Article: 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(5):306-14.
Take Home Points:
- Open repair of moderately displaced condylar fractures is superior to closed treatment in that it provides less pain, improved restoration of mandibular dimensions, fewer post-treatment occlusal disturbances and less subjective functional impairment.
- The authors believe the literature that had made conservative approach popular was flawed by significant selection bias. After performing their study, they believe that closed management is clearly inferior and should not be performed for condylar fractures with 10-45˚ of condylar rotation and/or >2mm loss of ramus height.
- The study design is an international, multicenter, prospective randomized study which followed 66 patients with 79 fractures treated either with open surgical reduction and fixation versus closed management with rigid or elastic Maxillomandibular Fixation (MMF).
- Prior to this study, both open surgical reduction and fixation, as well as, closed treatment were considered equally effective treatments for condylar fractures.
- Results were so overwhelmingly favorable for open surgical group that the randomization and recruitment of patients was halted due to ethical concerns.
- Objective measurements made included post-treatment ramus height, residual condyle rotation, interincisal opening, mandible protrusion, and lateral excursion. All of these measurements were better after open approach when compared to closed.
- Six month VAS pain scores (1-100) showed that the average reported score among patients with closed technique was 13.5 with less than half reporting no pain whereas 78% in the open group had no pain and average VAS was only 2.9.
- Mandibular function impairment questionnaire scores were 10.5 v 2.4 favoring open group. This is significant as this is a validated, patient-reported measure.
- Both subjective malocclusion and objective measurements to suggest malocclusion, such as terminal deviations, were less for the open group.
- The authors note that while absolute values of the parameters measured in this study might suggest adequate function, pain, cosmesis profile for closed treatment, it should not be considered equal to open approach.
Summary Contributed by Enrique Gorbea, MD