Treatment of Intra-articular Fractures of the Mandibular Condyle

The mandibular condyle is one of the most frequent locations of facial fractures. It can lead to severe functional impairment if the occlusion is not properly restored and the mandibular mobility not recovered totally or within an acceptable range. Most frequent sequels of these fractures include limitation of mandibular movements resulting in limited mouth opening, occlusal disturbance causing chewing malfunction, chronic pain, chronic temporo-mandibular joint (TMJ) disorder and facial asymmetry. The risk of permanent limited mouth opening is even higher when the fracture is located inside the TMJ. Although the superiority of surgical treatment is now widely accepted for low-level fractures of the condylar unit (i.e., extra-articular fractures) the treatment of fractures involving the TMJ in adult patients is still controversial.

Treatment principles in these fractures can be ranked in two groups: closed and open treatments. Closed treatment - also called closed reduction or conservative treatment - consists in prolonged physical therapy frequently associated with transient maxillo-mandibular fixation (MMF). Open treatment consists in open reduction and internal fixation of the fracture (ORIF).

No randomized controlled trial has ever evaluated the superiority of open versus closed treatment, and treatment strategy for IAFC remains a matter of ongoing debate.

The primary objective of this trial is to compare mandibular mobility at 3 months post-treatment between open (surgical) and closed (conservative) treatment of intra-articular fracture (high fracture) of the mandibular condyle.

The secondary objectives are to compare between open (surgical) and closed (conservative) treatments:

At 3 weeks, 6 weeks, 3 months, 6 months, and 12 months post-treatment:

* maximal mouth opening (in mm)
* maximal mandibular protrusion (in mm),
* maximal lateral excursion (in mm),
* lateral deviation of the mandible during mouth opening
* occlusal disturbance evaluated by both the patient and the surgeon
* pain using a visual analog scale
* subjective functional impairment as assessed by the Mandibular Function Impairment Questionnaire

Overall:

* duration of sick leave
* time to normal activity recovery (social activities, eating, sports) We will also evaluate compliance with the intervention. This trial is an open multicenter randomized controlled trial with 2 parallel arms. Eligible patients will be randomized 1 :1 between open and closed-treatment group.

• Open treatment (Procedure), also known as Surgical treatment: Open (i.e. surgical) treatment will be performed following the usual practice of the including centre adopting a pragmatic approach.
• Closed treatment (Other), also known as Conservative treatment: Closed (i.e. conservative) treatment will be performed following the usual practice of the including centre adopting a pragmatic approach.

Primary outcomes

• Maximal mouth opening (in mm) at 3 months [3 months (+/-10 days)]: It will be obtained by measuring the interincisal distance at maximum mouth opening with a caliper or a ruler. The patient will be first asked to open the mouth as widely as possible for 3 seconds and to rest for 5 seconds. This sequence will be repeated 2 times and at the third repetition the patient will keep his/her mouth opened while the physician will measure inter-incisal distance

Secondary outcomes

• Maximal mouth opening (in mm) [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: Measured following the method described for primary outcome.
• Maximal mandibular protrusion (in mm) [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: \- Maximal mandibular protrusion in mm measured with a caliper or with a ruler, asking the patient to move the mandible as far as possible in the forward direction while keeping a slight contact between the dental arches. This measure will be done only after repetition of mouth opening and measurement of the maximum mouth opening, which will warm up mandibular mobilization
• Maximal lateral excursion (in mm) [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: Maximal lateral excursion in mm measured with a caliper or with a ruler, asking the patient to move the mandible as far as possible in the right and left directions while keeping a slight contact between the dental arches. These measurements will be done only after repetition of mouth opening and measurement of the maximum mouth opening, which will warm up mandibular mobilization
• Lateral deviation of the mandible during mouth opening [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: Lateral deviation of the mandible during mouth opening will be ranked as straight, right, or left. This observation can be made during the first measurement of mandibular opening
• Occlusal disturbance reported by the patient [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: The patient will be asked to describe how his/her teeth touch as referring to his/her previous occlusion. He/she will rank his/her occlusion as: * not modified * slightly modified as compared to before the trauma but with no significant disturbance * significantly disturbed
• Occlusal disturbance evaluated by the surgeon [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: The surgeon will ask the patient to bite and describe the occlusion as: * Not modified * Open bite: barely detectable (right / anterior / left) or clearly detectable (right / anterior / left) * Premature contact: barely detectable (right / anterior / left) or clearly detectable (right / anterior / left)
• Evaluation of pain using a visual analog scale [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: The patient will be asked to rate his/her maximum pain in the last 2 days on a visual analog scale, 0 representing no pain and 10 representing the worst pain imaginable. For bilateral fractures, the pain will be assessed separately on each side.
• Subjective functional impairment evaluated by the patient using the Mandibular Function Impairment Questionnaire (MFIQ) [3 weeks (+/- 7 days), 6 weeks (+/-7 days), 3 months (+/-10 days), 6 months (+/-20 days) and, 12 months (+/- 30 days) post-treatment]: The Mandibular Function Impairment Questionnaire (MFIQ) consisting in 17 items, rated between 0 and 4, which describes the difficulty in several common movement/activities involving the mandible (see questionnaire 1).
• Duration of sick leave [From treatment until 12 months]
• Time to normal activity recovery [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: Patient will asked on return to work and to normal daily activities (social activities, eating, sports)
• Compliance with the intervention - Number of appointments with a physical therapist [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: The patient will fill in a notebook the number of appointments with a physical therapist since last patient report.
• Compliance with the intervention - Number of self-training sessions [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: The patient will fill in a notebook the number of the number of self-training sessions since last patient report
• Compliance with the intervention - Duration of permanent MMF [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: The patient will fill in a notebook the number of permanent MMF since last patient report
• Compliance with the intervention - Duration of transient MMF [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: The duration of permanent MMF the duration of transient MMF since last patient report
• Compliance with the intervention - Duration of application of mobilization elastic band [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: The patient will fill in a notebook the duration of application of mobilization elastic band.
• Compliance with the intervention - Average and Maximal pain [Every week from week 1 to 6, every 2 weeks from week 8 to 12, and every month from month 4 to 12]: The patient will fill in a notebook the average and maximal pain rate since last patient report

Sex: All, ages: 18 Years to 84 Years

Inclusion Criteria:

1. Adult (≥18 y-o) < 85 years
2. Displaced non-comminuted intra-articular fracture of the mandibular condyle (IAFC) as defined by a fracture line above a horizontal line tangent to the mandibular notch
3. Objectifiable induced malocclusion and/or ramus shortening ≥2 mm on CT-scan (a ramus shortening ≥2 mm on CT-scan is necessary in case of other associated mandibular or occluso-facial fractures)
4. Unilateral or bilateral fracture
5. Isolated or associated with other facial / extra-facial skeleton / dental / soft tissue lesions
6. Treatment within 14 days post trauma
7. Affiliation to a social security regime (excepted AME)
8. Written informed consent

Exclusion Criteria:

1. Contraindication to surgical treatment (for any medical or anatomical reason, like comminuted fracture for instance)
2. Major teeth loss or edentulous patient (occlusion impossible to assess)
3. History of mandibular fracture
4. History of temporo-mandibular joint (TMJ) disorder
5. Dentofacial dysmorphosis causing significant malocclusion
6. Predictable inability to comply with the follow-up
7. Unconsciousness / severe polytrauma
8. Participation in another interventional study

• Thomas SCHOUMAN, MD, Principal investigator, AP-HP - Hôpital Pitié-Salpêtrière