Surgical Versus Non-Surgical Treatment of Mandibular Condylar Fractures: A Meta-Analysis

Int. J. Oral Maxillofac. Surg.
2015; 44: 158–179

http://dx.doi.org/10.1016/j.ijom.2014.09.024, available online at http://www.sciencedirect.com
Meta-Analysis
Trauma
Surgical versus non-surgical B. R. Chrcanovic

Department of Prosthodontics, Faculty of
Odontology, Malmö University, Malmö,
Sweden
treatment of mandibular
condylar fractures: a meta-
analysis
B. R. Chrcanovic: Surgical versus non-surgical treatment of mandibular condylar
fractures: a meta-analysis. Int. J. Oral Maxillofac. Surg. 2015; 44: 158–179. # 2014
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
Abstract. The aim of the present study was to test whether there is a significant
difference in the clinical outcomes between surgical and non-surgical treatment of
mandibular condylar fractures. An electronic search was undertaken in February
2014. Eligibility criteria included clinical human studies, either randomized or not.
The search strategy resulted in 36 publications. The estimates of an intervention
were expressed as the risk ratio (RR) and mean difference (MD) in millimetres. A
statistically significant effect was observed for the outcome of post-treatment
malocclusion (RR 0.46, P < 0.00001), lateral deviation during maximum inter-
incisal opening (RR 0.56, P = 0.0001, dichotomous; MD 0.75, P = 0.002,
continuous), protrusion (MD 0.68, P = 0.01), and laterotrusion (MD 0.53, P = 0.03)
favouring surgical treatment, and for infection (RR 3.43, P = 0.03) favouring non-
surgical treatment. There was no statistically significant effect on
temporomandibular joint pain (RR 0.81, P = 0.46) or noise (RR 1.44, P = 0.24), or
Key words: mandibular condylar fracture
maximum inter-incisal opening (MD 2.24, P = 0.14). The test for overall effect
surgical treatment; internal fixation; non-
showed that the difference between the procedures significantly affected the surgical treatment; complications; meta-analysis.
incidence of post-treatment complications, favouring surgical treatment, when all
dichotomous and continuous outcomes were analysed (RR 0.70, P = 0.006 and MD Accepted for publication 26 September 2014
1.17, P = 0.0006, respectively). Available online 1 November 2014
Approximately 11–16% of all facial frac- elsewhere. Consequently, mandibular serious late complications have been
tures1–4 and 30–40% of all mandibular condylar fractures (MCFs) are those most reported such as pain, restricted mandibu-
fractures (MFs) are fractures of the man- commonly missed.6 MCFs have a distinc- lar movement, muscle spasm and devia-
dibular condyle.1–3,5 Most are not caused tive position in oral and maxillofacial tion of the mandible, malocclusion,
by direct trauma, but follow indirect forces surgery because, although in many cases pathological changes in the temporoman-
transmitted to the condyle from a blow good initial clinical results are achieved, dibular joint (TMJ), osteonecrosis, facial
0901-5027/020158 + 022 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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Surgical/non-surgical condylar fracture treatment 159
asymmetry, and ankylosis, irrespective of all the reported advantages of the surgical The reference lists of the identified
treatment performed or not.7–11 treatment of MCFs, the objective of this studies and relevant reviews on the subject
There are two principal therapeutic mo- study was to conduct a systematic review were also scanned for possible additional
dalities for these fractures: non-surgical and meta-analysis of studies published in studies. Moreover, online databases pro-
(functional) and surgical. Historically, the literature up to and including February viding information on clinical trials in
non-surgical treatment of MCFs by means 2014 in order to verify whether there is a progress were checked (http://clinical-
of maxillomandibular fixation (MMF) fol- significant difference in the clinical out- trials.gov; http://www.centerwatch.com/
lowed by physiotherapy was the standard comes and post-treatment complications clinical-trials; http://www.clinicalconnec-
practice.10 between the surgical and the non-surgical tion.com).
Arguments for non-surgical treatment treatment of unilateral or bilateral MCFs,
include reduced overall morbidity, in most in patients of any age or gender.
cases acceptable occlusal results, avoid- Inclusion and exclusion criteria
ance of typical surgical complications, a
Materials and methods Eligibility criteria included clinical human
simpler procedure, and less risk of anky-
losis and avascular necrosis.12 However, This study followed the guidelines of the studies—randomized controlled trials
long-term complications such as pain, ar- PRISMA statement.17 A review protocol (RCTs), controlled clinical trials (CCTs),
thritis, open bite, deviation of the mandi- does not exist. or retrospective—comparing the clinical
ble on opening and closing, inadequate outcomes between surgical and non-sur-
restoration of vertical height of the ramus gical treatment of MCFs, and reporting the
Objective incidence of post-treatment complica-
leading to malocclusion, and ankylosis do
occur with non-surgical treatment.13 The purpose of the present review was to tions. The following were excluded: case
With the development of improved test the null hypothesis of no difference in reports, technical reports, animal studies,
materials for fixation and the refinement the incidence of post-treatment complica- in vitro studies, and reviews papers.
of surgical techniques, open reduction and tions for MCFs treated surgically or non-
internal fixation (ORIF) has gained higher surgically, against the alternative hypoth-
acceptance by surgeons for the manage- esis of a difference. Study selection
ment of MCFs, especially in severely The titles and abstracts of all reports iden-
displaced and dislocated fractures, in tified through the electronic searches were
Search strategies
edentulous patients, in cases of loss of assessed. The full text was obtained for
ramus height, and when a closed approach An electronic search without time or lan- studies appearing to meet the inclusion
with manipulation cannot re-establish the guage restrictions was undertaken in Feb- criteria and for studies for which there
pre-trauma occlusion or excursions, i.e., ruary 2014 in the following databases: were insufficient data in the title and ab-
the tendency to treat operatively usually PubMed, Web of Science, and the stract to make a clear decision.
increases with increasing complexity of Cochrane Oral Health Group Trials Reg-
the fracture. The ORIF technique provides ister. The following terms were used in the
stable three-dimensional reconstruction, search strategy: {Subject AND Adjective}
Quality assessment
promotes primary bone healing, shortens {Subject: (condylar fracture [text words])
the treatment time, and eliminates the AND Adjective: (open closed OR surgical The quality assessment was performed
need for early release of the MMF. A conservative OR surgical nonsurgical using the recommended approach for
decreased dependence on MMF improves [text words])}. assessing the risk of bias in studies includ-
post-treatment respiratory care, nutritional The following terms were used in the ed in Cochrane reviews.18 The classifica-
intake, and oral hygiene measures.14 How- search strategy on Web of Science, refined tion of the risk of bias potential for each
ever, ORIF of MCFs is technically diffi- by the research area ‘dentistry oral surgery study was based on the following four
cult due to the difficulty in manipulating medicine’ and ‘otorhinolaryngology’: criteria: sequence generation (random se-
the fragments in a small area, leaves a {Subject AND Adjective} {Subject: (con- lection in the population), allocation con-
visible external scar, results in increased dylar fracture [title]) AND Adjective: cealment (steps must be taken to secure
costs and hospitalization time, and carries (open closed OR surgical conservative strict implementation of the schedule of
the risk of facial nerve injury, damage OR surgical nonsurgical [title])}. random assignment by preventing fore-
to vessels such as the internal maxillary The following terms were used in the knowledge of the forthcoming alloca-
artery, and wound infection.15,16 search strategy on the Cochrane Oral tions), incomplete outcome data (clear
There has been considerable controver- Health Group Trials Register: (condylar explanation of withdrawals and exclu-
sy regarding the treatment of MCFs, in fracture AND (open closed OR surgical sions), and blinding (measures to blind
particular whether they should be treated conservative OR surgical nonsurgical)). study participants and personnel from
conservatively or surgically. Moreover, an A manual search of journals on the knowledge of which intervention a partic-
increasing number of articles in the cur- subject was also performed, including ipant received). Incomplete outcome data
rent literature report good results for the British Journal of Oral and Maxillo- was also considered addressed when there
surgically treated MCFs compared with facial Surgery, International Journal of were no withdrawals and/or exclusions. A
non-invasive techniques. As the philoso- Oral and Maxillofacial Surgery, Journal study that met all the criteria mentioned
phies on the treatment of maxillofacial of Craniofacial Surgery, Journal of Cra- above was classified as having a low risk
trauma alter over time, a periodic review nio-Maxillofacial Surgery, Journal of of bias. A study that did not meet one of
of the different concepts is necessary to Maxillofacial and Oral Surgery, Journal these criteria was classified as having a
refine techniques and eliminate unneces- of Oral and Maxillofacial Surgery, and moderate risk of bias. When two or more
sary procedures. This would form a basis Oral Surgery Oral Medicine Oral Pathol- criteria were not met, the study was con-
for optimum treatment. Thus, in light of ogy Oral Radiology and Endodontology. sidered to have a high risk of bias.
160 Chrcanovic
Data extraction and meta-analysis reporting the same outcome measures was attempted in order to obtain detailed
was a meta-analysis to be attempted. information, but without success; three
The following data were extracted (when A funnel plot (plot of effect size versus papers were the same article published
available) from the studies included in the standard error) was drawn. Asymmetry of in different journals; and one article did
final analysis: year of publication, study the funnel plot may indicate publication not report the number of fractures and
design, number of patients, patient age bias and other biases related to sample patients in one of the groups. Additional
range and/or mean age, follow-up period, size, although asymmetry may also repre- hand-searching of the reference lists of
number of MCFs, associated MFs, fixation sent a true relationship between trial size selected studies yielded eight additional
methods, surgical approach, length of op- and effect size. papers. Thus, a total of 36 publications
eration, post-treatment MMF, use of anti- The data were analysed using the statis- were included in the review.
biotics and/or chlorhexidine, inclusion tical software Review Manager (version
criteria for patients, post-treatment radio- 5.2.8, The Nordic Cochrane Centre, The
Description of the studies
logical assessment, and post-treatment Cochrane Collaboration, Copenhagen,
complications. Authors were contacted Denmark, 2014). Detailed data for the 36 studies included are
via e-mail for possible missing data. listed in Tables 1 and 2.12,16,20–53 When the
The post-treatment complications eval- of one or more authors of an article was
uated were infection, post-treatment dis- Results available, the author was contacted to ob-
turbance in occlusion, malunion, non- tain any missing data. An was not available
Literature search
union, TMJ noise/click/sound, and TMJ anywhere for the authors of three stud-
pain, all dichotomous outcomes. The con- The study selection process is summarized ies.20–22 An e-mail was sent to the authors
tinuous outcomes evaluated were the du- in Fig. 1. The search strategy resulted in of 33 articles.12,16,23–53 All e-mails were
ration of the operation, maximum inter- 400 entries. The initial screening of titles sent within a period of 24 h. The authors of
incisal opening (MIO), laterotrusion (lat- and abstracts resulted in 94 full-text six (18%) studies replied.29–31,33,38,52 Five
eral excursion), protrusion (protrusive papers, of which 13 were cited in more RCTs,42–45,51 13 CCTs,12,25,28,29,32,35–
37,40,41,46,47,49
movement), and the lateral deviation dur- than one research of terms. Assessment of and 18 retrospective
ing MIO. When provided in different units the full-text reports of the remaining 81 studies16,20–24,26,27,30,31,33,34,38,39,48,50,52,53
(number of observations, or mean stan- articles led to the exclusion of 53 because were included in the meta-analysis.
standard deviation), the outcome was they did not meet the inclusion criteria: 21 Many studies had the inclusion criterion
evaluated as both a dichotomous and a were reviews articles; nine studies did not of unilateral MCF only.16,23,29,32,39,43–46,49
continuous outcome. The results of differ- evaluate post-treatment complications Three studies evaluated only patients with
ent follow-ups were included in the meta- (three evaluating condylar motion, one bilateral MCFs.26,38,50 Two studies includ-
analysis when the information was provid- evaluating masticatory motion, one eval- ed diacapitular (intracapsular) MCFs
ed by the study. The incidences of wound uating bite force, one evaluating occlusion only,34,41 three studies included only sub-
dehiscence, facial nerve injury, hardware only, one evaluating facial symmetry, one condylar MCFs,35,45,51 and one study in-
failure (fracture or loosening), and hard- evaluating TMJ anatomical–radiological cluded only condylar head and high
ware removal for the surgical group were aspects, and one evaluating intraoperative condylar fractures.37 The absence of head
recorded in a table. The statistical unit for methods to determine the treatment ap- fractures was also mentioned,31,43,49 as well
the dichotomous outcomes was the num- proach); 10 articles did not correctly re- as the absence of midface fractures,16,43
ber of MCFs treated by surgery or not. port the incidence of post-treatment maxillary fractures,38 pan-facial frac-
Weighted mean differences were used to complications; five studies were per- tures,51 or any other facial fracture,44,52
evaluate the continuous outcomes. formed in animals (in vivo); four articles except for associated MFs.44 One study
Whenever outcomes of interest were were not published in English (two in assessed only patients younger than 14
not clearly stated, the data were not used Japanese, one in Korean, and one in Chi- years of age,12 and another evaluated only
for analysis. The I2 statistic was used to nese), for which contact with the authors patients in the age range of 20–40 years.51
express the percentage of the total varia- The absence of any history of TMJ disor-
tion across studies due to heterogeneity, der/dysfunction was cited as an inclusion
with 25% corresponding to low heteroge- criterion in nine studies,12,29,35,37,40–43,45
neity, 50% to moderate heterogeneity, and sufficient dentition to allow MMF and re-
75% to high heterogeneity. The inverse produce occlusal relationships was cited in
variance method was used for random- 10 studies,12,29,35,37,40,41,43–45,50 and the ab-
effects or fixed-effects model. Where sta- sence of severe pre-traumatic dysgnathia
tistically significant (P < 0.10) heteroge- was mentioned as an inclusion criterion
neity was detected, a random-effects in eight studies.12,29,35,37,40–43 Ten
model was used to assess the significance studies did not report the inclusion crite-
of treatment effects. Where no statistically ria.20,22,27,28,30,33,36,47,48,53 The classifica-
significant heterogeneity was found, the tion of Spiessl and Schroll54 for MCFs
analysis was performed using a fixed- was used in 11 articles.12,25,33–37,40,41,46,48
effects model.19 The estimates of an inter- In total 1982 patients were enrolled in
vention for dichotomous outcomes were the 36 studies, with 1094 MCFs in the
expressed as the risk ratio (RR) and for surgical treatment group and 1307 MCFs
continuous outcomes as the mean differ- in the non-surgical treatment group. The
ence (MD) in millimetres, both with a 95% presence of associated MFs was reported
confidence interval (CI). Only if there in 19 studies, but only seven studies
were studies with similar comparisons Fig. 1. Study screening process. reported the precise location of the
Table 1. Details of the studies comparing surgical versus non-surgical treatment of mandibular condylar fractures.
Patient age
range Bilateral MCFs MF fixation Post-treatment
Authors and Total patients (average), Follow-up MCFs (per group) Dislocated/non- (number of Associated methods (number Surgical approach MMF (number
year published Study design (n, per group) years period Aetiology (%) (level) dislocated MCFs patients) MFs (n) of fractures) (G1) (n) (G1) of patients)
Takenoshita RA (single 36 (G1, 16; NM 2 years NM 36 (16, G1; 20, G2) NM 6 (G1) 13 (G1) 2.0-mm Pre-auricular + 3 weeks (16,
et al., 199020 centre) G2, 20) (NM) 3 (G2) 13 (G2) miniplate, screws, submandibular (16) G1)
stainless wires, or 3 weeks (20,
a Kirschner pin G2)
Hidding RA (single 34 (G1, 20; 17–60 Range 1–5 years NM 34 (20, G1; 14, G2) 20/0 (G1) 0 (G1) NM Wire or plating Submandibular (20) 2 weeks (20,
et al., 199221 centre) G2, 14) (31, G1) (all neck) 14/0 (G2) 0 (G2) osteosynthesis G1)
18–50 2 weeks (14,
(29, G2) G2)
Moritz RA (single 76 (G1, 25; NM (23, G1) NM NM 109 (29, G1; 80, G2) 0/29 (G1) 4 (G1) NM Mini-dynamic Intraoral (29) 2 weeks (51,
et al., 199422 centre) G2, 51) NM (32, G2) (29, head, 8 neck, 40/40 (G2) 29 (G2) compression G2)
72, subcondylar) plates (29)
Worsaae and RA/RCTa 52 (G1, 24; 21–70 Mean 21 months NM 52 (24, G1; 28, G2) 24/0 (G1) 0 (G1) 11 (G1) Wire Submandibular (24) Mean 42 days
Thorn, 199423 (single G2, 28) (36, G1) (G1) (all subcondylar) 28/0 (G2) 0 (G2) 11 (G2) osteosynthesis (24, G1)
centre) 18–71 Mean 30 months Mean 28 days
(38, G2) (G2) (28, G2)
Widmark RA (single 32 (G1, 19; 17–73 1 year NM 35 (21, G1; 14, G2) 21/0 (G1) 14/0 (G2) 2 (G1) Body (5, G1), 2.0-mm miniplate Submandibular (21) 2 weeks (7, G1)
et al., 199624 centre) G2, 13) (39.5, G1) (all subcondylar) 1 (G2) coronoid (2, G1) (21) 3 weeks (13,
17–76 G2)
(30, G2)
Joos and CCT (single 51 (G1, 25; 16–69 (23.7) 10 days, 6 Traffic accident 51 (25, G1; 26, G2) 9/16 (G1) 0 (G1) 52% (G1) 2.0-mm titanium Retro-mandibular 10 days (26, G2)
Kleinheinz, centre) G2, 26) weeks, 3, 6, (49.9%), fall, (all neck) 4/22 (G2) 0 (G2) 62% (G2) miniplate (25) (25)
199825 and 12 months (24.5%), assault
(12.8%),
occupational
(3.2%), sport
(4.3%), recreational
(5.3%)
Surgical/non-surgical condylar fracture treatment

Newman, 199826 RA (single 61 (G1, 9; 12–80 (NM) Mean 64 months Fall (52%), traffic 122 (10, G1; 112, 4/6 (G1) 2/110 (G2) 9 (G1) 30 (predominantly at 2.0-mm titanium Submandibular and Mean 37 days
centre) G2, 52) (6 months to 13 accident (33%), G2) (8 diacapitular, 52 (G2) parasymphysis) miniplate (8), pre-auricular (8), (39, G2)
years) assault (8%), sports 59 neck, 55 Brown–Obeid retro-mandibular (2)
(5%), work (2%) subcondylar) technique (2)
Oezmen RA (single 30 (G1, 20; 16–59 (31.5) Range 6–24 NM 37 (24, G1; 13, G2) NM 4 (G1) NM Transfixation NM 2 weeks (30,
et al., 199827 centre) G2, 10) months (6 head, 28 3 (G2) screw (24) G1 + G2)
subcondylar, 3 NM)
Santler CCT (single 150 (G1, 37; 6–73 (24, G1) Range 6–46 Traffic accident 189 (43, G1; 146, 132/57 (G1 + G2) 6 (G1) 13 (G1) 2.0-mm NM NM (107
et al., 199928 centre) G2, 113) 8–71 (24, G2) months (55%), assault (7%), G2) (27, head, 162 33 (G2) 59 (G2) miniplates (13), patients, 132
(24, G1) fall (21%), sports neck) anchor screws fractures, G2)
Range 6–103 (9%), work accident (10), open
months (5%), horse kick reduction without
(39, G2) (3%) fixation (9),
microplates (4),
wire
osteosynthesis
(4), screws (2),
and removal of
the small
fragment (1)
Throckmorton CCT (single 136 (G1, 62; NM 6 weeks, 6 Most assaultb 136 (62, G1; 74, G2) NM 0 (G1) 39 (G1) Mini-dynamic Retro-mandibular NP (G1 + G2)
and Ellis, 200029 centre) G2, 74) months, 1, 2, (101 subcondylar, 35 0 (G2) 44 (G2) compression (62) (in G2, training
and 3 years neck) plates (most elastics without
fractures), 2 lag MMF was
screws applied)
161
162
Table 1 (Continued )
Patient age
Chrcanovic
De Riu RA (single 39 (G1, 20; 13–69 Range 5–6 years Most traffic accident 49 (27, G1; 22, G2) 10/12 (G1) 7 (G1) NM 2.0-mm titanium Submandibular or 3–5 days (20,
et al., 200130 centre) G2, 19) (NM, G1) (G1) and assaultb (19 neck, 25 14/8 (G2) 3 (G2) miniplate (27) pre-auricular (27) G1)
13–25 Range 8–12 subcondylar, 5 NM) 5–7 days (19,
(NM, G2) years (G2) G2)

Haug and RA (single 20 (G1, 10; NM (37, 2.3 years (G1) Motor vehicle 20 (10, G1; 10, G2) NM 0 (G1) NM 2.0-mm Submandibular 2–6 weeks (10,
Assael, 200131 centre) G2, 10) G1; 36, G2) 4.4 years (G2) (45%), (all subcondylar) 1 (G2) miniplateb (10) (10)b G2)
motorcycle (10%),
assault (20%), fall

(20%)
Hyde et al., 200232 CCT (multi- 54 (G1, 33; >16 Mean 14.5 NM 54 (33, G1; 21, G2) NM 0 (G1) Parasymphysis (30) 2.0-mm miniplate Retro-mandibular 7–10 days (21,
centre) G2, 21) months (NM) 0 (G2) (33) (33) G2)
(range 1–36)
Yang et al., 200216 RA (single 66 (G1, 36; 19–70 1 and 2 weeks, NM 66 (36, G1; 30, G2) 14/0 (G1) 0 (G1) 27 (G1) 2.0-mm miniplate Endoscope-assisted 1 week (36, G1)
centre) G2, 30) (26, G1) 1, 2, 3, (30 neck, 36 4/12 (G2) (not all 0 (G2) 23 (G2) (36) intraoral (26), or pre- 3 weeks (30,
17–68 4, 6, and 12 subcondylar) fractures were auricular (10) G2)
(25, G2) months evaluated)
Villarreal RA (single 84 (G1, 10; 5–81 (27) Mean 14.6 Traffic accident 104 (12, G1; 92, G2) 82/22 (G1 + G2) 2 (G1) Symphysis (35), 2.0-mm miniplate Pre-auricular (11), Mean 23.7 days
et al., 200433 centre) G2, 74) months (63.1%), (37 head, 28 neck, 18 (G2) body (7), angle (9), (5), wire coronal (1) (10, G1)
(range 3–31, casual accident 39 subcondylar) ramus (2), osteosynthesis Mean 25.3 days
G1) (16.7%), dentoalveolar (1) (1)c (G2) (71,
Mean 7.6 assault (9.5%) sports G1 + G2)
months (9.5%), fall (1.2%)
(range 1–33,
G2)
Hlawitschka RA (single 43 (G1, 14; 15–74 Mean 11 (G1) NM 49 (15, G1; 34, G2) 0/15 (G1) 1 (G1) NM Titanium Auricular (15) 1 day (14, G1)
et al., 200534 centre) G2, 29) (30, G1) and 20 (all diacapitular) 0/34 (G2) 5 (G2) compression 10 days (29, G2)
14–77 (G2) months screw (10),
(28, G2) titanium
micromesh (4),
absorbable screw
(1)
Landes and CCT (single 42 (G1, 32; 9–79 1, 6, and 12 NM 47 (36, G1; 11, G2) 36/0 (G1) 4 (G1) 14 (NM) One (90%) or two Retro-mandibular 2 weeks (10,
Lipphardt, 200535 centre) G2, 10) (36, G1) months (all subcondylar) 0/11 (G2) 1 (G2) (10%) 2.0-mm (36) G2)
15–60 miniplates
(30, G2)
Stiesch-Scholz CCT (single 27 (NM) 19–70 (32) NM NM 37 (24, G1; 13, G2) 2/35 (G1 + G2) 10 (G1 + G2) NM NM NM NM
et al., 200536 centre)
Landes and CCT (single 35 (G1, 24; 6–79 1, 6, and 12 NM 50 (33, G1; 17, G2) 13/20 (G1) 9 (G1) 6 (NM) 1.2-mm Pre-auricular (33) 2 weeks (11,
Lipphardt, 200637 centre) G2, 11) (33, G1) months (all head) 0/17 (G2) 6 (G2) microplate (33) G2)
6–34
(15, G2)
Ishihama RA (multi- 55 (G1, 18; 16–74 (34) Range 6 months Fall (40.3%), traffic 110 (36, G1; 74, G2) 27/9 (G1) 18 (G1) Parasymphysis (12, 2.0-mm miniplate Submandibular (36) 1–3 weeks (37,
et al., 200738 centre) G2, 37) to accident (34.3%), (40 head, 67 neck, 58/16 (G2) 37 (G2) G1; 25, G2), body (6), lag screw (4), G2)
2.5 years (NM) bicycle (19.4%), 27 subcondylar)d (7, G1; 6, G2) wire
assault (3%), sports osteosynthesis (1),
(1.5%), unknown open reduction
(1.5%) without fixation
(2), extracorporeal
osteosynthesis by
vertical ramus
osteotomy (2),
condylectomy and
artificial caput
placement (2) and
condylectomy (10)
Carneiro RA (single 30 (G1, 11; NM (32) NM NM 30 (11, G1; 19, G2) NM 0 (G1) NM NM NM NM
et al., 200839 centre) G2, 19) (NM) 0 (G2)
Landes CCT (single 24 (G1, 11; 7–14 1, 2, and 5 years NM 25 (11, G1; 14, G2) 11/0 (G1) 0/14 (G2) 1 bilateral fracture, NM One (55%) or two Retro-mandibular 2 weeks (14,
et al., 2008a12 centre) G2, 14)e (10.4, G1) (17 subcondylar, 5 each one treated in a (45%) 2.0-mm (neck fractures), pre- G2)
5–14 head, 3 diacapitular) different group titanium or auricular (high Patients younger
(9.3, G2) biodegradable fractures) than 12 years
miniplate for neck had guided
fractures, 1.2-mm occlusion by a
microplate for removable

high fractures orthodontic
appliance for an
average of 3
months to spare
the tooth buds a
trauma by set
screw insertion
Landes CCT (single 129 (G1, 87; 17–80 12 months NM 158 (106, G1; 52, 106/0 (G1) 19 (G1) 42 (NM) 2.0-mm Retroangular, pre- 2 weeks (42,
et al., 2008b40 centre) G2, 42) (39, G1) G2) (15, 0/52 (G2) 10 (G2) miniplate, 1.2- auricular G2)
15–73 diacapitular, 23 mm microplate
(36, G2) neck, 120
subcondylar)
Landes CCT (single 22 (G1, 9; 16–54 1, 2, 4, and 12 NM 26 (11, G1; 15, G2) 0/11 (G1) 2 (G1) 3 (G1) 1.2-mm Pre-auricular (11) 2 weeks (13,
et al., 2008c41 centre) G2, 13) (27, G1) weeks, (all diacapitular) 0/15 (G2) 2 (G2) 2 (G2) microplate (11) G2)
12–56 6 and 12 months
(31, G2)
Schneider RCT (multi- 66 (G1, 36; >18 (32) 6 months NM 79 (42, G1; 37, G2) 42/0 (G1) 6 (G1) NM Miniplates (33), Submandibular, 10 days (30, G2)
et al., 200842 centre) G2, 30) (23 head, 14 neck, 37/0 (G2) 7 (G2) miniscrews (4), or peri-angular (12),
42 condylar base) (displaced) lag screws (5) retro-mandibular
(5), pre-auricular
(12), or transoral
(13)
Danda RCT (single 32 (G1, 16; NM Mean 22.3 Traffic accident 32 (16, G1; 16, G2) NM 0 (G1) NM One or two 2.0- Pre-auricular, 2 weeks (16,
et al., 201043 centre) G2, 16) months (75%), (all subcondylar or 0 (G2) mm miniplates submandibular, G1)

(range 9–39, assault (18.7%), fall neck) (16) transmasseteric 4 weeks (16,
G1) (6.3%) anterior parotid, or G2)
Mean 21.5 retro-mandibular
months
(range 4–42,
G2)
Rasheed RCT (single 60 (G1, 30; NM 1, 3, 6, and 12 NM 60 (30, G1; 30, G2) NM 0 (G1) NM 2.0-mm titanium Pre-auricular (30) 4–6 weeks (30,
et al., 201044 centre) G2, 30) months (32 subcondylar, 28 0 (G2) miniplate (30) G2)
neck)
Singh RCT (single 40 (G1, 18; NM (30.6) 6 weeks, 3 and 6 Traffic accident 40 (18, G1; 22, G2) NM 0 (G1) NM 2.0-mm titanium Retro-mandibular Mean 20 days
et al., 201045 centre) G2, 22) months (60%), (all subcondylar) 0 (G2) miniplate (18) (18) (22, G2)
assault (30%), others
(10%)
Sforza CCT (single 21 (G1, 9; 18–50 (27) Mean 26 months NM 21 (9, G1; 12, G2) (9 5/4 (G1) 0 (G1) 0 NM NM NM
et al., 201146 centre) G2, 12) (range 6–66) neck, 9 diacapitular, 0/12 (G2) 0 (G2)
3 NM)
Gupta CCT (single 28 (G1, 10; 2–65 (28.4) 1, 4, 8, and 12 Traffic accident 34 (11, G1; 23, G2) NM 1 (G1) Symphysis (2, G1; 3, 2.0-mm stainless Pre-auricular and/or 4 weeks (14,
et al., 201247 centre) G2, 18) weeks (53.6%), assault (NM) 5 (G2) G2), parasymphysis steel miniplate retro-mandibular G2)
(10.7%), (5, G1; 12, G2)
fall (28.6%), horse
kick
(3.5%), hit by a
block of
wood (3.5%)
163
164
Patient age
Chrcanovic
Handschel RA (single 105 (NM) NM >1 year NM 111 (83, G1; 28, G2) 66/45 (G1 + G2) 6 (G1 + G2) NM One 2.0-mm Intraoral (14), pre- 10 days or 3
et al., 201248 centre) (12 diacapitular, 66 titanium miniplate auricular (3), weeks (NM, G2)
neck, 33 NM) (41), two 2.0-mm submandibular (38),
titanium or retro-mandibular
miniplates (10), (28)
locking 2.0-mm
miniplate (23),
Würzburger
tension screw (2),
others (7)
Kokemueller CCT (multi- 75 (G1, 31; NM 8–12 weeks, 1 NM 75 (31, G1; 44, G2) NM 0 (G1) NM NM Endoscope-assisted Mean 11 days
et al., 201249 centre) G2, 44) (38, G1) year (all neck) 0 (G2) transoral (31) (range 7–14; 31,
NM G1)
(32, G2) Mean 33 days
(range 14–56;
44, G2)
Singh RA (single 44 (G1, 24; 19–55 1, 2, 3, and 4 Traffic accident 88 (48, G1; 40, G2) NM 24 (G1) Symphysis/ 2.0-mm titanium Retro-mandibular 3–5 days (24,
et al., 201250 centre) G2, 20) (28.2) weeks, 2, 3, (65%), (all subcondylar) 20 (G2) parasymphysis (25), miniplate (48) (48) G1)
and 6 months assault (20%), fall body (10) angle (9) 21–35 days (20,
(12%), G2)
sports (3%)
Kotrashetti RCT (single 22 (G1, 10; NM 3 and 6 months Traffic accident 22 (10, G1; 12, G2) 10/0 (G1) 0 (G1) 16 (7, G1; 9, G2) 2.0-mm titanium Retro-mandibular 2–3 days,
et al., 201351 centre) G2, 12) (100%) (all subcondylar) 12/0 (G2) 0 (G2) Parasymphysis miniplate (10) (10) elastics; 3–4
(40%) weeks, wires
(12, G2)
Leiser RA (single 37 (G1, 10; 19–42 Mean 49.2 (G1) Traffic accident 38 (11, G1; 27, G2) 11/0 (G1) 1 (G1) 0 One or two 2.0- Anteroparotid 14 days (27, G2)
et al., 201352 centre) G2, 27) (30, G1) and 28.2 (30%), (all subcondylar) 27/0 (G2) 0 (G2) mm titanium transmasseteric (11)
12–66 (G2) months assault (24%), fall miniplate (11)
(27, G2) (46%)
Reddy RA (single 124 (NM) NM NM Traffic accident 175 (110, G1; 65, 39/136 (G1 + G2) 51 (G1 + G2) Symphysis (45), NM (110) Retro-mandibular NM (NM, G2)
et al., 201353 centre) (64%), G2) (88 parasymphysis (33), (65), pre-auricular
assault (17%), fall subcondylar, 32 body (3) angle (3) (30), submandibular
(8.6%), head, 55 neck) (15)
sports (9.6%)
MCFs, mandibular condylar fractures; MFs, mandibular fractures; MMF, maxillomandibular fixation; RA, retrospective analysis; RCT, randomized clinical trial; CCT, controlled clinical trial; G1, surgical treatment group; G2, non-surgical treatment group; NM, not mentioned; NP,
not performed.
a
The study had two different design approaches. From 1980 to 1983, all patients were treated non-surgically, while from 1983 to 1989 patients were treated in a randomized manner depending on the day of admission: surgically on even days and non-surgically on uneven days.
b
Unpublished information was obtained by personal communication with one of the authors.
c
Of the 12 MCFs treated surgically, six were fixed, the fragment was replaced as a free graft in five, and in one case fixation was not possible.
d
There were 137 MCFs initially, but only 110 were followed up.
e
Here the sum of the number of patients for both groups (n = 25) is greater than the number of patients in the study (n = 24) because one patient had a bilateral fracture: one fracture was treated surgically and the other was treated non-surgically.
Table 2. Further details of the studies comparing surgical versus non-surgical treatment of mandibular condylar fractures.
Facial
Hardware failure Wound nerve Hardware
Post-treatment radiological (fracture, loosening) dehiscence injury removal
Authors and year published Inclusion criteria assessment (G1) (G1) (G1) (G1)
Takenoshita et al., 199020 NM NM NM NM NM NM
Hidding et al., 199221 Dislocated neck fractures In G1, 19 out of 20 joints (95%) NM NM NM NM
were anatomically
reconstructed, with only one

displacement. In G2 there was
only one joint in correct
alignment whereas 13 joints
were in malposition (93%)
Moritz et al., 199422 NM The G1 patients had NM NM 0 NM
improvement of the condyle
position after surgery, which did
not occur in G2
Worsaae and Thorn, 199423 Unilateral dislocated low No correlation between the NM NM 0 NM
subcondylar fractures degree of radiographically
recorded dislocation or
angulation of the condylar
fragment and the number of
complications was found
Widmark et al., 199624 Subcondylar fractures Good anatomic positioning in NM 0 1 NM
G1 in all but 2 patients, who had
a medially dislocated condyle
with increased condyle–fossa

distance
Joos and Kleinheinz, 199825 Low condylar neck fractures with The G2 had on average 4 mm NM NM NM NM
displacement or dislocation more correction of the ramus
height than the surgically treated
G1 patients
Newman, 199826 Bilateral condylar fractures NM NM NM 0 NM
Oezmen et al., 199827 NM In 8 patients (80%) from G2, the NM NM 0 NM
condylar process healed in a
dislocated position with severe
disfigurement of the condylar
head. None of the patients in G1
showed any axis misalignment or
deformation of the condylar head
Santler et al., 199928 NM NM NM NM NM NM
Throckmorton and Ellis, 200029 Unilateral condylar fractures, At 6 weeks, surgery had NM NM NM NM
absence of any history of TMJ uprighted the condylar processes
dysfunction, sufficient dentition to in G1 so that there was a
allow MMF and reproduce occlusal significant change in the coronal
relationships, absence of severe displacement and ramus length
pre-traumatic dysgnathia (but not for the sagittal position)
between pretreatment and 6
weeks post-treatmently. G2
165
showed no significant change in
any displacement variables
166
Facial
Chrcanovic
30
De Riu et al., 2001 NM G1 patients showed TMJ NM NM 0a NM
morphology similar to that on
the contralateral unaffected side.

Neither differences in the height
of the rami nor alterations of the
glenoid fossa were recorded,

compared to the frequent ramus
asymmetry observed in G2
patients
Haug and Assael, 200131 Subcondylar fractures, non- The G1 patients had 0a 0a 0 0a
comminuted, absence of head improvement of the condyle
fractures position after surgery, which did
not occur in G2a
Hyde et al., 200232 Unilateral condylar fractures with NM NM NM 3 NM
deranged occlusion
Yang et al., 200216 Unilateral condylar fractures, NM NM NM 3 NM
absence of midface fractures
Villarreal et al., 200433 NM The post-treatment coronal NM NM NM 0a
displacement of the condyle was
between 608 (medial) and 208
(lateral) with a mean of
6.078 15.068, with no
statistically significant
relationship with the method of
treatment. There were
statistically significant
differences between the
preoperative and post-treatment
coronal and sagittal
displacement
Hlawitschka et al., 200534 Diacapitular fractures In G1 significant improvement 0 0 1 0
in the position of the major
fragments was achieved. In G2
considerable misalignment,
distinctive changes in condylar
form and resorption of the
fractured condyle were
frequently seen
Landes and Lipphardt, 200535 Unilateral or bilateral condyle Angular repositioning of the 1 NM 2 1
fractures located at the sigmoid condyle in relation to the
notch or subcondylar, absence of ascending ramus was better than
any history of TMJ dysfunction, vertical reduction of the
sufficient dentition to reproduce condylar height
occlusal relationships, absence of
severe pre-traumatic dysgnathia
Stiesch-Scholz et al., 200536 NM NM NM NM 0 NM
Landes and Lipphardt, 200637 Unilateral or bilateral condylar NM 0 NM 3 0
head and high condylar fracture,
absence of any history of TMJ
dysfunction, sufficient dentition to
reproduce occlusal relationships,
absence of severe pre-traumatic
dysgnathia
Ishihama et al., 200738 Bilateral condylar fractures, The G1 patients had NM NM NM 36a,b
absence of maxillary fractures improvement of the condyle

not occur in G2a
Carneiro et al., 200839 Unilateral condylar fractures On the fractured side in only NM NM NM NM
26.7% was the morphology of
the mandibular condyle not
preserved, while on the non-
fractured side most patients
(73.3%) displayed a preserved
morphology
Landes et al., 2008a12 Patients under 14 years of age, NM 2 (fracture) NM 2 2
dysfunction, sufficient dentition to
reproduce occlusal relationships,
absence of severe pre-traumatic
dysgnathia
Landes et al., 2008b40 Neck and head fractures, absence Shortening of the ascending 5 (fracture) NM 7 5
of any history of TMJ disorder, ramus and fracture angulation
sufficient dentition or prosthetic had not substantially improved
rehabilitation to check the when compared with the

occlusion, absence of prevalent preoperative values for G2. For
severe dysgnathia G1, both parameters improved
substantially
Landes et al., 2008c41 High non-displaced, non- Angular rectification in G1 was 1 (broken) NM 0 1
dislocated diacapitular fractures, successful; in G2 a slight
absence of previous history of TMJ enlargement of the angulation
dysfunction, sufficient dentition to was encountered at follow-up
reproduce an occlusion, absence of
severe pre-traumatic dysgnathia
Schneider et al., 200842 No history of TMJ pathologies, no At 6 months follow-up in G2 NM NM 0 NM
pre-existing skeletal discrepancies shortening of the ascending
with malocclusion ramus and fracture angulation
had not improved substantially
when compared with the
preoperative values. In G1, both
parameters improved
substantially
167
168
Facial
Chrcanovic
43
Danda et al., 2010 Unilateral displaced subcondylar or Four patients (25%) in G2 and NM NM 2 NM
neck condylar fractures, absence of 14 patients (87.5%) in G1 had an
condylar head fractures, sufficient anatomic reduction of the

dentition to reproduce normal condyle radiographically; the
occlusion, absence of any difference was statistically
associated midface fractures, significant

dysfunction, absence of a history of
occlusal disturbances or skeletal
malocclusion
Rasheed et al., 201044 Unilateral condylar fractures, NM NM NM NM NM
dentition complete enough to apply
stable Erich arch bars, absence of
other facial fractures (except in the
mandible)
Singh et al., 201045 Unilateral subcondylar fractures, For G2, at 6 months follow-up, NM NM 0 NM
sufficient dentition to reproduce the shortening of the ascending
occlusal relationships. Degree of ramus and fracture angulation
displacement of the condylar had not improved substantially
fragment in the coronal plane: 108 when compared with the
to 358 and/or shortening of the preoperative values. For G1,
height of the ascending ramus of both parameters improved
the mandible >2 mm, absence of substantially
condylar head or neck fractures. No
previous history of TMJ
dysfunction
Sforza et al., 201146 Unilateral condylar fractures NM NM NM NM NM
Gupta et al., 201247 NM NM NM NM 2 NM
Handschel et al., 201248 NM NM 8 (loosening) NM 0 37
Kokemueller et al., 201249 Unilateral condylar neck fractures, NM 1 (fracture) NM 1 NM
displacement of the condyle with
an inclination >308 and/or severe
functional impairment such as
malocclusion or an open bite, with
or without dislocation of the
condylar fragment, non-high or
non-intracapsular condylar neck
fractures
Singh et al., 201250 Bilateral condylar fractures, all NM 0 0 2 0
patients partially or totally
dentulous
Kotrashetti et al., 201351 Displaced subcondylar fractures, NM 0 NM 1 0
absence of pan-facial trauma,
patients 20–40 years old
fractures.24,32,33,38,47,50,53 The most prev- intraoral approach,22 and one study the
alent associated MF was fracture of the anteroparotid transmasseteric approach.52
0a
5
symphysis/parasymphysis region, with Twelve studies used more than one ap-
78.3% (227/290) of the reported associat- proach.12,16,20,26,30,33,40,42,43, 47,48,53
ed MFs of known location. Fourteen stud- Twenty-four studies mentioned that

ies reported the aetiology of the MCFs; post-treatment physiotherapy was per-
traffic accident (including motor vehicle formed by the patients.12,16,20,21,23–25,29–
19
0
31,33,35,37,40–42,44–47,49,50,52,53
and bicycle accidents) was the most prev-
alent aetiology in 11 studies,25,28,30,31, Only one study provided information on
33,38,43,45,47,50,53
fall was the most preva- the mean operation time.33 Three studies
lent aetiology in two studies,26,52 and as- made use of prophylactic antibiotics for a
sault/altercation was the most prevalent in period of 5–8 days,30,38,52 whereas one
one study.29 study did not provide details.24 No study
0
0
G1, surgical treatment group; G2, non-surgical treatment group; NM, not mentioned; TMJ, temporomandibular joint; MMF, maxillomandibular fixation.
The maximum follow-up period varied reported on the use of chlorhexidine rinse.
between 3 months and 13 years. Some Information on post-treatment radiologi-
studies had short maximum follow-up per- cal assessment was provided in 19 articles;
iods, like 3 months47 or 6 months.42,45,50,51 all stated that the shortening of the ascend-
Four studies did not report the follow-up ing ramus and the fracture angulation had
5 (loosening)
period.22,36,39,53 improved substantially when compared

Concerning the surgical treatment with the preoperative values in the surgi-
group, 22 studies performed the fixation cal treatment group.21–25,27,29,30,33–35,38–
43,45,52
using one 2.0-mm miniplate in one or In one study, no correlation be-
0a
more patients,12,16,20,24–26,28,30,32,33,35,38, tween the degree of radiographically

40,42–45,47,48,50–52
and five studies used recorded dislocation or angulation of the
two 2.0-mm miniplates,12,35,43,48,52 condylar fragment and the number of
whereas one study used a locking 2.0- complications was found.23
mm miniplate,48 five studies used 1.2-
mm microplates,12,28,37,40,41 six studies

improvement of the condyle
Quality assessment
used wire osteosynthesis,20,21,23,28,33,38
two studies used mini-dynamic compres- Each trial was assessed for risk of bias; the
The G1 patients had
sion Plates,22,29 one study used titanium scores are summarized in Table 3. All 36
Removal of plates was a standard procedure in the department where the study was conducted.
micromesh,34 and eight studies20,27– studies were judged to be at high risk of

not occur in G2a
29,34,38,42,48
Unpublished information was obtained by personal communication with one of the authors.
used screws (transfixation bias.

screws, lag screws, miniscrews, anchor
screws, compression screws, absorbable
Meta-analysis
screws, Würzburger tension screws).
NM
Some studies performed open reduction When considering only the dichotomous
without fixation28,38 or condylectomy.38 outcomes, there was heterogeneity among
Six studies did not report the fixation the studies for the outcome TMJ pain
method used in the patients in the surgical (I2 = 53%, P = 0.009), but not for infec-
reduction of associated facial bone
fractures with no need for further
treatment group.31,36,39,46,49,53 Twelve tion (I2 = 0%, P = 0.99), malocclusion

studies also performed MMF in some24,33 (I2 = 11%, P = 0.30), lateral deviation dur-
Low dislocateda subcondylar
or all patients16,20,21,23,27,30,34,43,49,50 in ing MIO (I2 = 24%, P = 0.21), or TMJ

the surgical treatment group. Concerning noise (I2 = 0%, P = 0.41). There was a
the non-surgical treatment group, 14 stud- statistically significant effect on the out-
ies performed the MMF for up to 2 come of post-treatment malocclusion (RR
weeks,12,21,22,25,27,30,32,34,35,37,40–42,52 0.46, 95% CI 0.34–0.62, P < 0.00001;
whereas in 16 studies the MMF was per- Fig. 2) and lateral deviation during MIO
fractures
formed for more than 2 weeks.16,20,23, (RR 0.56, 95% CI 0.43–0.74, P < 0.0001;
24,26,31,33,38,43–45,47–51
One study did not Fig. 3) favouring surgical treatment, and
NM
perform MMF in any group,29 three of post-treatment infection (RR 3.43, 95%
studies did not report the MMF CI 1.10–10.75, P = 0.03; Fig. 4) favouring
period,28,36,53 and two studies did not non-surgical treatment. There was no sta-
report whether MMF was performed or tistically significant effect on the outcome
not.39,46 TMJ pain (RR 0.81, 95% CI 0.46–1.42,
Six studies did not report the type of P = 0.46; Fig. 5) or TMJ noise (RR 1.44,
surgical approach used.27,28,31,36,39,46 Four 95% CI 0.78–2.65, P = 0.24; Fig. 6) in
Reddy et al., 201353
Leiser et al., 201352
studies exclusively used the submandibu- favour of surgical treatment. Only three
lar approach,21,23,24,38 seven studies the studies provided information on malunion
retromandibular approach,25,29,32,35,45, and non-union, with no cases reported.31,
50,51 50,52
three studies the pre-auricular ap- Thus, an analysis of these outcomes
proach,37,41,44 two studies an endoscope- was not performed.
assisted intraoral approach,16,49 one study The test of heterogeneity among all
b
a
the auricular approach,34 one study the studies in all dichotomous outcomes
170 Chrcanovic
Table 3. Results of the quality assessment.

Sequence Incomplete Estimated
generation Allocation outcome data potential risk
Authors Published (randomized?) concealment addressed Blinding of bias
Takenoshita et al.20 1990 No No No No High
Hidding et al.21 1992 No No No No High
Moritz et al.22 1994 No No No No High
Worsaae and Thorn23 1994 No No Yes No High
Widmark et al.24 1996 No No No No High
Joos and Kleinheinz25 1998 No No No No High
Newman26 1998 No No Yes No High
Oezmen et al.27 1998 No No No No High
Santler et al.28 1999 No No Yes No High
Throckmorton and Ellis29 2000 No No Yes No High
De Riu et al.30 2001 No No Yes No High
Haug and Assael31 2001 No No No No High
Hyde et al.32 2002 No No Yes No High
Yang et al.16 2002 No No Yes No High
Villarreal et al.33 2004 No No No No High
Hlawitschka et al.34 2005 No No No No High
Landes and Lipphardt35 2005 No No Yes No High
Stiesch-Scholz et al.36 2005 No No No No High
Landes and Lipphardt37 2006 No No Yes No High
Ishihama et al.38 2007 No No Yes No High
Carneiro et al.39 2008 No No No No High
Landes et al.12 2008 No No Yes No High
Schneider et al.42 2008 Yes Unclear Yes No High
Danda et al.43 2010 Yes Unclear No Yes High
Rasheed et al.44 2010 Yes Unclear No No High
Singh et al.45 2010 Yes Unclear No No High
Sforza et al.46 2011 No No No No High
Gupta et al.47 2012 No No No No High
Handschel et al.48 2012 No No No No High
Kokemueller et al.49 2012 No No Yes No High
Singh et al.50 2012 No No Yes No High
Kotrashetti et al.51 2013 Yes No No No High
Leiser et al.52 2013 No No No No High
Reddy et al.53 2013 No No No No High
showed heterogeneity (x2 = 119.54, P = 0.18). There was a statistically signif- (MD 1.17, 95% CI 0.50–1.84;
df = 61, P < 0.0001; I2 = 47%), therefore icant effect on the outcome of protrusion P = 0.0006).
a random-effects model was used. The test (MD 0.68, 95% CI 0.14–1.22, P = 0.01; Concerning the length of operation, on-
for subgroup differences (inconsistency Fig. 7), laterotrusion (MD 0.53, 95% CI ly one study33 provided information on the
across the subgroups) was statistically 0.05–1.01, P = 0.03; Fig. 8), and lateral mean operation time, with a mean time of
significant (x2 = 16.69, df = 4, P = deviation during MIO (MD 0.75, 95% 132 min for the surgical treatment group
0.002; I2 = 76%). The test for overall ef- CI 1.23 to 0.27, P = 0.002; Fig. 9) and 72 min for the non-surgical treatment
fect revealed a statistically significant ad- favouring surgical treatment. There was group. Thus, a meta-analysis was not
vantage for surgical treatment when the no statistically significant effect on the possible.
incidence of all post-treatment complica- outcome of MIO (MD 2.24, 95% CI The outcome lateral deviation during
tions (dichotomous outcomes) was consid- 0.70 to 5.19, P = 0.14; Fig. 10) in favour MIO was analysed as both a dichotomous
ered (RR 0.70, 95% CI 0.54–0.90; of surgical treatment. and continuous outcome, as some studies
P = 0.006). The cumulative RR was The test of heterogeneity among all provided its incidence related to the num-
0.70, meaning that surgical treatment in studies in all continuous outcomes showed ber of fractures and others provided
the management of MCFs decreases the heterogeneity (x2 = 804.83, df = 70, results as the mean value and standard
risk (relative risk reduction—RRR) of P < 0.00001; I2 = 91%), therefore a ran- deviation.
these events (post-treatment complica- dom-effects model was used. The test for
tions of dichotomous outcome) by 30%. subgroup differences (inconsistency
Publication bias
When only considering the continuous across the subgroups) was not statistically
outcomes, there was heterogeneity among significant (x2 = 1.68, df = 3, P = 0.64; The funnel plot for the dichotomous out-
the studies for the outcomes MIO I2 = 0%). The test for overall effect comes (Fig. 11) did not show asymmetry,
(I2 = 95%, P < 0.0001), laterotrusion revealed a statistically significant advan- indicating an absence of publication bias.
(I2 = 61%, P < 0.0001), and protrusion tage for surgical treatment when the inci- The funnel plot for the continuous out-
(I2 = 59%, P = 0.004), but not for lateral dence of all post-treatment complications comes (Fig. 12) showed asymmetry, indi-
deviation during MIO (I2 = 31%, (continuous outcomes) was considered cating the possible presence of publication
Fig. 2. Forest plot for the dichotomous outcome ‘malocclusion’ (‘mild’ indicates mild malocclusion and ‘sev.’ indicates severe malocclusion; mo,
months; yr, years).
Fig. 3. Forest plot for the dichotomous outcome ‘lateral deviation during maximum inter-incisal opening’.
172 Chrcanovic
Fig. 4. Forest plot for the dichotomous outcome ‘post-treatment infection’.
bias. The study of Newman26 was the interpreted with caution when they are seven additional studies were limited to
cause of this asymmetry, showing a large included in reviews and meta-analyses.18 two or fewer studies. In meta-analyses
MD for MIO between groups, also with an So what was the reason for the inclusion of such as these, adding more information
asymmetrical distribution of the number non-randomized studies in the present from observational studies may aid in
of observations between groups (n = 10 meta-analysis? This issue is important clinical reasoning and establish a more
for the surgical treatment group, n = 112 because meta-analyses are frequently con- solid foundation for causal inferences.55
for the non-surgical treatment group). ducted on a limited number of RCTs.55 In a meta-analysis, homogeneity implies a
Shrier56 highlighted this in a review of a mathematical compatibility between the
random 1% sample of meta-analyses pub- results of each individual trial. Narrowing
Discussion
lished by the Cochrane Collaboration in the inclusion criteria increases homogene-
Potential biases are likely to be greater 2003; it was found that six of 16 reviews ity but also excludes the results of more
for non-randomized studies compared included two studies or fewer. Further- trials and thus risks the exclusion of sig-
with RCTs, so results should always be more, 158 of 183 analyses conducted in nificant data.
Fig. 5. Forest plot for the dichotomous outcome ‘TMJ pain’.
Fig. 6. Forest plot for the dichotomous outcome ‘TMJ noise’.
Concerning the results of the present relationship between the duration of MMF outcome of MIO was observed (P = 0.14).
meta-analysis, the outcome lateral devia- and the degree of reduction in mouth open- This may be related to the fact that the
tion during MIO showed a statistically ing, such that the shorter the duration of surgical treatment causes incisional pain,
significant difference between groups fixation, the less the reduction. A possible muscle stripping, and post-treatment scar-
when analysed as both a dichotomous explanation for this may be a combination of ring, all of which might also lead to mandib-
outcome (P = 0.0001) and a continuous muscle disuse atrophy and scarring in the ular hypomobility and less mouth opening.16
outcome (P = 0.002), with both favouring region of the fracture following tissue dis- One study showed that greater MIO was
surgical treatment. Factors affecting later- ruption and haematoma formation.58 This noted earlier in the non-surgical treatment
al midline deviation during MIO include might explain why a greater MIO was noted group than in the surgical treatment group,29
damage to the TMJ, shortening of the earlier in the surgical treatment group than in the opposite of the observation of Villarreal
ramus height, and loss of lateral pterygoid the non-surgical treatment group in one et al.,33 whereas another continued to show
muscle function.16 Deflection and lateral study.33 The variable use of post-treatment greater MIO for the surgical treatment group
shift of the mandible during mouth open- MMF in the non-surgical treatment group is at different follow-up periods,44 and two
ing are often signs of compensatory move- a confounding risk. The use of MMF after others showed a greater MIO for the non-
ments of the contralateral joint due to fracture reduction in the surgical treatment surgical treatment group in all follow-up
shortening of the ramus height on the group versus allowing immediate function periods.16,20 Thus, it is suggested that the
affected side.42 Since there is no reposi- might further influence success rates. In post-treatment MIO may not only be influ-
tioning of the condylar head in non-surgi- most studies, only the patients in the non- enced by the duration of MMF, but also by
cal treatment, a greater lateral deviation surgical treatment group received the degree of fracture displacement before
during MIO is expected in the non-surgi- MMF.12,22,25,26,28,31,32,35,37,38,40–42,44,45,47,48, treatment, and possibly the surgical manip-
51–53
cal treatment group. Both factors aggra- In most studies in which both groups ulation over the fracture site16 and post-
vate the potential risk of chin deviation.16 received MMF, patients in the non-surgical treatment physiotherapy, which was
An animal study has revealed that a long treatment group received a longer period of reported in most of the articles reviewed
duration of MMF (>3 weeks) results in post- MMF when compared to those in the surgi- here.12,16,20,21,23–25,29–31,33,35,37,40–42,44–47,49,
treatment mandibular hypomobility.57 de cal treatment group.16,24,30,33,34,43,49,50 How- 50,52,53
However, compliance with post-
Amaratunga58 observed that there was a ever, no statistically significant effect on the treatment physiotherapy may be low.37
Fig. 7. Forest plot for the continuous outcome ‘protrusion’ (w, weeks; m, months; y, years).
174 Chrcanovic
Fig. 8. Forest plot for the continuous outcome ‘laterotrusion’ (w, weeks; m, months; y, years; FS, laterotrusion to the fractured side; NFS,
laterotrusion to the non-fractured side; R, laterotrusion to the right side; L, laterotrusion to the left side).
Another observation that helps to corrobo- non-surgical treatment, particularly of dis- dence in the surgical treatment group can
rate this comes from the study of Worsaae located TMJs.59 Moreover, it was sug- be explained by the fact that the joint
and Thorn.23 Although patients treated sur- gested in the report of an animal study60 space is reduced after surgical reposition-
gically were immobilized for 2 weeks more that a limited range of motion after non- ing of the condylar head.16
on average, the MIO of surgically and non- surgical treatment and MMF happens be- There was no statistically significant
surgically treated patients was not signifi- cause the immobilization of a damaged effect on post-treatment TMJ pain
cantly different. joint leads to degeneration of the articular (P = 0.46). This may be explained by
Statistically significant differences be- surfaces and the development of fibrous the fact that both techniques result in
tween the different treatments was found adhesion, limiting mobility. This is because post-treatment pain. In the case of the
in the present meta-analysis with regard to the fracture fragments cannot be reposi- non-surgical treatment group, it is sug-
laterotrusion (P = 0.03) and protrusion tioned during non-surgical treatment.36 gested that the pain is caused by muscle
(P = 0.01), both favouring surgical treat- Even though no statistically significant spasms resulting from MMF,47 and in the
ment. Authors have found that impairment difference between groups was observed surgical treatment group the pain is due to
of TMJ function frequently occurs after for TMJ noise (P = 0.24), the higher inci- the invasive surgical procedure.
Fig. 9. Forest plot for the continuous outcome ‘lateral deviation during maximum inter-incisal opening’ (w, weeks; m, months; y, years).
Fig. 10. Forest plot for the continuous outcome ‘maximum inter-incisal opening’ (w, weeks; m, months; y, years).
Fig. 11. Funnel plot—publication bias according to the reported incidence of post-treatment complications (dichotomous outcomes).
176 Chrcanovic
Fig. 12. Funnel plot—publication bias according to the reported incidence of post-treatment complications (continuous outcomes).
A statistically significant effect on post- length of follow-up. However, it appears studies, not necessitating MMF, could
treatment malocclusion (P < 0.00001) reasonable to assume that a careful, non- have influenced the outcome of these
was observed favouring surgical treat- traumatizing, anatomically correct reposi- studies.
ment. The incidence of occlusal distur- tioning of a dislocated MCF no more The possible relationship between the
bance is attributed to the reduction in frequently predisposes to such late com- presence of bilateral MCFs and the com-
ramus height or to condyle dislocation plications than a non-reduced, malposi- plication rate is also worth mentioning. It
from the fossa. In the long term, incom- tioned MCF.23 Moreover, it is has been stated that patients with bilateral
plete anatomical restoration with a reasonable to assume that follow-ups were MCFs treated with the placement of arch
remaining reduced ramus height in non- not attended by all patients in some stud- bars and using a short course of MMF
surgical treatment can cause facial asym- ies, i.e. poor compliance. followed by guiding elastics, may still
metry and inclination of the occlusal The different follow-up regimens develop asymmetry, malocclusion, and
plane, as well as functional occlusal adopted by the studies is a confounding an open bite.15 Moreover, it has been
problems, such as premature contact in risk factor, as well as the presence of shown that the improvement in mobility
protrusion and lateral protrusion.30 associated MFs, the differences in selec- in unilateral fracture patients is better than
A statistically significant higher inci- tion criteria, the missing information on the reported improvement in patients with
dence of post-treatment infection in the antibiotic prophylaxis in most studies, and bilateral fractures.61 The results of the
surgical treatment group in comparison the use of different osteosynthesis sys- study of Schneider et al.42 showed that
with the non-surgical treatment group tems. The disadvantage of open reposi- the treatment outcomes of unilateral
(P = 0.03) was expected, as the surgical tioning, wire osteosynthesis, and MCFs were significantly better than those
approaches were performed only in the Kirschner wires lies in the lack of func- of bilateral MCFs, in terms of objective
patients in the surgical treatment group. tional stability. Miniplates, lag screw criteria (mouth opening, protrusion, later-
A short follow-up period was a limita- osteosynthesis, and pin fixation allow otrusion) and subjective criteria (visual
tion of some studies, even though it is hard functional stability and early movement analogue scale (VAS) and mandibular
to define what would be considered a short of the joint.28 A disadvantage of some functional impairment questionnaire
follow-up period for the evaluation studies is the fact that they used an unsta- (MFIQ)) in the surgical treatment group.
of post-treatment complications in ble fixation method (wire osteosynth- After non-surgical treatment of bilateral
MCFs.42, 45,47,50,51 Possible complica- esis).20,21,23 Thus, additional MMF was MCFs, a higher level of pain and a higher
tions, such as arthrosis, which may occur also needed in the ORIF group. The use level of functional impairment were evi-
after 10, 15, or 20 years,23 were not of a more stable internal fixation method dent. Thus, it can be said that a bilateral
revealed by these studies due to the short such as the 2.0-mm miniplate used in most MCF is a predictive factor for a poor
outcome, and this was also a confounding relationship between the presence of dis- It is important to consider that with any
risk factor for the present analysis. placement and the method of treatment. In intervention the risks must be weighed
A confused terminology of MCFs has the study of Sforza et al.46 the main crite- against the benefits. The surgical treat-
existed for a long time and some studies rion for treatment selection was the pres- ment of MCFs necessitates a certain
included MCFs of all levels (head, neck, ence of condylar displacement or amount of surgical training, is time- and
and subcondylar fractures), reporting no dislocation. manpower-consuming compared with
fracture level distinction while presenting Many studies included not only adults, non-surgical treatment because it has to
the results. As the functional outcome but also teenagers and children. This is be done under general anesthesia,23 and it
varies with the level of the fracture,16 it also considered a confounding factor, is not indicated for the management of all
may be difficult, if not impossible in these since increasing dysfunction indices and types of MCF. With these considerations
cases to evaluate the influence of the incomplete remodelling in dislocated frac- in mind, provided the results are equal, the
fracture level on the post-treatment com- tures proportional with age at the time of simpler and easier treatment is the treat-
plications, and this may also be considered trauma are reported.62 It is suggested that ment of choice.
a confounding factor. Moreover, the level the need for surgical treatment is greater in Another important factor in decision-
of the MCF and the degree of displace- the postpubertal patient than in the prepu- making for the treatment of MCFs is
ment are some of the variables that strong- bertal patient.10 Age also plays a role in whether the association of the surgical
ly influence the choice of a treatment.33 the surgeon’s decision on how to treat treatment with a better restoration of the
The classification of Spiessl and Schroll54 MCFs when anatomical aspects of the occlusion overcomes the risks of an oper-
was used in some articles,12,25,33–37,40, mandibular condyle are considered. It ation. It has been shown that displaced
41,46,48
which allows differentiation of was observed in an anatomical study that MCFs may result in a reduction in the
the outcome depending upon the degree the mean anteroposterior and medial–lat- mandibular-ramus and posterior facial
of dislocation and vertical loss of support. eral thickness of the condylar neck was height, with a consequent clockwise (pos-
Some authors consider that randomiz- thinner in edentulous mandibles in com- terior) rotation of the mandibular plane, an
ing patients is not ethical for this non- parison with dentulous ones,63 which increase in the lower anterior face height,
lethal injury, even though both are accept- could presumably be related to age, be- and a reduction in overbite.64 Depending
ed modalities of treatment, because one cause the prevalence of edentulism on the severity of malocclusion, treatment
involves open surgery and one does not.59 increases with age. This may result in a options include functional rehabilitation,
The reliability of randomized studies is patient/treatment selection bias: surgeons occlusal equilibration, removal of hyper-
limited in the field of MCFs because treat- could be more prone to select patients with occluding teeth, orthodontics, prosthetic
ment is not always codified, and the num- a thinner condylar neck (patients with a reconstruction of the dentition, orthog-
ber of fractures for which both types of higher probability of being older and to- nathic surgery, temporomandibular recon-
treatment can be considered is small.46 tally edentulous) for non-surgical treat- struction, and combinations of these
The treatment modality was, in many ment, whereas younger adult dentate methods.65 As displaced MCFs treated
studies, influenced by the wishes of the patients (with a higher probability of hav- non-surgically might result in complica-
patient (surgical or non-surgical treat- ing a sufficient amount of bone to permit tions that may lead to future surgical
ment), the experience/preference of the the placement of two screws per segment) interventions to correct the malocclusion,
various surgeons, the type of fracture, would more often undergo a surgical it might be reasonable to surgically treat
and the radiological degree of displace- treatment. MCFs that are believed to lead to such
ment or dislocation, which characterizes Other limitations of some of the stud- sequelae. The risk of these complications
patient selection bias. Usually the more ies reviewed here include no qualifica- should be discussed sufficiently with the
complicated displaced or dislocated frac- tion of clinical variables, the small patient before any decision is made.
tures are more likely to receive operative number of patients, and different treat- In conclusion, the results of the present
treatment and less displaced fractures to ment protocols and methods of evalua- meta-analysis suggest that the surgical
receive non-surgical treatment, even tion of the results. Thus, it must be treatment of MCFs provides a better clini-
though the question of what degree of stressed that this meta-analysis has lim- cal outcome with regard to post-treatment
displacement and angle of dislocation ben- itations due to the variation in the manner malocclusion, protrusion, laterotrusion,
efits more from surgical treatment than in which the various study parameters and lateral deviation during MIO in com-
non-surgical treatment is still unresolved. were reported. All these limitations, vari- parison to non-surgical treatment. On the
Thus, non-surgical treatment was com- ables, and confounding factors (short other hand, patients are more affected by
monly chosen for diacapitular linear frac- follow-up periods, poor compliance, post-treatment infection when a surgical
tures, comminuted condylar fractures, presence of associated fractures or bilat- treatment is performed. There was no
and fractures with small displacement, eral MCFs, use or not of antibiotic pro- statistically significant difference in
whereas surgical treatment was usually phylaxis, use of different osteosynthesis post-treatment TMJ pain, TMJ noise, or
performed in severe dislocation/displace- systems, MCFs of different levels, pa- MIO when the two techniques were com-
ment cases.16,20,33,35–37 Oezmen et al.27 tient and treatment selection bias, age of pared.
only performed surgical treatment in the patient) may have affected the results
adults with low, displaced or dislocated of the present study, and not just the fact
fractures with a condylar axis deviation of that the MCFs were treated by surgery or Funding
more than 308. Hyde et al.32 only offered not; the impact of these variables on the
None.
surgical treatment to patients with medial post-treatment complications rate is dif-
dislocation of the condyle >308, displaced ficult to estimate. A greater level of
fractures with >5 mm bone overlap, or statistical significance might have been
Competing interests
complete loss of bone contact. Villarreal realized had the confounding variables
et al.33 found a statistically significant and biases not been present. None declared.
178 Chrcanovic
Ethical approval a systematic review and meta-analysis. Int J fractures. A study of functional rehabilita-
Oral Maxillofac Surg 2014;43:708–16. tion. Int J Oral Maxillofac Surg
Not required. 12. Landes CA, Day K, Glasl B, Ludwig B, 1996;25:107–11.
Sader R, Kovacs AF. Prospective evaluation 25. Joos U, Kleinheinz J. Therapy of condylar
Patient consent of closed treatment of nondisplaced and neck fractures. Int J Oral Maxillofac Surg
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displaced and dislocated fractures in term outcome of patients treated for bilateral
children. J Oral Maxillofac Surg 2008; fracture of the mandibular condyles. Br J
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to thank Dr Kohji Ishihama and Dr Fab- 13. Suzuki T, Kawamura H, Kasahara T, Naga- 27. Oezmen Y, Mischkowski RA, Lenzen J,
rizio Spallaccia for sending me their arti- saka H. Resorbable poly-l-lactide plates and Fischbach RMRI. examination of the TMJ
cles, and Dr Yoav Leiser, Dr Pedro screws for the treatment of mandibular con- and functional results after conservative and
Villarreal, Dr Richard H. Haug, Dr dylar process fractures: a clinical and radio- surgical treatment of mandibular condyle
Edward Ellis III, Dr Giacomo De Riu, logic follow-up study. J Oral Maxillofac fractures. Int J Oral Maxillofac Surg
and Dr Kohji Ishihama who provided Surg 2004;62:919–24. 1998;27:33–7.
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Surgical Versus Non-Surgical Treatment of Mandibular Condylar Fractures: A Meta-Analysis

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Surgical Versus Non-Surgical Treatment of Mandibular Condylar Fractures: A Meta-Analysis

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Int. J. Oral Maxillofac. Surg.

2015; 44: 158–179

Surgical versus non-surgical B. R. Chrcanovic

Surgical/non-surgical condylar fracture treatment

(NM, G2) years (G2) G2)

assault (20%), fall

microplate for removable

Surgical/non-surgical condylar fracture treatment

reconstructed, with only one

Surgical/non-surgical condylar fracture treatment

the contralateral unaffected side.

glenoid fossa were recorded,

position after surgery, which did

Surgical/non-surgical condylar fracture treatment

condylar head fractures, sufficient anatomic reduction of the

associated midface fractures, significant

ed MFs of known location. Fourteen stud- Twenty-four studies mentioned that

period.22,36,39,53 improved substantially when compared

more patients,12,16,20,24–26,28,30,32,33,35,38, tween the degree of radiographically

mm microplates,12,28,37,40,41 six studies

micromesh,34 and eight studies20,27– studies were judged to be at high risk of

used screws (transfixation bias.

treatment group.31,36,39,46,49,53 Twelve tion (I2 = 0%, P = 0.99), malocclusion

or all patients16,20,21,23,27,30,34,43,49,50 in ing MIO (I2 = 24%, P = 0.21), or TMJ

Table 3. Results of the quality assessment.

Fig. 4. Forest plot for the dichotomous outcome ‘post-treatment infection’.

Fig. 5. Forest plot for the dichotomous outcome ‘TMJ pain’.

Fig. 6. Forest plot for the dichotomous outcome ‘TMJ noise’.

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