Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management

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 ).

Table 1
Inclusion and exclusion criteria.
Criteria
Inclusion criteria:
Systematic review and meta-analysis of randomised or non-randomised controlled trials
Adult condylar fracture
In English
Exclusion criteria:
Non-systematic review
No studies on children
Critically low overall rate as judged by AMSTAR 2

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.

Table 2
Keywords used in search.
Keywords
Mandibular condyle fracture
Mandibular subcondylar fracture
Mandibular neck fracture
Open treatment
Open reduction and internal fixation
Closed treatment
Conservative treatment
Surgical treatment
Non-surgical treatment
Systematic review
Meta-analysis

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 ).

Table 3
AMSTAR-2 evaluation of the systematic reviews.
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
Only gold members can continue reading. Log In or Register to continue

Aug 5, 2020 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management
Premium Wordpress Themes by UFO Themes