BASIC AND PATIENT-ORIENTED RESEARCH

J Oral Maxillofac Surg

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.
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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. Yang WG, Chen CT, Tsay PK, et al: Functional results of
unilateral mandibular condylar process fractures after open and
closed treatment. J Trauma 52:498, 2002
5. Santler G, Karcher H, Ruda C, et al: Fractures of the condylar
process: Surgical versus nonsurgical treatment. J Oral Maxillo-
fac Surg 57:392, 1999
6. Konstantinovic VS, Dimitrijevic B: Surgical versus conservative
treatment of unilateral condylar process fractures: Clinical and
radiographic evaluation of 80 patients. J Oral Maxillofac Surg
50:349, 1992
7. Takenoshita Y, Ishibashi H, Oka M: Comparison of functional
recovery after nonsurgical and surgical treatment of condylar
fractures. J Oral Maxillofac Surg 48:1191, 1990
8. Hidding J, Wolf R, Pingel D: Surgical versus non-surgical treat-
ment of fractures of the articular process of the mandible. J
Craniomaxillofac Surg 20:345, 1992
9. 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