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Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management
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ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2020) xxx–xxx
Review
Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management A. Alyahya ∗ , A. Bin Ahmed, Y. Nusair, R. Ababtain, A. Alhussain, A. Alshafei Department of Oral and Maxillofacial Surgery, King Abdulaziz Medical City, National Guard, Riyadh, 14611, Saudi Arabia Accepted 14 March 2020
Abstract 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. © 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Mandibular Condyle fracture; Surgical treatment; Non-surgical treatment; Open and closed treatment; Systematic review
Introduction Before the era of internal rigid fixation and computed tomographic (CT) scanning, predicting the outcome of surgically-treated mandibular condylar fractures was extremely difficult.1,2 Initial trials faced difficulties in the exploration of the surgical anatomy and struggled with the armamentarium and wire fixation. These trials yielded multiple surgical complications and disappointing outcomes of treatment, which led surgeons to think that non-surgical treatment was the preferred choice in condylar fractures.3–5 With improvements in diagnostic and surgical tools, the understanding of anatomy, and the availability of internal rigid fixation, surgical treatment started to show its superiority ∗
over non-surgical treatment in certain cases.6–14 In addition, condylar fractures are now recognised as a complex entity, and the need to differentiate between cases most likely to benefit from surgical treatment, and cases better managed by non-surgical treatment, has become more evident. Many indications for surgical treatment have been proposed that depend on many factors such as; age, level of the fracture, degree of dislocation or displacement, malocclusion, other associated fractures, loss of height of the ramus, and facial asymmetry.15 Despite the tremendous effort by research workers to clarify criteria for the management of condylar fractures, many surgeons find themselves in a dilemma every time they encounter one. The aim of this paper was to review all systematic reviews of surgical compared with non-surgical treatment of condylar fractures systematically, and to propose an algorithm for their management.
Corresponding author. Tel.:+966 50 4169769. E-mail address: [email protected] (A. Alyahya).
https://doi.org/10.1016/j.bjoms.2020.03.014 0266-4356/© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Alyahya A, et al. Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.03.014
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Table 1 Inclusion and exclusion criteria. Criteria Inclusion criteria: Systematic review and meta-analysis of randomised or non-randomised controlled trials Adult condylar fracture In English Exclusion criteria: Non-systematic review No studies on children Critically low overall rate as judged by AMSTAR 2 Table 2 Keywords used in search. Keywords Mandibular condyle fracture Mandibular subcondylar fracture Mandibular neck fracture Open treatment Open reduction and internal fixation Closed treatment Conservative treatment Surgical treatment Non-surgical treatment Systematic review Meta-analysis
screened by title and abstract, and duplicates or irrelevant reports were excluded. Full texts of the remaining articles were read and further exclusions made according to the exclusion criteria. Reference lists of the identified systematic reviews were checked and citations of related studies were searched using Google Scholar. The search strategy was reviewed by, and agreed, by a health information specialist.
Data collection Using a standardised collection form, the following variables were recorded: date of conducting the review search, the focused question, type of included studies, the primary measured outcome, collected variables, review, conclusion and recommendations. In case of meta-analyses the outcome comparison and pooled complication rates were also included. Two independent reviewers (AY and AB) were involved in searching, screening, reviewing, and collecting data. There were no disagreements between the two reviewers except for the inclusion of one systematic review (Sherif 2010)25 which after discussion, the reviewers agreed to exclude as it included no studies.
Methods Results A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement.16 The protocol for this review was established before the beginning of the identification and review process. Criteria for eligibility All systematic reviews and meta-analyses published before January 2019 (the time the study was begun) that compared the outcome of surgical compared with non-surgical treatment of mandibular condylar fractures in adults were considered. Only reviews of human studies and that were published in English were considered. The quality of the systematic reviews and meta-analyses was evaluated with AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews - 2) 17 and reviews that were rated “critically low” were excluded (Table 1). Search strategy A pilot search was made on PubMed (National Library of Medicine, NCBI) about the management of mandibular condylar fractures to identify relevant keywords. The terms were analysed with medical subject headings (MeSH) and a list of keywords developed (Table 2). In January 2019 a comprehensive search was made on PubMed, the Cochrane Database of Systematic Reviews, and The Database of Abstracts of Reviews of Effects (DARE). The results were
The database search yielded 186 studies. After screening titles and removing duplicates, 22 papers were considered, and their full texts were obtained and read. Only 10 reviews were systematic and restricted to surgical compared with non-surgical treatment of mandibular condylar fractures in adults (Table 3). All 10 reviews were evaluated and rated by AMSTAR-2 and only two reviews met our inclusion criteria (Fig. 1). The two reviews included11,13 were both completed in 2015 and contained meta-analyses. Similar studies were included in both reviews, but Chrcanovic had broader selection criteria and included 14 more studies. Both reviews had randomised, non-randomised, and retrospective studies. The common comparative outcomes were: maximum interincisal opening (MIO), lateral excursion, protrusion (protrusive movement), lateral deviation of the chin during MIO, pain and sounds in the temporomandibular joint (TMJ), malocclusion, and complications. Surgical treatment had a significantly better outcome in both meta-analyses in terms of malocclusion, protrusion, lateral excursion, and lateral deviation of the chin during MIO. Additionally, Al-Moraissi and Ellis 11 found significantly better outcomes of surgical treatment for pain during MIO and in the TMJ. The incidence of facial nerve injury in the pooled data was 8.3%, and only 2.2% had not recovered after six months. Both reviews concluded that surgical treatment has a better outcome than non-surgical treatment, but both stressed the need for better-designed randomised trials to support this conclusion.
Please cite this article in press as: Alyahya A, et al. Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.03.014
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Table 3 AMSTAR-2 evaluation of the systematic reviews. First author, year, and reference
Overall AMSTAR rate
Weakness
Decision
Almoraissi 201511
Moderate
Include
Berner 201512
Critically low
Chrcanovic 201226
Critically low
Chrcanovic 201513
Moderate
Garc´ia-Guerrero 201714
Critically low
Kyzas 20128
Critically low
Liu 20139
Critically low
Nussbaum 200824
Critically low
Sharif 201025 Yao 201410
Moderate Critically low
No double selection and review No report of studies funding No report of review funding Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No report of review funding No justification of excluded studies* Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No report of review funding No justification of excluded studies* No consideration of risk of bias* No report of publication bias* No double selection and review No report of studies funding Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No justification of excluded studies* No consideration of risk of bias* No report of publication bias* No report of meta-analytic method* No report of publication bias* No double selection Protocol was not registered* No report of studies funding No report of review funding No justification of excluded studies* Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No justification of excluded studies* It did not include any study No report of publication bias* No justification of excluded studies* No double selection No detailed studies report No report of studies funding No report of review funding
∗
Exclude
Exclude
Include Exclude
Exclude
Exclude
Exclude
Exclude Exclude
Critical weakness.
Discussion Although treating other mandibular fractures with nonsurgical treatment is possible, no one doubts the superiority of surgical treatment over non-surgical treatment for an angle fracture, for example. Open reduction and internal fixation offers fast recovery with predictable occlusion and eliminates the need for intermaxillary fixation, which allows quick return to normal diet and better oral hygiene.18,19 In condylar fractures the case is different, because of the complexity of the surgical access.
The risk of facial nerve injury could be the main reason that many surgeons choose non-surgical treatment for condylar fractures.20 Unfortunately, the studies included in our systematic reviews reported no more than six months follow-up of the incidence of facial nerve injury in cases managed with surgical treatment, even though it is generally accepted that at least one year of follow-up is required to report a permanent nerve injury.21 Reducing this terminal articulating part is made more complicated because the surgeon needs to reduce the fracture line as well as the dislocated head. It is also of great importance to preserve the limited blood supply and the integrity of the joint capsule and meniscus. The superiority of
Please cite this article in press as: Alyahya A, et al. Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.03.014
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Fig. 1. Flowchart of the search and selection process according to PRISMA.
surgical treatment for condylar fractures has therefore been questioned based on reducing risks rather than assuming a better outcome.15 To answer the question whether surgical treatment gives better outcomes than non-surgical treatment, the correct reply is: for which case? This question has no correct answer if it is assumed that condylar fractures are a single entity. Intracapsular comminuted fractures cannot be mixed with subcondylar fractures in one group and the outcome of surgical and non-surgical treatment compared. Randomisation is correct only for similar injuries, and this may be the cause of variable outcomes among patients who were incorrectly randomised with no clear indications for each treatment. There are a lot of classifications for condylar fractures, but none of them helps the clinician to decide which cases need to be treated surgically and which can be treated nonsurgically.6 In 1983, Zide and Kent 22 proposed the absolute and relative indications for surgical treatment; these have been modified over the years and served as a reference for many surgeons.23 They were developed before CT scans and rigid internal fixation, and based on the authors’ experience of certain clinical presentations, which may vary from what the surgeon sees in real practice. Other studies have discussed factors such as the age of the patient, the degree of dislocation and displacement of the fracture, the dental status of the patient, unilateral compared with bilateral fractures, the size of the fractured segment, and the presence of other facial fractures which must be consid-
ered when deciding the treatment options. 24–26 In a valuable article, Assael in 2003 discussed 26 variables which should be considered in selecting the treatment of choice for condylar fractures. 15 A clinical decision algorithm that guides the surgeon to a predictable outcome, while taking into consideration the clinical findings and the available resources, is therefore needed. Development of the algorithm We propose an algorithm based on the best available evidence, the common clinical practice and the experience of a group of surgeons working in a trauma centre (Fig. 2). The first logical step is to check the feasibility of fixing the fractured condyle. Surgical treatment without the ability to fix the fracture is just extra trauma for the patient. The ability to fix a condylar fracture is dependent on comminution of the fracture, available resources and training, and experience of the surgeon.27–30 As a condylar neck fracture could be difficult to fix in the absence of a proper armamentarium and lack of surgical experience, non-surgical treatment would be the treatment of choice. On the other hand, a small fracture of the head could be approached and fixed with resorbable screws by an experienced surgeon in a well-equipped hospital.31 We think that, regardless of any other factor, the inability to fix a condylar fracture is a contraindication for surgical treatment. The second step is to check the dislocation of the condyle. To guarantee a functioning joint, the condylar head should
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Fig. 2. Algorithm for management of condylar fractures.
be reduced to the glenoid fossa. 10,32–34 Although extra-fossa articulation is possible and seen in some cases, it is extremely unpredictable to leave a dislocated condyle with such an assumption. The capacity of the condyle to remodel and return to function without operation depends on the degree of dislocation and the age of the patient.35–37 The dislocated condyle may remain in situ without any complications, except being non-functional. However, chronic pain associated with non-surgical treatment has been reported. 38,39 Even though one of the systematic reviews included in this study reported significantly better outcomes in terms of TMJ pain for surgical treatment, the pretraumatic status of the TMJ was not reported, and so the actual effect of the injury, or the selected method of treatment, or both, remain unclear. In the case of a unilateral condylar fracture, the patient might be guided into good occlusion with closed treatment, but the long-term consequences of the overloaded contralateral joint are not known. 40 In the systematic reviews included in this study, chin deviation/asymmetry during MIO was more significant with non-surgical treatment.11,13 This means that the entire mandible is dependent on the contralateral joint during function, and ipsilateral posterior teeth serve as a vertical stop that may predispose them to occlusal trauma.15 In cases of bilateral condylar fractures, having one or two dislocated condyles further compromises posterior facial height and leads to loss of the posterior stop and articulation with
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associated malocclusion.41–43 One of the main goals of the treatment of condylar fractures is to restore normal mandibular function, which will be more predictable if the dislocated condyle is reduced. When the condylar head is dislocated outside the glenoid fossa (and it is possible to reduce and fix it), therefore, surgical treatment becomes indicated. In a non-dislocated condylar fracture, the next step is to check the displacement of the fracture. One must ensure good union of the fractured condyle because in case of non-union, the goal of restoring the TMJ as a functional unit is not achieved, and the same possible compromised outcome of a dislocated condyle could happen. Malunion of one of the fracture ends could also result in restricted mandibular movement. In one of the systematic reviews included, the MIO was significantly better in the surgical treatment group than in the non-surgical treatment group.11,13 In a non-displaced or minimally displaced fracture, good bony union could be achieved by non-surgical treatment, so if the fracture is displaced to the extent that may compromise healing, surgical treatment is indicated. When the articulation of the condyle and union of the fracture are predictable, checking the occlusion of the patient should be the next step. If the occlusion cannot be guided ¨ because of interference by the fracture, or if there is dropping back¨as a result of lack of a posterior stop, then surgical intervention is recommended.44 In addition, the presence of other factors that make non-surgical treatment unpredictable, such as other mandibular fractures, mid-facial fractures, or partial edentulism, are an indication that surgical treatment should be considered.15,45 In cases where occlusal discrepancy is minor and the patient could benefit from orthognathic surgery because of pretraumatic malocclusion, the surgeon may suggest nonsurgical treatment with an orthognathic plan. This could also be applicable for a growing patient with mixed dentition. If the occlusion is good or can easily be guided, non-surgical treatment should be considered. In edentulous patients, occlusion can be checked on existing dentures. In a non-dislocated and non-displaced condylar fracture in an edentulous patient, surgical treatment is hardly justified, particularly when their medical status is considered. Predictable healing of the fracture will take place with conservative treatment and then their dentures can be adjusted or replaced. The last step is to check whether the patient is a good candidate for non-surgical treatment or not. 46,47 He or she might not be able to follow non-surgical treatment instructions because of any medical or psychological factors (disabled or unconscious) or might need quick recovery for social (job demand, travel,or a prisoner) or economic reasons (cost of multiple follow-up visits compared with surgery). In these cases, surgical treatment may be more predictable than nonsurgical treatment. On the other hand, patients who would not tolerate any chance of facial nerve injury or other surgical complications should be treated non-surgically. Although facial scarring is well concealed with the contemporary
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approaches to condylar fracture, scarring is the most frequent complaint from patients.39 After all, what the patient wants is a major factor in deciding the treatment.15 The patient’s medical status and fitness for general anaesthesia should be considered, together with the algorithm as an independent factor for all patients. This treatment algorithm is based on four main factors: the feasibility of fixation, restoring joint and occlusal function, ensuring adequate healing of the fracture, and considering patient-centred factors. The indications for surgical treatment should not include the presence of a foreign body or the displacement of the condyle to the middle cranial fossa, because this will be the treatment of the complication, not the fracture. We think that the factors discussed in our algorithm are already used by many surgeons and supported by the best available evidence. The formulation of such an algorithm aims to help surgeons with different circumstances in the decision-making process. Although the algorithm needs to be validated by randomised controlled trials, preliminary retrospective analysis of the patients who underwent treatment of condylar fractures in our centre showed promising results. We invite research workers to analyse their data and compare the outcome and rate of complications in patients who were treated by following this algorithm with those in patients who were treated otherwise. Obviously, patients who were not treated properly (either with surgical or non-surgical treatment) should be excluded.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission Not applicable.
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8. Kyzas PA, Saeed A, Tabbenor O. The treatment of mandibular condyle fractures: a meta-analysis. J Craniomaxillofac Surg 2012;40:e438–52. 9. Liu Y, Bai N, Song G, et al. Open versus closed treatment of unilateral moderately displaced mandibular condylar fractures: a meta-analysis of randomized controlled trials. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:169–73. 10. Yao S, Zhou J, Li Z. Contrast analysis of open reduction and internal fixation and non-surgical treatment of condylar fracture: a meta-analysis. J Craniofac Surg 2014;25:2077–80. 11. Al-Moraissi EA, Ellis III E. Surgical treatment of adult mandibular condylar fractures provides better outcomes than closed treatment: a systematic review and meta-analysis. J Oral Maxillofac Surg 2015;73:482–93. 12. Berner T, Essig H, Schumann P, et al. Closed versus open treatment of mandibular condylar process fractures: a meta-analysis of retrospective and prospective studies. J Craniomaxillofac Surg 2015;43:1404–8. 13. Chrcanovic BR. Surgical versus non-surgical treatment of mandibular condylar fractures: a meta-analysis. Int J Oral Maxillofac Surg 2015;44:158–79. 14. Garcia-Guerrero I, Ramirez JM, Gomez de Diego R, et al. Complications in the treatment of mandibular condylar fractures: Surgical versus conservative treatment. Ann Anat 2018;216:60–8. 15. Assael LA. Open versus closed reduction of adult mandibular condyle fractures: an alternative interpretation of the evidence. J Oral Maxillofac Surg 2003;61:1333–9. 16. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009;62:e1–34. 17. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358, j4008. 18. Phelps-Sandall BA, Oxford SJ. Effectiveness of oral hygiene techniques on plaque and gingivitis in patients placed in intermaxillary fixation. Oral Surg Oral Med Oral Pathol 1983;56:487–90. 19. Hayter JP, Cawood JI. The functional case for miniplates in maxillofacial surgery. Int J Oral Maxillofac Surg 1993;22:91–6. 20. Bruneau S, Courvoisier DS, Scolozzi P. Facial nerve injury and other complications following retromandibular subparotid approach for the management of condylar fractures. J Oral Maxillofac Surg 2018;76:812–8. 21. Gordin E, Lee TS, Ducic Y, et al. Facial nerve trauma: evaluation and considerations in management. Craniomaxillofac Trauma Reconstr 2015;8:1–13. 22. Zide MF, Kent JN. Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 1983;41:89–98. 23. Zide MF. Open reduction of mandibular condyle fractures. Indications and technique. Clin Plast Surg 1989;16:69–76. 24. Nussbaum ML, Laskin DM, Best AM. Closed versus open reduction of mandibular condylar fractures in adults: a meta-analysis. J Oral Maxillofac Surg 2008;66:1087–92. 25. Sharif MO, Fedorowicz Z, Drews P, et al. Interventions for the treatment of fractures of the mandibular condyle. Cochrane Database Syst Rev 2010. Cd006538. 26. Chrcanovic BR. Open versus closed reduction: diacapitular fractures of the mandibular condyle. Oral Maxillofac Surg 2012;16:257–65. 27. Assael LA. Assisting the deficient resident in oral and maxillofacial surgery. J Oral Maxillofac Surg 1987;45:1058–61. 28. Assael LA. Evaluation of rigid internal fixation of mandible fractures performed in the teaching laboratory. J Oral Maxillofac Surg 1993;51:1315–9. 29. Sugiura T, Yamamoto K, Murakami K, et al. A comparative evaluation of osteosynthesis with lag screws, miniplates, or Kirschner wires for mandibular condylar process fractures. J Oral Maxillofac Surg 2001;59:1161–70. 30. Assael LA. A devotion to trauma. J Oral Maxillofac Surg 2003;61:415–6.
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31. McLeod NM, Saeed NR. Treatment of fractures of the mandibular condylar head with ultrasound-activated resorbable pins: early clinical experience. Br J Oral Maxillofac Surg 2016;54:872–7. 32. Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 1: patterns of distribution of types and causes of fractures in 348 patients. Br J Oral Maxillofac Surg 2000;38:417–21. 33. Eckelt U, Schneider M, Erasmus F, et al. Open versus closed treatment of fractures of the mandibular condylar process-a prospective randomized multi-centre study. J Craniomaxillofac Surg 2006;34:306–14. 34. Abdel-Galil K, Loukota R. Fractures of the mandibular condyle: evidence base and current concepts of management. Br J Oral Maxillofac Surg 2010;48:520–6. 35. Hollender L, Lindahl L. Radiographic study of articular remodeling in the temporomandibular joint after condylar fractures. Scand J Dent Res 1974;82:462–5. 36. Lindahl L. Condylar fractures of the mandible. I. Classification and relation to age, occlusion, and concomitant injuries of teeth and teethsupporting structures, and fractures of the mandibular body. Int J Oral Surg 1977;6:12–21. 37. Lindahl L, Hollender L. Condylar fractures of the mandible. II: a radiographic study of remodeling processes in the temporomandibular joint. Int J Oral Surg 1977;6:153–65. 38. Umstadt HE, Ellers M, Muller HH, et al. Functional reconstruction of the TM joint in cases of severely displaced fractures and fracture dislocation. J Craniomaxillofac Surg 2000;28:97–105.
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39. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg 2001;59:370–6. 40. Tabrizi R, Bahramnejad E, Mohaghegh M, et al. Is the frequency of temporomandibular dysfunction different in various mandibular fractures? J Oral Maxillofac Surg 2014;72:755–61. 41. Chen CT, Feng CH, Tsay PK, et al. Functional outcomes following surgical treatment of bilateral mandibular condylar fractures. Int J Oral Maxillofac Surg 2011;40:38–44. 42. Forouzanfar T, Lobbezoo F, Overgaauw M, et al. Long-term results and complications after treatment of bilateral fractures of the mandibular condyle. Br J Oral Maxillofac Surg 2013;51:634–8. 43. Ho SY, Liao HT, Chen CH, et al. The radiographic and functional outcome of bilateral mandibular condylar head fractures: a comparison between open and closed treatment. Ann Plast Surg 2015;74(suppl 2):S93–8. 44. Ellis III E. Method to determine when open treatment of condylar process fractures is not necessary. J Oral Maxillofac Surg 2009;67:1685–90. 45. He D, Ellis III E, Zhang Y. Etiology of temporomandibular joint ankylosis secondary to condylar fractures: the role of concomitant mandibular fractures. J Oral Maxillofac Surg 2008;66:77–84. 46. Walker RV. Condylar fractures: nonsurgical management. J Oral Maxillofac Surg 1994;52:1185–8. 47. Mitchell DA. A multicentre audit of unilateral fractures of the mandibular condyle. Br J Oral Maxillofac Surg 1997;35:230–6.
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Review
Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management A. Alyahya ∗ , A. Bin Ahmed, Y. Nusair, R. Ababtain, A. Alhussain, A. Alshafei Department of Oral and Maxillofacial Surgery, King Abdulaziz Medical City, National Guard, Riyadh, 14611, Saudi Arabia Accepted 14 March 2020
Abstract 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. © 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Mandibular Condyle fracture; Surgical treatment; Non-surgical treatment; Open and closed treatment; Systematic review
Introduction Before the era of internal rigid fixation and computed tomographic (CT) scanning, predicting the outcome of surgically-treated mandibular condylar fractures was extremely difficult.1,2 Initial trials faced difficulties in the exploration of the surgical anatomy and struggled with the armamentarium and wire fixation. These trials yielded multiple surgical complications and disappointing outcomes of treatment, which led surgeons to think that non-surgical treatment was the preferred choice in condylar fractures.3–5 With improvements in diagnostic and surgical tools, the understanding of anatomy, and the availability of internal rigid fixation, surgical treatment started to show its superiority ∗
over non-surgical treatment in certain cases.6–14 In addition, condylar fractures are now recognised as a complex entity, and the need to differentiate between cases most likely to benefit from surgical treatment, and cases better managed by non-surgical treatment, has become more evident. Many indications for surgical treatment have been proposed that depend on many factors such as; age, level of the fracture, degree of dislocation or displacement, malocclusion, other associated fractures, loss of height of the ramus, and facial asymmetry.15 Despite the tremendous effort by research workers to clarify criteria for the management of condylar fractures, many surgeons find themselves in a dilemma every time they encounter one. The aim of this paper was to review all systematic reviews of surgical compared with non-surgical treatment of condylar fractures systematically, and to propose an algorithm for their management.
Corresponding author. Tel.:+966 50 4169769. E-mail address: [email protected] (A. Alyahya).
https://doi.org/10.1016/j.bjoms.2020.03.014 0266-4356/© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Alyahya A, et al. Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.03.014
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Table 1 Inclusion and exclusion criteria. Criteria Inclusion criteria: Systematic review and meta-analysis of randomised or non-randomised controlled trials Adult condylar fracture In English Exclusion criteria: Non-systematic review No studies on children Critically low overall rate as judged by AMSTAR 2 Table 2 Keywords used in search. Keywords Mandibular condyle fracture Mandibular subcondylar fracture Mandibular neck fracture Open treatment Open reduction and internal fixation Closed treatment Conservative treatment Surgical treatment Non-surgical treatment Systematic review Meta-analysis
screened by title and abstract, and duplicates or irrelevant reports were excluded. Full texts of the remaining articles were read and further exclusions made according to the exclusion criteria. Reference lists of the identified systematic reviews were checked and citations of related studies were searched using Google Scholar. The search strategy was reviewed by, and agreed, by a health information specialist.
Data collection Using a standardised collection form, the following variables were recorded: date of conducting the review search, the focused question, type of included studies, the primary measured outcome, collected variables, review, conclusion and recommendations. In case of meta-analyses the outcome comparison and pooled complication rates were also included. Two independent reviewers (AY and AB) were involved in searching, screening, reviewing, and collecting data. There were no disagreements between the two reviewers except for the inclusion of one systematic review (Sherif 2010)25 which after discussion, the reviewers agreed to exclude as it included no studies.
Methods Results A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement.16 The protocol for this review was established before the beginning of the identification and review process. Criteria for eligibility All systematic reviews and meta-analyses published before January 2019 (the time the study was begun) that compared the outcome of surgical compared with non-surgical treatment of mandibular condylar fractures in adults were considered. Only reviews of human studies and that were published in English were considered. The quality of the systematic reviews and meta-analyses was evaluated with AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews - 2) 17 and reviews that were rated “critically low” were excluded (Table 1). Search strategy A pilot search was made on PubMed (National Library of Medicine, NCBI) about the management of mandibular condylar fractures to identify relevant keywords. The terms were analysed with medical subject headings (MeSH) and a list of keywords developed (Table 2). In January 2019 a comprehensive search was made on PubMed, the Cochrane Database of Systematic Reviews, and The Database of Abstracts of Reviews of Effects (DARE). The results were
The database search yielded 186 studies. After screening titles and removing duplicates, 22 papers were considered, and their full texts were obtained and read. Only 10 reviews were systematic and restricted to surgical compared with non-surgical treatment of mandibular condylar fractures in adults (Table 3). All 10 reviews were evaluated and rated by AMSTAR-2 and only two reviews met our inclusion criteria (Fig. 1). The two reviews included11,13 were both completed in 2015 and contained meta-analyses. Similar studies were included in both reviews, but Chrcanovic had broader selection criteria and included 14 more studies. Both reviews had randomised, non-randomised, and retrospective studies. The common comparative outcomes were: maximum interincisal opening (MIO), lateral excursion, protrusion (protrusive movement), lateral deviation of the chin during MIO, pain and sounds in the temporomandibular joint (TMJ), malocclusion, and complications. Surgical treatment had a significantly better outcome in both meta-analyses in terms of malocclusion, protrusion, lateral excursion, and lateral deviation of the chin during MIO. Additionally, Al-Moraissi and Ellis 11 found significantly better outcomes of surgical treatment for pain during MIO and in the TMJ. The incidence of facial nerve injury in the pooled data was 8.3%, and only 2.2% had not recovered after six months. Both reviews concluded that surgical treatment has a better outcome than non-surgical treatment, but both stressed the need for better-designed randomised trials to support this conclusion.
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Table 3 AMSTAR-2 evaluation of the systematic reviews. First author, year, and reference
Overall AMSTAR rate
Weakness
Decision
Almoraissi 201511
Moderate
Include
Berner 201512
Critically low
Chrcanovic 201226
Critically low
Chrcanovic 201513
Moderate
Garc´ia-Guerrero 201714
Critically low
Kyzas 20128
Critically low
Liu 20139
Critically low
Nussbaum 200824
Critically low
Sharif 201025 Yao 201410
Moderate Critically low
No double selection and review No report of studies funding No report of review funding Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No report of review funding No justification of excluded studies* Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No report of review funding No justification of excluded studies* No consideration of risk of bias* No report of publication bias* No double selection and review No report of studies funding Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No justification of excluded studies* No consideration of risk of bias* No report of publication bias* No report of meta-analytic method* No report of publication bias* No double selection Protocol was not registered* No report of studies funding No report of review funding No justification of excluded studies* Protocol was not registered* No comprehensive search* No double selection and review No report of studies funding No justification of excluded studies* It did not include any study No report of publication bias* No justification of excluded studies* No double selection No detailed studies report No report of studies funding No report of review funding
∗
Exclude
Exclude
Include Exclude
Exclude
Exclude
Exclude
Exclude Exclude
Critical weakness.
Discussion Although treating other mandibular fractures with nonsurgical treatment is possible, no one doubts the superiority of surgical treatment over non-surgical treatment for an angle fracture, for example. Open reduction and internal fixation offers fast recovery with predictable occlusion and eliminates the need for intermaxillary fixation, which allows quick return to normal diet and better oral hygiene.18,19 In condylar fractures the case is different, because of the complexity of the surgical access.
The risk of facial nerve injury could be the main reason that many surgeons choose non-surgical treatment for condylar fractures.20 Unfortunately, the studies included in our systematic reviews reported no more than six months follow-up of the incidence of facial nerve injury in cases managed with surgical treatment, even though it is generally accepted that at least one year of follow-up is required to report a permanent nerve injury.21 Reducing this terminal articulating part is made more complicated because the surgeon needs to reduce the fracture line as well as the dislocated head. It is also of great importance to preserve the limited blood supply and the integrity of the joint capsule and meniscus. The superiority of
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Fig. 1. Flowchart of the search and selection process according to PRISMA.
surgical treatment for condylar fractures has therefore been questioned based on reducing risks rather than assuming a better outcome.15 To answer the question whether surgical treatment gives better outcomes than non-surgical treatment, the correct reply is: for which case? This question has no correct answer if it is assumed that condylar fractures are a single entity. Intracapsular comminuted fractures cannot be mixed with subcondylar fractures in one group and the outcome of surgical and non-surgical treatment compared. Randomisation is correct only for similar injuries, and this may be the cause of variable outcomes among patients who were incorrectly randomised with no clear indications for each treatment. There are a lot of classifications for condylar fractures, but none of them helps the clinician to decide which cases need to be treated surgically and which can be treated nonsurgically.6 In 1983, Zide and Kent 22 proposed the absolute and relative indications for surgical treatment; these have been modified over the years and served as a reference for many surgeons.23 They were developed before CT scans and rigid internal fixation, and based on the authors’ experience of certain clinical presentations, which may vary from what the surgeon sees in real practice. Other studies have discussed factors such as the age of the patient, the degree of dislocation and displacement of the fracture, the dental status of the patient, unilateral compared with bilateral fractures, the size of the fractured segment, and the presence of other facial fractures which must be consid-
ered when deciding the treatment options. 24–26 In a valuable article, Assael in 2003 discussed 26 variables which should be considered in selecting the treatment of choice for condylar fractures. 15 A clinical decision algorithm that guides the surgeon to a predictable outcome, while taking into consideration the clinical findings and the available resources, is therefore needed. Development of the algorithm We propose an algorithm based on the best available evidence, the common clinical practice and the experience of a group of surgeons working in a trauma centre (Fig. 2). The first logical step is to check the feasibility of fixing the fractured condyle. Surgical treatment without the ability to fix the fracture is just extra trauma for the patient. The ability to fix a condylar fracture is dependent on comminution of the fracture, available resources and training, and experience of the surgeon.27–30 As a condylar neck fracture could be difficult to fix in the absence of a proper armamentarium and lack of surgical experience, non-surgical treatment would be the treatment of choice. On the other hand, a small fracture of the head could be approached and fixed with resorbable screws by an experienced surgeon in a well-equipped hospital.31 We think that, regardless of any other factor, the inability to fix a condylar fracture is a contraindication for surgical treatment. The second step is to check the dislocation of the condyle. To guarantee a functioning joint, the condylar head should
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Fig. 2. Algorithm for management of condylar fractures.
be reduced to the glenoid fossa. 10,32–34 Although extra-fossa articulation is possible and seen in some cases, it is extremely unpredictable to leave a dislocated condyle with such an assumption. The capacity of the condyle to remodel and return to function without operation depends on the degree of dislocation and the age of the patient.35–37 The dislocated condyle may remain in situ without any complications, except being non-functional. However, chronic pain associated with non-surgical treatment has been reported. 38,39 Even though one of the systematic reviews included in this study reported significantly better outcomes in terms of TMJ pain for surgical treatment, the pretraumatic status of the TMJ was not reported, and so the actual effect of the injury, or the selected method of treatment, or both, remain unclear. In the case of a unilateral condylar fracture, the patient might be guided into good occlusion with closed treatment, but the long-term consequences of the overloaded contralateral joint are not known. 40 In the systematic reviews included in this study, chin deviation/asymmetry during MIO was more significant with non-surgical treatment.11,13 This means that the entire mandible is dependent on the contralateral joint during function, and ipsilateral posterior teeth serve as a vertical stop that may predispose them to occlusal trauma.15 In cases of bilateral condylar fractures, having one or two dislocated condyles further compromises posterior facial height and leads to loss of the posterior stop and articulation with
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associated malocclusion.41–43 One of the main goals of the treatment of condylar fractures is to restore normal mandibular function, which will be more predictable if the dislocated condyle is reduced. When the condylar head is dislocated outside the glenoid fossa (and it is possible to reduce and fix it), therefore, surgical treatment becomes indicated. In a non-dislocated condylar fracture, the next step is to check the displacement of the fracture. One must ensure good union of the fractured condyle because in case of non-union, the goal of restoring the TMJ as a functional unit is not achieved, and the same possible compromised outcome of a dislocated condyle could happen. Malunion of one of the fracture ends could also result in restricted mandibular movement. In one of the systematic reviews included, the MIO was significantly better in the surgical treatment group than in the non-surgical treatment group.11,13 In a non-displaced or minimally displaced fracture, good bony union could be achieved by non-surgical treatment, so if the fracture is displaced to the extent that may compromise healing, surgical treatment is indicated. When the articulation of the condyle and union of the fracture are predictable, checking the occlusion of the patient should be the next step. If the occlusion cannot be guided ¨ because of interference by the fracture, or if there is dropping back¨as a result of lack of a posterior stop, then surgical intervention is recommended.44 In addition, the presence of other factors that make non-surgical treatment unpredictable, such as other mandibular fractures, mid-facial fractures, or partial edentulism, are an indication that surgical treatment should be considered.15,45 In cases where occlusal discrepancy is minor and the patient could benefit from orthognathic surgery because of pretraumatic malocclusion, the surgeon may suggest nonsurgical treatment with an orthognathic plan. This could also be applicable for a growing patient with mixed dentition. If the occlusion is good or can easily be guided, non-surgical treatment should be considered. In edentulous patients, occlusion can be checked on existing dentures. In a non-dislocated and non-displaced condylar fracture in an edentulous patient, surgical treatment is hardly justified, particularly when their medical status is considered. Predictable healing of the fracture will take place with conservative treatment and then their dentures can be adjusted or replaced. The last step is to check whether the patient is a good candidate for non-surgical treatment or not. 46,47 He or she might not be able to follow non-surgical treatment instructions because of any medical or psychological factors (disabled or unconscious) or might need quick recovery for social (job demand, travel,or a prisoner) or economic reasons (cost of multiple follow-up visits compared with surgery). In these cases, surgical treatment may be more predictable than nonsurgical treatment. On the other hand, patients who would not tolerate any chance of facial nerve injury or other surgical complications should be treated non-surgically. Although facial scarring is well concealed with the contemporary
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approaches to condylar fracture, scarring is the most frequent complaint from patients.39 After all, what the patient wants is a major factor in deciding the treatment.15 The patient’s medical status and fitness for general anaesthesia should be considered, together with the algorithm as an independent factor for all patients. This treatment algorithm is based on four main factors: the feasibility of fixation, restoring joint and occlusal function, ensuring adequate healing of the fracture, and considering patient-centred factors. The indications for surgical treatment should not include the presence of a foreign body or the displacement of the condyle to the middle cranial fossa, because this will be the treatment of the complication, not the fracture. We think that the factors discussed in our algorithm are already used by many surgeons and supported by the best available evidence. The formulation of such an algorithm aims to help surgeons with different circumstances in the decision-making process. Although the algorithm needs to be validated by randomised controlled trials, preliminary retrospective analysis of the patients who underwent treatment of condylar fractures in our centre showed promising results. We invite research workers to analyse their data and compare the outcome and rate of complications in patients who were treated by following this algorithm with those in patients who were treated otherwise. Obviously, patients who were not treated properly (either with surgical or non-surgical treatment) should be excluded.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission Not applicable.
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