Closed treatment versus open reduction and internal fixation for mandibular condylar head fractures: A systematic...

Mandibular condylar head fractures remain controversial with respect to optimal management. This systematic review and meta-analysis compared closed treatment and open reduction and internal fixation for intracapsular condylar head fractures. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was prospectively registered in the International Prospective Register of Systematic Reviews (CRD420261292186). Electronic databases were searched up to 31 December 2025. Randomized and non-randomized comparative studies with a minimum follow-up of three months were included. Risk of bias was assessed using the ROBINS-I and RoB 2 tool, and certainty of evidence was evaluated using the GRADE framework. Random-effects meta-analyses were performed where appropriate. Nine studies, including 547 patients, of which two were randomized trials, met the inclusion criteria. In the ORIF group, pre- and postoperative maximum mouth opening improved by a pooled mean difference of 19.70 mm (95% CI 3.22-36.18 mm), with substantial heterogeneity (I² = 97.9%). In the closed treatment group, the pooled mean improvement was 14.91 mm (95% CI -2.58 to 32.41 mm), with similarly high heterogeneity (I² = 98.3%). Direct comparison of postoperative maximum mouth opening demonstrated a small statistical difference favoring ORIF (mean difference 2.72 mm; 95% CI 0.28-5.17 mm; I² = 32.9%). Open reduction and internal fixation was associated with lower odds of postoperative occlusal discrepancy (odds ratio 0.14; 95% CI 0.03-0.79; I² = 68.1%). The pooled proportion of TMJ-related morbidity after closed treatment was 11% (95% CI 4-25%; I² = 75.7%); a pooled estimate for ORIF was not feasible. The pooled incidence of facial nerve weakness was 3% (95% CI 1-8%; I² = 0%) for standard preauricular approaches and 23% (95% CI 14-35%; I² = 62.0%) for modified preauricular approaches. Implant removal occurred in 4% of cases (95% CI 1-14%; I² = 24.0%). Radiological outcomes were heterogeneous and synthesized descriptively. The certainty of evidence ranged from low to very low. The differences observed were modest and should be interpreted cautiously. Both treatment strategies remain acceptable options pending higher-quality comparative evidence.