Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review

YIJOM-3574; No of Pages 8

Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.12.010, available online at http://www.sciencedirect.com

Systematic Review Trauma

Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review

A. N. Bobrowski1, M. A. Torriani1, C. L. Sonego2, P. H. deA.Carvalho1, L. K. Post1, O. L. Chagas Ju´nior1 1

Oral and Maxillofacial Surgery Residency Program, University Hospital at the Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil; 2Graduate Program in Dentistry, Oral and Maxillofacial Surgery, Lutheran University of Brazil, Canoas, Rio Grande do Sul, Brazil

A. N. Bobrowski, M. A. Torriani, C. L. Sonego, P. H. deA. Carvalho, L. K. Post, O. L. Chagas Ju´nior: Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This study aimed to answer the following question: What is the best treatment option for fractures of the dentate portion of the mandible in paediatric patients when considering the occurrence of postoperative complications? A systematic literature review was done using the PubMed, Scopus, and Cochrane Library databases, and 1186 articles on the topic were found. Twelve of these articles were included in the final review after the full texts had been read. A sample of 178 paediatric patients was obtained. In the six cases in which treatment was surgery with titanium plate fixation, there were no postoperative complications, whereas in the 141 cases in which treatment was surgery with biodegradable plates, there were 12 postoperative complications, and in the 31 cases in which treatment was non-surgical, there were three postoperative complications. A connection between the best treatment and the number of postoperative complications in fractures of the dentate portion of the mandible in paediatric patients could not be established; however, the occurrence of postoperative complications was low for both surgical and non-surgical treatments.

Mandible fractures are one of the most common types of injuries resulting from maxillofacial trauma in children, comprising 20–50% of all facial fractures.1 Following the nasal bones, the mandible is the most frequently fractured facial bone in 0901-5027/000001+08

this age group. The condyle is the most common region, followed by the symphysis and parasymphysis, which is affected more often in children than in adults, possibly due to the presence of canine tooth germs at the lower edge of the mandible.2

Key words: mandibular fractures; child; treatment. Accepted for publication 19 December 2016

Automobile and sports accidents, falls from height, bicycle falls, and violence are the most frequent mechanisms.3 The management of paediatric mandible fractures is particularly challenging because of significant differences from

# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

YIJOM-3574; No of Pages 8

2

Bobrowski et al.

adults, whether related to the anatomy, the dynamic nature of the developing mandible, and/or the clinical management of these patients. These differences include the small size of the facial bones, the instability of the deciduous or mixed dentition, the development of tooth germs, the relatively soft bone showing good elasticity, the rapid repair process, and difficulties in acceptance and cooperation.1 Due to the characteristics mentioned above, the management of paediatric mandible fractures requires extra care, and can range from treatment with a soft diet and clinical follow-up, to non-surgical treatment (closed reduction associated with non-rigid fixation – splints or intermaxillary fixation (IMF)), and to surgical treatment (open reduction associated with functionally stable fixation with titanium or biodegradable osteosynthesis plates).4–6 Because a child’s mandible is more fibro-elastic than an adult’s, incomplete fractures are more common, and the presence of permanent tooth germs often leads to non-surgical treatment of the fractures.7 When complete, these fractures generally show small displacement without causing dental disocclusion, and their management only requires painkillers, a liquid or soft diet, attention to oral hygiene, an observation period, and long-term followup; the patient should also avoid intense physical activity for a few weeks.4 However, for complex fractures, whether displaced or comminuted, the method of treatment is controversial. Mandible fractures are difficult to handle because of the need for three-dimensional mandible control. Although non-surgical treatment with non-rigid fixation (splints) is effective in stabilizing the fracture, this technique does not ensure three-dimensional control in all cases. According to Glazer et al.8 and Ferreira et al.,9 non-rigid fixation is not suitable for children. IMF is not easily tolerated by children, as it blocks mandibular movements, causing discomfort and increased anxiety; furthermore, it is detrimental to the child’s quality of life, as a liquid diet adversely affects nutritional intake. Moreover, this type of fixation should be used with caution, inasmuch as it may also result in ankylosis of the temporomandibular joint. Due to the number, stability, and anatomy of the crowns of the teeth available – some deciduous teeth and some partially erupted permanent teeth – proper anchoring of Erich arch bars may be difficult to obtain and result in tooth avulsion, undermining the dental arch stabilization.10 Splint fixation with circum-mandibular wires is effective in providing stability to

the mandible and can eliminate the need for IMF, but requires intraoperative moulding and the production of models, which are difficult to manufacture in the operating room, as timing is important and materials may not be available.4 Furthermore, splint removal requires a second procedure under general anaesthesia. Open reduction and internal fixation (ORIF) of mandible fractures in children is generally avoided due to the potential damage to developing tooth germs and disruption of the periosteum.11 Osteosynthesis plates installed at the bottom edge of the mandible, in association with monocortical screws, do not usually affect the germs, but extra care is required in the canine area, since these teeth have a lower position and are close to the inferior alveolar nerve.12 A reduction of the mandibular immobilization period also contributes to the recovery of joint function.13 According to Iatrou et al.,1 surgery is the standard treatment for displaced mandible fractures in children, but issues may arise with the use of titanium fixation, such as allergy, corrosion, plate migration, and limitations of bone growth, and a second intervention may be required for their removal. Although there is no definite evidence of the metal fixation effect on mandibular growth, there is great concern regarding the removal of these materials in children.14 Alternatively, resorbable plates can be considered for the treatment of paediatric mandible fractures15; such plates will contribute to a reduction in secondary interventions.1 Due to the load-bearing nature and direction of various opposing muscle groups on the mandible, isolated biodegradable plates may not be able to withstand the forces acting on displaced mandible fractures. In order to improve the capacity of resorbable plates to withstand these forces, additional stabilization of the dental arch using Erich bars, or steel or orthodontic wire splinting is employed to help fixation.16 Economic factors can also restrict the use of resorbable materials.17 The aim of this study was to perform a systematic literature review to determine the best choice of treatment for fractures

of the dentate portion of the mandible in paediatric patients through an analysis of the postoperative complications presenting for each mode of treatment. Materials and methods

This systematic review was based on the PRISMA P-2015 criteria for systematic reviews (preferred reporting items for systematic review and meta-analysis protocols).18 The following databases were searched to identify articles: PubMed (http://www.ncbi.nlm.nih.gov/ pubmed), Scopus (http://www.scopus. com/search/form.url?zone=TopNavBar &origin=searchadvanced), and Cochrane Library (http://onlinelibrary.wiley.com/ cochranelibrary/search/). Selection criteria

The following inclusion criteria were applied for the initial selection: publications in English, without time restriction; studies performed in humans; specific studies showing the treatment of fractures of the dentate portion of the mandible in paediatric patients. For the initial selection, article titles and/or abstracts were analyzed. The criteria outlined in Table 1 were used for the final selection in this review, after the previously selected articles had been read in full. The selection criteria were established by the authors before the start of the study. Search strategies

After a brief reading on the topic, a search was performed using the following keywords: ‘‘mandibular fractures’’; ‘‘mandible fracture’’; ‘‘child’’; ‘‘children’’; ‘‘treatment’’; ‘‘therapeutics’’; ‘‘not condyle’’. The databases used have different advanced search engines; the search lines shown in Table 2 were adopted for each database. The titles and abstracts of all articles identified were read by two independent reviewers (ANB and CLS). After the initial selection, the two examiners (ANB and CLS) read the full texts of the selected articles against the eligibility criteria

Table 1. Eligibility criteria. Eligibility criteria for inclusion in the final review Systematic reviews and meta-analyses, randomized clinical trials, prospective and retrospective clinical studies, case series Number of patients treated Location and treatment of fractures (surgical or non-surgical) Postoperative follow-up Eventual complications of each treatment modality

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

YIJOM-3574; No of Pages 8

Mandibular fractures in paediatric patients Table 2. Search line used for each database. Search line

Database PubMed

(((((((mandibular fractures[MeSH Terms]) OR mandible fracture)) NOT condyle)) AND ((child[MeSH Terms]) OR children))) AND ((therapeutics[MeSH Terms]) OR treatment)

Scopus

TITLE-ABS-KEY(mandibular fractures OR mandible fracture) AND TITLEABS-KEY(child OR children) AND TITLE-ABS-KEY(treatment OR therapeutics) AND NOT TITLE-ABS-KEY(condyle)

Cochrane

(mandibular fractures OR mandible fracture) AND NOT (condyle) AND (child OR children) AND (treatment OR therapeutics)

MeSH, medical subject heading.

(Table 1) for either exclusion or final inclusion of each article in the study. Data extraction

The following data were obtained for analysis during the full-text reading of the included articles: type of study, number of patients treated, proposed treatment (surgical access, osteosynthesis materials, removal of osteosynthesis materials), postoperative characteristics and complications, monitoring time, and study conclusions. Studies that also discussed condyle/ branch fractures were retained if these fractures, along with their respective complications, could be isolated and removed (edentulous portion of the mandible) from other parts (dentate portion of the mandible). Any disagreements between the reviewers were settled after further discussion under the supervision of the senior reviewers (LKP, MAT, and OLCJr). Quality evaluation

The methodological quality was assessed by combining the PRISMA statement,19 CONSORT statement,20 QUOROM statement,21 MOOSE statement,22 and STROBE statement23 criteria in order to check the strength of the scientific evidence available in the literature for clinical decision-making use. The classification of the potential risk of bias for each study was performed using the criteria of Bobrowski et al.24: random selection of (the) population (sample); definition of inclusion/exclusion criteria; report of loss to follow-up (monitoring); validated measurements; statistical analysis. Studies that satisfied all of these criteria were classified as having a low risk of bias, those that did not satisfy one of the above criteria were classified as having a moderate risk of bias, and those that did not satisfy two or more of the criteria were classified as having a high risk of bias.

Results

The database review, updated to June 19, 2016, yielded 1186 results. Twenty-seven articles were considered relevant after title and/or abstract reading.3,5,6,13,15–17,25–44 The full texts of these 27 studies were evaluated for treatment of fractures of the dentate portion of the mandible in paediatric patients using the eligibility criteria shown in Table 1. Of these 27 articles, 15 did not meet one or more of the selection criteria and were excluded.3,17,28–39,41 The reasons for exclusion are listed in Table 3. Twelve articles were accepted for the final review – three retrospective studies, five prospective studies, and four case series (Table 4).5,6,13,15,16,25–27,40,42–44 A flowchart of the selection and evaluation process according to the PRISMA statement is presented in Fig. 1.19 Regarding the evaluation of quality, all 12 studies showed a high risk of bias, as shown in Table 5. A selection of common variables among studies was performed in order to evaluate the types of treatment to which

3

patients were submitted and their influence on postoperative complications. After grouping common data among studies and relating the mode of treatment to postoperative complications, a sample of 178 patients was obtained. Six of these patients were treated surgically with titanium plate fixation, 141 cases were treated surgically with the use of biodegradable plates, and 31 were treated non-surgically with the use of a compression acrylic splint and circum-mandibular wiring. In the six cases in which the treatment chosen was surgical with titanium plate fixation, there were no postoperative complications. When surgical treatment with biodegradable plate fixation was selected (141 cases), 12 postoperative complications were detected, accounting for 8.5% of cases. When non-surgical treatment with a compression acrylic splint associated with circum-mandibular wiring was chosen (31 cases), postoperative complications occurred in three cases, representing 9.7% of the sample. Discussion

In children, bone formation and the biomechanics of the mandible, as well as the presence of dental germs, are a challenge to the maxillofacial surgeon when mandible fractures have to be treated, as there is the risk of immediate, early, and late complications both of the fractures and their treatment. The search for the best scientific evidence on which clinical management can be based should always guide the clinician. This study aimed to investigate the best treatment proposal for fractures of the dentate portion of the mandible in paediatric patients, as well as its influence on postoperative complications.

Table 3. Articles excluded after assessment for eligibility. Author (year) 29

Andrade et al. (2015) Swanson et al.30 (2015) Naran et al.28 (2014) Siwani et al.31 (2014) Aldelaimi and Khalil32 (2013) Chandan et al.41 (2013) Smith et al.3 (2013) Mun˜ante-Ca´rdenas et al.17 (2010) Davison et al.33 (2001) Fasola et al.34 (2001) Nishioka et al.35 (1997) Thaller and Mabourakh36 (1991) Jones et al.37 (1989) Zohar and Laurian38 (1984) Lehman and Saddawi39 (1976)

Study type

Reason for exclusiona

Retrospective Retrospective Retrospective Retrospective Retrospective Prospective Retrospective Retrospective Retrospective Retrospective Case series Retrospective Prospective Technique description Retrospective

1 1 1 1 2 2 1 1 1 1 1 1 1 3 1

a Reasons: (1) not possible to identify the treatment given to each patient and/or its respective complications, or to determine the location of fracture; (2) postoperative follow-up not described; (3) absence of new data.

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

Study typea

Number of cases (Age) [Fracture site]

Postoperative characteristics evaluated

Treatment

Description

Surgical access

Osteosynthesis material [Position installed]

Farber et al.43 (2016)

RS

1 patient (5 years) [Left parasymphysis]

IMF with zero silk sutures and posterior ORIF (GA)

Intraoral

Singh et al.44 (2016)

PS

60 patients (Range 8–15 years) [Body, angle, and parasymphysis]

ORIF with extraction of the tooth in the fracture line if the tooth was fractured, periodontally involved, non-restorable, grossly carious, or interfering with the reduction of the fracture or occlusion (GA)

Intraoral or 2.5 Inion CPS plating kit through [Champy’s line of ideal existing osteosynthesis] traumatic scar

Khairwa et al.42 PS (2015)

6 patients (Range 2–5 years) [Parasymphysis]

Open reduction and stabilization Intraoral with MacLennan splint (GA)

Acrylic cap splint and circummandibular wiring [4–5 mm from the midline]

Iatrou et al.25 (2015)

RS

6 patients (Range 4–14 years; average 10 years) [Angle]

ORIF (GA) + IMF (Erich bar/ Ernest splinting) for 1 week

An et al.6 (2015)

PS

39 patients (Range 7 months–12 years; average 4.10 years) [Symphysis, parasymphysis, body, and angle]

Bhola et al.26 (2014)

RS

Li et al.16 (2014)

CS

Follow-up

Conclusions

Osteosynthesis material removal (Time postop.) 3 months

This alternative method can be applied by surgeons treating paediatric mandibular fractures and might be better tolerated by paediatric patients

Bite force recording, TMJ function, aesthetics, and complications

2 soft tissue infection, 2 6 months nerve injury (paresthesia), 1 implant exposure, 1 malocclusion

Bioresorbable plate system provides reliable stability for osteosynthesis of mandibular fractures without major complications, case selection is the key, and it should only be used as a loadsharing plate in a semi-rigid technique after anatomical reduction

Occlusion (radiographic)

1 malocclusion, 3 12 months postoperative swelling, 2 postoperative pain

Preliminary impression is favourable; the splint showed sufficient rigidity and stability to enable initial bone healing of the mandible

Titanium plate and monocortical Yes screws (1.5-mm system for age 5– (3–12 months) 6 years and 2.0-mm system for age 7–14 years) [External oblique line]

Occlusion, mouth opening

None

12–18 months (average 14.7 months)

Osteosynthesis with intraoral approach and short-term IMF is suitable for the treatment of paediatric mandible angle fractures

ORIF (GA) + dental splinting for Intraoral 1 month + soft diet and oral physiotherapy (after 2 postoperative weeks)

NR Biodegradable plate (85:15 poly(D,L-lactide-co-glycolide); PLGA, PolyMax; Synthes, Oberdorf, Switzerland) w/4 holes (1.0 mm thick) and system 2.0mm screws (4–10 mm) [Lower edge]

Occlusion, mouth opening, facial symmetry, infection, poor or no union, plate exposure, fracture consolidation

2 fistulae in the intraoral incision (healed after 1 month without special treatment)

6 months–5 Biodegradable fixation devices are safe/ years (average 1 efficient for the treatment of paediatric year and 2 mandible fractures months)

10 patients (Range 5–9 years) [Body, parasymphysis, and symphysis]

Manual reduction of NR fracture + lateral compression acrylic splint (open occlusal and reinforcement with 19 gauge wire) w/circum-mandibular wiring (steel wire) at the two fractured ends (perpendicularly inserted via submandibular approach) for 15–21 days (GA)

NR

NR

Occlusion, healing/fragment union, dental eruption, TMJ problems

1 postoperative submental infection (resolved with antibiotic therapy)

6 months

Open lateral compression protective splints are a reliable treatment modality for paediatric mandible fractures

13 patients (Range 2–12 years) [Body, parasymphysis, and symphysis]

ORIF (GA) + Erich bar or Intraoral orthodontic wire (w/steel wire or tooth resin) for 4 weeks + soft diet, oral hygiene 0.1% chlorhexidine 2/day

Biodegradable plate and monocortical screws (2.0-mm system) [Lower edge]

No

Mouth opening, fracture consolidation, mandible movement, mandible growth

None

12–36 months

Resorbable plates and dental arch stabilization provide good stabilization of mandible fractures and can be promising for displaced paediatric mandible fractures

Intraoral

0.75 Stryker Delta Absorbable System

Postoperative complications

No

Occlusion and mouth opening None

NR

Yes (3 weeks)

Bobrowski et al.

Author (year)

YIJOM-3574; No of Pages 8

4

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

Table 4. Articles included in the final review.

YIJOM-3574; No of Pages 8

Author (year)

Study typea

Number of cases (Age) [Fracture site]

Postoperative characteristics evaluated

Treatment

Description

Surgical access

Osteosynthesis material [Position installed]

Postoperative complications

Follow-up

Conclusions

Osteosynthesis material removal (Time postop.)

Stanton et al.15 (2014)

CS

15 patients (Average 8.13 years) [Body, parasymphysis, and symphysis]

ORIF (GA) + IMF (Erich bar or Intraoral Risdon wire or skeletal fixation w/circum-mandibular wires and piriform steel wires or zygomatic arch wires) for 14–21 days

Biodegradable plate (polyglycolic No copolymer and poly-L-lactic acid) and 4-mm monocortical screws (1.5 mm/2 mm) system []

Occlusion, mouth opening, inter-fragmentary mobility, abnormal local oedema

Bali et al.40 (2013)

PS

2 patients (NR) [Angle and parasymphysis]

ORIF (GA)

Biodegradable Inion CPS (2.0No mm) plating system (Inion, Tempere, Finland) (copolymer of LPLA, DLPLA and TMC and PGA) [Inferior border]

Adequate reduction, stability 1, not specified of fracture segments, occlusion, and postoperative complications

24 h; 1, 4, 12, and 24 weeks

Biodegradable plate and screw system provided satisfactory stabilization when used as internal fixation for mandibular fractures in early childhood

Kale et al.27 (2013)

CS

10 patients (Range 1–11 years; average 6 years) [Symphysis, parasymphysis]

Acrylic splint with circumNR mandibular wiring for 2–3 weeks (GA)

NR

NR

Occlusion, poor union, infection, healing, TMJ problems, pain, trismus

None

6 months

Open splints for the treatment of paediatric mandible fractures (parasymphysis/symphysis) are more reliable than open reduction/IMF with respect to occlusion, fracture reduction, stability, ease of application and removal, surgical time, minimal trauma, safe use, oral hygiene, and comfort

Hegab5 (2012)

CS

5 patients (Range 3–7 years) [Symphysis or parasymphysis or body]

Acrylic splint and circummandibular wiring (steel wire) for 4 weeks (GA)

NR

NR

Occlusion, infection, mandible symmetry, ankylosis, growth

None

4 years

Occlusion was satisfactory, without infection or malocclusion

Yerit et al.13 (2005)

PS

11 patients (Range 5–16 years; average 12 years) [Symphysis, parasymphysis, body, and angle]

ORIF w/2 plates (1 for the very Intraoral young) + IMF for 3 weeks in 3 patients w/associated condylar fractures + soft diet for 14 days and antibiotic prophylaxis (penicillin, clindamycin, or cephalosporin, 10 days) + analgesics

NR

NR

Biodegradable plate (poly-L-lactic NR acid isomers with 30% D-lactide and 70% L-lactate) (SR-PLGA) (Biosorb FX, Linvatec Corp., Largo, FL, USA) []

1 < 30 mm mouth 29 months opening; 2 seromatous collections at the surgical site (1 treated with clindamycin/noninfectious nature)

Stability of reduction, None displacement, diastasis, visibility of the fracture line/ fracture perforation and ossification, inflammation, fistula, occlusion, and sensitivity

Resorbable polyglycolic and poly-Llactic acid systems and short-term postoperative IMF provide effective fixation for paediatric mandible fractures

10.9–43.4 Self-reinforced fixation devices are safe months (average and effective for the treatment of 26.4 months) paediatric mandible fractures

DLPLA, poly(D,L-lactide); GA, general anaesthesia; IMF, intermaxillary fixation; LPLA, poly(L-lactide); NR, not reported; ORIF, open reduction and internal fixation; PGA, poly(glycolic acid); TMC, trimethylene carbonate; TMJ, temporomandibular joint; w/, with. a RS, retrospective study; PS, prospective study; CS, case series.

Mandibular fractures in paediatric patients

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

Table 4 (Continued )

5

YIJOM-3574; No of Pages 8

6

Bobrowski et al.

Table 5. Quality assessment of the included studies.

Author Farber et al.43 (2016) Singh et al.44 (2016) Khairwa et al.42 (2015) Iatrou et al.25 (2015) An et al.6 (2015) Bhola et al.26 (2014) Li et al.16 (2014) Stanton et al.15 (2014) Bali et al.40 (2013) Kale et al.27 (2013) Hegab5 (2012) Yerit et al.13 (2005)

Random selection in population

Defined inclusion/exclusion criteria

Report loss to follow-up

No No No No No No No No No No No No

No No No Yes Yes Yes Yes Yes No Yes Yes Yes

No Yes Yes No No No No No No Yes No No

SCREENING

IDENTIFICATION

The literature shows that most paediatric mandible fractures are incomplete (due to fibro-elasticity), and it is agreed that due to the presence of dental germs and the high osteogenic potential of the paediatric mandible, the treatment of these

Validated measurements

fractures should be non-surgical.7,9 The same applies to complete fractures that show small displacement, whose management may require only analgesics, a liquid or soft diet, adequate oral hygiene, and a short observation period.4 However, the

On 02/10/2016: Electronic search PubMed = 709 hits

Electronic search Scopus = 467 hits

Electronic search Cochrane = 10 hits

Title and/or abstract of 18 articles screened

Title and/or abstract of 16 articles screened

Title and/or abstract of 0 articles screened

Potentially relevant = 39 articles

Total duplicates removed = 12 articles

Potentially relevant = 27 articles

INCLUDED

ELIGIBILITY

Full-text of 27 articles assessed

Accepted for appraisal using eligibility criteria (Table 1) = 27 articles

Not meeting one or more of the eligibility criteria = 15 articles (Table 3)

Included in the final review = 12 articles (Table 4)

Fig. 1. Flow diagram of the study selection process; adapted from the PRISMA statement.19

No Yes Yes No No No Yes No Yes No No No

Statistical analysis

Estimated potential risk of bias

No Yes No No No No Yes No No No No No

High High High High High High High High High High High High

method of treatment is controversial when it comes to complex fractures, whether displaced or comminuted. Hegab,5 Bhola et al.,26 and Kale et al.27 used non-surgical treatment in their studies, comprising a compression acrylic splint associated with circum-mandibular fixation. They argued that this method results in satisfactory occlusion and stability, is easy to apply and remove, reduces the operating time, and causes minimal trauma. Khairwa et al. used a MacLennan splint with a short incision for a duration of 3 weeks to treat parasymphysis fractures.42 They concluded that this treatment covers both the lingual and buccal cortical plates and holds the mandibular cortices securely, with further advantages such as the absence of IMF, preservation of function, and reduction of the catabolic phase. Among the studies that complied with the inclusion criteria, none used non-surgical treatment through IMF. According to Kocabay et al., IMF is not easily accepted by children because it causes discomfort and anxiety, in addition to hindering nutritional intake, and should be used with caution as it may result in TMJ ankylosis.10 Furthermore, it is difficult to anchor the Erich bar properly, which may result in tooth avulsion. Nonetheless, Naran et al., in a report of 23 cases of paediatric mandible fracture, stated that IMF in children during the deciduous and mixed dentition phases can be performed safely without periodontal defects, dental avulsion, or disturbance of the permanent dentition, and suggested that surgeons should re-evaluate the paediatric use of Erich bars.28 An alternative method of IMF for simple paediatric mandible fractures has been reported by Farber et al.43; this consists of silk sutures tied around individual erupted molars and canines in the mandible and maxilla. According to an

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

YIJOM-3574; No of Pages 8

Mandibular fractures in paediatric patients algorithm proposed in that manuscript, it can be applied by surgeons treating paediatric mandibular fractures and might be better tolerated by paediatric patients. An et al.,6 Yerit et al.,13 Stanton et al.,15 Li et al.,16 and Iatrou et al.25 used surgical treatment, alleging this to be an effective and safe method for the treatment of paediatric facial fracture. Moreover, no complication associated with injury to the tooth germs and their eruption, one of the greatest restrictions to the use of ORIF in the paediatric mandible, was reported. Iatrou et al. used titanium osteosynthesis materials, which were removed after a 3– 12-month postoperative period25; however, there is no exact evidence of the effect of this type of material on mandible growth.14 An et al.,6 Yerit et al.,13 Stanton et al.,15 and Li et al.16 observed good results in fracture ossification and material resorption upon using biodegradable osteosynthesis materials. Similarly to An et al.,6 Stanton et al.,15 Li et al.,16 and Iatrou et al.25 associated ORIF with extra mandible stabilization through dental splinting, Erich bars, or orthodontic wires (to control the tensile forces). Yerit et al. did not use any extra stabilization, and there were no negative consequences.13 According to the latter, biodegradable materials are resistant and provide adequate stability for these types of fracture. According to Li et al., ORIF reconstructs bone continuity, facilitating the physiological function and early movement of the mandible, which is of great importance for mandibular growth.16 Furthermore, according to Haug and Foss, children can resume their normal diet more quickly, thus ensuring the nutrition needed for fracture repair and bone growth.45 With regard to the variables analyzed, there is consensus among authors on the use of intraoral access, as it prevents the formation of visible scars and eventual facial nerve injury, in addition to allowing adequate reduction and osteosynthesis. In terms of osteosynthesis plate positioning, the lower edge of the mandible seems to be the most appropriate site; however, in fractures located in the posterior region, such as at the angle, the plate can be positioned on the oblique line without causing problems for the dental germs.25 The eventual postoperative complications were mild and not associated with the fracture, but rather to the surgery. One should also highlight the importance of the age of the paediatric patient when selecting the treatment. Different age groups should be considered, such as

3 years, 4–8 years, and 9–12 years. An older patient, for example, can tolerate treatment with splints and circummandibular wiring better than a younger one. Despite the vast literature on this topic, there is a need to confirm procedures based on scientific evidence following PRISMA parameters for randomized clinical trials (RCTs), as there are authors who advocate either surgical or non-surgical treatment as the best treatment modality for fractures of the dentate portion of the mandible in paediatric patients. A connection between the best treatment and the number of postoperative complications in fractures of the dentate portion of the mandible in paediatric patients could not be established based on the results obtained in this study. However, the incidence of postoperative complications was low for both surgical (with either biodegradable materials or titanium, with or without further stabilization of the dental arch) and non-surgical (with compression splints and circum-mandibular wiring) treatments. In addition, infection is most commonly associated with postoperative complications. In order to evaluate postoperative complications related to mandibular growth, such as deformities/facial and dental asymmetries, a postoperative follow-up period of longer duration is necessary. No literature criteria have been established to determine the best treatment modality for these fractures, such as age and/or displacement of the fracture, although there are advantages and disadvantages to each technique. Considering the rarity of paediatric mandible fractures, the authors suggest that a multicenter study with standard data collection could improve the evaluation of the clinical outcomes and complications of all major treatment modalities for paediatric mandible fractures. Funding

There were no sources of funding. Competing interests

The authors declare that there is no conflict of interest. Ethical approval

Not required. Patient consent

Not required.

7

References 1. Iatrou I, Theologie-Lygidakis N, Tzermpos F. Surgical protocols and outcome for the treatment of maxillofacial fractures in children: 9 years’ experience. J Craniomaxillofac Surg 2010;38:511–6. 2. Kaban LB, Mulliken JB, Murray JE. Facial fractures in children: an analysis of 122 fractures in 109 patients. Plast Reconstr Surg 1977;59:15–20. 3. Smith DM, Bykowski MR, Cray JJ, Naran S, Rottgers SA, Shakir S, et al. 215 mandible fractures in 120 children: demographics, treatment, outcomes, and early growth data. Plast Reconstr Surg 2013;131:1348–58. 4. Goth S, Sawatari Y, Peleg M. Management of paediatric mandible fractures. J Craniofac Surg 2012;23:47–56. 5. Hegab A. Management of mandibular fractures in children with a split acrylic splint: a case series. Br J Oral Maxillofac Surg 2012;50:e93–5. 6. An J, Jia P, Zhang Y, Gong XI, Han X, He Y. Application of biodegradable plates for treating pediatric mandibular fractures. J Craniomaxillofac Surg 2015;43:515–20. 7. Rottgers SA, Decesare G, Chao M, Smith DM, Cray JJ, Naran S. Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme. J Craniofac Surg 2011;22:1260–5. 8. Glazer M, Joshua BZ, Woldenberg Y, Bodner L. Mandibular fractures in children: analysis of 61 cases and review of the literature. Int J Pediatr Otorhinolaryngol 2011;75:62–4. 9. Ferreira PC, Amarante JM, Silva AC, Pereira JM, Cardoso MA, Rodrigues JM. Etiology and patterns of paediatric mandibular fractures in Portugal: a retrospective study of 10 years. J Craniofac Surg 2004;15:384–91. 10. Kocabay C, Atac¸ MS, Oner B, Gu¨ngo¨r N. The conservative treatment of paediatric mandibular fracture with prefabricated surgical splint: a case report. Dent Traumatol 2007;23:247–50. 11. Imola MJ, Hamlar DD, Shao W, Chowdhury K, Tatum S. Resorbable plate fixation in paediatric craniofacial surgery: long-term outcome. Arch Facial Plast Surg 2001;3:79–90. 12. Cole P, Kaufman Y, Izaddoost S, Hatef DA, Hollier L. Principles of paediatric mandibular fracture management. Plast Reconstr Surg 2009;123:1022–4. 13. Yerit KC, Hainich S, Enislidis G, Turhani D, Klug C, Wittwer G, et al. Biodegradable fixation of mandibular fractures in children: stability and early results. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:17–24. 14. Paeng JY, Hong J, Kim CS, Kim MJ. Comparative study of skeletal stability between bicortical resorbable and titanium screw fixation after sagittal split ramus osteotomy for mandibular prognathism. J Craniomaxillofac Surg 2012;40:660–4.

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010

YIJOM-3574; No of Pages 8

8

Bobrowski et al.

15. Stanton DC, Liu F, Yu JW, Mistretta MC. Use of bioresorbable plating systems in paediatric mandible fractures. J Craniomaxillofac Surg 2014;42:1305–9. 16. Li Z, David O, Li ZB. The use of resorbable plates in association with dental arch stabilization in the treatment of mandibular fractures in children. J Craniomaxillofac Surg 2014;42:548–51. 17. Mun˜ante-Ca´rdenas JL, Asprino L, De Moraes M, Albergaria-Barbosa JR, Moreira RW. Mandibular fractures in a group of Brazilian subjects under 18 years of age: an epidemiological analysis. Int J Pediatr Otorhinolaryngol 2010;74:1276–80. 18. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1–9. 19. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009;62:1006–12. 20. Moher D, Jones A, Lepage L. CONSORT Group (Consolidated Standards for Reporting of Trials): a comparative before-andafter evaluation. JAMA 2001;285:1992–5. 21. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomized controlled trials: The QUOROM statement. Quality of Reporting of Meta-Analysis. Lancet 1999;354:1896–900. 22. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analyses of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–12. 23. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370: 1453–7. 24. Bobrowski AN, Sonego CL, Chagas Junior OL. Postoperative infection associated with mandibular angle fracture treatment in the presence of teeth on the fracture line: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2013;42:1041–8.

25. Iatrou I, Theologie-Lygidakis N, Tzermpos F, Kamperos G. Internal fixation of mandibular angle fractures using one miniplate in Greek children: a 5-year retrospective study. J Craniomaxillofac Surg 2015;43:53–6. 26. Bhola N, Jadhav A, Borle R, Khemka G, Adwani N, Bhattad M. Lateral compression open cap splint with circummandibular wiring for management of pediatric mandibular fractures: a retrospective audit of 10 cases. Oral Maxillofac Surg 2014;18:65–82. 27. Kale TP, Urologin SB, Kapoor A, Lingaraj JB, Kotrashetti SM. Open cap splint with circummandibular wiring for management of pediatric mandibular parasymphysis/symphysis fracture as a definitive treatment modality: a case series. Dent Traumatol 2013;29:410–5. 28. Naran S, Keating J, Natali M, Bykowski M, Smith D, Martin B, et al. The safe and efficacious use of arch bars in patients during primary and mixed dentition: a challenge to conventional teaching. Plast Reconstr Surg 2014;133:364–6. 29. Andrade NN, Choradia S, Sriram SG. An institutional experience in the management of pediatric mandibular fractures: a study of 74 cases. J Craniomaxillofac Surg 2015;43: 995–9. 30. Swanson EW, Susarla SM, Ghasemzadeh A, Mundinger GS, Redett RJ, Tufaro AP, et al. Application of the mandibular injury severity score to pediatric mandibular fractures. J Oral Maxillofac Surg 2015;73:1341–9. 31. Siwani R, Tombers NM, Rieck KL, Cofer SA. Comparative analysis of fracture characteristics of the developing mandible: the Mayo Clinic experience. Int J Pediatr Otorhinolaryngol 2014;78:1166–70. 32. Aldelaimi TN, Khalil AA. Surgical management of pediatric mandibular trauma. J Craniofac Surg 2013;24:785–7. 33. Davison SP, Clifton MS, Davison MN, Hedrick M, Sotereanos G. Pediatric mandibular fractures: a free hand technique. Arch Facial Plast Surg 2001;3:185–9. 34. Fasola AO, Obiechina AE, Arotiba JT. Fractures of the mandible in children. East Afr Med J 2001;78:616–8. 35. Nishioka GJ, Larrabee WF, Murakami CS, Renner GJ. Suspended circummandibular wire fixation for mixed-dentition pediatric mandible fractures. Arch Otolaryngol Head Neck Surg 1997;123:753–8.

36. Thaller SR, Mabourakh S. Pediatric mandibular fractures. Ann Plast Surg 1991;26: 511–3. 37. Jones KM, Bauer BS, Pensler JM. Treatment of mandibular fractures in children. Ann Plast Surg 1989;23:280–3. 38. Zohar Y, Laurian N. Fracture of the mandible in children. Laryngoscope 1984;94:704–5. 39. Lehman JA, Saddawi ND. Fractures of the mandible in children. J Trauma 1976;10: 773–7. 40. Bali RK, Sharma P, Jindal S, Gaba S. To evaluate the efficacy of biodegradable plating system for fixation of maxillofacial fractures: a prospective study. Natl J Maxillofac Surg 2013;4:167. 41. Chandan S, Halli R, Joshi S, Chhabaria G, Setiya S. Transosseous fixation of pediatric displaced mandibular fractures with polyglactin resorbable suture—a simplified technique. J Craniofac Surg 2013;24:2050–2. 42. Khairwa A, Bhat M, Sharma A, Sharma R. Management of symphysis and parasymphysis mandibular fractures in children treated with MacLennan splint: stability and early results. Int J Clin Pediatr Dent 2015;8: 127–32. 43. Farber SJ, Nguyen DC, Harvey AA, Patel KB. An alternative method of intermaxillary fixation for simple pediatric mandible fractures. J Oral Maxillofac Surg 2016;74: 582e1–8. 44. Singh M, Singh RK, Passi D, Aggarwal M, Kaur G. Management of pediatric mandibular fractures using bioresorbable plating system—efficacy, stability, and clinical outcomes: our experiences and literature review. J Oral Biol Craniofac Res 2016;6: 101–6. 45. Haug RH, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90: 126–34.

Address: Otacı´lio Luiz Chagas Ju´nior School of Dentistry Pelotas Federal University of Pelotas Rua Gonc¸alves Chaves 457 – 3rd floor Pelotas RS 96015-560 Brazil E-mail: [email protected]

Please cite this article in press as: Bobrowski AN, et al. Complications associated with the treatment of fractures of the dentate portion of the mandible in paediatric patients: a systematic review, Int J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/ j.ijom.2016.12.010