Evidence-Based Issues in Maxillofacial Trauma

In summary, the evidence-based decisions for subcondylar fractures treatment depend on the fracture type and pattern as reflected in the indications. Some fractures will heal without much deficits with closed treatment and occlusal posterior bite planes; open reduction for either or both sides must be selected appropriately [915]. A patient with aesthetic form and normal function as the final result is the goal of treatment. The appearance of the radiograph is insignificant when these two goals have been met. Open method does not by itself guarantee that these goals will be met. In most cases, these can be met with closed method, meticulous postoperative physical therapy, and follow-up. Clinical judgment and consideration of other medical conditions must always influence the treatment choice for any particular patient. Therefore, treatment should be chosen based on patient choice, indication, and suitability for either procedure.
Bilateral condylar in association with midfacial fractures
The patient who has both bilateral condylar fractures and midfacial fractures poses a challenge for the reconstructive surgeon. The surgeon, thus, takes into consideration the degree of comminution, the associated injuries, and the state of the dentition when determining whether to open one or both subcondylar fractures in such a patient. The decision is that ORIF on both sides can facilitate the care of the patient with an orthognathic problem that predates the fracture, but splints should be constructed to facilitate the care of these patients as well [4, 7, 915, 23, 29, 45, 57]. If such patients are to be treated in an open fashion, models should be made and splints should be fabricated for intraoperative use. A millimeter of error at the fracture line may not be apparent to the operator, but a millimeter of error at the occlusion may be apparent to the patient.
Malunited condyle fracturesThere are but few articles on these fractures, but suggestions for management tend toward open treatment. Although there is yet no agreement on whether to create a new functional joint by doing sagittal split and/or external vertical ramus osteotomy or to refracture the malunion, the former option was consistently found to restore vertical ramus height and functions in patients compared to the latter [21, 29]. There were also good functional movements, occlusion, and sufficient bite force. It has also been argued that refracturing the malunion is technically difficult and may result in communition of the fragments [915, 21, 29]. Others have sectioned the upper fragment of the malformed condyle and restored with free nonvascularized bone graft. Associated donor site morbidities and unpredictable take of such grafts are important considerations [22].

9.2.7 The Approach to Open Treatment: Extraoral, Intraoral, or Endoscopy

There are various approaches in order to visualize and reduce the fractures of the condyles, these can be divided into two broad groups – extraoral and intraoral [11, 25, 60].
Extraoral approaches include preauricular, retroauricular, retromandibular, submandibular, and rhytidectomy (face-lift) incisions. These can also be used in different combinations [11, 25, 60].
Risdon described the submandibular approach; 4–5 cm skin incision, 2 cm below the angle of the mandible [60]. Access to the high condyle fractures with this approach is not as good as in preauricular and retromandibular approach, but the facial nerve, parotid gland, external carotid artery, and retromandibular vein are better avoided and kept out of the operation field. The scars are also more hidden in the submandibular approach. However, most surgeons prefer retromandibular approach described by Hinds and Girotti [60] because of better direct access, shorter working distance from the incision to the condyle, excellent exposure even in the presence of marked edema, easy retrieval of the medially displaced condyle, and less conspicuous facial scar [1014, 25, 29, 41, 44, 53, 60].
Silverman first described the open reduction and internal fixation of the condyle via intraoral route [60]. The major problem with this approach is access to the condylar fragments with consequent difficulty in manipulating and reducing the fragments. The merit is no obvious scars [44, 60]. Intraoral approach is usually by the mandibular vestibular incision with or without the use of an endoscope [11, 43, 100]. In any case, a transbuccal trocar is often necessary to aid the placement of some or all of the screws through plates on the reduced fragment [29, 41, 44, 60]. The use of an endoscope to assist with visualization of the fracture has become popular, and is commonly done in some centers. New instrumentation is frequently being developed.
In some cases, the use of the endoscope can add quite a bit to the length of the procedure, and therefore, to the anesthetic time and hospital charges without adding a great deal of advantage in terms of outcome [43, 100]. The evidence in support of its use elucidates the fact that it minimizes the incision needed and enhances visualization of small fragments. However, manipulation can be difficult and operation time increased especially with inexperienced surgeons [43, 68, 100]. As the equipment improves and operators’ experience increases, operating times are expected to be reduced.
There are only few articles reporting outcomes with the use of endoscopes [43, 68, 100]. Hence, there is insufficient evidence to compare outcomes in terms of functional and aesthetic goals with properly performed and followed closed reduction, invasive intraoral, or extraoral approaches. In this regard, multidata based studies have to be conducted to answer the questions.
Generally speaking, most surgeons favor retromandibular approach, even though there are no conclusive evidences to suggest that outcome with one extraoral approach is better than the other or that extraoral approach is better than intraoral approach. In terms of scar perception, many patients prefer intraoral approach, even though access is better with the extraoral approach [11, 29, 41, 44, 60]. The approach used in each case would be determined by the surgeons’ and patients’ choice, amount of access obtainable, and the site of condyle fracture.

9.2.8 Debates on Fixation vs. No Fixation and the Types of Fixation

Whatever approach is chosen, once the fracture is exposed, it must be reduced. Whether the fracture must be fixated and how stable that fixation should be are other issues of controversy. Some surgeons believe that fixation is not always required. In studies that looked at a series of patients who had condyles significantly displaced out of the fossa and open reduction without fixation was done, the surgeons argued that significant malunion was prevented while avoiding rigidly fixating the condyles in a nonphysiologic position [815, 19, 21, 26, 32, 33, 41]. In essence, each of these markedly displaced fractures was converted to an undisplaced fracture and then treated as such, with occlusal control and physical therapy. If the fracture segment is unilateral and small enough, some surgeons advocate condylectomy [53, 74] instead of ORIF. The procedure simply removes the proximal segment altogether, while controlling the occlusion; the patient participates in extensive physical therapy afterward.
On the contrary, some others advocate mandatory fixation once a fracture is opened up and different methods of fixation have been discussed. Wire fixation and intramedullary pins have been used to stabilize condylar fractures [26, 32, 104, 110]. Again, occlusal control and physiotherapy remain crucial to successful outcomes.
In some cases, external fixators (e.g., Joe Hall Morris-type appliances) have been used with good success. Once again, occlusal control and physiotherapy are crucial to successful outcomes [6871, 73, 74]. Finally, miniplates and screws are discussed. Argument exists as to whether these constitute rigid fixation or not [2326, 32, 33]. The conclusion is that stable fixation, either semirigid with transosseous wires or external fixators or rigid with miniplates, is necessary once open treatment is performed to keep the segments in physiologic position. Unstable fixation or fixation in a nonphysiologic position sets up the patient for pain, poor function, and degenerative joint disease [41, 53, 74, 91, 98, 99, 104, 110, 112, 120, 122, 123].

9.2.9 Physical Therapy Regimen

Of utmost importance for all patients, whether treated with closed or open techniques, is the general agreement that compliance with physical therapy regimens is highly essential [915]. These regimens do not require the patient to visit a rehabilitation center or to have any outside personal assistance (except for patients who are very young and/or some with physical or mental disabilities). Rather, physical therapy consists of a series of mouth opening exercises. There are commercially available devices such as the Therabite or EZ Flex jaw exercisers, which can be used by patients. An alternative and inexpensive method consists of a stack of tongue blades that can be increased in number each day [53, 74, 91, 98, 99]. Regardless of any device, during the first week posttreatment (i.e., non-IMF) or post-IMF, the patient should begin active movement of the jaws by attempting to open widely using their masticatory muscles. If sideward deviation is noted during this period, they are instructed to place a hand on the side of the face toward which the jaw deviates and apply gentle medial pressure as they open and close. By week 2, passive opening should begin with fingers, tongue blades, or exercise devices. Normal mandibular range of motion is 40 mm or more between the incisal edges of the anterior maxillary and mandibular teeth. In most patients, this distance should be achievable by week 2, if not sooner. Once the patient has reached the minimum goal of 40 mm, continued work in the straight opening plane is augmented with lateral and protrusive movements. The treatment is not complete until the patient has both a stable occlusion and normal function. Many care providers do not remove hardwares until both goals have been achieved; the removal thus serves as an additional motivational factor for some patients [19, 21, 26, 32, 33]. The result of an appropriate physical therapy regimen is a functional joint and masticatory system with little or no deformity [21, 26, 32].

9.2.10 Conclusion

The conclusive evidence based on collective reports of experiences documented in the literature can be itemized as follows:


Intracapsular fractures are best treated closed.

Fractures in children are best treated closed except when the fracture itself anatomically prohibits jaw function.

Most fractures in adults can be treated closed except in cases of gross displacements of the fragments and/or severe dislocations of the condylar head.

Physical therapy that is goal-directed and specific to each patient is integral to good patient care and is the primary factor influencing successful outcomes, whether the patient is treated open or closed.

When open reduction is indicated, the procedure must be performed well, with an appreciation for the patient’s occlusal relationships, and it must be supported by an appropriate physical therapy and follow-up regimen.

The fractures that are openly reduced can be rigidly or semirigidly fixed in very stable physiologic position.
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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on Evidence-Based Issues in Maxillofacial Trauma
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