a 34-year - old male patient reported with a history of road traffic accident under the influence of alcohol . the chief complaint was restricted mouth opening , tenderness over temporomandibular joint , fractured upper central incisors , and intraoral swelling in submental region with extraoral laceration . the patient had no history of loss of consciousness , vomiting , seizure , convulsion , and ent bleeding after trauma . on extraoral examination , laceration was seen on the lower lip and submental region and abrasion was seen on the tip of the nose and lateral border of the left eye and forehead . the extraocular muscle movements were normal and pupils were equally reacting to light which had a positive response . complete examination of the body was done for any injuries and there were no positive findings . on intraoral examination , the following were observed : anterior open bite , restricted mouth opening ( 20 mm ) , tenderness while opening mouth over temporomandibular joint on both sides , condylar movement palpable on both sides , fractured maxillary incisor , swelling in the sublingual region , and root stumps in the posteriors . the patient was advised for computed tomography scan , orthopantomogram ( opg ) , and chest x - ray [ figure 1 ] . on radiological examination , opg revealed extracapsular bilateral high condyle fracture with lateral displacement , dentoalveolar fracture in the lower anterior region , and maxillary central incisor . under the guidance of the general medicine department , preoperative computed tomography scan the patient was informed and explained about the findings in the radiological examination and consequences if the fracture was not treated at the earliest . the patient was convinced for the full treatment of open reduction and internal fixation under general anesthesia and consent was taken . before using the risdon arch bar wiring , the patient was advised for blood investigation , the result was normal , and hiv and hbsag were negative . to treat dentoalveolar after extra- and intra - oral painting with povidone  iodine solution , preauricular incision was planned and surface marking was done using sterile toluidine blue on the right side . about 2% of xylocaine with adrenaline was infiltrated into the preauricular region , incision and dissection were made layer wise , and as exposing the fracture site , encountered vessels and nerve were identified and ligated . the fracture site was exposed , but there was difficulty in accessibility for reduction and fixation [ figure 2 ] . hence , in addition , retromandibular approach was planned and executed [ figure 3 ] . unlike the first approach , the fracture site was exposed and reduction was done . considering the difficulties encountered for the right condyle reduction , retromandibular approach was planned for the left condylar fracture [ figure 4 ] and executed by the same procedure . after the reduction of bilateral condyle , the occlusion was checked and using tie wires , intermaxillary fixation was done . preauricular approach ( right ) retromandibular approach ( right ) retromandibular approach ( left ) fixation was done using conventional mini plates and screws made of stainless steel on both sides , respectively : 
 on the right condyle : 2 mm  4 hole miniplate with gap and 2 mm  2 hole miniplate with gap were placed and secured with 2 mm  6 mm screws [ figure 5]on the left condyle : 2 mm  4 hole miniplate with gap was palced and secured with 2 mm  6 mm screws [ figure 6 ] . 
  on the right condyle : 2 mm  4 hole miniplate with gap and 2 mm  2 hole miniplate with gap were placed and secured with 2 mm  6 mm screws [ figure 5 ] on the left condyle : 2 mm  4 hole miniplate with gap was palced and secured with 2 mm  6 mm screws [ figure 6 ] . meticulous wound closure was done in layers using 30 vicryl and 30 ethilon suture on the right preauricular incision and the right and left retromandibular incision . beta - iodine was the ointment applied over the incised region and dressing was done with compression bandage on either side . postoperative instruction and medication were given and the patient was under observation for the next 3 days after surgery . postoperative x - ray was advised after 2 days [ figure 7 ] and checked for occlusion . to treat dentoalveolar fracture and stabilization , risdon arch bar wiring under local anesthesia is done . after extra- and intra - oral painting with povidone  iodine solution , preauricular incision was planned and surface marking was done using sterile toluidine blue on the right side . about 2% of xylocaine with adrenaline was infiltrated into the preauricular region , incision and dissection were made layer wise , and as exposing the fracture site , encountered vessels and nerve were identified and ligated . the fracture site was exposed , but there was difficulty in accessibility for reduction and fixation [ figure 2 ] . hence , in addition , retromandibular approach was planned and executed [ figure 3 ] . unlike the first approach , the fracture site was exposed and reduction was done . considering the difficulties encountered for the right condyle reduction , retromandibular approach was planned for the left condylar fracture [ figure 4 ] and executed by the same procedure . after the reduction of bilateral condyle , the occlusion was checked and using tie wires , intermaxillary fixation was done . preauricular approach ( right ) retromandibular approach ( right ) retromandibular approach ( left ) fixation was done using conventional mini plates and screws made of stainless steel on both sides , respectively : 
 on the right condyle : 2 mm  4 hole miniplate with gap and 2 mm  2 hole miniplate with gap were placed and secured with 2 mm  6 mm screws [ figure 5]on the left condyle : 2 mm  4 hole miniplate with gap was palced and secured with 2 mm  6 mm screws [ figure 6 ] . 
  on the right condyle : 2 mm  4 hole miniplate with gap and 2 mm  2 hole miniplate with gap were placed and secured with 2 mm  6 mm screws [ figure 5 ] on the left condyle : 2 mm  4 hole miniplate with gap was palced and secured with 2 mm  6 mm screws [ figure 6 ] . the occlusion was checked again and intermaxillary fixation wires were released . meticulous wound closure was done in layers using 30 vicryl and 30 ethilon suture on the right preauricular incision and the right and left retromandibular incision . beta - iodine was the ointment applied over the incised region and dressing was done with compression bandage on either side . postoperative instruction and medication were given and the patient was under observation for the next 3 days after surgery . postoperative x - ray was advised after 2 days [ figure 7 ] and checked for occlusion . on postoperative examination ; intraorally , the occlusion was maintained and extraorally , there was mild pain and difficulty during wrinkling of forehead , closure of eye , blowing of air , and whistling on the right side , which eventually recovered in 3 weeks ; whereas the left side of the face was normal and radiological  there was a complete reduction , fixation , continuity of the bony contour was maintained , and condyle on both sides was in a proper position . there is controversy when it comes to treatment plan , either surgical ( open reduction internal fixation ) or functional ( closed reduction ) treatment . after many studies , it was given that fractures occurring in childhood can be treated with nonsurgical method to exploit the capability of the growing skeleton whereas in adult patients , surgical treatment depends on the type of fracture ( displaced / dislocated ) . depending on the height and position of the fractured segment , there are various approaches to the condylar process , but the only criteria for selection of the approach is done with the distance between the incision and the level of fracture . the preauricular approach was initially given by risdon ( 1934 ) and after that various modifications were proposed . the present modification widely followed is the modification made by rowe ( 1972 ) and al - kayat and bramley . in preauricular approach , the layers and structures encountered are skin , superficial fascia , deep fascia , parotid gland , facial nerve trunk and branches , superficial temporal vessels , auricular temporal nerve , transverse facial artery , periosteum , and condylar head and neck . the advantages includes visualization and alignment of high condylar and anteromedially displaced fractures whereas the disadvantages are scar formation , loss of sensation , frey 's syndrome , etc . the retromandibular approach was initially given by hinds and girroti ( 1967 ) and modified by koberg and momma ( 1978 ) . in retromandibular approach , the layers and structures encountered are skin , superficial fascia , buccal and marginal mandibular branch of facial nerve , parotid gland , masseter muscle , pterygomasseteric sling , retromandibular vein , external carotid artery , periosteum , posterior border of ramus , subcondyle and condylar neck , and the body of mandible . the advantages include exposure of entire ramus , distance from skin incision to the fractured site is less with minimal invasion , good access , and visualization . . the disadvantage would be its reduced accessibility to the medial displacement of fractured segment and damage to retromandibular vein . there are limitations to each approach . in this particular case , though there was an adequate access and visibility to the fracture to retrieve , reduction and fixation were difficult through preauricular approach on the right side . therefore , retromandibular approach was planned since the entire ramus can be approached easily for reduction and fixation of fracture . combination of preauricular and retromandibular approaches can be done for easy accessibility , reduction , and fixation . on the other side , wiring , stainless steel and titanium mini plates and screws were used , and the recent method would be the three - dimensional plates and screws . the result of mouth opening and mandibular movement in both the approaches is the same except clicking and mild pain are present in preauricular approach . apart from several surgical approaches to laterally displaced condylar fracture , the reliable one for open reduction is retromandibular approach . there are several studies that have been done with the combination of al - kayatbramley incision and retromandibular incision for easy reduction and fixation . depending on the difficulties encountered during the surgery and postoperative complication of this particular case , retromandibular approach was the better approach when compared to preauricular approach and as a combination , it provides a wide access for the fixation of upper segment of the fracture . hence , one can give preference to retromandibular approach over preauricular except in cases such as medial or anteromedially displaced or complete dislocation of the condylar segment .
fracture of mandible can be classified according to its anatomical location , in which condylar fracture is the most common one overall and is missed on clinical examination . due to the unique geometry of the mandible and temporomandibular joint , without treatment 
 the fractures can result in marked pain , dysfunction , and deformity . 
 the condylar fracture may be further classified depending on the sides involved : unilateral / bilateral , depending on the height of fracture : intracapsular ( within the head of condyle ) , extracapsular - head and neck ( high condyle fracture ) , and subcondylar ( low condyle fracture ) , and depending on displacement : nondisplaced , displaced ( anteromedially , medially , and lateral ) , and dislocated . 
 the clinical features include swelling and tenderness over the temporomandibular joint region , restricted mouth opening , and anterior open bite . a 34-year - old male patient reported to the department of oral and maxillofacial surgery at madha dental college and hospital ; suffered fall trauma resulting in bilateral condyle fracture , dentoalveolar fracture in mandible with restricted mouth opening , and anterior open bite .