70.Dayalan N, Kumari B, Khanna SS, Ansari FM, Grewal R, Kumar S, Tiwari RVC. Is Open Reduction and Internal Fixation Sacrosanct in the Management of Subcondylar Fractures: A Comparative Study. J Pharm Bioallied Sci. 2021 Nov;13(Suppl 2):S1633-S1636. doi: 10.4103/jpbs.jpbs_352_21. Epub 2021 Nov 10. PubMed PMID: 35018044; PubMed Central PMCID: PMC8686876.

1. S1633
© 2021 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
Purpose: This paper is intended to compare and evaluate the better treatment
option in the management of subcondylar fractures of the mandible.
Materials and Methods: This study included 20 patients who were diagnosed
clinically and radiologically to have sustained an isolated subcondylar fracture
of the mandible. They were divided into two groups randomly. Group I included
10 patients who underwent treatment by intermaxillary fixation alone followed by
active physiotherapy in the form of conservative management. Group II included
10 patients who underwent treatment by surgical intervention for open reduction
and internal fixation under general anesthesia following elastic guidance. Factors
such as maximal mouth opening, pain scores, and deviation of mandible on mouth
opening were taken into consideration and evaluated. Results: It is observed that
the patients in Group I had weight loss and restrictions in their social well‑being in
the early recovery phase, in addition to delay in return to function. In spite of the
early return to function, patients in Group II were subjected to all kinds of surgical
complications such as transient facial nerve injury, infection, and unesthetic scar.
The maximal mouth opening and deviation of the mandible on mouth opening
remained almost the same in both groups. Conclusion: A regular follow up of
operated patients post trauma is essential to obtain morphological and functional
recovery. When the respective advantages and disadvantages of both treatment
options were compared and evaluated, it was observed that patients treated by
closed reduction had a better clinical and psychological outcome.
Keywords: Closed reduction, condylar fracture, open reduction
Is Open Reduction and Internal Fixation Sacrosanct in the Management
of Subcondylar Fractures: A Comparative Study
Nandini Dayalan1
, Bhawna Kumari2
, Shilpa Sunil Khanna3
, Faisal Mohiuddin Ansari4
, Ramandeep Grewal5
, Sanket
Kumar6
, Rahul V. C. Tiwari7
Access this article online
Quick Response Code:
Website: www.jpbsonline.org
DOI: 10.4103/jpbs.jpbs_352_21
Address for correspondence: Dr. Nandini Dayalan,
Department of Oral and Maxillofacial Surgery, Dr.Syamala Reddy
Dental College and Research Center, Bengaluru, Karnataka, India.
E‑mail: nandedentist@gmail.com
of the condylar head are rarely encountered.[6]
Ever since
the introduction of osteosynthesis materials for rigid
internal fixation, there has been a never‑ending debate
pertaining to the treatment of condylar fractures of the
mandible. Literature shows that open reduction and
internal fixation (ORIF) of the condylar fractures may be
Introduction
Mandibular fractures are extremely frequent in facial
trauma, and 19%–52% involves the condyle.[1‑3]
As a consequence of condylar fracture, patient may
encounter pain, restricted mandibular movement, muscle
spasm and deviation of the mandible, malocclusion,
and pathological changes in the temporomandibular
joint (TMJ), osteonecrosis, facial asymmetry, and
ankylosis.[4,5]
The majority of mandibular condyle
fractures involve the condylar neck, with few reports of
intracapsular fractures. Sagittal or vertical fractures of the
mandibular condyle and chip fractures of the medial part
1
Department of Oral and
Maxillofacial Surgery, Dr.
Syamala Reddy Dental
College and Research Center,
Bengaluru, Bengaluru, India,
2
Department of Prosthodontics
and Crownn Bridge Inlucding
Implantology, Government
Medical College, Bettiah, Bihar,
India, 3
Department of Oral
and Maxillofacial Surgery, Sri
Ramakrishna Dental College
and Hospital, Coimbatore, Tamil
Nadu, India, 4
Department of
Orthodontics and Dentofacial
Orthopedic, Government Dental
College and Hospital, Hyderabad,
Telangana, India, 5
Department of
Oral and Maxillofacial Surgery,
J.C.D Dental College, SIRSA,
Haryana, India, 6
Consultant
Dental Surgeon, Bettiah, Bihar,
India, 7
Department of Oral
and Maxillofacial Surgery,
Narsinbhai Patel Dental College
and Hospital, Sankalchand Patel
University, Visnagar, Gujarat,
India
Received: 28‑Apr‑2021.
Revised: 14-May-2021.
Accepted: 21‑May‑2021.
Published: 10-Nov-2021.
Abstract
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Dayalan N, Kumari B, Khanna SS, Ansari FM,
Grewal R, Kumar S, et al. Is open reduction and internal fixation sacrosanct
in the management of subcondylar fractures: A comparative study. J Pharm
Bioall Sci 2021;13:S1633-6.
Original Article
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2. S1634 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
Dayalan, et al.: ORIF and subcondylar fractures
indicated for bilateral injuries or considerably displaced
condylar fractures or with dislocation of condylar heads,
but closed treatment and intermaxillary fixation may
be indicated in cases where condylar displacement is
minimal and the height of the ramus is almost normal.[7,8]
This study is designed to evaluate the better treatment
option in the management of subcondylar fractures
of the mandible in clinical scenarios where there was
an isolated low unilateral subcondylar fracture with
moderate displacement between the fracture segments,
but the condyle is still seated in the glenoid fossa.
Materials and Methods
This study included 20 patients who were diagnosed
clinically and radiologically to have sustained isolated
unilateral subcondylar fracture of the mandible.
Selection criteria is based on:
1. Level of condylar fracture
This study included patients in whom there was an
isolated low unilateral subcondylar fracture
2. Severity of displacement of fracture segments
This study included patients in whom there is
moderate displacement between the fracture segments
but the condyle is still seated in the glenoid fossa.
Inclusion criteria
• Patients who were diagnosed clinically and
radiographically to have sustained unilateral
subcondylar fracture
• Patients who were followed up for a minimum period
of 6 months
• Patients who are healthy and fall between the age
group of 18–60 years.
Exclusion criteria
• Patients with associated fractures of the facial
skeleton
• Patients who underwent previous TMJ surgeries
• Patients who are medically compromised
All patients were divided randomly into two groups.
Group I include 10 patients who were diagnosed
clinically and radiographically to have sustained
unilateral subcondylar fracture and were treated by
closed reduction.
Group II include 10 patients who were diagnosed
clinically and radiographically to have sustained
unilateral subcondylar fracture and were treated by open
reduction.
All the patients were clinically and radiographically
evaluated preoperatively (T1), at 3 months (T2), and at
6 months (T3).
Parameters evaluated:
1. Maximal mouth opening – interincisal distance
2. Pain on maximal mouth opening – visual analog
scale score
3. Deviation of mandible on mouth opening – with
reference to dental midline
4. Nutritional deficiency – weight loss
5. Facial nerve palsy – frontal frowning and eye closure
6. Presence or absence of scar
7. Any infection at surgical site
8. Return to function – duration.
Results
A total of 20 patients (18 males and 2 females) who
met the inclusion criteria were included in this study,
with 10 patients being treated by open treatment
and 10 patients being treated by closed treatment in
each group, as shown in Figure 1. Mean age of the
patients was 29.15 ± 9.84 years (range = 18–60 years).
Mean age of the patients in Group II was
30.5 ± 8.67 years (range = 18–52 years), while
the mean age of the patients in Group I was
28.80 ± 12.12 years (range = 18–55 years). Road
traffic accident was identified as the major cause for
the fracture of the mandibular condylar. It was noticed
that following 6 months of the surgical intervention, the
mean mouth opening of all the patients in Group II was
37.39 ± 2.72 mm while in Group I was 34.74 ± 2.72 mm
as shown in Figure 2. Independent samples t‑test was
applied to compare the means and the P = 0.035 which
shows statistically significant difference between both
the groups. After 6 months of treatment, deviation of the
mandible on opening was found to be 0.3 ± 0.78 mm in
Group II while 1.3 ± 1.60 mm in Group I. Independent
samples t‑test showed P = 0.045 which is statistically not
significant. In both the groups, none of the patients had
occlusal disturbances at 6 months’ postoperative time.
Independent samples t‑test was applied, and P = 0.265
which is statistically not significant.
It was observed that 6 out of the 10 patients in Group II
had transient facial palsy which recovered within
6 months’ time as shown in Figure 3. It was observed that
2 out of the 10 patients in Group II had an unesthetic scar
in the postoperative period as shown in Figure 4. None of
the patients in Group II had any infection at the surgical
site. It is observed that the patients in Group I had weight
loss and restrictions in their social well‑being in the early
recovery phase in addition to delay in return to function
as shown in Figures 5 and 6. In spite of the early return
to function, patients in Group II were subjected to all
kinds of surgical complications such as transient facial
nerve injury, infection, and unesthetic scar.
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3. S1635
Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
Dayalan, et al.: ORIF and subcondylar fractures
Discussion
It is a well‑known fact that the treatment of mandibular
condylar fractures is one of the most controversial
subjects of maxillofacial trauma management. Even
though closed treatment for the management of condylar
fractures has long been the method of choice with the
advent of rigid osteosynthesis, numerous treatment
options have been employed to improve the functional
outcomes and decrease the period of maxillomandibular
fixation and early return to function.[9,10]
This study
employed closed treatment by immobilization with
maxillomandibular fixation for a period of 5–6 weeks,
while open treatment was done by an extraoral
approach via retromandibular and anterior parotid
and transmasseteric approach. With regard to the
mean mouth opening in the postoperative period, it
was noticed that Group I had 34.74 ± 2.72 mm while
Group II had 37.39 ± 2.72 mm. The difference in the
mean mouth opening was only 3 mm. Previous studies
compared the functional outcomes of surgical and
nonsurgical treatment for the management of condylar
fracture and found that the results were nearly similar
in both the groups.[11,12]
The results of this study are in
accordance with previous studies. However, another
study revealed a better mobility of mandible in closed
treatment group when minimally displaced condylar
fractures were managed by closed reduction.[13]
The
limited mouth opening following open reduction
compared to a closed reduction can be attributed to the
fact that in open reduction there is excessive muscle
stripping, scar formation, and incisional pain.
A randomized control trial of moderately displaced
fractures of the subcondylar region with ramal
shortening ≥2 mm or deviation 10°–45° revealed that
both surgical and nonsurgical treatments resulted in
acceptable results, but open treatment was superior
to closed treatment in all functional variables studied
including maximal interincisal opening.[14]
Another
meta‑analysis revealed that even though the mean
maximal mouth opening was nearly similar in both open
and close reduction, there existed a gross difference
in terms of protrusive and excursive movements with
Figure 1: Graph showing the demographic data in both the groups Figure 2: Graph showing the mean mouth opening in both the groups
Figure 3: Graph showing the transient facial palsy in both the groups Figure 4: Graph showing the unesthetic scar in both the groups
Figure 6: Graph showing the duration for return to function in the
postoperative period
Figure 5: Graph showing the weight loss in both the groups in the
postoperative period
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4. S1636 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
Dayalan, et al.: ORIF and subcondylar fractures
superior results in open treatment.[15]
It is advocated
that protrusion is a better indicator of the mobility of
the TMJ than passive opening because it requires active
movement of condyle during functional activity. With
regard to the occlusal discrepancies in the postoperative
period, the results of this study did not find any
significant difference between both the groups. The
results of this study are in accordance with previous
studies.[11,14]
However, few previous studies revealed a
greater incidence of occlusal discrepancy in patients
treated by closed reduction compared to patients who
were treated with ORIF.[15,16]
In patients in Group II who
are treated with ORIF through retromandibular extraoral
approach, two patients were associated with visible
uanesthetic scars, but previous studies have shown that
ORIF through retromandibular extraoral approach is
not always associated with visible scars.[17‑19]
Literature
reveals that the risk of facial nerve injury for ORIF in
subcondylar fractures depend on various factors such as
prolonged traction at the operative site, experience of
the surgeon, and postinjury edema.[20]
This study noticed
transient facial nerve palsy in six patients following open
reduction for the management of subcondylar fractures.
Conclusion
The results of this study reveal that open treatment
of unilateral mandibular condylar fractures results in
better functional outcomes, particularly in terms of
maximal mouth opening. However, it is worth noting
from the results of this study that fractures of the
mandibular condylar with moderate displacement can
be successfully managed by closed method to obtain
better functional results with the elimination of surgical
complications such as transient facial nerve palsy and
unesthetic scar. Studies with longer follow‑up period
and a wider variable base are essential to provide a
better understanding of the functional outcomes of open
and closed treatment of mandibular condylar fractures.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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