There is insufficient data to reliably determine the importance of treatment delay as an independent predictor of postoperative complications following ORIF of traumatic mandible fracture(s). Only 5 of the 20 studies included in this systematic review concluded that prolonged treatment delay increased the risk of postoperative complications for traumatic mandible fractures. There was significant variation in the time thresholds proposed delineating “early” versus “delayed” ORIF, ranging from 6 hours to 7 days (Fig. 2). Significant time threshold heterogeneity for cohort studies, incomplete data reporting of mean treatment delay times for case–control studies, and overall insufficient stratification of reported data prevented synthesis of the collected data into a formal meta-analysis. The optimal treatment delay for minimizing complications in patients requiring mandible fracture ORIF remains unknown.
Alternative Risk Factors for Postoperative Complications
Alternative risk factors, other than treatment delay, have been posited as contributors to the development of postoperative complications in patients with mandible fractures (Table 10). It has been suggested that these factors may be confounders resulting in prolonged treatment delay, such as noncompliance and comorbid substance use.19 , 20
With respect to patient factors increasing complication rates, Malanchuk and Kopchak22 demonstrated that age was a significant predictor of infection for tooth-bearing mandible fractures treated with open or closed reduction, with patients less than 20 years old and greater than 60 years old having infection rates of 9.4% and 55%, respectively. Periodontal disease has been linked to delayed healing of mandibular body fractures.45 Luz et al.28 found that 75% of patients with complications following ORIF for mandible fractures were partially edentulous, whereas 76.2% of patients without complications were fully dentate. One of the most significant contributors for developing complications in patients with traumatic mandible fractures is substance use, including alcohol abuse.4 , 19–21 , 23 , 32 , 45 Domingo et al.5 found that as many as 53.6% of drug users with mandible fractures developed surgical-site infection and suggested this may be due to their relatively poor nutrition, wound healing, and compliance with postoperative oral care. Smoking has also been reported to increase post-ORIF complication rates 4-fold and infection rates 6-fold, as compared with nonsmokers receiving ORIF.5 , 26 , 27
With regard to mandible fracture factors influencing postoperative complications, higher risk anatomic regions include the mandibular angle22 , 34 and the body; Luz et al.28 reported that 43.8% of body fractures had complications requiring reoperation. Patients with comminuted21 , 22 , 28 and multifocal26 mandible fractures were found to be at higher risk of developing complications, including infection. Czerwinski et al.21 reported that the rate of comminution in patients with complications was 32% compared with 22% in patients without complications. Compared with closed fractures, open fractures have been reported to have as high as a 14-fold increased complication rate (14% versus 1%),5 and another study found that 80% of patients with postoperative complications had open mandibular fractures.28 Similarly, Anderson and Alpert31 reported that 100% of patients with complications (predominantly infectious) had teeth in the line of their mandible fracture, which are considered open fractures by definition,8 and theoretically create a conduit for bacterial seeding. In keeping with this hypothesis, Wagner et al.34 reported that 69% of patients (9 of 13) receiving mandible fracture treatment involving tooth extraction had post-ORIF complications.
Lastly, there is evidence to suggest that ORIF surgical technique is a factor in predicting increased complication rates. An included study31 reported a 46% infection rate (6/13 mandible fractures) associated with improper ORIF technique. Odom and Snyder-Warwick26 reported that ORIF utilizing intraoral incision was associated with a 16.8% complication rate, compared with 0% with extraoral incision, and 27% with combined intraoral and extraoral incisions. However, these data may have been confounded by the fact that more complex and comminuted mandible fractures tend to require a combined approach.28
To date, this is the first systematic review on mandible fracture treatment delay that focuses specifically on ORIF intervention timing. Ensuring the best possible methodological quality was of high importance, and this systematic review was designed in adherence with PRISMA guidelines.44 The search strategy was constructed in collaboration with our health sciences librarian using a PICOT question formulated a priori and was also registered a priori in the PROSPERO database. The literature search was conducted in duplicate and the included studies were also scored in duplicate using MINORS, a validated tool for assessing the methodological quality of nonrandomized studies.
Incomplete data reporting and insufficient data stratification were frequently encountered, as the majority of included studies were retrospective in nature. Six of 20 included studies did not report mean patient age making exclusion of irrelevant studies more difficult.8 , 31 , 33 , 37 , 40 , 41 Reported follow-up times were regularly shorter than 12 weeks, and 9 of 20 included studies did not report any follow-up data (Table 6). Inadequate follow-up periods were, however, penalized as part of the MINORS scoring criteria (Tables 3, 4).
There was variation among the types of mandible fracture included across studies with Spinelli et al.35 focusing on angle fractures only, Barker et al.29 excluding condylar and alveolar fractures, and 5 of 20 included studies not reporting mandible fracture location.8 , 29 , 30 , 36 , 43 It is therefore difficult to compare complication rates between such studies, given that mandible fracture location is considered an important factor influencing the development of complications.16
ORIF hardware has also changed over the decades, with the earlier studies in the 1970s to 1980s utilizing interosseous wiring in as many as 93.8–96.0% of cases,17 , 34 whereas recent studies have tended toward mini-plate use exclusively.35 , 36 Early adopters of mini-plate hardware may have encountered more complications related to operator learning before the popularization and refinement of this modern ORIF technique.31
The definition of treatment delay in the literature was highly variable. Unfortunately, some studies needed to be excluded during the full-text review, as they did not report time from injury to ORIF treatment, but rather used intervals such as injury to admission2 or diagnosis to treatment,3 or did not specify a time interval at all.46
Among the 20 included studies, there was still heterogeneity with respect to whether MMF was used as an adjunct to ORIF (Table 5). The utilization of MMF in addition to ORIF was deemed acceptable for inclusion, as MMF did not contribute to the development of mutually exclusive reported complications during review of the included studies.
There was heterogeneous reporting of parameters such as fracture location and complication data (Tables 7, 9), either in terms of number of patients affected (n),16 , 26 , 28 , 31 , 32 , 35 or number of fracture cases (N).27 , 33 , 34 , 38–42 This prevented pooling of data as it could not be assumed that each fracture case was attributed to an individual patient, such as in patients with multifocal fractures. A paucity of data reporting and stratification was also problematic for reporting substance abuse data, with only 1 study individually stratifying by number of patients using tobacco, alcohol, and illicit drugs.38 No useful data could be extracted from studies like Luz et al.28 that reported all forms of substance abuse (ie, smoking, alcohol, and illicit drug use) in a single category, and many studies did not report substance use data at all (Table 6). Therefore, sample sizes were too small to determine if complications were correlated with any particular type of substance abuse.
Formal statistical analysis in the form of P values or confidence intervals was lacking among included studies to substantiate recommendations supporting shorter treatment delay.8 , 31 , 37 In general, there was a lack of stratified time delay data for cohort study subgroups and case–control subgroups, thereby preventing meaningful statistical calculations that could determine quantitatively if in fact treatment delay was associated with an increased risk of complications. Even in the best-case scenario (Fig. 3), small sample sizes, large confidence intervals, and a heterogeneity score > 50% led our statistician to recommend against pooling of data in a formal meta-analysis.
A well-designed prospective cohort study is the next logical step to answer the question of whether treatment delay is an independent factor impacting postoperative mandible fracture complications and accurately estimate an optimal time threshold for treatment delay. A priori sample size calculations will be necessary to ensure adequate study power for patients and operative characteristics adjustments.47 A prospective design will ensure complete and consistent data collection and reporting for the primary and secondary outcomes, but also ensure appropriate stratification for other factors such as fracture location, fracture etiology, substance abuse, and especially treatment delay data. Based on the most commonly reported complications in this systematic review, we propose that all future studies include the following outcomes: infection (all cause), osteomyelitis, hardware infection, malocclusion, malunion, nonunion, wound dehiscence, and hardware failure (Table 11). Lastly, confounding factors such as substance abuse (ie, tobacco, alcohol, and illicit drugs), noncompliance, fracture complexity, and comorbid injury severity must be collected and controlled for to ensure that treatment delay is the only independent variable in the study design.
There is no consensus on whether ORIF treatment delay is an independent risk factor for the development of postoperative complications in patients with traumatic mandible fractures. There is no consistently utilized time threshold distinguishing “early” versus “delayed” treatment, and 14 of 20 included studies did not conclude that treatment delay was a predictor of postoperative complications. Future well-designed prospective studies of higher methodological quality are essential to determine if there exists an optimal treatment delay threshold that mitigates complication risks.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.
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