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Potentially modifiable patient factors in mandible fracture complications: a

systematic review and meta-analysis

Asad Ahmed, Eiling Wu, Rupinder Sarai, Rhodri Williams, John Breeze

PII: S0266-4356(21)00253-9
DOI: [Link]
Reference: YBJOM 6521

To appear in: British Journal of Oral & Maxillofacial Surgery

Received Date: 15 March 2021

Accepted Date: 4 July 2021

Please cite this article as: A. Ahmed, E. Wu, R. Sarai, R. Williams, J. Breeze, Potentially modifiable patient
factors in mandible fracture complications: a systematic review and meta-analysis, British Journal of Oral &
Maxillofacial Surgery (2021), doi: [Link]

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Potentially modifiable patient factors in mandible fracture
complications: a systematic review and meta-analysis
Asad Ahmed, Email: [Link]@[Link]
Eiling Wu, Email: eilingwu@[Link]
Rupinder Sarai, Email: [Link]@[Link]
Rhodri Williams, Email: [Link]@[Link]
John Breeze, Email: [Link]@[Link],b
a Department of Maxillofacial Surgery, University Hospitals Birmingham, Mindelsohn Way,
Birmingham, B15 2TH
b Royal Centre for Defence Medicine, University Hospitals Birmingham, Mindelsohn Way,

Birmingham, B15 2TH

Corresponding Author:
Name: Asad Ahmed
Email: [Link]@[Link]
Address: Department of Oral and Maxillofacial Surgery, University Hospitals Birmingham,
Mindelsohn Way, Birmingham, B15 2TH

Potentially modifiable patient factors in mandible fracture

complications: a systematic review and meta-analysis

Abstract
Introduction: The mandible is the most common bone to develop complications following

treatment of facial fractures. This is due to a complex interaction of both fracture specific

and patient factors. Our aim was to identify those patient factors, with a specific focus on

those that may be potentially modifiable to reduce the incidence of complications.

Method: A systematic review of the literature was undertaken using the Preferred

Reporting Items for Systematic Reviews and Meta-Analyses methodology to identify patient

factors ascribed to an increased risk of complications following mandible fracture

treatment. These were divided non- modifiable and potentially modifiable factors. A meta-
analysis was performed to weight those factors for which statistical analysis had been

performed.

Results: 22 pertinent papers were identified, of which 8 described non-modifiable and 7

potentially modifiable factors. The most common potentially modifiable factor identified

was smoking. Meta-analysis established that tobacco smoking demonstrated an increased

risk of complications in three studies (OR: 4.04 – 8.09).

Conclusions: Division of patient factors into those that are potentially modifiable and those

that are not will enable clinicians to focus on those in which change within the immediate

post-operative period can be instigated. This includes smoking cessation assistance,

education as to the need for a soft diet and facilitating post- operative clinic attendance. It

also enables stratification of risk in terms of consent, and choice of treatment. Further

research should use standardised terminology, particularly in stopping the use of

generalizable terms such as patient compliance and instead describing its individual

components.

Keywords: Morbidity, Mandible, Complication, Surgery, Treatment, Compliance

Introduction
The mandible is the most commonly fractured bone in the maxillofacial region1 with most

fractures requiring emergency admission and treatment. This is usually by surgical

intervention with fixation using either load-sharing or load-bearing osteosynthesis. This

incurs a significant financial burden to healthcare systems; an NHS report for the 2017/2018

period demonstrated the unit costs for each emergency hospital admission to be in the

region of £1,600.2 Complications following surgical intervention can further add to this

financial burden particularly where quality of life is affected. Such complications include

altered sensation, fracture mobility and malocclusion, of which many will require re-

treatment. Comparisons of complications are difficult to make reflecting the heterogeneity

of fracture types, treatment performed and underlying patient factors.3

Determining the reasons for failure of mandible fracture fixation is dependent upon

identifying a complex interplay of variables including injury characteristics (e.g., fracture

location and degree of comminution) and patient factors. Patient factors can include

systemic conditions that increase the risk of infection. For example, post- operative

infections in diabetic patients are more common due to the hyperglycaemic environment

which favours immune dysfunction.4 Other patient factors that are broadly termed ‘patient

compliance’ are often implicated in unsuccessful treatment. However, what actually

constitutes patient compliance is not agreed upon, but commonly includes a soft diet and

cessation of tobacco smoking.

Identification of those factors that may alter the choice of fixation, or are more likely to

result in post-operative complications, are important in reducing patient morbidity and

reduce the financial burden of treatment. The aim of this systematic review was to identify

patient factors increasing the risk of complications, and dividing those into factors that are

inherent (non-modifiable) and those that could be altered by the patient (potentially

modifiable). The latter would include factors traditionally incorporated in patient

compliance, but any that clinicians could potentially modify.

Materials and Methods

A systematic review of the literature was undertaken using the Preferred Reporting Items

for Systematic Reviews and Meta-Analyses methodology 5 to identify patient factors

ascribed to an increased risk of complications following mandible fracture treatment.

Complications within our analysis included wound dehiscence, malocclusion, mal-union,

non-union, hardware exposure, infection and return to theatre. Databases searched

comprised PubMed, Google Scholar and Cochrane Library. The following keywords were
used: facial fractures, mandibular fractures, patient compliance, non-compliance and risk

factors. Inclusion criteria were all mandibular fractures requiring open reduction and

internal fixation. Exclusion criteria comprised any mandibular fractures managed non-

operatively and pathological fractures of the mandible. Patient factors were divided into

those that were non-modifiable and those that were potentially modifiable. Medical co-

morbidities were defined as non-modifiable for the purpose of this analysis. A meta-analysis

was performed to weight those patient factors in which statistical analysis had been

performed in the original paper.

Results
Database searching identified 102 papers, which was supplemented by 8 additional papers

that were identified from reading the references from those papers (Figure 1). No

systematic reviews on the subject have been published. 22 pertinent papers describing

patient factors were identified3,6–24, including 7 potentially modifiable and 8 non-modifiable

factors (Table 1).

Figure 1: Results of systematic review using Preferred Reporting Items for Systematic Reviews and Meta-
analyses methodology 5

Potentially modifiable factors Non-modifiable factors

 Smoking 3,6,7,10–16,18,19,22,23 Age 3,6–8,10–19,21,22
Alcohol abuse 6,9–11,13,15,16,18–20,22,23 Gender 3,6–8,10–16,18,19,21,22
Substance Abuse 10,11,13,15,16,18–20,23 Ethnicity 3,6,13,14,21,22
Use of antibiotics 3,7,9–11,13,15,17,18 Employment status 11,13,19,21
Use of antiseptic mouthwash 11,13,18 Insurance 13,14
Soft diet 11,13 Distance from hospital 11,13,14
Poor attendance at follow-up Medical Comorbidities’ 3,6,7,12,13,16,18,20,22,23
appointments 10,11,17,18,21 Poor dental health 9–12,16
Table 1: 22 papers identified patient factors causing increased risk of complications following mandible fracture
treatment. These are categorised by those that are potentially modifiable vs non-modifiable

10 papers were identified that found statistical significance for one or more potentially

modifiable and non-modifiable patient factors (Table 2). Stewart et al.21 investigated factors

predictive of poor compliance not factors predictive of complications.

Lead author Statistically significant factors Statistically non-significant factors

Gutta 3 Smoking Age, Gender, Ethnicity
Medical comorbidities Use of antibiotics
Daar 6 Age Gender, Ethnicity
Smoking Medical comorbidities
Alcohol abuse
Chen 7 Smoking Age, Gender
Medical comorbidities
Use of antibiotics
Hurrell 11 None Age, Gender, Distance from hospital,
Dental status, Alcohol abuse, Substance
abuse, Smoking, Employment, Use of
antibiotics, Use of mouthwash, Soft
diet, follow-up appointment attendance
Odom 12 Smoking Age, Gender
Medical comorbidities
Dental status
Hsieh 13 Smoking Age, Gender, Ethnicity
Distance from hospital Insurance
Alcohol abuse
Substance abuse
Use of mouthwash
 Use of antibiotics
Soft diet
Radabaugh 14 Smoking Age
Gender
Ethnicity
Distance from hospital
Furr 15 Smoking Age, Gender
Alcohol abuse Use of antibiotics
Substance abuse
Luz 16 Smoking Age, Gender
Alcohol abuse Medical comorbidities
Substance abuse
Dental status
Christensen 18 Medical comorbidities Age, Gender
Non-compliance Alcohol abuse
Smoking
Use of mouthwash
Use of antibiotics
Table 2: Statistically significant and non-significant factors identified as causing increased risk of complications
following mandible fracture treatment

Non-modifiable factors

Daar et al. found older age (mean age: 35 years) to be a significant risk factor for

reoperation. It was overwhelmingly more likely for males to sustain a mandibular fracture

compared to females.3,6–8,10–16,18,19,21,22 Ethnicity was also considered in the majority of

studies but only Stewart et al.21 found ethnicity to be significant, specifically with respect to

poor compliance with follow-up care.

Employment status was generally categorised as either employed or un-employed and no

statistical significance was ascribed to this factor. Having medical insurance and the

different subtypes (such as Medicaid) was investigated by two American studies, but neither

found any subgroup to be statistically significant with respect to complications following the

treatment of mandibular fractures.13,14

The distance the patient lived from the hospital was investigated by 3 studies11,13,14, with

one being statistically significant.13 The rationale for investigating this was that patients

living closer to the hospital are more likely to attend follow-up appointments and access to

specialised care is improved.

Ten studies investigated the impact of medical comorbidities on the risk of complications

following mandibular fracture fixation.3,6,7,12,13,16,18,20,22,23 The most common comorbidities

identified were diabetes, heart disease, COPD, bleeding disorders and immunosuppression.

Studies by Gutta3 and Christensen18 were the only studies to find medical comorbidities to

be statistically significant but only the latter provided an odds ratio (OR: 2.404).

Dental status was recognised as an independent risk factor for developing complications.

but only Luz et al.16 found it to be statistically significant (p < 0.001).

Seven Potentially modifiable factors

Cigarette smoking, alcohol and substance abuse were significantly more likely to result in

complications.3,6,7,12–16 Use of antibiotics was described by half of the papers identified but

definitions varied and none were found to be significant. Most commonly this was defined

as antibiotics administration during hospital stay, but two studies defined this as completion

of the antibiotic course following discharge.11,17

Attendance at follow-up appointments was investigated by five papers.10,11,17,18,21 Although

Stewart et al.21 found poor attendance at follow-up appointments to be predictive of poor

compliance, none of the studies found it to be predictive of increased risk of complications.

Meta-analysis of statistically significant variables

Meta-analysis demonstrated that tobacco smoking was associated with an increased risk of

complications in three studies (OR 4.04 - 8.09). Radabaugh et al.14 demonstrated that

smoking was associated with an increased odds of non-compliance but did not relate to

complications. Christensen et al.18 identified ‘non- compliance’ as a statistically significant

increased risk of odds for complications but did not describe what the term actually meant.

Hurrell et al.11 analysed the effects of five individual variables as part of patient compliance

(such as mouthwash use or soft diet) on eight treatment outcomes (such as non-union or

return to theatre) but none reached statistical significance.

Author Factor Odds 95% Confidence P-value

Ratio Interval (CI)
(OR)
Hsieh 13 Smoking 8.09 1.26 – 51.78 0.03
Chen 7 Smoking 4.04 1.07 – 15.34 0.04
Daar 6 Smoking 4.86 1.17 – 20.12 0.03
Daar 6 Age * 1.03 1.01 – 1.05 0.02
Christensen 18 Medical comorbidities * 2.404 1.118 – 5.171 0.025
Christensen 18 Non-compliance 3.539 1.435 – 8.728 0.006
Hsieh 13 Living in same city as medical 0.08 0.01 – 0.69 0.02
centre *
Table 3: Meta-analysis of statistically significant variables pertaining to the odds of developing complications
following mandible fracture fixation. Morbidities with * are not modifiable.

Discussion
Patient factors are an important cause of complications following treatment of mandibular

fractures with patient compliance in particular being critical to a successful outcome. The
term patient compliance is used loosely in the literature and pertains to factors which

clinicians consider the patient is directly responsible for and can potentially alter. This

includes a soft diet, cigarette smoking, wound hygiene and avoidance of further trauma to

the area. However, using the term patient compliance may have negative connotations

because it suggests that the patient alone is responsible for failure in these cases. Successful

treatment of mandible fractures is more about identification of risk factors, using those to

correctly determine the type of surgery (such as load sharing fixation), and correcting those

factors that are within both the patients and clinician’s control. For this reason, we have

chosen to divide patient factors into those that are non-modifiable and those that are

potentially-modifiable.

Our systematic review has demonstrated that in the existing literature, there are 7 patient

factors that are potentially modifiable. Of these, smoking was the only potentially

modifiable factor that was statistically significant on meta-analysis. Nicotine in cigarettes

causes ischaemia and vasoconstriction, thereby impairing healing, particularly intra-oral

incisions.25 The effect of smoking was clear, with three studies demonstrating increased

odds of post-operative complications6,7,13 and one study indicated tobacco use was

negatively associated post-operative compliance.14 Alcohol has been established as a major

risk factor for traumatic injuries26. Within our review, alcohol and substance abuse were

identified as being associated with increased risks of complications following mandibular

fracture treatment, two studies found this to be statistically significant.15,16 Alcohol has been

shown to significantly impair wound angiogenesis.25 Those with high alcohol intakes are at

increased risk of re-injury and this may occur within the immediate post-operative period

but not be reported.27–29

Patient compliance is a broad term used in the literature to describe multiple factors that

are thought to be directly controllable by a patient; compliance with such factors will reduce

the chances of complications and prediction of compliance can be used to choose the most

pertinent type of fixation. Many papers however did not break down patient compliance

further, which limits its use a term as it ranges from continuation of smoking, not adhering

to a soft diet to lack of attendance at follow up appointments. What the literature does not

demonstrate though is how we as clinicians can assist in improving compliance.

Understanding of their importance can be improved through education such as patient

information leaflets and detailed post- operative instructions. Follow up attendance can be

assisted in some cases by virtual appointments. Tobacco replacement therapy is not

routinely provided in most institutions, yet cigarette smoking was demonstrated to be the

most important potentially modifiable factor in failure.

While our analysis focuses on patient factors, we recognise the role of non-modifiable

factors such as fracture pattern and complexity which are out of the surgeon’s control yet

can influence the incidence of complications. Luz et al.16 demonstrated in patients where

there were multiple fractures and/or a higher degree of fragmentation, retreatment was

more likely. These more complex cases should be identified early on so that both the most

appropriate fixation technique is utilised and seniority of surgeon required to be present is

identified.

Lastly, we acknowledge a number of limitations in this analysis, most of which are inherent

to the data identified. Only 4 papers were identified that described odds ratios of statistical

significance, potentially leading to reporting bias. Multiple papers used ambiguous

terminology, and in particular the use of the words ‘poor patient compliance’ which limited

comparisons between studies.

Conclusions
Division of patient factors into those that are potentially modifiable and those that are not

will enable clinicians to focus on those in which change within the immediate post-operative

period can be instigated. This includes smoking cessation assistance, education as to the

need for a soft diet and facilitating post- operative clinic attendance. It also enables

stratification of risk in terms of consent, and choice of treatment including fixation types.

Further research should use standardised terminology, particularly in stopping the use of

generalizable terms such as patient compliance and instead describing its individual

components.

Conflict of Interest
We have no conflicts of interest.

Ethics statement/confirmation of patient’s permission

Neither was required for this review
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Figure 2, Results of systematic review using Preferred Reporting Items for Systematic Reviews and Meta-
analyses methodology 5

Potentially modifiable factors Non-modifiable factors

Smoking 3,6,7,10–16,18,19,22,23 Age 3,6–8,10–19,21,22
Alcohol abuse 6,9–11,13,15,16,18–20,22,23 Gender 3,6–8,10–16,18,19,21,22
Substance Abuse 10,11,13,15,16,18–20,23 Ethnicity 3,6,13,14,21,22
Use of antibiotics 3,7,9–11,13,15,17,18 Employment status 11,13,19,21
Use of antiseptic mouthwash 11,13,18 Insurance 13,14
Soft diet 11,13 Distance from hospital 11,13,14
 Poor attendance at follow-up Medical Comorbidities’ 3,6,7,12,13,16,18,20,22,23
appointments 10,11,17,18,21 Poor dental health 9–12,16
Table 3: 22 papers identified patient factors causing increased risk of complications following mandible fracture
treatment. These are categorised by those that are potentially modifiable vs non-modifiable

Lead author Statistically significant factors Statistically non-significant factors

Gutta 3 Smoking Age, Gender, Ethnicity
Medical comorbidities Use of antibiotics
Daar 6 Age Gender, Ethnicity
Smoking Medical comorbidities
Alcohol abuse
Chen 7 Smoking Age, Gender
Medical comorbidities
Use of antibiotics
Hurrell 11 None Age, Gender, Distance from hospital,
Dental status, Alcohol abuse, Substance
abuse, Smoking, Employment, Use of
antibiotics, Use of mouthwash, Soft
diet, follow-up appointment attendance
Odom 12 Smoking Age, Gender
Medical comorbidities
Dental status
Hsieh 13 Smoking Age, Gender, Ethnicity
Distance from hospital Insurance
Alcohol abuse
Substance abuse
Use of mouthwash
Use of antibiotics
Soft diet
Radabaugh 14 Smoking Age
Gender
Ethnicity
Distance from hospital
Furr 15 Smoking Age, Gender
Alcohol abuse Use of antibiotics
Substance abuse
Luz 16 Smoking Age, Gender
Alcohol abuse Medical comorbidities
Substance abuse
Dental status
Christensen 18 Medical comorbidities Age, Gender
Non-compliance Alcohol abuse
Smoking
 Use of mouthwash
Use of antibiotics
Table 4: Statistically significant and non-significant factors identified as causing increased risk of complications
following mandible fracture treatment

Author Factor Odds 95% Confidence P-value

Ratio Interval (CI)
(OR)
Hsieh 13 Smoking 8.09 1.26 – 51.78 0.03
Chen 7 Smoking 4.04 1.07 – 15.34 0.04
Daar 6 Smoking 4.86 1.17 – 20.12 0.03
Daar 6 Age * 1.03 1.01 – 1.05 0.02
Christensen 18 Medical comorbidities * 2.404 1.118 – 5.171 0.025
Christensen 18 Non-compliance 3.539 1.435 – 8.728 0.006
Hsieh 13 Living in same city as medical 0.08 0.01 – 0.69 0.02
centre *
Table 3: Meta-analysis of statistically significant variables pertaining to the odds of developing complications
following mandible fracture fixation. Morbidities with * are not modifiable.