When determining the optimal treatment strategy for a pediatric mandible fracture, planning must factor in the patient’s age, anatomy, stage of dental development, fracture site, and ability to cooperate with the proposed treatment plan. Careful consideration must be given to the possibility of long-term growth disturbance with various fracture locations and types of treatment. This article reviews the current principles of the management of pediatric mandibular fractures.
Key points
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Pediatric mandible fractures require a systematic and thorough initial assessment to evaluate the mandibular injury and associated injuries, including cervical spinal injury.
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Management should be performed by a team approach, which includes the plastic surgeon, pediatric dentist, orthodontist, and appropriate consultations to manage associated injuries.
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Most pediatric mandibular fractures can be managed conservatively with a soft diet, analgesics, and movement restrictions.
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The type of treatment modality is often determined by 2 primary considerations: location of fracture and status of dentition.
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Long-term follow-up is required for all pediatric mandible fractures.
Background
When determining the optimal treatment strategy for a pediatric mandible fracture, planning must factor in the patient’s age, anatomy, stage of dental development, fracture site, and ability to cooperate with the proposed treatment plan. Careful consideration must be given to the possibility of long-term growth disturbances secondary to various fracture locations and types of treatment. As such, the management of a pediatric mandible fracture is substantially different from that of the adult injury. This article reviews the current principles of the management of pediatric mandibular fractures.
Background
When determining the optimal treatment strategy for a pediatric mandible fracture, planning must factor in the patient’s age, anatomy, stage of dental development, fracture site, and ability to cooperate with the proposed treatment plan. Careful consideration must be given to the possibility of long-term growth disturbances secondary to various fracture locations and types of treatment. As such, the management of a pediatric mandible fracture is substantially different from that of the adult injury. This article reviews the current principles of the management of pediatric mandibular fractures.
Epidemiology
Pediatric mandible fractures account for 32.7% of all facial fractures, followed by nasal bone fractures (30.2%) and midface/zygoma fractures (28.6%). Mandible fractures are rare in the children younger than 5 years. The condyle is the most common fracture site in pediatric patients, accounting for 40% to 70% of mandibular fractures. Unilateral condylar fractures are more common than bilateral condylar fractures, with bilateral fractures seen approximately 20% of the time. Symphyseal fractures account for approximately 2% to 30% of all mandible fractures. Fractures of the body, angle, and ramus account for the remainder of the fracture locations. Symphyseal and parasymphyseal fractures occur more often in children than in adults, which may be partially explained by the presence of developing canine tooth buds resulting in a stress point at the inferior border of the mandible. Following eruption of the canine, bone fills this vulnerable location, making it more durable. On reaching adolescence, fracture-location patterns become similar to those of an adult, with an increase in fractures of the body of the mandible. Multiple fracture sites occur in approximately 40% to 60% of cases and are more frequent in adolescent children.
Motor vehicle accidents and falls are responsible for most pediatric mandibular fractures. As children age, a greater proportion of their injuries are associated with sporting accidents. As teenagers (and likewise adults), more fractures are a result of assault. Overall, mandible fractures may have a high rate of associated injuries that commonly affect the head, face, and spine. When examining a patient, the physician should carefully evaluate for associated injuries. Studies have shown that greater than 75% of patients with mandibular fracture had additional injuries, including 8% with associated midface fractures. Associated midface fractures are more common in adolescent-aged children than in younger children. Whether assessed clinically or with additional imaging, careful evaluation of the cervical spine is a required part of the assessment of a pediatric patient with a traumatic mandible injury.
Development
Facial Skeleton
Drastic changes in the proportions of the facial skeleton can be seen as the child ages. At birth, the face-to-cranium ratio is 1:8, compared with a ratio of 1:2 in an adult. There is marked growth in the facial skeleton in relation to the rest of the head as the child ages. Vertical growth of the mandible is achieved through bony remodeling along with the development of alveolar process and eruption of the dentition. The posterior borders of the condyle and ramus are particularly active in bone growth with new bone deposition and remodeling, while the anterior surface undergoes bone resorption ( Fig. 1 ). There are minimal changes in the body or symphysis of the mandible, with significant growth and remodeling at the ramus and condyle. This process results in a translation forward and downward of the mandible as it grows superiorly and posteriorly, maintaining condylar contact with the glenoid fossa.
The pediatric facial skeleton during early development has many protective features that make it more resilient to withstand traumatic forces. The bones are resistant to fracture because of poor pneumatization, higher elasticity, high ratio of cancellous to cortical bone, and relatively more thick surrounding soft tissue and adipose coverings. The mandible and maxilla also benefit from lying in a relatively more protected position, with additional stability provided by the unerupted dentition. These factors decrease the likelihood of fractures of the mandible and explain why greenstick and condylar fractures are more common in children than in adults.
As the child develops from an infant to an adolescent, the anatomic relationships of key structures change. The inferior alveolar nerve (IAN) travels adjacent to the lingual cortical surface close to the inferior border of the mandible in younger children. As a child ages and the mandible grows, the nerve progressively becomes more superior in location. This anatomic finding is an important consideration in avoiding injury when placing plate-and-screw fixation.
Dentition
Teeth begin to appear in a child at around 6 months of age. Deciduous teeth gradually erupt until a full complement of 20 primary teeth is seen, at around age 2 years. The primary teeth are relatively stable until age 6, when exfoliation begins to occur and the roots are resorbed. Root resorption causes the crowns of deciduous dentition to loosen and eventually fall out. At around the same time, permanent dentition eruption begins with the initial eruption of central incisors and first molars. Eruption of secondary (permanent) dentition continues through age 12. Children older than 12 years generally have a healthy complement of permanent teeth. The wisdom teeth usually erupt around early adulthood.
During this transition from edentulous stage to mixed dentition stage to permanent dentition stage, the ratio of tooth to bone transitions from high to low. The location of unerupted permanent tooth follicles as an important consideration in terms of where to place plate-and-screw fixation during operative repair of pediatric mandible fractures. Care should be taken to not disrupt the tooth buds. In addition, fractures can occur through the developing tooth crypts, owing to the unerupted teeth having only a very thin cortex overlying this area. If a crypt is fractured or disrupted, devitalization and maldevelopment of the permanent teeth may occur.
Presentation and workup
Initial Assessment
Initial evaluation of an injured child in whom a facial fracture is suspected begins with a systematic approach and close adherence to Advance Trauma Life Support principles. The primary and secondary trauma surveys should be performed routinely on all patients. A systematic and detailed physical examination is performed to avoid missing any associated injuries.
Based on the mechanism and force of trauma, a child with a traumatic mandibular injury is at risk for associated airway compromise, cervical spinal injury, and neurologic injury. Causes of airway obstruction include direct trauma, swelling, hematoma, or foreign bodies (including aspirated teeth and bone fragments). Often airway obstruction can be managed with patient repositioning, but one needs to remain aware of cervical spine precautions. Suctioning or a finger-sweep technique to remove blood and debris within the oropharynx may also be necessary. Manual anterior traction of the mandibular symphysis or placement of a traction stitch on the tongue may alleviate airway obstruction, particularly in cases where the mandible is displaced posteriorly. Orotracheal intubation or placement of an emergent surgical airway may need to be performed. A spinal injury should be assumed until excluded clinically and/or radiographically. Most patients with facial trauma will undergo computed tomography (CT) scanning to evaluate the facial skeletal injury. Additional CT imaging of cervical spine or head and a modified Glasgow Coma Scale assessment for infants and children to assess neurologic status may be required, depending on mechanism of injury.
Once the patient is stable and a trauma evaluation is complete, a thorough history should be obtained. The patient’s allergies, medications, medical and surgical history, timing of last meal, and events surrounding the accident should be obtained. Information regarding the mechanism of injury may help guide the examiner as to the extent of injury. Furthermore, evidence of abuse should be suspected if the narrative of the caregiver’s account of the injury does not match the extent and pattern of the injuries.
Physical Examination
Once the trauma evaluation is completed and an open airway is secured, a more focused examination of the injury can be undertaken. A thorough examination of the head and neck should be performed, evaluating the skin, soft tissue, neurovascular structures, and bone. One should begin with an examination of the face and make note of any gross visual asymmetry. Ecchymosis and soft-tissue swelling may be indicators of underlying fracture locations. Lacerations may also provide clues to fracture locations. A chin laceration often indicates a forward fall with a midline force distributed superiorly, which may cause injury to the condyles; this may result in a crush-type injury or displacement of the condyle.
The examiner should then carefully assess the patient for neurologic deficits. Examination of the cranial nerves should be attempted. Particular attention should be given to paresthesias in the forehead, cheek, and lower lip as well as any deficits in facial nerve function. A fracture of the body of the mandible may injure the ipsilateral IAN, resulting in numbness of the chin and teeth. Injuries to the lingual and long buccal nerve have been reported in displaced fractures. Lingual and long buccal nerve injuries result in sensory deficits of the anterior tongue and lip and cheek mucosa, respectively. Nerve injuries that are not carefully documented during the preoperative examination may be later attributed to an iatrogenic complication.
The patient should be asked about how his or her bite feels and about pain, particularly with mandible excursions on mouth opening. Patients are capable of subjectively assessing minute changes in their occlusion and intercuspation. Examining the patient during mouth opening and closure can be quite revealing as to the presence of a fracture and its location. The patient’s jaw may deviate or have limited mobility, with decreased maximal incisor opening. Translational movement of the condyle should also be tested by evaluating lateral excursive movements of the mandible. In addition, drooling and trismus may be seen in association with mandible fractures. Trismus is often the result of significant muscle spasm and pain seen after fracture.
Palpation of facial skeleton may reveal step-offs or structural instability. The entire mandible should be palpated intraorally and extraorally. The authors recommend bimanual examination of the mandible, as deviations in symmetry can expose underlying injuries. The insertion of the medial pterygoid muscle on the medial mandibular surface, and the insertion of the temporalis muscle on the coronoid process, should also be assessed for tenderness and mobility. Palpation of the temporomandibular joints while the patient opens and closes the mouth allows for assessment of condyle symmetry, condylar head rotation, and translation of the condyle down the articular eminence. In addition, palpation of the external auditory canal during jaw movement may disclose a displaced condylar head or crepitation. Further examination of the ear may provide evidence for condylar fracture, as these fractures can cause bleeding or ecchymosis of the anterior wall of the external auditory canal.
Examination of the oral cavity is essential, and the patient should be checked for loose teeth, bone fragments, and foreign bodies. The intraoral examination includes evaluation of the entire mouth including teeth, floor of the mouth, tongue, buccal mucosa, vestibular mucosa, and the hard and soft palate. Depending on the patient’s age, loose permanent teeth may suggest a fracture along the tooth orientation.
Intraoral examination may be revealing if one is aware of the child’s prefracture occlusion status. Evaluation of the occlusion in a pediatric patient can be difficult, especially in a child with mixed dentition. Attention to wear facets, preinjury dental records, and parental input can be helpful in predicting the preinjury occlusion. Minor displacement of the mandible can lead to significant changes in occlusion. Evidence of an anterior open bite indicates bilateral condylar fractures. A unilateral condylar fracture will result in a contralateral posterior open bite. Intraoral examination may also reveal lacerations or hematomas. Antibiotic therapy with appropriate coverage for oral and cutaneous pathogens should be administered if intraoral or through-and-through cutaneous lacerations are present. Any mandible fracture through a tooth-bearing region is considered an “open” fracture, and requires prophylactic antibiotic therapy.
Assessment of dental injuries is also important. Children with permanent dentition injuries require rapid treatment. If teeth are believed to be missing and unaccounted for, a chest radiograph should be obtained as a precautionary measure to evaluate for aspiration. If an intraoral laceration overlying an unerupted tooth occurs, the laceration should be copiously irrigated, and an absorbable suture should be used to reapproximate the mucosa. Every effort should be made to leave the unerupted permanent teeth unscathed.
Imaging
When high clinical suspicion of a mandible fracture is present, further confirmation and characterization of the fracture type, location, and pattern should be performed with radiographic imaging. There are multiple modalities that can be used appropriately in varying situations. These modalities include plain radiographs, panoramic radiograph (orthopantomogram), and CT. Panorex was historically considered to be the study of choice, although this modality has several obvious limitations. A patient needs to be sufficiently cooperative and motionless for Panorex imaging. Extraneous movements and inaccurate patient position may lead to movement artifact that may conceal a fracture and prevent an accurate diagnosis. Another issue is that a Panorex cannot always be taken with a patient in a supine position. A supine Panorex requires special equipment. If this equipment is unavailable and the patient has spinal precautions, another imaging modality should be used. Often in these cases, a series of plain radiographs are taken. Plain radiographs can provide similar timely information in the acute trauma setting. A mandible series may be obtained, which includes a posteroanterior radiograph, a Townes view, bilateral obliques, lateral view, and often a submentovertex view. In all cases, it is important to obtain multiple views from which a fracture can be visualized in at least 2 planes. Fractures may not be visible in 1 dimension alone. This principle also applies to CT, as axial, sagittal, and coronal cuts allow for more precise and accurate diagnosis. Three-dimensional reconstruction of CT data is also invaluable in evaluating the pattern of injury, and is especially useful in evaluating condylar injuries ( Fig. 2 ). Overall CT imaging is the most versatile and clinically useful modality for imaging traumatic mandible injuries, allowing for accurate diagnosis and detailed, targeted treatment planning.
Consults
Based on the presence of associated injuries after completion of detailed physical and imaging assessment, the examiner should involve consulting specialties such as Neurosurgery, Ophthalmology, and Dentistry in a timely fashion. Based on the authors’ experience, the care of a child with a traumatic facial injury is best directed by a dedicated trauma team. Presence of such a system ensures appropriate and thorough workup, as well as recruitment of ancillary services such as Social Work and Child Life specialists to assist in the care of the injured child.
Initial Management
When caring for these injuries, operative and nonoperative management as well as inpatient or outpatient management should be determined. Some patients may benefit from a 24-hour overnight observation to assess pain management and oral intake. Others can be managed strictly as outpatients until further intervention is required. These patients are managed conservatively with a soft diet and appropriate analgesics to maintain adequate nutrition and comfort. An oral mouthwash is also provided. If surgical intervention is necessary, it should be completed within the first 7 days. Given the rapid healing potential of children, a longer wait time may make obtaining surgical reduction more difficult, owing to callus formation at the fracture site.
Treatment
General Treatment Considerations
Treatment of pediatric mandible fractures during the deciduous and mixed dentitions has remained a topic of debate. Depending on the type and pattern of injury, the treating surgeon may elect a conservative approach with soft diet and observation versus an operative approach. An operative approach, in turn, may involve a spectrum of techniques, such as closed reduction with maxillomandibular fixation (MMF), splinting techniques, or formal open reduction and internal fixation (ORIF).
In all cases, the overriding goal of treatment is restoration of function and preinjury occlusion and reestablishment of facial symmetry, while minimizing disruption of normal mandible growth and development. The type of treatment appropriate to achieve these goals depends on several factors including the location of fracture, displacement of fracture fragments, presence of malocclusion, and stage of dental development.
In general, most nondisplaced pediatric mandible fractures may be managed conservatively with close observation, soft diet, analgesics, and activity precautions. Certain cases may require a short period of MMF for 7 to 14 days to reduce pain and correct minor malocclusions. Malocclusion or significant displacement of fracture fragments requires a more involved approach. The type of treatment modality in these cases is further determined by 2 primary considerations: location of fracture and status of dentition.
As a general guideline, intracapsular condylar fractures and subcondylar fractures without significant malocclusion may be successfully managed with a soft diet and initiation of early range of motion. Occasionally, a brief period (no greater than 7–10 days) of temporary MMF may be appropriate to stabilize the fracture fragments, optimize patient comfort, and allow for bony healing. The concern for postinjury ankylosis dictates the short duration of MMF. Displaced fractures in other locations of the mandible may be managed effectively with a 2.0-mm miniplate placed at the lower mandible border with monocortical screw fixation or acrylic lingual splinting. More detailed management descriptions based on the stage of dental development and fracture location are described here.
Management Considerations Based on Stage of Dental Development
The developmental growth of a child must be considered when managing a pediatric mandible fracture. Treatment of a pediatric mandibular fracture should be performed in an appropriate manner based on the age and available dentition. One of the largest differences in treating a child’s maxillofacial traumatic injury is the variable dentition status.
Before age 2 years, children can be considered edentulous because the erupted teeth rarely provide adequate support for fixation. An acrylic splint may be useful in these cases to help immobilize the fracture with the addition of circum-mandibular wires. The splint may be fixated through either the piriform aperture or a paramedian palatal drill hole to immobilize the jaw. Following eruption of the deciduous teeth (age 2–5 years), the teeth may be used for fixation. The conical shape of these teeth is amenable to interdental wiring. Risdon cables or mini-arch bars may be used to treat nondisplaced fractures. During mixed dentition (age 6–12 years), the teeth should be evaluated for stability and strength. Primary tooth roots are being resorbed during this stage, which may lead to presence of loose teeth that are not amenable to MMF use. Combinations of the MMF techniques are used to immobilize the jaw for short durations during this mixed-dentition stage. Primary molars and incisors may serve as anchors for fixation during this time frame. After around age 9, children generally are able to tolerate arch-bar placement, because of the establishment of a majority of their permanent dentition. These children’s mandibular injuries are treated with standard MMF with ORIF techniques, as required, similar to those used in adult patients.
Management Considerations Based on Fracture Location
Condylar fractures
In the pediatric patient population, the condyle is the most common site of fracture. These fractures rarely require operative management. Children with condylar fractures generally have adequate range of motion and occlusion. Certain cases may require a short period of MMF for 7 to 14 days to reduce pain and correct minor malocclusions. Surgery should be reserved for those with severely displaced fractures, substantial malocclusion, and cases with dislocation obstructing or limiting mandibular range of movement. In these few indications, a sumandibular or preauricular approach to surgery should be performed, depending on the fracture height within the condyle.
Condylar fractures are classified as intracapsular fractures, high condylar neck fractures, and subcondylar fractures. Intracapsular fractures and high condylar fractures are differentiated by involvement of the articular surface. Intracapsular fractures can result from chin impact that disperses force on the condyles, causing crush-type injuries to the articular disk. High condylar fractures have no articular involvement but are located superior to the sigmoid notch. The force of impact that results in high condylar fractures may also medially dislocate the condyle. High neck fractures demonstrate good regenerative potential and union with conservative management alone. Subcondylar fractures are more caudally located and are the most common type of pediatric mandible fracture; they are generally greenstick fractures and do not require open surgical intervention.
Once the surrounding edema has subsided, emphasis on aggressive physical therapy with early range of motion at the temporomandibular joint (TMJ) is the mainstay of treatment. In younger children, range-of-motion exercises can be accomplished with a large lollipop. In older children, the use of stacked popsicle sticks can be used with a steady increase in number of sticks to increase the incisor opening. This action is taken to prevent TMJ ankylosis and dysfunction. If ankylosis is allowed to occur, it is one of the most difficult complications to remedy. Patients at greater risk for posttraumatic ankylosis of the condyle are children younger than 3 years and those with a prolonged period (usually greater than 3 weeks) of maxillomandibular immobilization.
A condylar fracture may cause concern for disruption of normal mandibular growth. It is not uncommon to see restricted growth on the injured side that results in ipsilateral chin deviation and facial asymmetry. This condition is more likely to be seen in cases of comminuted intracapsular fracture. This disruption of normal mandibular growth can lead to a malocclusion that did not exist immediately following the traumatic injury or the operative treatment. The abnormal growth is often a result of residual poor mandibular function caused by the fracture. Once this poor growth is noted, the patient should be referred to an orthodontist.
In all cases of condylar fractures, long-term follow-up is important. An orthodontist consult can prove invaluable as an adjunct for treatment, and preoperative planning and preparation.
Symphysis, parasymphysis, and body fractures
Management of fractures in the body of the mandible ranges from conservative management to ORIF, depending on the extent of the injury and amount of displacement of the fracture. Nondisplaced and greenstick fractures are managed conservatively. Manual closed reduction of displaced factures may be achieved with the patient under anesthesia followed by immobilization in MMF. ORIF is frequently required for fractures of the symphysis, body, and angle.
Emphasis on occlusion status is important in these fractures, as several deforming muscle forces may differentially act on this portion of the mandible. Occlusion may initially appear adequate, but these injuries are prone to subsequent displacement owing to the submental muscular pull and masticatory stresses. Therefore, close follow-up with such patients is essential for their care, and any new findings should be fully investigated with reexamination and imaging.
Angle and ramus fractures
Greenstick fractures are common at the angle and can be managed conservatively. Immobilization of the fracture at the angle is slightly more difficult, as it is not amenable to splints. However, if the angle is not significantly displaced, closed reduction with placement of the patient in MMF is typically sufficient to treat most fractures. ORIF is required only in highly comminuted fractures or when an acceptable reduction cannot be achieved with less invasive methods. When plating the angle, the addition of an extraoral incision may be beneficial to achieve appropriate exposure of fracture and to allow for easier instrumentation.
Ramus fractures may prove to be more difficult to plate relative to other fractures of the mandible. An external approach or a combined intraoral and extraoral approach may be required. Closed reduction with placement of the patient in MMF or arch bars with elastics may occasionally be sufficient to care for these patients.
Dentoalveolar fractures
Dentoalveolar fractures are common, although the true incidence is unknown because most of these injuries are unreported and treated in an office setting. The maxillary incisors are most commonly injured in the pediatric patient population.
Highly mobile permanent teeth located in the line of the fracture may need to be removed. Avulsed or luxated permanent teeth are considered dental emergencies, as timely treatment is required. The injured tooth needs to be reimplanted within a 1- to 2-hour window from the time of the injury. Replacement of a primary tooth is unnecessary. If a permanent tooth is not avulsed but slightly mobile, soft diet and immobilization with semirigid orthodontic wire can help fixate the teeth for 10 days until healing occurs. Splinting of the mobile deciduous or permanent teeth can also benefit the healing process and salvage the mobile tooth. Intruded primary teeth should be left alone. These teeth will eventually reerupt. Some dentoalveolar injuries can result in malformation of the tooth. Follow-up with a pediatric dentist experienced in treating dental trauma is recommended.
Fractures involving the alveolar aspect of the mandible may be treated with open or closed reduction in similar fashion to those in other regions of the mandible. Immobilization and restoration of occlusion with the use of splints or arch bars is vital to reestablish alveolar-arch continuity. Immobilization is limited to 2 weeks in younger children and up to 4 weeks in adolescents. These patients should undergo long-term follow-up to determine if there has been any disruption of permanent dentition development.
Resorbable versus nonresorbable fixation systems
Use of resorbable fixation systems has become routine in several types of craniofacial reconstruction surgery. These materials provide temporary rigid fixation for bone healing to occur and degrade over time as the reconstructed bone regains strength. These characteristics prove particularly ideal for the pediatric population, in which bone growth and turnover creates potential problems for nonresorbable, permanent plates.
The ideal biodegradable plate is mechanically strong and undergoes resorption within a predictable time frame. Variable chemical compositions of these plates attempt to balance an expedient degradation process while minimizing local foreign-body inflammatory reactions. Advantages of currently available resorbable polylactic and polyglycolic acid plates and screws are their radiolucency and elimination of the need to return for hardware removal. Typically their strength holds for 4 to 6 weeks while the complete degradation process may take 1 to 2 years. However, the application of resorbable plates in pediatric facial fracture treatment, particularly pediatric mandible fractures, is not currently widespread. Data from future studies would be required to examine their utility in treating this patient group. Titanium miniplates are still widely used despite the possible benefits of resorbable plates. Titanium plates demonstrate good long-term biocompatibility, have favorable physical properties, can be easily manipulated intraoperatively to treat the fracture, and have the benefit of several decades of predictable use in facial fracture fixation.
Some investigators have advocated for removal of nonresorbable plates following a 3- to 4-month healing period. Others argue that performing an additional surgery may actually cause more harm and disrupt the future development of the mandible. No clear answers are available to settle the debate of whether routine hardware removal is necessary. The effects on growth inhibition are difficult to quantify. The need for hardware removal is primarily dependent on an individual surgeon’s preference.
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