Page 160 - Open versus closed Mandibular condyle fractures

172
Chapter 5
Our cross-sectional study indicates that there is a significant difference in the MFIQ results between open and closed treatments. Although good outcomes are achieved by each type of treatment, it seems preferable to avoid surgery and the concomitant surgery-related complications as long as the indications for surgical repositioning are not evident. Closed treatment also avoids a protracted operating time, use of more expensive hardware, a protracted general anesthesia time, hospitalization, and sickness leave costs.44 Therefore, closed treatment should not be overlooked but rather advocated when it can be performed by a competent surgeon following a strict treatment protocol with appropriate patient compliance. Clearly, there are strong indications for open treatment, e.g., displacement into the middle cranial fossa, lateral extracapsular displacement of the condylar head, and bilateral mandibular condyle fractures in dentulous and edentulous patients who cannot have a splint, comminuted fractures involving other facial bones, jaw deformities, foreign material at the fracture site, and inappropriate occlusal restoration by closed reduction.
Future perspectives
The evidence-based pyramid teaches us that the choice of study design is a pivotal factor if we truly want to determine how to treat mandibular condyle fractures. A randomized controlled trial (RCT) is the golden standard for evaluating the effects of medical interventions but is challenging in terms of logistics, planning, and costs.45
Few RCTs have been published on this topic,25,38,46–50 most of which have had limiting inclusion criteria, e.g., fracture angulation or shortening of the height of the ascending ramus, small populations, a high rate of loss to follow-up, and included no subjective outcome measures. A promising alternative to the conventional pragmatic RCT is the cohort multiple RCT concept, which is designed to facilitate randomized trials for pragmatic evaluation of interventions.45,51 In a cohort multiple RCT, all patients would undergo ‘standard treatment’ and be known as an ‘observational cohort’. Within this observational cohort, eligible patients would be identified and randomly selected for an offer of open intervention. In this way, two groups can be formed in a random manner for comparison of two treatment modalities. Until this research concept becomes established in the clinical setting, the best option would be to refine our current treatment methods.