s

v

v

v

v

g

G

J Oral Maxillofac Surg68:611-617, 2010

Clinical Follow-Up Examination ofSurgically Treated Fractures of the

Condylar Process Using theTransparotid Approach

Jan Klatt, MD, DMD,* Philipp Pohlenz, MD, DMD, PhD,†

Marco Blessmann, MD, DMD,‡ Felix Blake, MD, DMD,§

Wolfgang Eichhorn, MD, DMD, PhD,¶

Rainer Schmelzle, MD, DMD, PhD,� and

Max Heiland, MD, DMD, PhD#

Purpose: The surgical approaches for the open treatment of condylar process fractures have beencontroversial. In our study, we evaluated the morbidity of the transparotid approach during 2 years offollow-up.

Patients and Methods: A total of 48 patients with condylar process Class II and IV fractures accordingto classification of Spiessl and Schroll, were included in the present study. Of the 48 patients, 16 werefemale and 32 male. The patient age range was 16 to 79 years (average 36.52). All patients were treatedusing the transparotid approach, with rigid internal fixation using miniplates. Follow-up examinationswere performed for a minimum of 6.5 months and a maximum of 25 months (average 12.16) aftersurgical treatment. At the follow-up examination, the patients completed the Mandibular FunctionImpairment Questionnaire, and the examiner completed the Helkimo index. X-rays taken before, directlyafter, and 6 months after surgery were compared.

Results: None of our patients had problems with wound healing; 2 patients developed a fistula of theparotid gland; and 4 patients developed palsy of the facial nerve that was completely reversible after 6weeks. The results of the Mandibular Function Impairment Questionnaire and the Helkimo indexrevealed only a few subjective and objective problems after 6 months.

Conclusions: The transparotid approach to condylar process fractures is most appropriate for stronglydisplaced Class II fractures. Especially for very old patients with dementia, for whom maxillomandibularfixation is contraindicated, this approach is very appropriate. Another benefit to this type of patient is theshort operating time, with an average of 45 minutes.© 2010 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 68:611-617, 2010

*Resident, Department of Oral and Maxillofacial Surgery, Univer-

ity Medical Center Hamburg-Eppendorf, Hamburg, Germany.

†Consultant, Department of Oral and Maxillofacial Surgery, Uni-

ersity Medical Center Hamburg-Eppendorf, Hamburg, Germany.

‡Consultant, Department of Oral and Maxillofacial Surgery, Uni-

ersity Medical Center Hamburg-Eppendorf, Hamburg, Germany.

§Consultant, Department of Oral and Maxillofacial Surgery, Uni-

ersity Medical Center Hamburg-Eppendorf, Hamburg, Germany.

¶Consultant, Department of Oral and Maxillofacial Surgery, Uni-

ersity Medical Center Hamburg-Eppendorf, Hamburg, Germany.

�Professor and Head, Department of Oral and Maxillofacial Sur-

ery, University Medical Center Hamburg-Eppendorf, Hamburg,

ermany.

#Professor and Head, Department of Oral and Maxillofacial Sur-

gery, Medical Center, Bremerhaven-Reinkenheide, Bremerhaven,

Germany.

Drs Klatt and Pohlenz contributed equally to this work.

Address correspondence and reprint requests to Dr. Klatt: De-

partment of Oral and Maxillofacial Surgery (Nordwestdeutsche

Kieferklinik), University Medical Center Hamburg-Eppendorf, Mar-

tinistraße 52, Hamburg D-20246 Germany; e-mail: j.klatt@uke.uni-

hamburg.de

© 2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/6803-0019$36.00/0

doi:10.1016/j.joms.2009.04.047

611

Ctltrdcata

tscbbcfiemius

mfttsc

duecat

rtaoidf

ia1art3pal

u

Fl

KT

KT

Fw

612 TREATMENT OF CONDYLAR PROCESS FRACTURES USING TRANSPAROTID APPROACH

ondylar fractures are the most common fractures ofhe lower jaw, comprising approximately 30% of allower jaw fractures.1 Therefore, they play an impor-ant part in the trauma of the oral and maxillofacialegion. Apart from occurring as an isolated single orouble-sided fracture, they are often encountered inombination with fractures of the lower jaw body andlveolar ridge. The etiologic factors include falling onhe chin during sports injuries, vehicular accidents, orssaults.

Because of the common occurrence of this frac-ure, various therapeutic options have been de-cribed. Currently, 2 main modalities can be defined:onservative treatment with 10 to 14 days of immo-ilization of the lower jaw using dentally affixed splintandages; or surgical therapy, including the anatomi-ally correct repositioning of the fragments and theirxation with miniplates. For surgical therapy, differ-nt osteosynthesis procedures have been used. Theiniplate osteosynthesis of the condylar process us-

ng an extraoral approach is currently the most pop-lar method, followed by the miniplate osteosynthe-is using a transoral approach.

It is not only the type of osteosynthesis that deter-ines the choice of the surgical approach. Other

actors, such as the anatomic positioning of the frac-ure of the condylar process, concomitance of addi-ional jaw fractures, experience of the surgeon, pos-ible complications, and, last but not least, cosmeticonsiderations, are equally important.Extraoral approaches such as preauricular, subman-

ibular, or retromandibular approaches are frequentlysed, because they facilitate better exposure of the op-rating field and thus simplify fracture repositioningompared to the cosmetically more favorable transoralpproach and its endoscopically assisted modifica-ions.2-4 Extraoral approaches, however, result in the

IGURE 1. Intraoperative site with transparotideal/retromandibu-ar incision lines marked.

latt et al. Treatment of Condylar Process Fractures Usingransparotid Approach. J Oral Maxillofac Surg 2010.

KT

isk of serious complications, especially those involvinghe facial nerve. The pre- and postauricular approachesre favored for intracapsular and more caudad fracturesf the condylar process, if, in these cases, osteosynthesis

s indicated.5 In contrast, submandibular and retroman-ibular approaches are mainly used for more caudadractures of the condylar process.6

For more caudad fractures for which surgical therapys indicated, a transparotid, retromandibular approachccording to Ellis and Zide7 is used at our institution (Fig). The main difference from extraoral approaches, suchs the submandibular approach, is the direct transpa-otid exposure of the condylar process region, respec-ively the fractured area, from the skin incision (Figs 2,). Hence, considerably less tissue needs to be dis-laced, especially compared with the submandibularpproach, allowing a clearer exposure of the mandibu-ar branch and condylar region.

Because of these differences, a prospective study eval-ating the morbidity of the retromandibular transparotid

FIGURE 2. Intraoperative site of condylar process fracture.

latt et al. Treatment of Condylar Process Fractures Usingransparotid Approach. J Oral Maxillofac Surg 2010.

IGURE 3. Condylar process fracture after rigid internal fixationith Synthes 2.0 DCP plate.

latt et al. Treatment of Condylar Process Fractures Usingransparotid Approach. J Oral Maxillofac Surg 2010.

aac

P

apTrH1emp

perpt

cwvpc4cwae

K

KLATT ET AL 613

pproach, with regard to nerve injury, wound healing,nd other surgical and functional complications wasompleted.

atients and Methods

A total of 48 patients treated using a transparotidpproach were included in the present study. The 48atients had a total of 60 condylar process fractures.he patients underwent follow-up examinations ategular intervals at the University Medical Centeramburg-Eppendorf. The sutures were removed 7 to0 days postoperatively. At 3 and 6 months postop-ratively, the patients underwent radiologic assess-ent. After the 6-month x-ray examination and beforelate removal, clinical follow-up examinations com-

FIGURE 4. Right, Preoperative condylar process fracture and L

latt et al. Treatment of Condylar Process Fractures Using Transparoti

lemented the radiologic assessment. The follow-upntailed analysis of the pre-, intra-, and postoperativeesults of the patients, including the pre-, intra, andostoperative x-ray diagnostics (pre- and postopera-ive panoramic view and Clementschitsch view).

The follow-up examinations were performed ac-ording to a fixed protocol. First, the patients under-ent radiologic examination, including a panoramic

iew and Clementschitsch view. On the basis of thereoperative imaging findings, the fractures werelassified according to Spiessl and Schroll8 (FigsA,B). Furthermore, the angle of displacement of theondylar process in relation to the ramus mandibulaeas determined in the preoperative, postoperative,

nd 6-month postoperative images (Figs 5A,B). Theventual existence of ramus shortening was analyzed

pus fracture. A, Panoramic view and B, Clementschitsch view.

eft, cor

d Approach. J Oral Maxillofac Surg 2010.

umeiapMp3mtai

fopnp

hptpw

R

caaEmf2ff

K rotid A

614 TREATMENT OF CONDYLAR PROCESS FRACTURES USING TRANSPAROTID APPROACH

sing the preoperative images compared with the im-ediate postoperative images and the 6-month postop-

rative images. The x-ray images were evaluated accord-ng to the work of Eckelt9 and Härle et al.10 Andditional classification of the postoperative fragmentositioning was performed using the classification ofokros and Erle11 of the repositioning results after jointrocess fractures. Also, the data sets of the Arcadis OrbicD C-arm (Siemens Medical Solutions, Erlangen, Ger-any) were individually evaluated (Fig 6). The descrip-

ive statistic showed how many patients did not requiren additional revision operation owing to the results ofntraoperative three-dimensional imaging.

Additionally, photographic documentation of theunctional mobility and photographic documentationf extraoral scarring were performed. Patients com-leted the Mandibular Function Impairment Question-aire (MFIQ).12,13 The clinical examination included the

FIGURE 5. Same fracture as in Figure 4 after open reduction and

latt et al. Treatment of Condylar Process Fractures Using Transpa

arameters of nerve injury, mouth opening, wound u

ealing, scar length, salivary fistula, functional outcome,ermanent deflection of the lower jaw, asymmetry ofhe face, scar pain, occlusional dysfunction, and tem-oromandibular joint disorders. Functional impairmentas measured using the Helkimo dysfunction index.14

esults

From January 2005 to April 2007, 48 patients with aondylar process type II fracture according to Spiesslnd Schroll8 underwent surgery with the transparotidpproach at the University Medical Center, Hamburg-ppendorf. The 48 patients included 16 females and 32ales. Of the 48 patients, 17 did not return for the

ollow-up examination at 6 months postoperatively and9 did. The 48 patients had a total of 60 fractures. Theractures were classified as 53 type II fractures, 5 type Iractures, 1 type VI fracture, and 1 type III fracture,

nternal fixation. A, Panoramic view and B, Clementschitsch view.

pproach. J Oral Maxillofac Surg 2010.

rigid i

sing the system by Spiessl and Schroll.8 The average

papTwqtmteavob

1paltl2taTtcofoc

iaP7y

ot(

omOcrpwtda

1scctepsas

rttosoireassgmccsmt2ra

D

tab

Ff

KT

KLATT ET AL 615

atient age was 36.52 years (range, 16 to 79). Thege-related classification of the patient groups revealed aeak incidence in patients between 20 and 30 years old.he main cause for mandibular fractures in this groupas associated with cycling (18 patients). A similaruantity of fractures was caused by violence (16 pa-ients) or when walking and stumbling or during a do-estic accident (10 patients). Only a small number of

he patients were injured by a traffic accident, if wexcluded the cycling population (1 patient injured in a carccident and 1 in a motorcycle accident). One case in-olved a drug addict who had jumped from the fourth floorf a building, and another case, a patient who was trappedetween 2 panes of glass during an accident at work.The analysis of the preoperative x-ray images showed

3 condylar process fractures with a dislocation of theroximal fragment in a posterior medial direction. Innother 17 fractures, the proximal fragment was dis-ocated in an anterior-medial direction. Also, 12 frac-ures were posterior laterally displaced, 11 anterioraterally, 3 medially, and 1 laterally. Of the 48 patients,

showed symptoms of a wound healing disorder inhe region of entry for the transparotid approach,ccompanied by the development of a salivary fistula.hese patients experienced spontaneous healing of

he salivary fistula, followed by a normal healing pro-ess. No patient showed signs of eminent hematomar seroma. Of the 48 patients, 4 showed temporaryacial atony; however, none of these 4 patients devel-ped a permanent condition. The longest period untilomplete recovery was 6 weeks.The clinical examinations, using our clinical exam-

nation protocol, showed that the 29 patients had anverage internal space of 42.37 mm (range, 33 to 59).rotrusion in the examined group was an average of.14 mm (range, 2 to 11.33). The mediotrusion anal-

IGURE 6. Intraoperative 3-dimensional reconstruction. SSD, sur-ace-shaded design.

latt et al. Treatment of Condylar Process Fractures Usingransparotid Approach. J Oral Maxillofac Surg 2010.

sis on the fractured side showed an average distance s

f 8.32 mm (range, 2.66 to 15). The mediotrusion onhe nonfractured side was an average of 10.12 mmrange, 7 to 15).

Five patients developed a permanent occlusion dis-rder. Two of these patients had had polytrauma withultiple additional midfacial and lower jaw fractures.ne female patient had severe dislocated bilateralollum fractures. Of the 29 patients, 2 had unilateralamus shortening, leading to facial asymmetry. Bothatients with ramus shortening had had polytraumaith multiple additional mid-facial and lower jaw frac-

ures. Five patients had lasting preauricular sensibilityisorders, including the 2 patients with polytraumand the patient with the dislocated bilateral fracture.

The evaluation of the Helkimo index revealed that9 patients had no clinical dysfunction (D0), 8 hadlight clinical dysfunction (DI), and 2 had moderatelinical dysfunction (DII). Of the 8 patients with slightlinical dysfunction, 2 achieved 2 points and 6 pa-ients achieved 1 point (range DI 1 to 4 points). Thevaluation of the MFIQ revealed that 19 patients ex-erienced no functional limitation (grade 0), 5 hadlight functional impairment (grade I), 5 had moder-te functional limitation (grade II), and none hadevere functional limitations (grade III).

Intraoperative imaging was performed after openeduction and internal fixation on 34 patients, usinghe Acardis Orbic 3D C-arm (Siemens Medical Solu-ions) under sterile conditions. Because of the resultsf the intraoperative 3-dimensional imaging, a revi-ion was performed in 4 patients (11.8%). The post-perative repositioning results were classified accord-

ng to Mokros and Erle.11 One moderate repositionesult was evident. This was a lateral-anterior length-ning of the head of the bone, with postoperativengular displacement of 30°. The postoperative ramushortening was more than 10 mm. One patient hadatisfactory repositioning results, with an anterior an-ular displacement 42° and ramus shortening of 10m, postoperatively. However, the results using the

lassification system of Mokros and Erle11 did notorrelate with our collected clinical results. The mea-uring technique must be criticized as being prone toisinterpretation owing to the range differences in

he results produced from the x-ray images. In total,6 of the 29 patients were satisfied with the operatingesults and 3 were unsatisfied. The scar length was anverage of 17.05 mm (range, 10 to 25).

iscussion

The various types of surgical approaches to treathe condylar process of the lower jaw are all associ-ted with specific advantages and disadvantages. Theroad spectrum of approaches and the very different

urgical techniques make a comparison of the opera-

tfiiapr

ittgtdtwmtfoccfot

acdswlnataeaetspDnspnofpnpbtdmp

etrdratadtOutt1Rapttpdoap

apan6dswps

weabsftpspsoiatpas

616 TREATMENT OF CONDYLAR PROCESS FRACTURES USING TRANSPAROTID APPROACH

ional techniques for joint process fractures very dif-cult. For treatment of type II to IV fractures accord-

ng to Spiessl and Schroll,8 the most commonly usedpproaches are the submandibular (or Risdon) access,eriangular access, or the retromandibular/transpa-otid approaches.

Submandibular access is obtained by the surgeonnserting 2 fingers laterally under the lower jaw,hrough a 4 to 5-cm incision. Next, a large amount ofissue must be moved and the masseter muscle andlandula parotis prepared. Periangular access is ob-ained by incising the first skin flap below the man-ibular angle.15 Access through the retromandibular/ransparotid is obtained 0.5 cm below the ear lobeith direct preparation through the parotid gland andasseter muscle on the fracture gap.16 All of these

echniques have the aim of treating the same type ofracture. The differences in each technique make anbjective comparison of the complications difficult. Be-ause of the direct access to the fracture, good visualontact with the fracture, easy identification of theacial nerve within the parotid gland, and the shortperative time made possible by the direct access, theransparotid approach is our preferred method.

When considering the complications that can occurfter surgical treatment of fractures of the condylar pro-ess, only very small variations with respect to the inci-ence of complications have been found. In 1996, Cho-segros and Cheynet17 examined 19 patients, all ofhom had undergone surgery with the retromandibu-

ar approach, for a 6-month period. The study foundo patient with permanent atony of the facial nerve,lthough 1% experienced temporary atony; 11% ofhe patients had a permanent occlusion disorder, 5%wound infection, 11% a temporary preauricular hyp-sthesia, and 5% extended scarring. A study by Ellisnd McFadden18 examined the complications afterxtraoral osteosyntheses of the condylar process frac-ures. They examined 93 patients who had undergoneurgery using the retromandibular approach and 85atients who had received conservative treatment.uring the 93 operations, contact with the facialerve was reported in 63. In no case was the nerveevered. At 6 weeks postoperatively, 17.2% of theatients still showed atony in the region of the facialerve. After 6 months, no patient reported facial at-ny. Manisali and Amin1 treated a condylar processracture using the retromandibular access route in 20atients. Intraoperatively, they visualized the facialerve in 30% of the cases. Postoperatively, 30% of theatients reported temporary atony of the facial nerve,ut none had permanent atony. Also, 10% reportedemporary atony of the major auricular nerve, and 5%eveloped a salivary fistula, although the develop-ent stopped spontaneously. Devlin and Hislop19 re-

orted on 40 patients, from 1991 to 1999, who were c

xamined at 3 weeks, 6 weeks, and 3 months afterreatment. All the patients had been treated using aetromandibular approach; 7.5% of the patients hadeveloped facial atony, 5% had poor repositioningesults, and 5% had hypertrophic scarring. Vesnavernd Gorjanc20 treated 34 patients with 36 fractures ofhe condylar process. All patients were treated usingtransparotid facelift approach or extraoral retroman-ibular access. In their study group, 22% of the pa-ients reported facial atony (duration 4 to 8 weeks).ne patient reported slight atony of the lower andpper lip at 13 months postoperatively. Also, 14% ofhe patients developed a fracture of the osteosyn-hetic plate (each with a 1.7 miniplate or smaller), and4% developed a salivary fistula. A study by Vogt andoser21 reported on the possible advantages and dis-dvantages of extraoral treatment. They examined 48atients with 42 fractures of the condylar processype II�IV according to Spiessl and Schroll. All pa-ients underwent surgery using the transparotidal ap-roach. The following complications developed: 7.8%eveloped a self-limiting salivary fistula, 19.6% devel-ped temporary facial atony, 0% permanent facialtony, 0% temporary occlusion disorder, and 6% (3atients) a fracture of the osteosynthetic plate.Our patients, who were treated using the transparotid

pproach, had an overall low complication rate. Of ouratients, 10% had temporary atony of the facial nerve,nd no patient developed permanent atony of the facialerve. Five patients (16%) still had an occlusion disordermonths postoperatively (2 had had polytrauma and 1 aouble collum fracture). The 5 patients (16%) with per-istent preauricular sensibility disorder were patientsho had experienced polytrauma or a double jointrocess fracture. Finally, 4% of our patients developed aelf-limiting salivary fistula.

Apart from the different complications associatedith the different extraoral approaches, whether op-

rative treatment of fractures of the condylar processchieves better results than conservative therapy haseen discussed. Yang and Chen22 compared the re-ults after conservative and operative therapy for thisracture entity. The preoperative comparison showedhat patients who were treated using extraoral ap-roaches had far greater dislocation in the frontal andagittal levels and ramus shortening compared withatients treated conservatively. The results of theirtudy showed that the patients who had receivedperative treatment, regardless of the severity of the

nitial diagnosis, achieved the same level of functions those who had been treated conservatively. A mul-icenter study by Eckelt and Schneider23 examined 66atients with 79 condylar process fractures 6 weeksnd 6 months after the initial fracture. The final resultshowed that both treatment methods produced ac-

eptable results. However, Eckelt and Schneider23

fmw

fYwtcod2Tocceta

cHoeoiatfitioo

doamsht

R

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

KLATT ET AL 617

ound operative treatment, regardless of the operativeethod applied, to be in the ascendency comparedith conservative treatment.Examination of intraorally treated condylar process

ractures has shown a wide range of results. Lee andoung24 examined 40 patients, from 1995 to 1999,ho were treated transorally, with endoscopic assis-

ance. Lee and Young24 found intraoral treatment ofondylar process fractures to be a valid therapeuticption. A study by Jensen and Jensen25 came to aifferent conclusion. They examined 15 patients with4 condylar process fractures for a 23-month period.hey concluded that endoscopic intraoral treatmentf joint process fractures was technically a very diffi-ult procedure and associated with a high rate ofomplications. The main disadvantage of the intraoralndoscopically assisted treatment was the long dura-ion of the operation.3,26 Lee et al3 reported an aver-ge operative duration of 143 � 63 minutes.

The overview of complications reported duringlinical follow-up at the University Medical Centeramburg-Eppendorf showed similar results to thosef the previously cited studies. Most had good toxcellent reposition results, coupled with low levelsf patient problems. The analysis of the Helkimo

ndex confirmed the low level of clinical dysfunctionfter extraoral treatment of condylar process frac-ures. The analysis of the patients’ MFIQ also con-rmed the results. Additional studies that have usedhe Helkimo index and MFIQ to collect data on clin-cal dysfunction showed that the operative treatmentf joint process fractures of the jaw leads to low levelsf dysfunction.23,27-30

Open reduction and rigid internal fixation of the con-ylar process using the transparotid approach is a rec-mmended procedure for Class II fractures, as classifiedccording to Spiessl and Schroll.8 With the advantages ofinimal tissue alteration and rare complications and

ufficient exposure of the fracture site, this techniqueas been proved to be a valid surgical alternative for thereatment of condylar process fractures.

eferences1. Manisali M, Amin M: Retromandibular approach to the mandib-

ular condyle: A clinical and cadaveric study. Int J Oral Maxillo-fac Surg 32:253, 2003

2. Lachner J, Clanton JT, Waite PD: Open reduction and internalrigid fixation of subcondylar fractures via an intraoral ap-proach. Oral Surg Oral Med Oral Pathol 71:257, 1991

3. Lee C, Lee K, Mathes SJ: Endoscopic subcondylar fracturerepair: Functional, aesthetic and radiographic outcomes. PlastReconstr Surg 102:1434, 1998

4. Schmelzeisen R, Lauer G, Wichmann U: Endoskop-gestütztefixation von Gelenkfortsatzfrakturen des Unterkiefers. MundKiefer Gesichtschirurgie 2:168, 1998

5. Ivy RH: Post-auricular approach to mandibular condyle. PlastReconstr Surg 46:390, 1970

6. Zide MF, Kent JN: Indications for open reduction of mandibularcondyle fractures. J Oral Maxillofac Surg 41:89, 1983

7. Ellis E, Zide MF: Surgical Approaches to the Facial Skeleton:Retromandibular Approach. Baltimore, Williams & Wilkins, 1995,p 139

8. Spiessl B, Schroll K: Gesichtsschädel: Gelenkfortsatz und Ge-lenkköpfchenfrakturen. Stuttgart, Georg Thieme Verlag, 1972,pp 58-99, 136-152

9. Eckelt U: Clinical, radiographic and axiographic control aftertraction-screw osteosynthesis of fractures of the mandibularcondyle region. Rev Stomatol Chir Maxillifac 96:158, 1995

0. Härle F, Champy M, Terry B: Atlas of Craniomaxillofacial Os-teosynthesis. Stuttgart, Georg Thieme Verlag, 2000

1. Mokros S, Erle A: Die transorale Miniplattenosteosynthese vonGelenkfortsatzfrakturen-Optimierung der operativen methode.Fortschr Kiefer Gesichts Chir 41:136, 1996

2. Stegenga B, de Bont LG: Assessment of mandibular functionimpairment associated with temporomandibular joint osteoar-throsis and internal derangement. J Orofac Pain 7:183, 1993

3. Kropmans TJ, Dijkstra PU: The smallest detectable differenceof mandibular function impairment in patients with a painfullyrestricted temporomandibular joint. J Dent Res 78:1445, 1999

4. Helkimo M: Studies on function and dysfunction of the masti-catory system. II. Index for anamnestic and clinical dysfunctionand occlusal state. Sven Tandlak Tidskr 67:101, 1974

5. Eckelt U: Zugschraubenosteosynthese bei Unterkiefergelenkfort-satzfrakturen. Dtsch Z Mund Kiefer Gesichts Chir 15:51, 1991

6. Ellis E, Dean J: Rigid fixation of mandibular condyle fractures.Oral Surg Oral Med Oral Pathol 76:6, 1993

7. Chossegros C, Cheynet F: Clinical results of therapeutic tem-poromandibular joint arthroscopy: A prospective study of 34arthroscopies with prediscal section and retrodiscal coagula-tion. Br J Oral Maxillofac Surg 34:504, 1996

8. Ellis E, McFadden D: Surgical complications with open treat-ment of mandibular condylar process fractures. J Oral Maxillo-fac Surg 58:950, 2000

9. Devlin MF, Hislop WS: Open reduction and internal fixation offractured mandibular condyles by a retromandibular approach:Surgical morbidity and informed consent. Br J Oral MaxillofacSurg 40:23, 2002

0. Vesnaver A, Gorjanc M: The periauricular transparotid ap-proach for open reduction and internal fixation of condylarfractures. J Cranio-Maxillofacial Surg 33:169, 2005

1. Vogt A, Roser M: Transparotid approach to surgical manage-ment of condylar neck fractures: A prospective study. MundKiefer Gesichtschirurgie 9:246, 2005

2. Yang WG, Chen CT: Functional results of unilateral mandibularcondylar process fractures after open and closed treatment.J Trauma 52:498, 2002

3. Eckelt U, Schneider M: Open versus closed treatment of fracturesof the mandibular condylar process—A prospective randomizedmulti-centre study. J Cranio-Maxillofacial Surg 34:306, 2006

4. Lee C, Young DM: Cranial nerve VII region of the traumatizedfacial skeleton: Optimizing fracture repair with the endoscope.J Trauma 48:423, 2000

5. Jensen T, Jensen J: Open reduction and rigid internal fixation ofmandibular condylar fractures by an intraoral approach: Along-term follow-up study of 15 patients. J Oral Maxillofac Surg64:1771, 2006

6. Lauer G, Schmelzeisen R: Endoscope-assisted fixation of mandib-ular condylar process fractures. J Oral Maxillofac Surg 57:36, 1999

7. Härtel J, Mielke C: Klinische Funktionsanalyse nach der Behan-dlung von Gelenkfortsatzfrakturen des Unterkiefer. Dtsch ZMund Kiefer Gesichts Chir 2994:224, 1994

8. Eulert S: Die Behandlung von Gelenkfortsatzfrakturen des Un-terkiefer unter besonderer Berücksichtigung der WürzburgerZugschrauben-Platte. Würzburg, Germany, Julius-Maximilians-University Würzburg, 2002

9. Rutges JP, Rosenberg A, Koole R: Functional results after con-servative treatment of fractures of the mandibular condyle. Br JOral Maxillofac Surg 45:30, 2007

0. Schneider M, Lauer G: Surgical treatment of fractures of themandibular condyle: A comparison of long-term results follow-ing different approaches—Functional, axiographical, and ra-

diological findings. J Cranio-Maxillofacial Surg 35:151, 2007