2017-18 HSC Section 4 Green Book

Doerr

mandible. In a clinical trial published after this re- view, Ahmed and colleagues 25 directly compared, in a randomized fashion, fractures repaired with titanium or resorbable plates. With at least 34 sub- jects in each group, the investigators noted increased implant failure in the resorbable group with more screw and plate breakage during place- ment. Conversely, more plate removals were required in the titanium group. These results further supplement the conclusions drawn by Dorri and colleagues. 24 Given the technical difficulties with resorbable plating and the increased costs of these fixation systems for mandible fractures, these are not supported by the current literature. No area of facial fracture management generates more controversy than the treatment of condylar neck and subcondylar fractures. There are several techniques to manage these fractures. Some sur- geons advocate for conservative treatment with MMF, whereas others encourage open reduction and internal fixation (ORIF). Those favoring conser- vative treatment maintain that patients gain an equivalent functional status without the risks of infection, scar, or facial nerve injury that can be associated with open techniques. Supporters of an open approach claim there is earlier return to function and less malocclusion when patients are treated with ORIF. Several recent trials suggest improved out- comes with open repair of condylar fractures. In 2006, Eckelt and colleaues 26 presented a multi- institutional prospective RCT comparing open operative with conservative treatment of displaced condylar fractures. Eighty-eight subjects were ran- domized resulting in 66 subjects with 79 fractures. All fractures were displaced with either excessive angulation or more than 2 mm shortening of the vertical ramus. At 6 weeks and 6 months after treatment, the investigators found correct anatomic positioning significantly more often in the open group. They also saw significant differ- ence in function along with less pain after an open approach. The study concluded that, although both groups gained acceptable occlu- sion results, open treatment was superior to all other studied outcomes. In 2010, Singh and colleagues 27 looked at 40 subjects with displaced fractures of the condyle; again, either excessively angulated or shortened by more than 2 mm. Subject function, occlusion, and radiograph parameters were compared 6 months after treatment. This study showed that anatomic reduction was more accurate and func- tional parameters superior in the open treatment Condylar and Subcondylar Fractures

fractures repaired with miniplates plus 2 weeks of postoperative MMF with fractures repaired with no postoperative MMF. They found no differences between the groups in terms of weight loss, trismus, dental hygiene, or wound complications. These studies suggest that in the appropriate frac- tures, a brief period of MMF or no MMF does not seem to negatively affect outcomes and will improve patient satisfaction. Looking to identify best practice for the man- agement of fractures of the mandible, Nasser and colleagues 23 conducted a 2013 Cochrane re- view. The reviewers systematically assessed the management of adult mandibular fractures not involving the condyle. They identified 12 studies that met their inclusion criteria, with half of these studies having a high risk of bias and half having an unclear risk of bias. Not surprisingly, the studies were very different in design and included compar- isons of many different surgical approaches, fixa- tion techniques, and postoperative protocols. The studies also differed widely in terms of end- points, with patient-oriented outcomes largely ignored and postoperative pain scores inade- quately reported. This Cochrane review found only 1 or 2 studies all of small sample size con- ducted for each comparison or outcome. Thus, a pooled analysis was possible in only a couple of areas. From these data, no difference in postoper- ative infection was seen using either 1 or 2 mini- plates to repair an angle fracture. This review otherwise failed to identify the effectiveness of any single treatment approach for mandible frac- tures without condylar involvement. The review investigators thought that the absence of high- quality evidence was due to the clinical diversity of subjects along with the lack of consistent assessment tools and standardized outcome measures. The review concluded that, until high- level evidence is available, treatment of mandible fractures should be based on surgeon experience and patient circumstances. With the development of resorbable plating sys- tems there has also been enthusiasm for the use of these systems to fix mandible fractures. In a Co- chrane review, Dorri and colleagues 24 attempted to compare mandible fracture repairs with tradi- tional titanium plates with those repaired with a re- sorbable plate. This systematic review was unable to identify any eligible studies for comparison. The review was able to identify 2 ongoing studies that were halted because of increased complications. The investigators concluded that, in the absence of any reliable high-level evidence, surgeons should rely on clinical experience. Based on the aborted trials, it does not seem that resorbable plates were as effective as titanium plates for the

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