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Article

Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis

by
Matthew E. Pontell
1,*,
Eva B. Niklinska
2,
Stephane A. Braun
1,
Nolan Jaeger
3,
Kevin J. Kelly
3 and
Michael S. Golinko
3
1
Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
2
School of Medicine, Vanderbilt University, Nashville, TN, USA
3
Division of Pediatric Plastic Surgery, Division of Cleft and Craniofacial Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2022, 15(3), 189-200; https://doi.org/10.1177/19433875211022573
Submission received: 1 November 2020 / Revised: 1 December 2020 / Accepted: 1 January 2021 / Published: 21 June 2021
Browse Figures
Versions Notes

Abstract

:
Study Design: Pediatric mandible fractures mandate special consideration because of unerupted teeth, mixed dentition, facial growth and the inability to tolerate maxillomandibular fixation. No consensus exists as to whether resorbable or titanium plating systems are superior with regards to clinical outcomes. Objective: This study aims to systematically review and compare the outcomes of both material types in the treatment of pediatric mandible fractures. Methods: After PROSPERO registration, studies from 1990-2020 publishing on outcomes of ORIF of pediatric mandible fractures were systematically reviewed according to PRISMA guidelines. An additional retrospective review was conducted at a pediatric level 1 trauma center. Results: 1,144 patients met inclusion criteria (30.5% resorbable vs. 69.5% titanium). Total complication rate was 13%, and 10% required a second, unplanned operation. Complication rates in the titanium and resorbable groups were not significantly different (14% vs. 10%; P = 0.07), and titanium hardware was more frequently removed on an elective basis (P < 0.001). Condylar/sub-condylar fractures were more often treated with resorbable hardware (P = 0.01); whereas angle fractures were more often treated with titanium hardware (P < 0.001). Within both cohorts, fracture type did not increase the risk of complications, and comparison between groups by anatomic level did not demonstrate any significant difference in complications. Conclusions: Pediatric mandible fractures requiring ORIF are rare, and hardware-specific outcomes data is scarce. This study suggests that titanium and resorbable plating systems are equally safe, but titanium hardware often requires surgical removal. Surgical approach should be tailored by fracture anatomy, age-related concerns and surgeon preference.

Introduction

Pediatric facial fractures are rare, representing less than 15% of craniomaxillofacial (CMF) injuries.[1,2,3,4,5,6,7,8] Roughly half of pediatric facial fractures include the mandible,[1,2] making it one of the most commonly fractured facial bones.[9,10,11] The decreased incidence of CMF fractures results from fibrous and elastic bone that allows for ‘greenstick’ fractures, which less frequently require fixation.[9,12,13,14,15] As such, the need for open reduction and internal fixation (ORIF) is relatively rare in the setting of pediatric facial trauma and is avoided if possible.[16,17,18] ORIF in this population mandates special consideration of unerupted tooth buds, mixed dentition, ongoing growth of the facial skeleton and the relative inability to tolerate maxillomandibular fixation (MMF).[1,15,19] Nonetheless, improperly treated fractures during childhood and adolescence can result in facial asymmetry, poor aesthetic outcomes and malocclusion, which ultimately result in a higher incidence of corrective orthognathic surgery after skeletal maturity.[20,21,22]
Titanium osteosynthesis has been the standard of care for complex mandibular fractures[9,11]; however, risks inherent to non-resorbable systems are of added concern in the pediatric population. Hazards include transcranial implant migration, metallosis, implant extrusion, stress shielding, imaging interference, growth restriction, thermal sensitivity, and ultimately the need for hardware removal with quoted rates as high as 12-18%.[1,9,11,20,23,24,25,26,27,28,29,30,31] As a result of these concerns, bioresorbable poly(lactic acid) (PLA) based fixation systems commonly used in infant cranial vault remodeling have been explored for use in the ORIF of mandible fractures. While a promising alternative, PLA-based systems have been scrutinized on their ability to provide durable rigid fixation in the presence of the complex muscular forces constantly applied to the mandible.[15,32,33,34]
While the debate on hardware superiority continues, concrete evidence remains scarce.
A systematic review and meta-analysis has been published for adults,[35] and a Cochrane analysis was performed for all patients; however, it was aborted due to lack of evidence.[36,37] To date, no comparative systematic analysis has been conducted that compares the outcomes of titanium and resorbable hardware for the ORIF of pediatric mandible fractures.[38] This study aims to systematically review the studies published on outcomes of ORIF of pediatric mandible fractures, and conduct a retrospective institutional review. A comparative analysis will be performed between those treated with both types of hardware in an effort to determine which material demonstrates a superior complication profile.

Materials and Methods

This study was approved by the Institutional Review Board at Vanderbilt University Medical Center (VUMC) (IRB #191822) and registered with PROSPERO international prospective register of systematic reviews (CRD42020207561). Using the criteria set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a systematic review of the literature pertaining to the treatment of pediatric mandible fractures was conducted. Published studies were identified by searching the following databases: MEDLINE, Web of Science, Cochrane Collaboration Library, Google Scholar and EMBASE. The search consisted of studies published in the English language between 1990-2020 using any combination of the following search terms: “pediatric mandible fracture,” “open reduction and internal fixation,” “rigid fixation,” “osteosynthesis,” “resorbable,” “absorbable,” “biodegradable,” “titanium,” “metallic,” and/or “outcomes.”
After the initial list of citations was created, abstracts with relevant titles were reviewed. Studies reporting on treatment outcomes of pediatric traumatic mandible fractures by ORIF were then reviewed further. Pediatric patients were defined as those 18 years of age or younger and pathologic fractures were excluded. The resulting manuscripts were reviewed and included in the final analysis if the outcomes were able to be attributed to the specific type of hardware used. In studies with adult and pediatric patients, information was extracted on those 18 and under on a patient-by-patient basis if outcomes and hardware data were available. Patients treated by open reduction only, closed reduction only, MMF only, ORIF with both titanium and resorbable hardware, and those without documented outcomes were excluded.
A retrospective review was then conducted at Monroe Carell Junior Children’s Hospital at Vanderbilt, which is a pediatric, regional level 1 trauma center. The research derivative, which is a database of clinical data derived from VUMC’s clinical systems that has been restructured for research purposes, was used to query electronic medical records. The research derivative was queried for patients 18 and under, treated at Monroe Carell Junior Children’s Hospital at VUMC from 2003-2020. The search included the following ICD-10 diagnostic codes: S02.600-S02.69, S02.80-S02.82, S02.90-S02.92. Query results included ICD-9 procedure text, and those who underwent ORIF were included for review. Patients were included if they underwent ORIF of a traumatic mandible fracture and the hardware system was documented. Patients with pathologic mandibular fractures, those treated by open reduction only, closed reduction only, MMF only, or ORIF with both titanium and resorbable hardware were excluded. Patients abstracted from the systematic and institutional reviews were then combined into a single database for analysis of demographics, treatment and clinical course (Figure 1). The primary endpoint for analysis was complications of any type. Data analysis was then conducted using SPSS (IBM, USA). Discrete numbers were recorded in percentages. Pearson and 2-proportion 2-tailed z-test calculations were used to determine statistical significance, which was defined as a P value <0.05.

Results

Thirty seven studies met inclusion criteria for systematic review, none of which were prospective, randomized clinical trials[1,9,11,15,16,20,21,23,33,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65] (Table 1). After excluding patients over the age of 18, 1,086 patients from the systematic review and 58 from the institutional cohort were included in the final database (Figure 1, Supplement 1). Only 29 studies provided sufficient information to calculate a mean age. The mean ages of each study are listed in Table 1. The means ranged from 0.5 to 17 years; however, only 1 study had a mean age of 17 years and that study presented only 4 patients for analysis. The mean ages from the remaining studies ranged from 0.5-13.3 years and mean follow up time ranged from 1.5 to 67 months.
Of the 1,144 patients analyzed, 349 were treated by ORIF with resorbable hardware and 795 were treated by ORIF with titanium hardware. Information on patient gender, mechanism of injury and patient age was inconsistently available for patient-by-patient abstraction. Descriptive information regarding fracture anatomy, treatment specifics, complications and management thereof are included in Table 2. Only 362/1,144 patients were able to have outcomes to the specific type of fracture treated and the majority (60.2%) were of the symphyseal/parasymphyseal region. Patients were more often treated by ORIF/MMF vs. ORIF alone (59.4% vs. 40.6%) and most (69.5%) patients were treated with titanium hardware. Total complication rate of all patients was 13% and the most common complication was malocclusion. Only 10% of all patients with complications returned to the operating room for management. The most common operative and non-operative interventions for complications were non-elective hardware removal and placement of guiding elastics, respectively. Just over 65% of all patients underwent elective, planned hardware removal (Table 2). The use of ORIF/ MMF instead of ORIF alone did not decrease complications (13%, 24/187 vs. 8%, 8/95; P = 0.32).
Comparisons between the titanium and resorbable groups revealed that condylar/sub-condylar fractures requiring ORIF were more often treated with resorbable hardware (P = 0.01); whereas angle fractures requiring ORIF were more often treated with titanium hardware (P < 0.001). Patients were more likely to be treated by ORIF/MMF vs. ORIF alone in the resorbable group (P = 0.007). Total complications in the titanium and resorbable groups were 14% and 10% respectively and were not significantly different (P = 0.07). Patients treated by ORIF with titanium hardware were more likely to undergo elective hardware removal (P < 0.001) (Table 3). The percentage of complications between resorbable and titanium groups were then compared and stratified by primary, mixed and adult dentition. In each stage of dentition, the percentage of complications between the 2 hardware groups was not statistically different (Table 4).
Hardware subgroups were then compared and analyzed for factors that were associated with a higher risk of complications. In those treated by ORIF with titanium hardware and those treated with resorbable hardware, the specific type of fracture treated did not increase the risk of complications (Figure 2). Within the resorbable cohort, the use of ORIF/ MMF was associated with an increased risk of complications compared to the use of ORIF alone (12.7% vs. 0%, P = 0.004). This was not true for patients treated by ORIF with titanium hardware. Neither hardware subgroup demonstrated an association between plate thickness and complication risk. The risk of complications by fracture site was then compared by plate material, i.e., risk of complications of ramus ORIF with titanium hardware vs. risk of complications of ramus ORIF with resorbable hardware, and there were no significant differences at any anatomic level.

Discussion

The mandible is one of the most commonly fractured facial bones in the setting of pediatric trauma.[9,10,11] For displaced fractures, ORIF remains the standard of care, even in the pediatric population.[9,11,13,44] In addition to fracture stabilization, ORIF can also reduce the duration of MMF, thereby minimizing the risk of TMJ ankylosis.[9,44,45] Substantial progress in the synthesis of biomaterials has resulted in an increase in the amount of pediatric mandible fractures treated with ORIF.[9] These patients present a particular challenge that requires a careful assessment of the risks and benefits of fixating alloplastic material on a growing facial skeleton.[33] While pediatric mandible fractures are often grouped with midand upper facial fractures during analysis, the loadbearing mandible is subject to a unique set of complex muscular forces. As such, mandible fractures warrant individual analysis, especially with regards to the outcomes of specific plating materials.

Titanium Hardware

Historically, titanium plates and screws have been the standard for the ORIF of mandible fractures given their long history of use.[9,33,66] This systematic review identified twice as many pediatric mandible fractures that were fixed with titanium systems vs. resorbable systems. Proposed advantages of titanium hardware include efficiency in placement due to the self drilling nature of some screws and plate versatility, durability and biocompatibility.[14,66,67,68] In this comparative analysis, titanium plates were more frequently used than resorbable plates in the ORIF of angle and symphysis/parasymphysis fractures (Table 3). This may result from the assumption that titanium better resists the complex muscular forces that act on each of these anatomic locations. It also appears that the use of titanium systems is associated with a lower need for postoperative MMF (Table 3). This may be a result of the presumption that titanium results in a more rigid fixation than resorbable plates. Nevertheless, analysis by fracture location did not demonstrate that titanium was superior or inferior to resorbable hardware with regards to total complications (Figure 2).
Disadvantages of titanium hardware include imaging interference, temperature sensitivity, corrosion, hypersensitivity reactions, stress shielding, hardware translocation through the growing skeleton, palpability, chronic pain and infection.[9,11,14,33,69,70,71,72] The presence of developing dentition deserves special consideration. Depending on the child’s age, dentition status varies considerably. In the primary and mixed dentition phases the majority of the mandibular body can be occupied by tooth buds with displacement of the inferior alveolar nerve increasing the risk of bicortical screw placement. Metal hardware may also translocate through the growing mandible into the tooth buds.[44,55] Nevertheless, total complication rates were not significantly different between hardware. 15/ 1,144 patients required reoperation and only 5 required unplanned hardware extraction (Table 2). Many studies also cite concerns for growth restriction of the developing mandible,[9,11,14,33,55,69,70,71,72] which have resulted in many surgeons electively removing hardware used for rigid fixation at a variable number of months postoperatively. While this effectively resolves the issue of growth retardation, it does subject the patient to a second surgery.[9,11,33,44,55] The literature quotes the need for plate removal in the pediatric patient population around 8%[14] and this systematic review shows that 90% of pediatric mandible fractures underwent elective titanium plate removal (Table 3).

Resorbable Hardware

Attempts to avoid placing permanent hardware in the developing skeleton has led to the continued interest in bioresorbable hardware since the 1960’s.[14,73,74,75] Current biodegradable hardware is composed of polygolic acid (PGA), PLA and their co-polymers.[16] PLA has 2 forms, poly L-lactic acid (PLLA) and poly D-lactic acid (PDLLA), the former of which is most commonly used in combination with PGA. Self-reinforcing (SR) techniques have increased the strength of PLLA and PDLLA poly isomers.[76,77] The use of PGA or PLLA alone has resulted in degradationassociated inflammation and foreign body reactions. As such, neither molecule is used in isolation and it is the PGA to PLLA ratio that determines the implant properties.[14] These implants are hydrolyzed, metabolized into carbon dioxide and water, and eliminated through the pulmonary and renal systems. They hold their strength for at least 4 to 9 weeks[16,29,55] and completely degrade by 1-4 years.[16,44,45,55,67,76,78,79]
While multiple studies have shown that current resorbable systems demonstrate comparable flexural and tensile strength to titanium microplates[11,14,33,80]; many still debate that resorbable systems are unable to withstand the loadbearing forces of the mandible. In this systematic review, overall complications were not significantly different between the groups, and neither material was superior with regards to the outcomes of ORIF of any specific fracture (Table 3, Figure 2). The resorbable nature of the plating systems mitigates the risk of growth restriction, plate infection, implant migration and the need for removal.[1,9,33,46] No patients in this study underwent elective hardware removal in the resorbable group, in comparison to 90% of patients in the titanium group (Table 3). Resorbable screws are also mono-cortical, mitigating the risk of tooth bud and inferior alveolar nerve damage.[21,44] Resorbable plates were more commonly used in the ORIF of condylar/subcondylar fractures (Table 3), presumably due to the difficulty of removal and the likely concomitant use of MMF adding an additional layer of immobilization for what some may presume is a weaker fixation system.
Disadvantages of bioresorbable systems include increased placement difficulty due to the need for predrilling and/or pre-tapping of screw threads and the need for a heating device for plate contouring.[9,14,67,68] Additionally, many studies suggest that bioresorbable materials are unable to replicate the strength of titanium systems to withstand the complex muscular forces acting on the mandible.[14,32,34,55,68,81] Although total complications were not different between the groups, the use of MMF was higher in the resorbable group, suggesting that surgeons may agree with this assumption. This is supported by several clinical studies reporting on the increased use of MMF after ORIF of pediatric mandible fracture with resorbable systems[11,34,44,47,82,83,84] Complications associated with resorbable systems include swelling, fistula formation, sterile abscesses, osteolysis, plate fracture and plate dehiscence.[9,14,23,34,45,47,50,68,82,83,84,85,86,87,88] Lastly, the use of bioresorbable systems for ORIF of mandible fractures is still considered off-label by the US Food and Drug Administration.[14]

Maxillomandibular Fixation

The need for MMF adds a layer of complexity to the management of pediatric mandible fractures. Placement becomes more difficult due to exfoliated teeth and the crown shape of the primary dentition.[44] In addition, MMF is poorly tolerated in younger patients due to the risks of airway compromise, decreased nutritional intake, difficulty phonating, TMJ ankylosis, insomnia and poor oral hygiene.[15,61,89,90,91,92] As such, one goal in the management of pediatric mandible fractures is to minimize and/or completely eliminate the use of MMF.”[15,89,90,93] While MMF was more commonly used in the resorbable subgroup, over 50% of patients in both subgroups still required MMF placement of some duration (Table 3), indicating that neither hardware appears to obviate the need for MMF in the pediatric patient. The use of ORIF was also not associated with a statistically significant decrease in complications. Another disadvantage in the pediatric population is that some form of anesthetic is usually required for MMF removal.[44] In the institutional cohort, 85% (41/48) patients required either intravenous sedation or general anesthesia for MMF removal (Supplement 1).
As a systematic review, this study is limited by the quality of published evidence, which in turn precluded the ability to perform a meta-analysis. The studies that were systematically reviewed were more often than not of low sample size (Table 1). A major limitation of this study was the lack of available data to conduct a subset analysis by stage of dentition. Of the 1,144 patients analyzed in this study, only 184 patients (66 titanium and 108 resorbable) had individual age data available. Most studies reported mean ages, rather than the ages of each patient analyzed. When individual patient ages were available, they were abstracted and input into the master data set. Additionally, many of the studies systematically analyzed presented data on mandible and midfacial fractures mixed together. While the analysis demonstrated no significant difference in complications when patients were stratified by dentition stage, this data should be interpreted with caution given the small sample sizes analyzed. Additionally, due to the relatively short mean follow-up time, conclusions could not be drawn regarding growth restriction. While results were calculated by specific resorbable plate manufacturers, the sample sizes were too small to allow for a meaningful statistical analysis. The institutional review arm of the study was limited by the retrospective, observational nature. Future studies should seek to publish their outcomes with as much patient and treatment specific data as possible to help increase the pool of data available for analysis. Future studies should aim to conduct randomized, controlled clinical trials on the treatment of pediatric mandible fractures by site. Patients should also be controlled for the use of MMF.
In conclusion, this study represents the largest summary of evidence comparing titanium and resorbable hardware for the ORIF of pediatric mandible fractures. The results of this study show that neither titanium nor resorbable hardware has a superior complication profile when treating pediatric mandible fractures that require ORIF. There is no benefit of using one material over the other with regards to specific fracture patterns and neither material obviates the need for MMF. Consideration of the use of resorbable hardware should be given when available, given the noninferior complication profile and the fact that titanium hardware often requires extraction with additional anesthetic. The ultimate choice of hardware selection should remain at the discretion of the surgeon with the goals of obtaining rigid fixation while minimizing MMF and secondary procedures requiring anesthesia.

Supplementary Materials

Supplemental material for this article is available online.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Acknowledgments

The authors would like to thank the Surgical Outcomes Center for Kids (SOCKS) at Monroe Carell Jr. Children’s Hospital at Vanderbilt. Special thanks to M. Owais A. Ghani, MBBS; Brittany E. Lipscomb, CCRP and Heidi Chen, PhD for their assistance with critical data analysis.

Conflicts of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

  1. Singh, M.; Singh, R.K.; 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, 101–106. [Google Scholar] [CrossRef]
  2. McCoy, F.J.; Chandler, R.A.; Crow, M.L. Facial fractures in children. Plast Reconstr Surg. 1966, 37, 209–215. [Google Scholar] [PubMed]
  3. Ferreira, P.C.; Barbosa, J.; Braga, J.M.; Rodrigues, A.; Silva, A.C.; Amarante, J.M. Pediatric facial fractures: a review of 2071 Fractures. Ann Plast Surg. 2016, 77, 54–60. [Google Scholar]
  4. Haug, R.H.; Foss, J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000, 90, 126–134. [Google Scholar] [CrossRef] [PubMed]
  5. Gassner, R.; Tuli, T.; Hachl, O.; Moreira, R.; Ulmer, H. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg. 2004, 62, 399–407. [Google Scholar] [CrossRef]
  6. Gassner, R.; Tuli, T.; Hachl, O.; Rudisch, A.; Ulmer, H. Craniomaxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg. 2003, 31, 51–61. [Google Scholar] [CrossRef]
  7. Hogg, N.J.; Stewart, T.C.; Armstrong, J.E.; Girotti, M.J. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma. 2000, 49, 425–432. [Google Scholar] [PubMed]
  8. Hatef, D.A.; Cole, P.D.; Hollier, L.H., Jr. Contemporary management of pediatric facial trauma. Curr Opin Otolaryngol Head Neck Surg. 2009, 17, 308–314. [Google Scholar] [PubMed]
  9. An, J.; Jia, P.; Zhang, Y.; Gong, X.; Han, X.; He, Y. Application of biodegradable plates for treating pediatric mandibular fractures. J Craniomaxillofac Surg. 2015, 43, 515–520. [Google Scholar]
  10. Grunwaldt, L.; Smith, D.M.; Zuckerbraun, N.S.; et al. Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg. 2011, 128, 1263–1271. [Google Scholar]
  11. Iatrou, I.; Theologie-Lygidakis, N.; Tzerbos, F. Surgical protocols and outcome for the treatment of maxillofacial fractures in children: 9 years’ experience. J Craniomaxillofac Surg. 2010, 38, 511–516. [Google Scholar] [CrossRef]
  12. Rottgers, S.A.; Decesare, G.; Chao, M.; et al. Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme. J Craniofac Surg. 2011, 22, 1260–1265. [Google Scholar] [PubMed]
  13. Zimmermann, C.E.; Troulis, M.J.; Kaban, L.B. Pediatric facial fractures: recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg. 2006, 35, 2–13. [Google Scholar]
  14. Goth, S.; Sawatari, Y.; Peleg, M. Management of pediatric mandible fractures. J Craniofac Surg. 2012, 23, 47–56. [Google Scholar] [PubMed]
  15. Li, Z.; David, O.; Li, Z.B. The use of resorbable plates in association with dental arch stabilization in the treatment of mandibular fractures in children. J Craniomaxillofac Surg. 2014, 42, 548–551. [Google Scholar] [PubMed]
  16. Imola, M.J.; Hamlar, D.D.; Shao, W.; Chowdhury, K.; Tatum, S. Resorbable plate fixation in pediatric craniofacial surgery: long-term outcome. Arch Facial Plast Surg. 2001, 3, 79–90. [Google Scholar]
  17. McNichols, C.H.; Hatef, D.A.; Cole, P.D.; Hollier, L.H., Jr. Optimizing pediatric interdental fixation by use of a paramedian palatal fixation site. J Craniofac Surg. 2012, 23, 605–607. [Google Scholar]
  18. Aizenbud, D.; Emodi, O.; Rachmiel, A. Nonsurgical orthodontic splinting of mandibular fracture in a young child: 10-year follow-up. J Oral Maxillofac Surg. 2008, 66, 575–577. [Google Scholar]
  19. Posnick, J.C.; Wells, M.; Pron, G.E. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofac Surg. 1993, 51, 836–844; discussion 844–835. [Google Scholar]
  20. Burlini, D.; Conti, G.; Amadori, F.; Bardellini, E.; De Giuli, C. Management of paediatric maxillofacial fractures: conventional methods and resorbable materials. Eur J Paediatr Dent. 2015, 16, 24–28. [Google Scholar]
  21. Davison, S.P.; Clifton, M.S.; Davison, M.N.; Hedrick, M.; Sotereanos, G. Pediatric mandibular fractures: a free hand technique. Arch Facial Plast Surg. 2001, 3, 185–189; discussion 190. [Google Scholar] [CrossRef] [PubMed]
  22. Demianczuk, A.N.; Verchere, C.; Phillips, J.H. The effect on facial growth of pediatric mandibular fractures. J Craniofac Surg. 1999, 10, 323–328. [Google Scholar] [CrossRef] [PubMed]
  23. Landes, C.A.; Ballon, A. Indications and limitations in resorbable P(L70/30DL)LA osteosyntheses of displaced mandibular fractures in 4.5-year follow-up. Plast Reconstr Surg. 2006, 117, 577–587; discussion 588–579. [Google Scholar] [CrossRef]
  24. Fiala, T.G.; Paige, K.T.; Davis, T.L.; Campbell, T.A.; Rosen, B.R.; Yaremchuk, M.J. Comparison of artifact from craniomaxillofacial internal fixation devices: magnetic resonance imaging. Plast Reconstr Surg. 1994, 93, 725–731. [Google Scholar] [CrossRef] [PubMed]
  25. Fiala, T.G.; Novelline, R.A.; Yaremchuk, M.J. Comparison of CT imaging artifacts from craniomaxillofacial internal fixation devices. Plast Reconstr Surg. 1993, 92, 1227–1232. [Google Scholar]
  26. Katou, F.; Andoh, N.; Motegi, K.; Nagura, H. Immunoinflammatory responses in the tissue adjacent to titanium miniplates used in the treatment of mandibular fractures. J Craniomaxillofac Surg. 1996, 24, 155–162. [Google Scholar] [CrossRef]
  27. Jorgenson, D.S.; Mayer, M.H.; Ellenbogen, R.G.; et al. Detection of titanium in human tissues after craniofacial surgery. Plast Reconstr Surg. 1997, 99, 976–979; discussion 980–971. [Google Scholar] [CrossRef]
  28. Chaushu, G.; Manor, Y.; Shoshani, Y.; Taicher, S. Risk factors contributing to symptomatic plate removal in maxillofacial trauma patients. Plast Reconstr Surg. 2000, 105, 521–525. [Google Scholar] [CrossRef]
  29. Pietrzak, W.S.; Eppley, B.L. Resorbable polymer fixation for craniomaxillofacial surgery: development and engineering paradigms. J Craniofac Surg. 2000, 11, 575–585. [Google Scholar] [CrossRef]
  30. Nagase, D.Y.; Courtemanche, D.J.; Peters, D.A. Plate removal in traumatic facial fractures: 13-year practice review. Ann Plast Surg. 2005, 55, 608–611. [Google Scholar] [CrossRef]
  31. Francel, T.J.; Birely, B.C.; Ringelman, P.R.; Manson, P.N. The fate of plates and screws after facial fracture reconstruction. Plast Reconstr Surg. 1992, 90, 568–573. [Google Scholar] [PubMed]
  32. Bayram, B.; Araz, K.; Uckan, S.; Balcik, C. Comparison of fixation stability of resorbable versus titanium plate and screws in mandibular angle fractures. J Oral Maxillofac Surg. 2009, 67, 1644–1648. [Google Scholar] [PubMed]
  33. Stanton, D.C.; Liu, F.; Yu, J.W.; Mistretta, M.C. Use of bioresorbable plating systems in paediatric mandible fractures. J Craniomaxillofac Surg. 2014, 42, 1305–1309. [Google Scholar]
  34. Vazquez-Morales, D.E.; Dyalram-Silverberg, D.; Lazow, S.K.; Berger, J.R. Treatment of mandible fractures using resorbable plates with a mean of 3 weeks maxillomandibular fixation: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013, 115, 25–28. [Google Scholar]
  35. Chocron, Y.; Azzi, A.J.; Cugno, S. Resorbable implants for mandibular fracture fixation: a systematic review and metaanalysis. Plast Reconstr Surg Glob Open. 2019, 7, e2384. [Google Scholar] [CrossRef] [PubMed]
  36. Dorri, M.; Nasser, M.; Oliver, R. Resorbable versus titanium plates for facial fractures. Cochrane Database Syst Rev. 2009, CD007158. [Google Scholar]
  37. Dorri, M.; Oliver, R. Withdrawn: Resorbable versus titanium plates for facial fractures. Cochrane Database Syst Rev. 2018, 5, CD007158. [Google Scholar]
  38. Chocron, Y.; Azzi, A.J.; Davison, P. Management of pediatric mandibular fractures using resorbable plates. J Craniofac Surg. 2019, 30, 2111–2114. [Google Scholar]
  39. Hardt, N.; Gottsauner, A. The treatment of mandibular fractures in children. J Craniomaxillofac Surg. 1993, 21, 214–219. [Google Scholar]
  40. Wong, G.B. Pediatric mandibular fractures treated by rigid internal fixation. J Can Dent Assoc. 1993, 59, 759–760. [Google Scholar]
  41. Koltai, P.J.; Amjad, I.; Meyer, D.; Feustel, P.J. Orbital fractures in children. Arch Otolaryngol Head Neck Surg. 1995, 121, 1375–1379. [Google Scholar] [PubMed]
  42. Tuovinen, V.; van Steenis, K.; Sindet-Pedersen, S. Internal fixation of a mandibular fracture in a 6-month-old girl—a case report. Int J Oral Maxillofac Surg. 1995, 24, 210–211. [Google Scholar]
  43. Kumar, A.V.; Staffenberg, D.A.; Petronio, J.A.; Wood, R.J. Bioabsorbable plates and screws in pediatric craniofacial surgery: a review of 22 cases. J Craniofac Surg. 1997, 8, 97–99. [Google Scholar]
  44. Eppley, B.L. Use of resorbable plates and screws in pediatric facial fractures. J Oral Maxillofac Surg. 2005, 63, 385–391. [Google Scholar] [PubMed]
  45. Yerit, K.C.; Hainich, S.; Enislidis, 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. [Google Scholar] [CrossRef]
  46. Senel, F.C.; Tekin, U.S.; Imamoglu, M. Treatment of a mandibular fracture with biodegradable plate in an infant: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006, 101, 448–450. [Google Scholar]
  47. Ferretti, C. A prospective trial of poly-L-lactic/polyglycolic acid co-polymer plates and screws for internal fixation of mandibular fractures. Int J Oral Maxillofac Surg. 2008, 37, 242–248. [Google Scholar] [PubMed]
  48. Poore, M.C.; Penna, K.J. The use of resorbable hardware for fixation of pediatric mandible fracture. Case report. N Y State Dent J. 2008, 74, 58–61. [Google Scholar]
  49. Saikrishna, D.; Gupta, N. Comparison of circummandibular wiring with resorbable bone plates in pediatric mandibular fractures. J Maxillofac Oral Surg. 2010, 9, 116–118. [Google Scholar]
  50. Aldana, P.R.; Wieder, K.; Postlethwait, R.A.; James, H.E.; Steinberg, B. Ultrasound-aided fixation of biodegradable implants in pediatric craniofacial surgery. Pediatr Neurosurg. 2011, 47, 349–353. [Google Scholar] [CrossRef]
  51. Singh, G.; Mohammad, S.; Chak, R.K.; Lepcha, N.; Singh, N.; Malkunje, L.R. Bio-resorbable plates as effective implant in paediatric mandibular fracture. J Maxillofac Oral Surg. 2012, 11, 400–406. [Google Scholar] [CrossRef] [PubMed]
  52. Kim, T.W.; Seo, E.W.; Song, S.I. Open reduction and internal fixation of mandibular fracture in an 11-month-old infant: a case report. J Korean Assoc Oral Maxillofac Surg. 2013, 39, 90–93. [Google Scholar] [CrossRef] [PubMed]
  53. Ongodia, D.; Li, Z.; Xing, W.Z.; Li, Z.B. Resorbable plates for fixation of complicated mandibular fractures in children. J Maxillofac Oral Surg. 2014, 13, 99–103. [Google Scholar] [CrossRef]
  54. Zhang, B.; Liu, Z.H.; Li, J.; Zhang, K.; Chen, J.J.; Zhang, R.M. 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, 1987–1992. [Google Scholar] [CrossRef]
  55. Taylan Filinte, G.; Akan, I.M.; Aycicek Cardak, G.N.; Ozkaya Mutlu, O.; Akoz, T. Dilemma in pediatric mandible fractures: Resorbable or metallic plates? Ulus Travma Acil Cerrahi Derg. 2015, 21, 509–513. [Google Scholar] [CrossRef] [PubMed]
  56. Joshi, S.; Kshirsagar, R.; Mishra, A.; Shah, R. Clinical efficacy of open reduction and semirigid internal fixation in management of displaced pediatric mandibular fractures: a series of 10 cases and surgical guidelines. J Indian Soc Pedod Prev Dent. 2015, 33, 161–165. [Google Scholar] [CrossRef]
  57. Mazeed, A.S.; Shoeib, M.A.; Saied, S.M.; Elsherbiny, A. Early experience with biodegradable fixation of pediatric mandibular fractures. Craniomaxillofac Trauma Reconstr. 2015, 8, 205–210. [Google Scholar] [CrossRef]
  58. Sheta, M.S.; Shoushan, M.M.; Hussein, M.M.; Abd Elaal, S.E. Evaluation of using microplates osteosynthesis for pediatric mandibular fractures. Tanta Dental Journal. 2015, 12, 149–155. [Google Scholar] [CrossRef]
  59. Sukegawa, S.; Kanno, T.; Katase, N.; Shibata, A.; Takahashi, Y.; Furuki, Y. Clinical evaluation of an unsintered hydroxyapatite/poly-L-lactide osteoconductive composite device for the internal fixation of maxillofacial fractures. J Craniofac Surg. 2016, 27, 1391–1397. [Google Scholar] [CrossRef]
  60. Wong, F.K.; Adams, S.; Hudson, D.A.; Ozaki, W. Use of resorbable fixation system in pediatric facial fractures. J Craniofac Surg. 2017, 28, 635–637. [Google Scholar] [CrossRef]
  61. El-Anwar, M.W.; Salah, M.; Abdulmonaem, G. C-arm-assisted internal fixation of pediatric mandibular fracture. Egypt J Otolaryngol. 2018, 34, 122–126. [Google Scholar] [CrossRef]
  62. McGoldrick, D.M.; Parmar, P.; Williams, R.; Monaghan, A.; McMillan, K. Management of pediatric condyle fractures. J Craniofac Surg. 2019, 30, 2045–2047. [Google Scholar] [CrossRef]
  63. Tusek, I.; Ilic, M.P.; Tusek, J.; Ivic, S.; Tusek, B. Pediatric mandibular fracture therapy—a case report. Vojnosanitetski Pregled. 2020, 77, 647–650. [Google Scholar] [CrossRef]
  64. Fernández, E.C.; Moreira, E.M.; Martínez, A.P. Mandible fracture in children: a case report. South Sudan Medical Journal. 2020, 13, 116–119. [Google Scholar]
  65. Yesantharao, P.S.; Lopez, J.; Reategui, A.; et al. Managing isolated symphyseal and parasymphyseal fractures in pediatric patients. J Craniofac Surg. 2020, 31, 1291–1296. [Google Scholar] [CrossRef] [PubMed]
  66. Siy, R.W.; Brown, R.H.; Koshy, J.C.; Stal, S.; Hollier, L.H., Jr. General management considerations in pediatric facial fractures. J Craniofac Surg. 2011, 22, 1190–1195. [Google Scholar] [CrossRef]
  67. Bell, R.B.; Kindsfater, C.S. The use of biodegradable plates and screws to stabilize facial fractures. J Oral Maxillofac Surg. 2006, 64, 31–39. [Google Scholar] [CrossRef]
  68. Bos, R.R. Treatment of pediatric facial fractures: the case for metallic fixation. J Oral Maxillofac Surg. 2005, 63, 382–384. [Google Scholar] [CrossRef]
  69. Manson, P.N. Commentary on the long-term effects of rigid fixation on the growing craniomaxillofacial skeleton. J Craniofac Surg. 1991, 2, 60–70. [Google Scholar]
  70. Murthy, A.S.; Lehman, J.A., Jr. Symptomatic plate removal in maxillofacial trauma: a review of 76 cases. Ann Plast Surg. 2005, 55, 603–607. [Google Scholar] [CrossRef]
  71. Tatum, S.A., 3rd. Retrospective review of resorbable plate fixation in pediatric craniofacial surgery: long-term outcome. Arch Facial Plast Surg. 2012, 14, 11–13. [Google Scholar] [CrossRef]
  72. Berryhill, W.E.; Rimell, F.L.; Ness, J.; Marentette, L.; Haines, S.J. Fate of rigid fixation in pediatric craniofacial surgery. Otolaryngol Head Neck Surg. 1999, 121, 269–273. [Google Scholar] [CrossRef]
  73. Degala, S.; Shetty, S.; Ramya, S. Fixation of zygomatic and mandibular fractures with biodegradable plates. Ann Maxillofac Surg. 2013, 3, 25–30. [Google Scholar] [CrossRef] [PubMed]
  74. Leenslag, J.W.; Pennings, A.J.; Bos, R.R.; Rozema, F.R.; Boering, G. Resorbable materials of poly(L-lactide). VII. In vivo and in vitro degradation. Biomaterials 1987, 8, 311–314. [Google Scholar]
  75. Leenslag, J.W.; Pennings, A.J.; Bos, R.R.; Rozema, F.R.; Boering, G. Resorbable materials of poly(L-lactide). VI. Plates and screws for internal fracture fixation. Biomaterials 1987, 8, 70–73. [Google Scholar] [CrossRef]
  76. Ashammakhi, N.; Peltoniemi, H.; Waris, E.; et al. Developments in craniomaxillofacial surgery: use of self-reinforced bioabsorbable osteofixation devices. Plast Reconstr Surg. 2001, 108, 167–180. [Google Scholar] [PubMed]
  77. Tormala, P. Biodegradable self-reinforced composite materials; manufacturing structure and mechanical properties. Clin Mater. 1992, 10, 29–34. [Google Scholar] [PubMed]
  78. Cheung, L.K.; Chow, L.K.; Chiu, W.K. A randomized controlled trial of resorbable versus titanium fixation for orthognathic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004, 98, 386–397. [Google Scholar]
  79. Laughlin, R.M.; Block, M.S.; Wilk, R.; Malloy, R.B.; Kent, J.N. Resorbable plates for the fixation of mandibular fractures: a prospective study. J Oral Maxillofac Surg. 2007, 65, 89–96. [Google Scholar]
  80. Wittenberg, J.M.; Wittenberg, R.H.; Hipp, J.A. Biomechanical properties of resorbable poly-L-lactide plates and screws: a comparison with traditional systems. J Oral Maxillofac Surg. 1991, 49, 512–516; discussion 517–518. [Google Scholar]
  81. Esen, A.; Ataoglu, H.; Gemi, L. Comparison of stability of titanium and absorbable plate and screw fixation for mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008, 106, 806–811. [Google Scholar] [PubMed]
  82. Kallela, I.; Iizuka, T.; Salo, A.; Lindqvist, C. Lag-screw fixation of anterior mandibular fractures using biodegradable polylactide screws: a preliminary report. J Oral Maxillofac Surg. 1999, 57, 113–118. [Google Scholar] [PubMed]
  83. Lee, H.B.; Oh, J.S.; Kim, S.G.; et al. Comparison of titanium and biodegradable miniplates for fixation of mandibular fractures. J Oral Maxillofac Surg. 2010, 68, 2065–2069. [Google Scholar]
  84. Yerit, K.C.; Enislidis, G.; Schopper, C.; et al. Fixation of mandibular fractures with biodegradable plates and screws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002, 94, 294–300. [Google Scholar]
  85. Agarwal, S.; Gupta, A.; Grevious, M.; Reid, R.R. Use of resorbable implants for mandibular fixation: a systematic review. J Craniofac Surg. 2009, 20, 331–339. [Google Scholar] [CrossRef] [PubMed]
  86. Turvey, T.A.; Bell, R.B.; Phillips, C.; Proffit, W.R. Self-reinforced biodegradable screw fixation compared with titanium screw fixation in mandibular advancement. J Oral Maxillofac Surg. 2006, 64, 40–46. [Google Scholar] [CrossRef]
  87. Mackool, R.; Yim, J.; McCarthy, J.G. Delayed degradation in a resorbable plating system. J Craniofac Surg. 2006, 17, 194–197; discussion 197–198. [Google Scholar]
  88. Yerit, K.C.; Hainich, S.; Turhani, D.; et al. Stability of biodegradable implants in treatment of mandibular fractures. Plast Reconstr Surg. 2005, 115, 1863–1870. [Google Scholar]
  89. Kocabay, C.; Atac, M.S.; Oner, B.; Gungor, N. The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: a case report. Dent Traumatol. 2007, 23, 247–250. [Google Scholar]
  90. Glazer, M.; Joshua, B.Z.; Woldenberg, Y.; Bodner, L. Mandibular fractures in children: analysis of 61 cases and review of the literature. Int J Pediatr Otorhinolaryngol. 2011, 75, 62–64. [Google Scholar]
  91. Ferreira, P.C.; Barbosa, J.; Amarante, J.M.; Carvalho, J.; Rodrigues, A.G.; Silva, A.C. Associated injuries in pediatric patients with facial fractures in Portugal: analysis of 1416 patients. J Craniomaxillofac Surg. 2015, 43, 437–443. [Google Scholar] [CrossRef] [PubMed]
  92. Schneider, M.; Erasmus, F.; Gerlach, K.L.; et al. Open reduction and internal fixation versus closed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process: a randomized, prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg. 2008, 66, 2537–2544. [Google Scholar] [CrossRef] [PubMed]
  93. Ferreira, P.; Silva, N.; Silva, A.; et al. Pediatric facial fractures. Characteristics of Portuguese population. Acta Med Port. 2004, 17, 123–128. [Google Scholar] [PubMed]
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Figure 1. Trial flow diagram demonstrating the process by which patients were selected for systematic and institutional review.
Figure 1. Trial flow diagram demonstrating the process by which patients were selected for systematic and institutional review.
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Figure 2. Image depicts 2 separate analyses. On the left, complication rates for resorbable fixation are listed by fracture site, statistical analysis was then performed to determine if the use of resorbable hardware for ORIF of any of the fractures listed increased the risk of complications in the resorbable subgroup. The process was then repeated on the right side for the titanium subgroup. A separate analysis was then performed comparing the risk of complications between the titanium and resorbable subgroups by fracture site.
Figure 2. Image depicts 2 separate analyses. On the left, complication rates for resorbable fixation are listed by fracture site, statistical analysis was then performed to determine if the use of resorbable hardware for ORIF of any of the fractures listed increased the risk of complications in the resorbable subgroup. The process was then repeated on the right side for the titanium subgroup. A separate analysis was then performed comparing the risk of complications between the titanium and resorbable subgroups by fracture site.
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Table 1. Summary of Studies Included in Systematic Review and Final Comparative Analysis.
Table 1. Summary of Studies Included in Systematic Review and Final Comparative Analysis.
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*Number of patients included in final analysis; **Plate manufacturer for resorbable systems. Monroe Carrel Jr. Children’s Hospital at Vanderbilt; LactoSorb (Zimmer Biomet, Jacksonville, FL); OSTEOTRANS MX (Takiron Co, Ltd., Osaka, Japan); SK Surgical (Pune, India); BioSorb FX (Linvatec Corp, Largo, FL); MacroSorb (MacroPore, San Diego, CA); PolyMax (Synthes, Oberdorf, Switzerland); Inion CPS (Inion, Tampere, Finland); Delta (Stryker, Kalamazoo, MI); SonicWeld Rx (KLS Martin, Jacksonville, FL); Grand Fix (Gunze Ltd., Kyoto, Japan); Rapidsorb (Synthes, Oberdorf, Switzerland).
Table 2. Analysis of Total Patient Sample.
Table 2. Analysis of Total Patient Sample.
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Information on age, gender and mechanism of injury were inconsistently available and unable to be abstracted by individual patients in most studies. ORIF – open reduction and internal fixation, MMF – maxillomandibular fixation, SSI – surgical site infection, I&D – incision and drainage/debridement. KLS (KLS Martin, Jacksonville, FL); Synthes (Synthes, Oberdorf, Switzerland); Stryker (Stryker, Kalamazoo, MI); LactoSorb (Zimmer Biomet, Jacksonville, FL); OSTEOTRANS MX (Takiron Co, Ltd., Osaka, Japan); SK Surgical (Pune, India); BioSorb FX (Linvatec Corp, Largo, FL); MacroSorb (MacroPore, San Diego, CA); PolyMax (Synthes, Oberdorf, Switzerland); Inion CPS (Inion, Tampere, Finland); Delta (Stryker, Kalamazoo, MI); SonicWeld Rx (KLS Martin, Jacksonville, FL); Grand Fix (Gunze Ltd., Kyoto, Japan); Rapidsorb (Synthes, Oberdorf, Switzerland).
Table 3. Treatment Comparisons Between Patients Undergoing ORIF with Titanium or Resorbable Systems.
Table 3. Treatment Comparisons Between Patients Undergoing ORIF with Titanium or Resorbable Systems.
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ORIF—open reduction and internal fixation, MMF – maxillomandibular fixation. 1Groups were compared using Pearson’s chi-squared test with P values of less than 0.05 were considered significant. Bolded and italicized values indicate statistical significance.
Table 4. Comparison of Complications Between Hardware Groups By Dentition Stage.
Table 4. Comparison of Complications Between Hardware Groups By Dentition Stage.
Titanium System ComplicationsResorbable System ComplicationsTest Statistic1
Dentition Stage
 • Primary12.5% (3/24)13.3% (4/30)P = 1.00
 • Mixed12% (3/25)6.7% (3/45)P = 0.66
 • Adult11.1% (3/27)6.1% (2/33)P = 0.65
Primary dentition stage was defined as 6 months to 6 years, mixed dentition stage was defined as > 6 years until 12 years and adult dentition stage was defined as greater than 12 years. 1Groups were compared using Fisher’s 2-tailed t test with P values of less than 0.05 were considered significant. Bolded and italicized values indicate statistical significance.

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MDPI and ACS Style

Pontell, M.E.; Niklinska, E.B.; Braun, S.A.; Jaeger, N.; Kelly, K.J.; Golinko, M.S. Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis. Craniomaxillofac. Trauma Reconstr. 2022, 15, 189-200. https://doi.org/10.1177/19433875211022573

AMA Style

Pontell ME, Niklinska EB, Braun SA, Jaeger N, Kelly KJ, Golinko MS. Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis. Craniomaxillofacial Trauma & Reconstruction. 2022; 15(3):189-200. https://doi.org/10.1177/19433875211022573

Chicago/Turabian Style

Pontell, Matthew E., Eva B. Niklinska, Stephane A. Braun, Nolan Jaeger, Kevin J. Kelly, and Michael S. Golinko. 2022. "Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis" Craniomaxillofacial Trauma & Reconstruction 15, no. 3: 189-200. https://doi.org/10.1177/19433875211022573

APA Style

Pontell, M. E., Niklinska, E. B., Braun, S. A., Jaeger, N., Kelly, K. J., & Golinko, M. S. (2022). Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis. Craniomaxillofacial Trauma & Reconstruction, 15(3), 189-200. https://doi.org/10.1177/19433875211022573

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