(71) Role of Nonoperative Management in the Treatment of Subcondylar Fractures in Adults: Is Less More?

Abstract: Subcondylar fractures, located below the condylar neck and in the high ramus region, account for approximately 20.6% of all mandible fractures. Treatment options for these fractures include expectant non-operative management with soft diet, closed reduction with maxillomandibular fixation, or open reduction and internal fixation. Despite recent advancements in oral surgery, there are a lack of studies and evidence-based guidelines involving non-operative management of subcondylar fractures in adults. For patients without indications for operative treatment such as persistent pain, loss of ramus height, malocclusion or condylar dislocation, non-operative management and closed treatment may yield the same results. Our aim was to compare outcomes associated with non-operative management and closed treatment for these types of isolated subcondylar fractures.An IRB-approved retrospective review evaluated patients undergoing non-operative management or closed treatment of isolated subcondylar fractures at LA General Medical Center (formerly known as LAC+USC Medical Center) from January 2016 to December 2023. Ramus fractures located below the condylar neck and traveling through the sigmoid notch were defined as subcondylar fractures. Non-operative management consisted of a wired jaw or mechanical soft diet for four weeks. Closed treatment involved closed reduction and maxillomandibular fixation (CRMMF) for 4 to 6 weeks. All patients were required to have had a follow-up of at least 2 weeks, and those patients lost early to follow-up were excluded. Patients who presented with other mandibular fractures, comminuted fractures, pre-existing temporomandibular disorder (TMD) and pre-existing paresthesia also were excluded. We compared outcomes including malocclusion, paresthesia, improvement in maximal incisal opening (MIO), and new-onset TMD. We examined variables that could possibly affect outcome using the t-test for continuous variables and chi-square and Fisher’s exact test for binary variables. We examined the relationship between treatment type and outcomes using Fisher’s exact test and Wilcoxon’s rank sum test.Forty patients were included in the review. Twenty patients were treated with non-operative management and 20 patients received closed treatment. Participants receiving closed treatment were approximately 9 years younger and had almost 20 days longer follow-up than those who received non-operative management (P < .05) (Figure 1). We found that none of the outcomes under study were statistically different between the treatment groups (P > .05) (Figure 2). There was an average MIO increase of 5 mm in the non-operative group and 9 mm in the closed treatment group. Three patients from each group developed new-onset TMD. Of the 19 patients with post-traumatic malocclusion, 12 patients received closed treatment while 7 patients declined closed treatment and were managed non-operatively. When analyzing patients with post-traumatic malocclusion, 1 out of 7 patients improved to premorbid occlusion with non-operative management whereas 10 out of 12 patients improved with closed treatment (Figure 3). No patients who presented without post-traumatic malocclusion and were managed non-operatively developed new-onset malocclusion. Overall, our study found no statistically significant differences in outcomes between the non-operative and closed treatment groups such as new-onset TMD or change in MIO. Furthermore, patients who were managed non-operatively did not develop any new-onset malocclusion. Our data suggests that patients without post-traumatic malocclusion can be managed non-operatively and avoid the morbidity associated with closed treatment. However, patients who present with post-traumatic malocclusion should be treated with closed treatment given the high probability of persistent malocclusion when managed non-operatively.References1.Natu SS, et al. An epidemiological study on pattern and incidence of mandibular fractures. Plast Surg Int. 2012;2012:834364.2.Shikara M, et al. Current Management of Subcondylar Fractures: A Systematic Review. Otolaryngol Head Neck Surg. 2023 May;168(5):956-969.

Table 1. Patient Demographics and Fracture Characteristics
Table 2. Differences in Outcome by Treatment Group
Table 3. Proportion of Patients with Persistent Malocclusion Among Those who had Post-Traumatic Malocclusion