Introduction

Mandibular fractures are among the most common traumatic injuries managed by oral and maxillofacial surgeons [1]. Condylar fractures have been reported to account for 19.3–33.2% of mandibular fractures [2]. The primary causes of condylar fractures include: motor vehicle accidents (MVA), interpersonal violence, falls and sports injuries [1, 2]. Treatment options for mandibular condyle fractures are conservative management, closed reduction (CR) and open reduction with internal fixation (ORIF) [2]. The definition of conservative management for mandibular condyle fractures varies. However, in this case report it refers to management with soft diet and physiotherapy. Closed reduction is defined as treatment that does not involve surgical exposure of the fracture. This usually consists of a period of maxillomandibular fixation (MMF) using either stainless steel wires, elastics or a combination of both followed by physiotherapy [2].

Maxillomandibular fixation involves binding the lower jaw to the upper jaw, ensuring stability and proper alignment during the healing process. Traditionally, the length of MMF used for immobilization of adult mandibular fractures has been 6 weeks [2, 3]. However, prolonged MMF has been criticized for complications such as pain, poor oral hygiene, articulation disturbances, loss of effective work time, weight loss, reduced masticatory efficiency, and reduced mouth opening [3]. The necessity of MMF in every case has been a topic of ongoing debate, with some clinicians advocating for conservative management in selected patients.

The presented case study reports a 22-year-old male admitted to the emergency department following a violent encounter. He was diagnosed with a fracture of the left condyle. The patient received conservative treatment with no MMF, regular follow-up visits, and only a soft diet and rehabilitation of the jaw. This case report examines the decision-making process and outcomes in the treatment of a left condylar fracture without the use of MMF.

Case report

This case report presents a male patient, 22, referred from a tertiary hospital to the emergency department following a violent encounter with no loss of consciousness. Upon admission, an X-ray diagnosis revealed a fracture of the left condyle. The patient was referred to a maxillofacial surgeon for consultation. Physical examination was within normal limits, revealing full consciousness and no neurological defects. A chief patient complaint was pain during mouth opening. However the patient reported normal occlusion as prior to the accident. A computed tomography (CT) scan of the facial skeleton showed no additional fractures. The reported patient was cooperative during the examination. Hence, the on-call maxillofacial surgeon provided the patient with two treatment modalities: conservative approach without MMF or with MMF.

The patient decided on conservative treatment with no MMF, regular follow-up visits, and only a soft diet, over-the-counter analgesic medication and rehabilitation of the jaw. The first follow-up visit occurred 1 week after the injury. A control X-ray was taken on the second follow-up visit. The second follow-up visit confirmed correct bone positioning. Pain during mouth opening still persisted, however, was decreased in comparison to that on admission. The patient attended all his biweekly follow-up visits up to 7 weeks post-admission. Orthopantomogram and computed tomography scans were done during the last follow-up visit, showing sound bone healing. The patient reported normal occlusion, no problems with mouth opening and no associated pain. The patient reintegrated into his work as a teacher 2 weeks after admission (Figures 1–3).

Discussion

Whilst there are some definite indications for the use of MMF, there are clear advantages of a conservative modality [4]. Avoiding the onset of associated complications of MMF should be favoured by surgeons when establishing a treatment plan for their patients. Adopted methods for managing mandibular condyle fractures state that fractures that are not displaced and with intact occlusion should be managed conservatively with rehabilitation and follow-up visits [2–4]. Excessive treatment of patients who do not have displaced condyle fractures or deranged occlusion can yield unnecessary side effects [5]. As described, the presented patient is an exemplary candidate for a condyle fracture conservative management approach.

Criteria for adopting this treatment should be case dependent and not solely evaluate the condyle fracture but also the level of compliance and general health status of the patient. No MMF treatment introduces the risk of inadequate fracture healing [4–6]. Hence, follow-up visits are compulsory. In this case, the patient’s compliance allowed surgeons to monitor the correct condyle positioning and bone healing and offer rapid intervention with MMF if deviations occur. Rehabilitation and regular follow-up visits demonstrated sound condyle fracture healing, allowing the patient to reintegrate into his regular work routine after 2 weeks post-trauma.

The conservative approach reduced MMF-related physical and psychological burden associated with MMF, reduced pain, enhanced oral hygiene, absence of phonetic disturbance, uninterrupted work productivity, minimised weight loss, maintained masticatory efficiency, and preserved mouth opening. Moreover, the risk of MMF placement was averted, with complications such as iatrogenic damage to teeth when inserting the wire and screws, which can lead to loss of bony sequestra around the screw or even tooth loss [7, 8]. The literature provides evidence of MMF resultant hypercapnia, reduced pulmonary function, osteoporosis, and decreased concentration of nutrient veins’ Ph of immobilized bones [1]. Other studies on animals reported the risk of muscle weakness due to the decrease of the masseter and temporalis muscle fibres after 5 weeks of MMF and atrophy [1].

Selective application of MMF can reduce the complications mentioned above while simultaneously reducing the healthcare hospital burden associated with MMF placement. Hence, this will reduce the time and expenses for maxillomandibular fixation for both patients and hospitals and decrease the workload for on-call maxillofacial surgeons. The conservative modality described can also be implemented for compliant paediatric patients and individuals with disabilities. Further research with larger cohorts comparing the effectiveness of no MMF versus MMF treatment for similar fractures is recommended. Avoiding MMF for similar cases increases operative efficiency, safety, and the patient’s well-being while providing sound treatment outcomes.

Funding

No external funding.

Ethical approval

No consent of the Bioethics Committee was required. We complied with the policy of the journal on ethical consent.

Conflict of interest

The authors declare no conflict of interest.

References