The most preferred method of management of displaced pediatric mandibular fracture: a systematic review and meta-analysis

Satnam Singh Jolly; Kamaljit Kaur; Vidya Rattan; Apoorva Singh; Tanvi Kiran

doi:10.7181/acfs.2026.0007

Arch Craniofac Surg > Volume 26(2); 2025 > Article

Jolly, Kaur, Rattan, Singh, and Kiran: The most preferred method of management of displaced pediatric mandibular fracture: a systematic review and meta-analysis

Review Article

Archives of Craniofacial Surgery 2025;26(2):43-50.

Published online: April 20, 2025

DOI: https://doi.org/10.7181/acfs.2026.0007

The most preferred method of management of displaced pediatric mandibular fracture: a systematic review and meta-analysis

Satnam Singh Jolly^1,^*

, Kamaljit Kaur^2,^*

, Vidya Rattan¹

, Apoorva Singh¹

, Tanvi Kiran³

¹Oral and Maxillofacial Surgery, Oral Health Science Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

²Department of Pediatric and Preventive Dentistry, Bhojia Dental College, Baddi, India

³Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence: Apoorva Singh Oral and Maxillofacial Surgery, Oral Health Science Centre, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh PIN-160012, India E-mail: apoorva.omfssurgeon@gmail.com

^* The first two authors contributed equally to this work.

Received March 25, 2025 Revised March 25, 2025 Accepted April 9, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

There are diverse treatment modalities available for managing pediatric dentate mandibular fractures, ranging from various closed reduction techniques to open reduction methods. This systematic review and meta-analysis aim to evaluate the most appropriate and preferred management method for pediatric dentate mandibular fractures, focusing on outcomes such as wound infection and malocclusion.

Methods

A systematic search was performed using the PubMed Central and Scopus databases from January 1980 to December 2022, following PRISMA guidelines. The inclusion criteria comprised case reports with more than 10 cases, clinical trials, and prospective and retrospective clinical studies addressing the management of displaced dentate-segment mandibular fractures in patients up to 15 years old using open and/or closed reduction techniques.

Results

Six retrospective studies were included in the systematic review and meta-analysis. The primary outcomes assessed were wound infection and malocclusion. The pooled estimate for wound infection significantly favored the maxillomandibular fixation (MMF) group (p= 0.0007). In contrast, although the pooled estimate for malocclusion favored surgical treatment, the difference was not statistically significant (p= 0.86).

Conclusion

The risk of wound infection is significantly lower with MMF in pediatric mandibular fractures, while open reduction and internal fixation (ORIF) using miniplates is associated with a relatively lower risk of malocclusion, although this difference is not statistically significant. The authors conclude that, based on reduced wound infection rates, MMF should be the preferred management approach, whereas ORIF should be reserved for severely displaced and comminuted fractures. Future randomized controlled trials with larger sample sizes are needed to validate and strengthen these findings.

Keywords: Mandibular fracture / Pediatric / Treatment

Abbreviations

confidence interval

JBI

Joanna Briggs Institute

MMF

maxillomandibular fixation

ORIF

open reduction and internal fixation

PICO

population, intervention, comparison, and outcome

PRISMA

Preferred Reporting Items for Systematic Reviews and MetaAnalyses

PROSPERO

Prospective Register of Systematic Reviews

INTRODUCTION

In pediatric maxillofacial trauma, the mandible is the most common site of fracture [1,2]. The management of mandibular fractures in children is challenging due to factors such as the developing state of the mandible, the lack of permanent dentition for immobilization, and the presence of tooth buds in the jaws. These considerations necessitate the use of diverse surgical procedures. The appropriate treatment is determined by factors including the degree of fracture displacement, occlusion, fracture type, age, and the potential for growth disturbances [3]. Regardless of the treatment modality, the aim of fracture management is to achieve adequate bony union, restore pre-morbid occlusion, re-establish normal form and function, and prevent growth restriction.

For years, the management of pediatric mandibular fractures has been a subject of debate [4]. The principles of mandibular management differ between pediatric patients and adults. Treatment modalities are broadly categorized into closed reduction and open reduction and internal fixation (ORIF). Closed reduction methods include a soft diet and observation, bridle wiring, maxillomandibular fixation (MMF) with arch bars, and cap splints. Undisplaced or greenstick fractures are typically managed conservatively due to the higher osteogenic potential and rapid healing in children. Displaced mandibular fractures may be managed with closed reduction techniques, such as cap splints with circum-mandibular wiring or MMF, or with ORIF using titanium miniplates or microplates with monocortical screws, or resorbable plates.

To the best of our knowledge, no systematic review has evaluated the preferred method for managing displaced pediatric mandibular fractures in the dentate segment based on outcome measures. Therefore, this systematic review and meta-analysis aim to identify the optimal approach for managing pediatric dentate mandibular fractures based on clinical outcomes.

METHODS

Study design

This systematic review and meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist [5]. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42021250485 in 2021. The population, intervention, comparison, and outcome (PICO) framework, along with the inclusion/exclusion criteria, search strategy, data extraction, and study quality assessment procedures, are described in detail below.

PICO, inclusion and exclusion criteria of the study

Keeping the study objectives in mind, the research protocol was developed using the PICO framework:

· P (Population/Patient): Pediatric patients up to 15 years old with displaced mandibular fractures in the dentate segment (including the symphysis, parasymphysis, body, or angle).

· I (Intervention): ORIF using resorbable or metal plates.

· C (Comparison): Closed reduction techniques, such as MMF or circum-mandibular wiring.

· O (Outcome): Incidence of reported complications.

The inclusion criteria comprised case reports with more than 10 cases, clinical trials, and prospective and retrospective clinical studies (published between January 1980 and December 2022) that address the management of displaced mandibular fractures in patients up to 15 years old using open and/or closed reduction techniques. Case reports and case series with fewer than 10 patients; isolated condylar fractures; in-vitro studies; animal studies; review articles; posters; letters to the editor; and short communications were excluded.

Search strategy

Electronic searches were systematically performed using the PubMed Central and Scopus databases to identify relevant articles published between January 1980 and December 2022 that met the predefined inclusion and exclusion criteria. The search was conducted using advanced filters with multiple Medical Subject Headings (MeSH) terms, including: (((“therapy”[Sub-heading] OR “therapy”[All Fields] OR “treatment”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“pediatrics”[MeSH Terms] OR “pediatrics”[All Fields] OR “pediatric”[All Fields]) AND (“mandibular fractures”[MeSH Terms] OR (“mandibular”[All Fields] AND “fractures”[All Fields]) OR “mandibular fractures”[All Fields] OR (“mandible” [All Fields] AND “fracture”[All Fields]) OR “mandible fracture”[All Fields])) AND (“1980/01/01”[PubDate]: “2022/12/31”[PubDate])). The combined search results were screened for duplicates, and articles were managed using Mendeley software. No additional articles were identified upon manual searching.

Data extraction and quality assessment

During the literature search, data extraction based on the inclusion and exclusion criteria was performed by two independent authors (SSJ and AS). Discrepancies regarding article inclusion were resolved by authors TK and KK, and the final list of articles was selected through mutual consensus. The extracted data were recorded in a spreadsheet using Microsoft Excel 2019 under the following column headings: Author’s name, year of study, sample size, and study outcomes. Using the Critical Assessment Checklist for Cohort Studies from the Joanna Briggs Institute (JBI), two reviewers (SSJ and AS) independently evaluated the quality of all relevant studies. This checklist contains 11 questions that assess each study’s quality (potential risk of bias) and can be answered with “yes,” “no,” or “unclear.” Discrepancies among reviewers were discussed and resolved by consensus. The following cutoffs were used to determine the risk of bias for each study: low risk of bias was defined as a yes score of 70% or more, moderate risk as a yes score between 50% and 69%, and high risk as a yes score of less than 50% [6]. Individual analysis of complete texts helped resolve disagreements between the authors. Any remaining discrepancies were resolved through discussion with a third author (TK).

Data analysis

The primary outcomes of the study were wound infection (C2) and malocclusion (S1). Separate meta-analyses were performed for these outcomes. Adverse events related to wound infection and malocclusion were compared between the two groups (conservative versus surgical) using risk ratios.

The I² statistic and the Cochran Q test were employed to assess study variability attributable to heterogeneity, which was considered significant if I²> 50% and p< 0.10. Publication bias was evaluated using funnel plot analysis and Egger’s test. A null hypothesis in Egger’s test indicates the absence of publication bias and funnel plot symmetry [6]. Based on the I² and Cochran’s Q test results, a fixed-effect model was used, given the absence of significant heterogeneity among the selected studies. The Mantel-Haenszel method, which is typically favored for fixed-effect meta-analyses with a limited number of studies, was employed to stabilize variance and determine the pooled risk ratios at a 95% confidence interval (CI). The risk ratios served as the effect size for both study outcomes in this investigation.

RESULTS

Study selection

Of the 3,057 studies identified from the primary search, 17 duplicates were removed, leaving 3,040 studies for title screening. After excluding 2,817 irrelevant studies based on their titles, 233 studies were screened by abstract. A total of 101 studies were reviewed in full to determine their potential eligibility, and six studies were ultimately included in our meta-analysis. Of these six studies, five were used for the wound infection outcome and four for the malocclusion outcome. The study selection process is summarized in the PRISMA diagram (Fig. 1).

Study characteristics

Table 1 presents the relevant descriptions and characteristics of the included studies (published between 1994 and 2022). All six studies included in this meta-analysis were retrospective. Each study evaluated the complication rate for each treatment modality. Out of a total of 444 patients, 45 (10.1%) experienced complications. Among these patients, 304 (68.5%) were managed conservatively, while 140 (31.5%) underwent surgical treatment. Of the 304 conservatively managed patients, 11 (3.6%) developed complications, whereas 34 (24.2%) of the 140 surgically treated patients experienced complications. Among the various complications, wound infection and malocclusion were selected as the primary outcomes for comparison, as they are the most common complications observed with both conservative and surgical treatment modalities.

Pooled estimates

The pooled effect, estimated using a fixed-effect model for wound infection, was 0.13 (95% CI, 0.04–0.42), significantly favoring conservative treatment. This indicates that the risk of wound infection is 88% lower in the conservative treatment group compared to surgical treatment (p= 0.0007) (Fig. 2). The I² statistic indicated an absence of significant heterogeneity, which was confirmed by Cochran’s Q test (p= 0.32) (Fig. 2). The funnel plot for the wound infection outcome (Fig. 3A) and the non-significant Egger’s test (p> 0.05) (Table 2) indicate an absence of publication bias.

The pooled effect estimated using a fixed-effect model for malocclusion was 1.11 (95% CI, 0.35–3.48), favoring surgical treatment. However, this pooled effect was not statistically significant (p= 0.86) (Fig. 4). The I² statistic indicated an absence of significant heterogeneity, as confirmed by Cochran’s Q test (p=0.54). The funnel plot for the malocclusion outcome (Fig. 3B) and the non-significant Egger’s test (p> 0.05) (Table 2) indicate an absence of asymmetry and publication bias.

Quality assessment and sensitivity analysis

All six studies were assessed for quality using the JBI Critical Appraisal Checklist for Cohort Studies (Table 3) [13]. One study was found to have a high risk of bias (poor quality), two studies had a moderate risk of bias, and the remaining three studies were classified as having a low risk of bias. The study by Kambalimath et al. [11] was excluded from the wound infection outcome analysis. A sensitivity analysis was then performed by removing this study, and the fixed-effect meta-analysis was repeated using the Mantel-Haenszel method. The pooled risk ratio changed slightly to 0.16 (95% CI, 0.05–0.51), which remained statistically significant, indicating that the risk of wound infection is 83% lower in the conservative treatment group compared to surgical treatment (Fig. 5). Thus, the sensitivity analysis confirms a robust pooled estimate for wound infection favoring conservative treatment.

DISCUSSION

The treatment of mandibular fractures in pediatric patients remains a matter of debate. The principles of mandibular management differ between pediatric patients and adults. Pediatric mandibular fracture treatment is complex due to anatomical differences, including increased bone elasticity, a thicker layer of adipose tissue, a higher cancellous-to-cortical bone ratio, and flexible suture lines. Additionally, the presence of developing tooth buds necessitates extra caution to prevent injury. Minimal manipulation of the facial skeleton is crucial to avoid unpredictable effects on growth. For undisplaced and minimally displaced fractures, conservative management is typically recommended. The primary rationale for this approach is the higher osteogenic potential and faster healing in children, particularly in cases of undisplaced or minimally displaced fractures. Consequently, the duration of closed treatment is generally shorter in children than in adults. Conservative treatment options for mandibular dentate segment fractures vary widely, ranging from a soft diet and observation to more active interventions such as bridle wiring and MMF, with or without elastic guidance. Various wiring techniques, including Risdon cables, eyelet wiring, the use of pre-existing orthodontic appliances, and cap splints with circum-mandibular wiring, may be employed [14]. Notably, the acrylic cap splint used in pediatric displaced mandibular fractures offers several advantages, such as cross-arch stability, uniform force distribution, ease of application and removal, and the ability to maintain normal biting and chewing [15].

ORIF is considered necessary for severely displaced mandibular fractures exhibiting significant mobility, comminution, multiple fractures, and anterior mandibular fractures associated with unilateral or bilateral condylar process fractures, even in pediatric patients [16]. When performing fixation, care must be taken to avoid disrupting erupting tooth buds while positioning the miniplate along the inferior border of the mandible using monocortical screws. Although metal plates are effective, they carry a risk of restricting mandibular growth, necessitating their removal once bone healing is complete. Consequently, bioresorbable plates have become increasingly popular for managing pediatric fractures [11].

Surgical intervention for mandibular fractures can lead to various complications, including intrabony embedment of metal screws, palpability of plates through the chin, wound dehiscence, nerve paresthesia, damage to developing tooth buds, and the need for secondary surgery to remove plates [17]. In contrast, complications associated with closed reduction include non-union, malunion, malocclusion, iatrogenic luxation of primary teeth, infection, and trismus. Contributing factors to non-union and malunion in pediatric mandibular fractures include insufficient immobilization of fracture segments, infection at the fracture site, the presence of foreign bodies between segments, improper fracture reduction, and severe comminution.

For the purpose of comparison in this systematic review and meta-analysis, MMF was selected as the representative closed reduction modality, while ORIF with metal miniplates was chosen for the surgical group. This selection was based on the fact that the included studies reported outcomes for these two treatment approaches separately. Among the various complications associated with both closed reduction and surgical management, wound infection and malocclusion were chosen as the primary outcome criteria due to their consistent occurrence across both treatment modalities.

The meta-analysis revealed that the pooled estimate for wound infection strongly favored the MMF group (p= 0.0007), indicating a significantly lower risk of infection compared to the ORIF group. During ORIF, surgical access to the fracture site is achieved via either an extraoral or intraoral approach, which can introduce contamination from oral and/or skin flora [18]. The increased risk of infection following ORIF is largely attributed to disruption of the vascular supply to the cortical bone when the periosteum is elevated. Additionally, drilling and the insertion of wires or screws may further compromise the endosteal blood supply and damage developing tooth buds, collectively increasing the likelihood of infection [19]. Moreno et al. [20] reported that postoperative infection was more closely associated with fracture severity rather than the treatment method used. Consequently, the infection rate and incidence of wound dehiscence are lower in the closed reduction group, as uncomplicated fractures are generally more amenable to this technique. Timing also plays a critical role in infection risk; early treatment, ideally within the first few hours to 1–2 days after trauma, is associated with lower postoperative infection rates, while delayed treatment (1–2 weeks post-trauma) increases the risk of infection due to prolonged wound exposure [21].

The pooled estimate for malocclusion in this meta-analysis favored surgical treatment; however, the difference was not statistically significant (p= 0.86). A slightly higher prevalence of malocclusion was observed with closed reduction, largely due to challenges in achieving adequate reduction and proper fragment contact, especially in severely displaced fractures. Bansal et al. [16] reported that 1.3% of patients in the closed treatment group exhibited mobility and malocclusion during follow-up, whereas all cases in the ORIF group showed no mobility and maintained satisfactory occlusion. Similarly, Ellis et al. [21] observed lower complication rates in patients with comminuted mandibular fractures treated with ORIF (10.3%) compared to those managed with MMF (17.1%). However, Shetty et al. [22] reported lower complication rates in the MMF group (8.1%) compared to the ORIF group (12.5%), aligning with our findings. Residual malocclusions following closed reduction may improve over time through alveolar bone growth, permanent tooth eruption, and the natural remodeling of growing bone.

The strengths of this meta-analysis include its novelty, as no previous studies have evaluated the outcomes of different treatment modalities for pediatric mandibular fractures. Additionally, robust analytical methods were employed, including assessments for publication bias and sensitivity analysis, which confirmed that wound infection management significantly favored MMF (conservative treatment). However, this study has certain limitations that must be considered when interpreting the findings. The retrospective and prospective nature of the included studies introduces potential biases. Furthermore, only a limited number of studies have reported outcomes for the treatment modalities analyzed. Isolating variables such as the degree and extent of fracture displacement remains challenging. The lack of clinical trials and the wide range of treatment approaches available for pediatric mandibular fractures further restrict the generalizability of the results. Therefore, additional research, preferably randomized controlled trials with extended follow-up periods, is needed to determine the most effective treatment for displaced mandibular fractures in children and adolescents, particularly regarding malocclusion.

CONCLUSION

The authors conclude that the risk of wound infection is significantly lower with closed reduction methods for pediatric mandibular fractures. In contrast, ORIF with miniplates is associated with a lower risk of malocclusion, although the difference is not statistically significant. Based on wound infection outcomes, MMF should be the preferred management method for pediatric mandibular fractures, while ORIF should be reserved for severely displaced and comminuted fractures. Further clinical studies are needed to confirm these findings.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Acknowledgments

This article is dedicated to the Late Prof. Sachin Rai for his contribution and guidance to the department.

Author contributions

Conceptualization: Satnam Singh Jolly, Kamaljit Kaur, Vidya Rattan, Apoorva Singh. Data curation: Satnam Singh Jolly, Apoorva Singh. Formal analysis: Tanvi Kiran. Methodology: Satnam Singh Jolly. Writing – original draft: Satnam Singh Jolly, Kamaljit Kaur, Apoorva Singh, Tanvi Kiran. Writing – review & editing: Vidya Rattan, Apoorva Singh. Software: Tanvi Kiran. Supervision: Satnam Singh Jolly, Vidya Rattan. Validation: Satnam Singh Jolly, Vidya Rattan, Tanvi Kiran. All authors read and approved the final manuscript.

Fig. 1.

PRISMA flow chart of the present study.

Fig. 2.

Forest plot comparing risk ratio of wound infection among conservative (C2) versus surgical (S1) groups (fixed-effect inverse-variance model). CI, confidence interval.

Fig. 3.

Funnel plots of outcomes. (A) Funnel plot of wound infection outcome. (B) Funnel plot of malocclusion outcome. SE, standard error; RR, risk ratio.

Fig. 4.

Forest plot comparing risk ratio of malocclusion among conservative (C2) versus surgical (S1) groups (fixed-effect inverse-variance model). CI, confidence interval.

Fig. 5.

Forest plot comparing risk ratio of wound infection among conservative (C2) versus surgical (S1) groups after sensitivity analysis (M-H method). M-H, Mantel-Haenszel method; CI, confidence interval.

Table 1.

Showing study characteristics of the included studies

Author (year)	Country	Type of study	No. of patients	Treatment modality^a)							Maximum follow-up period	Wound infection and malocclusion in S1 and C2 group	Other complications
				Conservative			Surgical (ORIF)
				C1	C2	C3	S1	S2	IOW	Others
Yesantharao et al. (2021) [7]	USA	Retrospective	21	6	7	-	5	1	-	2 lag screws	30 day	S1 (1 wound infection, 3 malocclusion);	S1 (1 dental complication, 1 gingival hypertrophy);
Yesantharao et al. (2021) [7]	USA	Retrospective	21	6	7	-	5	1	-	2 lag screws	30 day	C2 (1 malocclusion)	C2 (1 dental complication)
Yesantharao et al. (2020) [8]	USA	Retrospective, longitudinal cohort	17	7	1	0	8	1	-	0	1 mo	S1 (2 wound infection, 1 malocclusion)	S1 (2 transient nerve paresthesia);
Yesantharao et al. (2020) [8]	USA	Retrospective, longitudinal cohort	17	7	1	0	8	1	-	0	1 mo	S1 (2 wound infection, 1 malocclusion)	S2 (1 transient nerve paresthesia, 1 open bite)
Yesantharao et al. (2020) [9]	USA	Retrospective cohort	14	3	4	2	4	1	-	0	30 day	S1 (1 malocclusion);	S1 (1 hardware loosening, 1 transient nerve paresthesia);
Yesantharao et al. (2020) [9]	USA	Retrospective cohort	14	3	4	2	4	1	-	0	30 day	C2 (1 malocclusin)	C1 (2 malocclusion)
Karim et al. (2010) [10]	India	Retrospective study	45	9	22	0	6	0	8	0	NA	S1 (3 wound infection)	-
Kambalimath et al. (2012) [11]	India	Retrospective	112	0	83	10	19	0	-	0	6 mo	S1 (5 wound infection)	-
Eskitascioglu et al. (2009) [12]	Turkey	Retrospective	235	28	122	0	81	4	-	0	NA	S1 (6 wound infection, 1 malocclusion);	S1 (1 hypoesthesia, 2 exposure of plate)
Eskitascioglu et al. (2009) [12]	Turkey	Retrospective	235	28	122	0	81	4	-	0	NA	C2 (1 wound infection, 5 maloccusion)	S1 (1 hypoesthesia, 2 exposure of plate)

MMF, maxillomandibular fixation; ORIF, open reduction and internal fixation.

^a) For modalities: C1, observation/soft diet; C2, closed reduction with MMF; C3, closed reduction with acrylic splint; S1, ORIF with miniplate; S2, ORIF with bioresorbable plate.

Table 2.

Egger’s test for publication bias (fixed effect model)

Type of secondary outcome	Method	p-value
Wound infection	Traditional Egger’s test	0.185
Malocclusion	Traditional Egger’s test	0.495

Table 3.

JBI risk of bias quality assessment for included studies

Study (year)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Yes rate (%)	Risk
Karim et al. (2010) [10]	Yes	Yes	Yes	Yes	No	Yes	UC	Yes	Yes	No	No	63	Moderate
Eskitascioglu et al. (2009) [12]	Yes	Yes	Yes	Yes	UC	Yes	Yes	Yes	NA	NA	NA	63	Moderate
Kambalimath et al. (2013) [11]	Yes	Yes	Yes	Yes	UC	Yes	UC	UC	UC	No	NA	45	High
Yesantharao et al. (2020) [8]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	NA	Yes	82	Low
Yesantharao et al. (2021) [7]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	NA	Yes	82	Low
Yesantharao et al. (2020) [9]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	NA	Yes	82	Low

Q1–Q11 refer to questions 1 to 11 from the JBI critical appraisal checklist for risk of bias assessment.

JBI, Joanna Briggs Institute; UC, unclear; NA, not applicable.

REFERENCES

1. Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofac Surg 1993;51:836-45.

2. Wainwright DJ, Moffitt JK, Bartz-Kurycki M, Wainwright DJ, Anderson K, Demian N, et al. The trends of pediatric facial fractures due to violence in a level one trauma population. J Craniofac Surg 2019;30:1970-3.

3. Zhang B, Liu ZH, Li J, Zhang K, Chen JJ, Zhang RM. Open reduction and internal fixation of severely dislocated fractures of condylar neck and base using bioabsorbable miniplate in children: a 3-10 years follow-up study. Int J Pediatr Otorhinolaryngol 2014;78:1987-92.

4. Moffitt JK, Wainwright DJ, Bartz-Kurycki M, Wainwright DJ, Demian N, Teichgraeber JF, et al. Factors associated with surgical management for pediatric facial fractures at a level one trauma center. J Craniofac Surg 2019;30:854-9.

5. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71.

6. Sedgwick P. Meta-analyses: how to read a funnel plot. BMJ 2013;1:346:f1342.

7. Yesantharao PS, Lopez J, Reategui A, Jenny H, Najjar O, Yu JW, et al. Combined symphyseal and condylar fractures: considerations for treatment in growing pediatric patients. Plast Reconstr Surg 2021;148:51e-62e.

8. Yesantharao PS, Lopez J, Reategui A, Najjar O, Yu JW, Pourtaheri N, et al. Open reduction, internal fixation of isolated mandible angle fractures in growing children. J Craniofac Surg 2020;31:1946-50.

9. Yesantharao PS, Lopez J, Reategui A, Najjar O, Redett RJ, Manson PN, et al. Managing isolated symphyseal and parasymphyseal fractures in pediatric patients. J Craniofac Surg 2020;31:1291-6.

10. Karim T, Khan AH, Ahmed SS. Trauma of facial skeleton in children: an Indian perspective. Indian J Surg 2010;72:232-5.

11. Kambalimath HV, Agarwal SM, Kambalimath DH, Singh M, Jain N, Michael P. Maxillofacial injuries in children: a 10 year retrospective study. J Maxillofac Oral Surg 2013;12:140-4.

12. Eskitascioglu T, Ozyazgan I, Coruh A, Gunay GK, Yuksel E. Retrospective analysis of two hundred thirty-five pediatric mandibular fracture cases. Ann Plast Surg 2009;63:522-30.

13. Goplen CM, Verbeek W, Kang SH, Jones CA, Voaklander DC, Churchill TA, et al. Preoperative opioid use is associated with worse patient outcomes after total joint arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord 2019;20:234.

14. Hajibandeh J, Peacock ZS. Pediatric mandible fractures. Oral Maxillofac Surg Clin North Am 2023;35:555-62.

15. 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;18:65-8.

16. Bansal A, Yadav P, Bhutia O, Roychoudhury A, Bhalla AS. Comparison of outcome of open reduction and internal fixation versus closed treatment in pediatric mandible fractures-a retrospective study. J Craniomaxillofac Surg 2021;49:196-205.

17. Ongodia D, Li Z, Xing WZ, Li ZB. Resorbable plates for fixation of complicated mandibular fractures in children. J Maxillofac Oral Surg 2014;13:99-103.

18. Kostares E, Kostare G, Kostares M, Kantzanou M. Prevalence of surgical site infections after open reduction and internal fixation for mandibular fractures: a systematic review and metaanalysis. Sci Rep 2023;13:11174.

19. Andreasen JO, Storgård Jensen S, Kofod T, Schwartz O, Hillerup S. Open or closed repositioning of mandibular fractures: is there a difference in healing outcome? A systematic review. Dent Traumatol 2008;24:17-21.

20. Moreno JC, Fernandez A, Ortiz JA, Montalvo JJ. Complication rates associated with different treatments for mandibular fractures. J Oral Maxillofac Surg 2000;58:273-81.

21. Ellis E 3rd, Muniz O, Anand K. Treatment considerations for comminuted mandibular fractures. J Oral Maxillofac Surg 2003;61:861-70.

22. Shetty V, Atchison K, Leathers R, Black E, Zigler C, Belin TR. Do the benefits of rigid internal fixation of mandible fractures justify the added costs? Results from a randomized controlled trial. J Oral Maxillofac Surg 2008;66:2203-12.