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Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials
Essam Ahmed Al-Moraissi1, Andreas Neff2, Amanjot Kaur3
1Assistant Professor, Department of Oral and Maxillofacial Surgery, Thamar University, Yemen.
Purpose:
Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.
Methods:
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.
Results:
The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).
Conclusions:
This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).
Insights
Network meta-analysis shows 3D-miniplates and double miniplates are most effective for treating mandibular condylar process fractures (MCPFs), reducing malocclusion and improving function. Double miniplates offer better outcomes than closed treatment.
Area of Science:
- Oral and Maxillofacial Surgery
- Orthodontics
- Biomaterials Engineering
Background:
- Mandibular condylar process fractures (MCPFs) are common facial injuries requiring effective treatment.
- Existing treatments for MCPFs lack direct comparative data, necessitating advanced analytical methods.
- Network meta-analysis (NMA) provides a framework to compare multiple interventions simultaneously.
Purpose of the Study:
- To conduct the first NMA of randomized clinical trials (RCTs) comparing all available treatments for MCPFs.
- To compare and rank the efficacy of various surgical and non-surgical interventions for MCPFs.
- To identify optimal treatment strategies for reducing postoperative complications and improving functional outcomes.
Main Methods:
- Systematic literature search adhering to PRISMA guidelines across major databases up to January 2023.
- Included RCTs comparing treatments: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF, AB functional treatment, single/double/lambda/rhomboid/trapezoidal miniplates.
- Assessed postoperative complications (occlusion, mobility, pain) using risk ratios and standardized mean differences; evaluated study quality with Cochrane risk-of-bias tool and GRADE.
Main Results:
- The NMA included 10,259 patients from 29 RCTs.
- Double miniplates significantly reduced malocclusion compared to rigid MMF and functional treatment at ≤6 months (very low to low quality evidence).
- 3D-miniplates and double miniplates were ranked highest for reducing malocclusion and improving mandibular function, with trapezoidal plates and AB functional treatment leading in specific categories.
Conclusions:
- No significant difference in functional outcomes between 2-miniplates and 3D-miniplates for MCPFs (low evidence).
- Double miniplates demonstrated superior outcomes compared to closed treatment methods (moderate evidence).
- 3D-miniplates showed better outcomes for occlusion and mandibular movements than closed treatment at ≤6 months (very low evidence).
