Management of Pediatric Mandible Fractures



Management of Pediatric Mandible Fractures


Nataliya Biskup

Brian S. Pan





ANATOMY



  • The mandible is a unique bone composed of vertical and horizontal elements that form a U-shaped construct.


  • The growth pattern of the mandible occurs in a superior and posterior direction, resulting in a concomitant downward and forward displacement of the mandibular body and symphysis.3


  • From early childhood through adolescence, the inferior alveolar nerve changes in position as the canal migrates cephalically from the lingual inferior border of the mandible to a more superior position.


  • The preadolescent mandible has high osteogenic potential due to its rich blood supply from the inferior alveolar artery.


  • Following permanent tooth eruption, the medullary center of the mandible becomes more thickened and calcified.


PATHOGENESIS



  • The most common cause for facial injuries in children is motor vehicle collisions.


  • Sports-related injuries are the second most common cause of facial fractures.


  • These injuries occur more commonly in older children and in adolescence.


  • Childhood falls and assault/nonaccidental trauma are the least common causes.


  • Assaults occur most commonly in adolescence.


  • Males are twice as likely to sustain facial fractures compared with females.4


  • Condyle fractures are considered the most common type of mandible fractures followed by the symphysis, the body of the mandible, the angle, and lastly the ramus.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Depending upon the age of the child, an accurate history may not be available.


  • If patient compliance for an adequate exam is not possible, proceed with imaging and consider an exam under sedation.


  • Physical exam findings may include pain on palpation over the fracture site, malocclusion, decreased maximal incisive opening, jaw deviation with opening, loose teeth, and intraoral lacerations or ecchymosis.


  • Assess for paresthesia or anesthesia caused by injury of the inferior alveolar and mental nerves.


  • Chin abrasions and lacerations, coupled with blood in the external auditory canal, should raise suspicion for a condylar fracture.5


IMAGING



  • Although a panorex and plain films of the mandible can be obtained, a computed tomographic (CT) scan is the standard for imaging in the setting of facial trauma.


  • Cone beam CT (CBCT) scans are another means for accurately diagnosing facial fractures and have the advantage of exposing the child to less radiation.


NONOPERATIVE MANAGEMENT



  • Most pediatric mandible fractures are treated conservatively. Minor malocclusions will self-correct by the ability of the pediatric mandible to remodel and with minor orthodontic manipulations at skeletal maturity.


  • Children with deciduous and mixed dentition have a capacity for spontaneous occlusal readjustment after injury and treatment, as deciduous teeth are shed and permanent teeth erupt.6


  • Observation is indicated for:



    • Patients with condylar and subcondylar fractures



      • Mild malocclusions may be treated with soft diet and/or maxillomandibular fixation (MMF).


      • Moderate to severe malocclusion may be treated with closed reduction and MMF. Open reduction is rarely indicated, especially in intracapsular fractures. Open reduction risks vascular compromise to the condyle, which is a growth center for the mandible with high remodeling capacity.7,8


    • Minimally displaced fractures in the tooth-bearing mandible, namely, parasymphysis, body, angle. These areas are filled with developing tooth follicles, and thus operative intervention should be avoided if possible.


  • Start the patient on a mechanical soft diet, rigorous physiotherapy, avoidance of rigorous physical contact, and symptomatic pain control for 4 to 6 weeks. Arrange long-term follow-up to closely monitor mandibular growth.


SURGICAL MANAGEMENT


Position



  • Place the patient supine under anesthesia with nasotracheal intubation.


  • May consider sedation-only anesthesia, if only closed reduction is to be performed without MMF or with minimal MMF (such as an Ivy loop or lingual splint).


Nov 24, 2019 | Posted by in Craniofacial surgery | Comments Off on Management of Pediatric Mandible Fractures

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