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 .
1 2

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
3 4

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

. . (b) Unilateral or bilateral condylar fractures in patient with seizure disorders. open bite. (d) Concomitant panfacial injury. (c) Acrylic splints and circumferential wires to a plaster of paris head splint with bite slightly open can support a bilateral condyle fracture. (c) Lateral extracapsular displacement of condyle. Maclennan described that 93% of fractured condyles in children produced good results on conservative treatment and bony union occurred with some modeling resorption. 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. Roy J. 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) 2-4yrs. 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. 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. which has potential hazards. (b) In vast majority of condylar fractures. cap splints should be given. alcoholism. good masticatory function. They stated that the conservative approach to the treatment of condylar fractures is one of choice in almost all instances. loops. arch bars. D. N. 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. (c) 5-8yrs. (b) Inability to achieve occlusion by closed reduction. (d) Invasion by foreign body. Eubanks has indicated that when open reduction is resorted to. (c) In adults signs of dysfunction were frequently observed but not considered serious by the patients. periodontal problem.JOURNAL OF DENTAL SCIENCES of pereauricular approach for open reduction. prognathism. Relative indications for open reduction include: (a) Bilateral fracture in an edentulous patient where splinting is not possible. condylar head displacement and resorption leading to shortened vertical ramus and decreased vertical posterior facial height. Dahlstrom. Khosla has stated that conservative management of fracture 5 6 7 8 9 10 11 12 13 14 Volume 2 Issue 2 of condyles is indicated in children. (e) Bicondylar fractures with gnathologic problems like retrognathia.No immobilization with gunning splint with thick lining of gutta percha. In a well-documented publication Konstantinovic and Dimetrijevic have compared surgical and non-surgical 15 16 17 18 19 20 5 . Rubens and Stoelinga have emphasized the disadvantages of closed reduction as articular imbalance. (c) Bilateral condylar fractures with communited midfacial fractures.as resorbing roots are present cap splints to be given stabilized by circumferential wires. Absolute indications for open reduction include: (a) Displacement into middle cranial fossa. (d) 9-11yrs. W. (d) Open reduction to be carried in grossly displaced fracture condyle in older patients to maintain vertical height. 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. (e) Condylectomy should be considered if closed reduction results in limited movement or painful TMJ movements. psychiatric problems. Freid has advocated use of acrylic splints and orthodontic bands and brackets for management of fractures in children. Zide and Kent have set a pillar of guidelines regarding indications for open reduction of mandibular condylar fractures. . L.Rowe on studying fractures of jaws in children has described following modalities of immobilization: (a) 0-2 yrs.arch bars splints can be given as permanent teeth are developing. 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.As there are well-formed roots. Lindahl in their 15 yrs follow-up of condylar fractures have stated that conservatively treated : (a) Children had no major growth disturbances. . TMJ dysfunction. (b) In teenagers anatomical and functional restitution of TMJ was not as good as in children but showed no symptoms. 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.

(c) Restoration of occlusion to preinjury state. trauma to a very unique joint. and that condylar remodeling was mode of fracture healing in instances of displaced and dislocated condylar fractures. 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.Ellis.JOURNAL OF DENTAL SCIENCES treatment employed in 80 patients with unilateral condylar fractures. This twisting of neck at a different axis makes it more vulnerable to fracture. (e) Facial symmetry. (c) Adults – unilateral or bilateral intracapsular fracture. Condylar neck is inherently a weak region so it fractures easily. 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. (b) Pain free mouth opening with interincisal distance of more than 40mm or more. Widmark stated that open reduction should be restricted to low subcondylar fractrues. 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 29 30 31 32 33 6 . If the above criteria are met then it does not matter which mode of therapy is employed. Joos and Kleinheinz have stated absolute indications for non-surgical treatment namely: (a) Condylar neck fractrues in children. (c) Intracapsular condylar 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. Kallela have advocated use of axial anchor screw fixation for condylar fracture. He laid down the following criteria which should be met before judging appropriateness of treatment: (a) Free movement of jaw in all directions. He has also advocated the use of retromandibular approach for open reduction. 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. Silvennoinen . 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. parasymphysis or body regions. 1 21 22 34 23 24 25 26 27 28 Volume 2 Issue 2 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. direction and magnitude of impact and anatomical considerations related to the architectural configuration of the mandible. E. Neuromuscular adaptations to the fractured mandibular condylar process occurs in both groups. He also supported use of postramal incision. (a) Children – functional therapy (b) Adolescents – in cases of occlusal disharmony immobilization for 2-3 weeks. Ellis and Throckmorton have stated that maximum voluntary bite forces in patients treated do not differ significantly whether treatment is open or closed. (d) Stable TMJ. 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. Furthermore. The precise location of tensile strain depends on site. 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. E. Moreover there is a change of axis from condylar neck to head. deviation. protrusion). 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. Using clinical parameters (maximal mouth opening. Peter Banks has advocated use of conservative therapy in children and immobilization for 3 weeks is optimum. 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. (b) High condylar neck fractures without dislocation. a viable growth centre in children. Fractures at condylar region occur when the concentration of tensile strain exceeds the limit of tolerance of the bone. no statistical differences were found. Neiderdellman. he stated that no major differences were evident in open and closed reduction in relation of jaw function. Majority of condylar fractures are caused by indirect trauma resulting from injury over symphysis. radiographic examination showed slightly better position of surgically reduced condylar process fractures. However. conservative therapy for 2-3 weeks.

however. As for adults a large number of factors determine the modality of treatment employed. with a relatively slender condylar neck and a thicker cortical layer covering the articular surface. lateral extracapsular displacement of condyle and invasion by foreign body. Intracapsular fractures are common in children owing to a short stubby condylar neck. 23. As the mandible further matures. Condylar fractures in children deserve special attention because of their potential complications and healing potential. The concept of. patients with seizure disorders. the mandibular neck grows longer. that would entail a residual postional change with a reestablishment of the articulation of the condyle.e. The shallow glenoid fossa is easily traumatized and the extensive vascularity in this region results in haemarthrosis. 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. No major structure is encountered except margnial madibular nerve which is retracted. Although a period of Maxillo-mandibular fixation (hereafter known as MMF) is necessary. Older children and adolescents have a similar capacity for extensive new bone formation but lack a similar resorptive capacity.38. inability to achieve occlusion by closed reduction. but to a progressively lesser extent . which is now more like the adult configuration morphologically.28. post treatment rehabilitation is an equally important aspect of successful therapy. The age related distribution of fracture sites corresponds to the anatomical development of the condylar process. injuries to the condylar region. 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. 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.29 36 11 6 Volume 2 Issue 2 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. This capacity for remodeling change is also seen in older age group. Retromandibular (postramal) approach advocated by Edward Ellis III provides excellent exposure even in face of marked oedema.JOURNAL OF DENTAL SCIENCES middle cranial fossa by fracturing the tympanic plate and shall result into a much more morbid situation. Practically speaking open reduction should be confined to low dislocated subcondylar fractures and bilateral fractures with loss of vertical ramus height. 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.39 7 .25. They require a brief period of immobilization followed by active jaw movements. 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.37. So we can opine that chances of dysfunction increase with age Conservative management is the line of treatment well postulated for children. The medially dislocated condylar stump is more easily retrieved than by the preauricular approach. 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. Absolute indications are displacement into middle cranial fossa. a pseudo joint cannot also be discounted for . 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. fracture with panfacial injury or with gnathologic problems.35. accounting for higher incidence of double contoured heads and condylar hyperplasia. Management would make early mobilization mandatory to circumvent the possibility of ankylotic change supervening in this highly osteogenic environment. These fractures are mostly of the compression type and crush injury type . 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 . It will be pressed against the glenoid fossa and when the forces are strong enough intracapsular fracture will occur. The major advantage of this approach is that one is working at a much shorter distance from incision to the condyle. During jaw 35 14 1. The two schools of thought i. The degree of reduction achieved would of course be consistent with the interfragmentory displacement after injury. 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. Very often condylar fractures in infancy and childhood are missed altogether and become the leading cause for ankylosis and impaired mandibular growth. becomes thinner and is more prone to fracture.26. This 34 2 23 11. infact throughout life. The chances of subcondylar fractures increase with age. The relative indications include bilateral fractures in an edentulous patient where splinting is not possible.26. closed reduction and open reduction still continue with their endless skirmish. Above the age of 6 yrs. 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.

5 mm loss in post. D. deviation. Intracapsular condylar fractures are technically difficult to treat and are better treated by closed reduction and functional therapy. Pg 423 – 427 10) W. The relative merits and demerits of open and closed reduction have been discussed.. The obvious difficulties following closed reductions are deviation to side of fracture. Rowe (1968):Fractures of facial skeleton in children Journal of oral surgery (vol 26). 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 . 89 – 98 21 8 . Macgregor (1957): The treatment of fracture of the neck of the mandibular condyle British Dental Journal [May. fracture level. the adequacy of occlusion and patients choice for having MMF or not. 45 – 74 4) Thoma (1954): Treatment of condylar fractures Journal of oral surgery Vol 12. References 1) Edward Ellis III (1993) :Rigid fixation of mandibular condyle fractures [Oral Surg Oral Med Oral Path: Vol 76. difficulty in lateral excursions to unaffected site and minor occlusal discrepancies. Dislocated subcondylar fractures are more suitable to be treated by open reduction using a retromandibular approach. Anaesth. L. 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. Closed reduction and active jaw rehabilitation can maintain majority of these fractures. Maclennan (1969) : Fractures of the mandibular condylar process British Journal of oral surgery Pg 31 – 39 11) Daniel M. Finally. Post treatment maximum bite forces in patients treated for mandibular condylar process fracture do not differ significatnly when treatment is open or closed .e. parotid fistulae may result in cases with open reduction . 29 (2): Pg 116 – 121 14) Michael F. Is this difference seen extraorally and does it motivate the patient to have an open reduction performed? May be patients are more concerned 20. training elastics and occlusal guiding bite planes. 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. Choice of treatment should depend upon age. These can be corrected by proper rehabilitation which includes isometric jaw exercises. detailed. pg 112 – 120 5) Marvin G.40. Journal of oral surg. Condylar process fractures in children younger than 12 yrs should not be subjected to open reduction . Gores RJ (1961):Fractures of the mandibular condyloid process. However. scars. 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. Freid (1945):Management of fractures in children Journal of oral surgery Vol 12. facial height) means to the patient. Conclusion Proverbially speaking in Shakespeare’s words ‘TO OPEN OR NOT NOT TO OPEN IS THE QUESTION’. Beekler (1969) : Condyle fractures Journal of oral surgery Vol 27 . According to Konstantinovic using clinical parameters (maximal mouth opening. 1957]. degree of displacement. Results of conservative treatment in 140 patients. 392. Kent (1983) : Indications for open reduction of mandibular condylar fractures Journal of oral & maxillofacial surgery (41). 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).29 16 33 20 18 41 42 43 44 31 45 Volume 2 Issue 2 about major facial scars than having a perfect post surgical radiographic appearance . Vol 19.Journal of oral surgery : Vol 5. Lyons Club (1947) Fractures involving the mandibular condyle A post treatment survey of 120 cases. analyzed and critically evaluated in the literature. 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. 129 – 139 6) Alexander B. The most important question is what the difference in results between open and closed reduction (i. protrusion) no statistical differences between surgically and conservatively treated fractures were found. Zide John N. pg 6 – 15] 2) Norman L. 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.Pg 505 – 515 3) Members of the Chalmers J. 8) Roy J. Dental services. Pg 563 – 564 12) N. wound infection. No major difference existed between surgically and nonsurgically treated group . radiographic examinations showed slightly better position of surgically reduced fractures. And Hosp. The major advantage of open reduction is the possibility of achieving anatomically correct repositioning of the condylar fragment and preventing facial asymmetry.25.JOURNAL OF DENTAL SCIENCES movement healing proceeds in the hard and soft tissue concomitantly. 351 – 357 7) Blevins C.

. British Journal of Oral and Maxillofacial Surgery 40. Surg : Vol 27. Ellis III. [Oral surg. pg 405 – 473 Edward Ellis III & (2000) Throckmorton : Open treatment of mandibular process fractures: assessment of adequacy of repositioning and maintenance of stability Jour. 23-26(2001) Edward Ellis III. Throckmorton: Adaptation of the masticatory system after bilateral fractures of the mandibular condylar process Jour. Int. Surg. 2000 nd 31) 32) 33) 34) 35) 36) 37) 38) 39) 40) 41) 42) 43) 44) 45) 9 . Journ. Of Oral & Maxillofac. A. Jour. Of oral & maxillofac. David Macfadden (2000) : Surgical Complications with open treatment of mandibular condylar process fractures Journ. Jour.: 59.19-22(2002) Delvin. 719 – 728 Edward Ellis III.A clinical and radiological study of 13 patients. Oral Path. 27 – 34 Hyde et al : The role of open reduction and internal fixations in unilateral fractures of the mandibular condyle: a prospective study.950-958 Haug & Assael (2001) : Outcomes of open versus closed treatment of mandibular subcondylar fractures Journal of Oral & Maxillofac. Non Surgical management Jour. Surg. pg 22 – 25 18) Takenoshita & Ishibashi (1990): Comparision of functional recovery after non surgical and surgical treatment of condylar fractures. pg 30-33 25) Goran Widmark (1996) : Open reduction of subcondylar frctures: A study of functional rehabilitation Int. Surg: Vol 27.401 Maria J. Troulis : Endoscopic open reduction of internal rigid fixation of Subcondylar fractures Jounal of Oral and Maxillofacial Surgery 62 : 1269-1271. L. Journal of Oral & Maxillofac. 400 . Surg :58.Int. : Vol 25. E.407] 20) Konstantinovic & Dimitrijevic (1992): Surgical versus conservative treatment of unilateral condylar process fractures: Clinical & radiographic evaluation of 80 patients. Jour of Oral & Maxillofac. pg 349 – 353 21) Walker (1994): Condylar fractures. Oral Med.JOURNAL OF DENTAL SCIENCES 15) A. Paris D. Vol 72. Throckmorton (2000) : Facial symmetry after closed and open treatment of fractures of the Volume 2 Issue 2 mandibular condylar process. Jour. 389 – 395 Dufourmental M. Brown & G. 58. 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. Surg. 429 – 440 30) E. (1929)De l’articulationtemperomaxillaire’.2004 Goran Widmark: Facial symmetry after closed and open treatment of fractures of mandibular condylar process Journal of Oral & Maxillo-facial Surgery[Discussion]: 58. Of Oral & Maxillofac.. Of Oral & Maxillofac. (1996) : Comparison of CT imaging before and after functional treatment of condylar fractures in adults Int. Of Oral maxillofac. (1998) Rina Jalwar. Surgery: Vol 35. Lindahl (1989): Fifteen years follow up on condylar fractures International Journal of Oral & Maxillofacial surgery Vol 18. 95 – 98 29) Hovenga & Boeringa (1999) : Long term resuls of nonsurgical management of condylar fractures in children. of Oral & Maxillofac. Of Oral & Maxillofac. Surg. 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. Dahstrom. Hislop and Carlon : Open reduction and internal fixation of fractured mandibular condyles by retromandibular approach: surgical morbidity and informed consent British Journal 40. pg 7 – 16 24) Choi B.: 59. 2011 Loukota : Fixation of dicapitular fractures of mandibular condyle with a headless bone screw British Journal of Oral and Maxillofacial Surgery 45 (2007) 399. Surg. 28. XI : Vol 1 & 2. 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. Of Oral & Maxillofac. Pg 18 – 23 17) Rubens & Stoelinga (1990) : Management of malunited mandibuar condylar fractures Int. 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. Journal of Oral & Maxillofac. Vol 52. (2001) Gaylord Throckmorton : Bite forces after open or closed treatment of mandibular condylar process fractures. Surg. Surg: Vol 66. Sug. pg 107 – 111 26) Peter Banks (1998): A pragmatic approach to management of condylar fractures. pg 244 – 246 27) Joos & Kleinheinz (1998) : Therapy of condylar neck fractures Int. Mitchell (1997) : A multicentric audit of unilateral fractures of mandibular condoyle British Journal of Oral & Maxillofac. Journal of Oral & Maxillofacial surgery : Vol 48. Journal of oral & maxillofac. Journal of oral and maxillofacial Surgery : vol 19. Journal of Oral & Maxillofacial Surgery: vol 50. 1185 22) Silvennoinen (1995): Surgical treatment of condylar process fractures using axial anchor screw fixation Journal of Oral & Maxillofac. Surgery : Vol 25. pg 884 – 893 23) Niederdellman & Srinivasan (1996): Current concepts in management of condylar fractures (An Indo German study) Indian Journal of Oral Maxillofacial surg. Surg: Vol 53. 1191 – 1195 19) Iizuka & Lindqvist (1991):Severe bone resorption and osteoarthrosis after miniplate fixation of high condylar fractures.: 58. 370 – 375 Edward Ellis III. 729 – 730. H. pg 230 – 236 Rowe & Williams (1994): Maxillofacial Injuries Vol 1. 2 edition. Surg: 28 .