A comparative study of closed versus open reduction and internal fixation (using retromandibular approach) in the management of subcondylar fracture

Complications of Open Reduction and Internal Fixation of Mandibular Condyle Fractures in Oman

Objectives

This study aimed to report the complication rate associated with open reduction and internal fixation (ORIF) of mandibular condyle fractures in Oman.

Methods

This retrospective cohort study was conducted among patients who underwent ORIF of mandibular condyle fractures at Al-Nahdha Hospital and the Sultan Qaboos University Hospital in Muscat, Oman, from January 2008 to December 2020. Data collected included patient demographics, fracture aetiology, fracture side and type, surgical approach and recorded complications and outcomes.

Results

A total of 68 patients (59 males and 9 females; mean age of 30.1 years) with 83 mandibular condyle fractures underwent ORIF during the study period. Subcondylar fractures were the most common type, occurring in 62.7% of patients, while bilateral fractures were observed in 21 (30.8%) patients. The most common surgical approach was retromandibular, used in 42.2% of patients. The overall complication rate was 42.6%, with the most frequently reported complications being transient facial nerve palsy (18.1%), malocclusion (14.7%) and restricted mouth opening (10.3%). Subsequent surgical interventions to correct malocclusion were performed in 6 cases. There was no statistically significant association between the overall complication rate and the patients' clinical characteristics.

Conclusion

Although ORIF of mandibular condyle fractures generally offers favourable outcomes, it carries a risk of complications.

Comparative Evaluation of Open Reduction with Internal Fixation Against Closed Reduction Methods for Condylar Fracture Management: A Systematic Review and Meta- analysis

Background

Mandibular fractures are frequent in facial trauma. Management of mandibular condylar fractures (MCF) remains an ongoing matter of controversy in maxillofacial injury. A number of techniques, from closed reduction (CR) to open reduction and internal fixation (ORIF), can be effectively used to manage these fractures. The best treatment strategy, that is, closed reduction or open reduction with internal fixation, remains controversial.

Aim

The aim of this study is to systematically review the existing scientific literature to determine whether open reduction with internal fixation or closed reduction is a better treatment alternative for the patients with condylar fractures through a meta-analysis.

Methods

A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Electronic databases like PubMed, google scholar and Ebsco Host were searched from 2000 to December 2021 for studies reporting management of condylar fractures through open reduction with internal fixation against closed reduction and reporting the outcome in terms of mean and standard deviation (SD). Quality assessment of included case control and cohort studies was performed using Newcastle-Ottawa Scale, and randomized studies were evaluated using Cochrane risk-of-bias (ROB)-2 tool through its domains. The risk of bias summary graph and risk of bias summary applicability concern was plotted using RevMan software version 5.3. The standardized mean difference (SDM) was used as summary statistic measure with random effect model and p value <0.05 as statistically significant.

Results

Seventeen studies fulfilled the eligibility criteria and were included in qualitative synthesis, of which only nine studies were suitable for meta-analysis. The pooled estimate through the Standardized Mean Difference (SMD) of 0.80, 0.36 and 0.42 for maximum inter incisal opening, laterotrusion and protrusion favours CR compared to ORIF for condylar fracture management. Also, most results of heterogeneity tests were poor and most of the funnel plots showed asymmetry, indicating the presence of possible publication bias.

Conclusion

The results of our meta-analysis suggest that CR provides superior outcomes in terms of maximum inter incisal opening, laterotrusion and protrusion compared to ORIF in condylar fractures management. It is necessary to conduct more prospective randomized studies and properly control confounding factors to achieve effective results and gradually unify clinical guidelines.

Which Factors Affect the Reduction Quality of Open Reduction Internal Fixation of Mandibular Subcondylar Fractures?

BACKGROUND

Open reduction internal fixation (ORIF) of mandibular subcondylar fractures (MSF) involves several variables that could affect decision making. There is insufficient data regarding factors influencing the outcomes of MSF ORIF.

PURPOSE

The purpose of this study was to investigate factors associated with quality of bony reduction of MSF and occlusion, after ORIF.

STUDY DESIGN, SETTING, AND SAMPLE

We designed a retrospective cohort study of consecutively treated subjects for MSF ORIF, ages 18 to 64 years, by University of Illinois' Department of Oral and Maxillofacial Surgery, between January 1, 2013, and January 26, 2021.

PREDICTOR VARIABLE

The primary predictor variable was the vertical level of MSF from the gonial angle. Secondary predictor variables included surgeon, fixation scheme (number and configuration of miniplate), surgical approach, time to surgery, mechanism of injury, vertical fragment overlap, overlying soft tissue thickness, presence of other mandibular fractures, and severity and direction of displacement.

MAIN OUTCOME VARIABLES

The primary outcome variable was the mean radiographic reduction score (RRS), rated by 2 blinded observers on a 1 to 5 scale. The secondary outcome variable was presence of postoperative malocclusion as documented in the medical records.

COVARIATES

Covariates were age and sex.

ANALYSES

Descriptive statistics were computed. To investigate the influence of the predictor variables on reduction quality, multifactorial analysis of variance with post hoc Tukey test was performed. For malocclusion, χ2 test was performed. The level of significance was set at P < .05.

RESULTS

Thirty-eight MSF in 37 subjects were included. Mean age was 32.7 years (range 18 to 64), and 83.8% were male. Mean RRS was 4.38 (standard deviation 0.77). Fixation scheme was the only variable that showed significant impact on RRS: single-straight miniplate had lower scores than double-straight (-1.50, P = .011), rhomboid (-1.29, P = .036), and ladder miniplates (-1.38, P = .048). There was 1 incidence of malocclusion (2.7%) which resolved without intervention.

CONCLUSIONS AND RELEVANCE

Favorable reduction (anatomic reduction to mild discrepancies) can be achieved without malocclusion using double-straight, or rhomboid-shaped or ladder-shaped miniplates, without influences from patient or injury-related factors. In contrast, single-straight miniplate fixation resulted in moderate discrepancies in reduction, although it did not lead to malocclusion.

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).

Does the Treatment Approach for Mandibular Condyle Fractures Impact Self-Perceived Quality of Life?

PURPOSE

There is no consensus in mandibular condylar fracture/s treatment. In medicine, quality of life (QOL) includes the individual's satisfaction toward their own health condition, disease, or treatment. The purpose of this study was to investigate self-perception QOL outcomes for patients who sustained mandibular condylar fracture/s.

METHODS

This cross-sectional study surveyed patients at Grady Memorial Hospital in Atlanta, Georgia from November 2016 to June 2020. The study included patients who were at least 16 years old at the time of injury, diagnosed with mandibular condylar fracture/s, treated by close reduction or open reduction and internal fixation (ORIF), presented for 6-months post-operative follow-up, and had a valid phone number. The primary predictor variable was treatment approach. The primary outcome variable was mood. Covariates were demographics, injury details, and self-perception QOL questionnaire. Univariate, bivariate, and ordinal regression analysis were performed (P < .05 significance).

RESULTS

A total of 108 patients met inclusion criteria. Response rate was 84.2%. Our data showed that patients who underwent ORIF treatment were statistically more likely to experience no or milder pain when chewing (tau = 0.390, P = .002), to not require pain medications (tau = 0.389, P = .002), to report larger maximum mouth opening (tau = 0.402, P = .0003), and to report better QOL (tau = 0.440, P = 7.407e-05). Ordinal regression analysis showed that patients who had undergone ORIF treatment were positively associated with better mood (estimate: -0.062; OR: 0.54; P = .29) and statistically significant associated with excellent QOL (estimate: -2; OR: 0.13; P = 3.99e-05). Patients who sustained class III Lindahl mandibular condyle fracture were statistically significantly associated with depressed mood (estimate: 1.46; OR: 4.33; P = .002).

CONCLUSION

ORIF treatment was positively associated with better QOL when compared to closed reduction for mandibular condyle fracture.

Current Management of Subcondylar Fractures: A Systematic Review

OBJECTIVE

The aim of this study is to review the current literature on treatment of subcondylar fractures using traditional open reduction internal fixation (ORIF), closed reduction with maxillomandibular fixation (MMF), and endoscopic open approaches.

DATA SOURCES

PubMed, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and WHO ICTRP.

REVIEW METHODS

A comprehensive database search was performed in accordance with PRISMA guidelines. All English-only texts published in the last 20 years with ≥10 patients were included. Studies that included patients <16 years old were excluded.

RESULTS

Thirty-two studies met the final inclusion criteria. Nine studies compared ORIF with closed reduction using MMF, 12 studies evaluated ORIF via different approaches, and 10 studies evaluated outcomes after endoscopic approaches. Five studies reported significant improvement in mouth opening with ORIF compared to closed reduction. In 1 study that recorded patient-reported outcomes measure (FACE-Q scale), quality of life scores and patient satisfaction were significantly higher in the ORIF group. Among the 10 studies that used the endoscopic approach, transient facial nerve injury ranged from 0% to 10%.

CONCLUSION

Several studies report better mouth opening, dental occlusion, and functional outcomes after ORIF compared to closed reduction, while some found no significant difference. Endoscopic approaches provide ease of access to the condyle with a low incidence of facial nerve injury. However, limitations include special equipment, longer operative times, and a steep learning curve using an endoscope. This review provides surgeons with an overview of the current literature on subcondylar fractures to allow for an individualized management approach for each patient.

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.

Open Reduction and Internal Fixation Versus Closed Reduction and Maxillomandibular Fixation of Condylar Fractures of the Mandible: A Prospective Study

Background

The choice of surgical versus nonsurgical treatment for fractures of the condylar process has its own limitations and remains a controversial issue. Improved knowledge of anatomy, technique, and technology combined with adequate experience with careful planning of surgical technique can avoid all the possible complications.

Aim

To compare open reduction and internal fixation with closed reduction and maxillomandibular fixation in the management of condylar fractures.

Materials and method

A prospective study was carried out among 22 patients who had minimally displaced or displaced condylar fractures. The patients were divided into two groups of 11 each: group A patients treated with open reduction and rigid internal fixation and group B patients treated with closed reduction and maxillomandibular fixation. Follow-up examinations were performed at one week, one month, three months, and six months postoperatively.

Results

Preauricular pain was significantly decreased (p < 0.001) in both groups postoperatively but more significantly decreased in the open reduction group. There was a significant improvement in the mouth opening at every follow-up to a maximum mean of 37.36 mm in group A and a mean of 33.64 mm in group B. Significantly more improvement in protrusive and lateral movements and reduced deviation on mouth opening at every follow up was observed in the open reduction group.

Conclusion

Both the treatment options for condylar fractures of the mandible yielded acceptable results with significant clinical differences in terms of occlusion, mouth opening, functional movements, and pain among patients with open reduction.

Mandibular Condylar Fractures

Mandibular condyle fractures can result in short-term and long-term morbidity. As a weak area of the mandible, the condyle is vulnerable to injury by a direct impact or an indirect force. Current treatment recommendations aim to better match the severity of the fracture with the choice of closed or open approach. Long-term follow-up of patients provides the best opportunity to monitor the degree of functional restoration after treatment. There is a growing consensus regarding the use of standardized fracture classification methods and outcomes measures that will allow better assessment of treatment results and strengthen the quality of outcomes research.

Is the Use of Intermaxillary Fixation Screws an Alternative to Erich Arch Bars for Maxillomandibular Fixation During Management of Maxillofacial Fractures? A Systematic Review and Meta-Analysis

Study Design

Systematic review and meta-analysis.

Objective

Maxillomandibular fixation (MMF) is a step of paramount importance during the management of maxillofacial trauma. Erich arch bars are being used for this purpose for decades but with advances in maxillofacial trauma management, intermaxillary fixation screws came into existence and are being used routinely. The present study was designed to identify if the intermaxillary fixation screws are really an alternative to Erich arch bars for management of maxillofacial trauma.

Methodology

An exhaustive literature search was conducted in May 2020 on various electronic databases and studies comparing Erich arch bars and intermaxillary fixation screws were recruited for the analysis. Random-effects model with Mantel Haenszel statistics was used to analyze oral hygiene and duration of achieving MMF.

Results

A total of 96 studies were identified, out of which 8 studies were included in the meta-analysis. There was no statistically significant difference in oral hygiene status of the patients in both the groups. Intermaxillary fixations screws required statistically significantly less time in achieving MMF. Needle stick injury was prominently seen with the use of Erich arch bar whereas other complications like mucosal coverage, root injury, screw loosening and screw fracture makes the use of intermaxillary fixation screws questionable.

Conclusion

The present meta-analysis suggests that there is not enough evidence to recommend the use of intermaxillary fixation screws as an alternative to Erich arch bars. Further research with large sample size, high quality evidence and better methodology is recommended in this direction.

What is a better modality of maxillomandibular fixation: bone-supported arch bars or Erich arch bars? A systematic review and meta-analysis

Any procedure that aims to manage maxillofacial fracture is incomplete without meticulous maxillomandibular fixation (MMF). For decades, Erich arch bars (EABs) have been used for this purpose, but with the advent of bone-supported arch bars (BSABs), more surgeons now prefer them to conventional EABs. The present study was designed to identify which of the two methods is best. An exhaustive literature search was conducted in June 2020 on various electronic databases to select studies that compared EABs and BSABs. Outcomes such as duration of placement, stability, oral hygiene, and complications such as damage to the roots of teeth and needle-stick injury, were analysed. A total of 716 studies were identified, of which seven were eligible for inclusion. The meta-analysis showed that the use of BSABs is significantly faster with no needle penetration and better oral hygiene. Both arch bars are equally stable, but root damage is an associated complication. The available literature to date shows that BSABs are a better option than EABs. However, further research is recommended, as these studies are associated with various confounding factors.

Will Closed Treatment Provide Better Mandibular Motion Than Open Reduction and Internal Fixation in Cases of Unilateral Displaced Subcondylar Fracture? A Systematic Review and Meta-Analysis

PURPOSE

The aim of the present systematic review was to determine whether closed treatment (CLT) with intermaxillary fixation (IMF) is superior or equivalent to open reduction and internal fixation (ORIF) in the management of unilateral displaced subcondylar fractures regarding the range of mandibular motion.

MATERIALS AND METHODS

To address our question, we conducted a systematic review and meta-analysis of the reported data after a comprehensive manual and electronic database search of studies reported up to 2017 in the English language that had compared CLT and ORIF of mandibular condyle fractures in adults. The following outcomes were recorded: maximum interincisal opening (MIO), protrusive movement (PM), lateral excursion toward the fractured side (LEFS), and lateral excursion toward the nonfractured side (LENFS).

RESULTS

The search resulted in 8 studies, 4 of which were included in the meta-analysis. The MIO and PM showed no statistically significant differences, with an effect size of -0.823 (P = .112) and -0.633 (P = .079), respectively. However, the LEFS and LENFS were superior after CLT, with an effect size of -0.710 (P = .031) and -0.682 (P = .017), respectively.

CONCLUSIONS

The findings from the present review suggest that both ORIF and CLT can provide comparable MIO and PM in subjects with unilateral displaced subcondylar fractures. However, CLT was superior to ORIF for both LEFS and LENFS.

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.

Open reduction and internal fixation of mandibular condylar fractures: A national inpatient sample analysis, 2005-2014

The purpose of this study was to compare outcomes of open reduction and internal fixation (ORIF) versus closed reduction (CR) for mandibular condylar fractures.Patients included in the National Inpatient Sample (NIS) database (2005-2014) who were admitted to the hospital for unilateral mandibular condylar fracture were included in the analysis. Patient characteristics and clinical outcomes were compared between those who received ORIF and those receiving CR. Logistic regression analysis was performed to estimate odds ratios (ORs) for each aspect of the main observed events.NIS data of 12,303 patients who underwent ORIF and 4310 patients who underwent CR were analyzed. Compared to CR, ORIF had an increased risk of longer hospital stay (adjusted OR [aOR] = 1.78, 95% confidence intervals [CIs] = 1.51-2.09), higher total medical cost (aOR = 2.57, 95% CI = 2.17-3.05), and hematoma development (aOR = 10.66, 95% CI = 1.43-75.59), but had a lower risk of having wound complications (aOR = 0.86, 95% CI = 0.79-0.93).Patients with mandibular condylar fractures who receive ORIF have greater risk of having an extended hospital stay, higher total medical costs, and hematoma development but lower risk of experiencing wound complications compared to those who receive CR.

Experiences with a modified preauricular mini incision with subdermally dissection in condylar and subcondylar fractures of the mandible

OBJECTIVE

Condylar and subcondylar fractures (CSFs) are among the most common mandible fractures. If reduction of these fractures is not carried out correctly, serious complications can result, including infection, damage to temporomandibular joint (TMJ) function, malocclusion, nonunion, malunion, and ankylosis of the TMJ.

METHODS

We used a preauricular, mini-incision, open technique (PMIOT) for CSF of the mandible. 66 patients (48 males, 18 females), with a total of 72 CSFs of the mandible, were repaired with PMIOT between 2011 and 2016. Average age was 37.8 years (range: 8-78). CSFs were located on the right side, left side, and bilaterally in 21, 27 and six patients, respectively. We used only one mini incision of length 2 cm for non-displaced subcondylar fractures. However, we had to perform a second mini incision for condylar fractures displaced by more than 45°, where subcondylar fractures overlapped, or where there was deep surgical exposure and difficulty with reduction.

RESULTS

No early complications, such as bleeding, hematoma, seroma, infection, or parotid fistula, were seen in any patients. Temporary facial nerve paresis was reported in three patients, but these recovered spontaneously with conservative treatment within 15 days. Permanent facial nerve paralysis occurred in none of the patients.

CONCLUSION

We believe that PMIOT is an effective, reliable, and feasible method for repair of CSF. It does not need any expensive and sophisticated tools, and has low complication rates. The mini incision used in our technique results in both a hidden scar and protection of essential structures in the region.

Is the Retromandibular Transparotid Approach a Reliable Option for the Surgical Treatment of Condylar Fractures?

PURPOSE

This study evaluated the outcomes and complications of the surgical treatment of condylar fractures by the retromandibular transparotid approach. The authors hypothesized that such an approach would be safe and reliable for the treatment of most condylar fractures.

MATERIALS AND METHODS

A retrospective evaluation of patients who underwent surgical reduction of a condylar fracture from January 2012 to December 2014 at the Clinic of Dentistry and Maxillofacial Surgery of the University Hospital of Verona (Verona, Italy) was performed. Inclusion criteria were having undergone surgical treatment of condylar fractures with a retromandibular transparotid approach and the availability of computed tomograms of the preoperative and postoperative facial skeleton with a minimum follow-up of 1 year. Static and dynamic occlusal function, temporomandibular joint health status, presence of neurologic impairments, and esthetic outcomes were evaluated in all patients.

RESULTS

The sample was composed of 25 patients. Preinjury occlusion and temporomandibular joint health were restored in most patients. Esthetic outcomes were deemed satisfactory by clinicians and patients. Neither permanent neurologic impairments nor major postoperative complications were observed.

CONCLUSIONS

According to the results of the present study, the retromandibular transparotid approach is a viable and safe approach for the surgical treatment of condylar fractures.

Reporting of Postoperative Pain Management Protocols in Randomized Clinical Trials of Mandibular Fracture Repair: A Systematic Review

IMPORTANCE

The control of pain associated with mandibular fractures is an important treatment outcome that affects function, adherence to treatment regimens, and patient comfort and satisfaction.

OBJECTIVE

To explore the pain management protocols reported in studies of mandibular fractures, including the reporting of quality-of-life measures.

EVIDENCE REVIEW

PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov were searched for randomized clinical trials published from 1970 to July 2014. We followed PRISMA reporting standards to assess study eligibility and extract data. Studies of patients older than 16 years who underwent operative mandibular fracture management were included. The primary data collected included the type of analgesic prescribed, associated adverse effects of the analgesic, method of pain assessment, and use of quality-of-life measures. A pain attentiveness score was assigned to studies based on the comprehensiveness of the information reported. Several variables were reviewed to determine the factors that predict reporting of pain-related data. Assessments of risk for bias were performed using the Cochrane Collaboration's domain-based evaluation method.

FINDINGS

The initial search identified 111 articles, of which 38 met inclusion criteria. Among the 38 reviewed articles, there were 38 trials and 1808 unique patients represented. Among the 38 articles, the procedures reported included maxillomandibular fixation only in 6 (16%), open reduction with internal fixation only in 20 (53%), and both in 12 (32%). Specific analgesics prescribed were reported in only 5 of the 38 studies (13%), and 3 of these used a combination of nonsteroidal anti-inflammatory drugs and acetaminophen (paracetamol). Thirteen studies (34%) reported pain assessments and 5 (13%) included quality-of-life measures. Geographic region was the only variable that predicted pain attentiveness, with studies from Europe (3 of 11 studies [27%]) and Asia (6 of 16 studies [38%]) most likely to have a high pain attentiveness score. A low rating was least common in the United States (2 of 5 studies [40%]) (P = .047, Fisher exact test). Most of the studies had unclear (n = 27) or high (n = 6) risks for bias in the key domains assessed.

CONCLUSIONS AND RELEVANCE

Pain management is a neglected outcome in randomized clinical trials of mandibular trauma; most studies did not describe the specific analgesics used. Many randomized clinical trials (13 [34%]) assessed pain levels among patients without providing information about the agents prescribed. The incorporation of validated pain measures and quality-of-life scores in future studies of mandibular trauma would focus attention on this key outcome measure.

Evidence-Based Facial Fracture Management

With demands for an evidence-based approach to patient care, the management of facial fractures will come under increasing scrutiny because there is an overall deficiency in higher level clinical evidence. This article reviews the management of facial fractures, focusing on an evidence-based approach. It focuses on select areas of facial trauma in which there is controversy and presents randomized studies and meta-analysis to help define best practice. The article notes the many areas where the evidenced-based literature is weak and looks at the future of evidence-based facial trauma care.