CRANIOMAXILLOFACIAL TRAUMA

Surgical Treatment of Adult Mandibular

Condylar Fractures Provides Better
Outcomes Than Closed Treatment:
A Systematic Review and Meta-Analysis
Essam Ahmed Al-Moraissi, BDS, MSc, PhD,* and Edward Ellis III, DDS, MSy
Purpose: The purposes of this study were to identify significant differences in clinical outcomes
between open reduction and rigid internal fixation (ORIF) and closed treatment (CT) for adult mandibular
condylar fractures (MCFs) and to support or refute the superiority of one method over the other.
Materials and Methods: To address our purpose, we designed and implemented a systematic review
with meta-analysis. A comprehensive electronic search without date and language restrictions was
performed in May 2014. The inclusion criteria were studies in humans, including randomized or quasi–
randomized controlled trials, controlled clinical trials, and retrospective studies, that compared ORIF
and CT regarding maximal interincisal opening, laterotrusive and protrusive movements, pain, malocclu-
sion, chin deviation on mouth opening, and temporomandibular joint signs or symptoms for the manage-
ment of unilateral or bilateral adult MCFs. Meta-analysis was conducted only if there were studies of similar
comparisons reporting the same outcome measures. For binary outcomes, we calculated a standard esti-
mation of the odds ratio by the random-effects model if heterogeneity was detected; otherwise, a fixed-
effects model with a 95% confidence interval was performed. Weighted mean differences or standard
mean differences were used to construct forest plots of continuous data.
Results: Twenty-three publications were included: 5 randomized controlled trials, 16 controlled clinical
trials, and 2 retrospective studies. Five studies showed a low risk of bias, whereas 18 showed a moderate
risk of bias. There were statistically significant differences between ORIF and CT regarding maximal
interincisal opening, laterotrusive movement, protrusive movement, malocclusion, pain, and chin devia-
tion on mouth opening (P = .001, P = .001, P = .001, P = .001, P = .001, and P = .05, respectively).
Conclusions: The result of the meta-analysis confirmed that ORIF provides superior functional clinical
outcomes (subjective and objective) compared with CT in the management of adult MCFs.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:482-493, 2015

The mandible is frequently injured after facial trauma,
and 25 to 40% of mandibular fractures involve the
condyle.1-3 Management of mandibular condylar
fractures (MCFs) remains an ongoing matter of
controversy in maxillofacial surgery. This controversy
is reflected in the wide variety of opinions and
proposed treatment modalities offered in the
literature.4 For decades, closed treatment (CT) has
been the preferred treatment because treatment is
easier and less invasive,5 and the results are comparable,
with no surgical complications. However, CT may
comprise varying periods of intermaxillary fixation

Received from Department of Oral and Maxillofacial Surgery, Faculty Thamar University, Redaa Street, Thamar, Yemen; e-mail: dr_
of Oral and Dental Medicine, Cairo University, Egypt. essamalmoraissi@yahoo.com
*Assistant Professor, Department of Oral and Maxillofacial Received September 2 2014
Surgery, Faculty of Dentistry, Thamar University, Thamar, Yemen. Accepted September 30 2014
yProfessor and Chair, Department of Oral and Maxillofacial Ó 2015 American Association of Oral and Maxillofacial Surgeons
Surgery, University of Texas Health Science Center, San Antonio, TX. 0278-2391/14/01534-1
Conflict of Interest Disclosures: None of the authors reported any http://dx.doi.org/10.1016/j.joms.2014.09.027
disclosures.
Address correspondence and reprint requests to Dr Al-Moraissi:
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,

482
AL-MORAISSI AND ELLIS III
(IMF) (0 to 6 weeks) followed by aggressive physio-
therapy.6 In addition, long-term complications such
as pain, arthritis, malocclusion, deviation of the
mandible on opening and closing movements, temporo-
mandibular joint (TMJ) dysfunction, facial asymmetry,
and ankylosis may occur in patients with condylar in-
juries treated in a closed manner.6,7 If there is severe
displacement or dislocation, surgical management
seems to be preferred.8-10 Open reduction–internal
fixation (ORIF) allows anatomic repositioning and
immediate functional movements of the jaw,11 but has
the potential complications of damaging the facial nerve
and of forming visible scars.4 With the implementation
of rigid internal fixation over the past 30 years, the indi-
cations for surgical treatment of MCFs have broadened.
A review of the literature showed several studies
comparing CT and ORIF in the treatment of MCFs, but
there is still a continuing debate over how to best
manage this type of fracture. Therefore the overall
goal of this study was to test the null hypothesis that
there is no difference between CT and ORIF in adult
MCFs against the hypothesis that there is a difference.
The specific aims of this study were 1) to compare clin-
ical outcomes between ORIF and CT for MCFs and 2) to
support or refute the superiority of one method over
the other.
Materials and Methods
INCLUSION CRITERIA
Any quasi–randomized controlled trials or random-
ized controlled trials (RCTs), controlled clinical trials
(CCTs), and retrospective studies that compared
maximal interincisal opening (MIO), laterotrusion (ie,
excursive movement away from the side of the condylar
fracture), protrusion, pain, malocclusion, chin deviation
on mouth opening, and the incidence of postoperative
complications for patients treated by ORIF or CT for uni-
lateral or bilateral MCFs and reporting were included.
The exclusion criteria were case reports, technical re-
ports, animal studies, in vitro studies, review articles,
studies of pediatric or edentulous MCF patients, studies
that did not report data (mean and standard deviation)
or the outcomes of interest, and studies in which a com-
parison group was absent.
SEARCH METHODS FOR IDENTIFICATION OF
STUDIES
To address the research purpose, we designed and
implemented a systematic review with meta-analysis.
We conducted the systematic review and meta-
analysis according to the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-Analyses)–E
2012 checklist.12 A comprehensive electronic search
without date and language restrictions was performed
in May 2014 using the following electronic databases:
483
PubMed, Cochrane Database of Systematic Reviews,
Cochrane Central Register of Controlled Trials, Em-
base, Medline, CINAHL (Cumulative Index to Nursing
and Allied Health Literature), and Electronic Journal
Center. We used one or a combination of the following
search terms: ‘‘surgical versus nonsurgical treatment in
mandibular condylar fractures’’ AND/OR ‘‘open versus
closed reduction in treatment of unilateral OR bilateral
mandibular condylar process fractures’’ AND/OR
‘‘surgical versus conservative/functional treatment
of mandibular condylar/subcondylar fractures,’’
‘‘condylar/masticatory motion after open treatment
and CT of mandibular condylar fractures,’’ ‘‘clinical out-
comes after open treatment versus CT of mandibular
condylar fractures,’’ ‘‘surgical complication/occlusal
results AND mandibular condylar/diacapitular frac-
tures AND/OR open versus closed approach,’’ and ‘‘dis-
placed/dislocated mandibular condylar fractures AND
surgical versus nonsurgical treatment.’’
In addition, a manual search of oral and maxillofacial
surgery–related journals was performed, including
International Journal of Oral and Maxillofacial
Surgery; British Journal of Oral and Maxillofacial Sur-
gery; Journal of Oral and Maxillofacial Surgery; Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
and Endodontology; Journal of Cranio-Maxillo-Facial
Surgery; Journal of Craniofacial Surgery; Journal of
Trauma Injury, Infection, and Critical Care; and Jour-
nal of Maxillofacial and Oral Surgery. The reference
lists of the identified studies and the relevant reviews
on the subject also were scanned for possible additional
studies. Moreover, online databases providing informa-
tion about clinical trials in progress were checked
(clinicaltrials.gov, www.centerwatch.com/clinical-trials,
and www.clinicalconnection.com).
DATA COLLECTION PROCESS
We carefully assessed the eligibility of all studies
retrieved from the databases. From the studies
included in the final analysis, the following data were
extracted (when available): authors, year of publica-
tion, study design, number of patients, gender (male-
female ratio), mean age (in years), follow-up period,
MCF fixation method, associated mandibular frac-
tures, and outcome variables (MIO, laterotrusive
movement, protrusive movement, pain, malocclusion,
chin deviation on mouth opening, and TMJ signs or
symptoms). The authors of the studies were contacted
for possible missing data.
RISK OF BIAS IN INDIVIDUAL STUDIES
A methodologic quality rating was assigned by
combining the proposed criteria from the MOOSE
(Meta-Analysis of Observational Studies in Epidemi-
ology) statement,13 STROBE (Strengthening the
484
Reporting of Observational Studies in Epidemiology)
statement,14 and PRISMA statement15 to verify the
strength of scientific evidence in clinical decision mak-
ing. The classification of the risk-of-bias potential for
each study was based on the following 5 criteria: random
selection in the population, definition of inclusion and
exclusion criteria, reporting of loss to follow-up, vali-
dated measurements, and statistical analysis. A study
that included all of these criteria was classified as having
a low risk of bias, whereas a study that did not include 1
of these criteria was classified as having a moderate risk
of bias. When 2 or more criteria were missing, the study
was considered to have a high risk of bias.
META-ANALYSIS
Meta-analysis was conducted only if there were
studies of similar comparisons reporting the same
outcome measures. For binary outcomes, we calculated
a standard estimation of the odds ratio (OR) by the
random-effects model if heterogeneity was detected;
otherwise, a fixed-effects model with a 95% confidence
interval (CI) was performed. Weighted mean differ-
ences (WMDs) or standard mean differences (if the
included studies have used different instrument to mea-
sure the same outcome) were used to construct forest
plots of continuous data. The data were analyzed using
Review Manager statistical software (version 5.2.6; The
Nordic Cochrane Centre, The Cochrane Collaboration,
Copenhagen, Denmark).
ASSESSMENT OF HETEROGENEITY
The significance of any discrepancies in the estimates
of the treatment effects of the different trials was as-
sessed using the Cochran test for heterogeneity and
the I2 statistic, which describes the percentage total vari-
ation across studies that is due to heterogeneity rather
than chance. Heterogeneity was considered statistically
significant if P < .1. A rough guide to the interpretation
of I2 given in the Cochrane Handbook is as follows: 1)
for values from 0 to 40%, the heterogeneity might not be
important; 2) values from 30 to 60% may represent mod-
erate heterogeneity; 3) values from 50 to 90% may repre-
sent substantial heterogeneity; and 4) for values from 75
to 100%, there is considerable heterogeneity.16
INVESTIGATION OF PUBLICATION BIAS
A funnel plot (plot of effect size vs standard error)
was drawn. Asymmetry of the funnel plot could indi-
cate publication bias and other biases related to sam-
ple size, although asymmetry also may represent a
true relationship between trial size and effect size.
SENSITIVITY ANALYSIS
When the number of included studies was sufficient,
a sensitivity analysis was performed to assess the
ADULT MANDIBULAR CONDYLAR FRACTURES
robustness of the review results by repeating the anal-
ysis after exclusion of studies with a high risk of bias.
Results
The study selection process is summarized in
Figure 1. The electronic search resulted in 905 entries.
Of 905 articles, 143 were excluded because they were
in vitro studies. After the initial screening of the titles
and abstracts, 537 articles were excluded because they
were off topic or duplicates. The full-text reports of
the remaining 225 articles led to the exclusion of
202 because they did not meet the inclusion criteria.
Thus a total of 23 publications were included in
the review.1,4,7,17-36 Fifteen studies compared CT and
ORIF in the management of MCFs regarding MIO
and laterotrusion.1,7,17,19,20,22,25,27-31,33,34,36 Fourteen
studies compared CT and ORIF in the management
of MCFs regarding protrusion.1,7,17,19,20,22,24,25,
28-31,33,34
Sixteen studies assessed malocclusion
between CT and ORIF.4,7,17,18,21,23-26,28,29,31,32,34-36
Five studies investigated pain on a visual analog scale
(VAS) between CT and ORIF.7,22,25,30,34 Lastly, 10
studies evaluated chin deviation on mouth opening
between CT and ORIF,1,4,7,18,20,22,24,25,28,29 and 5
studies compared CT and ORIF regarding TMJ pain,
tenderness, noise, and clicking.4,7,24,31,32
CHARACTERISTICS OF INCLUDED STUDIES
Detailed characteristics of the included studies
are shown in Table 1. Five RCTs,7,25,30,31,36 16
CCTs,1,4,17-21,23,24,26-29,32-34 and 2 retrospective
studies22,35 were included in the meta-analysis and crit-
ical appraisal. A total of 1,318 patients were enrolled in
23 studies comparing ORIF (n = 615) versus CT (n =
703) treatment in the management of MCFs at follow-
up periods ranging from 6 months to 3 years.1,4,7,17-36
Concerning the surgical technique, for all patients
allocated to the CT group, the surgical technique con-
sisted of IMF for a period of 0 to 35 days (according to
the studies). Either initially or after any period of IMF,
guiding elastics were used for a variable period to main-
tain proper occlusion, followed by mouth-opening exer-
cises and physiotherapy. In the ORIF group, the surgical
approaches comprised preauricular, submandibular,
transmasseteric anterior parotid, retromandibular, and
endoscope-assisted intraoral approaches. The fractures
were stabilized with miniplates or lag screws plus IMF
with elastics for 3 days or less (according to the studies).
Postoperative instructions regarding mouth-opening ex-
ercises and physiotherapy were given to all the patients
in both groups.
RISK OF BIAS WITHIN STUDIES
Concerning the quality assessment of the included
studies, 5 studies showed a low risk of bias7,25,30,31,36
AL-MORAISSI AND ELLIS III 485

FIGURE 1. Study screening process.

Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.

and 18 studies showed a moderate risk of Laterotrusive Movement

bias.1,4,17-24,26-29,32-35 The scores are summarized Fifteen studies compared laterotrusive excursions
in Table 2. between the CT (n = 434) and ORIF (n = 338)
groups.1,7,17,19,20,22,25,27-31,33,34,36 There was a
RESULTS OF INDIVIDUAL VARIABLES statistical difference in favor of the ORIF group
Maximal Interincisal Opening (WMD, 1.14 mm; 95% CI, 0.73 to 1.55 mm; P < .001
Fifteen studies compared MIO between [fixed-effects model]). The test of heterogeneity
the CT (n = 464) and ORIF (n = 332) showed no significant heterogeneity (c2 = 44.20,
groups.1,7,17,19,20,22,25,27-31,33,34,36 There was a df = 14 [P < .001], I2 = 68%) (Fig 3).
statistically significant advantage for the ORIF group
(WMD, 3.32 mm; 95% CI, 2.42 to 4.04 mm; P < .001 Protrusive Movement
[fixed-effects model]). The test of heterogeneity Fourteen studies compared protrusive move-
showed no significant heterogeneity (c2 = 64.61, ment between the CT (n = 422) and ORIF
df = 14 [P < .001], I2 = 78%) (Fig 2). (n = 328) groups.1,7,17,19,20,22,24,25,28-31,33,34 There was
 486
Table 1. CHARACTERISTICS OF INCLUDED STUDIES

No. of
Patients Associated
Year Study Age, Mean Female-Male Follow-Up Mandibular
Authors Published Design or Range, yr Ratio ORIF CT Period MCF Fixation Method Surgical Approach Fractures

Worsaae and 1994 CCT ORIF: 29 ORIF: 16:8 24 28 ORIF: 21 mo CT: IMF for 5-6 wk NM Yes
Thorn17 CT: 37 CT: 21:7 CT: 30 mo ORIF: transosseous wire
osteosynthesis
Oezmen et al18 1998 CCT ORIF, CT: 31.5 ORIF, CT: 23:7 20 10 24 mo CT: IMF ORIF: submandibular incision No
ORIF: ORIF
Palmieri et al19 1999 CCT ORIF, CT: 16-70 ORIF, CT: 121:27 62 85 Up to 3 yr CT: IMF for 2 wk ORIF: retromandibular Yes
ORIF: ORIF approach
Santler et al20 1999 CCT ORIF: 24 ORIF: 20:17 37 113 6-130 mo CT: IMF NM ORIF: 13
CT: 23 CT: 90:23 ORIF: ORIF CT: 59
Ellis et al21 2000 CCT ORIF, CT: 16-70 CT: 62:10 65 77 Up to 3 yr CT: IMF ORIF: retromandibular Yes
ORIF: 51:14 ORIF: ORIF approach
De Riu et al1 2001 CCT ORIF, CT: 13-69 NM 20 19 CT: IMF for 5-7 days ORIF: submandibular or NM
ORIF: ORIF + IMF for 3-5 days preauricular approach
Haug and 2001 RS CT: 36.1 CT: 8:2 10 10 6 mo CT: IMF NM NM
Assael22 ORIF: 36.5 ORIF: 7:3 ORIF: ORIF
Yang et al4 2002 CCT ORIF, CT: 25.53 ORIF, CT: 41:25 36 30 1 yr CT: IMF for 3 wk ORIF: preauricular extraoral Yes
ORIF: ORIF + IMF for 1 wk approach, endoscope-
assisted intraoral approach
Hlawitschka 2005 CCT ORIF: 30 ORIF: 13:1 14 29 CT: 20 mo CT: IMF for 10 days + 8 wk of ORIF: modified auricular Yes
et al23 CT: 28 CT: 25:4 ORIF: 11 mo functional therapy approach

ADULT MANDIBULAR CONDYLAR FRACTURES

ORIF: ORIF + IMF for 2 days
Stiesch-Scholz 2005 CCT ORIF, CT: 32 ORIF, CT: 117:17 24 13 NM CT: IMF NM No
et al24 ORIF: ORIF
Eckelt et al25 2006 RCT ORIF, CT: 32 ORIF, CT: 52:14 36 33 6 mo CT: IMF + elastics for 10 days ORIF: preauricular, Yes
ORIF: miniplates or miniscrews submandibular, perangular,
and lag screws and transoral approach
Landes and 2006 CCT ORIF, CT: >16 NM 24 14 42 mo CT: IMF for 2 wk ORIF: preauricular approach Yes
Lipphardt26 ORIF: 33 ORIF: ORIF
CT: 15
Ishihama 2007 CCT ORIF: 34.8 ORIF: 17:7 18 43 6 mo to 2.5 CT: IMF + elastics for 1-3 wk ORIF: submandibular approach Yes
et al27 CT: 33.5 CT: 26:17 yr ORIF: lag screw, miniplate, or
wire
Landes et al28 2008 CCT ORIF: 39 NM 30 29 1 yr CT: IMF + elastics for 2 wk ORIF: preauricular and Yes
CT: 36 ORIF: 1 or 2 miniplates or retromandibular approach
T-shaped microplates
 AL-MORAISSI AND ELLIS III
Landes et al29 2008 CCT CT: 31 NM 9 13 12 mo CT: IMF for 2 wk ORIF: preauricular approach Yes
ORIF: 27 ORIF: ORIF
Schneider 2008 RCT ORIF, CT: >18 NM 36 30 6 mo CT: IMF for 10 days + elastics ORIF: preauricular, transoral, Yes
et al30 ORIF: ORIF with 1 or 2 and retromandibular
miniplates or lag screws approach
Danda et al31 2010 RCT NM ORIF, CT: 27:5 16 16 CT: 21.5 mo CT: IMF for 2 wk + elastics for 2 ORIF: preauricular, NM
ORIF: 22.3 wk submandibular,
mo ORIF: ORIF with 1 or 2 transmasseteric anterior
miniplates + IMF for 2 wk parotid, or retromandibular
approach
Singh et al7 2010 RCT ORIF, CT: 30.6 ORIF, CT: 33:7 18 22 6 mo CT: IMF + elastics for 7-35 days ORIF: retromandibular and Yes
ORIF: 2-mm titanium anterior parotid approach
miniplates + IMF with
elastics for 3-5 days
Park et al32 2010 CCT ORIF, CT: 27.5 ORIF, CT: 52:19 63 35 12 mo CT: IMF for 2 wk ORIF: intraoral and No
ORIF: ORIF + IMF for 1 wk submandibular approaches
Sforza et al33 2011 CCT ORIF: 26.8 NM 9 12 ORIF: 16.4 CT: IMF NM No
CT: 27.1 mo ORIF: ORIF
CT: 32.8 mo
Gupta et al34 2012 CCT CT: 15-65 CT: 8:2 10 10 1, 4, 8, and CT: IMF ORIF: preauricular or No
ORIF: 28.2 ORIF: 10:0 12 wk ORIF: 2-mm stainless steel retromandibular approach
plates and screws (or both)
Singh et al35 2012 RS ORIF, CT: 28.2 CT: 16:4 24 20 6 mo CT: IMF for 21-35 days ORIF: retromandibular and Yes
ORIF: 19:5 ORIF: ORIF + IMF for 3-5 days anterior parotid approach
Kotrashetti 2013 RCT NM NM 10 12 6 mo CT: IMF + elastics for 3-4 wk ORIF: retromandibular Yes
et al36 ORIF: titanium miniplates and approach
26 mm titanium screws

Abbreviations: CCT, controlled clinical trial; CT, closed reduction treatment; IMF, intermaxillary fixation; MCF, mandibular condylar fracture; ORIF, open reduction–internal
fixation; NM, not mentioned; RCT, randomized controlled trial; RS, retrospective study.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.

487
488 ADULT MANDIBULAR CONDYLAR FRACTURES

Table 2. RESULTS OF QUALITY ASSESSMENT

Defined Inclusion
Year Random Selection and Exclusion Loss to Validated Statistical Estimated Potential
Authors Published in Population Criteria Follow-Up Measurement Analysis Risk of Bias

Worsaae and Thorn17 1994 No Yes Yes Yes Yes Moderate

Oezmen et al18 1998 No Yes Yes Yes Yes Moderate
Palmieri et al19 1999 No Yes Yes Yes Yes Moderate
Santler et al20 1999 No Yes Yes Yes Yes Moderate
Ellis et al21 2000 No Yes Yes Yes Yes Moderate
De Riu et al1 2001 No Yes Yes Yes Yes Moderate
Haug and Assael22 2001 No Yes Yes Yes Yes Moderate
Yang et al4 2002 No Yes Yes Yes Yes Moderate
Hlawitschka et al23 2005 No Yes Yes Yes Yes Moderate
Stiesch-Scholz et al24 2005 No Yes Yes Yes Yes Moderate
Eckelt et al25 2006 Yes Yes Yes Yes Yes Low
Landes and Lipphardt26 2006 No Yes Yes Yes Yes Moderate
Ishihama et al27 2007 No Yes Yes Yes Yes Moderate
Landes et al28 2008 No Yes Yes Yes Yes Moderate
Landes et al29 2008 No Yes Yes Yes Yes Moderate
Schneider et al30 2008 Yes Yes Yes Yes Yes Low
Danda et al31 2010 Yes Yes Yes Yes Yes Low
Singh et al7 2010 Yes Yes Yes Yes Yes Low
Park et al32 2010 No Yes Yes Yes Yes Moderate
Sforza et al33 2011 No Yes Yes Yes Yes Moderate
Gupta et al34 2012 Yes Yes Yes Yes Moderate
Singh et al35 2012 No Yes Yes Yes Yes Moderate
Kotrashetti et al36 2013 Yes Yes Yes Yes Yes Low

Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.

a statistical difference in favor of ORIF (WMD, 0.99 mm;
95% CI, 0.70 to 1.29 mm; P < .001 [fixed-effects
model]). The test of heterogeneity showed no signifi-
cant heterogeneity (c2 = 48.48, df = 13 [P < .001],
I2 = 73%) (Fig 4).
group, it did not reach statistical significance
(standard mean difference, 0.74 mm on VAS; 95% CI,
1.07 to 0.41 mm on VAS; P = .001 [fixed-effects
model]). There was no heterogeneity (c2 = 0.25,
df = 1 [P < .62], I2 = 0%) (Fig 5).

Pain on VAS Malocclusion

Four studies assessed pain on a VAS after 6 months Sixteen studies assessed malocclusion between
between the CT (n = 155) and ORIF (n = 74) the CT (n = 388) and ORIF (n = 388)
groups.7,22,25,34 Although pain was less in the ORIF groups.4,7,17,18,21,23-26,28,29,31,32,34-36 There was a

FIGURE 2. Forest plot for maximal interincisal opening: open reduction–internal fixation (ORIF) versus closed treatment (CT) (continuous data).
CI, confidence interval; IV, inverse variance.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.
AL-MORAISSI AND ELLIS III 489

FIGURE 3. Forest plot for laterotrusive movement: open reduction–internal fixation (ORIF) versus closed treatment (CT) (continuous data).
CI, confidence interval; IV, inverse variance.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.

significant difference in favor of the ORIF group
regarding postoperative malocclusion (OR, 0.41 mm;
95% CI, 0.26 to 0.62 mm; P = .001 [fixed-effects model]).
The test of heterogeneity indicated the absence of het-
erogeneity (c2 = 10.79, df = 14 [P = .70], I2 = 0%).
The OR was 0.41, meaning that using ORIF in the treat-
ment of MCFs decreases the incidence of malocclusion
by 59% compared with using CT (Fig 6).
Chin Deviation on Mouth Opening
Ten studies evaluated chin deviation on mouth
opening between the CT (n = 294) and ORIF (n =
227) groups.1,4,7,18,20,22,24,25,28,29 There was a
significant advantage for the ORIF group in
preventing chin deviation (OR, 0.62 mm; 95% CI,
0.39 to 0.99 mm; P = .05 [fixed-effects model]). There
was no heterogeneity among studies (c2 = 14.46, df =
8 [P = .07], I2 = 45%). The OR was 0.62, meaning that
using ORIF in the treatment of MCFs decreases the
incidence of chin deviation on opening by 38%
compared with using CT (Fig 7).
TMJ Pain, Tenderness, Noise, and Clicking
Five studies compared TMJ pain, tenderness, noise,
and clicking between the CT (n = 117) and ORIF
(n = 129) groups after 6 months.4,7,24,31,32 There
was an advantage for the ORIF group in reducing
TMJ pain, noise, and clicking, but this advantage
did not reach significant levels (OR, 0.57 mm; 95%
CI, 0.31 to 1.04 mm; P = .07 [fixed-effects model]).
There was no heterogeneity among studies (c2 =
7.96, df = 4 [P = .09], I2 = 50%). The OR was 0.57,
meaning that using ORIF in the treatment of MCFs
decreases the incidence of TMJ pain, tenderness,
noise, and clicking by 43% compared with using
CT (Fig 7).
SENSITIVITY ANALYSIS AND PUBLICATION BIAS
The results after the exclusion of the retrospective
studies did not change the overall results. The funnel
plot did not show any noticeable asymmetry, indi-
cating the absence of publication bias (Fig 8).

FIGURE 4. Forest plot for protrusive movement: open reduction–internal fixation (ORIF) versus closed treatment (CT) (continuous data).
CI, confidence interval; IV, inverse variance.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.
490 ADULT MANDIBULAR CONDYLAR FRACTURES

FIGURE 5. Forest plot for pain on visual analog scale: open reduction–internal fixation (ORIF) versus closed treatment (CT) (continuous data).
CI, confidence interval; IV, inverse variance; Std, standard.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.

Discussion Chin deviation toward the fractured side on mouth

The purpose of this study was to determine whether
the literature shows the superiority of open treatment
versus CT for adult condylar fractures. In general, the
results of this study show that ORIF leads to improve-
ments in most measures of condylar and mandibular
mobility (MIO, laterotrusion, protrusion, lack of chin
deviation). In addition, improvements in postopera-
tive pain reduction and occlusion were better for
patients treated in an open manner. For instance, this
meta-analysis showed that ORIF patients had a
greater postoperative MIO than patients treated
with CT (WMD, 3.23 mm; 95% CI, 2.42 to 4.04
mm; P = .001). This finding is consistent with
some studies1,7,19,22,25,27,30,31,34,36 and inconsistent
with others.4,17,20,28,29,33,37 Similarly, laterotrusive
movement was better in ORIF patients, indicating
better condylar motion (WMD, 1.14 mm; 95% CI, 0.73
to 1.55 mm; P = .001). This finding is compatible with
the results of some studies,7,22,24,30,31 but disagrees
with the results of others.28,29,33 In addition, the ORIF
group had greater protrusive movement than the
CT group (WMD, 0.99 mm; 95% CI, 0.70 to 1.29 mm;
P = .001), similar to the results of previous
literature1,7,19,22,24,25,30,31,34 and opposite to others.29,33
opening was lower in the ORIF group than in patients
treated with CT. This finding also indicates that the
mobility of the condyle on the fractured side is better
in patients treated in an open manner. The OR
was 0.62, meaning that using ORIF in the treatment
of MCFs decreases the incidence of chin deviation
by 38% compared with using CT. This finding is in
agreement with most studies.4,7,22,24,25 Concerning
occlusal discrepancies, the ORIF group was superior
regarding reducing postoperative malocclusion (OR,
0.41 mm; 95% CI, 0.26 to 0.62 mm; P = .001). This
finding is in accordance with most previous
results.7,17,18,21,23,25,26,28,31,35,36
The 5 studies that assessed pain on a VAS 6 months
or more after treatment showed better pain reduction
in the ORIF group.7,22,25,30,34 In addition, the results of
our study showed that there was an advantage for
ORIF in reducing TMJ pain, noise, and clicking but
this advantage did not reach a statistically significant
level. The OR was 0.57, meaning that using ORIF in
the treatment of MCFs decreases the incidence of
TMJ pain, tenderness, noise, and clicking by 43%
compared with using CT.
Although there are various guidelines regarding the
management of condylar fractures of the mandible by

FIGURE 6. Forest plot for malocclusion: open reduction–internal fixation (ORIF) versus closed treatment (CT) (dichotomous data). CI, confi-
dence interval; M-H, the Mantel-Haenszel method.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.
AL-MORAISSI AND ELLIS III
FIGURE 7. Forest plot for temporomandibular joint (TMJ) pain, tenderness, noise, and clicking and chin deviation on mouth opening: open
reduction–internal fixation (ORIF) versus closed treatment (CT) (dichotomous data). CI, confidence interval; M-H, the Mantel-Haenszel method.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J Oral Maxillofac Surg 2015.
open treatment or CT, there is still continuing debate
over how to best manage these fractures. This is attrib-
utable in part to a potential misinterpretation of the
literature from decades prior, a lack of uniformity of
classification of the various anatomic components of
the mandibular condyle, a lack of scientifically valid
studies comparing treatments, and a perceived poten-
tial to cause harm through the open approach based in
part on the surgeon’s lack of experience and critical
examination of the literature.38 Other factors con-
founding the strategy for the management of condylar
FIGURE 8. Funnel plot for publication bias according to reported
incidence of postoperative malocclusion. OR, odds ratio; SE, stan-
dard error.
Al-Moraissi and Ellis III. Adult Mandibular Condylar Fractures. J
Oral Maxillofac Surg 2015.
491
fractures are the anatomic position of these fractures;
the influence of the fractures and surgery on facial
growth; and the potential complications, such as
malocclusion, chin deviation, ankylosis of the TMJ,
and internal derangement of the joint.5,39
This study had several limitations. Fourteen of the
studies that were used in our analysis included pa-
tients with associated mandibular and midface frac-
tures.4,7,17,19,21,23,25-30,35,36 It is believed that a
second fracture of the mandible can confound the
outcome data because the fixation requirements for
a double fracture are often different from those for
an isolated fracture.40 Biomechanically, a mandible
with bilateral condylar fractures is a much more
complicated construct than one with a unilateral
condylar fracture. Rehabilitating such patients using
CT is more difficult because of the deficiency in struc-
tural support from the lack of both craniomandibular
articulations. We included patients with bilateral frac-
tures because some of the studies had included these
patients and they were impossible to separate. Theo-
retically, their inclusion can blur the data because
some of the measures (laterotrusion, protrusion, devi-
ation on opening) make less sense when used for pa-
tients with bilateral fractures of the condyle.
However, the number of patients with bilateral frac-
tures was small.
Another potential weakness of this study is that
only 5 studies were RCTs,7,25,30,31,36 16 were
492
CCTs,1,4,17-21,23,24,26-29,32-34 and 2 were retrospective
studies.22,35 Although many of these studies are not
ideally designed, an ethical prospective randomized
trial may not be possible given that one treatment
arm includes surgery.41,42 Therefore we performed a
sensitivity analysis to assess the robustness of our
results by repeating the analysis with exclusion of the
retrospective studies.22,35 After doing so, the overall
results did not change.
Although the aforementioned findings make it
sound like ORIF is superior to CT, it must be remem-
bered that when one selects ORIF, one is increasing
the cost of treatment because ORIF engenders a longer
operating room time, more expensive hardware, and a
longer general anesthesia time. One also is imposing a
potential set of complications that must be carefully
weighed to determine whether the potential benefits
of open treatment are worth the potential surgical
and postsurgical risks. The potential complications
include injury to nerves and blood vessels, sialocele
or salivary fistulae, facial scarring, loosening of hard-
ware, and infection.
It also should be mentioned that individuals who
publish studies on the treatment of condylar fractures
usually have a great amount of experience performing
whatever treatment they are providing. Even though
the outcomes of the studies in the literature might
favor ORIF over CT for many of the outcome variables,
individual practitioners may not see that benefit if
their amount of surgical experience is not great. One
must be able to safely perform ORIF with minimal
complications if one is to see improved outcomes.
For those with little experience, it may be better to
use CT, and should a malocclusion occur, one can cor-
rect it later with orthognathic surgery.
Although not all potential complications have
been adequately studied, 10 studies evaluated
nerve VII function after ORIF of condylar frac-
tures.7,8,17-20,25,29,43,44 The incidence of facial nerve
injury ranged from 0 to 21%, but it was temporary in
most of the patients. Overall, from the available data,
22 of 265 patients treated with ORIF (5.83%) had
postoperative facial nerve weakness; however, in the
vast majority of the cases, the nerve function totally
recovered in less than 6 months (16 of 22 patients).
Data about unacceptable scarring were limited, but
in most studies, the scar was described as
imperceptible and acceptable by the patient.44
New technology to facilitate transoral ORIF has
offered the promise of eliminating some of the adverse
sequelae associated with ORIF through a transfacial
approach, such as facial nerve injury and scarring.
For instance, using an endoscope to assist in visualiza-
tion and right-angle drills and screwdrivers has made
transoral surgical approaches a reality, minimizing
the risk of injury to the facial nerve and eliminating
ADULT MANDIBULAR CONDYLAR FRACTURES
the risk of facial scarring.45 This technique has been
used in the management of MCFs,38 but after a decade
of development, the technique has not been widely
accepted.46-49
In conclusion, the result of this meta-analysis
confirmed that ORIF provides superior clinical out-
comes (subjective and objective) compared with CT
in the management of adult MCFs. Better-designed pro-
spective randomized CCTs with adequate sample sizes
and long follow-up periods comparing open treatment
and CT of isolated adult MCFs would be useful in
exploring this question further. Other variables such
as treatment cost and patient satisfaction also should
be studied to determine the differences between
open treatment and CT of adult condylar fractures.
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