FIGURE 3 - uploaded by Risimati Ephraim Rikhotso
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A, Posteroanterior (PA) mandible preoperative x-ray showing bilateral condylar fractures (white arrows: Wits type III right and type II B left fracture sides) with a symphyseal fracture (yellow arrow). (Fig 3 continued on next page.) Rikhotso, Reyneke, and Nel. Open Versus Closed Reduction. J Oral Maxillofac Surg 2022.
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Purpose:
Despite decades of study, a consensus on therapeutic approaches to condylar fractures remains elusive, and the vexing question of invasive or noninvasive therapy remains to be definitively answered. This randomized clinical study aimed to compare the outcomes of mandibular condylar fractures (MCFs) treated by closed treatment (CT) with th...
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Introduction: Condyle of mandible plays crucial role in functioning of jaw. Untimely and inadequate treatment leads to deformity of face along with range of complications. The purpose of this study was to assess outcomes of open reduction and internal fixation of mandibular condyle fractures in terms of mouth opening, facial nerve function and occl...
Citations
... Lima et al. observed an incidence of 1.8% of FNP after the retromandibular approach [12]. In another study, 21% of the closed-treated patients and 2% of the open-treated patients showed post-treatment malocclusion [13]. In a recent study conducted in our own department, the post-treatment rate of malocclusion was 18.0%; temporary FNP occurred in 7.1% compared to 1.7% permanent FNP. ...
Background: The aim of this study is to assess patients’ subjective perception of treatment outcome after extracapsular fractures of the mandibular condyle. Methods: A questionnaire survey regarding facial nerve palsy (FNP), malocclusion, pain, reduction in maximum mouth opening (MMO) and further discomfort after 3, 6, and 12 months was carried out. Patients aged 18 or more presenting with an extracapsular condylar fracture between 2006 and 2020 were identified by purposive sampling Questionnaires were received from 115 patients. Fractures were classified on the basis of the pre-treatment imaging, the way of treatment was obtained from patients’ medical records. Data were analyzed using Pearsons’ chi-square-test, descriptive statistics and Student’s t-test. Results: 93.0% of the fractures were treated by open reduction and internal fixation (ORIF). MMO reduction was the most common post-treatment complication (55.6%). ORIF was associated with less pain after 3 months (p = 0.048) and lower VAS scores compared to conservative treatment (p = 0.039). Comminuted fractures were more frequently associated with post-treatment malocclusion (p = 0.048), FNP (p = 0.016) and MMO reduction (p = 0.001). Bilateral fractures were significantly accompanied by malocclusion (p = 0.029), MMO reduction (p = 0.038) and pain occurrence (p < 0.001). Conclusions: Patients report less pain after ORIF. Comminuted and bilateral fractures seem to be major risk factors for complications. Subjective perception of complications after extracapsular condylar fractures differs from objectively assessed data.
... The majority of previous clinical studies analyzing mandibular fractures focused on the dynamics of trauma or on the long-term healing conditions and complications [31][32][33]. Only a few studies focused on pre-existing anatomical conditions that may influence the healing process of mandibular fractures. ...
Mandibular fractures are very common in maxillofacial trauma surgery. While previous studies have focused on possible risk factors related to post-operative complications, none have tried to identify pre-existing conditions that may increase the risk of mandibular fractures. We hypothesized, through clinical observation, that anatomical conditions involving poor dental contacts, such as malocclusions, may increase the risk of mandibular fractures. This work was subdivided into two parts. In the first part, Digital Imaging and Communications in Medicine (DICOM) data of four healthy patients characterized by different dentoskeletal occlusions (class I, class II, class III, and anterior open bite) have been used to develop four finite element models (FEMs) that accurately reproduce human bone structure. A vertical and lateral impact have been simulated at increasing speed on each model, analyzing the force distribution within the mandibular bone. Both vertical and lateral impact showed higher level of stress at the impact point and in the condylar area in models characterized by malocclusion. Specifically, the class III and the open bite models, at the same speed of impact, had higher values for a longer period, reaching critical stress levels that are correlated with mandibular fracture, while normal occlusion seems to be a protective condition. In the second part of this study, the engineering results were validated through the comparison with a sample of patients previously treated for mandibular fracture. Data from 223 mandibular fractures, due to low-energy injuries, were retrospectively collected to evaluate a possible correlation between pre-existing malocclusion and fracture patterns, considering grade of displacement, numbers of foci, and associated CFI score. Patients were classified, according to their occlusion, into Class I, Class II, Class III, and anterior open bite or poor occlusal contact (POC). Class I patients showed lower frequencies of fracture than class II, III, and open bite or POC patients. Class I was associated with displaced fractures in 16.1% of cases, class II in 47.1%, class III in 48.8% and open bite/POC in 65.2% of cases (p-value < 0.0001). In class I patients we observed a single non-displaced fracture in 51.6% of cases, compared to 12.9% of Class II, 19.5% of Class III and 22.7% of the open bite/POC group. Our analysis shows that class I appears to better dissipate forces applied on the mandible in low-energy injuries. A higher number of dental contacts showed a lower rate of multifocal and displaced fractures, mitigating the effect of direct forces onto the bone. The correlation between clinical data and virtual simulation on FEM models seems to point out that virtual simulation successfully predicts fracture patterns and risk of association with different type of occlusion. Better knowledge of biomechanics and force dissipation on the human body may lead to the development of more effective safety devices, and help select patients to plan medical, orthodontic/dental, and/or surgical intervention to prevent injuries.
... Open reduction and the internal fixation of condylar head fractures is finding increasing favour, irrespective of the location of the fracture, in the event of instability of the vertical dimension-especially in the absence of dental supporting zones-and in dislocated fractures [4][5][6][7][8][9][10][11][12][13]. Especially in the case of multifragmented condylar head fractures, patients can benefit functionally from surgical treatment, especially regarding avoidance of occlusion disorders [5,10,11]; however, surgical treatment of such multifragmented condylar head fractures is routinely performed only at specialized centers because of the considerable effort and expertise required [14]. ...
Prolonged operation times should be avoided due to the associated complications and negative effects on the efficiency of the use of operating room resources. Surgical treatment of mandibular condylar head fractures is a well-established routine procedure at our department, nevertheless, we recognized fluctuating operating times. This study aims to pinpoint the influencing factors, in particular the hypothesis whether the efficiency of intraoperative muscle relaxation may decisively affect the duration of surgery. It analyses 168 mandibular condylar head fractures that were surgically treated in the period from 2007 to 2022 regarding the duration of the surgery and potential factors affecting it. The potential predictors’ influence on the dependent variable operation time was mainly calculated as a bivariate analysis or linear regression. Efficiency of relaxation (p ≤ 0.001), fragmentation type (p = 0.031), and fracture age (p = 0.003) could be identified as decisive factors affecting the duration of surgery, as the first surgeon was a constant. In conclusion, surgical intervention should start as soon as possible after a traumatic incident. In addition, a dosage regimen to optimize the efficiency of relaxation should be established in future studies. Fragmentation type and concomitant fractures should also be considered for a more accurate estimation of the operating time.
... Seven RCTs including 368 patients comparing rigid MMF/Functional treatment (n=189) to 2-miniplates (n=170) with respect to malocclusion. 31,33,36,37,39,50 The follow up time ranged from one postoperative day to 3.5 years. There was significant reduction of malocclusion after 2-miniplates when compared to closed treatment at follow up time of less than 6 months (RR= 3.7, CI: 1.46 to 4.9, P = 0.001, moderate quality evidence) and more than 6 postoperative months (RR= 2.68, CI: 1.75 to 8.1, P = 0.001, moderate quality evidence). ...
... there was heterogeneity (I 2 =81), So, random effect model was used.b. Direct meta-analysis, functional treatment vs ORIF with 2-miniplatesSix RCTs including 300 patients compared MMO in patients treated with AB functional treatment (n=162) or ORIF with 2-miniplates (n=138).32,34,40,41,46,50 The follow up time ranged from one month to 3.5 years. ...
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 PRISMA guidelines, a systematic search was conducted in three major databases up to January 2023 to retrieve randomized controlled trials (RCTs) that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (AB) + wire maxillomandibular fixation (MMF), rigid MMF with IMF 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 (SMD) were calculated. Version 2 of the Cochrane risk-of-bias tool and GRADE 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, 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 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)
Conclusion
This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat CMPFs (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)
... 17 Several studies showed a positive association of CR treatment approach with pain when chewing. [18][19][20][21] In the general population, the prevalence of mood disorders (including depressive mood) during the postinjury period is 18%. Mood disorders develop regardless of severity of injuries (ie, patients with minor or major injuries suffer equally from postoperative depressive mood). ...
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.
MATERIALS AND METHODS
This cross-sectional study surveyed patients at Grady Memorial Hospital in Atlanta, Georgia from November 2016 to June 2020. 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 (CR) 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, and bivariate, and ordinal regression analysis were performed (P < 0.05 significance).
RESULTS
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 = 0.002), do not require pain medications (tau = 0.389, p = 0.002), reported larger MIO (tau = 0.402, p = 0.0003), and 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= 0.29) and statistically significant associated with excellent QOL (estimate: -2; OR: 0.13; p = 3.99e-05). Patients who sustained class 3 Lindahl mandibular condyle fracture were statistically significantly associated with depressed mood (estimate: 1.46; OR: 4.33; p = 0.002)
CONCLUSION
ORIF treatment was positively associated with better QOL when compared to CR for mandibular condyle fracture.
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 1-5 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, chi-square test was performed. The level of significance was set at p<0.05.
Results
38 MSF in 37 subjects were included. Mean age was 32.7 years (range 18-64), 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=0.011), rhomboid (-1.29, p=0.036), and ladder miniplates (-1.38, p=0.048). 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- 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.
The treatment of condylar fractures has been the subject of debate and controversy. Open reduction and internal fixation, along with closed reduction, are the 2 main treatment modalities when well indicated and performed. In specific situations, however, the success of both treatment modalities can be challenged by local or systemic conditions. Alloplastic total temporomandibular joint replacement (TMJR) with the current systems, Biomet and Stryker, has proven to be successful in the long-term. The authors present 2 cases and propose the consideration of TMJR as a first-line treatment for condylar fractures in the following situations: fractures older than 4 weeks; 2) elderly patients with severely dislocated or displaced condyles; 3) condylar dislocation into the cranial fossa; 4) maxillomandibular fixation is not a viable option.
