ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Patients Surgically Treated Via Open Reduction and Internal Fixation (ORIF) for Mandibular Condyle Fractures Have Less Postoperative Pain Than Patients Treated Closed with Maxillomandibular Fixation (MMF)
Clinical Question In a patient with a mandibular condyle fracture, which type of surgery results in the least amount of pain for the patient post-operatively: open reduction and internal fixation (ORIF) or closed treatment with maxillomandibular fixation (MMF)?
Clinical Bottom Line All three RCTs listed indicate that postoperative pain at six months is decreased in patients who are treated surgically via ORIF compared to those patients treated closed with MMF.
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) 20363548Singh/201040 patients with displaced subcondylar fractures of the mandible either angulated between 10 and 350 or with the ascending ramus shortened by more than 2 mm.Randomized Controlled Trial
Key resultsUsing the Visual Analog Scale (0 to 100), there was a significant (P<0.001) difference between the operative treatment group and the closed treatment group with the operative treatment group reporting less pain (1.11 open vs. 5.27 closed) 6 months post-operatively.
#2) 16781159Eckelt/200666 patients with 79 displaced fractures of the mandibular condylar process either angulated between 10 and 450 or with the ascending ramus shortened by more than 2mm.Randomized Controlled Trial
Key resultsUsing the Visual Analog Scale (0 to 100), there was a significant (p<0.01) difference between the operative treatment group and the closed treatment group with the operative treatment group reporting less pain (2.9 open vs. 13.5 closed) 6 months post-operatively. The authors also reported that there was significantly (p<0.001) “less pain and discomfort in the open treatment group “ according to the Mandibular Function Impairment Questionnaire Index (2.4 points open versus 10.5 points closed), also assessed 6 months post-operatively.
#3) 19022134Schneider/200866 patients with 79 displaced mandibular condylar process fractures (deviation of 10 to 45o or a shortening of the ascending ramus ≥2 mm) treated at 7 clinical centersRandomized Controlled Trial
Key resultsThe average pain level (using the Visual Analog Scale) 6 months post-operatively for the ORIF group was 1, while the average pain level 6 months post-operatively for the CRMMF group was 25 (p≤0.001).
Evidence Search ((( "Mandibular Condyle/injuries"[Mesh] OR "Mandibular Condyle/surgery"[Mesh] )) AND ( "Mandibular Fractures/surgery"[Mesh] OR "Mandibular Fractures/therapy"[Mesh] )) AND "Pain Measurement"[Mesh]
Comments on
The Evidence
Validity: Singh et. al., (2010) conducted a double-blind RCT and Eckelt et. al., (2006) and Schneider et. al., (2008) conducted RCTs comparing open reduction surgery versus closed treatment for displaced subcondylar fractures of the mandible evaluating pain 6 months post-operatively in both treatment groups. Singh et. al. (2010) reported that groups were similar at the start of the study and were treated the same throughout, but did not mention if there was a >80% completion rate by the selected participants in the study. They reported adequate follow-up and compliance of the patients with recall bias being unlikely and no statement of competing interests. Although pain is the specified outcome of this report, Singh et al., does report that open surgery has the adverse effect of possible nerve damage. Eckelt et. al. (2006) and Schneider et. al. (2008) both reported that groups were similar at the start and were treated the same throughout, but also mentioned that there was not a >80% completion rate by the selected participants in the multi-center studies. They reported adequate follow-up with recall bias being unlikely and no statement of competing interests. Unlike the Singh et al. paper, these two studies were limited in that they did not present any signifiant adverse events associated with open surgery. All three studies showed patients treated surgically via open reduction and internal fixation for fractures of the mandibular condyle had less postoperative pain at 6 months than those treated closed with maxillomandibular fixation. Perspective: While these three articles have similar findings, one must always weigh the risks of open surgery against the potential benefits. Surgical and post-surgical complications such as injury to the facial nerve, hypertrophic scars, infection, experience of the surgeon, etc. all must be factored into the decision about whether or not to perform open treatment.
Applicability Singh et. al., (2010), Eckelt et. al., (2006), and Schneider et. al., (2008) all clearly state both inclusion and exclusion criteria for their studies indicating that the subjects are both identifiable and reasonable as patients that might be seen in the clinic. Based on their findings, open reduction with internal fixation would be both a feasible and favorable treatment option for fractures of the condylar process of the mandible. As a benefit, this treatment option would reduce postoperative pain severity at 6 months for these patients.
Specialty/Discipline (Oral Surgery)
Keywords Trauma, fracture, Pain, Mandibular Condyle
ID# 2611
Date of submission: 02/17/2014spacer
E-mail jonesjp@livemail.uthscsa.edu
Author Jason Jones
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Edward Ellis, III, DDS
Faculty mentor/Co-author e-mail Ellise3@uthscsa.edu
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