Use of miniplates in the treatment of mandibular angle fractures: a narrative review

Introduction

Background

Mandibular angle fractures are among the most common mandibular fractures encountered in maxillofacial trauma (1). The angle region—where the horizontal mandibular body meets the ascending ramus—is anatomically susceptible to fracture from lateral impact forces. The presence of third molars confers a 2.8-fold increased risk of angle fracture compared with sites where third molars are absent [adjusted odds ratio (OR) 2.8, 95% confidence interval (CI): 2.3–3.4] (2), and the thin cross-sectional cortex at the angle further predisposes this region to injury.

Rationale and knowledge gap

Management has evolved substantially over the past century. Early reliance on maxillomandibular fixation (MMF) required 4–6 weeks of jaw immobilization with associated morbidity including weight loss, poor oral hygiene, and airway concerns (3). The introduction of transosseous wiring reduced immobilization duration but provided limited resistance to functional forces. Compression plating techniques introduced by the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) group in the 1970s achieved greater stability but required extensive transcervical exposure and were associated with stress shielding (4,5).

The development of miniplate technology by Michelet in 1973, subsequently refined by Champy in 1978, represented a paradigm shift: functionally stable fixation respecting the biomechanical principles of the mandible while permitting controlled micromovement conducive to bone healing (6). Contemporary systems—including three-dimensional (3D) plates, locking plates, and patient-specific implants—have expanded the available options without establishing clear evidence-based selection criteria.

Objective

Despite extensive literature, controversy persists regarding optimal fixation strategies. This narrative review addresses the following questions: (I) What evidence supports different miniplate configurations for mandibular angle fractures, and how should selection be individualized based on fracture and patient characteristics? (II) How do biomechanical principles translate to clinical outcomes with modern plating systems? (III) What patient-specific factors should guide fixation choice? (IV) How do emerging technologies compare to established techniques? We present this article in accordance with the Narrative Review reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-2026-0017/rc).

Methods

A comprehensive literature search was conducted using PubMed, MEDLINE, Cochrane Database of Systematic Reviews, Google Scholar, ScienceDirect, and Embase from January 1970 to April 2026, restricted to English-language publications. Search terms are detailed in Table 1 and were combined using Boolean operators AND, OR, and NOT. This review was conducted as a narrative review; it does not employ the formal systematic synthesis methodology of a systematic review, and no meta-analytic pooling was performed.

Inclusion criteria encompassed clinical studies, systematic reviews, meta-analyses, randomized controlled trials (RCTs), prospective and retrospective cohort studies, biomechanical studies, and case series with a minimum of 10 patients. Exclusion criteria included case reports, non-English language publications, conference abstracts without full-text availability, and studies with insufficient outcome reporting or not focused on mandibular angle fractures. Initial title and abstract screening was performed independently by two reviewers; disagreements were resolved through discussion with a third reviewer.

Results

The literature search identified studies spanning biomechanical investigations, clinical case series, RCTs, and systematic reviews across the defined timeframe. Key findings are organized by fixation approach below.

Single miniplate fixation

Following Champy’s principles, single superior border miniplate placement demonstrates high success rates in appropriately selected cases—specifically favorable, minimally displaced fractures with adequate bone quality (6). Biomechanical testing confirms that a single miniplate along the external oblique ridge resists forces up to 150 N, sufficient for most healing-phase functional requirements (7). Comparative bench-top testing of multiple plating systems indicates that monocortical superior border constructs are adequate for incisal-edge loading but may be insufficient under contralateral molar loading conditions, with appreciable differences in stiffness and yield behaviour between fixation configurations (8). Single plating performs less favorably in unfavorable fracture patterns and is contraindicated in comminuted and significantly displaced fractures (9). A recent quasi-experimental study of 60 patients with favorable angle fractures confirmed that single miniplate fixation (Champy’s technique) at the superior border produced fewer postoperative complications than a two-miniplate approach in this selected population (10). Novel plate geometries, including angled ‘banana’ plates designed to conform anatomically to the mandibular angle, have shown favorable tridimensional stability with fewer complications than conventional straight miniplates in prospective comparative studies, though sample sizes remain limited (11). A prospective clinical study evaluating new design miniplates against conventional miniplates for angle fracture fixation found significantly improved bite force adaptation at 6-month follow-up (P=0.003) with the novel design, without significant differences in paresthesia, malunion, non-union, occlusal discrepancy, or hardware failure rates, suggesting that plate geometry refinements may yield meaningful functional gains while preserving the established safety profile (12).

Double miniplate fixation

In vitro biomechanical testing demonstrates that single miniplate fixation in the Champy position does not sufficiently control bending or torsional forces under loading conditions close to the fracture site, particularly during ipsilateral molar loading (7). An RCT by Danda (n=54, 27 per group) comparing single versus double noncompression miniplate fixation for non-comminuted mandibular angle fractures found no statistically significant differences in wound dehiscence (11.1% vs. 7.4%, P>0.99), infection (3.7% vs. 7.4%, P>0.99), or malocclusion between groups, concluding that two miniplates confer no advantage over one for appropriately selected non-comminuted fractures (13). Transcutaneous access required for inferior border plate placement was associated with scar formation at the stab incision site in 18.5% of the double plate group (13). A prospective study by Ellis comparing three treatment methods for isolated angle fractures found that single miniplate fixation (Champy technique) was the easiest to perform and associated with the lowest number of complications, while rigid two-plate fixation increased operative time and complication burden without improving union rates for non-comminuted, favorably patterned fractures (14). Biomechanical rationale nonetheless supports double plating for unfavorable patterns, comminuted fractures, and cases with significant displacement, where single superior border fixation may be insufficient to resist displacing forces. A more recent RCT comparing sagittal split osteosynthesis plate (SSOP) fixation against conventional two-miniplate fixation for angle fractures found equivalent stability and clinical outcomes, suggesting that alternative double-plating geometries may offer comparable efficacy with potentially simpler application (15). Long-term follow-up data suggest that union rates at one year are comparable between fixation strategies in properly selected cases.

3D plating systems

A systematic review and meta-analysis of six clinical studies (307 patients; 196 in the 3D group, 111 in the standard group) found statistically lower overall postoperative complication rates with 3D miniplate fixation compared to standard miniplate fixation (cumulative OR 0.42, 95% CI: 0.27–0.66; P<0.001), representing a 58% reduction in the risk of postoperative complications (16). The advantage reached statistical significance for hardware failure (OR 0.18, 95% CI: 0.05–0.60; P=0.005) and postoperative trismus (OR 0.23, 95% CI: 0.06–0.86; P=0.03). There were no significant differences in the incidence of infection, malocclusion, wound dehiscence, non-union/malunion, or paresthesia. Mean operative time data were reported in four studies but a definitive comparison was not possible due to missing standard deviations.

Locking plate technology

Locking plates—featuring threaded screw holes creating a fixed-angle construct—offer theoretical advantages in poor bone quality, particularly osteoporotic or atrophic mandibles. A prospective randomized study comparing 2.0-mm locking plate versus 2.0-mm nonlocking plate systems in mandibular fractures (n=50 patients, 76 fracture sites) found no significant difference in overall postoperative complications between the two systems (7 complications, 9% total), but a significantly higher number of patients in the nonlocking group required postoperative MMF (P<0.01), suggesting the locking construct may provide superior immediate stability (17). A separate RCT comparing 2.0-mm locking and standard plates demonstrated comparable complication profiles with both systems (18). However, controlled trial data specific to mandibular angle fractures remain limited, and the increased cost of locking systems must be weighed against their potential benefit.

Overall outcomes and predictors

Miniplate fixation achieves high overall success rates across the reviewed literature. A large 10-year retrospective study of 322 patients with 335 surgically treated mandibular angle fractures reported successful treatment with a single open reduction in 93.7% of cases (19). Overall, 71.5% of patients were completely free of complications. The most frequent complication was wound-healing disturbance (15.3%, n=51 of 335 fractures), followed by infection (9.9%, n=33), osteosynthesis failure including plate or screw fracture and screw loosening (5.7%, n=19), functional impairment including limited temporomandibular joint movement (5.4%, n=18), pseudarthrosis (4.8%, n=16), severe permanent nerve trauma (1.5%, n=5), and dis-occlusion (0.6%, n=2). A cumulative rate of wound-healing disturbance and infection combined was 20% of fractures, reflecting their frequent co-occurrence. A second open reduction was required in 6.3% of fractures.

Risk factors consistently associated with complications across clinical series include smoking, poor oral hygiene, retained infected third molars in the fracture line, delayed treatment, and preoperative infection (19,20). These findings emphasize the importance of comprehensive preoperative patient assessment and counselling, perioperative antibiotic prophylaxis, and oral hygiene instruction in reducing preventable complications.

Discussion

Anatomical considerations

The mandibular angle represents a structurally vulnerable region where the horizontal body meets the ascending ramus. The cross-sectional area at the angle is thinner than both the body region anteriorly and the ramus posteriorly, creating a zone of structural vulnerability. The presence of third molars can substantially reduce cross-sectional bone area, further weakening the angle. The inferior alveolar canal traverses this region, necessitating careful hardware placement to avoid neurosensory injury (Figure 1).

Figure 1 CT maxillofacial anatomy of the mandibular angle. (A) Angle boundaries defined by the anterior masseter margin and posterior mandibular border on 3D CT reconstruction. (B) Coronal CT at the angle level demonstrating lateral cortex (red, 2.0–3.5 mm) thicker than medial cortex (green, 1.5–2.5 mm). (C) Sagittal CT showing the course of the inferior alveolar canal from the mandibular foramen to the mental foramen. (D) Axial CT cross-sections demonstrating reduction in cross-sectional bone area at the angle when a third molar is present (with-molar example 98 mm² vs. without-molar 148 mm²), with thinner cortical plates and reduced medullary cavity. CT, computed tomography; 3D, three-dimensional.

The masseter muscle inserts along the lateral angle surface and generates substantial masticatory forces during maximum clenching. The medial pterygoid, with its broad medial insertion, creates opposing forces that drive fracture displacement. The complex interplay of these muscles creates a tendency for superior and medial displacement of the proximal fragment, particularly in vertically unfavorable patterns (21).

Biomechanical principles

Champy’s experimental work defined the ideal lines of osteosynthesis based on predictable tension and compression zone distributions during mandibular function. The superior border posterior to the mental foramen experiences tensile forces during all loading types, with maximum tension occurring during contralateral molar biting under substantial functional loading (6). The inferior border undergoes compressive loading. Placing a miniplate along the superior border directly counteracts the primary deforming tensile force while the intact inferior border provides inherent compressive stability.

Miniplate fixation exemplifies load-sharing fixation, providing sufficient stability to maintain reduction while allowing the bone to bear some functional load—contingent on adequate bone contact and quality. When bone cannot contribute to mechanical stability (comminuted, pathological fractures, or significant bone loss), load-bearing fixation with larger or multiple plates becomes necessary (22). Small degrees of controlled micromovement at the fracture site promote secondary bone healing through mechanotransduction; limited interfragmentary movement with single miniplate fixation under physiological loads has been shown to be favorable for callus formation (23).

Primary bone healing (direct cortical remodeling without callus, typically with rigid fixation) and secondary bone healing (involving callus formation in response to controlled micromovement) both yield successful union when fixation is appropriately applied. Single miniplate fixation typically produces more robust callus formation consistent with secondary healing, while double plating or more rigid constructs may demonstrate less callus formation and a greater component of primary healing (24).

Classification and patient factors

The biomechanical classification categorizes fractures as favorable or unfavorable based on fracture line orientation relative to muscle pull. Horizontally favorable fractures resist the upward pull of elevator muscles; horizontally unfavorable fractures tend to displace under muscle action. Vertically favorable fractures resist the medial pull of the medial pterygoid; vertically unfavorable patterns are prone to medial displacement. Classification is determined by computed tomography (CT) or cone beam CT (CBCT), which delineates fracture line orientation and displacement vector relative to the muscle attachments. This classification directly informs fixation selection (9).

The etiology of angle fractures should also be considered during treatment planning. The majority of fractures are traumatic in origin; however, pathological fractures (from benign or malignant lesions, medication-related osteonecrosis, or osteomyelitis) and iatrogenic fractures (following third molar extraction) require distinct management strategies and may have different outcomes profiles. This review focuses primarily on traumatic angle fractures; pathological fractures are addressed separately in section “Special considerations”.

Patient factors significantly modulate outcomes. Age affects bone quality and healing potential, with elderly patients demonstrating slower healing and higher complication rates. Medical comorbidities—diabetes, immunosuppression, and conditions affecting bone metabolism—may necessitate enhanced fixation. Substance abuse, particularly tobacco and alcohol, increases complication risk. Compliance is critical: non-compliant patients may be better served by more rigid fixation or extended MMF periods (20).

Surgical access routes

The following three approaches are used for mandibular angle fracture fixation; all are described using a consistent format covering approach, advantages, limitations, and indications.

Transoral approach

Approach: incision along the external oblique ridge from the ascending ramus to the first molar region, extending into the mandibular vestibule. Subperiosteal dissection exposes the fracture site laterally. Advantages: absence of external scarring; direct visualization of occlusal relationships; reduced facial nerve risk. Limitations: restricted access to the inferior border; challenges in severely displaced or comminuted fractures; angled screw placement may compromise purchase. Indications: preferred first-line approach for most angle fractures amenable to single superior border plate placement (25).

Transbuccal approach

Approach: standard intraoral exposure combined with a small stab incision in the cheek overlying planned screw sites, through which a trocar system allows perpendicular drill and screw placement. Advantages: combines intraoral access with improved mechanical advantage; significantly reduces torque and screw stripping risk; associated with reduced operative time and improved screw purchase. Limitations: small additional external incision; requires specialized trocar instruments. Indications: particularly useful when inferior border fixation is planned or when angled intraoral screw placement is insufficient (26).

Extraoral (transcervical) approach

Approach: risdon incision placed 2 cm below the mandibular inferior border to protect the marginal mandibular nerve; or retromandibular incision for more direct ramus access. Layered dissection through platysma and superficial cervical fascia with identification and protection of facial vessels and marginal mandibular nerve. Advantages: direct access for complex reconstruction; optimal visualization for comminuted or pathological fractures. Limitations: external scar; risk of marginal mandibular nerve injury; potential sialocele formation with retromandibular approach. Indications: severely comminuted, pathological, or recurrent fractures requiring extensive reconstruction (27).

Plate configuration and selection

Selection among fixation systems should be individualized based on fracture characteristics, bone quality, and patient factors. Table 2 summarizes the comparative advantages, indications, and outcomes for each system.

Clinical outcomes: healing, MMF, and multiple fractures

Radiographic healing and remodeling progress gradually over weeks to months following fixation, with secondary bone healing characterized by progressive callus formation and remodeling (28). Long-term quantitative CT studies show variable mild cortical atrophy beneath plates, correlating with plate size and rigidity—supporting minimal hardware use when adequate. These healing patterns directly influence functional recovery: more rapid callus formation with single plate fixation is associated with earlier return of function when fracture stability is maintained, whereas rigid double plating may produce less callus but equivalent union rates by 1 year.

The role of adjunctive MMF has evolved toward selective application. Contemporary evidence supports omitting postoperative MMF for properly reduced, favorably patterned fractures treated with adequate miniplate fixation—allowing immediate function and avoiding the nutritional compromise, oral hygiene difficulties, and airway risks associated with jaw immobilization (14,29). Adjunctive MMF remains indicated for unfavorable patterns with persistent instability, comminuted fractures, compromised bone quality, or suboptimal intraoperative reduction. Rigid MMF (2–3 weeks) is reserved for highly unstable patterns; elastic MMF (3–4 weeks) is appropriate for moderate instability; light guiding elastics (2–4 ounces, 2–3 weeks) allow limited guided function while protecting fixation during early healing.

Concomitant mandibular fractures occur in a substantial proportion of angle fracture cases and significantly increase complication risk. A finite element analysis by Kimsal et al. evaluating different fixation schemes for angle fractures found that a dual-plate model combining a superior border tension band with a bicortical inferior border plate produced the lowest von Mises stresses in the plates and the lowest principal strain in the fracture callus compared to single-plate configurations, with peak plate and peri-screw bone stresses approaching the yield strength of titanium under physiological loading, providing biomechanical support for double plating in mechanically demanding scenarios (30). These findings mandate integrated treatment planning: when applying the Champy technique at the angle, rigid fixation of symphyseal or parasymphyseal fractures is strongly advised; a third fracture generally necessitates double miniplate or reconstruction plate fixation at the angle regardless of pattern favorability (31).

Complications and their management

Reported complication rates vary across studies depending on fracture pattern, fixation strategy, and follow-up duration. Early complications (within 2 weeks) include wound dehiscence, hematoma, and acute infection; intermediate complications (2–8 weeks) include hardware failure, malunion, and established infection; late complications (beyond 8 weeks) encompass nonunion, chronic infection, and hardware-related symptoms requiring removal (19).

Infection is the most common major complication and is the leading indication for hardware removal. A recent systematic review and meta-analysis specifically addressing fracture-related infections (FRIs) in maxillofacial trauma confirmed a pooled mandibular fracture infection rate of 8.9%, with smoking consistently identified as a significant risk factor across multiple studies (32). Perioperative prophylactic antibiotics are standard; evidence supports a short postoperative course rather than extended prophylaxis (33). A 2025 retrospective study further demonstrated that subacute fixation timing (beyond immediate repair) does not significantly increase infection risk in mandibular fractures when appropriate perioperative care is maintained (34). Neurosensory disturbance of the inferior alveolar nerve may occur in the immediate postoperative period but typically resolves over the following months with appropriate nerve preservation. Nonunion is uncommon and, when it occurs, requires hardware removal, debridement, and re-fixation, often with bone grafting. A 2025 systematic review of complications following miniplate insertion in maxillofacial fractures confirmed that minor complications occur in approximately 8% of cases and major complications in under 2%, consistent with the outcomes profile reported in earlier landmark studies (35).

Special considerations

Pediatric fractures

Pediatric angle fractures are less frequent due to mandibular elasticity and the protected position of the developing jaw, but tend to result from high-energy trauma when they do occur (36). Monocortical fixation avoiding dental crypts is preferred; resorbable plates offer theoretical growth-preservation advantages, though mechanical properties may be inadequate for older children. Closed reduction with brief MMF (2–3 weeks) may suffice for minimally displaced fractures; when open reduction internal fixation (ORIF) is required, smaller plates and fewer screws are generally adequate. Long-term growth monitoring is essential.

Edentulous and atrophic mandibles

Reduced bone height (often <15 mm) limits hardware placement options, and the absence of dental occlusion removes a key guide to reduction. Load-bearing reconstruction plates or locking plates are often necessary due to poor bone quality and inability to share load. Complication rates are significantly higher in atrophic edentulous mandibles, with delayed or fibrous union occurring in approximately 12–15% of fractures and infection a frequent contributor to non-union (37). Virtual surgical planning has demonstrated utility in these complex cases, enabling preoperative simulation of reduction and optimal plate positioning that reduces intraoperative decision-making burden and improves outcomes (38,39). Primary bone grafting may augment bone stock in severe atrophy. Conservative management may be appropriate for elderly patients with severe atrophy and minimal functional demands.

Pathological fractures

Pathological angle fractures require simultaneous management of the fracture and its underlying cause—a necessarily multidisciplinary undertaking (40). Fractures through benign lesions typically require excision with immediate reconstruction using load-bearing plates and bone grafting. Fractures associated with malignancy require careful staging; the timing of surgery relative to radiotherapy must be considered. In previously irradiated patients, hyperbaric oxygen (HBO) therapy may be beneficial by increasing tissue oxygen tension, promoting angioneogenesis and fibroblast proliferation, enhancing host defence against infection, and supporting osteoneogenesis in hypoxic bone—potentially reducing complication rates and improving wound healing. Bisphosphonate-related osteonecrosis presents particular challenges, with progressive bone loss risk and high complication rates requiring specific protocols.

Emerging technologies

Computer-assisted surgical planning using CT data allows preoperative simulation of fracture reduction and optimal plate positioning, with patient-specific surgical guides facilitating accurate hardware placement (41). A 2025 review of computer-assisted surgery (CAS) in oral and maxillofacial reconstruction confirmed that virtual surgical planning, computer-aided design/computer-aided manufacturing (CAD/CAM) technologies, and patient-specific plates have become increasingly integral to complex mandibular procedures, with evidence of improved surgical precision and efficiency, though high costs and long preparation times remain limiting factors for routine trauma applications (42). Intraoperative navigation provides real-time feedback on drill trajectory and depth, potentially reducing inferior alveolar nerve injury risk (42). Early evidence demonstrates improved reduction accuracy, though clinical outcome benefits above standard technique remain to be proven in adequately powered trials.

Novel biomaterials under investigation include titanium alloys with enhanced biocompatibility, magnesium-based resorbable plates with mechanical properties closer to cortical bone, and bioactive titanium coatings incorporating antimicrobial agents or osteoinductive factors. Human clinical data remain limited for most of these technologies in mandibular angle fracture applications (43).

Strengths and limitations of this review

This review synthesizes a broad body of evidence spanning biomechanical, experimental, and clinical literature from 1970 to April 2026, encompassing multiple fixation systems and patient populations. The inclusion of both foundational biomechanical studies and contemporary clinical trial data enables integration of mechanistic principles with patient-level outcomes.

Several limitations must be acknowledged. As a narrative review, it does not employ the formal systematic methodology of a meta-analysis, and the synthesis represents an interpretive rather than statistically pooled summary of evidence. The heterogeneity of included study designs, outcome definitions, follow-up durations, and fracture classification systems limits direct comparison across studies. The majority of available evidence derives from studies published between the 1990s and 2010s; contemporary data on newer technologies—particularly 3D plates and locking systems—remain limited. Long-term outcome data (>2 years) are sparse for most fixation systems. Publication bias toward positive results may inflate reported success rates. Finally, the search was conducted through April 2026, and studies published after this date are not captured.

Conclusions

Miniplate fixation represents the current standard of care for most mandibular angle fractures, with success rates consistently exceeding 90% when patient and fracture selection criteria are appropriately applied. The updated management algorithm presented in Figure 2 provides a comprehensive decision framework that begins with patient category determination—stratifying patients into adult dentate, pediatric, edentulous/atrophic, or systemic/special considerations pathways before proceeding to fracture-specific management. For adult dentate patients, fracture pattern assessment drives fixation selection: favorable, non-displaced fractures are appropriately treated with a single Champy miniplate, while unfavorable patterns, significant displacement, or comminution necessitate multiple miniplates, 3D plate systems, or load-bearing constructs. Pediatric patients are directed to age-appropriate fixation considerations including resorbable plates, monocortical fixation, and brief MMF. Edentulous and atrophic mandibles are directed to load-bearing fixation with virtual surgical planning and patient-specific implants where indicated. Third molar management—removal when mobile or infected, preservation when functional and non-interfering—is integrated as a discrete decision point. Surgical approach selection follows, guided by fracture characteristics and visualization requirements, with transoral, transbuccal, and extraoral routes each assigned specific indications. The algorithm concludes with a standardized postoperative management protocol encompassing early function, oral hygiene, analgesia, radiographic assessment, and complication monitoring, with the shared goal of optimal occlusion and patient satisfaction.

Figure 2 Mandibular angle fracture treatment algorithm. The algorithm integrates patient-specific factors (pediatric, edentulous/atrophic), fracture characteristics and surgical approach selection to optimize outcomes in mandibular angle fracture management. CBCT, cone beam computed tomography; 3D, three-dimensional; MMF, maxillomandibular fixation; OPG, orthopantomogram; VSP, virtual surgical planning.

The fundamental biomechanical principles established by Champy continue to guide practice, with modern systems offering complementary options for challenging cases rather than replacing the established framework. Appropriate patient selection, meticulous surgical technique, and comprehensive postoperative management remain the principal determinants of successful outcomes. Future high-quality RCTs comparing emerging fixation technologies to established techniques—with standardized outcome measures and adequate long-term follow-up—are needed to further refine evidence-based treatment selection.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-2026-0017/rc

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-2026-0017/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-2026-0017/coif). V.B.Z. serves as an unpaid editorial board member of Frontiers of Oral and Maxillofacial Medicine from November 2025 to October 2027. V.B.Z. also serves as the president of New Jersey Society Oral and Maxillofacial Surgeons. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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