CASE REPORTS
J Oral Maxillofac Surg
Endoscopic-Assisted Reduction and
Fixation of a Mandibular Subcondylar
Fracture: Report of a Case
Noah A. Sandler, DMD, MD*
Subcondylar fractures of the mandible are common,
accounting for approximately 30% of all fractures of
the mandible in dentate patients1 and 37% of mandib-
ular fractures in edentulous patients.2 A variety of
options have been described to treat these fractures,
including closed treatment and open techniques in-
volving a variety of surgical approaches. Each treat-
ment has its advantages and disadvantages depending
on the level of the fracture and the degree of displace-
ment. Disadvantages of open techniques include lim-
ited access for high subcondylar fractures, damage to
branches of the facial nerve, unaesthetic scarring,
and/or potential bleeding from the maxillary or mas-
seteric artery or the retromandibular vein.3-5
Recently, endoscopic procedures have become com-
mon in diagnostic, cosmetic, and other surgical proce-
dures. In a previous report, 7 subcondylar fractures in
cadavers were reduced and stabilized through an in-
traoral approach using a 30 endoscope and a modied
transcutaneous trocar.6 The present case report de-
scribes the clinical application of this technique.
Report of Case
A 27-year-old white woman was referred to the oral and
maxillofacial service from an outlying hospital 2 weeks after
being involved in a motor vehicle accident in which she was
a rear seat passenger in a car that was hit by a truck. Her
injuries included a pelvic fracture, a left humerus fracture, a
left rib fracture with pulmonary contusions, and a left ear
laceration with exposed cartilage. Her pelvis and humerus
were treated with closed reduction and the ear laceration was
repaired. The patient was subsequently discharged. However,
she noted a persistent malocclusion and tenderness in the left
*Assistant Professor, Department of Oral and Maxillofacial Sur-
gery, University of Minnesota, Minneapolis, MN.
Address correspondence and reprint requests to Dr Sandler:
Department of Oral and Maxillofacial Surgery, University of Minne-
sota, 7-174 Moos Health Science Tower, 515 Delaware St SE, Min-
neapolis, MN 55455; e-mail: sandl003@tc.umn.edu
2001 American Association of Oral and Maxillofacial Surgeons
0278-2391/01/5912-0015$35.00/0
doi:10.1053/joms.2001.27536
1479
59:1479-1482, 2001
preauricular region during mastication. She returned to the
hospital and mandibular oblique and open mouth Townes
view radiographs were obtained that were suspicious for a
previously undiagnosed left subcondylar fracture. Examination
showed a small step defect between the mandibular central
incisor teeth and a left anterior crossbite (Fig 1). Repeated
radiographs conrmed a subcondylar fracture and a symphysis
fracture (Figs 2, 3). After review of the risks and benets of
procedures to treat the fractures, the patient elected to have
open reduction and internal xation of both fractures via an
intraoral approach. The patient understood that a transcutane-
ous trocar would be used during treatment of the subcondylar
fracture and that a neck incision and/or maxillomandibular
xation may be required if this approach failed.
After exposing the symphysis fracture, it was reduced and
stabilized with 4-hole, 2-0 plates placed at the inferior and
superior borders. For the subcondylar fracture, an incision was
made in the buccal vestibule similar to the incision for a
sagittal ramus osteotomy and subperiosteal dissection was
used to expose the condylar process. Intraoral dissection was
also performed on the medial surface of the ramus above the
lingula to aid in manipulating the subcondylar segment.
Using the canthal-tragal line as a guide, a measurement 20
mm anterior to the tragus along this line and 10 mm inferior
to this point was marked to direct the site of the trocar
puncture. This site is commonly used as a second trocar site
in performing arthroscopy of the temporomandibular
joint.7 A blunt, 2-mm diameter trocar was introduced at this
site after a stab incision was made through the skin and
subcutaneous tissue. The check retractor for this trocar
(Leibinger Co, Irving, TX) had been modied to accommo-
date an endoscope to allow visualization of the condylar
neck region through the intraoral wound. The mechanism
on the cheek retractor consisted of a tube with custom-
FIGURE 1. Patients occlusion on presentation. Note the space
between the central incisors and the slight anterior open bite.
1480 ENDOSCOPIC SUBCONDYLAR FRACTURE

FIGURE 2. Preoperative pan-

oramic radiograph showing the
right parasymphysis (white ar-
row) and left subcondylar (black
arrow) fractures.

FIGURE 3. Preoperative modied Townes view of the left sub-

condylar fracture.

FIGURE 5. Final xation as visualized through the endoscope.

White arrow points to the fracture line. Proximal segment is oriented
toward the top of the picture.

FIGURE 4. Modied trocar with 30 endoscope in position. FIGURE 6. Postoperative occlusion.

NOAH A. SANDLER
FIGURE 7. Postoperative pan-
oramic radiograph showing good
fracture reduction.
milled nylon ttings to accommodate a 4-mm diameter, 30
angle Storz endoscope (Karl Storz Inc, Carlsbad, CA) (Fig 4).
Once dissection and approximate reduction were
achieved by manipulating the segments into position, a 2.3
mm, 5-hole straight plate was secured to the proximal
segment by 2 screws under endoscopic visualization. The
plate assisted in nal reduction of the proximal segment.
The patient was placed in maxillomandibular xation and
the distal segment was stabilized by placing 3 screws
through the plate using a second trocar site and direct
visualization. This second site was through the parotid gland in
the same region where a trocar would be used to assist in
xation of a sagittal split ostetomy (Fig 5). The time to perform
reduction and xation of the subcondylar portion of the pro-
cedure was approximately 50 minutes. Before extubation, the
maxillomandibular xation was removed.
The patient was subsequently seen 10 days postopera-
tively and then again 2 months postoperatively. She had no
complaints of paresthesia. Her maximal opening at 2
months was 30 mm without deviation on function. She had
undergone previous orthodontic therapy years before her
injury and presently has regained her premorbid occlusion,
FIGURE 8. Postoperative modied Townes radiograph showing
the reduced and xed fracture.
1481
with an anterior midline discrepancy that had been noted
previously by the patient (Fig 6). Postoperative radiographs
conrm adequate reduction of the fractures and good posi-
tion of the condylar process (Figs 7, 8). On further attempts
at follow-up, the patient has been unwilling to travel the
150 miles from her home to be seen.
Discussion
There presently exists considerable controversy as
to the benet of open reduction of mandibular con-
dyle fractures, especially in children.7-9 There seems
to be some benet in open treatment of signicantly
displaced subcondylar fractures. However, in these
same studies, open treatment was not always possible
due to the anatomic position of the proximal seg-
ment.10,11 Endoscopy has proven to be invaluable in
visualizing difcult to access regions due to anatomic
constraints. Subcondylar fractures of the mandible are
common and are difcult to access especially when
they occur high, near the condylar neck. Endoscopy
may be a useful adjunct to x subcondylar fractures.
Specialized equipment and techniques such as those
used in the present case may enhance visualization
and xation with the aid of the endoscope. Further
evaluation of more difcult to access fractures (high
fractures) and comparison of present closed and
open techniques of similar fractures is warranted.
Acknowledgment
The author thanks the Leibinger Corporation, Irving, TX, for their
nancial and technical support for trocar fabrication and Mr. Todd
Buelow of Phalen Manufacturing, Minneapolis, MN, for his technical
expertise in helping to design the modied trocar used in this study.
References
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