Management of condylar fractures: a narrative review of closed vs. open approaches

Introduction

Background

Mandibular condylar fractures account for up to 30–40% of all mandibular fractures and present a significant clinical challenge to surgeons (1). If not properly managed, these fractures may result in functional impairment, malocclusion, temporomandibular joint (TMJ) disorders, and facial asymmetry if inadequately treated (2). Historically, treatment was limited to conservative measures, but with the advent of internal fixation, the paradigm has shifted towards open reduction and internal fixation (ORIF) in certain scenarios (3).

Currently, two treatment philosophies dominate management of condylar fractures. Closed management emphasizes functional adaptation through early mobilization and physiotherapy, while avoiding surgical intervention (4). ORIF aims to restore anatomical alignment, condylar position, and ramus height to improve functional outcomes (5). However, ORIF carries intraoperative and postoperative complications that are not seen with closed management (6,7).

Rationale and knowledge gap

There is no consensus on which treatment method is better due to variability in fracture patterns, patient age, dentition, and surgeon expertise. While previous literature has explored these outcomes, there remains a need to synthesize a review of the most recent comparative data to establish clinical guidelines. Notably, the American Association of Oral and Maxillofacial Surgeons (AAOMS) maintains a conservative stance on management, furthering the need for higher-level evidence (8).

Objective

This narrative review examines comparative evidence published between 2000 and 2025 on closed and open management, with focused analysis on indications, functional recovery outcomes [such as maximum incisal opening (MIO) and lateral excursion], and complications. The primary goal is to clarify the clinical indications for closed reduction and ORIF to aid in evidence-based decision-making. While recent studies, such as that by Jazayeri et al., found ORIF superior in restoring function, this narrative review distinguishes itself by addressing the management of unique clinical scenarios—such as pediatric, bilateral, and edentulous fractures—and evaluates the impact of varying surgical approaches on patient outcomes to provide a more comprehensive framework for clinical decision making (9). We present this article in accordance with the Narrative Review reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-25/rc).

Methods

A literature search was performed in PubMed and Cochrane databases using combinations of MeSH and free-text terms: “condylar fracture”, “subcondylar fracture”, “open reduction internal fixation”, “closed treatment”, “functional therapy”, “maxillomandibular fixation”, “ORIF”, and “comparative outcomes” between July and October 2025. Inclusion criteria were English language, studies published 2000–2025, comparative studies, randomized trials, cohort studies, and systematic reviews/meta-analyses, and direct comparison of closed vs. open management. Exclusion criteria were case reports without comparative data and non-English articles without available translation. Screening was performed by Jacobs and Patil together. Methodology is summarized in Table 1.

Discussion

Historical evolution of condylar fracture management

The management of mandibular condylar fractures has undergone notable changes over the last century. Prior to the use of rigid fixation, conservative measures such as prolonged maxillomandibular fixation (MMF) were standard practice, with immobilization periods often exceeding 6 weeks (10,11). These approaches lowered surgical risk but were associated with joint stiffness, malocclusion, and long-term functional deficits (12). The usage of titanium plating, rigid internal fixation, and minimally invasive surgical approaches has created debate over the role of ORIF in condylar trauma.

By the early 2000s, evidence suggested that ORIF could restore ramus height, condylar position, and occlusion while allowing earlier mobilization (13,14). This shift paralleled the publication of European and Asian consensus guidelines advocating ORIF in selected displaced fractures (6,15). The AAOMS, however, retained a more conservative position, citing insufficient high-level evidence for universal adoption (16).

Biomechanical considerations and pathophysiology

The condyle’s load-bearing role introduces unique challenges for repair. The TMJ is a class III lever, meaning the input force (the force exerted by the muscles of mastication) is applied between the fulcrum (where the condyle articulates with the glenoid fossa) and the output force (the mandible itself) (17).

Displacement alters the mandibular lever arm, disrupts occlusion, and may impair TMJ biomechanics (18). Ellis and Throckmorton showed that masseter function increases on the nonfractured side, while masseter function decreases on the fractured side (19). Closed treatment relies on adaptive remodeling of the condyle, which is more predictable in children and less so in adults (20). However, the condyle’s articulation with the glenoid fossa tends to change to become lower and more anterior on the eminence. This can reduce translational movement of the joint (21). Conversely, ORIF restores anatomy and can prevent pathological remodeling and lateral deviation of the mandible (9,13,22,23).

Mouth opening, excursions, and deviation

Multiple comparative studies and meta-analyses have documented mixed results regarding mouth opening with ORIF. Measuring MIO lateral excursions is a surrogate of mouth function, as a more limited range of motion is associated with decreased function. Some studies show superior early and long-term functional outcomes with ORIF. Zide et al. reported that patients undergoing ORIF achieved a mean MIO of 42 mm at 3 months compared to 36 mm in the closed group (P<0.01) (24).

Similarly, Al-Moraissi et al.’s systematic review of 23 studies found significantly less deviation on mouth opening in ORIF patients (mean 1.8 vs. 3.4 mm in closed, P<0.05) (25). Lateral excursions are also restored more rapidly after ORIF, facilitating a symmetric bite.

Shiju et al. performed a randomized control trial comparing functional outcomes in patients who receive open treatment vs. closed treatment of displaced condylar fractures with the degree of deviation ranging from 10–45 degrees medially or laterally. They found that 70% of patients who underwent closed treatment developed deviation on mouth opening at 6 months follow-up, compared to 0% of those that underwent ORIF (26).

Eckelt et al. performed a similar randomized control trial to Shiju et al. and found superior functional outcomes in all categories in open treatment compared to closed treatment. MIO was greater in the open vs. closed group (46.5 vs. 40.9 mm, P=0.001). Maximum protrusion was greater in the open vs. closed group (7.3 vs. 4.7 mm, P=0.0005). 66% of patients treated with closed reduction developed terminal lateral shifts in opening compared to 19% of patients treated with ORIF (P=0.03) (27).

On the other hand, some studies show an insignificant difference in MIO between the two treatment approaches. Danda et al. (2010) and Rikhotso et al. (2022) demonstrated no statistically significant difference in long-term maximal incisal opening when comparing open versus closed treatment (28,29). Furthermore, Haug and Assael (2001) and Shiju et al. (2015) found that open treatment may facilitate a more rapid return to preoperative MIO, closed management ultimately results in MIO levels comparable to those achieved with ORIF (26,30).

Closed treatment patients frequently require longer physical therapy courses to achieve comparable range, and in some cases, limitations persist beyond 12 months (31).

Occlusal stability and malocclusion rates

Occlusal derangement is a key determinant of patient satisfaction and long-term functional outcomes. In a prospective cohort of 112 patients, Singh et al. found malocclusion in 11.1% of closed-treated cases compared with 4.0% after ORIF (32). These findings echo those of Haug et al., who reported a four-fold higher incidence of postoperative occlusal adjustment in closed patients (30). Eckelt et al. found that 20% of patients treated with closed reduction had objective evidence of malocclusion at 6 months followed up, compared to 0% of patients treated with ORIF (27). In a meta analysis performed by Berner et al., included studies that reported on malocclusion found a higher incidence in the closed treatment group, however each study did not find a statistically significant difference (33). One likely explanation for this is that each study had small sample sizes and were therefore underpowered.

The mechanism lies in the inability of closed management to fully restore ramus height in displaced fractures, resulting in premature contact on the contralateral side and posterior open bite ipsilaterally (34). ORIF mitigates this by anatomic reduction and rigid fixation (35).

Pain

Pain reduction is often faster and more complete after ORIF. VAS scores at 6 months were significantly lower in open-treated patients in the randomized trial by Schneider et al. (1.8 vs. 3.4, P=0.002) (13). Eckelt et al. found significantly higher VAS scores in the closed treatment group, compared to ORIF group at 6 months post operative (13.5 vs. 2.9, P=0.003) (27). Magnetic resonance imaging (MRI) studies have demonstrated better disc-condyle relationships post-ORIF, correlating with improved functional comfort (36).

A pooled analysis by Al-Moraissi et al. showed TMJ imbalance in 15.9% of closed cases versus 10.3% after ORIF (37).

Complication profiles

While ORIF offers functional superiority, it carries surgical risks. The most cited is facial nerve injury, with transient weakness occurring in 5–12% depending on surgical approach, and permanent weakness in <1% (16,38). Retromandibular and preauricular approaches exhibit the highest rates, whereas transoral and endoscopic methods significantly reduce nerve morbidity (39).

Infection rates remain low (<3%) for both modalities, although ORIF requires vigilant soft tissue handling to prevent plate exposure (39). Hardware removal can also rarely be necessary after ORIF.

Special populations

Pediatric patients

Children display remarkable condylar remodeling potential, with closed treatment often yielding excellent outcomes (40). ORIF is generally avoided in patients under 12 years due to risk to the growth center (41). After the age of 12, the mandible becomes more adult-like and the remodeling capacity decreases. Therefore, the risk for functional disturbances after closed reduction increase, and the decision to perform ORIF aligns closer to what is currently indicated in adults (42).

Bilateral fractures

Bilateral condylar fractures pose heightened challenges. Closed management risks anterior open bite and reduced ramus height bilaterally, compromising facial symmetry. Several series report superior functional and aesthetic outcomes with at least unilateral ORIF in such cases (13,34,35,37).

Edentulous patients

In edentulous mandibles, the lack of occlusal guidance complicates closed management. Generally, non-displaced or minimally displaced condylar fractures are managed via closed reduction, whereas displaced condylar fractures require ORIF in order to maintain posterior vertical height of the ramus. ORIF enables accurate ramus height restoration, aiding in prosthetic rehabilitation (43). Generally, this population tends to be older patients with multiple medical comorbidities such as chronic kidney disease, heart failure, diabetes, some of which could preclude the ability to perform ORIF.

Surgical approach variations in ORIF

Approach selection influences outcomes and complications:

• Preauricular: best for high condylar neck fractures; higher transient nerve injury rates (38).
• Retromandibular: versatile for neck/subcondylar fractures; good exposure; 6–8% transient nerve injury (44).
• Transoral with endoscopic assistance: minimally invasive, lower nerve injury risk, but technically demanding (45).

Conclusions

Patient-specific three-dimensional (3D)-printed plates, and fully endoscopic ORIF are gaining traction, promising reduced morbidity without compromising stability (46). Bioactive coatings and low-profile designs may further reduce hardware complications.

In conclusion, review of the literature shows superior outcomes with ORIF compared to closed reduction for displaced condylar fractures. However, ORIF caries surgical risks that closed management does not, and needs to be taken in consideration. Non displaced or minimally displaced condylar fractures are generally more amenable to closed reduction. Pediatric condylar fractures under the age of 12 are typically managed with closed treatment, whereas fractures above the age of 12 can be considered for open treatment depending on the nature and displacement of the fracture. Bilateral condylar fractures generally require ORIF of at least one side if displacement exists. Edentulous condylar fractures have similar considerations when deciding on ORIF vs closed treatment.

A primary strength of this review is its synthesis of comparative data published over a 25-year period. Additionally, unique clinical scenarios such as pediatric, bilateral, and edentulous fractures were included, which are frequently overlooked in standard reviews. However, the literature included is characterized by several significant limitations, most notably a lack of long-term randomized controlled data and high heterogeneity in both fracture classification and outcome reporting. Many comparative studies utilized small sample sizes, which often resulted in underpowered statistical analyses, particularly in malocclusion rates. Future research should standardize displacement thresholds for ORIF recommendation and include quality-of-life endpoints alongside functional metrics.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-25/rc

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-25/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-25/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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