HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Research Original Investigation

Management of Mandible Fracture in Children

severity, and typically transitions to the use of guiding elas- tics thereafter. 3,8 The short course of rigid MMF is used to decrease the risk of temporomandibular joint ankylosis. Although the fracture reduction in some instances may be imperfect, children in the primary and mixed dentition stages demonstrate some capacity for spontaneous occlusal realignment after injury and treatment, because primary teeth are shed and permanent teeth erupt. 7 Guiding elastics, as a healing suggestion, are thought to assist with this occlusal readjustment while the bone remains in a remodel- ing state. In specific instances, use of arch bars and guiding elastics alone may be sufficient to treat certain fractures. 3 Open reduction internal fixation with plating is often in- dicated in fractures of the mandibular arch or more complex fractures. In our study, ORIF was used nearly as often on its own as it was in conjunction withMMF for more complicated fractures. Nevertheless, the benefits of using ORIF alone cen- ter on the ability to not be “wired shut” inMMF, which has its ownpotentialmorbidities. These includeweight loss, poor hy- giene, and psychosocial and communicative difficulties. 9 Ti- taniumplates have good long-term biocompatibility, provide rigid fixation, and can be easilymanipulated intraoperatively to fixate the fracture reduction. 3 However, in younger chil- dren, the use of titaniumplates obliges the surgeon to at least consider the potential risk of facial deformity and asymme- try caused by the plates’ growth restriction on the mandible. In teenaged patients, the risk of facial asymmetry caused by plating should be considered but is less of a concern because themandible is typicallywell developed. Most surgeons keep titanium plates in place for 3 to 6 months, with some obtain- ing confirmationby computed tomography that adequate frac- ture healing has occurred before any consideration of hard- ware removal. In cases of ORIF in PMF with titanium plates, the senior author (T.Z.S.) prefers to remove plating approxi- mately 6months after initial fixation after confirmatory bone healing on computed tomography. In recent years, the use of resorbable polylactic and poly- glycolic acid plates has been introduced into the armamen- tarium in the treatment of pediatric fractures. In theory, re- sorbable platesmay be ideal for pediatricmaxillofacial trauma, because these plates are able to maintain fixation for 4 to 6 weeks during fracture healing, and degradation occurs across 1 to 2 years. 3 Therefore, resorption of that plate would theo- reticallyobviate theneed for plate removal and reduce or elimi- nate the growth restriction that titanium plates can cause. In our study, a single patient received resorbable platingwith no reported complication or revision surgeries. Further studies

Discussion The goals of treatment for pediatric mandible fractures are to reestablish normal jaw function, occlusion, and facial sym- metry. Management of pediatric mandible fractures has been largely dictated by fracture location and dentition status. For instance, it is generally accepted that pediatric condylar frac- tures should be managed conservatively, whereas more com- plex fractures involving the mandibular arch may require in- ternal fixation. In addition, deciduous teeth may not be appropriate forMMF use because they do not provide the ten- sile strength that cables or arch bars require. Current practice suggests that growth potential of the pediatricmandible is im- portant to consider in the long-term outcome of mandibular fracture management. In our study, we found that conservative management, specifically observation with a soft diet, or closed reduction with MMF and a soft diet, is favored across 3 different surgi- cal specialties for operative PMFs. Conservative manage- ment is often preferred owing to its lower potential for impairing pediatric mandibular growth. Maxillomandibular fixation, in contrast to internal fixation, does not require periosteal dissection, which can disrupt the osteogenic potential of the periosteum and cause scarring that can further restrict growth. 7 In cases where MMF is used, rigid MMF with use of wiring techniques can be maintained for 2 weeks, depending on surgeon preference and fracture

Figure 2. Mandible Fracture Operative Interventions

MMF (63; 56%)

MMF plus ORIF (20; 18%)

ORIF (24; 21%)

MMF inficates maxillomandibular fixation; ORIF, open reduction internal fixation.

Table 3. Repair Method for Pediatric Mandible Fracture by Patient Age

Age, y 0 to <6

Repair Method

6 to <12

12 to <18

Total

MMF ORIF

5 2 0

12

46 19 17 13

63 24 20 38

3 3

MMF+ORIF

OBS

11

14

Abbreviations: MMF, maxillomandibular fixation; OBS, observation; ORIF, open reduction internal fixation.

Other Total

0

1

4

5

18

33

99

150

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

jamafacialplasticsurgery.com

© 2019 American Medical Association. All rights reserved.

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