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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2018;18(7):e7344 doi: 10.5867/medwave.2018.07.7351
Surgical or conservative treatment for mandibular condyle fractures
Javier Cuéllar, Josefina Santana, Cristián Núñez, Julio Villanueva
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Key Words: Mandibular condyle fractures, Epistemonikos, GRADE.

Abstract

INTRODUCTION
Maxillofacial fractures are associated with significant morbidity, loss of function and aesthetic sequelae, among others. Within mandibular fractures, mandibular condylar fractures are the most frequent. These can be treated by surgical treatment or conservative treatment (orthopedic).

METHODS
We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS
We identified eight systematic reviews including 66 primary studies overall, of which six were randomized trials. We concluded surgical treatment of mandibular condyle fractures, compared to conservative treatment, is probably associated with less joint pain, less malocclusion and less lateral deviation in buccal opening.


 
Problem

The mandible is one of the most frequently fractured bony structures, with mandibular condyle fractures being the most recurrent (25% to 35% of total cases) [1]. In general terms, there are two definitive treatment options for mandibular condyle fractures: surgical and conservative.
The surgical options are open reduction of the condyle fracture, mainly by miniplates and titanium screws, and intraosseous fixation wires. Conservative or orthopedic treatment consist of intermaxillary fixation for one to two weeks duration and temporal fixation elements such as Erich splints, Ivy handles, monocortical or elastic screws.
Clinicians generally favor surgical treatment because it achieves a closer to normal anatomical reduction, a better recovery of joint function and adjacent soft tissues, among others. However, it is associated with an increased risk of neurological damage.
On the other hand, conservative or orthopedic treatment avoids surgical intervention with acceptable results, due to the capacity of condylar remodeling and the masticatory system. But, it carries a higher risk of temporomandibular joint pain, pseudarthrosis, facial asymmetry and malocclusion.

Methods

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others, to identify systematic reviews and their included primary studies. We extracted data from the identified reviews and reanalyzed data from primary studies included in those reviews. With this information, we generated a structured summary denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos) using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies when it is possible, a summary of findings table following the GRADE approach and a table of other considerations for decision-making.

Key messages

  • Surgical treatment, compared to conservative treatment, probably leads to less joint pain, malocclusion and lateral deviation in buccal opening in mandibular condyle fractures.
  • It is not clear if there are differences between surgical and conservative treatment in terms of the risk of facial paralysis, pseudoarthrosis or infection, because the certainty of the evidence is very low.
About the body of evidence for this question

What is the evidence.
See evidence matrix in Epistemonikos later

We found eight systematic reviews [2], [3], [4], [5], [6], [7], [8], [9] including 66 primary studies [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75] of which six were randomized controlled trials [18], [25], [33], [42], [46], [72].

This table and the summary in general are based on the latter, since the inclusion of observational studies did not increase the certainty of the evidence or provide relevant additional information.

What types of patients were included*

All trials included adults with unilateral mandibular condyle fracture. Only one trial also considered bilateral mandibular condyle fracture [45].
Three trials included only patients with subcondylar fractures [25], [33], [42].
Two trials included patients with a history of temporomandibular disorder [33], [46].

What types of interventions were included*

All trials used titanium miniplates as part of the surgical treatment.
Five trials used retromandibular access [18], [25], [33], [42], [46], four used preauricular access [18], [33], [46], [72], two transoral access [18], [46], two anteroparotid transmasseteric access [25], [33] and two submandibular access [18], [33].
All trials used maxillomandibular fixation with elastics as conservative treatment.

What types of outcomes
were measured

The trials measured multiple outcomes, which were pooled by the identified systematic reviews as follows:

  • Pain in temporomandibular joint
  • Malocclusion
  • Infection 
  • Lateral deviation in mouth opening
  • Reoperation
  • Salivary fistula
  • Pseudoarthrosis
  • Facial paralysis
  • Laterotrusion
  • Protrusion
  • Clicking joints

The duration of three trials was between four to six weeks [33], [42], [72]; in two trials it was 10 days [18], [46] and in one trial between seven to 35 days [25].

* The information about primary studies is extracted from the systematic reviews identified, unless otherwise specified.

Summary of Findings

Information on the effects of surgical compared to conservative treatment for mandibular condylar fractures is based on six randomized trials involving 288 patients.

Four trials measured pain in temporomandibular joint (138 patients) [25], [33], [42], [72], one trial reported infection (22 patients) [42], all trials measured malocclusion (288 patients) [18], [25], [33], [42], [46], [72], three trials measured lateral deviation in buccal opening (128 patients) [18], [25], [42] and two trials measured facial paralysis without presenting events [18], [25].
The summary of findings is as follows:

  • Surgical treatment probably leads to less joint pain than conservative treatment in mandibular condyle fractures. The certainty of the evidence is moderate.
  • Surgical treatment probably leads to less malocclusion than conservative treatment in mandibular condyle fractures. The certainty of the evidence is moderate.
  • It is not clear if there are differences in the risk infection between surgical and conservative treatment because the certainty of the evidence is very low.
  • Surgical treatment probably leads to less open lateral deviation than conservative treatment in mandibular condyle fractures. The certainty of the evidence is moderate.
  • It is not clear if there are differences in the risk of facial paralysis between surgical and conservative treatment because this outcome was not reported.
  • It is not clear if there are differences in the risk of pseudoarthrosis between surgical and conservative treatment because this outcome was not reported.

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)

Other considerations for decision-making

To whom this evidence does and does not apply
  • The included studies evaluated adult patients with mandibular condyle fracture, without restrictions based on comorbidity or use of drugs. 
  • This evidence does not apply to children, adults with mandibular condyle fracture in osteoporotic or neoplastic pathological bone (metastasis or primary).
About the outcomes included in this summary
  • The outcomes presented in the summary of findings table are those considered critical for decision-making by the authors of this summary. In general, they coincide with the outcomes reported by the systematic reviews identified.
Balance between benefits and risks, and certainty of the evidence
  • The existing evidence shows a possible benefit of surgical treatment with respect to conservative management.
  • The main advantage of conservative treatment is to avoid perioperative complications, including: post-surgical infection, iatrogenic neurological injury, failure in osteosynthesis and complications related to anesthesia.
  • Even so, being the surgical option possibly the preferable option, it is fundamental to involve the patient in the decision-making process to evaluate the risks and benefits of the conservative versus surgical treatment.
Resource considerations
  • Currently both strategies are widely available, however, the surgical intervention with titanium plates has greater limitations due to the need of a specialist who performs the procedure and the costs involved in the instruments.
What would patients and their doctors think about this intervention
  • Considering the evidence presented in this summary, most patients and clinicians should prefer surgical intervention.
  • However, there might be variability in the decisions made by patients, especially those who prefer to avoid complications of surgical treatment.

Differences between this summary and other sources
  • The conclusions of this summary agree with the most recent systematic reviews, which include all of the studies identified [2], [3], [4], [5], [6], [7], [8], [9].
Could this evidence change in the future?
  • The probability that future research changes the conclusions of this summary is high in relation to the risk of complications, due to the existing uncertainty. It is unlikely that new research could substantially change what we know about the benefits.
  • We identified three ongoing systematic reviews [73], [74], [75] in the PROSPERO database (International Prospective Register of Systematic Reviews).
  • We identified one ongoing trial [76] in the International Clinical Trials Registry Platform of the World Health Organization.
How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.

Follow the link to access the interactive version: Surgical compared with nonsurgical treatments for mandibular condylar fractures.

 

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier.

After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

This article is part of the Epistemonikos Evidence Synthesis project. It is elaborated with a pre-established methodology, following rigorous methodological standards and internal peer review process. Each of these articles corresponds to a summary, denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos), whose main objective is to synthesize the body of evidence for a specific question, with a friendly format to clinical professionals. Its main resources are based on the evidence matrix of Epistemonikos and analysis of results using GRADE methodology. Further details of the methods for developing this FRISBEE are described here (http://dx.doi.org/10.5867/medwave.2014.06.5997)

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

Potential conflicts of interest

The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

INTRODUCCIÓN
Las fracturas maxilofaciales se asocian a importante morbilidad, pérdida de función y secuelas estéticas, entre otros. Dentro de las fracturas mandibulares, las fracturas de cóndilo mandibular son las más frecuentes. Estas pueden ser tratadas mediante un tratamiento quirúrgico (reducción abierta más estabilización con miniplacas de titanio) o un tratamiento conservador (ortopédico).

MÉTODOS
Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE.

RESULTADOS Y CONCLUSIONES
Identificamos ocho revisiones sistemáticas que en conjunto incluyen 66 estudios primarios, de los cuales, seis corresponden a ensayos aleatorizados. Concluimos que, en comparación con el tratamiento conservador, el tratamiento quirúrgico en fracturas de cóndilo mandibular probablemente se asocia a menor dolor articular, menor maloclusión y menor desviación lateral en apertura bucal.

Authors: Javier Cuéllar[1,4], Josefina Santana[3,4], Cristián Núñez[2,3,4], Julio Villanueva[1,2,4]

Affiliation:
[1] Servicio Maxilofacial, Hospital Clínico San Borja Arriarán, Santiago, Chile
[2] Departamento de Cirugía y Traumatología Bucal y Maxilofacial, Facultad de Odontología, Universidad de Chile
[3] Servicio de Cabeza y Cuello y Plástica Maxilofacial, Hospital Barros Luco Trudeau, Santiago, Chile
[4] Proyecto Epistemonikos, Santiago, Chile

E-mail: javm@uchile.cl

Author address:
[1] Centro Evidencia UC
Pontificia Universidad Católica de Chile
Diagonal Paraguay 476
Santiago
Chile

Citation: Cuéllar J, Santana J, Núñez C, Villanueva J. Surgical or conservative treatment for mandibular condyle fractures. Medwave 2018;18(7):e7344 doi: 10.5867/medwave.2018.07.7351

Submission date: 13/5/2018

Acceptance date: 23/10/2018

Publication date: 26/11/2018

Origin: This article is a product of the Evidence Synthesis Project of Epistemonikos Fundation, in collaboration with Medwave for its publication.

Type of review: Non-blinded peer review by members of the methodological team of Epistemonikos Evidence Synthesis Project.

PubMed record

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Silvennoinen U, Raustia AM, Lindqvist C, Oikarinen K. Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. A prospective one-year study. Int J Oral Maxillofac Surg. 1998 Aug;27(4):280-5. | PubMed |

Murakami K, Yamamoto K, Sugiura T, Yamanaka Y, Kirita T. Changes in mandibular movement and occlusal condition after conservative treatment for condylar fractures. J Oral Maxillofac Surg. 2009 Jan;67(1):83-91. | CrossRef | PubMed |

Throckmorton GS, Ellis E 3rd, Hayasaki H. Masticatory motion after surgical or nonsurgical treatment for unilateral fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2004 Feb;62(2):127-38. | PubMed |

Ling J, Chu Z. [Anatomical and functional studies on surgical and non-surgical treatment of mandibular condylar process fractures]. Hua Xi Kou Qiang Yi Xue Za Zhi. 2001 Oct;19(5):306-8. Chinese. | PubMed |

Feifel H, Risse G, Opheys A, Bauer W, Reineke T. [Conservative versus surgical therapy of unilateral fractures of the collum mandibulae--anatomic and functional results with special reference to computer-assisted 3-dimensional axiographic registration of condylar paths]. Fortschr Kiefer Gesichtschir. 1996;41:124-7. German. | PubMed |

Ellis E 3rd, Throckmorton G. Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2000 Jul;58(7):719-28; discussion 729-30. | PubMed |

Neff A, Kolk A, Neff F, Horch HH. [Surgical vs. conservative therapy of diacapitular and high condylar fractures with dislocation. A comparison between MRI and axiography]. Mund Kiefer Gesichtschir. 2002 Mar;6(2):66-73. German. | PubMed |

Ellis E 3rd, Throckmorton GS. Bite forces after open or closed treatment of mandibular condylar process fractures. J Oral Maxillofac Surg. 2001 Apr;59(4):389-95. | PubMed |

Chen LJ, Hu M, Zhang LH, Wen WS, Liu SX, Zhan X. [Comparison of therapeutic efficacy between surgical and non-surgical treatment on mandibular condylar fractures]. Shanghai Kou Qiang Yi Xue. 2010 Aug;19(4):372-7. Chinese. | PubMed |

Sandner O. Conservative and surgical treatment of condylar fractures of the temporomandibular joint. Int J Oral Surg. 1974;3(5):218-22. | PubMed |

Rasheed A, Mumtaz M, Bhatti MU. Comparison of surgical with nonsurgical treat- ment for fractured mandibular condyle—a study. Pakistan Oral Dent J. 2010;30:295–8.

Yamamoto K, Murakami K, Sugiura T, Kirita T. Factors affecting mandibular function after conservative treatment of condylar fractures. Asian J Oral Maxillof Surg. 2004;16:160–5.

Leon M, Ulloa C, Nunez C, Gazitua G, Cerda P: Surgical and non-surgical treatment of mandibular condylar fracture: a comparison of results. Int J Oral Maxillofac Surg 1034, 2011.

De Riu G, Gamba U, Anghinoni M, Sesenna E. A comparison of open and closed treatment of condylar fractures: a change in philosophy. Int J Oral Maxillofac Surg. 2001 Oct;30(5):384-9. | PubMed |

Cardoso L, Fernandes A, Simamoto P. Complications associated with surgical or non-surgical treatment of mandibular condylar fractures: a systematic review. [CRD42017052346]. | Link |

Gualberto J, Rodrigues A, Cavalcanti S. Endoscope-assisted transoral reduction and internal fixation versus closed treatment of mandibular condylar fractures: a systematic review. [CRD42017064237]. | Link |

Cavalcanti S, Rodrigues A, Gualberto J. Endoscopic versus open reduction treatment of mandibular fractures: a meta-analysis. [CRD42017063762] | Link |

Ellis E, Díaz V. International, Multicenter, Prospective Registry to Collect Data of Treatment Patterns in Patients With Bilateral Condylar Fracture (BCFx) of the Mandible. [NCT02884765]. | Link |

Sawazaki, R., Lima Júnior, S.M., Asprino, L., Moreira, R.W.F., de Moraes, M., 2010. Incidence and patterns of mandibular condyle fractures. J. Oral Maxillofac. Surg. 68, 1252–1259, | CrossRef |

July 2022, Vol 22, Issue 6
icon Research papers
Association of biomarkers and severity of COVID-19: A crosssectional study

Systematization of initiatives in sexual and reproductive health about good practices criteria in response to the COVID-19 pandemic in primary health care in Chile

Clinical, psychological, social, and family characterization of suicidal behavior in Chilean adolescents: a multiple correspondence analysis

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