Unilateral Subcondylar and Condylar Neck Fractures: Randomized Clinical Study

Comparing Current Practice Habits for Treatment of Subcondylar Fracture Among Craniomaxillofacial Surgeons

Study Design

Survey.

Objective

Subcondylar fractures stand out as a particular challenge when treating maxillofacial trauma. The fracture site is often difficult to access and adjacent to critical structures like the facial nerve. Current treatment paradigms vary widely and we endeavored to elucidate these approaches from surgeons across the full breadth of Craniomaxillofacial Surgery.

Methods

A survey was designed to gather general background training and experience information, perceived indications for ORIF of subcondylar fractures, options for treating subcondylar fractures, and reasoning for choosing or not choosing a given treatment approach. The survey was sent to members of AO CMF and the American Academy of Facial Plastic Surgery. Responses were collected for 4 weeks.

Results

514 total responses to the survey were obtained (response rate 17%). Of these, 43 (8.4%) identified as Otolaryngology trained, 417 (81.1%) as OMFS trained, and 54 (10.5%) as Plastic Surgery trained. While there was broad agreement in the indications for open repair, surgical approaches differed by specialty background as well as AO faculty member status. Those with less experience were less likely to perform open approaches due to lack of comfort with this skill set.

Conclusions

There are some key differences in approaches to treatment of subcondylar fractures based upon specialty background and experience level. This provides an opportunity for further education to ensure optimal treatment for patients.

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).

Oral functioning after open versus closed treatment of unilateral condylar neck or base fractures: A two-centre controlled clinical trial

BACKGROUND

Oral functioning and rehabilitation in patients after condylar trauma can be measured by objective functional outcomes and patient-reported outcomes. The similarities or differences between these outcomes may contribute to the decision if open treatment (OT) or closed treatment (CT) will obtain the most advantageous results.

OBJECTIVES

The aim of this study was to compare OT versus CT for unilateral condylar mandibular neck or base fractures in a two-centre controlled clinical trial by objective functional outcomes and patient-reported outcomes measured at 6 weeks and 6 months follow-up. Additionally, these outcomes were compared within each group.

METHODS

Patients were enrolled between January 2017 and November 2019. In one centre, patients received OT by extra-oral open reduction and internal fixation. In another centre, patients received CT by maxillomandibular fixation. Objective measurements included the mixing ability test (MAT) and mandibular active range of motion (ROM). Patient-reported outcomes included the mandibular function impairment questionnaire (MFIQ) and visual analogue scale (VAS) for pain. Independent t-tests and Mann-Whitney U-tests were used to determine differences between the treatment groups at 6 weeks and 6 months follow-up. Paired t-tests and Wilcoxon signed rank tests were used to determine differences within each group.

RESULTS

Thirty-three patients were enrolled. No differences were found between the groups treated with OT or CT for MAT, ROM, MFIQ and VAS. Both groups showed functional improvement.

CONCLUSION

Good objective functional outcomes and patient-reported outcomes were achieved with both OT and CT in patients with unilateral condylar mandibular neck or base fractures.

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.

Does Dynamic Intermaxillary Fixation With Elastics Improve Outcomes Following Unilateral Condylar Fracture?

PURPOSE

The use of rigid versus semi-rigid intermaxillary fixation (IMF) following subcondylar fractures is controversial. This study aims to investigate whether the "dynamic" elastic fixation technique improves the outcomes, compared to the rigid fixation technique for the treatment of displaced subcondylar fractures in adults.

MATERIALS AND METHODS

This nonblinded randomized clinical trial was performed on adult patients with unilateral displaced mandibular subcondylar fractures. Patients were randomly allocated into two groups (n = 17). The primary predictor variable was wire versus elastic IMF. Changes in primary (mouth opening) and secondary (other clinical and radiological) outcomes were recorded. Data were analyzed with the t test and Mann-Whitney test with SPSS software version 20. P-value < .05 considered as significant.

RESULTS

In this study 34 patients (with mean age of 33.03 ± 1.79, 23.5% females & 76.5% males) in two groups (Elastics & Wire) followed up to 6 months. The Elastics group showed significant improvement in mouth opening (primary outcome) after 1 month of follow-up, but the differences were not significant at the end of the study. In terms of secondary outcomes, the ramus height shortening compared to the opposite side revealed favorable improvement in the Elastics group in the period of study. The differences between the two groups in the lateral movement and protrusive movement were significant in favor of the Elastics group. The differences in pain, fracture displacement, and midline deviation between study groups were not significant at the end of the study. Just 1 case with malocclusion was observed in the Wire group. Patients were more satisfied with dynamic nonrigid IMF with elastics.

CONCLUSIONS

The results of this study showed that using the dynamic IMF technique is more tolerable, and patients have better functional and clinical outcomes during and at the end treatment.