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Title Endoscope-Assisted Open Reduction And Internal Fixation of Mandibular Subcondylar Fractures Is a Reliable and Comparable Technique to an Extraoral Surgical Approach
Clinical Question Is an endoscope-assisted transoral open reduction and internal fixation (EAORIF) more likely to have a longer surgical duration, postoperative mandibular dysfunction, and surgical complications than an extraoral surgical approach without endoscopic assistance for patients undergoing surgical treatment for a mandibular subcondylar fracture?
Clinical Bottom Line Mandibular subcondylar fractures treated with an endoscope-assisted transoral technique is a reliable technique and may offer advantages for selected cases. Comparable functional results were noted in both transoral and extraoral groups without any statistical significant difference; however, an extraoral approach tended to have a greater number of facial nerve injuries. On the other hand, the extraoral approach had an average quicker operation time.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 19070761Schmelzeisen/200974 patients Randomized Controlled Trial
Key resultsPatients (n=74) with similar age, gender distribution, and condylar neck fractures were randomly treated for uni- or bilateral condylar neck fixation by either EAORIF (n=40) or open reduction and internal fixation (ORIF) without endoscopic assistance (n=34). Overall functional outcome, as measured by the asymmetric Helkimo dysfunction score (anamnestic, clinical dysfunction, and occlusion and articulation disturbance indexes) showed no significant differences between the two groups at 1 year post-op (P=0.711). The median operation time for the extraoral approach was 33 minutes less than the EAORIF. There were five patients in the extraoral group with postoperative complications (pain, implant breakage, superficial infection, hematoma, and hypoesthesia), whereas EAORIF resulted in one case of superficial infection and one patient with nonunion at 1-year follow up. Lastly, facial nerve damage occurred in eight extraoral and two EAORIF patients with four unresolved facial nerve palsy at the 1 year follow-up for the extraoral group compared to one unresolved facial palsy for the EAORIF group.
#2) 23147346Nogami/201230 patients Retrospective Comparative Study
Key resultsThirty patients were treated for subcondylar and condylar neck fractures with an extraoral retromandibular (n=15) or an EAORIF (n=15) approach. The average surgical duration was 103 and 111 minutes for the extraoral and EAORIF approaches, respectively. Neither group showed any postoperative malocclusion, TMJ pain, or deviation on opening at the 6-month follow-up. However, one patient treated with the extraoral approach had facial palsy or paralysis at the 6-month follow-up.
#3) 15452817Haug/200413 EAORIF studies (126 patients); 58 extraoral surgical studies (2900 patients)Narrative Review
Key resultsTraditional ORIF and EORIF showed similar results for functional measurements such as maximum interincisal opening, lateral/protrusive excursions, and deviation upon opening at follow-up. Facial nerve palsy was more likely to occur with an extraoral approach; however, palsy resolved during the period of postoperative follow-up in both groups. Procedure time for the extraoral approach ranged from 40 to 120 minutes, and the endoscope-assisted surgery ranged from 45 to 408 minutes. A wide range in duration was due to the variety of techniques and skill of the operators.
Evidence Search ("endoscopes"[MeSH Terms] OR "endoscopes"[All Fields] OR "endoscope"[All Fields]) AND assisted[All Fields] AND open[All Fields] AND reduction[All Fields]
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The Evidence
Validity: The randomized controlled trial provides a quality comparison between the two surgical approaches with minimal bias. Patients from a homogenous group were randomly assigned to receive one of the treatments. Investigators were blinded as best as possible, and complications were thoroughly examined and recorded according to their most likely causative factor. The principal investigator and one monitor of the study organization evaluated complications, and the severity of complications was classified to reduce variance across the multicenter study. Nonetheless, the small number of subjects included in the study is a weakness. The comparative study is weaker evidence due to lack of randomization. However, the investigators attempted to minimize variance in the results by using the same surgeon and procedure for every patient. The narrative review attempts to compare results of the two techniques by analyzing the data from previous studies; however, the studies had a high level of heterogeneity. These articles conclude that there is no significant difference between the two surgical approaches; however, higher levels of evidence are necessary in order to develop a more definitive conclusion. Perspective: Most of the literature comparing these two surgical approaches are not composed of homogenous groups. Due to the differences in the biological character and adaptive capability of the masticatory system, it is difficult to define which structural and functional factors influence the final outcome. Thus, it is critical to have a randomly selected homogenous group large enough to eliminate this variable for investigators to be able to conclusively state that there is a no significant difference between the two surgical approaches.
Applicability Endoscopic-assisted surgery for mandibular subcondylar fractures may be advantageous for patients wanting to minimize the risk of facial nerve damage and visible scaring immediately after surgery. However, there seems to be no significant difference between the two procedures at 1-year post-op. Doctors should be aware of the initial cost of endoscopic equipment, as well as the learning curve for handling the instruments and the intensive training required for endoscopic techniques. This tends to increase the surgical time significantly until the doctor becomes comfortable with the procedure. Furthermore, patients should be aware of the extra cost per hour of operating room time that may be associated with the endoscopic procedure.
Specialty/Discipline (Oral Surgery)
Keywords Endoscope, Subcondylar Fracture
ID# 2823
Date of submission: 04/09/2015spacer
E-mail tibbitts@livemail.uthscsa.edu
Author Luke Tibbitts
Co-author(s) e-mail
Faculty mentor/Co-author Daniel Perez, DDS & Kent Van Sickle, MD
Faculty mentor/Co-author e-mail PerezD5@uthscsa.edu; Sickle@uthscsa.edu
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