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Figure 1.
A, Intraoperative bony stabilization
using a bimanual technique. B, Bimanual reduction to establish clinical occlusion.
C, Emphasis on bony reduction rather than occlusal reduction in this pediatric
population with unstable dentition. D, Bony fixation with open reduction internal
fixation of the bone.

A, Intraoperative bony stabilization using a bimanual technique. B, Bimanual reduction to establish clinical occlusion. C, Emphasis on bony reduction rather than occlusal reduction in this pediatric population with unstable dentition. D, Bony fixation with open reduction internal fixation of the bone.

Figure 2.
Monocortical screw placement above
the tooth roots.

Monocortical screw placement above the tooth roots.

Figure 3.
Radiographic view of open reduction
internal fixation without intermaxillary fixation (A) and with intermaxillary
fixation (B).

Radiographic view of open reduction internal fixation without intermaxillary fixation (A) and with intermaxillary fixation (B).

Figure 4.
Fixed braces make ideal intermaxillary
fixation while requiring no additional surgical time.

Fixed braces make ideal intermaxillary fixation while requiring no additional surgical time.

Figure 5.
Example of a bilateral parasymphyseal
fracture in an adolescent patient with horizontal separation of the alveolar
bone off the basilar bone. This reduction requires intermaxillary fixation.

Example of a bilateral parasymphyseal fracture in an adolescent patient with horizontal separation of the alveolar bone off the basilar bone. This reduction requires intermaxillary fixation.

Table 1. 
Time Elapsed for Return of Dental and Hygiene Function*
Time Elapsed for Return of Dental and Hygiene Function*
Table 2. 
Complications Associated With Open Technique vs Closed Technique*
Complications Associated With Open Technique vs Closed Technique*
1.
Rowe  NL Fractures of the facial skeleton in children J Oral Surg. 1968;26505- 515Article
2.
Hardt  NGottsauner  A The treatment of mandibular fractures in children J Craniomaxillofac Surg. 1993;21214- 219Article
3.
Posnick  JCWells  MPron  GE Pediatric facial fractures—evolving patterns of treatment J Oral Maxillofac Surg. 1993;51836- 844Article
4.
Keniry  AJ A survey of jaw fractures in children Br J Oral Surg. 1971;8231- 236Article
5.
Gussack  GSLuterman  APowell  RWRodgers  KRamenofsky  ML Pediatric maxillofacial trauma: unique features in diagnosis and treatment Laryngoscope. 1987;97925- 930Article
6.
Norholt  SEKrishan  VSindet-Pedersen  SJensen  I Pediatric condylar fractures: a long-term follow-up study of 55 patients J Oral Maxillofac Surg. 1993;511302- 1310Article
7.
Kahl  BFischbach  RGerlach  KL Temporomandibular joint morphology in children after treatment of condylar fractures with functional appliance therapy Dentomaxillofac Radiol. 1995;2437- 45Article
8.
Tanaka  NUchide  NSuzuki  K  et al.  Maxillofacial fractures in children J Craniomaxillofac Surg. 1993;21289- 293Article
9.
Guven  O Fractures of the maxillofacial region in children J Craniomaxillofac Surg. 1992;20244- 247Article
10.
Cossio  IPGalvez  EFPerez  GLGarcia-Perla  AHernandez  JM Mandibular fractures in children: a retrospective study of 99 fractures in 59 patients Int J Oral Maxillofac Surg. 1994;23329- 331Article
11.
Demianczuk  ANVerchere  CPhillips  JH The effect on facial growth of pediatric mandible fractures J Craniofac Surg. 1999;10323- 328Article
12.
Nishioka  GJLarrabee  WFMurakami  CSRenner  GJ Suspended circumandibular wire fixation for mixed-dentition pediatric mandible fractures Arch Otolaryngol Head Neck Surg. 1997;123753- 758Article
13.
Schweinfurth  JMKoltai  PJ Pediatric mandible fractures Facial Plast Surg. 1998;1431- 44Article
14.
Fordyce  AMLalani  ZSongra  AKHildreth  AJCarton  ATHawkesford  JE Intermaxillary fixation is not usually necessary to reduce mandibular fractures Br J Oral Maxillofac Surg. 1999;3752- 57Article
15.
Siegel  MBWetmore  RFPolsic  WPHandler  SDTom  LW Mandibular fractures in the pediatric patient Arch Otolaryngol Head Neck Surg. 1991;117533- 536Article
16.
Anderson  PJ Fractures of the facial skeleton in children Injury. 1995;2647- 50Article
17.
Nixon  FLowey  MN Failed eruption of the permanent canine following open reduction of a mandibular fracture in a child Br Dent J. 1990;168204- 205Article
18.
Jones  KMBauer  BSPensler  JM Treatment of mandibular fractures in children Ann Plast Surg. 1989;23280- 283Article
Citations 0
Original Article
July 2001

Pediatric Mandibular FracturesA Free Hand Technique

Author Affiliations

From the Divisions of Plastic Surgery, Georgetown University Medical Center, Washington, DC (Drs Davison and Clifton and Ms Davison), and Surgery, University of Pittsburgh, Pittsburgh, Pa (Drs Hedrick and Sotereanos).

 

From the Divisions of Plastic Surgery, Georgetown University Medical Center, Washington, DC (Drs Davison and Clifton and Ms Davison), and Surgery, University of Pittsburgh, Pittsburgh, Pa (Drs Hedrick and Sotereanos).

Arch Facial Plast Surg. 2001;3(3):185-189. doi:
Abstract

Background  The treatment of pediatric mandibular fractures is rare, controversial, and complicated by mixed dentition.

Objectives  To determine if open mandibular fracture repair with intraoral and extraoral rigid plate placement, after free hand occlusal and bone reduction, without intermaxillary fixation (IMF), is appropriate and to discuss postoperative advantages, namely, maximal early return of function and minimal oral hygiene issues.

Patients  A group of 29 pediatric patients with a mandibular fracture were examined. Twenty pediatric patients (13 males and 7 females) with a mean age of 9 years (age range, 1-17 years) were treated using IMF. All patients were treated by the same surgeon (G.S.).

Results  Surgical time for plating was reduced by 1 hour, the average time to place patients in IMF. The patients who underwent open reduction internal fixation without IMF ate a soft mechanical diet by postoperative day 3 compared with postoperative day 16 for those who underwent IMF. Complication rates related to fixation technique were comparable at 20% for those who did not undergo IMF and 33% for those who did.

Conclusions  We believe that free hand reduction is a valuable technique to reduce operative time for pediatric mandibular fractures. It maximizes return to function while minimizing the oral hygiene issues and hardware removal of intermaxillary function.

PEDIATRIC mandibular fractures are rare and their treatment controversial. Management is complicated by mixed dentition that is inherently dynamic and unstable. In reports of large case series of maxillofacial trauma, children younger than 6 years constitute 1% of the fractures.1-2 The incidence of pediatric mandibular fractures increases to 5% at the ages 6 years or older; this is because the relative size of the cranium decreases.3 As the pediatric mandible is more malleable, a fracture involves significant force, with motor vehicle injuries consistently being the most frequent mechanism of injury.3-5

The ideal treatment approach is unclear as the number of patients to study are few and follow-up study difficult because it disturbs growth. Treatment options include soft diet, intermaxillary fixation (IMF) with eyelet wires, arch bars, circummandibular wiring, or stents. Alternative options include open reduction and internal fixation through either an intraoral or extraoral approach. Isolated condyle fractures have been successfully treated with closed functional therapy.6-7 The closed treatment of ramus, body, and symphysis fractures may require extended periods of IMF from 3 to 5 weeks8-10; however, unrecognized and untreated fractures can lead to increased rates of orthodontic and craniofacial surgery for facial asymmetry.11

To improve postoperative occlusion results with IMF in an inherently unstable dentition, suspended circummandibular wire fixation was devised.12 To reduce the length of IMF, it has been combined with miniplate osteosynthetic open reduction internal fixation (ORIF).2 Two recent large case series by Norholt et al6 and Posnick et al3 have treated up to 65% of noncondylar fractures with ORIF because of multiple concomitant fracture sites. Those techniques still require initial fracture reduction with IMF that may be retained as a tension band.2, 13 Studies performed on the adult population have shown that a reduction in operative time can be attained using a free hand technique in the absence of IMF, with no increase in occlusal discrepancies.14

We describe a technique of internal fixation in the pediatric population, after free hand occlusal and bone reduction without IMF. It emphasizes bone reduction under direct vision while eliminating the time and difficulty of applying IMF to an unstable dentition. We document the efficacy, efficiency, and complication of this technique and compare it with a group of patients treated with IMF. The purpose of this study was to illustrate the reduction in surgical time by eliminating concurrent IMF and to discuss postoperative advantages, namely, maximal early return of function and minimal oral hygiene issues.

PATIENTS AND METHODS

A retrospective review of oromaxillofacial trauma treated at a tertiary care pediatric hospital from January 18, 1992, to March 31, 1997, identified 39 mixed dentition pediatric mandibular fractures. Twenty pediatric patients (13 males and 7 females) with a mean age of 9 years (age range, 1-17 years) were treated with ORIF after the mandibles were reduced and stabilized with a bimanual technique without IMF. These were compared with 9 patients treated with IMF. All patients were treated by one of us (G.S.).

Diagnostic data were collected from hospital medical records, operative and dietary notes, and radiographic studies (including panoramic tomogram [Panorex] and computed tomographic scans). Clinical follow-up was recorded from office notes, panoramic tomograms, and clinical examination. All patients and their families were surveyed by telephone using a questionnaire on function modified from Norholt et al.6

The anatomical site of the mandibular fracture was identified, the surgical approach documented, and the number and type of plate were recorded. The surgeon's operative time for comparison with a sample-matched group treated with IMF was isolated. Postoperative clinical examination noted occlusion, malocclusion, masticatory function, oral opening, tooth loss or damage related to plate placement, and facial growth retardation. The treated fractures were separated into those whose fractures were reduced with a free hand and bimanual technique or IMF preoperatively, intraoperatively, or postoperatively.

SURGICAL TECHNIQUE

The distinguishing difference in the free hand technique is the emphasis on bone reduction. Adequate exposure via an intraoral or extraoral approach is accomplished and the fracture site prepared for the insertion of a plate, wires, or lag screws. An assistant, positioned cephalad, bimanually manipulates the dentition into the patient's centric occlusion. Under direct vision, the bone edges are manipulated into the ideal position, tripoding the fracture with the occlusion. The fractures are then fixated with plates, wires, lag screws, or a combination of these, focusing on bone reduction. The technique uses no intraoperative or postoperative IMF (Figure 1).

RESULTS

A total of 39 fracture sites in 20 pediatric patients (13 males and 7 females) were treated with a free hand technique. These patients had a mean age of 9 years (age range, 1-17 years). The mechanism of injury was motor vehicle/all-terrain vehicle crash in 9 patients (45%), playing sports in 8 patients (40%), assault or abuse in 2 patients (10%), and fall in 1 patient (5%). The surgical approach for placement of a total of 45 plates was intraoral in 11 patients (55%), extraoral in 7 patients (35%), or combined in 2 patients (10%).

The site of fracture was parasymphyseal in 8 (41%) of 20 patients or condylar or subcondylar in 9 patients (43%). The body and ramus constituted the fracture sites in 3 patients (16%). Surgical time for plating averaged 2½ hours. The average time for the placement of the IMF alone was 1 hour.

Functional results were reviewed at an average of 19 months' follow-up (Table 1). Complications were also listed (Table 2). Complications were considered to be related to reduction techniques either free hand or IMF when they affected occlusion, trismus, or function. In the free hand group 4 complications in 3 patients were related to the reduction technique. In the group who underwent IMF, 3 complications in 3 patients were related to the reduction technique.

Cephalometric and panographic examination revealed no facial growth disturbance or asymmetry. Four patients underwent elective plate removal to avoid facial growth retardation or plate exposure for a total patient reoperation ratio of 7:20 (35%). Of the patients treated with IMF, 6 (67%) of 9 needed general anaesthetic and reoperation to remove arch bars.

COMMENT

Many factors complicate the management of pediatric mixed-dentition mandibular fractures: tooth eruption, short roots, developing tooth buds, and growth issues. One major factor is the inherent instability of the occlusion in the mixed deciduous-permanent tooth phase. These fractures are rare and a vast treatment experience is hard to gather. Because there are no controlled studies, there is a lack of agreement in the ideal treatment. There are 2 philosophical approaches to management. One is conservative therapy with soft diet, and/or minimal functional IMF.2, 13 This relies on the plasticity of the pediatric occlusion. The second approach, used in more complex fracture patterns1, 4 in both the very young and the more adult patient, uses techniques standard to adult management. This includes rigid IMF and ORIF. Our technique, a free hand occlusal and bone reduction without IMF, is discussed as it combines the benefits of ORIF (early motion, rapid advancement of mastication, and hygiene) with the advantage of a malleable dentition.

The descriptive portion of this study mirrors findings found in other large case series.1, 3, 6, 10 Pediatric mandibular fractures require significant force to occur. Motor vehicle injuries are the most common causes, followed by high-velocity sports injuries, although in Europe a recent study found falls a greater problem, reflecting cultural differences.13 Children riding all-terrain vehicles are also at high risk of mandibular fractures; these fractures (3 of 20 patients) were associated with the most severe upper facial and cranium fractures. A recent treatise emphasizes the risks to the craniofacial skelton in all-terrain vehicle use.

The pediatric mandibular fractures in this case series were seen at the parasymphyseal and condylar or subcondylar region. A common combination was the parasymphyseal and condylar fracture.15 This is different from the pattern of parasymphyseal and angle fractures seen in adults. The controversy of open treatment vs closed treatment of pediatric mandibular fractures remains. However, the recent literature2-3,15-16 shows a change in using ORIF in fracture stablilization. The risks of facial growth disturbance in ORIF has not been supported.6 In contrast, no treatment in unrecognized mandibular fractures leads to a high incidence of orthognathic surgery and craniofacial treatment.11 The potential damage to tooth roots17 and follicles can be minimized with a careful technique, which places bicortical screws in the lower mandibular border with monocortical screws placed in more superior plates (Figure 2). This case series of patients with limited (19-month) follow-up showed no facial growth or tooth eruption problems. The most significant complication was a traction injury of the facial nerve in 1 patient who had a subcondylar fracture that subsequently improved with aggressive therapy. After primary repair and aggressive physical therapy, this patient's condition improved to a grade IV/VI Glasgow scale score for facial motion.

Our free hand technique concentrates on the reduction of the bony fragments under ideal visualization to achieve less than 1 mm of gapping. The occlusion is held in place manually. This relies on experienced assistance, but there is also the fact that in children small occlusal discrepancies will be rapidly compensated for by the plasticity of the mixed dentition and future eruption patterns. A large case series by Fordyce et al14 has already established that the use of anatomical reduction over IMF requires less intraoperative time with no long-term increase in malocclusion in the adult population. Our technique maximizes the advantages of an ORIF technique without the disadvantages of a closed technique with IMF because it eliminates 1 hour of surgical time and additional general anaesthetic for obtaining impressions18 or IMF removal. One case series of IMF/ORIF treatment required a 6% reoperation rate to revise IMF.15 This series illustrates that in pediatric patients the reoperative rate is much higher (66%) with IMF. Pediatric patients are less able to tolerate removal of IMF in the physician's office. This rate was higher for the 7 of 20 patients who were reoperated on in the free hand group for any reason, infection, scar revision, or plate removal (Figure 3). One clinical caveat is that which occurs when patients already have existing orthodontic devices in place. Fixed braces make ideal rapid IMF, and removable appliances and expanders function as tension bands (Figure 4).

In addition, the patients who were treated using the free hand technique quickly return to functional mastication. Drinking liquids was delayed by 0.2 days compared with IMF secondary to surgical pain and swelling. However, the patients who underwent the free hand technique ate a soft diet and performed oral hygiene at 3 days which was 13 and 15 days, respectively, earlier than those who underwent IMF. This has implication for normal condylar growth and normal joint function. The results of condylar function have been improved with early motion.18 When the free hand technique is compared with IMF, the rate of mastication or occlusion difficulties was similar. This is important as an ORIF was used in a more severely injured group.

This study was not a comparison between open and closed techniques, but rather between free hand fixation and IMF. The group who were treated with IMF included patients treated with ORIF. The group with free hand ORIF had complications not directly related to reduction, including scar formation, postoperative infection, and nerve injury. In the free hand group, 5 complications were in 2 patients with multiple associated midfacial or basilar skull injuries. This may suggest that they were better candidates for IMF with ORIF or would have had complications regardless of fixation modality.

The free hand technique is best suited to surgeons experienced in working with the facial skeleton and requires the presence of appropriately skilled assistants since there is potential for the incorporation of occlusal discrepancy in unskilled hands. However, the plasticity of the pediatric occlusion and dentofacial architecture reduces this risk. Some fracture patterns are not ideal for this bimanual technique, such as horizontally unfavorable fractures that tip the alveolar bone lingually off the basilar bone (Figure 5). Often, a lingual acrylic splint is needed to maintain arch contour in these situations. Fortunately, this fracture pattern is not often seen in children. Although this technique reduces operative time, cost, and reoperation to remove IMF, it is not easier than placing arch bars, and in certain circumstances requires more skill and experience. A notable improvement in eating a soft diet and tooth brushing and oral hygiene, particularly on the lingual tooth surface, is quickly appreciated.

CONCLUSIONS

We describe a technique for free hand occlusal and bone reduction without IMF in pediatric patients with mixed-dentition mandibular fractures. When an open technique is used for reduction, it emphasizes the bony reduction relying on the plasticity of pediatric occlusion. This free hand technique reduces surgical time by 1 hour and accelerates soft diet intake and oral hygiene capability by 2 weeks when compared with techniques that incorporate IMF. This technique can be successfully used when dentition has not yet erupted or is in a mixed phase and poorly able to support IMF. It does, however, require providing skilled assistance to the primary surgeon and as such is more applicable to a tertiary care center.

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Article Information

Accepted for publication February 8, 2001.

Corresponding author and reprints: Steven P. Davison, DDS, MD, Division of Plastic Surgery, Georgetown University Medical Center, 3800 Reservoir Rd NW, Washington, DC 20007.

References
1.
Rowe  NL Fractures of the facial skeleton in children J Oral Surg. 1968;26505- 515Article
2.
Hardt  NGottsauner  A The treatment of mandibular fractures in children J Craniomaxillofac Surg. 1993;21214- 219Article
3.
Posnick  JCWells  MPron  GE Pediatric facial fractures—evolving patterns of treatment J Oral Maxillofac Surg. 1993;51836- 844Article
4.
Keniry  AJ A survey of jaw fractures in children Br J Oral Surg. 1971;8231- 236Article
5.
Gussack  GSLuterman  APowell  RWRodgers  KRamenofsky  ML Pediatric maxillofacial trauma: unique features in diagnosis and treatment Laryngoscope. 1987;97925- 930Article
6.
Norholt  SEKrishan  VSindet-Pedersen  SJensen  I Pediatric condylar fractures: a long-term follow-up study of 55 patients J Oral Maxillofac Surg. 1993;511302- 1310Article
7.
Kahl  BFischbach  RGerlach  KL Temporomandibular joint morphology in children after treatment of condylar fractures with functional appliance therapy Dentomaxillofac Radiol. 1995;2437- 45Article
8.
Tanaka  NUchide  NSuzuki  K  et al.  Maxillofacial fractures in children J Craniomaxillofac Surg. 1993;21289- 293Article
9.
Guven  O Fractures of the maxillofacial region in children J Craniomaxillofac Surg. 1992;20244- 247Article
10.
Cossio  IPGalvez  EFPerez  GLGarcia-Perla  AHernandez  JM Mandibular fractures in children: a retrospective study of 99 fractures in 59 patients Int J Oral Maxillofac Surg. 1994;23329- 331Article
11.
Demianczuk  ANVerchere  CPhillips  JH The effect on facial growth of pediatric mandible fractures J Craniofac Surg. 1999;10323- 328Article
12.
Nishioka  GJLarrabee  WFMurakami  CSRenner  GJ Suspended circumandibular wire fixation for mixed-dentition pediatric mandible fractures Arch Otolaryngol Head Neck Surg. 1997;123753- 758Article
13.
Schweinfurth  JMKoltai  PJ Pediatric mandible fractures Facial Plast Surg. 1998;1431- 44Article
14.
Fordyce  AMLalani  ZSongra  AKHildreth  AJCarton  ATHawkesford  JE Intermaxillary fixation is not usually necessary to reduce mandibular fractures Br J Oral Maxillofac Surg. 1999;3752- 57Article
15.
Siegel  MBWetmore  RFPolsic  WPHandler  SDTom  LW Mandibular fractures in the pediatric patient Arch Otolaryngol Head Neck Surg. 1991;117533- 536Article
16.
Anderson  PJ Fractures of the facial skeleton in children Injury. 1995;2647- 50Article
17.
Nixon  FLowey  MN Failed eruption of the permanent canine following open reduction of a mandibular fracture in a child Br Dent J. 1990;168204- 205Article
18.
Jones  KMBauer  BSPensler  JM Treatment of mandibular fractures in children Ann Plast Surg. 1989;23280- 283Article
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