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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1633-1636  

Is open reduction and internal fixation sacrosanct in the management of subcondylar fractures: A comparative study


1 Department of Oral and Maxillofacial Surgery, Dr. Syamala Reddy Dental College and Research Center, Bengaluru, Bengaluru, India
2 Department of Prosthodontics and Crownn Bridge Inlucding Implantology, Government Medical College, Bettiah, Bihar, India
3 Department of Oral and Maxillofacial Surgery, Sri Ramakrishna Dental College and Hospital, Coimbatore, Tamil Nadu, India
4 Department of Orthodontics and Dentofacial Orthopedic, Government Dental College and Hospital, Hyderabad, Telangana, India
5 Department of Oral and Maxillofacial Surgery, J.C.D Dental College, SIRSA, Haryana, India
6 Consultant Dental Surgeon, Bettiah, Bihar, India
7 Department of Oral and Maxillofacial Surgery, Narsinbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India

Date of Submission28-Apr-2021
Date of Decision14-May-2021
Date of Acceptance21-May-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
Nandini Dayalan
Department of Oral and Maxillofacial Surgery, Dr.Syamala Reddy Dental College and Research Center, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.jpbs_352_21

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   Abstract 


Purpose: This paper is intended to compare and evaluate the better treatment option in the management of subcondylar fractures of the mandible. Materials and Methods: This study included 20 patients who were diagnosed clinically and radiologically to have sustained an isolated subcondylar fracture of the mandible. They were divided into two groups randomly. Group I included 10 patients who underwent treatment by intermaxillary fixation alone followed by active physiotherapy in the form of conservative management. Group II included 10 patients who underwent treatment by surgical intervention for open reduction and internal fixation under general anesthesia following elastic guidance. Factors such as maximal mouth opening, pain scores, and deviation of mandible on mouth opening were taken into consideration and evaluated. Results: It is observed that the patients in Group I had weight loss and restrictions in their social well-being in the early recovery phase, in addition to delay in return to function. In spite of the early return to function, patients in Group II were subjected to all kinds of surgical complications such as transient facial nerve injury, infection, and unesthetic scar. The maximal mouth opening and deviation of the mandible on mouth opening remained almost the same in both groups. Conclusion: A regular follow up of operated patients post trauma is essential to obtain morphological and functional recovery. When the respective advantages and disadvantages of both treatment options were compared and evaluated, it was observed that patients treated by closed reduction had a better clinical and psychological outcome.

Keywords: Closed reduction, condylar fracture, open reduction


How to cite this article:
Dayalan N, Kumari B, Khanna SS, Ansari FM, Grewal R, Kumar S, Tiwari RV. Is open reduction and internal fixation sacrosanct in the management of subcondylar fractures: A comparative study. J Pharm Bioall Sci 2021;13, Suppl S2:1633-6

How to cite this URL:
Dayalan N, Kumari B, Khanna SS, Ansari FM, Grewal R, Kumar S, Tiwari RV. Is open reduction and internal fixation sacrosanct in the management of subcondylar fractures: A comparative study. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Jun 28];13, Suppl S2:1633-6. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/1633/330101




   Introduction Top


Mandibular fractures are extremely frequent in facial trauma, and 19%–52% involves the condyle.[1],[2],[3] As a consequence of condylar fracture, patient may encounter pain, restricted mandibular movement, muscle spasm and deviation of the mandible, malocclusion, and pathological changes in the temporomandibular joint (TMJ), osteonecrosis, facial asymmetry, and ankylosis.[4],[5] The majority of mandibular condyle fractures involve the condylar neck, with few reports of intracapsular fractures. Sagittal or vertical fractures of the mandibular condyle and chip fractures of the medial part of the condylar head are rarely encountered.[6] Ever since the introduction of osteosynthesis materials for rigid internal fixation, there has been a never-ending debate pertaining to the treatment of condylar fractures of the mandible. Literature shows that open reduction and internal fixation (ORIF) of the condylar fractures may be indicated for bilateral injuries or considerably displaced condylar fractures or with dislocation of condylar heads, but closed treatment and intermaxillary fixation may be indicated in cases where condylar displacement is minimal and the height of the ramus is almost normal.[7],[8] This study is designed to evaluate the better treatment option in the management of subcondylar fractures of the mandible in clinical scenarios where there was an isolated low unilateral subcondylar fracture with moderate displacement between the fracture segments, but the condyle is still seated in the glenoid fossa.


   Materials and Methods Top


This study included 20 patients who were diagnosed clinically and radiologically to have sustained isolated unilateral subcondylar fracture of the mandible.

Selection criteria is based on:

  1. Level of condylar fracture


  2. This study included patients in whom there was an isolated low unilateral subcondylar fracture

  3. Severity of displacement of fracture segments


This study included patients in whom there is moderate displacement between the fracture segments but the condyle is still seated in the glenoid fossa.

Inclusion criteria

  • Patients who were diagnosed clinically and radiographically to have sustained unilateral subcondylar fracture
  • Patients who were followed up for a minimum period of 6 months
  • Patients who are healthy and fall between the age group of 18–60 years.


Exclusion criteria

  • Patients with associated fractures of the facial skeleton
  • Patients who underwent previous TMJ surgeries
  • Patients who are medically compromised


All patients were divided randomly into two groups.

Group I include 10 patients who were diagnosed clinically and radiographically to have sustained unilateral subcondylar fracture and were treated by closed reduction.

Group II include 10 patients who were diagnosed clinically and radiographically to have sustained unilateral subcondylar fracture and were treated by open reduction.

All the patients were clinically and radiographically evaluated preoperatively (T1), at 3 months (T2), and at 6 months (T3).

Parameters evaluated:

  1. Maximal mouth opening – interincisal distance
  2. Pain on maximal mouth opening – visual analog scale score
  3. Deviation of mandible on mouth opening – with reference to dental midline
  4. Nutritional deficiency – weight loss
  5. Facial nerve palsy – frontal frowning and eye closure
  6. Presence or absence of scar
  7. Any infection at surgical site
  8. Return to function – duration.



   Results Top


A total of 20 patients (18 males and 2 females) who met the inclusion criteria were included in this study, with 10 patients being treated by open treatment and 10 patients being treated by closed treatment in each group, as shown in [Figure 1]. Mean age of the patients was 29.15 ± 9.84 years (range = 18–60 years). Mean age of the patients in Group II was 30.5 ± 8.67 years (range = 18–52 years), while the mean age of the patients in Group I was 28.80 ± 12.12 years (range = 18–55 years). Road traffic accident was identified as the major cause for the fracture of the mandibular condylar. It was noticed that following 6 months of the surgical intervention, the mean mouth opening of all the patients in Group II was 37.39 ± 2.72 mm while in Group I was 34.74 ± 2.72 mm as shown in [Figure 2]. Independent samples t-test was applied to compare the means and the P = 0.035 which shows statistically significant difference between both the groups. After 6 months of treatment, deviation of the mandible on opening was found to be 0.3 ± 0.78 mm in Group II while 1.3 ± 1.60 mm in Group I. Independent samples t-test showed P = 0.045 which is statistically not significant. In both the groups, none of the patients had occlusal disturbances at 6 months' postoperative time. Independent samples t-test was applied, and P = 0.265 which is statistically not significant.
Figure 1: Graph showing the demographic data in both the groups

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Figure 2: Graph showing the mean mouth opening in both the groups

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It was observed that 6 out of the 10 patients in Group II had transient facial palsy which recovered within 6 months' time as shown in [Figure 3]. It was observed that 2 out of the 10 patients in Group II had an unesthetic scar in the postoperative period as shown in [Figure 4]. None of the patients in Group II had any infection at the surgical site. It is observed that the patients in Group I had weight loss and restrictions in their social well-being in the early recovery phase in addition to delay in return to function as shown in [Figure 5] and [Figure 6]. In spite of the early return to function, patients in Group II were subjected to all kinds of surgical complications such as transient facial nerve injury, infection, and unesthetic scar.
Figure 3: Graph showing the transient facial palsy in both the groups

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Figure 4: Graph showing the unesthetic scar in both the groups

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Figure 5: Graph showing the weight loss in both the groups in the postoperative period

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Figure 6: Graph showing the duration for return to function in the postoperative period

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   Discussion Top


It is a well-known fact that the treatment of mandibular condylar fractures is one of the most controversial subjects of maxillofacial trauma management. Even though closed treatment for the management of condylar fractures has long been the method of choice with the advent of rigid osteosynthesis, numerous treatment options have been employed to improve the functional outcomes and decrease the period of maxillomandibular fixation and early return to function.[9],[10] This study employed closed treatment by immobilization with maxillomandibular fixation for a period of 5–6 weeks, while open treatment was done by an extraoral approach via retromandibular and anterior parotid and transmasseteric approach. With regard to the mean mouth opening in the postoperative period, it was noticed that Group I had 34.74 ± 2.72 mm while Group II had 37.39 ± 2.72 mm. The difference in the mean mouth opening was only 3 mm. Previous studies compared the functional outcomes of surgical and nonsurgical treatment for the management of condylar fracture and found that the results were nearly similar in both the groups.[11],[12] The results of this study are in accordance with previous studies. However, another study revealed a better mobility of mandible in closed treatment group when minimally displaced condylar fractures were managed by closed reduction.[13] The limited mouth opening following open reduction compared to a closed reduction can be attributed to the fact that in open reduction there is excessive muscle stripping, scar formation, and incisional pain.

A randomized control trial of moderately displaced fractures of the subcondylar region with ramal shortening ≥2 mm or deviation 10°–45° revealed that both surgical and nonsurgical treatments resulted in acceptable results, but open treatment was superior to closed treatment in all functional variables studied including maximal interincisal opening.[14] Another meta-analysis revealed that even though the mean maximal mouth opening was nearly similar in both open and close reduction, there existed a gross difference in terms of protrusive and excursive movements with superior results in open treatment.[15] It is advocated that protrusion is a better indicator of the mobility of the TMJ than passive opening because it requires active movement of condyle during functional activity. With regard to the occlusal discrepancies in the postoperative period, the results of this study did not find any significant difference between both the groups. The results of this study are in accordance with previous studies.[11],[14] However, few previous studies revealed a greater incidence of occlusal discrepancy in patients treated by closed reduction compared to patients who were treated with ORIF.[15],[16] In patients in Group II who are treated with ORIF through retromandibular extraoral approach, two patients were associated with visible uanesthetic scars, but previous studies have shown that ORIF through retromandibular extraoral approach is not always associated with visible scars.[17],[18],[19] Literature reveals that the risk of facial nerve injury for ORIF in subcondylar fractures depend on various factors such as prolonged traction at the operative site, experience of the surgeon, and postinjury edema.[20] This study noticed transient facial nerve palsy in six patients following open reduction for the management of subcondylar fractures.


   Conclusion Top


The results of this study reveal that open treatment of unilateral mandibular condylar fractures results in better functional outcomes, particularly in terms of maximal mouth opening. However, it is worth noting from the results of this study that fractures of the mandibular condylar with moderate displacement can be successfully managed by closed method to obtain better functional results with the elimination of surgical complications such as transient facial nerve palsy and unesthetic scar. Studies with longer follow-up period and a wider variable base are essential to provide a better understanding of the functional outcomes of open and closed treatment of mandibular condylar fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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2.
Uppada UK, Sinha R, Susmitha M, Praseedha B, Ravi Kiran B. Mandibular fracture patterns in a rural setup: A 7-year retrospective study. J Maxillofac Oral Surg Press 2020. [doi: https://doi.org/10.1007/s12663-020-01358-3].  Back to cited text no. 2
    
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Revanth Kumar S, Sinha R, Uppada UK, Ramakrishna Reddy BV, Paul D. Mandibular third molar position influencing the condylar and angular fracture patterns. J Maxillofac Oral Surg 2015;14:956-61. doi: 10.1007/s12663-015-0777-2. PMID: 26604470; PMCID: PMC4648771.  Back to cited text no. 3
    
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7.
Terai H, Shimahara M. Closed treatment of condylar fractures by intermaxillary fixation with thermoforming plates. Br J Oral Maxillofac Surg 2004;42:61-3.  Back to cited text no. 7
    
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Valiati R, Ibrahim D, Abreu ME, Heitz C, de Oliveira RB, Pagnoncelli RM, et al. The treatment of condylar fractures: To open or not to open? A critical review of this controversy. Int J Med Sci 2008;5:313-8.  Back to cited text no. 8
    
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Asim MA, Ibrahim MW, Javed MU, Zahra R, Qayyum MU. Functional outcomes of open versus closed treatment of unilateral mandibular condylar fractures. J Ayub Med Coll Abbottabad 2019;31:67-71.  Back to cited text no. 9
    
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Uppada UK, Sinha R, Bharadwaj B, James K. Evaluation of the complications associated with ORIF in the management of mandibular fractures-A 7 years retrospective study. Int J Oral Facial Surg 2020;2:15-20.  Back to cited text no. 10
    
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Santler G, Kärcher H, Ruda C, Kole E. Fractures of the condylar process: Surgical versus non-surgical treatment. J Oral Maxillofac Surg 1999;57:397-8.  Back to cited text no. 12
    
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Yang WG, Chen CT, Tsay PK, Chen YR. Functional results of unilateral mandibular condylar process fractures after open and closed treatment. J Trauma 2002;52:498-503.  Back to cited text no. 13
    
14.
Singh V, Bhagol A, Goel M, Kumar I, Verma A. Outcomes of open versus closed treatment of mandibular subcondylar fractures: A prospective randomized study. J Oral Maxillofac Surg 2010;68:1304-9.  Back to cited text no. 14
    
15.
Liu Y, Bai N, Song G, Zhang X, Hu J, Zhu S, et al. Open versus closed treatment of unilateral moderately displaced mandibular condylar fractures: A meta-analysis of randomized control trials. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:169-S73.  Back to cited text no. 15
    
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Ellis E 3rd, Throckmorton G. Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 2000;58:719-28.  Back to cited text no. 16
    
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Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: A clinical study of 52 cases. J Oral Maxillofac Surg 1994;52:353-60.  Back to cited text no. 17
    
18.
De Riu G, Gamba U, Anghinoni M, Sesenna E. A comparison of open and closed treatment of condylar fractures: A change in philosophy. Int J Oral Maxillofac Surg 2001;30:384-9.  Back to cited text no. 18
    
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Newman L. A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles. Br J Oral Maxillofac Surg 1998;36:176-9.  Back to cited text no. 19
    
20.
Shiju M, Rastogi S, Gupta P, Kukreja S, Thomas R, Bhugra AK, et al. Fractures of the mandibular condyle – Open versus closed – A treatment dilemma. J Cranio-Maxillofac Surg 2015;43:448-51. doi: 10.1016/j.jcms.2015.01.012. PMID: 25726918.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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