Pediatric Mandibular Fractures

Armamentarium

  • Appropriate sutures

  • Arch bars (Erich or similar)

  • Dental impression material (e.g., alginate)

  • Dental impression trays

  • Dental cast models

  • Elastics

  • General anesthesia with nasotracheal intubation or tracheostomy (for severely injured patients)

  • Heavy needle drivers

  • Local anesthetic with vasoconstrictor

  • Mandibular fracture fixation kit (containing fracture plates, miniplates, and screws)

  • Oropharyngeal pack

  • Orthodontic acrylic

  • Orthognathic or craniofacial instrument kit

  • Pickle fork

  • Plastic double cheek retractor

  • Resorbable sutures

  • Retractors

  • Scalpel (#15) or needle-tip electrocautery

  • Stainless steel wire (24 and 26 gauge)

History of the Procedure

Mandibular fractures in children follow different patterns from those in adults. In children, 80% of mandibular fractures involve the condyle or subcondylar region (up to 50%) or the mandibular angle. Body fractures are relatively rare. Symphysis and parasymphysis fractures comprise approximately 20% of pediatric mandibular fractures. Younger children (under 6 years of age) have thick, short condylar necks that fracture less often, compared to older. Young children have highly vascular condylar heads that are susceptible to crush injuries. Treatment decisions must take into account the potential for mandibular growth and eruption of the primary and succedaneous teeth. This has been a recognized tenet of management since the 1960s. Since the advent of rigid fixation, there has been significant debate about its use in the growing mandible and also the use of resorbable materials for this purpose. The goals of treatment in children are to obtain bony union, restore occlusion, and prevent and subsequently monitor for growth disturbances.

History of the Procedure

Mandibular fractures in children follow different patterns from those in adults. In children, 80% of mandibular fractures involve the condyle or subcondylar region (up to 50%) or the mandibular angle. Body fractures are relatively rare. Symphysis and parasymphysis fractures comprise approximately 20% of pediatric mandibular fractures. Younger children (under 6 years of age) have thick, short condylar necks that fracture less often, compared to older. Young children have highly vascular condylar heads that are susceptible to crush injuries. Treatment decisions must take into account the potential for mandibular growth and eruption of the primary and succedaneous teeth. This has been a recognized tenet of management since the 1960s. Since the advent of rigid fixation, there has been significant debate about its use in the growing mandible and also the use of resorbable materials for this purpose. The goals of treatment in children are to obtain bony union, restore occlusion, and prevent and subsequently monitor for growth disturbances.

Indications for the Use of the Procedure

Mandibular fractures in pediatric patients always require some form of treatment, ranging from observation with close follow-up to open or closed reduction with or without maxillomandibular fixation.

Limitations and Contraindications

The presence of significant cranial, cervical spine, thoracoabdominal, or other injuries that may reduce the likelihood of survival should be assessed first. Although management of facial fractures is an important aspect of care of the traumatized pediatric patient, assessment generally occurs as part of the secondary survey and managed after life-threatening injuries. The practitioner should suspect additional injuries in any child with a mandibular fracture. Significant force is required to fracture the pediatric mandible, given its lower modulus of elasticity and tendency to green-stick rather than fracture completely.

Clinical and radiographic examinations are required for diagnosis of pediatric mandibular fractures. The ability to elicit subjective complaints of malocclusion or inferior alveolar nerve dysfunction is limited in children, and imaging is often the best method of diagnosis. Plain films are often inadequate because they rely on cooperation from the child for accuracy. The short condyle-ramus unit in children leads to overlapping structures in panoramic radiographs, and fractures can be missed. Computed tomography (CT) is needed to delineate this area and is becoming the standard in hospital settings due to its increased accuracy compared to plain films.

As with all operative procedures in pediatric patients, precise communication between the provider and parents, in addition to age-appropriate explanations to the patient, are required for full compliance with treatment. Although it was historically believed that children could not tolerate maxillomandibular fixation (MMF), age is not a contrain­dication to MMF. The presence of significant medical conditions (e.g., epilepsy, coagulopathy) may be relative contraindications to a given approach (i.e., closed and open reduction, respectively).

Technique: Closed Reduction with or without Maxillomandibular Fixation

Step 1:

Overview

The procedure is most appropriately completed in younger children under general anesthesia with nasotracheal intubation. In adolescents, local anesthesia and/or intravenous sedation may be appropriate ( Figure 70-1, A ).

Figure 70-1
A, Schematic diagram for a nasotracheal intubation. Nasotracheal intubation is required for operative management of mandibular fractures to allow for establishment of occlusion. It is our practice to use a nasal Ring-Adair-Elwyn (RAE) tube, secured to the cartilaginous nasal septum using a 2-0 dyed Vicryl suture. B, When the arch bars cannot be placed due to traumatized or otherwise inadequate dentition, the fracture site can be immobilized with a lingual splint. Dental impressions are taken using a fast-setting material (e.g., alginate). The models are then poured using dental stone. Model surgery is performed as necessary to realign any displaced segments of the mandibular arch. Once the final arch form has been constructed on the model, the splint can be fabricated using orthodontic acrylic. A 24-gauge stainless steel wire can be incorporated into the splint to help support the contour of the lingual splint, as seen here. The splint can be secured to several teeth on each side of the arch. C, The Risdon cable. A twisted 24-gauge wire is adapted to the cervical margins of the teeth across the dental arches and secured using interdental wires. This is a suitable alternative to arch bar placement in children and adolescents because its low profile is easier to adapt to the pediatric dentition.
( B from Zimmerman CE, Troulis MJ, Kaban LB: Pediatric facial fractures: recent advances in prevention, diagnosis and management, Int J Oral Maxillofac Surg 35:2, 2006; C from Kushner GM, Tiwana PS: Fractures of the growing mandible, Atlas Oral Maxillofac Surg Clin North Am 17:81, 2009.)

Step 2:

Reduction of Fracture

Once adequate anesthesia has been achieved, the fracture is reduced manually, based on the alignment of the mandibular dentition and occlusion. Once this has been accomplished, arch bars or equivalent should be placed.

Step 3:

Placement of Arch Bars

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Jun 3, 2016 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Pediatric Mandibular Fractures
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