66:1087-1092, 2008 Closed Versus Open Reduction of Mandibular Condylar Fractures in Adults: A Meta-Analysis Marcy L. Nussbaum, MS,* Daniel M. Laskin, DDS, MS, and Al M. Best, PhD Purpose: A review of the literature shows a difference of opinion regarding whether open or closed reduction of condylar fractures produces the best results. It would be benecial, therefore, to critically analyze past studies that have directly compared the 2 methods in an attempt to answer this question. Materials and Methods: A Medline search for articles using the key words mandibular condyle fractures and mandibular condyle fracture surgery was performed. Articles that compared open and closed reduction were selected for further evaluation. Additional articles were obtained from reference lists in the Medline-selected articles. Of the 32 articles identied, 13 met the nal selection criteria. These contained data on at least one of the following: postoperative maximum mouth opening, deviation on opening, lateral excursion, protrusion, asymmetry, and joint or muscle pain. Results: Numerous problems were found with the information presented in the various articles. These included lack of patient randomization, failure to classify the type of condylar fracture, variability within the surgical protocols, and inconsistencies in choice of variables and how they were reported. However, the results from the meta-analyses were explored in a general sense. Conclusions: Because of the great variation in the manner in which the various study parameters were reported, it was not possible to perform a reliable meta-analysis. There is a need for better standardization of data collection as well as randomization of the patients treated in future studies to accurately compare the 2 methods. 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:1087-1092, 2008 Whereas there are clearly dened guidelines for when an open or closed reduction is indicated in the man- agement of fractures in most areas of the mandible, there is still a continuing debate over how to best manage fractures of the condylar process. This di- lemma is partly related to the fact that one cannot use the occlusion to re-establish alignment of the seg- ments as in the body of the mandible, and partly related to the increased risk of open reduction related to the presence of the facial nerve in the surgical eld. A review of the literature shows that most of the studies on this subject have been retrospective case series using a single approach rather than a compari- son of the 2 techniques. In those case series in which the 2 methods have been compared, there are fre- quent differences in the selection criteria as well as the criteria by which the outcomes were judged. In such instances, the use of a meta-analysis can serve to combine information to form an overall conclusion. By including a group of studies in this manner, the power of detecting an overall treatment effect is in- creased, making it easier to show any differences that may not be shown by individual studies. Materials and Methods An initial literature search was conducted in PubMed using the keyword phrases mandibular con- * Research Biostatistician, Carolinas HealthCare System, Charlotte, NC. Professor and Chairman Emeritus, Department of Oral and Max- illofacial Surgery, School of Dentistry, Virginia Commonwealth Uni- versity, Richmond, VA. Associate Professor, Department of Biostatistics, School of Med- icine, Virginia Commonwealth University, Richmond, VA. Address correspondence and reprint requests to Dr Laskin: De- partment of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, PO Box 980566, Richmond, VA 23298-0566; e-mail: dmlaskin@vcu.edu 2008 American Association of Oral and Maxillofacial Surgeons 0278-2391/08/6606-0002$34.00/0 doi:10.1016/j.joms.2008.01.025 1087 Table 1. DATA FROM 13 STUDIES Study No. Authors Follow-Up Sample Size MMO (mm) Deviation (mm) Excursion (Lateral Movement) (mm) Protrusion (mm) Asymmetry Joint or Muscle Pain O C O C Frac (O) Frac (C) Frac (O) Non (O) Frac (C) Non (C) O C O C O C 1 Worsaae and Thorn 3 Median, 2 yr; minimum, 6 mo 24 28 Mean, 46; range, 34-61 Mean, 50; range, 34-65 Mean, 10; range, 5-15 Mean, 9; range, 4-18 Mean, 9; range, 4-14 Mean, 7; range, 3-12 Mean, 7; range, 4-13 Mean, 7; range, 3-12 Count, 0 Count, 3 Count, 1 Count, 6 2 Yang et al 4 1 wk, 2 wk, 1 mo, 2 mo, 3 mo, 4 mo, 6 mo, 1 yr 36 30 Mean, 41.57; range, 29-44 Mean, 46; range, 31-53 Count, 8 Count, 12 Count, 0 Count, 0 Count, 2 Count, 5 3 Santler et al 5 Mean, 2.5 yr; minimum, 6 mo 37 113 Mean, 45.5; SD, 7.3; range, 34-67 Mean, 47; SD, 6.8; range, 26-70 Mean, 8.5; SD, 3.3; range, 3-17 Mean, 8.7; SD, 3.4; range, 0-15 Mean, 5.9; SD, 2.3; range, 0-10 Mean, 6.2; SD, 2.7; range, 0-13 Count, 1 Count, 1 Count, approximately 1 Count, approximately 4 4 Konstantinovic and Dimitrijevic 6 Mean, 2.5 yr 26 54 Mean, 39 mm; range, 23-50 Mean, 39 mm; range, 10-60 Count, 2 Count, 3 5 Takenoshita et al 7 2 yr (mean, 11.6 mo) 16 20 Mean, 39 Mean, 50 Mean, 8.7; SD, 3 Mean, 7.9; SD, 2.1 Mean, 6; SD, 3.8 Mean, 6; SD, 3.8 Mean, 9.5 mm SD, 2.1 6 Hidding et al 8 1-5 yr 20 14 Count, 0 (30 mm) Count, 0 (30 mm) Count, 2 (3 mm) Count, 9 (3 mm) Count, 0 (5 mm) Count, 0 (5 mm) Count, 1 (5 mm) Count, 1 (5 mm) Count, 1 (5 mm) 7 Oezmen et al 9 6-24 mo 20 10 Count, 0 (40 mm) Count, 0 (40 mm) Count, 0 (2 mm) Count, 0 (2 mm) Count, 0 (6 mm) Count, 0 (6 mm) Count, 0 (6 mm) Count, 0 (6 mm) Count, 0 (6 mm) 8 Throckmorton and Ellis 10 6 wk, 6 mo, 1 yr, 2 yr, 3 yr 62 74 Mean, 45.7; SD, 9.4 Mean, 46; SD, 12.9 Mean, 0.4; SD, 6.8 Mean, 4.2; SD, 6.6 Mean, 10.9; SD, 2.5 Mean, 10.1; SD, 2.8 Mean, 10.3; SD, 3.6 Mean, 9.4; SD, 3.5 Mean, 8.3; SD, 2.8 Mean, 7.2; SD, 2.8 9 Widmark et al 11 1 yr 19 13 Count, 0 (40 mm) Count, 0 (30 mm); count, 3 (30-40 mm) Count, 6 (2 mm) Count, 2 (4 mm); count, 6 (4-6 mm) Count, 3 Count, 5 10 Villarreal et al 12 Mean, 8.45 mo; range, 0-33 mo 10 74 Mean, 38.8; SD, 5.71 Mean, 40.95; SD, 4.13 Count, 8 Count, 15 Count, 3 Count, 2 11 Haug and Assael 13 Minimum, 6 mo; range for open, 3.4-52.4 mo; range for closed, 34.8- 70.2 mo 10 10 Mean, 46.9; SD, 9.7 Mean, 42.5; SD, 9.92 Mean, 0.5; SD, 1.08 Mean, 0.8; SD, 0.92 Reported left and right Mean, 6.4; SD, 3.31 Mean, 5.1; SD, 2.42 12 De Riu et al 14 Range for open, 5-6 yr; range for closed, 8-12 yr 20 19 Mean, 43.7; SD, 5.9 Mean, 46; SD, 7 Count, 6 (3 mm); count, 2 (3 mm) Count, 4 (3 mm); count, 2 (3 mm) Mean, 8.6; SD, 2.2 Mean, 8.6; SD, 1.8 Mean, 8.5; SD, 3.5 Mean, 7.5; SD, 2.9 Mean, 7.4; SD, 2.2 Mean, 6.3; SD, 2.5 Count, 0 Count, 0 13 Joos and Kleinheinz 15 10 d, 6 wk, 3 mo, 6 mo, 12 mo 25 26 Mean, 45 Mean, 41 0.2 mm 1.2 mm Reported left and right Mean, 3.1 Mean, 5.1 Abbreviations: O, open; C, closed; Frac, fractured; Non, nonfractured. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. 1 0 8 8 C L O S E D V E R S U S O P E N R E D U C T I O N O F C O N D Y L A R F R A C T U R E S dyle fractures and mandibular condyle fracture sur- gery. The only restriction was that all articles had to be in the English language. Additional articles were then found by searching the references of those arti- cles discovered in the Medline search. The abstracts of all articles were reviewed, and those identied as off subject, without actual data, or not simultaneously comparing open and closed reduction were ex- cluded. For inclusion in the study, the remaining articles had to contain at least 1 outcome variable of interest in both the open and closed treatment groups. These outcomes were maximum postopera- tive mouth opening, amount of lateral excursion and protrusion, mandibular deviation on mouth opening, facial symmetry, and joint or muscle pain. All out- comes had to have been determined at least 6 months after treatment. The 2 primary statistical methods used for the meta- analyses were the weighted average method for xed effects and the weighted average method for random effects. 1 These methods can be used for both contin- uous and categorical data. The random effects model was chosen if there was signicant heterogeneity be- tween studies. In some instances continuous data were converted to dichotomous outcomes by use of Suissas method for conversion. 2 The Mantel-Haenszel method for xed effects is a third method that was used for categorical data. Results Of the 32 articles identied, 13 met the nal selec- tion criteria. Only 1 study was a randomized clinical trial. 3 As shown in Table 1, not all studies contained data on all of the outcome variables. Moreover, some studies used continuous measures whereas others used categorical measures for the same outcome. In many instances there were means given without SDs or ranges. The follow-up times were also inconsistent, as was the preoperative classication of the fracture type. Of the 13 studies, 8 contained continuous data on maximum mouth opening (MMO) that included ei- ther SDs or ranges. This analysis used Hedges g esti- mates, which are standardized mean differences be- tween the open and closed treatment groups for each study. 16,17 These data showed that those patients who underwent closed treatment had a moderately greater MMO than those who had open surgery (g 0.35; 95% condence interval [CI], 0.02 to 0.68; P .05). In an effort to use all of the available data, the con- tinuous outcomes were converted to counts. 2 These 8 counts, along with the data from the 3 studies that contained original count data, were then analyzed by FIGURE 1. MMO. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. FIGURE 2. Deviation on opening. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. NUSSBAUM, LASKIN, AND BEST 1089 use of the Mantel-Haenszel method of xed effects. The results of this analysis showed no difference be- tween the 2 treatment groups (log odds ratio, 0.35; 95% CI, 1.11 to 0.42; P .05) (Fig 1, right). Because only 2 studies reported continuous data on mandibular deviation, a meta-analysis for continuous data was not done. Instead, these data were con- verted into dichotomous variables by use of Suissas method, 2 and meta-analysis was done on the log odds ratios of the data (including studies 2, 6, 8, 10, 11, and 12 from Table 1). The weighted average method for random effects was used to test the cumulative effect- size estimate. This analysis was not signicant (log odds ratio, 0.36; 95% CI, 0.83 to 1.54; P .05), indicating that the odds of a patient who had closed treatment having postoperative mandibular deviation were the same as for a patient receiving open treat- ment (Fig 2). Lateral excursion was commonly reported in the various studies as excursion to the fractured side or nonfractured side of the jaw. In this regard, studies 11 and 13 had to be excluded because they indicated jaw side as left and right (Table 1). Two separate meta-analyses were performed on the continuous out- comes. The rst analysis was for excursion to the fractured side (studies 1, 8, and 12), and the second was for excursion to the nonfractured side (studies 1, 3, 8, and 12). In the rst analysis there was no differ- ence between open and closed treatment with re- spect to excursion to the fractured side (g 0.23; 95% CI, 0.03 to 0.50, P .05). However, the second analysis yielded a statistically signicant size effect for excursion to the nonfractured side (g 0.24; 95% CI, 0.03 to 0.46; P .05), indicating that patients who underwent open treatment had a slightly greater amount of lateral excursion to the nonfractured side than those in the closed treatment group (Fig 3). Mandibular protrusion was assessed by use of Hedges g estimators of the continuous data from 5 studies (studies 1, 3, 8, 11, and 12). This analysis showed no difference between the 2 groups (g 0.18; 95% CI, 0.03 to 0.39; P .05). The continuous FIGURE 4. Mandibular protrusion. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. FIGURE 3. Lateral excursion. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. 1090 CLOSED VERSUS OPEN REDUCTION OF CONDYLAR FRACTURES data were then converted to cell counts, and the log odds ratios were calculated for the 6 studies (studies 1, 3, 6, 7, 8, and 11). The cutoff was set at 5 mm so that the odds ratios were calculated from the propor- tions of patients with protrusion greater and less than this amount. These results also showed no signicant difference (log odds ratio, 0.31; 95% CI, 0.20 to 0.81; P .05) (Fig 4). The data for facial asymmetry were given as counts in 4 reports that contained such information, making it a subjective observation and giving the analysis low power. Log odds ratios were calculated for each study, and continuity corrections were applied. No statistically signicant differences were found (log odds ratio, 0.74; 95% CI, 2.56 to 1.07; P .05) (Fig 5). However, an additional study using quantita- tive measures of symmetry found that in patients treated by closed reduction, more asymmetries devel- oped. 18 In some studies the presence of joint or muscle pain was veried by the reaction to manual palpation, whereas in others it was reported as yes or no by the patient. In comparing these present/not present responses, the overall odds of a patient who had closed treatment having joint or muscle pain postop- eratively were over 3 times greater than in the open treatment group (log odds ratio, 3.19; 95% CI, 1.234 to 8.240; P .05) (Fig 6). In summary, most of the variables did not show signicant differences between open and closed treat- ment. Of the 3 analyses that showed a difference, 2 favored open reduction (excursion to the nonfrac- tured side and presence of joint or muscle pain) and 1 favored closed treatment (MMO) when one statisti- cal method was used but no difference when another method was used. Discussion A meta-analysis is only as good as the data in the studies that comprise it. If the individual studies are awed, the ndings from a review of these studies will also be awed. Under ideal circumstances, the trials included in a meta-analysis should be of high methodologic quality and free from bias so that any differences in outcomes between the groups can be condently attributed to the intervention under inves- tigation. 1 There are several types of bias that can potentially occur. These include systematic differ- ences in the patients characteristics at baseline (se- lection bias), unequal provision of care apart from the treatment under evaluation (performance bias), bi- ased assessment of outcomes (detection bias), and bias resulting from exclusion of patients after they have been allocated to treatment groups (attrition bias). The single most important limitation of the data in this meta-analysis is that only 1 study was a pro- spective, randomized clinical trial. This introduces selection bias, because retrospective studies are not randomized. There were considerable differences in the manner in which treatments were performed in the various studies. This included aspects of the surgical proto- cols as well as the materials used for xation. The length of time for maxillomandibular xation in the closed treatment group was also variable (0-6 weeks). Thus performance bias was introduced. Detection bias was certainly present in several of the studies. For the most part, outcome measures were given in millimeters, but asymmetry and joint and muscle pain data were collected subjectively. Attrition bias was also present in nearly all of the studies, because many patients were lost to long-term follow-up. Finally, publication bias is always a limita- tion when conducting a systematic review, because FIGURE 6. Joint or muscle pain. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. FIGURE 5. Facial asymmetry. Nussbaum, Laskin, and Best. Closed Versus Open Reduction of Condylar Fractures. J Oral Maxillofac Surg 2008. NUSSBAUM, LASKIN, AND BEST 1091 favorable results are generally more likely to be sub- mitted and accepted for publication. The results of this meta-analysis are inconclusive regarding whether open or closed treatment should be used for the management of mandibular condylar fractures. Because of the relatively poor quality of the available data and the lack of other important infor- mation, the question of preferred treatment still re- mains unanswered, and there is clearly a need for further research. However, such studies need to be done properly to provide useful information. First, in future investigations, the patients need to be random- ized into treatment groups, and the examiners need to be blinded to the manner in which the patients are treated. Second, similar methods of treatment need to be used. Third, standardized methods of fracture clas- sication, as well as data collection and reporting, need to be established so that valid comparisons among studies can be made. Fourth, studies with adequate sample sizes to determine clinically mean- ingful effects should be undertaken. 19 It is only through such coordinated efforts that the nal answer to the question of how to successfully treat mandib- ular condylar fractures will eventually be established. References 1. Sutton AJ, Abrams KR, Jones DR, et al: Methods for Meta- Analysis in Medical Research. New York, NY, Wiley, 2000 2. Suissa S: Binary methods for continuous outcomes: A paramet- ric alternative. J Clin Epidemiol 44:241, 1991 3. Worsaae N, Thorn JJ: Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: A clinical study of 52 cases. J Oral Maxillofac Surg 52:353, 1994 4. 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Oezmen Y, Mischkowski RA, Lenzen J, et al: MRI examination of the TMJ and functional results after conservative and surgical treatment of mandibular condyle fractures. Int J Oral Maxillofac Surg 27:33, 1998 10. Throckmorton GS, Ellis E III: Recovery of mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. Int J Oral Maxillofac Surg 29:421, 2000 11. Widmark G, Bagenholm T, Kahnberg KE, et al: Open reduction of subcondylar fractures. A study of functional rehabilitation. Int J Oral Maxillofac Surg 25:107, 1996 12. Villarreal PM, Monje F, Junquera LM, et al: Mandibular condyle fractures: Determinants of treatment and outcome. J Oral Max- illofac Surg 62:155, 2004 13. Haug RH, Assael LA: Outcomes of open versus closed treat- ment of mandibular subcondylar fractures. J Oral Maxillofac Surg 59:370, 2001 14. De Riu G, Gamba U, Anghinoni M, et al: A comparison of open and closed treatment of condylar fractures: A change in phi- losophy. Int J Oral Maxillofac Surg 30:384, 2001 15. Joos U, Kleinheinz J: Therapy of condylar neck fractures. Int J Oral Maxillofac Surg 27:247, 1998 16. Hedges LV: Distribution theory for Glasss estimator of effect size and related estimators. J Educ Stat 6:107, 1981 17. Hedges LV: Estimation of effect size from a series of indepen- dent experiments. Psychol Bull 92:490, 1982 18. Ellis E, Throckmorton G: Facial symmetry after closed and open treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg 58:719, 2000 19. Cohen J: Statistical Power Analysis for the Behavioral Sciences (ed 2). Mahwah, NJ, Lawrence Erlbaum Associates, 1988 1092 CLOSED VERSUS OPEN REDUCTION OF CONDYLAR FRACTURES