From Controversy to Clarity: Algorithmic Management of Condylar Fractures Supported by a 13-Year Institutional Experience Across 495 Joints

Background: Mandibular condylar fractures continue to be a subject of debate, traditionally framed as a choice between open and closed treatment. However, this binary approach fails to adequately account for fracture-level anatomy, Temporomandibular joint (TMJ) involvement, and functional outcomes. Purpose: To present an imaging-guided, fracture-level-based algorithm that integrates radiologic evaluation, surgical approach selection, fixation biomechanics, and functional rehabilitation. Review Strategy: This invited review combines current evidence with a 13-year institutional experience involving 495 joints. High-resolution CT was used to assess fracture morphology, displacement, and ramal height, while MRI was selectively employed in intracapsular fractures to evaluate disc-condyle relationships when intra-articular involvement was suspected. Management decisions, including surgical approach and fixation strategy, were guided by an institutional algorithm tailored to fracture characteristics. Results: Implementation of this approach yielded consistent and predictable outcomes. Mouth opening improved from approximately 18.77 mm preoperatively to 40 mm at 6 months. Lateral excursions became symmetrical (~9.6 mm), occlusion was restored in all patients, and bite force returned to near-physiological levels. Pain scores showed near complete resolution within 1 month. Postoperative morbidity remained low, with predominantly transient facial nerve weakness. Conclusion: This imaging-guided, algorithmic framework provides reproducible functional outcomes and signifies a shift toward structured, anatomically driven management of condylar fractures.