HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Research Original Investigation

Management of Mandible Fracture in Children

P ediatric facial fractures can cause lasting, irreversible impairment in function and cosmesis. 1 Comprising 15% of all facial fractures in the United States, facial frac- tures occur less frequently inpediatric patients than in adults. 2 Part of the reason for this disparity is that the pediatric skel- eton is more resilient to traumatic forces, owing to its higher elasticity, higher cancellous to cortical bone proportion, and thicker overlying soft tissue and fat. 3 Pediatric mandible fractures (PMF) are the most com- mon pediatric facial fracture requiring hospitalization. 4 The risk of PMF increases with age, in part owing to facial growth. First, the face to cranium ratio increases with age, from 1:8 at birth to 1:2 to 1:2.5 in adulthood. 5 The mandibular growth in height at the alveolus as well as posterior and superior growth at the condyle ultimately results in translation of the man- dible anteriorly and inferiorly. 3 This makes the mandible a larger and more accessible structure for trauma with age. To our knowledge, this study represents the largest single institution cohort study in theUnited States for pediatricman- dible fractures in the literature. The goal of this study was to retrospectively analyzemanagementmethods, outcomes, and complications of pediatric mandible fractures at our institu- tion. We hypothesize that owing to favorable biology, the pe- diatric trauma populationhas greater osteogenic potential than the adult trauma population. We believe that conservative management, using observation with a soft diet or maxillo- mandibular fixation (MMF), vs open reduction internal fixa- tion (ORIF) with plating, is favored in most pediatric man- dible fractures. ComparedwithORIF,MMF confers adecreased risk of long-term facial deformity and is a less extensive sur- gerywithdecreased soft tissue trauma; however, it is acknowl- edged that extended periods of MMF increase the risk of tem- poromandibular joint ankylosis. Methods This study followed the Strengthening the Reporting of Ob- servational Studies in Epidemiology ( STROBE ) reporting guideline. We performed a single-institution, retrospective cohort study at 2 level 1 trauma centers. Inclusion criteriawere (1) International ClassificationofDiseases,NinthRevision ( ICD-9 ) codes 802.xx, or ICD-10 code S02.6XX; (2) aged 0 to 17 years at time of presentation, and (3) occurring between January 1, 2010, andDecember 31, 2016, anddata analysiswas conducted from January 1, 2018, to March 1, 2018. At our institution, multiple surgical specialty teams treat pediatric mandible fractures, including otolaryngologists, plastic surgeons, and oral and maxillofacial surgeons. This study was approved by the Indiana University School ofMedicine institutional review board. Expedited review was obtained, allowing informed consent to be waived because no interventionwas performed and no patient contact occurred while obtaining, reviewing, or analyzing the data. Data extracted from the electronic medical record in- cluded basic demographic characteristics,mechanism(s) of in- jury, operations, complications, and follow-up. All imaging studieswere reviewed. All fractureswere categorizedaccording

to Association of Osteosynthesis, Craniomaxillofacial Man- dible Fracture Classifications. 6 Statistical analysis was per- formed using SPSS 22.0 for Windows (IBM Corp) using uni- variate andmultivariate analyses. Two-tailed P < .05 indicated statistical significance. Results A total of 150 patients with documented pediatric mandible fractures were evaluated at our institution. Themean (SD) age was 12.8 (4.6) years, and 99 (66%) of the patients were teen- agers. One hundred eight (72.0%) patients weremale; and 107 (71.3%)werewhite,which is representativeof our patient popu- lation. Insurance was most commonly provided by Medicaid (74 patients [49.3%]) and managed care programs (59 pa- tients [39.3%]). One hundred twenty-seven of the patients (84.7%) presented directly to our emergency department vs by transfer from another institution ( Table 1 ). Therewere 310 totalmandible fractures ( Table 2 ), with 109 (72.7%) patients having 2 or more fractures. The distribution of fracture locationwas evenly split among the 4major groups of condylar or subcondylar, ramus or angle, body, and sym- physeal or parasymphyseal, with each comprising between 22% to 25% of all fractures. Coronoid fractures were encoun- tered in 10 (6.7%) of the 150 patients. Themost common frac- ture combinations were condylar or subcondylar only (3 with bilateral fractures), condylar or subcondylar plus symphy- seal or parasymphyseal (10with bilateral condylar or subcon- dylar fractures), and angle or ramus plus body. The most common mechanisms of injury among the 150 patients were assault and battery (33 [22.0%]), motor vehicle collisions (31 [20.7%]), falls or play (22 [14.7%]), and sport- related (22 [14.7%]) ( Figure 1 ). Multivariate analysis showed that condylar or subcondylar fractures were statisticallymore likely to be caused by falls and play vs othermechanisms (falls vs assault: difference of means, 0.89 [95%CI, 0.15-1.30]; falls vs motor vehicle collision: difference of means, 0.56 [95%CI, 0.15-0.97]; falls vs sport, difference of means, 0.85 [95% CI, 0.41-1.30]; P < .001 for all), angle or ramus fracturesmore likely caused by assault (assault vs falls: difference in means, 0.37 [95% CI, 0.01-0.84]; P = .03; assault vs motor vehicle colli- sion: difference in means, 0.44 [95% CI, 0.01-0.84]; P = .04), Key Points Question What are the treatment methods and associated complication rates in pediatric mandible fractures managed at a tertiary care center? Findings In this cohort study with 150 patients, one-fourth of pediatric mandible fractures were treated without surgery. Most operative pediatric mandible fractures were treated with maxillomandibular fixation alone and a soft diet. Meaning This study suggests that conservative management of pediatric mandible fractures using maxillomandibular fixation or observation with a soft diet predominates over open reduction internal fixation with plating.

JAMA Facial Plastic Surgery Published online June 6, 2019 (Reprinted)

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