Highlights
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Applying of surgical and non-surgical procedures are actual.
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Main concept of this treatment is unloading of condyle and generating favorable background for enchondral osteogenesis.
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Surgical and conservative treatments are options for the treatment of condylar and subcondylar fracture in children.
The treatment tactics in case of mandibular fractures in children don’t differ much with adults one. The only one localization requires a different approach is a mandibular condyle [ ]. The cause of this difference could be explained by the incidence rate (15–86,7%) and continuous development of the facial skeleton in children [ ]. There are two options existing for the treatment of condylar and sub-condylar fractures in children: surgical and conservative approach [ ]. The indications for both age, fracture line localization, a degree of dislocation and fracture pattern. In spite of reasonable results of open reduction and internal fixation as a treatment method, it could be less effective in the case of condylar fractures in children. Therefore, a majority of pediatric cases aged 6–12 years old is receiving conservative treatment [ ]. However, there is still no common concept in the treatment of condylar fractures in children [ ]. This study aims to demonstrate the outcomes of conservative treatment done by the means of brackets and elastics application.
1
Material and methods
Within the current study, 15 children aged 2–15 years old with condyle fractures treated conservatively and surgically. All patients had undergone clinical investigation, blood and urine test and consulted with pediatricians and pediatric surgeon on the trauma. In all cases, a computerized tomography (CT) scan with 3D reconstruction used as a method of choice for diagnosis of the fracture patterns. Inclusion criteria for conservative treatment were under 12 years old and non-displaced or minimally displaced fracture with or without altered occlusion and severely displaced fracture with or minimally altered occlusion. In this study some of the conditions excluded such as displacement into middle cranial fossa, inability to get adequate occlusion, lateral extracapsular displacement of the condyle and lateral extracapsular displacement of the condyle.
All cases analyzed retrospectively. We used similar specific treatment protocol in all of them, a treatment includes 4 oz elastic bands for 2 weeks to get the first-class occlusion followed by application of 4 oz cross-midline elastic bands on injured site and Class III elastic on opposite over next 4 weeks.
2
Cases
2.1
Case 1. – unilateral condylar fracture
8 years old girl admitted to the hospital with complaints of swelling in the left parotid region, limitation in mouth opening and malocclusion. Upon analysis certain pathology related to trauma due to the fall. During a clinical investigation, painful swelling in the left parotid region, cross-bite, limitation on mouth opening as well as lacerations in the mental region of the mandible was found ( Figs. 1 and 2 ). CT scan showed a low sub-condylar fracture of the right condyle with medial shift dislocation ( Fig. 3 ).
A treatment protocol worked out, including the application of class I elastic bands for 2 weeks following to trauma, replaced by class III and cross-midline elastic bands for the next 4 weeks ( Fig. 4 ). A month later recall clinical investigation showed good mouth opening with a slight deviation of an interdental line ( Fig. 5 ). Radiological investigation detects partial repositioning of the condyle with signs of ossification on the lateral aspect of one ( Fig. 6 ).
6 months after trauma during clinical control good mouth opening with no any static or dynamic deviation of intra-dental line observed ( Fig. 7 ). The condyle showed a reasonable degree of reposition and remodeling on the radiological view ( Fig. 8 ). A soft diet and further follow-up recommended being done up to 16 years old.
2.2
Case 2. – bilateral sub-condylar fracture
8 years old boy admitted to the hospital with complaints on minor swelling in the left and right parotid region, limitation in mouth opening, malocclusion. Upon medical history certain pathology related to trauma due to the fall. During a clinical investigation, painful swelling in the left and right parotid region, open-bite, mouth opening limitation, as well as lacerations in the mental region were found ( Figs. 9 and 10 ). CT scan showed a sub-condylar fracture of the right and left condyle with minor dislocation medial shift of both condyles ( Fig. 11 ).
A treatment protocol worked out, including class I elastic bands for 2 weeks applied following to trauma, replaced by class III and cross-midline elastic bands for the next 4 weeks ( Fig. 12 ).
3
Results
Within the current study, 15 cases of treatment of condyle fractures analyzed. A slight male predilection showed (8 boys 62.85% and 7 girls 37.14%) with mean age 8.71 years old. Distribution due to fracture localization was as follows: in 9 (34.28%) cases, unilateral subcondylar fracture, in 3 cases (14.28%) bilateral sub-condylar fracture and in rest 4 (51.42%) cases condyle fracture associated with different sites of the mandible. According to medical histories in 12 (77.14%) cases, the cause of the fracture was fall, in 1 (17.14%) traffic accident, in 1 (2.85%) fall from bicycle and in 1 (2.85%) sports trauma. During clinical investigation majority of patients in 28 (80%) cases mesial cross-bite observed, in 6 cases (17.14%) mesial open bite, in one case mesial open cross-bite with mean range of deviation while mouth opening 2.9142 mm. Radiological investigation revealed the majority of patients in 12(54.28%) cases medial displacement of the condyle within fossa; in 3 (8.57%) cases minimal medial displacement within fossa detected.
Conservative treatment used as follows: in 7 (20%) of cases brackets and elastic bands, 3 (8.57%) arch bars and elastic bands, in one case (2.85%) IMF screws and elastic bands, in one case (2.85%) combination of IMF screws, brackets and elastic bands; in one case (2.85%) Erst ligature, in one (2.85%) plastic splint and in one (2.85%) soft diet. In one case patient’s parents refuses from any treatment.
On 6 month of follow-up majority (14 patients [91.42%]) showed I Class occlusion with a mean range of dynamic deviation of 0.628 mm; in only 1(8.57%) cases patients showed mesial crossbite. A complete distribution of clinical data is showing in Table 1 .
No | Age/Sex | The cause of injury | Localization of fracture | Occlusion Pre-OP | Deviation on mouth opening Pre-OP | Condyle displacement | Method of treatment | Occlusion Post OP | Deviation on mouth opening Post OP | Post OP radiological condyle status |
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1 | 7/b | Fall | L-side condyle + L-side angle | Mesial cross-bite | 3 mm | Anterior displacement out of fossa | ORIF | I class | 1 mm | None |
2 | 4/g | Fall | L-side condyle + R-side parasymphisis | Mesial cross-bite | 3 mm | Medial displacement within fossa | Brackets + elastics | I class | 0 mm | Repositioning and remodeling |
3 | 14/b | Sport | L-side condyle | Mesial cross-bite | 4 mm | Medial displacement within fossa | Brackets + elastics | I class | 1 mm | Repositioning and remodeling |
4 | 8/b | Fall | L-side condyle | Mesial cross-bite | 4 mm | Medial displacement within fossa | Brackets + elastics | I Class | 1 mm | Repositioning and remodeling |
5 | 5/g | Fall | L-side condyle | Mesial cross-bite | 4 mm | Medial displacement within fossa | Plastic splint | Mesial cross-bite | 4 mm | None |
6 | 11/b | Fall | L-side condyle | Mesial cross-bite | 4 mm | Medial displacement within fossa | Arch bar + elastics | I Class | 1 mm | Repositioning and remodeling |
7 | 4/b | Fall | L-condyle + L-side angle | Mesial cross-bite | 5 mm | Medial displacement out of fossa | ORIF + IMF screws | I Class | 1 mm | Repositioning and remodeling |
8 | 4/b | Fall | Bilateral condyle | Mesial open bite | 0 mm | Minimal medial displacement within fossa | Diet | I Class | 0 mm | None |
9 | 12/b | Fall | L-side condyle + R-side body | Mesial cross-bite | 4 mm | Medial displacement out of fossa | ORIF | I Class | 0 mm | None |
10 | 15/b | Fall | Bilateral condyle | Mesial open bite | 0 mm | Minimal medial displacement within fossa | Arch bar + elastics | I Class | 0 mm | None |
11 | 15/b | Traffic | L-side condyle + Le For III | Mesial open cross-bite | 5 mm | Total medial displacement out of fossa | ORIF | I Class | 0 mm | Repositioning and remodeling |
12 | 11/b | Fall | R-side condyle + L-side body | Mesial cross-bite | 3 mm | Total medial displacement out of fossa | ORIF + condylektomy | I Class | 1 mm | Repositioning and remodeling |
13 | 2/b | Fall | L-side condyle + R-side parasymphysis | Mesial cross-bite | 3 mm | Medial displacement within fossa | IMF screws + elastics | I Class | 1 mm | Repositioning and remodeling |
14 | 12/b | Traffic | R-side condyle + L-parasymphisis | Mesial cross-bite | 4 mm | Medial displacement within fossa | ORIF + Brackets + elastics | I Class | 0 mm | Repositioning and remodeling |
15 | 14/b | Traffic | L-side condyle | Mesial cross- bite | 3 mm | Total medial displacement out of fossa | ORIF | I Class | 0 mm | Repositioning and remodeling |
16 | 14/g | Fall | Bilateral condyle | Mesial open bite | 0 mm | Medial displacement within fossa | ORIF | I Class | 0 mm | Repositioning |
17 | 15/b | Fall | R-side condyle | Mesial cross-bite | 4 mm | Total medial displacement out of fossa | ORIF | I Class | 1 mm | Repositioning and remodeling |
18 | 7/b | Fall | L-side condyle + R-side parasymphysis | Mesial cross-bite | 3 mm | Medial displacement within fossa | ORIF + Brackets + elastics | I Class | 1 mm | Repositioning and remodeling |
19 | 10/g | Traffic | L-side condyle + R-side parasymphysis | Mesial cross-bite | 4 mm | Medial displacement within fossa | ORIF + Brackets + elastics | I Class | 0 mm | Repositioning and remodeling |
20 | 9/g | Fall | L-side condyle | Mesial cross-bite | 3 mm | Total medial displacement out of fossa | None | Mesial cross-bite | 3 mm | None |
21 | 3/b | Fall | R-side condyle | Mesial cross-bite | 3 mm | Total medial displacement out of fossa | ORIF | Mesial cross-bite | 3 mm | None |
22 | 15/b | Fall | Bilateral condyle | Mesial open bite | 0 mm | Total medial displacement out of fossa | ORIF | I Class | 0 mm | None |
23 | 12/g | Traffic | Bilateral condyle | Mesial open bite | 0 mm | Total medial displacement out of fossa | ORIF | I Class | 0 mm | Repositioning |
24 | 12/g | Fall | L-side condyle | Mesial cross-bite | 3 mm | Medial displacement within fossa | ORIF | I Class | 0 mm | None |
25 | 8/b | Fall | L-side condyle + R-side parasymphysis | Mesial cross-bite | 2 mm | Medial displacement within fossa | ORIF | I class | 0 mm | Repositioning |
26 | 6/g | Fall | L-side condyle | Mesial cross bite | 3 mm | Medial displacement within fossa | Arch bar + elastics | I class | 0 mm | Repositioning |
27 | 9/b | Fall | R-side condyle + L-side body | Mesial cross bite | 4 mm | Total medial displacement out of fossa | ORIF + condylectomy | I class | 2 mm | None |
28 | 8/b | Fall | Bilateral condyle + R-side body | Mesial open bite | 0 mm | Medial displacement within fossa | IMF screws + Brackets +elastics |
I class | 0 mm | Repositioning and remodeling |
29 | 6/g | Fall | L-side condyle | Mesial cross bite | 4 mm | Medial displacement within fossa | Brackets +elastics |
I class | 0 mm | Repositioning and remodeling |
30 | 6/g | Traffic | R-side condyle + symphysis | Mesial cross bite | 3 mm | Medial displacement within fossa | Brackets +elastics |
I class | 0 mm | Repositioning and remodeling |
31 | 2/b | Fall | R-side condyle + symphysis | Mesial cross bite | 3 mm | Medial displacement within fossa | ORIF + IMF screws + elastics | I class | 0 mm | Repositioning and remodeling |
32 | 11/g | Fall | L-side condyle | Mesial cross bite | 5 mm | Total medial displacement out of fossa | ORIF | I class | 0 mm | Repositioning |
33 | 2/b | Fall | R-side condyle + L-side parasymphysis | Mesial cross bite | 2 mm | Minimal medial displacement within fossa | Ernst ligature | I class | 1 mm | None |
34 | 6/g | Bicycle | R-side condyle + L-side body | Mesial cross bite | 4 mm | Medial displacement within fossa | Brackets +elastics |
I class | 0 mm | Repositioning and remodeling |
35 | 6/g | Fall | L-side condyle + R-side parasymphysis | Mesial cross bite | 3 mm | Medial displacement within fossa | Brackets +elastics |
I class | 0 mm | Repositioning and remodeling |