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. Following the nasal bones, the mandible is the most frequently fractured facial bone in 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. Automobile and sports accidents, falls from height, bicycle falls, and violence are the most frequent mechanisms.
The management of paediatric mandible fractures is particularly challenging because of significant differences from 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.
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).
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. 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 follow-up; the patient should also avoid intense physical activity for a few weeks.
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. and Ferreira et al., 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.
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. 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. 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. A reduction of the mandibular immobilization period also contributes to the recovery of joint function.
According to Iatrou et al., 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.
Alternatively, resorbable plates can be considered for the treatment of paediatric mandible fractures ; such plates will contribute to a reduction in secondary interventions. 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. Economic factors can also restrict the use of resorbable materials.
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). The following databases were searched to identify articles: PubMed ( ), Scopus ( ), and Cochrane Library ( ).
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.
|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)|
|Eventual complications of each treatment modality|
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.
|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 TITLE-ABS-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)|
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 ) for either exclusion or final inclusion of each article in the study.
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).
The methodological quality was assessed by combining the PRISMA statement, CONSORT statement, QUOROM statement, MOOSE statement, and STROBE statement 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. : 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.
The database review, updated to June 19, 2016, yielded 1186 results. Twenty-seven articles were considered relevant after title and/or abstract reading. 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. The reasons for exclusion are listed in Table 3 .
|Author (year)||Study type||Reason for exclusion a|
|Andrade et al. (2015)||Retrospective||1|
|Swanson et al. (2015)||Retrospective||1|
|Naran et al. (2014)||Retrospective||1|
|Siwani et al. (2014)||Retrospective||1|
|Aldelaimi and Khalil (2013)||Retrospective||2|
|Chandan et al. (2013)||Prospective||2|
|Smith et al. (2013)||Retrospective||1|
|Muñante-Cárdenas et al. (2010)||Retrospective||1|
|Davison et al. (2001)||Retrospective||1|
|Fasola et al. (2001)||Retrospective||1|
|Nishioka et al. (1997)||Case series||1|
|Thaller and Mabourakh (1991)||Retrospective||1|
|Jones et al. (1989)||Prospective||1|
|Zohar and Laurian (1984)||Technique description||3|
|Lehman and Saddawi (1976)||Retrospective||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.
Twelve articles were accepted for the final review – three retrospective studies, five prospective studies, and four case series ( Table 4 ). A flowchart of the selection and evaluation process according to the PRISMA statement is presented in Fig. 1 .
|Study type a||Number of cases
|Treatment||Postoperative characteristics evaluated||Postoperative complications||Follow-up||Conclusions|
|Description||Surgical access||Osteosynthesis material
|Osteosynthesis material removal
|Farber et al.
|IMF with zero silk sutures and posterior ORIF (GA)||Intraoral||0.75 Stryker Delta Absorbable System||No||Occlusion and mouth opening||None||3 months||This alternative method can be applied by surgeons treating paediatric mandibular fractures and might be better tolerated by paediatric patients|
|Singh et al.
(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 through existing traumatic scar||2.5 Inion CPS plating kit
[Champy’s line of ideal osteosynthesis]
|NR||Bite force recording, TMJ function, aesthetics, and complications||2 soft tissue infection, 2 nerve injury (paresthesia), 1 implant exposure, 1 malocclusion||6 months||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 load-sharing plate in a semi-rigid technique after anatomical reduction|
|Khairwa et al.
(Range 2–5 years)
|Open reduction and stabilization with MacLennan splint (GA)||Intraoral||Acrylic cap splint and circum-mandibular wiring
[4–5 mm from the midline]
|Occlusion (radiographic)||1 malocclusion, 3 postoperative swelling, 2 postoperative pain||12 months||Preliminary impression is favourable; the splint showed sufficient rigidity and stability to enable initial bone healing of the mandible|
|Iatrou et al.
(Range 4–14 years; average 10 years)
|ORIF (GA) + IMF (Erich bar/Ernest splinting) for 1 week||Intraoral||Titanium plate and monocortical screws (1.5-mm system for age 5–6 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|
|An et al.
(Range 7 months–12 years; average 4.10 years)
[Symphysis, parasymphysis, body, and angle]
|ORIF (GA) + dental splinting for 1 month + soft diet and oral physiotherapy (after 2 postoperative weeks)||Intraoral||Biodegradable plate (85:15 poly( d , l -lactide-co-glycolide); PLGA, PolyMax; Synthes, Oberdorf, Switzerland) w/4 holes (1.0 mm thick) and system 2.0-mm screws (4–10 mm)
|NR||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 years (average 1 year and 2 months)||Biodegradable fixation devices are safe/efficient for the treatment of paediatric mandible fractures|
|Bhola et al.
(Range 5–9 years)
[Body, parasymphysis, and symphysis]
|Manual reduction of 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||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|
|Li et al.
(Range 2–12 years)
[Body, parasymphysis, and symphysis]
|ORIF (GA) + Erich bar or orthodontic wire (w/steel wire or tooth resin) for 4 weeks + soft diet, oral hygiene 0.1% chlorhexidine 2×/day||Intraoral||Biodegradable plate and monocortical screws (2.0-mm system)
|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|
|Stanton et al. (2014)||CS||15 patients
(Average 8.13 years)
[Body, parasymphysis, and symphysis]
|ORIF (GA) + IMF (Erich bar or Risdon wire or skeletal fixation w/circum-mandibular wires and piriform steel wires or zygomatic arch wires) for 14–21 days||Intraoral||Biodegradable plate (polyglycolic copolymer and poly- l -lactic acid) and 4-mm monocortical screws (1.5 mm/2 mm) system
|No||Occlusion, mouth opening, inter-fragmentary mobility, abnormal local oedema||1 < 30 mm mouth opening; 2 seromatous collections at the surgical site (1 treated with clindamycin/non-infectious nature)||29 months||Resorbable polyglycolic and poly- l -lactic acid systems and short-term postoperative IMF provide effective fixation for paediatric mandible fractures|
|Bali et al.
[Angle and parasymphysis]
|ORIF (GA)||NR||Biodegradable Inion CPS (2.0-mm) plating system (Inion, Tempere, Finland) (copolymer of LPLA, DLPLA and TMC and PGA)
|No||Adequate reduction, stability of fracture segments, occlusion, and postoperative complications||1, not specified||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.
(Range 1–11 years; average 6 years)
|Acrylic splint with circum-mandibular wiring for 2–3 weeks (GA)||NR||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|
(Range 3–7 years)
[Symphysis or parasymphysis or body]
|Acrylic splint and circum-mandibular wiring (steel wire) for 4 weeks (GA)||NR||NR||NR||Occlusion, infection, mandible symmetry, ankylosis, growth||None||4 years||Occlusion was satisfactory, without infection or malocclusion|
|Yerit et al.
(Range 5–16 years; average 12 years)
[Symphysis, parasymphysis, body, and angle]
|ORIF w/2 plates (1 for the very 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||Intraoral||Biodegradable plate (poly- l -lactic acid isomers with 30% d -lactide and 70% l -lactate) (SR-PLGA) (Biosorb FX, Linvatec Corp., Largo, FL, USA)
|NR||Stability of reduction, displacement, diastasis, visibility of the fracture line/fracture perforation and ossification, inflammation, fistula, occlusion, and sensitivity||None||10.9–43.4 months (average 26.4 months)||Self-reinforced fixation devices are safe and effective for the treatment of paediatric mandible fractures|