condyle fracture journal club

1. Journal club
Mandibular condylar fracture
Done by Dr .Alaa Alayea PGY3
Moderated by Prof . Ashraf Abukaraki

3. 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.
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.
Introduction

4. There are a lot of classifications for condylar fractures ,but none of them helps
the clinician to decide which cases need to be treated surgically and which can
be treated non-surgically .
In 1983, Zide and Kent proposed the absolute and relative indications for
surgical treatment; these have been modified over the years and served as a
reference for many surgeons.
They were developed before CT scans and rigid internal fixation, and based on
the authors’ experience of certain clinical presentations, which may vary from
what the surgeon sees in real practice.

6. 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 withAMSTAR-2 (A MeasurementTool to Assess Systematic Reviews -
2)and reviews that were rated “critically low” were excluded (Table 1).
Criteria for eligibility

7.  A pilot search was made on PubMed (National Libraryof Medicine, NCBI)
about the management of mandibular condylar fractures to identify
relevant keywords.
 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

9. 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
byAMSTAR-2 and only two reviews met our inclusion criteria(Fig. 1).

10. The two reviews included were both completed in 2015 and contained meta-analyses.
The common comparative outcomes were:
maximum interincisal opening (MIO), lateral excursion, protrusion (protrusive movement),
lateral deviation of the chin during MIO, pain and sounds in the temporomandibular joint
(TMJ), malocclusion, and complications.
Surgical treatment had a significantly better outcome in both meta-analyses in terms of
malocclusion, protrusion, lateral excursion, and lateral deviation of the chin during MIO.
Additionally,Al-Moraissi and Ellis found significantly better outcomes of surgical treatment
for pain during MIO and in theTMJ.
The incidence of facial nerve injury in the pooled data was 8.3%, and only 2.2%had not
recovered after six months.

11. The risk of facial nerve injury could be the main reason that many surgeons choose non-
surgical treatment for condylar fractures.
Unfortunately, the studies included in our systematic reviews reported no more than six
months follow-up of the incidence of facial nerve injury in cases managed with surgical
treatment, even though it is generally accepted that at least one year of follow-up is
required to report a permanent nerve injury .
In condylar fractures the case is different, because of the complexity of the
surgical access
Both reviews concluded that surgical treatment has a better outcome than non-
surgical treatment, but both stressed the need for better-designed randomised trials
to support this conclusion.

12.  Reducing this terminal articulating part is made more complicated because
the surgeon needs to reduce the fracture line as well as the dislocated head.
 It is also of great importance to preserve the limited blood supply and the
integrity of the joint capsule and meniscus.

13. > based on
1. The best available evidence.
2. The common clinical practice .
3. The experience of a group of surgeons working in a trauma center .
Development of the algorithm

15. The first logical step is to check the feasibility of fixing the fractured condyle.
Surgical treatment without the ability to fix the fracture is just extra trauma for the
patient.
The ability to fix a condylar fracture is dependent on comminution of the fracture,
available resources and training, and experience of the surgeon.
As a condylar neck fracture could be difficult to fix in the absence of a proper
armamentarium and lack of surgical experience, non-surgical treatment would be the
treatment of choice.
On the other hand, a small fracture of the head could be approached and fixed with
screws by an experienced surgeon in a well-equipped hospital.
They think that, regardless of any other factor, the inability to fix a condylar fracture is a
contraindication for surgical treatment.

17. The second step is to check the dislocation of the condyle.
To guarantee a functioning joint, the condylar head should be reduced to the glenoid
fossa.
Although extra-fossa articulation is possible and seen in some cases, it is extremely
unpredictable to leave a dislocated condyle with such an assumption.
The capacity of the condyle to remodel and return to function without operation
depends on the degree of dislocation and the age of the patient.
The dislocated condyle may remain in situ without any complications, except being non-
functional.
However, chronic pain associated with non-surgical treatment has been reported.

18. In the case of a unilateral condylar fracture, the patient might be guided into
good occlusion with closed treatment ,but the long-term consequences of the
overloaded contralateral joint are not known.
In the systematic reviews included in this study, chin deviation/asymmetry
during MIO was more significant with non-surgical treatment.
This means that the entire mandible is dependent on the contralateral joint
during function, and ipsilateral posterior teeth serve as a vertical stop that
may predispose them to occlusal trauma.

19. In cases of bilateral condylar fractures, having one or two dislocated condyles
further compromises posterior facial height and leads to loss of the posterior
stop and articulation with associated malocclusion.
One of the main goals of the treatment of condylar fractures is to restore
normal mandibular function, which will be more predictable if the dislocated
condyle is reduced.
When the condylar head is dislocated outside the glenoid fossa (and it is
possible to reduce and fix it), therefore, surgical treatment becomes
indicated.

21. In a non-dislocated condylar fracture, the next step is to check the
displacement of the fracture.
One must ensure good union of the fractured condyle because in case of
non-union ,the goal of restoring theTMJ as a functional unit is not achieved,
and the same possible compromised outcome of a dislocated condyle could
happen.

22. Malunion of one of the fracture ends could also result in restricted mandibular
movement.
In one of the systematic reviews included, the MIO was significantly better in
the surgical treatment group than in the non-surgical treatment group.
In a non-displaced or minimally displaced fracture, good bony union could be
achieved by non-surgical treatment, so if the fracture is displaced to the
extent that may compromise healing, surgical treatment is indicated.

24. When the articulation of the condyle and union of the fracture are
predictable, checking the occlusion of the patient should be the next step.
If the occlusion cannot be guided because of interference by the fracture, or
if there is¨dropping back¨as a result of lack of a posterior stop, then surgical
intervention is recommended.
In addition, the presence of other factors that make non-surgical treatment
unpredictable, such as other mandibular fractures, mid-facial fractures, or
partial edentulism, are an indication that surgical treatment should be
considered.

25. In cases where occlusal discrepancy is minor and the patient could benefit from
orthognathic surgery because of pretraumatic malocclusion, the surgeon may
suggest non-surgical treatment with an orthognathic plan.
This could also be applicable for a growing patient with mixed dentition. If the
occlusion is good or can easily be guided, non-surgical treatment should be
considered.

26. In edentulous patients, occlusion can be checked on existing dentures.
In a non-dislocated and non-displaced condylar fracture in an edentulous
patient, surgical treatment is hardly justified, particularly when their medical
status is considered.
Predictable healing of the fracture will take place with conservative
treatment and then their dentures can be adjusted or replaced.

28. The last step is to check whether the patient is a good candidate for non-
surgical treatment or not.
He or she might not be able to follow non-surgical treatment instructions
because of any medical or psychological factors (disabled or unconscious) or
might need quick recovery for social (job demand, travel ,or a prisoner) or
economic reasons (cost of multiple follow-up visits compared with surgery).
In these cases, surgical treatment may be more predictable than non-surgical
treatment. On the other hand, patients who would not tolerate any chance of
facial nerve injury or other surgical complications should be treated non-
surgically.

29. This treatment algorithm is based on four main factors:
the feasibility of fixation, restoring joint and occlusal function ,ensuring adequate
healing of the fracture, and considering patient-centred factors.
The indications for surgical treatment should not include the presence of a
foreign body or the displacement of the condyle to the middle cranial fossa,
because this will be the treatment of the complication, not the fracture.