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Table of Contents   
SHORT COMMUNICATION  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 873-876
A conservative approach to pediatric mandibular fracture management: Outcome and advantages


Dental Department, University College of Medical Sciences and GTB Hospital, (University of Delhi), Delhi, India

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Date of Submission02-Mar-2010
Date of Decision08-Jun-2010
Date of Acceptance27-Apr-2011
Date of Web Publication5-Apr-2012
 

   Abstract 

Pediatric mandibular fractures are rare and their treatment remains controversial. Management is extremely complicated in mixed dentition as it is inherently dynamic and unstable. Treatment options include soft diet, intermaxillary fixation with eyelet wires, arch bars, circummandibular wiring, or stents. Alternative options include open reduction and internal fixation through either an intraoral or extraoral approach. This case report describes and evaluates the conservative technique of acrylic splint in the treatment of pediatric mandible fracture in a 12-year-old female child. The patient with isolated mandibular fracture was treated with acrylic splint and interdental wiring followed by evaluation of clinical and radiographic healing as well as the somatosensory status. Patient demonstrated clinical union to her pre-injury occlusion by three to four weeks. Panoramic finding supported the finding of clinical examination throughout the study. High osteogenic potential of the pediatric mandible allowed conservative management to be successful in this case.

Keywords: Acrylic splint, mandibular fracture, paediatric patients

How to cite this article:
Khatri A, Kalra N. A conservative approach to pediatric mandibular fracture management: Outcome and advantages. Indian J Dent Res 2011;22:873-6

How to cite this URL:
Khatri A, Kalra N. A conservative approach to pediatric mandibular fracture management: Outcome and advantages. Indian J Dent Res [serial online] 2011 [cited 2014 Apr 21];22:873-6. Available from: http://www.ijdr.in/text.asp?2011/22/6/873/94692
Trauma-induced maxillofacial injuries in children may affect function as well as esthetic appearance. Hence these must be diagnosed and managed appropriately to avoid disturbances of future growth and development. The overall frequency of facial fractures in children is much lower than that in adults (5-15%). [1],[2],[3],[4],[5],[6] The prevalence of pediatric facial fractures is lowest in infants and increases progressively with increasing age. [1],[2],[3],[4],[5],[7],[8] Only 0.87-1.0% of facial fractures occur in children younger than five years, whereas 1.0-14.7% occur in patients older than 16 years. [1],[2] Two peaks have been observed in the frequency of such fractures: The first, at the age of six to seven years, is associated with the beginning of school attendance. [1] The second, at 12-14 years, is related to increased physical activity and participation in sports during puberty and adolescence. [1],[3]

Approximately half of all pediatric facial fractures involve the mandible. [9] A fall from a bicycle or stairs is the most common cause of mandibular fractures. [10] Treatment principles of pediatric mandibular fractures differ from treatment of the adult population in that a conservative approach is advocated in most cases. [11] Not only do the consequences of trauma differ, but the management techniques should also be modified to address the child's particular stage of anatomic, physiologic and psychological development. [12]

Open reduction and osteosynthesis of the pediatric fracture with titanium plates and screws are thought to have a negative effect on the skeletal growth and unerupted teeth. [13] It involves two-stage surgery because of the need for plate removal after complete healing. [14] The use of absorbable plates and screws is less likely to disturb facial skeletal growth but is still associated with the risk of damaging unerupted teeth even when using mono cortical screws. [15],[16] Because of these obvious risks, closed reduction is advocated in these cases. [11] Growth and development of the maxillofacial structures should be considered to avoid malunion and subsequent deformities. [17]

The purpose of this paper is to present the advantages of a fabricated acrylic splint, which was chosen as a practical and effective conservative treatment approach and follow-up in a pediatric patient with a mandibular dentoalveolar fracture.


   Case Report Top


A 12-year-old girl reported to the Department of Dentistry of University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi with a history of fall from bicycle two days ago. After the fall, the patient did not lose consciousness, was well-oriented and had no history of convulsions or vomiting. The patient was anxious but co-operative and allowed conversation.

Clinical [Figure 1] and radiological examination Orthopantomograph (OPG) [Figure 2] showed a vertical fracture line between the right lower canine and the first premolar associated with medially dislocated right mandibular dentoalveolar segment with altered occlusion. There were no other fracture lines on the TMJ or other bony structures. No individual tooth fracture was present and none of the teeth in the line of fracture were mobile or missing. Radiological examination [Figure 2] showed congenitally missing lower left first premolar. Vitality of 32, 31, 41, 42, 43 and 44 were checked. All teeth showed positive response to electric and cold test.
Figure 1: Vertical fracture line between the right lower canine and first premolar

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Figure 2: OPG

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Under local anesthesia interdental wiring with 0.5 mm stainless steel wire was done between the right lower canine and first premolar to achieve temporary stabilization and favorable repositioning of fracture. This also created a compressive horizontal force marginally over the fracture site from one side to the other. Simultaneously, the fracture ends were manually moved carefully during compression so that further reduction of the fracture was seen. [18] Impressions of both jaws were taken with alginate impression material before manual reduction. The dislocated segment was reduced and aligned by bi-digital pressure with the guidance of occlusal plan. Surgical model setup of the mandible was prepared i.e. re-adjusted and re-assembled, to simulate the reduction that was done clinically and accurate occlusal plan was achieved for the dislocated dentoalveolar segment. Hard acrylic splint was cemented 3 hrs later [Figure 3]. Self-curing acrylic was used to construct the surgical splint. The fixation of the surgical splint to the dentoalveolar structure was achieved by Type I (luting) GIC, GC, JAPAN.
Figure 3: Hard acrylic splint

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The patient was discharged without intermaxillary fixation. The antibiotic treatment was begun with Augmentin 375 mg (three times a day, 25 mg/kg) (Duocid, Pfizer) and analgesic acetaminophen suspension (three times a day, 250 mg) (Calpol, Glaxo-Welcome) for one week; soft diet, avoidance of physical activities and antibacterial mouth rinse (Chlorhexidine 0.12%) was prescribed. Postoperative monitoring was performed on a weekly basis for the first month and was favorable in both healing and function. The interdental wiring and acrylic splint were removed after one month. Patient was kept under observation and periodic OPGs were taken at one month [Figure 4], three months [Figure 5] and six months [Figure 6]. The clinical and radiological evaluation after six months showed that both centric occlusion and healing at the fracture site were excellent. The teeth and periodontal tissue were also examined by testing vitality, mobility, percussion, periodontal probing and radiography. All investigations were normal. Further follow-up was planned after six months.
Figure 4: OPG after one-month follow-up

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Figure 5: OPG after three-month follow-up

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Figure 6: OPG after six-month follow-up

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   Discussion Top


The incidence of facial fractures is lower in the pediatric population than in the adult population and represents 1-14.7% of the facial fractures in the general population. [3] The reasons cited for this low incidence include, small volume of facial mass relative to the calvarium, the relative resilience of the pediatric skeleton and the protected environment in which children live, leading to less exposure to typical mechanism of injury. [16],[17] Many pediatric fractures are non-displaced or greenstick-type fractures, and observation alone is adequate. [2],[3] There is almost no indication to open a fracture because the abundance of developing teeth in the bone makes fixation almost impossible without damaging these structures. [2],[3] A conservative approach (observation or closed reduction) is the best approach to consider first for pediatric mandible fractures, as these fractures heal rapidly, and the children grow normally. [2],[3]

However, with unstable fractures that cannot be secured with closed reduction techniques, open reduction and internal fixation become necessary after the age of 12 years, when dentition has erupted and root formation has matured enough and at this time treatment becomes similar to that performed in the adult population. The use of absorbable plates and screws have nearly no side-effects on the growing facial skeleton but there is still the risk of damaging unerupted teeth during the drilling process. [2] However, this was not useful in this particular case because all permanent teeth were erupted.

The treatment of displaced symphyseal fractures has included a closed reduction and immobilization with arch bars and elastics. [18] This technique may lead to a great disturbance in the patient's lifestyle, particularly feeding and speaking. Various authors agree that a long period of immobilization (more than two weeks) may cause ankylosis of the temporomandibular joint and damage to developing teeth. [19],[20]

The degree of precision required in a child is not quite as great as in an adult, as the adaptive potential of the alveolar bone and the replacement of deciduous teeth by permanent teeth can bring about various degrees of self-correction. The high osteogenic potential of the pediatric mandible is responsible for a low complication rate. [18]

The objectives of surgical treatment of mandibular fractures are to restore normal occlusion and provide stability that supports fracture healing and allows normal eating and drinking. In a six-month follow-up of this case, the results showed complete healing without any complications on the surrounding tissues.

This case report describes a vertical fracture line extending between the right lower canine and first premolar which was successfully treated by means of applying direct interdental wiring combined with an acrylic splint. In a six-month follow-up of this case the patient neither showed occlusal disharmony nor any TMJ problems.

These clinical outcomes indicate that fabricated acrylic splints for conservative treatment of pediatric mandibular fracture are cost-effective, and easy to apply and remove. Also, these are less time-consuming as well as provide maximum stability during the healing period with minimal trauma to the adjacent anatomic structures and thereby are more comfortable for young patients.

However, periodic long-term follow-up is absolutely essential in pediatric facial trauma cases for early determination of possible growth disturbances. The treatment protocol should be expanded to include this approach and applied on children with mandibular fractures in the primary dentition, mixed dentition as well as permanent dentition.

 
   References Top

1.Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fractures: Recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg 2006;35:2-13.  Back to cited text no. 1
    
2.Haug RH, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Radiol Endod 2000;90:126-34.  Back to cited text no. 2
    
3.Ferreira PC, Amarante JM, Silva PN, Rodrigues JM, Choupina MP, Silva AC, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 2005;115:1500-8.  Back to cited text no. 3
    
4.Holland AJ, Broome C, Steinberg A, Cass DT. Facial fractures in children. Pediatr Emerg Care 2001;17:157-60.  Back to cited text no. 4
    
5.Faust RA, Younes AA, Gottlieb W, Phillips CD. Maxillary fractures in children. WebMD Web site. Available from: http://www.emedicine.com/ent/topic491.htm. [Last Accessed on 2007 March 17].  Back to cited text no. 5
    
6.Pachigolla R. Pediatric facial trauma. Grand rounds presentation, Department of Otolaryngology, University of Texas Medical Branch, Galveston, Tex. Available from: http://www.utmb.edu/otoref/Grnds/Pedfacial-trauma-9905/Ped-facial-trauma-9905.pdf. Published May 12, 1999. [Last Accessed on 2007 April 2].  Back to cited text no. 6
    
7.Triana RJ, Shockley WW. Pediatric zygomaticoorbital complex fractures: The use of resorbable plating systems-a case report. J Craniomaxillofac Trauma 1998;4:32-3.  Back to cited text no. 7
    
8.Anderson PJ. Fractures of the facial skeleton in children. Injury 1995;26:47-50.  Back to cited text no. 8
    
9.Iida S, Matsuya T. Pediatric maxillofacial fractures: Their etiological characters and fracture patterns. J Craniomaxillofac Surg 2002;30:237-41.  Back to cited text no. 9
    
10.Rowe NL. Fracture of the facial skeleton in children. Oral Surg 1968;26:505.  Back to cited text no. 10
    
11.Gawelin PJ, Thor AL. Conservative treatment of paediatric mandibular fracture by the use of orthodontic appliance and rubber elastics: Report of a case. Dent Traumatol 2005;21:57-9.  Back to cited text no. 11
    
12.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. 12
    
13.Anderson PJ, David DJ. Hyperostosis as a late sequel of parasymphyseal mandibular fractures in 2 children. J Craniomaxillofac Surg 2005;33:188-90.  Back to cited text no. 13
    
14.Koltai P, Rabkin D, Hoehn J. Rigid fixation of facial fractures in children. Craniomaxillofac Trauma11995;1:32-42.  Back to cited text no. 14
    
15.Imola MJ, Harnlar DD, Shao W, Chodhury K, Tatum S. Resorbable plate fixation in pediatric craniofacial surgery: Long-term outcome. Arch Facial Plast Surg 2001;3:79-90.  Back to cited text no. 15
    
16.Eppley BL. Use of resorbable plates and screws in pediatric facial fractures. Oral Maxillofac Surg 2005;63:385-91.  Back to cited text no. 16
    
17.Tanaka J, Uchide N, Suzuki K, Tashiro T, Tornitsuka K, Kimijirna Y, et al. Maxillofacial fractures in children. Craniomaxillofac Surg 1993;21:289-93.  Back to cited text no. 17
    
18.Qadri GW, Mokhtar SM. Paediatric mandibular fracture: Report of case. Dent Traumatol 2008;24:e67-70.  Back to cited text no. 18
    
19.Kaban LB, Troulis MJ. Pediatric oral and maxillofacial surgery. Philadelphia, Pa.; London: W. B. Saunders; 2004.  Back to cited text no. 19
    
20.Remi M, Christine MC, Gael P, Soizick P, Joseph-Andre J. Mandibular fractures in children: Long term results. Int J Pediatr Otorhinolaryngol 2003;67:25-3.  Back to cited text no. 20
    

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Correspondence Address:
Amit Khatri
Dental Department, University College of Medical Sciences and GTB Hospital, (University of Delhi), Delhi
India
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DOI: 10.4103/0970-9290.94692

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