成人髁突骨折保守治疗与手术治疗疗效对比的Meta分析

Meta⁃analysis of the effect of conservative treatment versus surgical treatment for adult mandibular condylar fractures

目的系统综述成人髁突骨折保守治疗与手术治疗的疗效对比,为临床治疗成人髁突骨折提供依据。方法不同的研究者分别检索Web of science、PubMed、Cochrane library和Embase等数据库,时间为数据库建库至2020年5月1日,查找关于成人髁突骨折保守治疗与手术治疗的相关文献,严格按照纳入、排除标准进行筛选,对纳入的文献进行质量评估,提取关于治疗成人髁突骨折疗效相关的数据,采用RevMan5.3软件计算疗效指标的比值比(OR)或均数差(MD)和95%置信区间(CI),采用StataSE 12.0软件对存在异质性的研究进行敏感性分析和发表偏倚检验。结果通过搜索共纳入23篇成人髁突骨折保守治疗与手术治疗的相关研究,含保守治疗患者917例,手术治疗患者819例。研究结果显示,髁突骨折手术治疗后咬合紊乱[OR=3.07,95%CI(2.07,4.58),P<0.001]、下颌偏斜[OR=2.51,95%CI(1.36,4.63),P=0.003]的发生明显低于保守治疗,最大开口度[MD=-3.70,95%CI(-4.39,-3.02),P<0.001]的恢复明显优于保守治疗;而手术治疗后软组织疼痛[OR=0.21,95%CI(0.07,0.62),P=0.005]、肿胀[OR=0.26,95%CI(0.15,0.46),P<0.001]和面神经损伤症状[OR=0.13,95%CI(0.03,0.61),P=0.009]的发生明显高于保守治疗;关节疼痛、下颌运动疼痛、开口度<35 mm、关节弹响、下颌升支高度降低、面型不对称、涎漏、瘢痕、横向偏斜在保守治疗与手术治疗中无明显差异(P>0.05)。结论成人髁突骨折经手术治疗后,咬合关系、下颌偏斜及最大张口度的恢复均优于保守治疗,而软组织疼痛、肿胀、面神经损伤症状的发生明显高于保守治疗。临床工作中,髁突骨折后出现咬合紊乱、下颌偏斜、张口受限症状者应手术治疗,反之采用保守治疗。

Objective To analyze and compare the curative effect of conservative and surgical treatment for adult mandibular condylar fracture,and to provide the basis for clinical treatment of adult mandibular condylar fracture.Methods Web of science,PubMed,Cochrane library,and Embase database were searched for literature about conservative and surgical treatment of adult condylar fracture.The searching time was from establishment of the databases to May 1st,2020.The literature was screened strictly according to the inclusion and exclusion criteria,of which the quality was evaluated.Adult mandibular condylar fracture related data were extracted for use.Odds ratio(OR)or mean difference(MD)and 95%confidence interval(CI)for efficacy indicators were calculated with a software(RevMan v.5.3).Sensitivity analysis and publication bias test were performed for studies with heterogeneity using Statase(v.12.0).Results A total of 23 studies related to conservative and surgical treatment of adult mandibular condylar fractures were included,involving 917 patients with conservative treatment and 819 patients with surgical treatment.The results showed that the incidence of occlusal disorder[OR=3.07,95%CI(2.07,4.58),P<0.001]and mandibular deviation[OR=2.51,95%CI(1.36,4.63),P=0.003]after surgical treatment of condylar fracture was significantly lower than that after conservative treatment.The recovery of maximum mouth width with surgical treatment[MD=-3.70,95%CI(-4.39,-3.02),P<0.001]was better than that with conservative treatment.However,the post⁃op pain of soft tissue[OR=0.21,95%CI(0.07,0.62),P=0.005],swelling[OR=0.26,95%CI(0.15,0.46),P<0.001],and injury of facial nerve after surgical treatment[OR=0.13,95%CI(0.03,0.61),P=0.009]were significantly higher than that after conservative treatment.No significant difference was found between the two groups in joint pain,jaw movement pain,mouth opening length<35 mm,joint clanging,reduced height of mandibular ramus,facial asymmetry,salivary leakage,scar and lateral deviation(P>0.05).Conclusions With surgical treatment,the recovery of occlusal relationship,mandibular deviation and the maximum degree of mouth opening were better than that with conservative treatment,but the occurrence of soft tissue pain,swelling and facial nerve injury was significantly higher.In the clinical work,the patients suffered from condylar fracture with occlusal disorder,mandibular deviation,and limitation of mouth opening should be treated surgically,otherwise the conservative treatment should be a better option.