Abstract
Mandibular fractures in the neonate are rare. The aetiological factors are traumatic delivery, accidental fall, road traffic accidents, and attempted infanticide. The diagnosis is difficult due to facial oedema masking the clinical features and the absence of dentition. The treatment of fractures in the newborn represents a unique problem in terms of investigations, diagnosis, selection of anaesthesia, and method of fixation. The case of a 1-day-old infant referred for the management of a mandibular fracture sustained in an accidental fall is presented herein. During oral suctioning, the neonatologist observed continuous blood-stained secretions, which raised the suspicion of a trauma to the oral cavity. The infant was diagnosed as having a fracture of the mandibular symphysis with displacement. The fracture was reduced under local anaesthesia with sedation, and was stabilized with an acrylic splint, which was secured with circum-mandibular wiring. The patient was followed up for 1.5 years and the healing was satisfactory.
Neonatal mandibular fractures are rarely encountered in day-to-day maxillofacial surgical practice. Most cases have been reported from tertiary care centres. The frequency of neonatal fracture before the age of 1 year has been estimated to be 0.9–2.6%. Of the 24 cases reported in the literature up until 2016, six were due to a traumatic delivery, one to caesarean section, and one had an unknown aetiology. The other aetiological factors were accidental fall, road traffic accidents, and attempted infanticide. Fracture of the mandibular symphysis is the most common in this age group.
The condylar neck in infants is relatively less developed and spongy in nature, and is therefore able to withstand significant force, with only a limited number of countercoup fractures occurring in combination with parasymphyseal fractures. There is a change in the fracture pattern as the condylar neck thins, becoming tall and cortical later in childhood.
In neonates less than 6 months of age, diagnosis is difficult due to the absence of dentition. Facial deformities and step deformities are barely appreciable in the presence of swelling. Irritability, continuous crying, and a refusal to feed are the first clinical features. The treatment of fractures in the newborn represents a unique problem in terms of investigations, diagnosis, selection of anaesthesia, and the method of fixation. The treating surgeon may not have enough experience to handle such cases. The case of a 1-day-old infant with a mandibular fracture is presented herein.
Case report
A call was received from the neonatal intensive care unit to attend to a newborn baby who was bleeding from the mouth. The patient was a healthy non-syndromic male baby who had been born to a prima gravida mother by vaginal delivery. The baby had slipped from the delivery chair and fallen on the ground.
Examinations revealed a systemically healthy child with all vital parameters within the normal limits. There was no facial asymmetry or extraoral injury marks. An oral examination revealed a midline cut and lacerated wound over the mandibular arch. The right half of the mandible was displaced towards the floor of the mouth thereby causing a step deformity at the midline. There was active oozing from the lacerated area. There were no other oral findings. Temporomandibular joint movements were adequate. Clinically he was diagnosed as a case of fracture of the mandibular symphysis due to birth trauma. The child underwent computed tomography imaging. The images were reformatted, and three-dimensional images showed a fracture of the mandibular symphysis and medial displacement of the right half of the mandible ( Fig. 1 a ). There was no other associated injury.
An attempt was made to manually reduce the fracture and stabilize it by suturing under local anaesthesia (lidocaine 2% with adrenaline 1:200,000) with sedation (midazolam 100 μg/kg), but the right segment was not stable. A lower arch impression was taken with thermoplastic impression compound and the model was poured in stone plaster. Model surgery was performed and both halves of the mandible were aligned with modelling wax and secured with a stone plaster base. Tin foil was adapted over the alveolar arch to act as a spacer, and a transparent self-polymerizing acrylic gunning splint was fabricated covering the entire mandibular arch. The fracture was reduced under local anaesthesia with sedation, and was stabilized with the acrylic splint, which was secured by circum-mandibular wiring in three different places using 26-gauge stainless steel wire ( Fig. 1 b). A postoperative radiograph confirmed satisfactory alignment of the segments ( Fig. 2 a ). The infant was tube-fed during the postoperative period and his recovery was uneventful. The splint was removed after 2 weeks. After 6 months there was eruption of a lower incisor ( Fig. 2 b).
The baby has been followed up for the last 1.5 years. Healing has been satisfactory. There has been sequential eruption of the primary dentition. The child has no limitation in jaw movement and his growth has been satisfactory.
Discussion
The incidence of jaw fractures in neonates is very low. As of 2016, only 24 cases had been reported in the English language literature, with six due to traumatic delivery and one to attempted infanticide. One case involved a neonate who was assaulted by her mother, who was suffering from puerperal psychosis. Forceps delivery has been reported as an aetiological factor. In the present case, the child sustained the injury in a fall from the delivery chair. During oral suctioning, the neonatologist observed continuous blood-stained secretions, which raised the suspicion of a trauma to the oral cavity. Hence the call was made to the oral and maxillofacial surgeon for further evaluation.
The aim of treatment is to maintain the form and function of the mandible, which has an important role in future facial development. As in adults, the neonatal mandibular fracture can be treated by closed method or open method with internal fixation. When selecting the treatment option, factors that should be taken into consideration include the number of fractures, site, displacement, presence of teeth, tooth buds, thickness of bone, age, associated systemic illness, and availability of technical expertise.
In neonates, fractures of the mandible are generally managed by closed method. Interdental wiring and intermaxillary fixation (IMF) are difficult in those with a partially erupted or unerupted primary dentition. Furthermore, the child may not tolerate IMF. It is not impossible to undertake open reduction and fixation, but by undertaking this, the potential complications include damage to the tooth buds and growth disturbances. Internal fixation is difficult in neonates due to the soft and spongy mandible. A combination of interdental wiring and lower border plating with a low profile microplate and 3-mm long screws has been reported for the management of mandibular fracture in an infant. Interosseous and circumferential stainless steel wiring has also been used previously to manage a mandibular fracture in a premature infant, as reported by Vasconcelos et al. In addition, resorbable suture fixation has recently been reported to be a safe and effective method for managing neonatal mandibular fractures.
The healing in the present case was satisfactory and the tooth buds were not damaged. The plate and screws were removed 9 weeks postoperatively under general anaesthesia, which is a disadvantage.
The fracture in the present case was a single midline fracture. Therefore closed reduction and splint fixation was chosen. The selection of anaesthesia is critical in such a small baby. Nasal intubation is difficult. Oral intubation interferes with intraoral procedures. Hence local anaesthesia with sedation was preferred to general anaesthesia. Local anaesthesia has a good analgesic effect during the immediate postoperative period thereby minimizing the need for analgesics. The acrylic splint was secured using circum-mandibular wiring in three different places, one wire in each first molar area and one in the right parasymphysis area to prevent medial displacement.
Postoperative antibiotics and analgesics were administered as part of the neonatal intensive care unit protocol. Nasogastric tube feeding was continued until the splint was removed. The highly osteogenic potential in neonates leads to rapid healing, and even imperfect opposition is later corrected by remodelling. The extent of any variation in odontogenesis depends upon the degree of trauma and how well the case is managed, minimizing any damage to the adjacent soft tissues. A case followed up for 9 years showed symmetrical development of the mandible with only the loss of the lower left deciduous lateral incisor and a deformed crown of the lower left central incisor.
In conclusion, mandibular fracture in the neonate will result in varying degrees of impairment depending on which part of the tooth forming structure is affected, the amount of damage, and the stage of development at the time of injury. Aggressive therapy when handling fractures in the neonate can cause long-term problems. Conservative fracture management should always be advocated in neonates.
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