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Pediatric Mandibular Fractures
A Free Hand Technique
Steven P. Davison, DDS, MD;
Matthew S. Clifton, MD;
M. Nora Davison, PA-C;
Marc Hedrick, MD;
George Sotereanos, DMD
Arch Facial Plast Surg. 2001;3:185-189.
ABSTRACT
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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.
INTRODUCTION
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).
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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.
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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
2 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.
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Table 1. Time Elapsed for Return of Dental and Hygiene Function*
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Table 2. Complications Associated With Open Technique vs Closed Technique*
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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.
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Figure 2. Monocortical screw placement above
the tooth roots.
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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).
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Figure 3. Radiographic view of open reduction
internal fixation without intermaxillary fixation (A) and with intermaxillary
fixation (B).
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Figure 4. Fixed braces make ideal intermaxillary
fixation while requiring no additional surgical time.
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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.
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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.
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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.
AUTHOR 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.
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).
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RELATED ARTICLE
Pediatric Mandibular Fractures—Editorial Comment
Joseph S. Gruss
Arch Facial Plast Surg. 2001;3(3):190.
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