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Table of Contents   
SHORT COMMUNICATION  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 723-725
Mandibular fracture in an 18-month-old child


1 Department of Pedodontics and Preventive Dentistry, Subharti Dental College, Meerut, UP, India
2 Department of Oral Surgery, Subharti Dental College, Meerut, UP, India

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Date of Submission08-Feb-2010
Date of Decision04-May-2010
Date of Acceptance30-Aug-2010
Date of Web Publication7-Mar-2012
 

   Abstract 

Facial trauma in a child can be a greatly distressing experience for the parents as well as the child, causing uncontrollable crying in the child and panic and fear in the parents. Facial injuries in children are less common than in adults. This case report describes the management of symphysial fracture of the mandible in an 18-month-old girl. The fracture was reduced under general anesthesia and then stabilized with an acrylic cap splint, utilizing circummandibular wiring.

Keywords: Cap splint, mandibular fracture, trauma

How to cite this article:
Adlakha VK, Bansal V, Chandna P, Agarwal A. Mandibular fracture in an 18-month-old child. Indian J Dent Res 2011;22:723-5

How to cite this URL:
Adlakha VK, Bansal V, Chandna P, Agarwal A. Mandibular fracture in an 18-month-old child. Indian J Dent Res [serial online] 2011 [cited 2014 Sep 18];22:723-5. Available from: http://www.ijdr.in/text.asp?2011/22/5/723/93465
Facial trauma in children can be a greatly distressing experience for both parents and children, causing uncontrollable crying in children and a great degree of panic and fear in parents. Facial injuries in children are less common than in adults. The incidence in children ranges from 0.6% to 1.2%. [1] Fracture at the condylar, the subcondylar, and the angle region account for the majority of mandibular fractures. Fracture in the symphysis and parasymphysis region are less common and fracture in the region of the body of the mandible is extremely rare. [2] The predilection for specific sites changes with increasing age, and in adolescents the mandibular angle becomes the most common region of fracture. [3]

The present case report describes the management of a mandibular symphysial fracture in an 18-month-old girl.


   Case Report Top


An 18-month-old girl was brought to the outpatient department of Pedodontics and Preventive Dentistry, Subharti Dental College, Meerut, India, with a history of a fall from her bed. The patient was not well oriented, but the parents reported no history of vomiting or loss of consciousness.

Extraoral examination revealed the presence of a swelling in the anterior region of the mandible [Figure 1]. There was limited mouth opening because of pain and, possibly, muscle spasm. On intraoral examination, bleeding was evident within the mouth. All primary incisors and first molars were present. Clinically, a fracture was evident in the symphysial region between teeth #71 and #81. The maxillary central incisors (teeth #51 and #61) were mobile. Since the child was fearful, mild sedation was utilized to obtain alginate impressions as well as to take paranasal sinus (PNS) view and posteroanterior (PA) view radiographs [Figure 2] and [Figure 3]. In the radiographs, mandibular symphysis fracture was evident between teeth #71 and #81. An acrylic cap splint was then constructed on the model of the patient's arches after reducing the fracture on the model.
Figure 1: Preoperative extraoral view

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Figure 2: Preoperative PA radiograph

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Figure 3: Preoperative PNS radiograph

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Under general anesthesia the fracture was reduced and then stabilized with an acrylic cap splint. A small stab incision was placed at the inferior border of the mandible on the right side. A William Velsey Fry awl was introduced through the stab incision. The bone awl was guided along the body of the mandible and taken out lingually [Figure 4]. Next, the wire was fed in and the awl was gently guided along the lower border of the mandible and passed into the buccal sulcus. The wire was held together and ironing was done to adapt the wire in close approximation to the bone. This also procedure prevents soft tissue injury and an unaesthetic scar. The acrylic cap splint was then stabilized on the right side by winding the wire in a clockwise direction [Figure 5]. The same procedure was followed on the left side. Care was taken to avoid pulling the wire through the mandible since the child was young and at this age the mandibular cortex is thin and relatively less dense. A PA view radiograph was taken postoperatively to check if the wires were properly secured to bone [Figure 6]. The acrylic cap splint and the circummandibular wiring were removed after 3 weeks.
Figure 4: Intraoperative photograph showing insertion of bone awl

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Figure 5: Intraoperative photograph showing stabilized acrylic splint

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Figure 6: Postoperative PA radiograph following circummandibular wiring

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   Discussion Top


Facial fractures in children are rarer than in adults. This is due to the elasticity of bones in them and the short condylar neck, which tends to resist fracture. [1] However, the mandible is full of tooth buds and hence the ratio of tooth to bone is high, which can predispose to fracture of the mandible. [4]

The primary concern during treatment planning for pediatric maxillofacial injuries is to prevent injury to the developing dentition. Another concern is the possibility of behavioral and nutritional disturbances that may be caused by the trauma, hospitalization, and surgery.

During treatment planning in pediatric patients a number of factors must be taken into consideration. These include the age of the patient; the degree of compliance; the anatomic site of the fracture; the particular stage of growth and development (anatomic, physiologic, and psychologic); the complexity of the injury; the presence of concomitant injury; the time elapsed since injury; and the surgical approach being contemplated (closed vs open). [5]

There are various options available for treatment of mandibular fractures, such as closed reduction and intermaxillary fixation, open reduction with intraosseous wires, and open reduction with mini-plates and screws for internal rigid fixation. By the age of 2 years, 10 teeth exist in each arch and maxillofacial fixation may be achieved. However, in our case, the child was just 18 months old and only six teeth were present in each arch, which ruled out the option of maxillomandibular fixation. The height of contour of primary dentition is lower as compared to permanent dentition, [5] implying that the vertical height of the mandible is shorter. Thus, acrylic support with circummandibular wiring is required, and this approach was followed in the present case.

Open reduction in children with deciduous and mixed dentition must be avoided since tooth buds are present throughout the body of mandible. Trauma to developing tooth buds and partially erupted teeth may occur when placing intraosseous wires or flats and screws for internal rigid fixation. This may result in failure of eruption of the permanent teeth and a narrow atrophic alveolar ridge. [6] Use of circumdental wires and arch bars is also difficult in children because of the shape and short height of deciduous crowns.

Young children (i.e., those without a complete dentition) may be effectively treated with monomandibular fixation for symphysis injuries. [5] In this case, reduction of the fracture was done on the cast and an acrylic splint was prepared on it. Care was taken to reduce the fracture to as close as possible to the original position. The acrylic splint was removed after 3 weeks since the reparative process in children is rapid due to the high metabolic rate and the high osteogenic potential of the periosteum, which results in early union of fractured segments. [4] Slight occlusal discrepancies resulting from the lack of a perfect reduction resolve spontaneously as the permanent teeth erupt and bone undergoes remodeling with function. [6]

 
   References Top

1.Das UM, Nagarathna C, Viswanath D, Keerthi R, Gadicherla P, Management of facial trauma in children: A case report. J Indian Soc Pedod Prev Dent 2006;24:161-3.  Back to cited text no. 1
    
2.Bataineh AB. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:31-5.  Back to cited text no. 2
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3.Thoren H, Lizuka T, Hallikainen D, Lindqvist C. Different patterns of mandibular fractures in children. An analysis of 220 fractures in 157 patients. J Craniomaxillofac Surg 1992;20:292-6.  Back to cited text no. 3
    
4.Rowe NL, Williams JL, Maxillofacial Injuries. New York (NY): Longman (Churchill Livingstone); 1985.  Back to cited text no. 4
    
5.Haug RH. Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34.  Back to cited text no. 5
    
6.Kaban LB, Troulis M. Pediatric oral and maxillofacial surgery. Philadelphia (PA): W.B. Saunders Co; 1990.  Back to cited text no. 6
    

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Correspondence Address:
Vivek Kumar Adlakha
Department of Pedodontics and Preventive Dentistry, Subharti Dental College, Meerut, UP
India
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DOI: 10.4103/0970-9290.93465

PMID: 22406722

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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