Commentary

The mandibular condyle is a common site of fracture, usually because of trauma. The best way to treat such fractures has been the subject of lengthy debate and discussion between oral and maxillofacial surgeons for many years. Treatment of such fractures can be either by surgical open reduction and fixation or by a much simpler closed method, in which the patient is given rigid intermaxillary fixation or, more commonly, intermaxillary elastic traction. An important potential complication of the open approach is damage to the facial nerve. Other techniques including endoscopic approaches are used in some centres. Condylar fractures commonly occur in conjunction with at least one other fracture elsewhere in the mandible, which usually require open reduction and fixation; this may influence the choice of treatment of the condyle.

The literature is littered with numerous studies that have attempted to address which modality of treatment is best. The problem with most of these is they are non-randomised, often retrospective case series, with mismatched groups and a multitude of outcome measures reported, as highlighted in this review. The authors did identify a RCT by Worsae and Thorn1 but with no clear method of randomisation, allocation concealment or blinding (which would be difficult for such a trial) and significant dropouts, this is not a good-quality RCT.

One of the main shortcomings of this review is that it failed to search the literature adequately using a fairly conservative and haphazard search strategy. A more comprehensive search and some clearly defined inclusion and exclusion criteria, as in a Cochrane review, would have improved this, and such a review is presently being undertaken.

The only other credible international multicentre RCT, by Eckelt et al. published in 2006,2 was not identified here. The Eckelt study concluded that either modality of treatment of condylar fractures yielded acceptable results but, for the outcomes assessed, the authors reported superior results with the open method and no cases of permanent damage to the facial nerve.

Nussbaum and co-authors highlighted the heterogeneity of published studies but proceeded with a meta-analysis of some outcome measures, which is not helpful. This intervention comparison would be well suited to a so-called pragmatic RCT using more patient-centred outcomes and particularly quality of life. This is because, ultimately, clinicians can undertake all manner of measurements of mandibular function, mouth opening and facial appearance, but what matters to the patients is how they feel undergoing each of these treatments and, in the longer term, how well they function in their everyday living.