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.
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. 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. 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. 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. 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.
Methods
A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. 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) and reviews that were rated “critically low” were excluded ( Table 1 ).
| 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 |
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 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.
| 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 |
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) which after discussion, the reviewers agreed to exclude as it included no studies.
Results
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 ).
| First author, year, and reference | Overall AMSTAR rate | Weakness | Decision |
|---|---|---|---|
| Almoraissi 2015 | Moderate | No double selection and review No report of studies funding No report of review funding |
Include |
| Berner 2015 | Critically low | 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 * |
Exclude |
| Chrcanovic 2012 | Critically low | 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 * |
Exclude |
| Chrcanovic 2015 | Moderate | No double selection and review No report of studies funding |
Include |
| García-Guerrero 2017 | Critically low | 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 * |
Exclude |
| Kyzas 2012 | Critically low | No report of meta-analytic method * No report of publication bias * No double selection |
Exclude |
| Liu 2013 | Critically low | Protocol was not registered * No report of studies funding No report of review funding No justification of excluded studies * |
Exclude |
| Nussbaum 2008 | Critically low | Protocol was not registered * No comprehensive search * No double selection and review No report of studies funding No justification of excluded studies * |
Exclude |
| Sharif 2010 | Moderate | It did not include any study | Exclude |
| Yao 2014 | Critically low | 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 |
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