O. Ross Beirne DMD, PhD
Closed reductions of mandible fractures result in fewer complications than open reductions with plate or wire fixation.
The studies were all retrospective and did not consistently report a significant difference in the rates of complications.
Do closed reductions of isolated mandible fractures result in fewer complications than open reductions with plate or wire fixation?
Three databases were search from 1980 to 2006. Studies that compared closed and open reductions of isolated mandible fractures without subcondylar injuries were identified for review. Infections, nerve injuries, occlusal disturbances, and/or wound dehiscences were the outcome measures examined.
Ten retrospective studies comparing closed and open reduction of mandible fractures met the inclusion criteria for review and eight studies were excluded for lack of a definition of closed reduction, mixing plating and wire techniques, inadequate reporting of outcomes, or lack of patients in one or both of the treatment groups. Six of the ten included studies reported statistically significant fewer infections with closed reduction of isolated mandible fractures (0-7%) compared to open reduction (9-21%). Four of the ten studies did not observe a statistically significant difference in the rate of infection between closed and open reductions. The three studies that evaluated nerve disturbances did not observe a statistically significant difference in outcome between open and closed reductions. Although the differences in nerve disturbances were not statistically significant, all three studies reported more nerve disturbances (3-16%) in patients with open reduction and plating than with closed reduction (0-8%). One study found a statistically significant greater rate of occlusal disturbances with closed reductions than with open reductions while four other studies did not find a statistically significant difference in occlusal disturbances. In one study, the difference in the overall complication rate, which was greater for open reduction than closed reduction, was statistically significant. The differences in the overall complication rates in the six other studies were not statistically significant.
Several studies demonstrated that patients treated with open reductions and plate fixation of their mandible fractures have statistically significant more complications than patients treated with closed reduction using maxillomandibular fixation. Other studies, however, did not find a statistically significant difference in complications when open reductions of mandible fractures were compared with closed reduction. In addition to the outcomes evaluated in this report overall cost of treatment and patient quality of life outcome measures need to be examined to compare the safety and efficacy of closed and open reduction of isolated mandible fractures.
Source of Funding:
Importance and Context:
Isolated mandible fractures can usually be managed with open or closed reduction. Closed reductions can usually be done faster than open reductions and do not necessitate direct surgical trauma at the site of the fracture. The health care cost of a closed reduction of an isolated mandible fracture is less than the cost of an open reduction. Patients treated with closed reductions, however, must maintain maxillomandibular fixation for several weeks while patients who have open reductions and plate fixation of a fracture require little or no time in maxillomandibular fixation. Early release of maxillomandibular fixation may improve the patients’ quality of life outcomes. However, it has not been established if the benefits of early function of the mandible outweigh the complications and costs associated with open exposure of the fracture site and plate fixation.
Strengths and Weaknesses of the Systematic Review:
Several databases were searched. The total number of studies identified by the search was not explicitly reported and the details of the search strategy were not described in the review. The exclusion and inclusion criteria were not specifically listed and it was unclear if at least two independent data extractors reviewed the studies. Because of the heterogeneity of the outcomes, the results of the different studies could not be combined for analysis. Some study outcomes were reported using the patients as the independent variable and other study outcomes were reported using fractures as the independent variable. The review did not correct for this difference in the analysis of the results. The quality of the studies was not assessed and heterogeneity of outcomes was not examined or discussed.
Strengths and Weaknesses of the Evidence:
All the studies included in the review were retrospective comparisons. None of the studies were prospective randomized clinical trials. The outcomes measures were not specifically defined in the review. Ten studies evaluated infection rates while only 3 studies examined nerve disturbances and five studies reported occlusal disturbances. The type of plate fixation was not the same in all the reports. Some studies evaluated the monocortical fixation system and other examined the compression fixation system. The surgical approach and rigidity of fixation are significantly different for these two plating systems. The patient populations evaluated in the studies were significantly different. One study included patients with HIV infection who had a greater rate of infections than patients without HIV infection while another study reported that complications were related to patients removing their maxillomandibular fixation prematurely. As noted by the authors, the differences in the severity of the fractures was not controlled in any of the studies included in the review. Differences in fracture severity might account for differences in complications and the review does not examine these differences or account for their influence on the outcomes.
Implications for Dental Practice:
The review was unable to demonstrate a consistent difference in the rate of complications associated with closed and open reduction of isolated mandible fractures. It is critical to determine if the rates of complications are different so that patients and clinicians can make treatment decisions based on clinical evidence rather than clinical impression or experience.