THE CONSERVATIVE TREATMENT OF SIMULTANEOUS FRACTURES

THROUGH THE NECKS OF BOTH MANDIBULAR CONDYLES

ASSOCIATED WITH MULTIPLE FRACTURES OF
OTHER PARTS OF THE MANDIBLE

LOREN W. QRUBER, D.D.S. AND JOHX LYFORD, III, M.D., BALTIMORE, MD.

F RACTURES about t,hc condylar processes of the mandible are of sufficiently

common occurrence to deserve special consideration. Thornal has classified
all fractures of the necks of the mandibular condyles into four types: 1. Frac-
[Link] with over-riding of the fragments. 2. Fractures with forward, medial, or
lateral displacement. 3. Fractures with medial or lateral dislocation of the
condyloid processes. 4. Fractures with subsequent ankylosis.
Simultaneous fractures Ohrough the necks of both mandibular condyles as-
sociated with fractures of other parts of the mandible are infrequent. But with
the increasing incidence of transportation and industrial accidents such in-
juries have been seen sufficiently often to raise the question of successful’treat-
ment, since loss of function of the jaw is a very distressing deformity. The pres-
ent report reviews the results of conservative therapy in a group of such frac-
t,ures and presents an analysis and discussion of the successful treatment em-
ployed in a recent case of this type in which the problem was further complicated
by a delay in instituting initial treatment. We feel that this case is of special
interest in that there was used a conservative procedure employing the prin-
ciple of force applied vertically downward through the line of the mandibular
ramus to overcome the action of the muscle elevators of the jaw, spasm of which
prevented reduction of the displaced fragment of a fractured coronoid proccm.
So far as is known to t,he authors the method utilizing this principle has not
been described previously. The literature contains a paucity of material con-
cerning the treatment of fractures of the necks of both mandibular condyles
associated with fractures of other parts of the mandible, and WC were unable
t,o find any adequate discussion of the conservative treatment of this type of
fracture. However, an abundance of literature is to be found on the therapy
by open reduction of fractures of the necks of the condyles of the mandible
and ankylosis of the temporovandibular joints.
i major problem in this type of injury is the prevention of loss of func-
[Link] through temporomandibular ankylosis. Campbell* stated that fractures or
other traumatic lesions rarely cause ankylosis of the jaw, but more often produce
restricted motion of the mandible. Federspie13 reported that he had never had
a case of dislocated and fractured mandibular condyles in which limitation of
motion was avoided. Risdon4 stated that following fractures of the necks of the
condyles occurring in the third decade of life ankylosis resulted in 5 per cent
‘From the Fracture Service, the Department of Dentistry and the Division of Orthopedic
Surgery, the Johns Hopkins Hospital, E3altimore, Md.
158
of the cases. Brown and Hamm” reported fractured necks of both mandibular
condyles in a S-year-old child, This patient was trcatcd by fixation of’ the jaw
in occlusion, and a good result was obtained. They belicvc this to be the treat-
ment of choice, and that it is followed by very few instances of ankylosis.
Honney6 stated that fractures through the necks of Ihc condylar processes of
the mandible, whether or not complicated by other fractures of the bone, can
be treated in most cases by simple immobilization of the jaw, and that open re-
duction should be a last resort after all other methods fail.
At the Johns Hopkins Hospital there were available for study the records
of ten patients treated between 1925 and 1941 for fractures through the necks
of both mandibular condyles associated with concomitant fractures of other
parts of the mandible. All were treated bJ- immobilization of the mandible
for approximately six weeks until the noncondylar fracture of the mandible was
solidly healed and there was no longer any danger of osteomyelitis. The man-
dible in each case was then mobilized, and the results in thcsc ten cases were
as follows :
1. Five patients made an uneventful recovery wit,11 minimal loss of func-
tion, ankylosis at the temporomandibular joints, deviation of the mandible, and
interference with occlusion.
2. Three patients had tither residual appreciable loss of’ function, maloc-
clusion, or deviation of the mandible.
3. Two patients suffered ankylosis of the Ic~inJ,oromandib~~lar joints, and
required surgical orthoplastic procedures.
Thus, in this group of patients simple immobilization gave good result,s in
50 per cent, fair results in 30 per cent, and failures in 20 per cent.
In addition to this group of patients the authors recently treated a patient
with fractures through the necks of both mandibular condyles with associated
fractures of other parts of the mandible in whom initial [Link] was delayed,
This cast is presented as being of particular int,erest for three main reasons.
(he, a good functional result was obtained in spite of a delay in instituting
initial treatment. Two, there was employed in the t,reatmcnt of the coronoid
I’rectnre a conservat,ivc method, not previously described, based on t,he prin-
ciplc 01: force applied vertically downward through 1~11~ line of the mandibular
ramus to overcome the spasm of the rrIusclc clcvators of the jaw which prevented
reduction of the displaced fragment. Three, it is an example of the growing
need of cooperation between dentists and orthopedic surgeons in the treatment
of multiple fractures of the mandible.

CASE HISTORE[

C:. J., a 21-year-old colored, married woman, entered the outpatient clinic
iIt the ,Johns Hopkins Hospital on Aug. 9, 1941, with the story of having been
struck on the left side of the jaw in an automobile accident twelve days pre-
viously. Iluring this period the patient had received no treatment, and had
had persistent pain, stiffness, and swelling about the left temporomandibular
region. When first seen in the clinic the patient showed considerable swelling
in t,hc left temporomandibnlar region, marked trismus, and displacement of
260 Loren IV. G,vuber and John Lyford, 111

the mandible to the right. There was crepitus in the body of the mandible
below the right cuspid and lateral incisor teeth, and the two maxillary central
incisor teeth were badly luxated and abscessed from the recent trauma. Radio-
graphs revealed a comminuted fracture of the right side of the mandible in the
region of the lateral incisor tooth, fractures through the necks of both condylar
processes of the mandible with the heads of the condyles dislocated from the
‘glenoid fossae, and a fracture of the left coronoid process with the fragment dis-
placed medially (Figs. 1, 2, and 3).

Fig. l.-Aug. 9. 1941. Anteroposterior radiograph showing fractures through the necks
of both mandibular condyles. both condyles displaced from the glenoid fossae, comminuted
fracture of the left coronoid process. and fracture of the body of the mandible.

The two abscessed and luxated maxillary central incisor teeth were ex-
tracted. The parasymphysis fracture has manually reduced and the mandible
wired in occlusion by the use of intermaxillary wiring and rubber elastic bands
between the two arches. This position was maintained for five weeks (seven
weeks postinjury). When the parasymphysis fracture was c’linically solid
and there was no longer any danger of osteomyelitis from this source, the wiring
and elastic bands were removed, and mobilization of the mandible was attempte?l
by means of having the patient chew gum. At this time there was noted some
atrophy with loss of function of the left masseter muscle, which persisted. After
two weeks of attempted mobilization there was still marked inability to open
the mouth, and this was felt’ to be due to the spasm of the muscle elevators of
the mandible associated with the fracture fragments displaced from the coronoid
 Prncturas of Necks of Condyles 261

and condylar processes. It was felt, also, that much of the muscle spasm could
be due to the irritation from the displaced coronoid fragment in the same manner
that fractures with displaced fragments in other bones such as the femur are

Fig. 2. Fig. 3.
Fig. 2.-(Left Side) and Fig. 3 (Right Side).-Aug. 9, 1941. Lateral radiographs of the
temporomandibular regions showing both condylar fragments displaced from the glrnoid fossne.

Fig. 4.-O&. 10, 1941. Anteroposterior radiograph showing reduction of the left coronoid
fracture, healing of the fracture of the body of the mandible, and the persisting displacement of
both condyloid fragments.

associated with muscle spasm. At this time a small truncated wedge of semi-
hard wood was placed between the maxillary and mandibular second molar
teeth on the right side and wired to the upper molars to prevent the patient
262 Loven IV. Gruber mad John Lyford, III

swallowing the appliance. As the muscle spasm decreased and the mobility of
the mandible ‘increased, a larger wedge was inserted every third day, being
alternately changed from right side to left side throughout the procedure.
Always the wedge was placed with the narrow end toward the back of the mouth
and shaped so as to fit as tightly as possible between the maxillary and mandibu-
lar molars. Also, the wedge was placed as far posteriorly as possible in order to
obtain the maximal vertical force along the line of the ramus of the mandible.
After ten days of this treatment the patient showed satisfactory function of
the jaw with depression of the mandible having been restored to about 75 per
cent of normal, and occlusion being complete. Radiographs at this time showed
the condylar heads still displaced from the glenoid fossae, but the coronoid frag-
ment had been reduced to its normal position (Fig. 4). Wedging was then dis-
continued, and free mobilization and use of the mandible by the patient were en-
couraged. Nine weeks later (nineteen weeks after injury) after free use of the
mandible, examination revealed the same satisfactory function of the jaw as
when treatment was discontinued, i.e., complete occlusion of the teeth, ancl ap-
proximately 75 per cent depression, 25 per cent lateral motion, and 10 per cent
protrusion of the mandible (Figs. 5 and 6). Radiographs taken at this time
again revealed the parasymphysis fracture well reduced and healed, the coronoid
fracture reduced with good callus formation, but the condylar heads unreduced
and outside the glenoid fossae (Fig. 7).

Fig. 5. Fig. G.

Fig. 5.-Dec. 9, 1941. The patient with the mandible in maximum occlusion, post-treatment.
Big. 6.--D%. 9, 1941. The patient with maximum opening of the mouth, post-treatment.

DISCUSSION

It is apparent that when the patient was first seen no treatment could be in-
stituted for the condylar and coronoid fractures until the fracture of the body
of the mandible was healed, and there was no longer any danger of osteomyelitis
from this source. Thus, the treatment of the fractures of the condyles was de-
layed until seven weeks after injury at which time there was about the fracture
sites definite callus holding the condylar fragments permanently displaced out
of the glenoid fossae medially and forward. Thornal points out that in frac-
tures through the necks of the mandibular condyles the most frequent displace-
ment of the fragment is forward, and the most common dislocation is medial.
He states that the former is brought about by the action of the external pterygoid
muscles, while the latter results from the action of the external pterygoid muscle
combined with the anatomic condition of the fossa articularis which favors a
tnedial dislocation with the condyle piercing the capsule while the meniscus gen-
erally remains in the fo*a. Zetnsky’ reported a case in which a displaced frac-
ture of a mandibular condyle was t,reated successfully by means of a modified
h’owler ‘s apparatus which gives a hinge-like action about t,he temporomandibu-
lar joints. Iii t,he present case it was felt that most of tllc loss of function was
due t.o t,he positions of the displaced condylar and coronoid fragments and to
the persisting spasm of the elevator muscles of the mandible (the strong temporal
and masseter and weaker internal pterygoid muscles). This muscle spasm, it
was reasoned, could be due to irrit,ation from the displaced coronoid fragment
in the same manner [Link] displaced fractures of other bones, such as the femur,
are associated with l~~usc~lc spasm. Since t,he elevators of the mandible all insert,
about the ramus OF the l~tlc, it was reasoned 1hat :I vertical force exerted down-
ward along the line ot’ 1he ramus should readily ovc~~t~~c the spasm of these
muscles. This was accotnylislicd 1)y increasingly larger ~~~[Link] inserted

rig. i.-Dec. 9, 1941. Anteroposterior radiograph showing reduction of the left coronoid
fracture, and the persisting displacement of both condylar fragments.

between the maxillary and mandibular posterior molar teeth as described above.
The upward force necessary to have the vertical downward component exerted
against the mandibular elevators through the wedge fulcrum was supplied by the
contraction of the anterior fibers of the masseter muscle which insert on the
body of the mandible anterior to the ramus. Overcoming the muscle spasm of
,264 Loren IV. Bruber and John Lyford, II1

the elevators of the mandible not only relieved the trismus, but permitted the
fracture fragment displaced from the coronoid process to fall back into its nor-
mal position (Fig. 4). The results in practice were gratifying. It is apparent
at once that this procedure employing wooden wedges could not be used in pa-
tients lacking posterior molar teeth. One of us (L. W. G.) is now designing
for use in place of the wedges for the fulcrum for exerting continual vertical
force downward along the line of the mandibular ramus a simple intraoral ap-
pliance which is not only adjustable, but can be used on patients lacking posterior
molar teeth. It is hoped that the results with this appliance can be reported in
a subsequent publication.

An analysis is presented of the results of conservative treatment in a group

of ten patients having fractures through the necks of both condylar processes of
the mandible associated with fractures of other parts of the bone. The end re-
sults in this group of cases were good in 50 per cent, fair in 30 per cent, and
failures in 20 per cent. This would indicate that conservative treatment is the
method of choice in this type of fracture.
There is discussed one additional case of fractures through the necks of
both mandibular condyles associated with a fracture of a coronoid process and
a fracture of the body of the mandible in which initial treatment was delayed,
and in which good functional results were obtained by using a conservative
procedure not previously described for this type of injury. The method was
based on the application of force exerted vertically downward through the line
of the mandibular ramus to overcome the spasm of the muscle elevators of the
jaw which prevented reduction of the displaced fragment of the fractured
coronoid process.
The results obtained in the outlined case would suggest that the procedure
of choice in the treatment of fractures of the coronoid process of the mandible
with the fragments displaced would be conservative and would be the applica-
tion of the method described for overcoming spasm of the elevator muscles of
l-he mandible.
The suggestion is made that in the treatment of the more complicated frac-
tures of the mandible there should be close cooperation between dental oral sur-
geons and brthopedic surgeons.

REFERENCES

I. Thoma, Ku& H.: Traumatic Injury of the Condyloitl Process of the Mandible, New
Eng. J. Med. 218: 63, Jan. 13, 1938; AM. J. ORTRODONTICS 24: 774, 1938; Oral
Pathology, The C. V. Mosby Co., 1941, pp. 787-790.
2. Campbell, Willis C.: Mobilization of the Ankylosed Jaw, J. A. D. A. 19: 1222, 1932.
3. Federspiel, M. N.: Incomplete and Complete Jaw Ankylosis, J. A. D. A. 26: 585, 1939.
4. Risdon, F. R.: Ankylosis of the Temporo-Mandibular Joint, J. A. D. A. 21: 1933, 1934.
5. Brown, J. B., and Hamm, W. G.: Diagnosis and Treatment of Lesions Preventing Nor-
mal Opening of the Mouth, INT. J. ORTHODONTIA AND ORAL SURG. 18: 353,1932.
6. Banney, T. C.: Fracture of the Body of the Mandible Complicated With Fractures of
the Neck of the Condyle, Dental Cosmos 69: 627, 1927.
7. Zemsky, J. L.: New Conservative Treatment versus Surgical Operation for Displaced
Fractures at the Neck of the Mandibular Condyle, Dental Cosmos 68: 43, 1926.
JOHNS HOPKINS HOSPITAL