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Open Versus Closed Management for Gunshot Wounds of the Mandible - Which More Frequently Achieves Satisfactory Bony
1Craniomaxillofacial Surgery Fellow at Duke University Medical Center, USA, on behalf of the Institute of Naval Medicine, Defence Medical Services, United Kingdom.
Purpose:
Closed management of high-energy mandibular injuries has been considered the gold standard for many years, but open management is preferable for its shorter overall treatment time. At present, there is a paucity of evidence on which to base management decisions, and as such there is a priority to review the literature to define the optimal treatment for mandibular gunshot wounds (GSWs).
Method:
The study design was a systematic review with meta-analyses and the protocol was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Electronic searches of published literature in the MEDLINE and Embase databases (1980-present) were conducted. Search terms included "gunshot", "firearm", "mandible", and "jaw". Inclusion criteria were randomized controlled trials (RCTs), cohort studies, case-control studies, and case series written in English describing studies involving patients with mandibular fractures caused by GSWs [population] containing information on treatment by either open reduction and (nonwire) internal fixation [intervention] or by closed reduction ± external fixation [comparator], and the frequency of bony union and complications [outcomes]. Meta-analysis was conducted using the Mantel-Haenszel odds ratio (OR) as the measure of effect. The quality of evidence was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the Newcastle-Ottawa Scale for observational studies.
Results:
159 studies were identified overall of which 6 studies (3.7%; 3 observational studies and 3 RCTs) met the eligibility criteria. Due to high heterogeneity the study subtypes were analyzed separately. In the observational studies (n = 137), open management resulted in bony union 43/52 (82.7%) times, whereas closed management resulted in bony union 78/85 (91.8%) times (OR 0.40, 95% CI 0.14 to 1.15, P = .09). In the RCTs (n = 190), open management resulted in bony union 89/95 (93.7%) times, whereas closed management resulted in bony union 70/95 (73.7%) times (OR 6.86, 95% CI 2.42 to 19.46, P = .0003).
Conclusion:
The practicalities of treating mandibular GSWs are nuanced, and the recommendation of a one-size-fits-all management approach would be inappropriate. However, there is sufficient evidence in the findings of this systematic review to support open management as first-line treatment, with closed management considered if the former is clinically or logistically unfeasible.
