Inter Maxillary Fixation Versus Open Reduction for the Treatment of Mandibular Condyle Fractures: A Comparative Evaluation.

BACKGROUND: The treatment for fractured mandibular condyles aims at restoring the masticatory ability, occlusion, symmetry, and function as the bit were before the trauma. The treatment of the mandibular condylar fracture can be done based on the two protocols. AIMS: The present clinical trial was conducted to collate aftertreatment upshot of closed treatment and open surgical treatment for mandibular condyle fractures.
MATERIALS AND METHODS: Forty-two patients were divided into two groups (n = 12) which were treated with either the closed reduction using intermaxillary fixation or open reduction and internal fixation. The following clinical parameters were assessed at 1st and 3rd day and at 1, 3, and 6 weeks: lateral excursion and protrusion, occlusion; interincisal opening, mandibular ramus height, deviation/deflection during jaw opening, and pain assessment using visual analog score. The collected data were subjected to statistical evaluation.
RESULTS: Interincisal opening was found to be 8.125 ± 0.3467 mm and 6.016 ± 0.1528 mm, respectively, for Group I and Group II which was statistically significant (P < 0.00001). At the 3 months and 6th week postoperatively, it was increased in the surgical groups to 17.433 ± 0.3822 mm and 19.175 ± 0.3696 mm, respectively.
CONCLUSION: The present trial suggests surgical open reduction and internal fixation treatment of the mandibular condylar fracture is better than the nonsurgical closed reduction in terms of interincisal opening, lateral excursion, and protrusive mandibular movement range. Copyright:

INTRODUCTION

Among all maxillofacial traumas, the fractures of the mandibular condyle are considered most common and constitute around 60% of total fractures. The common reasons for the fracture of the mandibular condyle are violence, fall from a height, and road traffic accidents (most common).[1] These protocols include either the closed treatment which focuses on immobilization of the fracture segments using closed reduction or the open treatment where surgically the open reduction of fracture segments is done followed by the internal fixation.[2] Both the treatment methods have their pros and cons as well as their applications and limitations. Absolute and relative indications and contraindications of both closed and open fracture reduction have been widely described in the literature.[3]

Various indications for mandibular condyle fracture for the applicable cases have been described. In the past, conservative and closed fracture reduction method was preferred widely by the surgeons as this method was thought to result in acceptable and satisfactory outcomes following the treatment.[45] In the literature, there is scarce data on the long-term evaluation of the postoperative results following open or closed reduction of the mandibular condyle fracture.[6]

Treating the mandibular condylar fractures by surgical means is risky and difficult owing to the potential damage it can cause to nerves most common facial nerve, muscles, and other anatomic structures during surgical exposure.[7] Although nonsurgical reduction usually results in malocclusion, decreased mouth opening, deviation or deflection on the opening of the jaws, closed reduction is also associated with few shortcomings including difficulty in speech, mastication, airway obstruction, nonfunctional masticatory muscle atrophy, and compromised oral hygiene.[89]

Restoring the natural normal position or a position nearly similar to the normal is easier to achieve with open reduction and internal fixation. Furthermore, open reduction and internal fixation help in maintaining the optimal occlusal position of the teeth and mandible.[10] In literature, no clear and decisive criteria exist to decide whether surgical or nonsurgical and whether the closed or open reduction is required.[11]

Hence, the present clinical trial was conducted to collate aftertreatment upshot of closed treatment and open surgical treatment for mandibular condyle fractures.

MATERIALS AND METHODS

The present clinical trial was prospective and included 24 subjects with the mandibular condylar fractures. The included patients were within the age range of 19 years–42 years with the mean age range of 32.6 years. To be included in the study, the patients had to be in the following inclusion criteria: age of 18 years or above, sole condylar fracture with no fracture of mandibular body/ramus, decrease in ramal height by at least 2 mm.

The selected 24 patients were randomly divided into two groups (n = 12). Group I patients were treated with intermaxillary fixation (IMF) using arch bar splinting and guiding elastics without surgical intervention, whereas, the patients of Group II were treated with open reduction and internal fixation with titanium mini plates and screws. In Group II, ORIF was done under general anesthesia.

Postoperatively, the patients of both the groups were assessed on 1st and 3rd day followed by evaluation at 1, 3, and 6 weeks. The following parameters were assessed for Group II at all the visits for follow-up: mandibular movements in lateral excursion and protrusion, bilateral optimal occlusion through intercuspation of first molars, inter incisal opening, mandibular ramus height, and deviation/deflection during jaw opening. For Group I, the parameters were assessed only at the 3rd and 6th weeks' postoperative. In addition, pain assessment was done with the visual analog score (VAS) at the scale of − 10 at all the recall intervals for both the groups. The collected data were subjected to statistical evaluation.

RESULTS

Included two groups (n = 12). One group was treated with a conservative approach and others with an open approach. The mean of included patients was 32.6 years with the age range of 19 years–42 years. There were 54.16% males (n = 13) and 45.83% females (n = 11). The demographic characteristics of the study patients are listed in Table 1.

Table 1

Demographic characteristics of the study subjects

Characteristic	Value
Total subjects	n=24
Groups	2 (n=12)
Mean age (years)	32.6
Age range (years)	19-42
Gender	54.16% males (n=13) and 45.83% females (n=11)

The distance between the incisors in the preoperative period was assessed for both the groups and was found to be 8.125 ± 0.3467 mm and 6.016 ± 0.1528 mm, respectively, for Group I and Group II which was statistically significant (P < 0.00001). At the 3 months, and 6th week postoperatively it was increased in the surgical groups to 17.433 ± 0.3822 mm, and 19.175 ± 0.3696 mm, respectively. For the nonsurgical group, the interincisal opening was reduced in the first postoperative week, and then it increased at 3rd and 6th months to 9.375 ± 0.2734 mm and 12.208 ± 0.1881 mm, respectively [Table 2]. These values were both statistically significant (P < 0.00001).

Table 2

Interincisal opening at different time-intervals of the study subjects

Time	Group I (IMF)	Group II (ORIF)	P
Preoperative	8.125±0.3467	6.016±0.1528	<0.00001
3 weeks postoperative	9.375±0.2734	17.433±0.3822
6 weeks postoperative	12.208±0.1881	19.175±0.3696

ORIF: Open reduction and internal fixation, IMF: Intermaxillary fixation

The mean of movements in lateral excursion and jaw protrusion was evaluated for both the groups. In Group I, the protrusive movement range was increased at 1, 3, and 6 months recall with the mean of 0.4667 ± 0.403, 2.275 ± 0.2006 mm, and 2.7917 ± 0.0289 mm, respectively. In Group II, it was increased by 1.7161 ± 0.5096 mm, 2.4333 ± 0.3339 mm, and 2.8083 ± 0.0289 mm, respectively, at 1, 3, and 6-month recall. Statistical significant improvement in surgical group was seen at 1 week (P < 0.00001). At 3 weeks and 6 weeks, the results were nonsignificant (P = 0.17309, and 0.17129, respectively) as shown in Table 3.

Table 3

Changes in protrusive movements at different time-intervals of the study subjects

Time	Group I (IMF)	Group II (ORIF)	P
1 week postoperative	0.4667±0.403	1.7161±0.5096	<0.00001
3 weeks postoperative	2.275±0.2006	2.4333±0.3339	0.17309
6 weeks postoperative	2.7917±0.0289	2.8083±0.0289	0.17129

ORIF: Open reduction and internal fixation, IMF: Intermaxillary fixation

Concerning the lateral excursion movement, for Group I at 1, 3, and 6 months, it was increased by 0.7917 ± 0.0289 mm, 4.3417 ± 0.4231 mm, and 5.0333 ± 0.2103 mm, respectively. The same findings for Group II were 2.4167 ± 0.038 mm, 6.2167 ± 0.3129 mm, and 8.3833 ± 0.4345 mm respectively. These values were statistically significant at all-time intervals with P < 0.00001 [Table 4].

Table 4

Changes in lateral excursive movements at different time-intervals of the study subjects

Time	Group I (IMF)	Group II (ORIF)	P
1 Week postoperative	0.7917±0.0289	2.4167±0.038	<0.00001
3 weeks postoperative	4.3417±0.4231	6.2167±0.3129
6 weeks postoperative	5.0333±0.2103	8.3833±0.4345

ORIF: Open reduction and internal fixation, IMF: Intermaxillary fixation

Occlusion was disturbed in seven patients of Group I and nine patients in Group II which were restored to optimal occlusion at 6 weeks' postoperatively by condylar repositioning. Changes in VAS score for pain at different time-intervals of the study patients were explained in Table 5.

Table 5

Changes in visual analog scale score for pain at different time-intervals of the study subjects

Time	Group I (IMF)	Group II (ORIF)	P
Preoperative	5.125±0.3415	4.75±0.3477	0.14127
6 weeks postoperative	4.275±0.3108	3.2833±0.2823	<0.00001

ORIF: Open reduction and internal fixation, IMF: Intermaxillary fixation

DISCUSSION

The present clinical trial was conducted to collate after-treatment upshot of closed treatment and open surgical treatment for mandibular condyle fractures. Although advancement in surgical technique and their predictability has shifted the focus towards surgical management, conventional management is liked widely owing to the risk of damaging facial nerve and difficulty in gaining surgical access as suggested by Ebenezer and Ramalingam[12] in 2010. In the present trial, interincisal opening significant was found in both the groups with a P < 0.00001, these findings were following the study by Hyde et al.[13] in 2002 where authors reported significant clinical improvement in the interincisal opening with both surgical and closed treatment. Concerning lateral excursion and protrusive movements were also found to be improved significantly for closed treatment and open reduction (P < 0.00001). Similar findings were reported by Eckelt et al.[14] in 2006 with the improvement of 16 mm with surgery and 13 mm with closed treatment. However, another study by Carneiro et al.[15] in 2008 was against the present study.

About pain perception, a significant difference was to see in two groups with significantly lesser pain perception in the surgical group (P = 0.14127 and <0.00001, respectively, at baseline and 6 weeks). These findings were following the studies by Haug and Assael[16] in 2001 and Hyde et al.[13] These findings supported the present study. In the present trial, acceptable fracture reduction and optimal occlusion were achieved with the reestablishment of the ramus height at the end of 6 months' postoperatively. These findings were following the studies by Eckelt et al.[14] in 2006, Ebenezer and Ramalingam[12] in 2010, and Danda et al.[17] in 2010.

The present study showed and accepted the surgical treatment better over the nonsurgical treatment for the reduction of the mandibular condyles and suggests the acceptance of the surgical therapy of open reduction and internal fixation by the surgeons at the place of nonsurgical closed reduction of the fracture of the mandibular condyle.

CONCLUSION

This study favors surgical open reduction and internal fixation treatment of the mandibular condylar fracture as better than a nonsurgical closed reduction in terms of inter-incisal opening, lateral excursion, and protrusive mandibular movement range, pain parameters, facial symmetry, occlusion, and ramal height restoration in 6 weeks' follow-up period. However, nonsurgical treatment is better in terms of less invasion and protection of potential 'anatomical structures from the injury. The present study has few limitations including a 0smaller monitoring period, confounding bias, and a small sample size. Hence, more studies with larger sample sizes and longer monitoring periods are required to reach a definitive conclusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.