The treatment of mandibular condyle fractures: A meta-analysis

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials

PURPOSE

Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.

RESULTS

The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).

CONCLUSIONS

This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Healthcare costs of different treatment options for condylar fractures

Objective

As treatment options for condylar fractures have comparable outcomes, getting insight into associated costs is a first step towards implementing value-based healthcare (VBH). Therefore, we described the actual costs of the different treatment options (surgical, conservative, and expectative treatment) for condylar fractures. We expected surgical treatment to be the most expensive treatment.

Study design

This is a cost-of-illness study, based on estimates from the literature. Firstly, care pathways of all treatment options were described. Secondly, the costs per step were calculated based on the literature and Dutch guidelines for economic evaluations in health care.

Results

The direct treatment costs of surgical treatment (€3721 to €4040) are three to five times higher than conservative treatment (€730 to €1332). When lost productivity costs during the recovery period are included, costs of surgical treatment remain 1.5 times higher (€9511 to €9830 for surgical treatment and €6224 to €6826 for conservative treatment). The costs of expectative treatment (€5436) are lower than both other treatments.

Conclusion

The costs for surgical treatment are considerably higher than those for conservative or expectative treatment, mainly related to direct treatment cost. Future research should focus on the patients' perspective, to support implementation of VBH in treating condylar fractures.

Innsbruck-style Retromandibular Anterior Trans-parotid Approach for Condylar Fractures: A Retrospective Review of 39 Fractures

The retromandibular anterior trans-parotid (RAT) approach and a triangular-positioned double mini-plate osteosynthesis (TDO) technique have been reported from Innsbruck Medical University. This minimally invasive technique involves direct visualization of the condyle and is associated with lower incidence of facial palsy.

Methods

A retrospective review was performed on the RAT approach and TDO technique conducted by a surgeon and team at two hospitals in Tokyo during a period of 3 years and 10 months.

Results

This technique was performed on 35 patients with 39 condylar fractures. Sixty-nine percent of cases were due to accidental fall, 17% to traffic accidents, and 9% to sports. Furthermore, 92% cases were condylar base fractures. Nighty-seven percent of cases achieved good occlusion. The mean maximum mouth opening was 49 ± 1.3 mm. Postoperatively, facial palsy developed in three patients (7.7%), and two of them developed Frey syndrome at approximately 2.5 years postoperatively (5.1%). All patients completely recovered within 3 months postoperatively. One case each of salivary fistula, visible scar, and condylar resorption was found (2.6%). No case of massive bleeding during surgery, hematoma, or TMJ pain after surgery was found.

Conclusion

This technique could achieve good occlusion with low incidence of complications and could contribute to early social reintegration among patients.

Postoperative Complications following Open Reduction and Rigid Internal Fixation of Mandibular Condylar Fracture Using the High Perimandibular Approach

The high perimandibular approach is a feasible surgical technique for treating mandibular condylar fractures with open reduction and internal fixation, followed by fewer complications. Temporary trismus is the only postoperative complication that may occur. This study evaluated postoperative complications following open reduction and rigid internal fixation (OR-IF) of mandibular condylar fractures using the high perimandibular approach. Twenty consecutive patients undergoing OR-IF were included in this study. They included 11 male and 9 female patients, of an average age of 58.5 years, all of whom responded to a follow-up call at least 12 months after the surgery. All patients were evaluated for range of mouth opening, postoperative complications, and radiological findings. A statistical analysis of the relationship between range of mouth opening and related clinical parameters at 6 months postoperative evaluation was conducted. The fracture of the condylar neck was associated with a limited range of mouth opening and longer operation time. However, longer operation time was not associated with a limited range of mouth opening. The high perimandibular approach with OR-IF in mandibular condylar fractures is a feasible and safe technique; however, prolonged surgery and mandibular condylar neck fractures could affect the postoperative range of mouth opening.

How should clinicians assess acute dental pain?: A review

Pain is the most common complaint in the dental field and may have a significant impact on the patients' quality of life. However, objective pain assessment is sometimes difficult, and medical and dental clinicians may encounter cases of pain in the head and neck region, making it difficult to establish differential diagnoses. This study aimed to review acute pain in clinical dentistry at each phase of dental procedures and discuss the current status and issues in the development of acute dental pain assessment methods in the future. Acute pain in clinical dentistry may differ in nature and modifying conditions of pain at each stage: before dental procedures, while visiting dentists, and during and after dental procedures. They are related to actual or potential tissue damage, and may be modified and aided by personal experiences, including psychological and social factors. With respect to the aging and multinational population and pandemic of infectious diseases, significant breakthroughs in the development of new pain scales without verbal descriptions are desirable. Furthermore, it is expected that a new pain scale that can be applied to acute pain in the head and neck regions, including the oral cavity, will be developed.

How far we have come with the Management of Condylar Fractures? A Meta-Analysis of Closed Versus Open Versus Endoscopic Management

Background

The treatment approaches for condylar fractures of the mandible include functional, closed reduction and open reduction-internal fixation. Recently endoscopic management of condylar fractures has been emphasized in the literature. We systematically review the studies comparing closed versus open versus endoscopic-assisted condyle fracture management with regard to the indications, effectiveness and complications of each modality.

Methods

A total of 11 articles were selected based on the inclusion and exclusion criteria from PubMed, Cochrane and clinical trials.gov. Differences in means and risk ratios were used as principal summary measures with p value < 0.05 as significant. For detection of any possible biases in sample sizes, the OR and its 95% CI for each study were plotted against the number of participants. Chi-square test, I2 test and the Cochrane bias tool were used to assess the bias in and across studies.

Results

Except for deviation on opening there was no significant difference between open versus closed treatment of condylar fractures. Endoscopic approach and open surgical approaches differed only in terms of operating time and TMJ pain. There was no significant difference in facial nerve injury among the two groups.

Discussion

Closed reduction is particularly indicated for minimally displaced fractures; for moderate to severe displacement, open reduction is preferred. Open reduction can also be preferred over endoscopic approaches as there is no significant advantage of using latter. Limitations of the study included specific treatment according to the site of fracture not addressed, limited data regarding pediatric condylar fracture, lack of homogenous classification schemes, etc.

Long-term Complications of Isolated and Combined Condylar Fractures: A Retrospective Study

Study Design

Fractures of the mandibular condyle are a common injury in maxillofacial trauma. Both conservative treatment (i.e., analgesic therapy and soft diet) and intermaxillary fixation (IMF) or open reduction internal fixation (ORIF) have satisfactory and functional outcomes, though severe late-onset complications have been reported.

Objective

We compared the long-term complications of patients with condylar fractures treated conservatively, with IMF, or with combined ORIF and IMF.

Methods

We retrospectively analyzed all patients diagnosed with unilateral or bilateral condylar fracture, isolated or combined with a fracture of the mandibular body, admitted to the Department of Maxillofacial Surgery at UZ Leuven between January 2013 and January 2020. We collected data on age, gender, side of condylar fracture, presence of associated fracture of the mandibular body, referrals, initial treatment, long-term complications and secondary treatment. Long-term complications were defined as sequelae still present 6 weeks after initial treatment.

Results

Among 192 patients, 68.8% had unilateral and 31.2% bilateral condylar fractures; an associated fracture of the mandibular body was seen in 45.8%, 31% received conservative treatment, 51% IMF only, and 18% combined ORIF and IMF. Forty-eight percent of all patients suffered from 1 or more long-term complications, most frequently malocclusion (24%), reduced mouth opening (15.1%), nerve disturbances (13.5%), pain (8.9%), and facial asymmetry (2.6%). Surgery as a secondary treatment was necessary in 25% of all cases.

Conclusions

The presence of bilateral condylar fractures or associated fracture of the mandibular body is a risk factor for developing long-term complications. Most patients with long-term complications were initially treated with combined ORIF and IMF, but long-term complications after initial conservative or IMF treatment were treated with secondary surgery.

Complications of the Transmasseteric Anteroparotid Approach for Subcondylar Fractures: A Retrospective Study

Study Design

A retrospective analysis of patients with subcondylar fractures treated via a transmasseteric anteroparotid approach by the Oral and Maxillofacial Department at the University of Oklahoma.

Objective

The goal of this study was to evaluate complications, morbidity, and safety with the transmasseteric anteroparotid approach for treatment of subcondylar fractures, and compare it to other findings previously reported in the literature.

Methods

A retrospective study was conducted that consisted of 23 surgically treated patients in the past 2 years for subcondylar fractures. Only patients with pre-operative malocclusion and who underwent open reduction with internal fixation with the transmasseteric anteroparotid (TMAP) approach were included. Exclusion criteria included 1) patients treated with closed reduction 2) patients who failed the minimum of 1, 3, and 6-week post-operative visits. The examined parameters were the degree of mouth opening, occlusal relationship, facial nerve function, incidence of salivary fistula and results of imaging studies.

Results

20 of the surgically treated patients met the inclusion criteria. Two patients were excluded due to poor post-operative follow up and 1 was a revision of an attempted closed reduction by an outside surgeon that presented with pre-existing complications. There were no cases of temporary or permanent facial nerve paralysis reported. There were 3 salivary fistulas and 2 sialoceles, which were managed conservatively and resolved within 2 weeks, and 2 cases of inadequate post-surgical maximal incisal opening (<40 mm) were observed.

Conclusion

The transmasseteric anteroparotid approach is a safe approach for open reduction and internal fixation of low condylar neck and subcondylar fractures, and it has minimal complications.

A comparative evaluation of retromandibular versus Modified Risdon approach in surgical treatment of condylar fracture

The purpose of this study was aimed to compare the efficiency and safety of retromandibular versus modified Risdon approach using periangular incision for open reduction and internal fixation of low subcondylar mandibular fracture. Open reduction and internal fixation with different plating systems were utilized via retromandibular approach (group I) and via modified Risdon approach with periangular incision (group II). Twenty four (n= 24) condylar fractures in 21 adult patients were divided randomly into two equal groups (12 each) according to the cutaneous incision (approach) utilized. The evaluation score for scarring in group I it was excellent in 9 patients, good in 2 patients and acceptable in only one patient (Mean 2.4 ± SD 3.38). While in group II was excellent in 10 patients and good in 2 patients (Mean 2.4 ± SD 3.87) and the p value was 0.591. Symptoms of transient facial nerve weakness were noted in only 3 patients in group I with slight to moderate dysfunction (Mean 2 ± SD 3.21), while only one patient had facial nerve weakness in group II with House - Brackman score of 2 immediate postoperatively and this got resolved in 6 weeks (Mean 2 ± SD 4.04) and the p value was 0.00022. Within the limitations of the study it seems that a modified Risdon approach using periangular incision for reduction and fixation of low subcondylar fracture should be preferred whenever possible because it yields better outcomes.

Mandibular Subcondylar Fracture: Improved Functional Outcomes in Selected Patients with Open Treatment

BACKGROUND

Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures.

METHODS

Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded.

RESULTS

Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases.

CONCLUSION

For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Outcomes of the Nonendoscopic Transoral Approach to Subcondylar Mandible Fractures

PURPOSE

The transoral approach (TRA) to subcondylar fractures without any endoscopic or transbuccal assistance is not a common technique. The purpose of this study was to measure and compare the quality of open reduction and internal fixation (ORIF) between the TRA and the retromandibular approach (RMB), including types and frequencies of postoperative complications.

METHODS

In our retrospective cohort study, we enrolled a sample of patients with displaced subcondylar mandible fractures treated by ORIF. The predictor was the approach mode: TRA or RMB. In postoperative computed tomography (CT) data sets, we measured the angles of the condylar process in relation to references: 1) midline, 2) lateral ramus border, and 3) posterior ramus border. The primary outcome variable was the reduction outcome, which was calculated as the difference between the total of all angles of the operated side and the non-affected side. Secondary outcomes were postoperative complications extracted from patients' files. Other variables were age, gender, number of plates, operation time and a modified AO trauma score. In bivariate analysis, we compared the outcome between both groups.

RESULTS

Sixty-four patients were included in total, with TRA performed in 50%. Patients with TRA were younger (31 vs 41, P = .003), and the trauma score was lower (1.9 vs 3.3, P < .001). Reduction outcome remained comparable between both techniques (mean 3.7° for both, P = .92). Complication rates were similar, although facial nerve palsy was absent for TRA (0 vs 4, P = .039).

CONCLUSION

We suggest TRA for selected patients with displaced, single fragmented subcondylar fractures. Reduction outcome shows a comparable exactness to RMB, while TRA is safer for the facial nerve.

Choice of Screws for Fixation of Mandibular Condyle Fractures Guided by Anthropometric Data

Open reduction and internal fixation (ORIF) is becoming increasingly common in treatment of the condylar process, including mandible head fractures. This approach significantly improves the results in terms of anatomical reduction of bone fragments, and shortens the treatment time, allowing for early functional recovery. The success of ORIF is largely determined by the stability of the osteosynthesis. The stabilization effect depends on the screw type and length of the plate used, in addition to the diameter and length of the screws used. The aim of this study was to determine the largest possible screw length that can be used in ORIF of the mandibular condyle considering the variable bone thickness. A total of 500 condyles were examined using computer tomography (CT)-based 3D models in Caucasians. For all models, three measurements were made in the frontal projection in places typical for the stabilization of osteosynthesis plates in the fractures of the condylar process: the base, the top, and the sigmoid notch. In addition, one measurement of the mandible head was made in the place of the greatest width. The results showed that 8 mm screws should be used in the region of the condylar base as the longest anatomically justified screw, whereas in the area of a sigmoid notch only 1.5–2 mm screws should be used. Measurements in the area of the neck top revealed statistically significant differences in the measurements between the sex of patients, with average differences below 1 mm (p < 0.05). In this area, the maximal length of the screw was found to be 10 mm. In mandibular head fractures, the use of long screws is extremely important due to the desired effect of fragment compression. Statistically significant differences were found in the measurement results between women and men. The maximal screw length for bicortical fixation was found to be 22 mm in men and 20 mm in women. In post-traumatic patients, the ability to obtain a clear measurement is often limited by a deformed anatomy. Taking into account the fact that the fracture stability is influenced by both the plate length and the length of the fixation screws, an assessment of the standard measurement values in a cohort group will improve the quality of the surgical fixations of the fractures.

Endoscopic surgery versus open reduction treatment of mandibular condyle fractures: A meta-analysis

The aim of the study was to compare open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) in adults in terms of reducing both needing of reoperation and/or facial nerve injury. An electronic search was undertaken (PubMed/MEDLINE, Web of Science, SCOPUS, and The Cochrane Library). The inclusion criteria were full text, published from their inception to June 2020, clinical trials, randomized or not, and retrospective studies, that compared ORIF and EORIF. The estimates of an intervention were expressed as the risk ratio (RR). From the 1338 articles found, 5 publications were included. There was no statistically significant difference between ORIF and EORIF regarding needing of reoperation (RR = 2.46, p = 0.42) or facial nerve injury (RR = 0.45, p = 0.14). Meta-analysis suggests that there is no difference between open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) regarding facial nerve injury risk or need for reoperation.

Comparison between 3D delta plate and conventional miniplate in treatment of condylar fracture: A randomised clinical trial

The aim of the study was to conduct a randomized clinical trial comparing the efficacy of standard non-compression miniplate and 3-dimensional (3D) titanium plate in the open reduction internal fixation (ORIF) of the mandibular condylar fractures. Patients who underwent open reduction of mandibular condylar fracture were recruited for the study. The patients satisfying the inclusion criteria were randomly assigned to two groups in a 1:1 ratio. Group A comprised patients treated using conventional miniplates, and Group B comprised patients treated using 3D Delta Plate. Informed consent was provided. All the patients underwent ORIF under GA via retromandibular approach. The sample size was set at 20 participants, with 10 participants in each group who were randomly allocated. Our study showed that patients in Group A had a significant statistical difference operating time (141.20 ± 2.59 min) than that of Group B (117.2 ± 9.63 min). Mouth opening was significantly greater in the 3^rd-month follow-up in Group B (mean = 42.40 ± 1.82) compared to Group A (mean = 35.80 ± 1.30). Biting efficiency in Group B was observed to be clinically and statistically better compared to Group A (P = 0.012). Wound dehiscence was managed efficiently by judicious use of antibiotics and wounds were free of any signs of infections or discharge in the consecutive follow-ups. No plate removal was required in either group. Patients treated with 3D delta plates have superior outcomes with regard to operation time, mouth opening, and biting efficiency compared with miniplates. Hence, it can be concluded that the triangular shape of the 3D Delta plate allows the stress distribution to be superior and multidimensional, leading to better post-operative stability, faster healing, and reduced complications.

Retromandibular transparotid approach for subcondylar mandibular fracture: A retrospective study

INTRODUCTION

The retromandibular transparotid approach provides the shortest and the most direct access to mandibular sub-condylar fractures. However, this approach is less preferred due to the fear of facial nerve injury. The aim of this study was to evaluate the safety and morbidity of the retromandibular transparotid approach for open reduction and internal fixation of sub-condylar mandibular fractures.

METHODS

A retrospective cohort study of 29 patients with 35 sub-condylar mandibular fractures who underwent open reduction and internal fixation through the retromandibular transparotid approach was conducted. The primary study variable was facial nerve palsy, whereas the secondary variables were infection, sialocele, salivary fistula, stability of the fractured segments, post-operative malocclusion, Frey's syndrome, and unesthetic scar. All patients were followed up for 6 months. Predictor variables included age, gender, side, location, displacement, etiology, concomitant maxillofacial fractures, and healing status. Fisher's exact test was calculated to find the association between primary variables and predictor variables.

RESULT

Out of 35 sub-condylar fractures (29 patients; 23 male, 6 female), four (11.42%) developed transient facial nerve palsy. Fractures at the condylar neck level (P = .045) and with displacement (P = .026) were significantly associated with the development of facial nerve palsy. Four patients (13.8%) developed slight malocclusion, two had surgical site infections, two developed sialoceles, and one had a salivary fistula.

CONCLUSION

The retromandibular transparotid approach is safe and effective with rare major complications in the management of sub-condylar fractures of the mandible. Condylar neck fractures and displaced fractured segments are associated with an increased risk of development of facial nerve palsy.

Changing trends in the management of condylar fractures

Our aim was to evaluate the functional outcomes and complications of mandibular condylar fractures managed surgically and non-surgically. Patients were identified retrospectively from audit data and clinical records from 2005-2018, and functional outcomes were evaluated based on the development of complications at clinical follow up. Patients were categorised into three treatment groups: conservative (management with soft diet, analgesia, and monitoring), closed (management with intermaxillary fixation), and open reduction and internal fixation (ORIF). A total of 358 patients were included with a median age of 33 years (mean 38), and a male:female ratio of 2.7:1. A total of 72 patients (20%) were treated conservatively, 177 (49%) were treated with closed management, and 109 (31%) with ORIF. The ORIF group demonstrated better outcomes than the closed group in terms of reduced protrusive and lateral excursive movements, and temporomandibular joint (TMJ) pain; and in terms of occlusal derangement when compared with the conservative group. The ORIF group had poorer outcomes than both the closed and conservative groups in terms of maximum mouth opening, and temporary facial nerve injury occurred in 5/109 (5%) and condylar resorption in 2/109 (2%) of patients in the ORIF group. There was no incidence of permanent facial nerve injury, Frey syndrome, or paraesthesia of the auricular nerve. The trend that favours ORIF can be justified, as it offers improved functional outcomes in severe or displaced condylar fractures. However, this must be evaluated against the risk of potential surgical complications. Careful case selection is therefore necessary to optimise management of these injuries.

Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management

The choice of surgical or non-surgical treatment of mandibular condylar fractures remains controversial. Earlier trials documented multiple complications of surgical treatment and recommended a non-surgical approach, while more recent trials have shown superior outcomes of surgical compared with non-surgical treatment in some cases. In this paper we systematically review the systematic reviews on the topic that were published before January 2019 and which followed the PRISMA statement, and propose an algorithm for the management of these fractures. Two systematic reviews met the inclusion criteria of the current review, both of which showed better outcome from surgical than non-surgical treatment. We propose an algorithm based on the feasibility of fixation, ability to restore joint and occlusal function, and ensure adequate healing, and consider patient-associated factors that facilitate decision-making.

Evaluation of Stress Distribution of Four Different Fixation Systems at High- and Low-Level Subcondylar Fractures on a Nonhomogenous Finite Element Model

PURPOSE

The aim of the present study was to provide insight into a suitable fixation system for subcondylar fractures located at different levels.

MATERIALS AND METHODS

High and low subcondylar fractures were simulated on a nonhomogenous mandibular model, and rhombic, trapezoid, and lambda plates and 2 miniplates were used for fixation. The stress in the bone and displacement of the fracture site were measured using finite element analysis.

RESULTS

For both high and low subcondylar fractures, the lowest von Mises stress was measured in the rhombic plate system. For high subcondylar fractures, the highest tension in the cortical bone was measured in the trapezoid plate system, and the highest compression was measured in the rhombic plate system. For low subcondylar fractures, the highest tension in the bone was measured in the rhombic system and the highest compression was measured in the trapezoid system. In both high and low subcondylar fracture models, the least displacement amount was measured in the 2-plate system.

CONCLUSIONS

The results of the present study have shown that the rhombic plate system might be the proper choice for high subcondylar fractures and the 2-plate system might provide better results for low subcondylar fractures.

Open Rigid Internal Fixation of Low-Neck Condylar Fractures of the Mandible: Mechanical Comparison of 16 Plate Designs

BACKGROUND

In the literature, no information on plates for low-neck mandibular condylar osteosynthesis can be found, despite the fact that 30 plate designs have already been published. The aim of this study was to compare any dedicated plates for possible use in low-neck condylar fracture osteosynthesis.

METHODS

The force required for 1-mm displacement of the fixed fracture fragments and incidents of screw loosening were recorded on polyurethane mandibles among 16 designs of titanium plates fixed by 6-mm screws in a 2.0 system.

RESULTS

Double-straight plate fixation was the mechanical gold standard (15.2 ± 3.5 N), followed by A-shape Condylar Plates (14.9 ± 2.1 N), X-shape Condylar Plates (14.2 ± 1.3 N) and Auto Repositioning Plates (11.8 ± 2.4 N). Screw loosening was uncommon, as a minimum of three screws were placed into the condylar part. Fewer screws were lost from the ramus part of the fixation if the plate was attached to the condylar part by three screws. Often, the stability of the ramus screws was lost when there were only two fixing screws in the condyle (p < 0.001).

CONCLUSIONS

It is advisable to consider the mechanical advantages as one decides which plate to choose for open rigid internal fixation in low-neck condylar fractures, or to only be aware of the significant differences in mobility within the fracture line after fixation with different dedicated plates.

Changes in mandibular and articular dynamics associated with surgical versus nonsurgical treatment of mandibular condylar fractures: a systematic review with meta-analysis

OBJECTIVE

The aim of this study was to evaluate the mandibular and articular dynamics and the presence of complications associated with surgical or nonsurgical treatments of condylar fractures.

STUDY DESIGN

Clinical trials that compared open reduction internal fixation and maxillomandibular fixation in patients with condylar fractures were included. We performed an electronic search of PubMed, Scopus, Cochrane Library, Web of Science, and LILACS (Latin American and Caribbean Health Sciences) databases starting from February 2017 and updated in January 2019 and found 467 articles. We evaluated methodologic quality by using the criteria from Cochrane's Collaboration Tool.

RESULTS

After independent screening of abstracts, we assessed the full texts of 88 articles; 9 studies were included for qualitative synthesis; but only 8 were included for the meta-analysis. Four studies were considered to have high risk of bias, and 5 were considered to have low risk. The risk ratio (RR = 0.20; 95% confidence interval [CI] 0.13-0.32) was observed for complications. The quality of evidence, using GRADE software, was considered low for maximum mouth opening and protrusive movement and moderate for lateral excursion movement and complications.

CONCLUSIONS

This review suggested that open reduction internal fixation and maxillomandibular fixation are effective. However, surgical treatment presented higher objective parameters. Nonsurgical treatment presented a high index of complications, such as malocclusion, pain and deviation.

Assessment of temporomandibular joint dysfunction in condylar fracture of the mandible using the Helkimo index

Introduction:

Condylar fractures of the mandible are functionally important fractures as the condyle of the mandible being a part of the temporomandibular joint (TMJ) and can lead to TMJ dysfunction if not properly treated.

Materials and Methods:

This was a cross-sectional study of a total of 33 treated patients with fracture of the mandibular condyle who underwent examination as per the Helkimo index. Their dysfunction was quantified and clinicoepidemiological characteristics were assessed. It was found that majority of our patients were young males involved in a two-wheeler accident. All patients underwent intermaxillary fixation as the minimum treatment and 30% underwent open reduction and internal fixation in addition.

Results:

There was no statistically significant association between the degree of clinical dysfunction and factors such as age, mechanism of injury, type of condyle fracture, presence of other mandible fractures, and surgical procedure. However, dislocation of the mandibular condyle was found to be a negative prognostic factor and all these patients had some degree of dysfunction.

Conclusion:

The overall prevalence of TMJ dysfunction according to the Helkimo index was 90%. About 61% of patients had mild dysfunction (Di1) and 30% had moderate dysfunction (Di2). None of the patients had severe dysfunction. To conclude, the Helkimo index is a simple, effective, inexpensive, reliable screening index to assess TMJ dysfunction in condylar fractures of mandible.

Does Fracture Pattern Influence Functional Outcomes in the Management of Bilateral Mandibular Condylar Injuries?

The purpose of this study was to compare the functional outcomes of different types of bilateral mandibular condylar fractures. This was a retrospective study of patients with bilateral mandibular condylar fractures at a level-1 trauma center over a 15-year period. The primary predictor variable was fracture pattern, classified as type I (bilateral condylar), type II (condylar-subcondylar), or type III (bilateral subcondylar). Secondary predictor variables were demographic, injury-related, and treatment factors. Bivariate associations between the predictors and complication rates were computed; a multiple logistic regression model was utilized to adjust for confounders and effect modifiers. Thirty-eight subjects with bilateral condylar injuries met the inclusion criteria. The sample's mean age was 37.6 + 18.2 years, and 16% were female. The most common mechanisms of injury were motor vehicle collisions (53%) and falls (29%). Seventy-four percent had associated noncondylar mandibular fractures, and 32% of cases had concomitant midface fractures. Fifty-three percent of cases were classified as type I, 21% as type II, and 26% as type III. Ten subjects (26%) were managed with open reduction and internal fixation. The average length of follow-up was 4.5 + 6.3 months. After adjusting for confounders and effect modifiers, the type of fracture was a significant predictor of functional complications with type II injuries having the highest likelihood of a poor functional outcome (odds ratio: 7.77, 95% confidence interval: 1.45-41.53, p  = 0.02). Asymmetric bilateral mandibular condylar fractures may be associated with an increased risk of poor functional outcomes.

Pseudoaneurysm of the internal maxillary artery secondary to subcondylar fracture: case report and literature review

Pseudoaneurysms are an uncommon complication of mandibular condylar-subcondylar fractures; however, if present, their recognition and management is mandatory to avoid life-threatening situations. The authors report a case of internal maxillary artery pseudoaneurysm rupture that occurred after an open reduction and internal fixation of a mandibular subcondylar fracture, along with a review of the literature.

In-vitro comparison of mechanical resistance between two straight plates and a Y-plate for fixation of mandibular condyle fractures

OBJECTIVE

To compare the mechanical resistance of conventional plates with a modified Y-plate in mandibular condyle fracture.

MATERIALS AND METHODS

40 synthetic hemi-mandibular polyurethane replicates were used. Two groups of fixing materials were included: 20 mandibles fixed with 40 straight plates with four roles each (2.0 mm system) and 20 mandibles fixed with 20 Y-shaped plates (2.0 mm system and 1.5 mm thickness). The samples were submitted to linear loading in the following directions: 10 mandibles from each group from lateral to medial and 10 mandibles from each group from anterior to posterior. A universal loading machine, Instron Universal 4411, was used to performed the tests, and the resistance of each fixed mandible was assessed at displacements of 1 mm, 3 mm, and 5 mm. The t-test for independent samples was performed. The p value was set at <0.05.

RESULTS

The worst mechanical resistance was found in the Y-plates loaded from anterior to posterior. The best mechanical resistance was in two straight hole plates loaded from lateral to medial. The Y-plates and two straight hole plates showed similar resistance when a lateral to medial load was applied.

CONCLUSION

There was no difference between the plates when lateral to medial loading was tested.

Evaluation of an experimental oblique plate for osteosynthesis of mandibular condyle fractures

OBJECTIVE

The aim of this study was to test the bone thickness and potential screw length for osteosynthesis of condylar base fractures (according to the Loukota classification) with an experimental titanium plate, placed in an ideal position against 2 types of conventional plates.

STUDY DESIGN

After exclusion of completely edentulous mandibles, 28 dentate macerated mandibles available at the time of the study were included. Linear regression models 1 and 2 compared the sums of the 2 cranial bone thicknesses and the 3 caudal thicknesses among the 3 different plate designs, and linear models 3 and 4 tested the bone thickness in the 2 most cranial screw axes.

RESULTS

Linear models 1 and 2 revealed significantly higher potential screw lengths for the experimental oblique plate. Equally, linear models 3 and 4 indicated significantly higher bone thickness for the novel oblique plate.

CONCLUSION

The novel proposed oblique plate allows for favorable plate positioning in a biomechanically ideal location with sufficient amounts of local bone for stable plate fixation. When plates with 15-degree angulated screw holes are used, stable bicortical plate fixation can be achieved.

Evidence-Based Medicine in Facial Trauma

This article provides the reader with a comprehensive review of high-level evidence-based medicine in facial trauma and highlights areas devoid of high-level evidence. The article is organized in the order one might approach a clinical problem: starting with the workup, followed by treatment considerations, operative decisions, and postoperative treatments. Individual injuries are discussed within each section, with an overview of the available high-level clinical evidence. This article not only provides a quick reference for the facial traumatologist, but also allows the reader to identify areas that lack high-level evidence, perhaps motivating future endeavors.

Mandible Fractures

Mandible fractures account for a significant portion of maxillofacial injuries and the evaluation, diagnosis, and management of these fractures remain challenging despite improved imaging technology and fixation techniques. Understanding appropriate surgical management can prevent complications such as malocclusion, pain, and revision procedures. Depending on the type and location of the fractures, various open and closed surgical reduction techniques can be utilized. In this article, the authors review the diagnostic evaluation, treatment options, and common complications of mandible fractures. Special considerations are described for pediatric and atrophic mandibles.

Physiotherapy Maneuver Is Critical to Recover Mouth Opening After Pediatric Trauma

PURPOSE

A restricted mouth opening (MO) is predominantly a complication of maxillofacial trauma in pediatric patients and develops in 4 to 26.2% of cases. The purpose of the present study was to quantitatively investigate the influence of patient demographic data, fracture characteristics, and regular vigorous physiotherapy, with either voluntary or forcible MO exercises, on the recovery of a post-traumatic restricted MO in pediatric patients.

PATIENTS AND METHODS

A prospective cohort study was performed of pediatric patients with maxillofacial injuries who had been referred to Al-Zahraa and El-Fayoum Hospitals from 2013 to 2015. The predictive variables were patient demographic data, fracture characteristics, and regular vigorous physiotherapy. The patients were treated with a closed technique. The MO measurements were the clinical outcome variables and were recorded at the first week and then monthly for 12 months. Regular vigorous physiotherapy was performed until the patients had returned to their preoperative MO. The data were tabulated and statistically analyzed.

RESULTS

Eighty-six patients were enrolled in the present study. Males predominated. Falls were the most common cause of fracture. Condylar fractures had the greatest incidence. A restricted MO occurred in 81 patients. The results showed no interaction between MO recovery and age, gender, etiology, or fracture site. After physiotherapy, the patients had returned to their preoperative MO at the fourth month, with the measurements fixed at normal values at the sixth month. The recovery rate was nonlinear, with faster improvement in the months closest to the injury.

CONCLUSION

Physiotherapy is more critical in the recovery of the MO and prevention of bony ankylosis than patient data or fracture characteristics in pediatric trauma. We highly advocate the performance of voluntary mouth exercises, even in the absence of fracture. Forcible MO exercises are mandatory to recover a restricted MO. These exercises should be performed under close supervision of the patient's surgeon with the parents motivated to cooperate for at least 6 months.

Which Factors Are Associated with Open Reduction of Adult Mandibular Condylar Injuries?

BACKGROUND

The purpose of this study was to identify factors associated with the decision to perform open reduction and internal fixation of mandibular condylar fractures.

METHODS

This was a retrospective cohort study of patients with mandibular condylar fractures managed by the plastic and reconstructive surgery, oral and maxillofacial surgery, and otorhinolaryngology services over a 15-year period. Bivariate associations and a multiple logistic regression model were computed for injury characteristics that were associated with open reduction and internal fixation. For all analyses, a value of p ≤ 0.05 was considered significant.

RESULTS

Six hundred fifty-four condylar injuries were identified in 547 patients. The sample's mean age was 36.0 ± 16.5 years, 20.5 percent were women, and 63 percent were Caucasian. The most common mechanisms of injury were motor vehicle collisions (49 percent), 53.4 percent involved the subcondylar region and 20 percent were bilateral injuries. Associated noncondylar mandibular fractures were present in 60 percent of cases; 20.7 percent were managed with open reduction and internal fixation. The overall complication rate was 21.6 percent. In a multiple logistic regression model, factors associated with an increased likelihood of open reduction and internal fixation were the presence of extracondylar mandibular injuries, condylar neck or subcondylar region injuries, increasing dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery (p ≤ 0.04).

CONCLUSIONS

Increasing severity of mandibular injury, lower level of fracture, joint dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery are associated with open reduction and internal fixation of mandibular condylar injuries.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.