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Management of Condylar Fracture of Children document sample
Management of Condylar Fracture of Children document sample
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 internal fixation of high and low condylar process fractures”. JOMFS 1994 ; 52 : 808 – 812. 2. Amaratunga N.A : “A study of condylar fracture in Sri Lanka patients with special reference to recent views on treatment, healing and sequelae”. Br. J Oral and Maxillofac surg. 1987. 3. Baker A.W., Moose K.F. et al : “Current causes on the management of fractures on mandibular condyle – A method by Questionnaire”. 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