the treatment of subcondylar fractures can be divided into two major treatment methods : closed treatment or closed reduction ( cr ) and open reduction and internal fixation ( orif ) . cr requires a period of maxillomandibular fixation ( mmf ) , followed by active physiotherapy . this study compares the clinical and radiological outcomes after cr and orif management of subcondylar fractures . forty - eight patients presenting with subcondylar fracture between january 2010 and march 2013 at the department of oral and maxillofacial surgery , gachon university gil medical center were included in this retrospective study . fifteen patients ( 14 males and 1 female ) with an age range of 6 to 52 years ( mean , 42 years ) were treated with cr , and 33 patients ( 28 males and 5 females ) with an age range of 17 to 62 years ( mean , 34 years ) underwent an orif operation . patients with cr were followed - up for an average of 10.7 months ( range , 3 to 36 months ) . those with orif were followed - up for an average of 3.8 months ( range , 3 to 24 months ) . all patients included in this study had more than three months of follow - up . a telephone survey was performed for the 6 cr patients who did not visit the clinic for three months after the first visit . chart review was performed , and occlusion , maximal mouth opening , deviation on mouth opening , and nerve injury were evaluated . radiologic assessment was also performed to evaluate the tangential angulation of the displaced fragment and loss of ramus height , as described in palmieri et al.3 . the amount of condyle fragment displacement ( tangential angulation and loss of ramus height ) was evaluated on panoramic radiographs at the first visit and three months later.(figs . 1 , 2 ) the data were analyzed using ibm spss statistics for windows , version 19.0 ( ibm co. , armonk , ny , usa ) . in the cr group , 2 condylar fragments were displaced medially , 7 laterally , and 6 were non - displaced . in the orif group , 2 condylar fragments were displaced medially , 24 laterally , and 7 were non - displaced . the average period of mmf was 5.47 days in the cr group and 6.33 days in the orif group . associated mandibular fractures occurred in 68.75% of cases , especially symphysis fractures ( 64.58% ) . twelve patients ( 11 symphysis , 1 body ) from the cr group and 21 patients ( 20 symphysis , 1 body ) from the orif group had concomitant mandibular fractures . all concomitant fractures were treated with orif.(table 1 ) in the cr group , the average loss of ramus height was 2.442.18 mm , and tangential angulation was 3.672.53 at the first visit . three months after cr , the average loss of ramus height was 1.990.99 mm , and tangential angulation was 2.352.23. the difference between the first visit and the three - month follow - up was 1.251.61 mm in loss of ramus height and 0.321.56 in tangential angulation . in the orif group , the average loss of ramus height was 3.612.33 mm , and tangential angulation was 8.665.12 at the first visit . three months after orif , the average loss of ramus height was 1.011.19 mm , and tangential angulation was 1.740.89. the difference between the first visit and three - month follow - up was 2.602.02 mm in loss of ramus height and 6.924.86 in tangential angulation . there was a statistically significant difference between the maxigroups in the loss of ramus height ( p=0.008 ) and tangential angulation ( p=0.000).(tables 2 , 3 ) there was also a statistically significant difference between the groups in preoperative tangential angulation ( p=0.002).(table 3 ) the clinical parameters were observed three months after treatment or by telephone survey . the mouth opening of all patients was greater than 40 mm . however , 6 of 15 patients ( 40% ) in the cr group showed deviation on mouth opening . similarly , 11 of 33 patients ( 33% ) in the orif group showed deviation on mouth opening.(table 4 ) in the cr group , 2 condylar fragments were displaced medially , 7 laterally , and 6 were non - displaced . in the orif group , 2 condylar fragments were displaced medially , 24 laterally , and 7 were non - displaced . the average period of mmf was 5.47 days in the cr group and 6.33 days in the orif group . associated mandibular fractures occurred in 68.75% of cases , especially symphysis fractures ( 64.58% ) . twelve patients ( 11 symphysis , 1 body ) from the cr group and 21 patients ( 20 symphysis , 1 body ) from the orif group had concomitant mandibular fractures . in the cr group , the average loss of ramus height was 2.442.18 mm , and tangential angulation was 3.672.53 at the first visit . three months after cr , the average loss of ramus height was 1.990.99 mm , and tangential angulation was 2.352.23. the difference between the first visit and the three - month follow - up was 1.251.61 mm in loss of ramus height and 0.321.56 in tangential angulation . in the orif group , the average loss of ramus height was 3.612.33 mm , and tangential angulation was 8.665.12 at the first visit . three months after orif , the average loss of ramus height was 1.011.19 mm , and tangential angulation was 1.740.89. the difference between the first visit and three - month follow - up was 2.602.02 mm in loss of ramus height and 6.924.86 in tangential angulation . there was a statistically significant difference between the maxigroups in the loss of ramus height ( p=0.008 ) and tangential angulation ( p=0.000).(tables 2 , 3 ) there was also a statistically significant difference between the groups in preoperative tangential angulation ( p=0.002).(table 3 ) the clinical parameters were observed three months after treatment or by telephone survey . neither group had any patients with post - treatment malocclusion or permanent nerve injury . the mouth opening of all patients was greater than 40 mm . however , 6 of 15 patients ( 40% ) in the cr group showed deviation on mouth opening . similarly , 11 of 33 patients ( 33% ) in the orif group showed deviation on mouth opening.(table 4 ) despite a plethora of treatment guidelines , management of subcondylar fracture of the mandible remains controversial . during the past few decades , cr has been the preferred treatment4 ; however , closed treatment requires a period of mmf , followed by active physiotherapy5 . also , long - term complications such as pain , arthritis , open bite , deviation of the mandible on opening , inadequate restoration of vertical height of the ramus leading to malocclusion , and ankylosis can result from the cr method6 . however , we found no significant differences between groups in the average period of mmf ( 5.47 days in cr group and 6.33 days in orif group ) and no serious complications . there is consensus that correct anatomical repositioning of the mandibular condyle process is an important prerequisite for reestablishing function8 . in cases of severe displacement or dislocation , surgical management is preferred6,9 . in our study , all treatment methods were decided by the treating surgeons . in our clinics , doctors tend to provide cr for patients with less displaced fractures and orif to those with more displaced fractures . the preoperative tangential angulation in the cr group ( 3.672.53 ) was significantly less ( p=0.002 ) than that in orif group ( 8.665.12 ) . however , the difference between the groups in preoperative loss of ramus height was not significant . palmieri et al.3 reported that open reduction might produce functional benefits for patients with severely dislocated condylar process fractures , and undt et al.7 reported that orif allows appropriate anatomical repositioning and immediate functional movement of the mandible . similarly , in our study , the difference between preoperative and postoperative loss of ramus height in the orif group ( 2.602.02 mm ) was statistically greater than that in the cr group ( 1.251.61 mm ; p=0.008 ) . the difference between preoperative and postoperative tangential angulation in the orif group ( 6.924.86 ) was statistically greater than that in the cr group ( 0.321.56 ; p=0.000 ) . haug and assael10 showed no differences for maximum interincisal opening , deviation on opening , and occlusion between closed and open management groups after treatment . likewise , we found no clinical differences , such as occlusion or interincisal mouth opening , between the cr and orif groups . however , 6 patients ( 40% ) in the cr group and 11 patients ( 33% ) in the orif group showed deviation on maximal opening of the lower jaw three months after treatment . future research should compare the outcomes of many more cases with long - term follow - up . in conclusion , cr had clinically satisfactory results , although orif produced more accurate reduction of fractured fragments . in the absence of distinct displacement of a fractured fragment , therefore , cr should be selected over orif to prevent the need for an operation .
objectivesto compare the clinical and radiological outcomes after closed reduction ( cr ) and open reduction and internal fixation ( orif ) in the management of subcondylar fractures.materials and methodsforty - eight patients presenting with subcondylar fracture between january 2010 and march 2013 were evaluated retrospectively . 
 fifteen patients were treated with cr and 33 patients with orif . 
 the clinical and radiologic parameters were evaluated during follow - up ( mean , 7.06 months ; range , 3 to 36 months).resultsin the cr group , no patients had any problems with regard to the clinical parameters . 
 the average period of maxillomandibular fixation ( mmf ) was 5.47 days . 
 the preoperative average tangential angulation of the fractured fragment was 3.67 , and loss of ramus height was 2.44 mm . in the orif group , no clinical problems were observed , and the average period of mmf was 6.33 days . 
 the preoperative average tangential angulation of the subcondylar fragment was 8.66 , and loss of ramus height was 3.61 mm.conclusioncr provided satisfactory clinical results , though orif provided more accurate reduction of the fractured fragment . 
 so there is no distinct displacement of fractured fragment , cr should be selected than orif because of no need for surgery .