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

Article information

Arch Craniofac Surg. 2025;26(2):43-50

Publication date (electronic) : 2025 April 20

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

Satnam Singh Jolly^1,*, Kamaljit Kaur^2,*, Vidya Rattan¹, Apoorva Singh^,1, 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 2025 March 25; Revised 2025 March 25; Accepted 2025 April 9.

Abstract

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

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).

Fig. 1.

PRISMA flow chart of the present study.

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.

Table 1.

Showing study characteristics of the included studies

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.

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.

Table 2.

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

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.

Fig. 4.

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

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.

Table 3.

JBI risk of bias quality assessment for included studies

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.

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.

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