JOURNAL OF DENTAL SCIENCES

Volume 2 Issue 2

MANAGEMENT OF MANDIBULAR CONDYLE FRACTURES: A REVIEW

Dr. Hitesh S. Dewan, M.D.S., DNB Dr. Hiren Patel M.D.S. Dr. Haren Pandya M.D.S. Dr. Bijal Bhavsar M.D.S., Dr Urvi Babaria M.D.S. Dr. Chintan Thakkar B.D.S., Dr. Shirish Shah B.D.S., Dr. Dipak Thakkar B.D.S. Abstract Management of mandibular condylar fractures has always been a controversial issue. Although closed reduction was extensively practiced in the past, open reduction and fixation has become the mainstay of therapy in selective displaced subcondylar fractures. This helps in restoring posterior facial height, early functional mobility and better occlusion. Key words: Condylar Fractures, Open Reduction, Early Mobilization Introduction Fractures of the condyle are one of the most commonly occuring mandibular fractures. Various series report an incidence of 25-35% of all mandibular fractures , occurring either as a single entity unilaterally or bilaterally or in association with other fractures along the mandibular body at one or more sites. Injuries of the condyle deserve special consideration apart from the rest of the mandible due to its anatomical differences and healing potential. The juxta position of the Temporo Mandibular joint (hereafter known as TMJ) articulation predisposes to the adverse implications of condylar fractures on the TMJ and its subsequent function. These fractures also modulate change in occlusal relationships, mandibular movements, masticatory muscle function, craniofacial development in children and adolescents, general well being and overall function of the stomatognathic systems. Indirect forces acting along the body of mandible essentially cause fractures of the mandibular condyle. The ease with which an inherently weak condylar neck may fracture is regarded as a safety mechanism. This implies that forces directed along the mandible do not perforate the middle cranial fossa and condyle fractures itself leaving a less morbid situation. Condyle fractures in children dictate a more careful supervision as untreated or maltreated cases can lead to ankylotic changes, facial asymmetry and deformity related to maldevelopment of craniofacial complex. The physiology of the region attributes a high restitutional capacity to these tissues after injury. Precise anatomic reduction is not required in children as along with injury there is excellent remodeling at fracture sites with readaptation of masticatory system and re-education of neuromuscular pathways .
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The treatment of condylar fractures has always been controversial. The two schools of thought, i.e. open and closed reduction continue with their everlasting argument. However, both have stressed the significance of active jaw movements after therapy. With the advent of newer surgical techniques and instrumentation, open reduction is advocated in highly selective cases of condylar fractures. The relative merits and demerits of non-surgical and surgical management have been excellently documented in the literature. The followers of a non-surgical approach advocate the effectiveness of intermaxillary elastic traction methods in sequence with training elastics and or physiotherapy. Active jaw function and early mobilization has been an important consideration for successful functional rehabilitation of the individual. With the advent on newer surgical techniques, improved instrumentation open reduction and fixation has carved a niche for itself in certain selected cases of condylar fractures, emphasizing the significance of proper anatomic repositioning of the fractured condylar stump. However, nonsurgical conservative therapy is still being applied to a large number of cases with a critical period of immobilization and active jaw function. The excellent remodeling characteristics of the condyle especially in children and young adults have alleviated the need for open reduction in high neck and intracapsular fractures. Review of literature Members of the Chalmers J. Lyons Club published radiographic and clinical data relating to the results of management of a series of 120 carefully followed cases of condylar fractures. They have opined that conservative management has yielded satisfactory results with minimal difficulties and functional problems were present only in 7 cases. Thoma a staunch follower of open reduction has advised use
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Professor & Head Professor Reader Tutor Department of Oral & Maxillofacial Surgery, Faculty of Dental Science, Dharmsinh Desai University, Nadiad - 387 001. Gujarat, India

Address for correspondence : Dr. Hitesh S. Dewan, M.D.S., DNB Department of Oral & Maxillofacial Surgery, Faculty of Dental Science, Dharmsinh Desai University, Nadiad 387 001. Gujarat, India Phone: (079) 26575509,26578432 Mobile: 9825011642 E-mail: dewanhitesh@yahoo.co.in 4

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of pereauricular approach for open reduction. Freid has advocated use of acrylic splints and orthodontic bands and brackets for management of fractures in children. MacGregor has described the morbidities of open reduction namely difficulty of access and danger of injuring adjacent structures and has implied use of non-operative techniques with Inter Maxillary Fixation for three weeks. On the basis of results of conservative treatment in 140 patients having suffered condylar fractures Blevins and Gores concluded that temporomandibular joint and condyloid process were an unusual portion of the skeletal system because of their remarkable properties of repair after injury. They stated that the conservative approach to the treatment of condylar fractures is one of choice in almost all instances. Roy J. Eubanks has indicated that when open reduction is resorted to, submandibular approach is generally more desirable and for assurance of proper reduction Inter Maxillary fixation should be done before patient was out of general anesthesia. Maclennan described that 93% of fractured condyles in children produced good results on conservative treatment and bony union occurred with some modeling resorption. W. D. Maclennan in an excellently documented publication in which he treated 1250 condylar fractures has concluded the following points: (a) Prolonged immobilization in intracapsular fracture is likely to create complications. (b) In vast majority of condylar fractures, the wound is a closed one and if conservative methods of treatment can offer satisfactory functional results with a minimum of complications there would be little justification for surgically exposing the area, which has potential hazards. (c) Acrylic splints and circumferential wires to a plaster of paris head splint with bite slightly open can support a bilateral condyle fracture. (d) Open reduction to be carried in grossly displaced fracture condyle in older patients to maintain vertical height. (e) Condylectomy should be considered if closed reduction results in limited movement or painful TMJ movements. Beekler on concluding animal studies in Rhesus monkey has opined that early controlled mobilization and well supervened conservative therapy results in fewer complications and pseudo arthrosis is desirable to prevent ankylosis. N. L.Rowe on studying fractures of jaws in children has described following modalities of immobilization: (a) 0-2 yrs. - No immobilization with gunning splint with thick lining of gutta percha. (b) 2-4yrs. - As there are well-formed roots, arch bars, loops, cap splints should be given. (c) 5-8yrs. - as resorbing roots are present cap splints to be given stabilized by circumferential wires. (d) 9-11yrs. - arch bars splints can be given as permanent teeth are developing. Khosla has stated that conservative management of fracture
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of condyles is indicated in children. Zide and Kent have set a pillar of guidelines regarding indications for open reduction of mandibular condylar fractures. Absolute indications for open reduction include: (a) Displacement into middle cranial fossa. (b) Inability to achieve occlusion by closed reduction. (c) Lateral extracapsular displacement of condyle. (d) Invasion by foreign body. Relative indications for open reduction include: (a) Bilateral fracture in an edentulous patient where splinting is not possible. (b) Unilateral or bilateral condylar fractures in patient with seizure disorders, psychiatric problems, alcoholism. (c) Bilateral condylar fractures with communited midfacial fractures. (d) Concomitant panfacial injury. (e) Bicondylar fractures with gnathologic problems like retrognathia, prognathism, open bite, periodontal problem. Open reduction depends on: (a) Age of patient (b) Medical and dental history (c) Current dental treatment (d) Pathogenesis and severity of injury (e) Fitness for surgery (f) Position of fracture (g) Concomitant facial fractures Brown and Obeid have advocated used of Kirschner wire for fixation of condylar fracture. Dahlstrom, Lindahl in their 15 yrs follow-up of condylar fractures have stated that conservatively treated : (a) Children had no major growth disturbances, good masticatory function. (b) In teenagers anatomical and functional restitution of TMJ was not as good as in children but showed no symptoms. (c) In adults signs of dysfunction were frequently observed but not considered serious by the patients. Rubens and Stoelinga have emphasized the disadvantages of closed reduction as articular imbalance, TMJ dysfunction, condylar head displacement and resorption leading to shortened vertical ramus and decreased vertical posterior facial height. Takenoshita and Ishibashi in their comparison of functional recovery after non-surgical and surgical treatment of condylar fractures have shown no major differences in 36 cases. Iizuka and Lindqvist have demonstrated radiological signs of condylar resorption and osteoarthrosis in all patients with miniplate fixation. In a well-documented publication Konstantinovic and Dimetrijevic have compared surgical and non-surgical
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treatment employed in 80 patients with unilateral condylar fractures. Using clinical parameters (maximal mouth opening, deviation, protrusion), no statistical differences were found. However, radiographic examination showed slightly better position of surgically reduced condylar process fractures. Edward Ellis III has comprehensively compared all the five approaches for open reduction and has opined that the postramal (retromandibular) incision is best for screw and plate fixation of subcondylar fractures and that 2mm bicortical screws should be used for plating. Robert Walker opined that rather than judging the appropriateness of surgical or non-surgical method the efficacy of any method in restoring the function with least harm is the main concern. He laid down the following criteria which should be met before judging appropriateness of treatment: (a) Free movement of jaw in all directions. (b) Pain free mouth opening with interincisal distance of more than 40mm or more. (c) Restoration of occlusion to preinjury state. (d) Stable TMJ. (e) Facial symmetry. If the above criteria are met then it does not matter which mode of therapy is employed. Silvennoinen , Kallela have advocated use of axial anchor screw fixation for condylar fracture. Neiderdellman, Srinivassan gave a comprehensive layout in current concepts in management of condylar fractures and have laid down certain protocols for treatment in relation with age. (a) Children functional therapy (b) Adolescents in cases of occlusal disharmony immobilization for 2-3 weeks. (c) Adults unilateral or bilateral intracapsular fracture, conservative therapy for 2-3 weeks. Extracapsular fractures open reduction. Choi studied 10 cases of bicondylar fractures treated nonsurgically and post treatment CT scans showed that fractured condyles had healed by bony union but relationships with fossa had not improved although function and pain free movement had been restored. Widmark stated that open reduction should be restricted to low subcondylar fractrues. He also supported use of postramal incision. Furthermore, he stated that no major differences were evident in open and closed reduction in relation of jaw function. Peter Banks has advocated use of conservative therapy in children and immobilization for 3 weeks is optimum. Joos and Kleinheinz have stated absolute indications for non-surgical treatment namely: (a) Condylar neck fractrues in children. (b) High condylar neck fractures without dislocation. (c) Intracapsular condylar fractures.
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Strobl & Emshoff have concluded from conservative treatment of unilateral condylar fractures in children that conservative therapy resulted in good condylar shape and anatomy in majority of patients, and that condylar remodeling was mode of fracture healing in instances of displaced and dislocated condylar fractures. Hovenga and Boering have concluded that neither major growth disturbance nor asymmetry was evident after nonsurgical therapy and non-surgical therapy in condylar fracture is still the treatment of choice in children. E.Ellis, Throckmorton (2000) have concluded in regards to facial symmetry that patients treated by closed methods develop asymmetry characterized by shorting of face on side of injury and it is likely that loss of posterior facial height on the side of fracture in these patients is an adaptation that helps to re-establish a new TMJ articulation. He has also advocated the use of retromandibular approach for open reduction. E. Ellis and Macfadden shortlisted surgical complications with open reduction of mandibular condylar process fractures namely: (a) Facial nerve injury (b) Surgical scars (c) Excessive intraoperative hemorrhage (d) Parotid fistulae (e) Excessive operative time and economic factor Haug and Assael used a treatment protocol and concluded that there were few differences in outcomes between patients treated with closed or open reduction. E. Ellis and Throckmorton have stated that maximum voluntary bite forces in patients treated do not differ significantly whether treatment is open or closed. Neuromuscular adaptations to the fractured mandibular condylar process occurs in both groups. Discussion Fractures of the mandibular condyle have always been enigmatic and challenging to the Oral and Maxillofacial surgeon owing to a plethora of factors including the complexity of injury, trauma to a very unique joint, a viable growth centre in children, a surgically restricted zone of access and employment of the right modality of treatment at the right time with a through knowledge of resulting complications of untreated and maltreated cases. Majority of condylar fractures are caused by indirect trauma resulting from injury over symphysis, parasymphysis or body regions. Fractures at condylar region occur when the concentration of tensile strain exceeds the limit of tolerance of the bone. The precise location of tensile strain depends on site, direction and magnitude of impact and anatomical considerations related to the architectural configuration of the mandible. Condylar neck is inherently a weak region so it fractures easily. Moreover there is a change of axis from condylar neck to head. This twisting of neck at a different axis makes it more vulnerable to fracture. The fracture of condyle itself is well reputed as a safety mechanism because if the condyle does not fracture itself the transmitted force will perforate into the
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middle cranial fossa by fracturing the tympanic plate and shall result into a much more morbid situation. The age related distribution of fracture sites corresponds to the anatomical development of the condylar process. When an injury occurs in the condylar process of a young child the thickness of the condylar neck and the flexibility of mandible directs the traumatic force towards the condylar head. It will be pressed against the glenoid fossa and when the forces are strong enough intracapsular fracture will occur. As the mandible further matures, the mandibular neck grows longer, becomes thinner and is more prone to fracture. The chances of subcondylar fractures increase with age. Condylar fractures in children deserve special attention because of their potential complications and healing potential. Very often condylar fractures in infancy and childhood are missed altogether and become the leading cause for ankylosis and impaired mandibular growth. Intracapsular fractures are common in children owing to a short stubby condylar neck. These fractures are mostly of the compression type and crush injury type . The shallow glenoid fossa is easily traumatized and the extensive vascularity in this region results in haemarthrosis. Management would make early mobilization mandatory to circumvent the possibility of ankylotic change supervening in this highly osteogenic environment. Above the age of 6 yrs, injuries to the condylar region, which is now more like the adult configuration morphologically, with a relatively slender condylar neck and a thicker cortical layer covering the articular surface, are likely to result in a green stick type of fracture with bending without overriding due to loss of continuity of the outer cortex and increased elasticity of bone. They require a brief period of immobilization followed by active jaw movements. Another aspect related to pediatric fractures is the excellent remodeling potential that is particularly marked below 12 yrs of age and even fractures with dislocation are expected to completely remodel to normal proportions. Older children and adolescents have a similar capacity for extensive new bone formation but lack a similar resorptive capacity, accounting for higher incidence of double contoured heads and condylar hyperplasia. This capacity for remodeling change is also seen in older age group, infact throughout life, but to a progressively lesser extent . So we can opine that chances of dysfunction increase with age Conservative management is the line of treatment well postulated for children. As for adults a large number of factors determine the modality of treatment employed. The two schools of thought i.e. closed reduction and open reduction still continue with their endless skirmish. Regarding the healing viewpoint many authors have implied that osseous healing will occur even in cases of dislocation provided that there is some contact between the proximal & distal fractured segments . The concept of, however, a pseudo joint cannot also be discounted for . Macgregor has said that unlike the majority of fractures in long bones the muscular forces applied to the upper fragment by the lateral pterygoid muscle is not acting against the direction of muscles attached to the main fragment. This
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allows the condylar head to move with the rest of the mandible during opening and the consequent absence of mobility of the fragments in opposite directions relative to one another allows osseous union to occur. Factors which influence the management of condylar fractures are : a) age of the patient b) location of fracture c) type of displacement of fracture d) direction of displacement e) medical state f) related injuries g) presence and state of dentition h) attainability of adequate occlusion i) presence of foreign body j) compound of closed injury Zide & Kent have laid down guidelines for open reduction that have stood like an iron pillar for almost two decades. Absolute indications are displacement into middle cranial fossa, inability to achieve occlusion by closed reduction, lateral extracapsular displacement of condyle and invasion by foreign body. The relative indications include bilateral fractures in an edentulous patient where splinting is not possible, patients with seizure disorders, fracture with panfacial injury or with gnathologic problems. Practically speaking open reduction should be confined to low dislocated subcondylar fractures and bilateral fractures with loss of vertical ramus height. The principal goal for patients who undergo open reduction and internal fixation of condyle fractures is to provide adequate stability to the fracture to allow immediate function as well as restoration of anatomical contour of condyle and vertical ramus height. Retromandibular (postramal) approach advocated by Edward Ellis III provides excellent exposure even in face of marked oedema. The medially dislocated condylar stump is more easily retrieved than by the preauricular approach. No major structure is encountered except margnial madibular nerve which is retracted. The major advantage of this approach is that one is working at a much shorter distance from incision to the condyle. Moreover the retraction with the retromandibular aproach is anteriorly & superiorly rather than only superiorly with submandibular approach and one can easily expose sigmoid notch with the former. Working with screw and plates is tricky as it is difficult to hold the fractured condyle in reduced position because of the heavy pull of the lateral pterygoid muscle. Although a period of Maxillo-mandibular fixation (hereafter known as MMF) is necessary, post treatment rehabilitation is an equally important aspect of successful therapy. Establishment of occlusion is thought to reflect on a certain variable degree of positional change of the condylar fragment that may be almost anatomical or as is more often the case, that would entail a residual postional change with a reestablishment of the articulation of the condyle. The degree of reduction achieved would of course be consistent with the interfragmentory displacement after injury. During jaw
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movement healing proceeds in the hard and soft tissue concomitantly. The soft tissue scarring would be the determinant of the range of jaw movement and a long stretch of soft tissue thus needs to be attained and maintained through period of rehabilitation. Closed reduction and active jaw rehabilitation can maintain majority of these fractures. The obvious difficulties following closed reductions are deviation to side of fracture, difficulty in lateral excursions to unaffected site and minor occlusal discrepancies. These can be corrected by proper rehabilitation which includes isometric jaw exercises, training elastics and occlusal guiding bite planes. The relative merits and demerits of open and closed reduction have been discussed, detailed, analyzed and critically evaluated in the literature. Statistically speaking there are no major differences between patients undergoing open or closed reduction however minute details still have to be evaluated before deciding the line of treatment. Choice of treatment should depend upon age, fracture level, degree of displacement, the adequacy of occlusion and patients choice for having MMF or not. Condylar process fractures in children younger than 12 yrs should not be subjected to open reduction . Intracapsular condylar fractures are technically difficult to treat and are better treated by closed reduction and functional therapy. Dislocated subcondylar fractures are more suitable to be treated by open reduction using a retromandibular approach. The major advantage of open reduction is the possibility of achieving anatomically correct repositioning of the condylar fragment and preventing facial asymmetry. Post treatment maximum bite forces in patients treated for mandibular condylar process fracture do not differ significatnly when treatment is open or closed . According to Konstantinovic using clinical parameters (maximal mouth opening, deviation, protrusion) no statistical differences between surgically and conservatively treated fractures were found. However, radiographic examinations showed slightly better position of surgically reduced fractures. No major difference existed between surgically and nonsurgically treated group . Luo et al and Loukota advocated use of single screw in selected cases of condylar fractures stating that use of miniplates caused poor vascularity and bone resortion Newer modalities have come to the fore like endoscope assisted open reduction but owing to increased operating time and cost factor it is rarely used It has been well postulated that surgical complications like facial nerve injury, wound infection, scars, parotid fistulae may result in cases with open reduction . Conclusion Proverbially speaking in Shakespeares words TO OPEN OR NOT NOT TO OPEN IS THE QUESTION. The most important question is what the difference in results between open and closed reduction (i.e. 5 mm loss in post. facial height) means to the patient. Is this difference seen extraorally and does it motivate the patient to have an open reduction performed? May be patients are more concerned
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about major facial scars than having a perfect post surgical radiographic appearance . Finally, rather than judging the appropriateness of surgical or non-surgical method the efficacy of any method in restoring the function with least harm is the main concern. Certain criteria should be met before judging the line of treatment given: free movement of jaw in all excursions pain free movement with normal interincisal distance restoration of occlusion to preinjury state stable temperomandibular joint acceptable facial symmetry If the above criteria are met then it does not matter which mode of therapy is employed . References 1) Edward Ellis III (1993) :Rigid fixation of mandibular condyle fractures [Oral Surg Oral Med Oral Path: Vol 76; pg 6 15] 2) Norman L. Rowe (1968):Fractures of facial skeleton in children Journal of oral surgery (vol 26);Pg 505 515 3) Members of the Chalmers J. Lyons Club (1947) Fractures involving the mandibular condyle A post treatment survey of 120 cases.Journal of oral surgery : Vol 5, 45 74 4) Thoma (1954): Treatment of condylar fractures Journal of oral surgery Vol 12, pg 112 120 5) Marvin G. Freid (1945):Management of fractures in children Journal of oral surgery Vol 12; 129 139 6) Alexander B. Macgregor (1957): The treatment of fracture of the neck of the mandibular condyle British Dental Journal [May, 1957]; 351 357 7) Blevins C., Gores RJ (1961):Fractures of the mandibular condyloid process. Results of conservative treatment in 140 patients. Journal of oral surg. Anaesth. And Hosp. Dental services, Vol 19, 392. 8) Roy J. Eubanks (1964):Fractures of the neck of the condyloid process Journal of oral surgery Vol 22: 285 291 9) Maclennan & Simpson (1964):Treatment of fractured mandibular condylar process in children British Journal of Plastic Surgery (Oct 1964), Pg 423 427 10) W. D. Maclennan (1969) : Fractures of the mandibular condylar process British Journal of oral surgery Pg 31 39 11) Daniel M. Beekler (1969) : Condyle fractures Journal of oral surgery Vol 27 , Pg 563 564 12) N. L. Rowe (1969):Fractures of the jaws in children Journal of oral surgery:Vol 27: 497 507 13) Ved M. Khosla (1971) : Mandibular fractures in children and their management Journal of oral surgery, 29 (2): Pg 116 121 14) Michael F. Zide John N. Kent (1983) : Indications for open reduction of mandibular condylar fractures Journal of oral & maxillofacial surgery (41), 89 98
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15) A. E. Brown & G. Obeid (1984) : A simplified method for the internal fixation of fractures of the mandibular condyle British Journal of Oral and Maxillofacial surgery 22: 145 150 16) L. Dahstrom, Lindahl (1989): Fifteen years follow up on condylar fractures International Journal of Oral & Maxillofacial surgery Vol 18, Pg 18 23 17) Rubens & Stoelinga (1990) : Management of malunited mandibuar condylar fractures Int. Journal of oral and maxillofacial Surgery : vol 19; pg 22 25 18) Takenoshita & Ishibashi (1990): Comparision of functional recovery after non surgical and surgical treatment of condylar fractures. Journal of Oral & Maxillofacial surgery : Vol 48; 1191 1195 19) Iizuka & Lindqvist (1991):Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures.A clinical and radiological study of 13 patients. [Oral surg. Oral Path, Oral Med, Vol 72; 400 - 407] 20) Konstantinovic & Dimitrijevic (1992): Surgical versus conservative treatment of unilateral condylar process fractures: Clinical & radiographic evaluation of 80 patients. Journal of Oral & Maxillofacial Surgery: vol 50; pg 349 353 21) Walker (1994): Condylar fractures, Non Surgical management Jour. Of Oral & Maxillofac. Surg., Vol 52, 1185 22) Silvennoinen (1995): Surgical treatment of condylar process fractures using axial anchor screw fixation Journal of Oral & Maxillofac. Surg: Vol 53, pg 884 893 23) Niederdellman & Srinivasan (1996): Current concepts in management of condylar fractures (An Indo German study) Indian Journal of Oral Maxillofacial surg. XI : Vol 1 & 2, pg 7 16 24) Choi B. H. (1996) : Comparison of CT imaging before and after functional treatment of condylar fractures in adults Int. Journ. Of Oral & Maxillofac. Surgery : Vol 25, pg 30-33 25) Goran Widmark (1996) : Open reduction of subcondylar frctures: A study of functional rehabilitation Int. Jour. Of Oral maxillofac. Surg. : Vol 25, pg 107 111 26) Peter Banks (1998): A pragmatic approach to management of condylar fractures.Int. Jour. Of Oral & Maxillofac. Surg: Vol 27, pg 244 246 27) Joos & Kleinheinz (1998) : Therapy of condylar neck fractures Int. Jour. Of Oral & Maxillofac. Surg : Vol 27; pg 247 254 28) Strobl & Emshoff (1999) : Conservative treatment of unilateral condylar fractures in children : a long term clinical and radiologic follow up of 55 patients Int. Journal of Oral & Maxillofac. Surg: 28 ; 95 98 29) Hovenga & Boeringa (1999) : Long term resuls of nonsurgical management of condylar fractures in children. Int. Jour of Oral & Maxillofac. Surg. 28; 429 440 30) E. Ellis III, Throckmorton (2000) : Facial symmetry after closed and open treatment of fractures of the

Volume 2 Issue 2 mandibular condylar process. Journal of oral & maxillofac. Sug.; 58; 719 728 Edward Ellis III, David Macfadden (2000) : Surgical Complications with open treatment of mandibular condylar process fractures Journ. Of Oral & Maxillofac. Surg.: 58;950-958 Haug & Assael (2001) : Outcomes of open versus closed treatment of mandibular subcondylar fractures Journal of Oral & Maxillofac. Surg.: 59; 370 375 Edward Ellis III, (2001) Gaylord Throckmorton : Bite forces after open or closed treatment of mandibular condylar process fractures. Journal of Oral & Maxillofac. Surg.: 59; 389 395 Dufourmental M. L. (1929)De larticulationtemperomaxillaire, Paris D. A. Mitchell (1997) : A multicentric audit of unilateral fractures of mandibular condoyle British Journal of Oral & Maxillofac. Surgery: Vol 35, pg 230 236 Rowe & Williams (1994): Maxillofacial Injuries Vol 1, 2 edition; pg 405 473 Edward Ellis III & (2000) Throckmorton : Open treatment of mandibular process fractures: assessment of adequacy of repositioning and maintenance of stability Jour. Of oral & maxillofac. Surg :58; 27 34 Hyde et al : The role of open reduction and internal fixations in unilateral fractures of the mandibular condyle: a prospective study. British Journal of Oral and Maxillofacial Surgery 40,19-22(2002) Delvin, Hislop and Carlon : Open reduction and internal fixation of fractured mandibular condyles by retromandibular approach: surgical morbidity and informed consent British Journal 40, 23-26(2001) Edward Ellis III, (1998) Rina Jalwar, Throckmorton: Adaptation of the masticatory system after bilateral fractures of the mandibular condylar process Jour, of Oral & Maxillofac. Surg: Vol 66; 430 439 Luo et al : Surgical treatment of Sagittal Fracture of mandibular condyle using long screw osteosynthesis Journal of Oral and Maxillofacial Surgery 69:1988-1994, 2011 Loukota : Fixation of dicapitular fractures of mandibular condyle with a headless bone screw British Journal of Oral and Maxillofacial Surgery 45 (2007) 399- 401 Maria J. Troulis : Endoscopic open reduction of internal rigid fixation of Subcondylar fractures Jounal of Oral and Maxillofacial Surgery 62 : 1269-1271, 2004 Haug and Brandt : Traditional versus endoscope assisted open reduction with rigid internal fixation (ORIF) of Adult mandibular condyle fractures Journal of Oral and Maxillofacial Surgery 62:1272-1279,2004 Goran Widmark: Facial symmetry after closed and open treatment of fractures of mandibular condylar process Journal of Oral & Maxillo-facial Surgery[Discussion]: 58; 729 730, 2000
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