in the material and are also determined by
the 3D shape of the system when fully assembled.23 Therefore, a
semirigid system guarantees a high stability as well as a quick
recovery of functional activity, essential for the therapy.13 More-
over, the relative elasticity of the system allows minimal fragments
movements, thus reducing the risk of pathological events such as
bone reabsorption of condyle or glenoid cavity, a possible compli-
cation of internal rigid fixation.23 From a physio-mechanical point
of view, the fixation system and the fractured bone form a func-
tional unit in which forces are partly dissipated on bone, improving
bone trophism and repairing23– 26 unlike in rigid fixation forces are
fully dissipated on plates.
The concept underlying this innovative surgical procedure, which
is also the primary goal of treatment, is the quick recovery of TMJ
function with subsequent maintenance of disc-condyle integrity. In
FIGURE 6. (A, B) A clinical patient showing a patient with a left condylar fact, in patients in whom an ideal repositioning of fragments is
fracture treated with condylar external fixator. The clinical and radiological
restoring of the pretrauma morphology and function is shown after 1-year impossible to achieve, the fixator can be removed after a shorter
follow-up. period of time and, since callus formation is still active, small
fragment position can be improved using occlusal traction forces
The first is the application of titanium miniplates, to reduce and applied to teeth using rubber bands or orthopedic/orthodontic appli-
contain the fracture. ances such as occlusal guidance appliances or functional appliances.
The second option consists in the use of an external fixator to This approach is based on the external fixator ability to convert a
realign the small fragment. dislocated fracture into a nondislocated fracture treatable with
The 2nd IBRA Symposium for Condylar Fracture Osteosynth- nonsurgical therapy (ie, functional treatment). This procedure
esis 20128 held at Marseille, succeeding the first congress in enables achieving acceptable results even when the fracture is
Strasbourg, in 2007, assessed current trends and potential changes not completely reduced, since the essential goal of the treatment
of treatment strategies for mandibular condylar fractures, which is the recovery of disc-condyle integrity. Although the size of the
remain controversial over the past decades. external fixator may cause a slight discomfort in the patient for 15
In that study it was found that most surgeons preferred to days, device removal will leave the treated area free of heterologous
perform ORIF for condylar base and neck fractures in both adults devices and there will be no need for further surgeries for devices
and growing patients (age >12–13 years), especially in displaced removal. In addition, external fixation removal is very easy and it
and dislocated fractures; treatment of condylar head fractures and can always be done outpatients without anesthesia or sedation,
condylar fractures in growing patients are no longer considered to resulting in cost reduction and allowing the future condyle growth
be nonsurgical only. in young patient.
Anyway, the application of titanium plates on condyle has often Especially in this last category of patients, the external fixation
been criticized,19–22 especially for issues related to the surgical system has the largest number of advantages.
access, the risk of injuries of facial nerve branches, and the It permits the correct mandibular growth and thus facial, without
development of hypertrophic scars.13 To avoid the risk of injury the need of continuous controls until adulthood (as in case of
to the facial nerve branches, the endoscopic access would be the nonsurgical treatment with intraoral device) with a considerable
best option. saving of resources for families and without undergoing a necessary
Endoscopic approach to the condylar region has gained more second operation for plaques removing (as in the patient of rigid
popularity but remains reserved for selected patients, for example internal fixation).
laterally displaced base fractures but requires a team of trained Moreover, it minimizes pain events because it can be removed
experts in endoscopy and longer operative times with continuous when the callus is still malleable, thus avoiding the risk of stabilizing
occupation of the operating rooms which results in a considerable the condyle head and the entire TMJ in a pathological position, while
increase of the specific costs. failure of a perfect reduction with plates can cause a misplacement of
A significant disadvantage of plates application is related to the the disc and result in local pain and longer recovery time.27
intraoperative reduction phase. If fragments are not perfectly
relocated during surgery, the condyle misplacement in its cavity CONCLUSIONS
could result in disc displacement with loco-regional pain and typical Condylar external fixator provides multiple and innovative bene-
symptoms such as headache, cervical pain, pain in the upper arms, fits: it is quite easy to apply, pins allow an easy fracture reduction
tinnitus, and dizziness, and a second surgery to remove them is especially when the small fragment is dislocated out of the glenoid

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Cascone et al The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

cavity and promote a fast functional recovery through the immedi- 10. Loukota RA, Eckelt U, De Bont L, et al. Subclassification of fractures of
ate joint mobilization. The first self-drilling self-tapping pin helps the condylar process of the mandible. Br J Oral Maxillofac Surg
to catch the small fragment dislocated. 2005;43:72–73
Condylar external fixator can be completely removed outpa- 11. Schneider M, Eckelt U, Reitemeier B, et al. Stability of fixation of
tients without anesthesia and this characteristic makes it the diacapitular fractures of the mandibular condylar process by ultrasound-
elective device for the surgical treatment of growing patients. aided resorbable pins (SonicWeld Rx! System) in pigs. Br J Oral
Maxillofac Surg 2011;49:297–301
Furthermore, short elastic fixation period (varying from 10 to 12. Clementschitsch F. Uber die Rontgendarstellung bei Erkrankungen und
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