2017-18 HSC Section 4 Green Book

Evidence-Based Facial Fracture Management

colleagues 31 rejected for deficiencies in the randomization process. The Liu and colleagues 32 meta-analysis concluded that, although both treatment methods can yield acceptable func- tional results, an ORIF was superior to closed treatment of moderately displaced subcondylar fractures ( Table 4 ). Although the debate over condyle fracture man- agement is not yet settled, there is an increasing body of evidence showing improved results with ORIF. With the interest in ORIF, there has also been interest in using an endoscopic approach to access these fractures to minimize facial nerve injury and avoid a scar. There has been a single randomized study comparing endoscopic with open repair of condyle fractures. 33 The study involved 34 fractures treated endoscopically and 40 treated with a standard open technique. The study found longer operative times in the endo- scopic group but equivalent function. In fractures in the open treatment group, facial nerve injury was not significantly increased and surgical scars were deemed cosmetically acceptable. The management of orbital fractures also creates considerable debate among the various special- ists treating these injuries. There is much uncer- tainty about which patients need surgery and when. There are also divergent opinions about what approach and which of the many materials Table 4 Comparison of clinical outcomes: open versus closed repair of moderately displaced unilateral subcondylar and condylar neck fractures Orbital Fractures

group. However, this study showed difference in final occlusion. Although both groups gained an acceptable occlusion, the open treatment was better in all other measures, including pain. In 2010, Danda and colleagues 28 studied dis- placed unilateral subcondylar and condylar neck fractures. This study found better radiographic reduction with an open repair but otherwise no dif- ferences in functional parameters. They thought that, although there were no ultimate differences in the functional parameters, a better radiographic result and earlier return to function supported treatment by ORIF. Finally, Kotrashetti and col- leagues 29 used a retromandibular approach for ORIF of subcondylar fractures and compared this with closed reduction with MMF. In this small RCT, 12 subjects were treated by closed reduction and 10 subjects underwent ORIF. With follow-up at 3 and 6 months, these investigators showed that ORIF of displaced subcondylar fractures was better clinically and radiographically than fractures treated by closed techniques. Proponents of an open approach argue that ob- taining a good clinical result with closed manage- ment requires early mobilization and aggressive physiotherapy. Even then, they note that the condyle is not its normal position and there is universally diminished ramus height. These obser- vations justify an open approach whenever there is significant overlap or angulation. Proponents of the open approach point to these recent studies sup- porting a better overall result with an acceptably low risk of soft tissue and nerve complications. There have been a few attempts to define the best evidence concerning management of condyle fractures by conducting systematic reviews of the world literature. Nussbaum and colleagues 30 iden- tified 13 potential studies in a meta-analysis but found most of the available data were poor quality that limited any meaningful analysis. In 2010, Sharif and colleagues 31 attempted a Cochrane systematic review of all RCTs concerning manage- ment of condyle fractures. After reviewing all potentially relevant articles, they found no studies that met their inclusion criteria. Several of the arti- cles were excluded for deficiencies in randomiza- tion or loss of subjects to follow-up. As a result, no treatment recommendations were offered. Liu and colleagues 32 conducted a more recent meta-analysis comparing open versus closed management of condyle fractures. From the litera- ture, they identified 4 studies totaling 177 subjects. They found that subjects treated with open man- agement had statistically better function, less pain, and less malocclusion. No difference was seen in maximum opening. Interestingly, this meta-analysis included studies that Sharif and

Open Reduction

Closed Treatment

Occlusion

1 1

1 1 1

Maximum opening

Deviation with opening Chronic pain Radiographic reduction Restoration of ramus height

—

—

1

—

11

—

11

Avoidance of facial nerve injury

—

1

1 a

Facial scar

1

Patient satisfaction

—

1

1 , indicating the relative benefit of each approach. a With transoral endoscopic approach.

249