Condylar fractures

©M. S. Ramaiah University of Applied Sciences
1
Condylar fractures
-Zeeshan Arif

2
Introduction
• Condylar and subcondylar fractures
constitute 26-40% of all mandible
fractures
• Given the unique geometry of the
mandible and temporomandibular
joints (TMJs), these fractures can
result in marked pain, dysfunction,
and deformity if not recognized and
treated appropriately.

3
Development
• Meckel’s cartilage.
• Intramembranous ossification
• Bone formation : secretion of bone matrix
directly within the connective tissue; without
any intermediate cartilage formation.
• Condensation of mesenchyme just lateral to the
Meckel’s cartilage.
• Cartilage then disappears as the bony mandible
develops.

4
Anatomy
• Condyle : knuckle like
• It is a strong upward projection from
the posterosuperior part of the ramus.
• Upper end : Head
• TMJ
• Pterygoid fovea

5
Surgical anatomy
• Elliptical in shape, long axis angled
backwards between 15-330 to frontal
plane.
• Long axis of 2 condyles meet at basion
on anterior ligament of foramen
magnum forming an angle 0f 145-160
degrees.

6
• Mediolateral width: 15-20
mm
• Anteroposterior width: 8 -
10mm
• Lateral pole: roughened,
bluntly pointed.
• Medial pole: rounded,
extends from plane of ramus

7
Blood supply
• Superficial temporal artery
• Transverse facial artery
• Posterior tympanic artery
• Posterior deep temporal artery

8
• Facial nerve
• Auriculotemporal nerve
Nerve supply

9
Muscle attachments
• Lateral pterygoid muscle
• Protrusion & lateral excursive movements

10

11
Etiology
 Assault
 RTA
 Sport injuries
 Falls
 Work-related incidents

12
Associated injuries
• Facial nerve injuries
• C-spine injuries
• Displacement of the mandibular condyle into the middle cranial fossa
• Injuries to the external auditory canal

13
Mechanism of injury

14
Classification of Condylar Fractures
Unilateral or bilateral condylar fractures
Rowe and Killey’s classification
• a. Simple fractures of condyle
• b. Compound fractures of condyle
• c. Comminuted fracture associated with zygomatic arch fractures

15
Rowe and Killey’s classification (1968)
a. Intracapsular fractures or high condylar fractures
i. Fractures involving the articular surface
ii. Fractures above or through the anatomical neck, which do not involve
the articular surfaces
b. Extracapsular or low condylar or subcondylar fractures:
c. Fractures associated with injury to the capsule, ligaments and meniscus.
d. Fractures involving the adjacent bone—e.g. fracture of the roof of the glenoid
fossa or the tympanic plate of the external auditory meatus

16
Clinical classification by MacLennan (1952)
a. No displacement
b. Deviation - Simple angulation exists between the condylar neck and the
ramus.
c. Displacement - Overlap occurs between the condylar process and the
ramus.
d. Dislocation - Disruption takes place between the condylar head and the
glenoid fossa.

17
Wassmund’s classification (1934)
• Type I- The angle between the head and the long axis
of the ramus :10 to 45 degrees.
• Type II- angle of 45 to 90 degrees, resulting in tearing
of the medial portion of the capsule.
• Type III- the fragments are not in contact, and the
head is displaced mesially and forward owing to
traction of the lateral pterygoid muscle. confined to
within the glenoid fossa.
• Type IV- fractures where the condylar head
articulates in an anterior position to the articular
eminence.
• Type V- vertical or oblique fractures through the head
of the condyle.

18
• Anatomic location of the fracture
• Condylar head
• Condylar neck
• Subcondylar
• Relationship of condylar fragment to mandible
• Nondisplaced
• Deviated
• Displacement with medial or lateral overlap
• Displacement with anterior or posterior overlap
• No contact between fractured segments
• Relationship of condylar head & fossa
• Nondisplaced
• Displacement
• Dislocation
Lindahl classification (1977)

19
• Spiessel and Schroll classification (1972)
• i. Nondisplaced fracture
• ii. Low neck fracture with displacement
• iii. High neck fracture with displacement
• iv. Low neck fracture with dislocation
• v. High neck fracture with dislocation
• vi Head fracture

20
Neff and Rasse’s modification (2006)
• Type A(VI A): Displacement of medial
condylar pole with preservation of the
vertical dimension
• Type B (VI B): The lateral condylar pole
is involved with loss of the vertical
dimension
• Type C (V): dislocation of the entire
condylar head
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian
Dental Association December 2006, Vol. 68, No. 11

21
R.A loukotaa et al subclassification
(2005)
Fracture of the condylar neck:
The fracture line starts somewhere above line A
and in more than half runs above the line A in
the lateral view. Line A is the perpendicular line
through the sigmoid notch to the tangent of the
ramus.
Fracture of the condylar base:
The fracture line runs behind the mandibular
foramen and, in more than half, below line A
Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian Dental
Association December 2006, Vol. 68, No. 11

22
Diagnosis
• History
• Clinical examination
• Radiographic examination

23
History
• How did the patient sustain the injury?
-Area of impact
-Direction of impact
-degree of force

24
Unilateral condylar fracture
A. Inspection
• Swelling over the TMJ area.
• Heamorrhage from ear on that side.
- bleeding from external auditory canal
- middle ear haemorrhage
• Haematoma on the involved side
• Ecchymosis of skin just below the mastoid process
• Characteristic hollow over the region of condylar head.

25
B. Palpation :
• Tenderness over the condylar
area.
• Mandibular movements:
- Protrusion
- Lateral excursion
• Determine the displacement of
the condylar head.

26
• Intra – orally :
• Mandible deviates on opening
towards the side of fracture.
• Painful protrusion or lateral
excursion to the opposite side.
• Premature contact of the molar
teeth on the side of fracture.

27
Bilateral condylar fractures
• Inspection & palpation are same as unilateral
• Overall mandibular movement is usually
more restricted than in case of unilateral.
• Mandible may not be deviated.
• The midlines are often coincident, and
premature contact is present bilaterally on
the posterior dentition with an anterior open
bite.

28
• Signs & symptoms :
1. Evidence of facial trauma especially in the area of mandible
& symphysis.
2. Localised pain & swelling in the region of TMJ.
3. Limitation in mouth opening.
4. Deviation, upon opening to the involved side.
5. Posterior open bite on the contralateral side
6. Shift of occlusion towards the ipsilateral side with possible
crossbite.
7. Blood in the external auditory canal.

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8. Pain on palapation
9. Lack of condylar movement on palpation
10. Difficulty in lateral excursion as well as protrusion
11. Occurrence of anterior open bite with bilateral subcondylar fractures.
12. Persistent cerebrospinal fluid leak through the ear: associated fracture of the
middle cranial fossa.

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Radiographic imaging
• OPG
• Bilateral lateral oblique.
• Towne view.
• Reverse Towne view.
• Computed Tomography.
• TMJ views
• CBCT

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OPG PA view

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Towne view

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Indications for CT scans
1. Significant displacement or dislocation,
particularly if open reduction is contemplated
2. Limited range of motion with a suspicion of
mechanical obstruction caused by the position of
the condylar segment
3. Alteration of the surrounding osseous
anatomy by other processes, such as previous
internal derangement or temporomandibular
joint surgery.

35
TREATMENT
Aims for surgery:
1. Relief from pain
2. Stable occlusion
3. Restoration of interincisal opening
4. Full range of mandibular movements
5. To minimize deviation
6. Avoid growth disturbances
7. Avoid Ankylosis

36
2 schools of thought:
•Conservative-functional therapy
•Surgical treatment

37
Indications:
• Non displaced or incomplete fractures
• Condylar neck fractures with little or no displacement
• Fractures occuring in children (10-12 yrs)
• Isolated Intracapsular fractures
• Medical illness or injury that inhibits the ability to receive
extended GA

38
Conservative therapy
• Involves no surgical intervention of the fracture site
instead it reduces the fracture taking occlusion as a key
factor.
• Immobilization usually involves fixation with arch bars,
eyelet wires or splints.
• Period of immobilization varies from 7-17 days

39
Conservative-functional management
• Exercise
• Increasing mouth opening
• Push the jaws laterally
• Diet: Soft diet
• Analgesics
• Anti-inflammatory
• Soft diet and mouth exercises-
• Teeth into normal occlusion
• Adequate Range of motion
• Elastic MMF for 2-3 weeks
• When occlusion is found to be altered
• Presence of pain or swelling

40
Elastic band – Class II light elastics
Review after 1
week
a) Normal occlusion: Remove when
brushing and replace immediately
b) Unable to achieve normal occlusion: to
be worn 24 hrs/day till next review
Review after next
week
a) Occlusion maintainable: halt elastics
b) Occlusion difficult obtain: continue
elastics (as long as 3 months)

41
Functional exercise:
• > 40 mm interincisal distance (adult)
• > 10 mm lateral excursion
• > 12 mm protrusion
Types of exercise:
• Maximal mouth opening
• Right lateral excursion
• Left lateral excursion
• Protrusive action

42
Advantage Disadvantage
• Relatively safe
• No injury of nerves and
blood vessels
• No postoperative
complications such as
infection or scar occurs.
• Fracture, loss, and eruption
delay of the growing teeth
can be avoided in pediatric
patients as no tooth germ
injury occurs
• Injury of the periodontal tissue and buccal mucosa
• Poor oral hygiene,
• Pronunciation disorder
• Imbalanced nutrition
• Growth disorder and excessive growth of the
injured mandible may occur
• Facial asymmetry may occur in pediatric patients
aged 10 to 15 years due to growth disorder or
functional disorder
• Growth and functional disorders of the TMJ may
occur in 20% to 25% of pediatric patients aged 7 to
10 years
Closed reduction

43
Open reduction
Absolute indications:
Fracture in to middle cranial fossa
Foreign body in to joint capsule
Lateral extracapsular deviation
Inability to open mouth or achieve occlusion after 1 week
Open fracture with potential for fibrosis
Relative indications:
Bilateral / unilateral fracture with crushed midface
Comminuted symphysis and condyle fracture with tooth loss
Displaced fracture with open bite or retrusion in mentally retarded or medically
compromised patients.
Displaced condyle in edentulous or partially edentulous mandible with
posterior bite collapse.

44
Open reduction
Advantage
• direct approach to the facture site.
• prevent complications such as
respiration disorder, pronunciation
disorder, and severe nutritional
imbalance by shortening intermaxillary
fixation period via rigid fixation.
Disadvatage
• injury of nerves or blood vessels during
operation, and postoperative
complications including infection.
• permanent scar

45
Surgical approaches
All open approaches have three common aspects to their success
• 1- the ramus must be distracted
• 2- the proximal condyle must be controlled and manipulated
• 3- the fracture must be anatomically reduced

46
Submandibular approach/ Ridsons appraoch
• Indications-
 axial anchor screw fixation
• Advantages –
 ability to distract the mandibular ramus
 direct access of the gonial angle
• Disadvantages-
 limited surgical site exposure
 difficult to reduce medially displaced condyle
 Plate and screw fixation restricted without a transfacial trocar

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Pertinent anatomy
• Marginal mandibular branch of the facial nerve
• Facial artery and vein

48
Incision

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Dissection
• Through the platysma
• From the platysma to the pterygomassetric sling
• Division of the pterygomassetric sling

50
Osteosynthesis
• axial anchor screw
• Visibility and reduction – sigmoid notch
retractor and condylar neck retractor is
used to reflect the soft tissues
• Direct fixation- a groove is made in the
lateral cortex ( 1cm anterior to the posterior
border) and 1.5 to 2cm inferior to the
fracture line

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52
• Indirect fixation- indicated when the
proximal condylar fragment is difficult to
reduce
• The screw is locked to the groove with the
help of a 2 hole mini plate

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Closure
• Pterygomassetric sling- masseter and the medial pterygoid is sutured
• Platysma – resorbale sutures are used in a running fashion
• Subcutaneous tissue – resorbable sutures are used
• Skin- non resorbale sutures are used

54
Retromandibular approach
• Indications
 large fractures which requires plates and screws
• Advantages
 short distance between incision and fracture site
 Better access to the fracture site
 No need for a transfacial trocar
 Scar is less noticeable than that of a submandibular incision
 Effective in patients with oedema
 Access for an osteotomy if required to reach the condyle
• Disadvantage-
 scar is more visible than that of a preauricular incision

55
Pertinent anatomy
• Facial nerve
• Retromandibular
vein

56
Incision
• 0.5 cm below the ear lobe
• Carry inferiorly for 3 to 3.5 cm
• Placed posterior to the posterior
border of the mandible

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Dissection
• Dissection of the platysma and
substance of the parotid
• Dissection to the pterygomassetric
sling
• Avoid injury to the facial nerve and
the retromandibular vein
• Division of the pterygomassetic sling

58
Osteosynthesis

59
Closure
• Pterygomassetric sling- masseter and the medial pterygoid is sutured together using
interrupted resorbable sutures
• Parotid capsule, platysma and the superficial muscular layer is sutured using a
horizontal mattress resorbale sutures
• Subcutaneous tissue
• Skin

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Rhytidectomy approach
• This approach provides the same exposure as the
retromandibular accesses.
• The only difference is that the skin incision is placed in a
more cosmetically acceptable location.
• It exposes the entire ramus from behind the posterior border.
• It therefore may be useful for procedures involving the
condylar neck/head, or the ramus itself.
• This approach is drained with closed suction drainage

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Transmassetric-anteroparotid approach
• Indications
 high and low subcondylar and ramus fractures
• Advantages –
 Quick and direct access to the fractured site
 Access to the gonial angle
 Ramus can be distracted
• Disadvantages
 Visible scar
 Potential damage to the facial nerve

63
Pertinent anatomy
• Marginal mandibular and the buccal branches of the facial nerve
• Layers of the parotid-massetric region- skin, subcutaneous fat, parotid-massetric
fascia,superficial and the deep bellies of the masseter and lastly the periostium of
the mandible

64
Incision
• Line through bottom of ear lobe till the
gonial angle in the posterior border
• 2nd line from gonial angle (same length) in
the inferior border
• Incision in the intersection 3rd

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Dissection
• Dissection to the
pterygomassetric sling
• Division of the massetric sling
• Exposure of the mandible and
fracture

66
Osteosynthesis
• Plates and screws are placed under direct
visualization
• A trocar may be required in cases of high
subcondylar fracture

67
Closure
• No closure of the periostium or the masseter muscle sling is necessary
• The paritomassetric fascia is sutured in running fashion to avoid any salivary fistula
• Subcutaneous tissue
• Skin

68
Preauricular approach
• Indications
 Whenever wire fixation of a high anteromedially displaced proximal fragment
• Advantages
 Provides access to the posterior most segment of the jaw
• Disadvantages
 Not ideal for plate and screw fixation
 No access to the angle of the mandible to distract the ramus inferiorly
 Limited ramus exposure makes the plate placement difficult

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Incision
• In the skin fold in the
entire length of the
ear
• Superiorly to the top
of the helix
• Incise to the depth of
the superficial layer
of the temporalis
fascia

70
• It provides an easier approach to high condylar fracture such as intercapsular
fracture
• Easy reduction of the injured soft tissues of the TMJ
• Reduction via a direct inspection of the appropriate relationship among the condyle,
disc, and joint.
• As the amount of mandibular ramus exposure is very limited, rigid fixation using
mini-plate is hard to be conducted if fracture site is positioned inferiorly to the
mandibular condyle neck.

71
Intraoral approach
• Indications
 Low subcondyar fractures,
 Axial anchor screws or mini plates can be used
• Adantages
 No visible scar
 No damage to the facial nerve
• Disadvantages-
 Intraoral approach without endoscope- very limited access, poorest access
among all the approaches
 Endoscope assisted intraoral approach- steep learning curve, difficulty in
reducing the fracture segments

72
Pertinent anatomy
• This is an anatomically safe approach with minimal risks

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Incision

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Dissection

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Osteosynthesis
• Miniplate and screw fixation
• Preauricular transcutaneous trocar insertion- drill and screw driver is inserted
through a trocar incision
• Screws and plates inserted via the intraoral incision

76
• Axial anchor screw
• The screw is positioned just superior and parallel
to the occlusal plane, superior to the mandibular
foramen
• The groove is placed in the medial cortical plate,
1.5 to 2cm anterior to the fracture line
• 2mm drill is used to drill a pilot hole-1.5 mm drill
penetrates beyond the fracture line upto 1 to
2mm
• Titanium screws are used for fixation

77
Endoscopic assisted osteosynthesis
• Advantages- access high condylar fractures, better visualization,
lesser complications
• Instruments required- angled drills, a 30 degree angled 4mm
endoscope, screwdrivers, illuminating hooks and retractors

78

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Fixation of fracture

80
Transosseous wiring
• Occasionally used in low subcondylar
fractures extending through the sigmoid
notch
• Access is possible through a submandibular
approach
• Higher level fractures are approached
through the pre auricular incision
• Damage to the maxillary artery
• Fracture segments are not stable because of
the pull from the lateral pterygoid muscle

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Bone pins
• Archer (1975) described the insertion of pins into the condylar
head and neck which were connected with an external bar
• This technique is rarely indicated

82
Glenoid fossa- condyle suture
• Wassmund (1935) described drilling a small hole through the
lateral edge of the glenoid fossa and the related edge of the
condylar articulating surface.
• A chromic catgut suture was looped through it and tied
• Disadvantage – resorb prematurely, loosen

83
Kirschner wire
• A k-wire may be drilled vertically through
the main mandibular fragment from the
angle, avoiding the inferior alveolar
bundle, so that it enters the fracture
interface
• Brown and obeid modified this technique
in 1984, in which they used two
interosseous wires to fix the k wire

84
Intramedullary screws
• Petzel (1982) described the use of an
intramedullary screw fixing the
fracture segments, through a
submandibular approach
• kitayama(1989) described the same
through an intraoral approach
• This technique requires special
instrumentation(tapping drills), a
variety of length of screws of correct
diameter and specialised forceps

85
Bone plating
• This the method of choice as it gives higher
stability and is relatively easy to apply
• Robinson and yoon (1960) described the use
of a 2-hole plate
• Koberg and momma (1978) advocated the
use of a 4-hole plate, which has become
standard

86
Axial anchor screw
• Generally approached by the submandibular or intraoral
incision
• This restores the vertical ramus height and may be more
effective than mini plates

87
Paediatric Condylar Fractures
• Most common pediatric mandibular fracture.
• Prior to age 6, most fractures are intracapsular, whereas after that age they occur
most frequently in the neck of the mandible.
• When normal occlusion is present, fractures of the condylar region are treated
conservatively with close observation, soft diet, and pain medication.
• When there is malocclusion, a short course of maxillary–mandibular fixation is
warranted.
• Limiting fixation to 7 to 10 days helps limit the chance of joint ankylosis, although
postoperative physiotherapy may still be beneficial.

88
• Choice of technique is largely dependent on the age of the child and, more
importantly, the quality and quantity of dentition.
• When possible, intradental wires with arch bars maybe placed.
• If not possible, intermaxillary fixation using 1-point circumandibular wiring should
be used
• Due to the possibility of injuring nonerupted teeth, intermaxillary fixation screws
should not be placed.
• It is important to discuss chin deviation during chewing and the possibility of long-
term growth abnormalities of the jaw with patients’ parents.

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CONDYLAR
TRAUMA?
Clinical Sign
Malocclusion
Deviation
Range of motion
Negative clinical exam
(-) Malocclusion
Minimal pain
Normal range of motion
No deviation on opening
Observation
Radiographs
Lateral obliques
opg
CT scan
No radiographic
evidence of condylar #
hemathrosis
Joint effusion
(+) Condylr fractre
Normal occlusion Malocclusion
ORIF?
ROM
Pain
Deviation
Conservative IMF (7-21 days)
ORIF Other # ?
IMF (7-21 days) Reduction/fixation of
other #
Follow up
Yes
YesNo
No
No
Yes

90
Open vs closed reduction

91
Ellis III E, Throckmorton GS. Facial Symmetry After Closed and Open Treatment of Fractures of the
Mandibular Condylar Process. J Oral Maxillofac Surg 2000; 58:719-728
• Ellis and Throckmorton conducted a study with open or closed treatment for
fractures of the mandibular condylar process, in 146 patients, 81 treated by closed
and 65 by open methods.
• The patients whose condylar process fractures were treated by closed methods had
significantly shorter posterior facial and ramus heights on the side of injury, and
more tilting of the occlusal and bigonial planes toward the fractured side, than
patients whose fractures were treated by open methods.
• The patients treated by closed methods developed asymmetries characterized by
shortening of the face on the side of injury.

92
Santler G, Kärcher H, Ruda C, Köle E. Fractures of the condylarprocess: surgical versus nonsurgical
treatment. J Oral Maxillofac Surg 1999;
• 234 patients with fractures of the mandibular condylar process were treated by
open or closed methods.
• In the follow-up study, 150 patients with a mean follow-up time of 2.5 years were
analyzed using radiologic and objective and subjective clinical examinations.
• No significant difference in mobility, joint problems, occlusion, muscle pain, or nerve
disorders were observed
• The only significant difference was in subjective discomfort.
• Surgically treated patients showed significantly more weather sensitivity and pain
on maximum mouth opening.
• Because of these disadvantages, open surgery is only indicated in patients with
severely dislocated condylar process fractures.

93
Marker P, Nielsen A, Lehmann Bastian H. Fractures of the mandibular condyle. Part 2: results of
treatment of 348 patients. British Journal of Oral and Maxillofacial Surgery 2000
• The ability to open the mouth, deviation and occlusion were recorded in closed
reduction cases
• After one year 45 of the 348 patients (13%) had minor physical complaints such as
reduced ability to open the mouth, deviation, or dysfunction.
• Ten of them (3%) had pain in the joint or muscles or both.
• Eight patients (2%) had malocclusion
• They concluded that closed treatment of condylar fractures is non-traumatic, safe,
and reliable and in only a few cases may cause disturbances of function and
malocclusion

94
Complications
Early complications:
1. Fracture of the tympanic plate
2. Fracture of the glenoid fossa with or without displacement of the
condylar segment into the middle cranial fossa
3. Damage to facial nerve
4. Vascular injury
Late complications:
1. Malocclusion
2. Growth disturbance
3. Temporomandibular joint dysfunction
4. Ankylosis
5. Asymmetry
6. Frey’s syndrome

95
CONCLUSION
• Intracapsular fractures are best treated closed.
• Fractures in children are best treated closed except when the fracture itself
anatomically prohibits jaw function.
• Physical therapy is integral to good patient care and is the primary factor
influencing successful outcomes, whether the patient is treated open or
closed.
• When open reduction is indicated, the procedure must be performed well,
with an appreciation for the patient's occlusal relationships, and must be
supported by an appropriate physical therapy and follow-up regimen

96
REFERENCES
1. Oral & maxillofacial trauma-Fonseca & walker
2. Oral & maxillofacial trauma-Rowe & Williams vol 2
3. Principles of Oral & maxillofacial surgery-Peterson
4. Maxillofacial trauma & facial reconstruction-Peter Ward Booth
5. Classification of condylar process fractures; M. Schneider, U. Eckelt; Journal of the Canadian
Dental Association December 2006, Vol. 68, No. 11
6. Ellis III E, Throckmorton GS. Facial Symmetry After Closed and Open Treatment of Fractures of
the Mandibular Condylar Process.Journal Of Oral Maxillofacial Surgery 2000;58 : 719 -728
7. Santler G, Kärcher H, Ruda C, Köle E. Fractures of the condylarprocess: surgical versus
nonsurgical treatment. J Oral MaxillofacialSurg1999
8. Marker P, Nielsen A, Lehmann Bastian H. Fractures of the mandibular condyle. Part 2: results
of treatment of 348 patients.British Journal of Oral and Maxillofacial Surgery 2000

97

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