Management of Condylar Fracture of Children by xjc52789

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									     A Study on Open Versus Closed Reduction of
               the Condylar Fractures



             Dissertation submitted to

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
       In partial fulfillment for the Degree of
      MASTER OF DENTAL SURGERY




BRANCH I ORAL AND MAXILLOFACIAL SURGERY
            FEBRUARY – 2005
                          CERTIFICATE


This is to certify that the dissertation entitled “A STUDY ON OPEN
VERSUS       CLOSED       REDUCTION       OF     THE    CONDYLAR
FRACTURES” is the bonafide work done by Dr. SADAM
SRINIVASA RAO, Post Graduate student, in the Department of Oral
and Maxillofacial Surgery of Saveetha Dental College and Hospitals,
Chennai under our guidance and supervision towards the partial
fulfillment of the requirement for the degree of “MASTER OF
DENTAL SURGERY” Branch – I Oral and Maxillofacial Surgery,
February 2005 under The Tamil Nadu Dr. M.G.R. Medical University,
Chennai.




Prof. M.R. MUTHUSEKHAR, M.D.S,          Prof. M.F. BAIG, M.D.S.,
Guide & Head of the Department,         Dean
Dept. of Oral & Maxillofacial Surgery   Saveetha Dental College & Hospitals
Saveetha Dental College & Hospitals     Chennai – 600 077.
Chennai – 600 077.


Place : Chennai
Date :
                    CONTENTS

1.   INTRODUCTION

2.   AIMS AND OBJECTIVES

3.   SURGICAL ANATOMY

4.   REVIEW OF LITERATURE

5.   MATERIALS AND METHODS

6.   RESULTS

7.   DISCUSSION

8.   SUMMARY AND CONCLUSION

9.   BIBLIOGRAPHY
                       INTRODUCTION

     In this fast moving world man has come up with newer and

newer machines and discoveries making him the fastest moving

animal on the land, air and water and all of it being behind the

wheels of a machine.       With all these high speed modes of

transportation, a fairly large number lands up in Road traffic

accidents.

     Road traffic accidents are responsible for majority of the

patients reporting with maxillofacial trauma. Mandibular fractures

are more common among fractures in maxillofacial region. Among

mandibular fractures, condylar region is the most frequent site

accounting for about 25-35% (Killey 1968)34. Condylar fractures arise

mainly through indirect injury from a traumatic impact on the chin

and seldom arise from direct trauma unless accompanied by fracture

of zygoma. Injury to condylar region deserves special consideration

apart from rest of the mandible because of anatomical differences and

healing potential (Rowe and Williams).37

     Condylar fracture are classified according to the anatomical

location and according to the degree of dislocation of the articular
head.     There are two principal therapeutic approaches to these

fractures : functional and surgical.

        There has been considerable controversy regarding the

treatment of condylar fractures, either they should be treated

conservatively or surgically. There are complications associated with

both types of treatment. Some authors prefer open reduction as there

is early recovery of function, less incidence of malocclusion and

adequate inter incisal mouth opening than those treated by closed

reduction.

        According to Alexander (1994)1 displaced low sub condylar

fractures should be treated by open reduction as there were no

malocclusion, wound infection and neurosensory deficits.

        Those preferring closed reduction claim that functional

recovery is to the same extent after both open and closed reductions

and also morbidities associated with surgical treatment could be

avoided.

        According to Wildmark G (1996)55 and Takenoshita (1990)45

satisfactory post operative function and occlusion were present in

both surgical and conservative groups.
      Although there are equal studies supporting both open and

closed reductions, there has been considerable increase in the

incidence of long term complications associated with closed form of

treatment.

      Edward Ellis (2000)16 had greater incidence (27.3%) of

malocclusion and Thoren H (2001)48 observed that 39% of patients

had deviation of jaw during mouth opening and 22% of patients had

joint clicking among those treated with closed reduction.

      It is still in dilemma about the clear guidelines for treatment

and precise functional evaluation of surgical treatment of condylar

fractures.

      This study is aimed at comparing outcome of closed and open

reduction of condylar fractures.


                    REVIEW OF LITERATURE

      Michael. F.    Zide & John Kent (1983)57 in their review of

articles had divided the indications for open reduction of condylar

fractures into :
Absolute indications for open reduction :

1. Displacement of fractured condylar fragment into middle cranial

   fossa.

2. Inability to achieve occlusion by closed reduction

3. Lateral extracapsular displacement of condyle

4. Invasion by foreign body (gunshot wound)

Relative indications for open reduction :

  1. Bilateral condylar fractures in edentulous patient when splint

      is unavailable.

  2. Unilateral /bilateral condylar fractures when splinting is not

      recommended for medical reasons.

  3. Bilateral condylar fractures associated with comminuted

      midifacial fractures

  4. Bilateral condylar fractures associated with retrognathia   or

      prognathism

     Amaratunga (1987)2 in his follow up study of 219 condylar

fractures which were treated by closed reduction found that

  • Incidence of condylar fractures was 40 .2 %

  • Deviation of jaw on opening was 17.3%
  • Reduced interinicisal distance was 5.5%

  • Patients with bilateral condylar fractures had anterior open

       bite.

  • 77.4%of the patient who were under 20 years age group had

       complete remodeling

  • 16.7%of the patients who were over 20 years age group had

       incomplete remodeling.

       Takenoshita et al (1989)45 in their follow up study          of 27

condylar       neck fractures which were treated   by open reduction

observed that there was :

  • Early restoration of function .

  • No neurosensory deficits.

       Dahlstrom et al (1989)9 in their 15 years follow up study on 36

condylar fractures which were treated by closed reduction found

that

In children         –   No major growth disturbances were observed

                    –   function of masticatory system was good .
In   teenagers      –   anatomic   and    functional    restitution   of

temperomandibular joint was not as good as as in children .

In adults – signs of dysfunction were observed but were not

considered serious by the patients.

      Joram Raveh (1989)27 the subject of this paper is the evaluation

of the results after surgical management of 29 dislocated fractures of

condylar process. Only fractures with total dislocation of the condyle

out of the articulate fossa were surgically treated. The low rate of

complications as well as the satisfactory function of the joints in spite

of severe dislocation seems to confirm the surgical treatment of this

type of fracture.

      Takenoshita et al (1990)45 compared functional recovery after

non –surgical and surgical treatment of condylar fractures in 36

patient s and found that satisfactory postoperative function and

occlusion at the same level in both groups         with out any serve

complications.

      Rubens and Steolinger (1990)38 this study on the management

malunited mandibular condylar fractures. They performed sagittal
split mandibular osteotomy and the external vertical ramus

osteotomy to restore the vertical ramus height and functions in

patients.   Post operative observation revealed good functional

movements, occlusion, and sufficient bite force.

      Joachim lachner et al (1991)29 in their follow-up study of 14

low subcondylar fracture which were treated        by intraoral open

reduction by percutaneous trocar observed that

   • 80% of the fractures demonstrated reduction

   • Normal range of motion was achieved in all patients .

   • Deviation of jaw towards fractured side was seen in 23%of the

      patients.

      They also observed following advantage of intraoral open

reduction such as :

   - Avoidance of facial nerve injury.

   - Avoidance of large external scars.

      Feifel. H et al (1992)18 in their 15 year follow-up study of 28

subcondylar fractures in children which were treated by closed
reduction found that there was good esthetic and functional results

although condylar remodeling occurred        in only about half the

individuals they concluded that there is no indication for      open

reduction of displaced condyle during growth period.

     Vitomirs.    S. Konstantinovic (1992)28 Compared functional

recovery after open and closed reduction of 80 unilateral condylar

fractures of which 26 surgically and 54 consevatively treated. There

was no statistical differences in functional recovery between both the

groups. But radiographic examination showed slightly better position

of surgically reduced condylar fractures.

     Johannes Hidding et al (1992)26 in this clinical radiographic

and axiographic study, they reinvestigated 34 patients with

dislocated fractures of condylar neck, 20 of them had been treated by

open reduction, 14 in a conservative functional way. The clinical

results were nearly equal in both groups X-ray findings showed

considerable deviation in the joint physiology in conservative group.

Author recommends open reduction in cases of dislocated sub

condylar or condylar neck fractures.
      Edward Ellis and Dean et al (1993)13 this article reviews the

anatomy and surgical approach for treating fractures of the

mandibular condyle with plate and screw fixation. Author discussed

about the advantages and disadvantages of the preauricular,

submandibular, intra oral, retromandibular and rhytidectomy

approaches.    Author says retromandibular approach is the most

reliable for applying plate and screw fixation.

      Hay ward et al (1993)21 in their 50 years review of literature of

condylar fractures stated that decision regarding open versus closed

reduction in management of condylar fractures depends upon.

   • Age of the patient.

   • Level of condylar fracture.

   • Degree of displacement

   • Presence of dentition

   • Presence of foreign body

   • Status of extending dentition.

   • Concomitant injuries.

   • Medical status of the patient.
      Sven Erik and Vejayan Krishnan et al (1993)44 in their 10.I

years mean observation of 55 patients ranging from 5-20 years age

group with mandibular condyle fractures treated conservatively.

Result were obtained from clinical, radiologic examinations.

      Clinical dysfunctional wider values increased significantly with

increasing age at the time of trauma.       Radiologic abnormalities

reduced ramus height, deviation of mandibular midline, and

irregular shape of the condyle were seen irregular shape of the

condyle were seen frequently. No cases of ankylosis. The results

support the opinion that conservative treatment is sufficient in

pediatric patients.

      Alexander       et al (1994)1 in their follow up study 23 low

subcondylar fractures which were treated by open reduction with

Luhr T - miniplate :luhr110º – miniplate observed that there were no

maloccusions, wound infection and neurosensory deficits they

stressed that displaced reduction of unilateral dislocated low

subcondylar fractures in 101 patients found that complication such a

s malocclusion , impaired masticatory function and pain located to
affected joint were   significantly greater (39%)in closed reduction

group patients    compared to those treated surgically (4%)they

concluded that dislocated low subcondylar fractures in adults be

treated by open reduction .

     Silvennoinen et al (1994)40 analyzed the possible factors

leading to problems after non surgical treatment of unilateral

condylar fractures in 92 patients they found that malocclusion

occurred due to decreased ramus height and deviation of jaw on

mouth opening occurred due to dislocated condylar fractures they

concluded that dislocated and decreased ramus height condylar

fractures should be identified ramus height condylar fractures should

be identified preoperatively by means of radiographs and should

be treated by open reduction.

     Upro Silvennoinen (1995)53 in their preliminary follow-up

study of seven adult patients with displaced condylar process

fractures were treated using axial anchor screw fixation. 2 years post

operative follow-up, all the patients were free of pain, occlusion and

facial symmetry were normal.        Radiographs showed excellent
fracture reduction. Translation of the condyle on mouth opening was

symmetrical. Some patients had complications such as unsatisfactory

reduction and fracture of screw.     Treatment of condylar process

fractures using axial anchor screw system is ideal in certain cases.

Author says complications and difficulties can be avoided by

appropriate patient selection and technique.

     Giorgio Iannetti (1995)7 this study was to evaluate the use of

external fixtion for the treatment of extracapsular condylar fractures

with luxation of the fragment out of the glenoid of the fragment out

of the glenoid cavity. 28 patients have been treated with the rigid

external fixation system. They observed complete recovery of the

occlusal situation and of the mouth opening. No patient presented

with problem.

     Ilkka Kallela et al (1995)25 in their study 11 adult patients

underwent surgery for displaced or dislocated mandibular condyle

fractures via a submandibular approach and the fragments were

fixed using lag screws. After 22.5 weeks follow up, clinically all

patients had a stable occlusion and symmetry of the face. All had
greater than 5mm symmetrical lateral jaw excursions.         Painless

mouth opening 4 cases there was considerable shortening of the

mandibular ramus. Despite good clinical results, lag screws do not

meet the needs for rigid internal fixation in the treatment of

mandibular condyle fractures.

     Cyrille Chossegros et al (1996)8 this study was to evaluate

long-term clinical and radiologic results of the short retromandibular

approach to displaced subcondylar fractures. 19 patients with follow

up longer than 6 months, author observed success in all the cases. 25

months after surgery, mouth opening was 43mm with symmetrical

laterotrusive movements and permanent marginal nerve palsy was

never observed.

     Widmark Goran et al (1996)55 in their comparative study of

functional recovery after closed and open reduction of unilateral

dislocated subcondylar fractures in 32      patients found that    no

significant differences in both the groups in relation postoperative

function and occlusion
      Hammer          et al (1997)19 in their follow up study      of   31

condylar fractures which were treated by open reduction observed

that complications such as plate failure or screw loosening was

found in 35% of the patients treated with single adaptation

miniplate no complications were observed in patients treated with

double adaptation         miniplate they stressed dislocated     condylar

fractures should be fixed double adaptation miniplates.

      Hillerup. S (1997)22 in their follow up study of 9 patients with

displaced mandibular condyle fractures were treated by open

reduction using internal fixation with the aid of ramus osteotomy. 2

years post operative follow up observation radiographically,

resorption sometimes produced, sometimes flattening of condyle. 8

patients had deviation to the operated side on maximal mouth

opening. Author says by doing this ,condyle stays vital because of

the vascular supply from the lateral pterygoid muscle remnants of

joint capsule.

      Baker and Moos et al (1998)3 gave a current consensus on

management       of     fractures   of   mandibular   condyle   based   on
questionnaire distributed to member surgeons of IAOMS from the

survey they concluded that :

      • 57% of surgeons preferred open reduction of condylar

         fractures

      • 40 % preferred closed reduction of condylar fractures with

         immobilization .

      • 79% preferred bone plating as internal fixation device

      • 70%preferred preauricular approach for surgical access .

      • 47% preferred submandibular approach.

      • most surgeons were concerned about malocclusion and

         osteoarthritis in adults disturbances of growth in children.

      Banks Peter (1998)4 in his review of literature had concluded

the following :

         Conservative management should be considered in children

         because of restitutional remodeling.

         Open reduction should be reserved for subcondylar

         fractures associated with loss of vertical ramus height.
        Open reduction should be considered when condylar

        fractures are associated with multiple facial injuries because

        establishment of stable mandibular platform is essential.

     Hanna Thoren (1998)20 this study evaluates the radiological

outcomes of pediatric condylar fractures 37 patients with 45 condylar

fractures follow up after 4.1 years were studied. They observed in

complete remodeling in 56% of the fractures.

        Deformation of condylar neck

        A difference ramus height between 2 sides

        Dislocated fractures, in particularly need special attention

        and long lasting followup.

     Newman L (1998)32 in his follow up study of 61 patients with

condylar fractures 51% of patients had bilateral condylar fractures

alone and the remainder also having another mandibular fractures.

7% intra capsular 48% condylar neck and remaining 45% were sub

condylar fracture. 21% of patients were treated with wire

intermaxillary fixation for a mean of 37 days. 15% of patients were

managed by open reduction of internal fixation. Post operatively
limited     mouth   opening   observed   in   patients   treated   with

intermaxillary fixation, which was significantly less in the open

reduction and internal fixation group. Author concludes that ORIF is

the most satisfactory method of treatment.

     Edward Ellis (1998)12 in his review of literature described

complications of mandibular condyle fractures.

  1. Malocclusion after closed reduction of condyle could be due

     to :

  - Failure in adaptation of neuromuscular system.

  - Failure to establish lost vertical ramus height.

  - Failure in restitution remodeling / functional remodeling

     seen in younger and older individuals respectively.

  2. Mandibular hypomobility seen in 8 -10% condylar fractures.

  3. Deviation of jaw to wards side of fracture seen in        50% of

     condylar fractures.

  4. 85% of dislocated fractures cause more dysfunction .
   5. Transient weakness of mandibular branch of facial nerve

      occur in 15% of the patients.

      Tateyuki Lizuka et al (1998)47 this study evaluates the long

term results of open reduction without fixation for displaced

fractures of the condylar process. 27 patients with 29 operated joints

an average of 6.7 year post operatively they observed clinically and

radiographic assessment. On final follow up 48% of the cases had a

normal condylar configuration radiologically, and remaining cases

normal function was established even though there were condylar

changes.     They say the surgical management described enables a

satisfactory outcome to be achieved with dislocated condylar process

fractures.

      Edward Ellis et al (1999)15 compared mandibular motion after

closed and open treatment of unilateral sub condylar fractures in

136 patients found that patients on fractured side than those

patients treated by closed reduction they concluded that open

reduction produce s functional benefits to patients with severely

displaced condylar process fractures.
     Edward Ellis et al (1999)14 studied the changes in position of

fractured condylar process immediately before and after closed

reduction of 66 unilateral condylar process fractures they found

that fractured segment was displaced either medially or laterally

after closed reduction in significant number of 26 patients (40%)

And also noted that fractured fragment was displaced either

anteriorly or posteriorly in less number of 9 patients (14%) they

concluded that open reduction must be considered in displaced

and dislocated condylar process fractures.

     Santler P. Karcher et al (1999)39 this study was to compare the

outcomes from the surgical and non surgical treatment of condylar

process fractures. 234 patients with fractures of mandibular condylar

process were treated by open or closed methods. 150 patients with a

mean followup time of 2.5 years were analyzed using radiologic and

objective and subjective clinical examinations.

     No significant differences in mobility, joint problems, occlusion,

muscle pain, or nerve disorders were observed when the surgically

and non surgically treated patients were compared. But surgically
treated patients showed significantly more weather sensitivity and

pain on maximum mouth opening. Because of its disadvantage, open

surgery indicated in patients with severely dislocated condylar

process fractures.

      Strobl et al (1999)43 treated 55 children age group 2 ½ - 9 ¾

years with unilateral condylar fracture non-surgically using an intra

oral myofunctional appliance. They found after 48 years no patients

showed occlusal or functional disturbances or any TMJ pain or

dysfunction. Remodeling was complete in all the cases. Patient age

group 7-10 years showed in complete regeneration resulting in

condylar deformity in 2 cases, reduced neck height in 2 cases and

hypertrophic condylar deformity in 4 cases, however there was no

incidence ankylosis.

      Byung Ho Choi et al (1999)5 they did a cadaveric study on

different types of plating techniques and suggested that two

miniplate system. One of the posterior and another at the anterior

border of the condylar neck have the beneficial effect of restoring

tension and compression trajectories.
      Hovinga et al (1999)23 treated 27 children with the fractured

condyle, non-surgically either by intermaxillary fixation or just

observation.    From their study they found that high condylar

fractures show good regeneration tendency while low condylar and

intra capsular fractures give rise to some asymmetry.           They

concluded that non surgical management is still the method of choice

in children with unilateral or bilateral fractures of the condyle and

surgical management should be considered only in selected cases

involving extensive dislocation with lack of contact between the

fragments, dislocation of condyle into the middle cranial fossa and in

cases with multiple mid facial fractures.

      Chien – Tzung Chen (1999)6 in their follow up study of eight

patients with mandibular subcondylar fracture were treated using

endoscopy. After 6-12 months follow up they found functionally all

patients recovered a normal range of motion. Technique provides

the benefits of rigid fixation and no facial scars.

      Edward Ellis (2000)16 compared occlusal results after open and

closed treatment of unilateral fractures of mandibular condylar
process in 137 patients and found that patients treated by closed

reduction had a greater percentage of malocclusion (27.3%) than

patients treated by open reduction. They stressed that consistent

occlusal results can be achieved when condylar fractures are treated

by open reduction.

     Edward Ellis et al (2000)17 in their follow up study of 61

unilateral condylar process fractures which were treated by open

reduction observed that :

     Immediately after open reduction, the difference in position

     between fractured and non fractured sides averaged less than 2

     degrees indicating good anatomic reduction of fractures.

     They also observed that 10-20% of condylar process fractures

     had post surgical changes in position of more than 10 degrees.

     Tulio et al (2000)52 in their 2 year follow up study of 9

dislocated condylar fractures which were treated by open reduction

observed that :

     Good amount of mouth opening in all patients

     Minimal deviation or pain in all patients
     Radiographic observation revealed restoration of posterior

     facial height in all the patients.

     G.S. Throckmorton et al (2000)50 compared mandibular motion

after closed and open reduction of unilateral subcondylar fractures in

136 patients found that the patients treated by open reduction had a

faster rate of improvement in maximum interincisal opening than in

whom treated by      closed reduction (0.43mm/month Vs 0.15mm/

month). They also observed that patients treated by open reduction

had a faster rate of improvement in maximum excursion towards

fractured   side   than    patients   treated   by   closed   reduction

(0.10mm/month Vs 0.04mm/month).

     Edward Ellis et al (2001)11 compared bite forces after open and

closed reduction of 155 unilateral condylar fractures. They found

that there was no significant differences in maximum voluntary bite

forces between the 2 groups.

     Richard et al (2001)36 compared long term treatment results of

open reduction and closed reduction of subcondylar fractures in 20

patients and found that open reduction group was associated with
perceptible scar and closed reduction group was associated with

chronic pain. They also observed that no differences existed between

both the groups with respect to maximal interincisal opening,

excursion, protrusive movements and deviation on opening.

     Thoren H. et al (2001)48 in their 10 year follow up study of 26

dislocated condylar fractures which were treated by closed reduction

observed that :

     39% of the patients had deviation of jaw during opening

     22% of the patients had joint clicking

     10% had reduced range of mouth opening

     5% had pain in TMJ region

Their radiologic observation revealed :

     Incomplete remodeling in 76.5% of patients

     Asymmetry of mandible in 65% of patients




     De Riu et al (2001)10 in their comparative study of functional

recovery after closed and open reduction of subcondylar fractures in
65 patients found that the functional results in both the groups were

similar. However open reduction gave better occlusal results with

anatomic restoration and faster recovery than closed reduction.

     Matthias et al (2002)31 studied different lines of intracapsular

fractures of mandibular condyle in 40 patients and evaluated their

influence on prognosis after closed treatment. They found moderate

to serious dysfunction occurred in (33%) of the cases and also

reported that comminuted fractures has got worst prognosis

followed by fractures associated with loss of vertical height of

mandibular ramus.

     Hyde et al (2002)24 in their prospective study of 28 unilateral

mandibular condyle fractures which were treated by open reduction

observed that normal mouth opening, full range of mandibular

excursions were achieved in all the patients.     They stressed the

displaced condylar fractures should be treated by open reduction.

     Leon A. Assael (2003)30 evaluated various factors effecting the

management of mandibular condyle fractures by open and closed

methods. He concluded that malocclusion, masticatory functional
deficitis and internal derangements occur in both surgical and non

surgical patients.      He also added patients age, gender, systemic

diseases, patient complaints, risk of infection, risk of nerve injury,

risk for scaring, risk for chronic pain, osteoorthorsis and bone

resorption, and associated mandible and midface fractures, and

patients expectations are the factors that influence the treatment of

mandibular condylar of fractures either by surgical or non surgical

methods.

         Todd Brandt and Haug (2003)51 they did a review of the

literature    regarding   the   evaluation    of   current   thoughts   on

management of mandibular condyle fractures in adults (open versus

closed). They discussed about the Lindahl classification of condylar

fractures, indication for open reduction by Zide and Kent (1983),

(1989), (1990).    And compared the outcomes of open reduction

internal fixation versus closed reduction and maxillomandibular

fixation given by various authors. He says open reduction provides

better     functional   reconstruction   of   mandibular     condyle    by

endoscopic surgical technique.
     Smets and Stoelinga et al (2003)42 in their follow up study of 60

patients with 71 condylar fractures were treated by non surgical

fashion.   The retrospective study, including clinical analysis of

occlusion, asymmetry at rest during mouth opening, maximum

interincisal distance, signs of TMJ dysfunction and analysis of

radiographic deta i.e. shortening of ascending ramus as measured on

sequential O.P.G.S.

     They found 8% with an unacceptable malocclusion one with

     limited mouth opening

     92% had none or only minor signs of TMJ dysfunction not

     requiring further treatment.

     Author says only in selected patients with shortening of the

     ascending ramus of 8mm or more and /or considerable

     displacement of the condylar fragment, surgically repositioning

     and rigid internal fixation should be considered.

Villarreal et al (2004)54 this study was done to analyze the principal

variables that determine the choice of the method of treatment and

the outcome in condylar fractures. They conducted a retrospective
analysis of 104 mandibular condyle fractures. All patients underwent

a clinicradiologic investigation focusing on fracture remodeling,

evoluation, dental occlusion, symmetry of the mandible.           The

principal factors that determined the treatment decision were the

level of the fracture and the degree of displacement. The level of the

fracture influenced the degree of pre operative coronal and sagittal

displacement and treatment applied.     The functional improvement

obtained by open method was greater than that obtained by closed

treatment. Open treatment increases the incidence of post operative

condylar deformities and mandibular asymmetry.


              SUMMARY AND CONCLUSION

      This retrospective cum prospective study was designed for the

patients who were treated for condylar fractures in the Department

of Oral and Maxillofacial surgery at Saveetha Dental College and

Hospitals, Chennai.

      The aim of the study was to compare the functional outcome

following non surgical and surgical management of condylar

fractures.
     24 patients with condylar fractures were included in the study.

16 patients were treated conservatively and 8 patients had undergone

open reduction and rigid internal fixation. Follow up period ranged

from 3-19months.

The present study concluded

  1. Pain in temporomandibular joint was more common in

      patients treated conservatively when compared to patients

      treated by open reduction and rigid fixation.

  2. No    statistically   significant   differences   were   found   for

      occlusion, muscle pain and jaw mobility in both the groups.

  3. On clinical observation the incidences of mandibular deviation

      towards the fractured side was more common in patients

      treated conservatively. In contrast to which it occurred less

      often in the patients treated with open reduction and internal

      fixation.   But statistically no significant difference could be

      found.

  4. Reduced mouth opening was noted more commonly in

      patients treated conservatively than those treated by open

      reduction and rigid fixation.
  5. Lateral excursive movements were within normal limits for

      both the groups.

  6. Pain on lateral excursive movements was noted more

      commonly in patients treated conservatively than those treated

      by open reduction.

  7. Facial nerve weakness observed in one patient, infection and

      wound dehiscence was noted in one patient treated by open

      reduction.

  8. Reduced ramal height is observed on a radiograph more

      commonly in patients treated by closed reduction. Inspite of

      fractured condyle not being there in its anatomical position as

      observed on a radiograph, the jaw functions were normal.

     Considering all the above findings we concluded that

conservative management gives good results clinically, though

radiographically the condylar position is not normal. This was

achieved by early mobilization and aggressive physiotherapy, so we

recommend closed reduction in cases of minimally displaced and

high condylar fracture.    Open reduction of displaced condylar

fractures led to excellent results in the clinical as well as x-ray
analysis.   Therefore we recommend open reduction in cases of

dislocated low level subcondylar fractures. But this study can be

substantiated with longer follow up and more number of cases from

both the treatment modalities.

                          BIBLIOGRAPHY


1.   Alexander R. et al : “An accurate method of open reduction and

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2.   Amaratunga N.A : “A study of condylar fracture in Sri Lanka

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3.   Baker A.W., Moose K.F. et al :          “Current causes on the

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4.   Banks P : “A pragmatic approach to management of condylar

     fractures”. Int JOMFS 1998 ; 27 : 244-246.
5.   Byung Ho Choi et al : “Evaluation of condylar neck fractures

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6.   Chien Tzung Chen et al : “ Endoscopically assisted mandibular

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