Int. J. Oral Maxillofac. Surg. 1994; 23:329-331 Printed in Denmark. All rights reserved

Copyright©Munksgaard 1994

international Journal of'

Oral Maxillofacial Surgery

ISSN 0901-5027

Mandibular fractures in children A retrospective study of 99 fractures in 59 patients

Trauma; oral surgery

Pedro Infante Cossio, Fernando Espin Galvez, Jose Luis Gutierrez Perez, Alvaro Garcia-Perla, Jose Maria Hernandez Guisado Department of Maxiilofacial Surgery and Stomatology, Virgen del Rocio University Hospital, University of Seville, Seville, Spain

P. Infante Cossio, F. Espin Galvez, J. L. Gutierrez Perez, A. Garcia-Perla, J. M. Hernandez Guisado. Mandibular J?actures in children. A retrospective study o f 99fractures in 59 patients'. Int. J. Oral Maxillofac. Surg. 1994; 23: 329-331. © Munksgaard, 1994

Abstract. Fifty-nine children younger than 16 years with mandibular fractures were studied by age, sex, type of fracture, cause, methods of treatment, and compli- cations. The cases were divided into three age groups. The male-to-female ratio w a s 2.9:1. Mo to r vehicle accidents were the most common cause of mandibular fractures. Associated injuries were more common in young children. The condyle w a s involved in 43.3% of fractures. Intermaxil lary fixation was the most common treatment used. Complications appeared to be rare.

Resumen. Se presenta un estudio de 59 nifios menores de 16 afios con fracturas de mandibula, considerando la edad, sexo, tipo de fractura, etiologia, tratami- ento empleado y complicaciones. Los pacientes se dividieron en 3 grupos de edad para su estudio. La proporcidn entre varones y hembras fue de 2, 9/1. La etiologla m~is frecuente de las fracturas de mandibula fueron los accidentes de tr/tfico. L a s

lesiones asociadas se dieron con mayor frecuencia en los nifios m~is pequefios. La fractura de cdndilo ocurri6 en un 43,3% de los casos. E1 tratamiento mils utiliza- do fue el bloqueo intermaxilar. Las complicaciones fueron raras.

Key words: fractures; maxillofacial injuries; traumatology; mandible; pediatric surgery.

Accepted for publication 28 May 1994

Maxillofacial fractures in general and mandibular fractures in particular are less common in children than in adults. Differences between children's and adults' facial osseous structures - essentially the resilience of the develop- ing mandible - and the smaller size of the mandible relative to the cranium and the forehead in infants seem to ac- count for this 7'13'16. The presence of tooth germs, the number of permanent teeth present, the size of the pr imary teeth and the resorption of their roots, and possible damage to the condylar growth center in children are factors that should be taken into account when treating these fractures ~'5. General measures such as the use o f seat belts and safety seats for children in moto r vehicles may explain the decrease in the

incidence of facial injuries in the pedi- atric populat ion 5,13.

The purpose of this investigation w a s

to analyze the incidence, cause, and an- atomic location of fractures; treatment methods; and results of treatment in 59 children with mandibular fractures.

Material and methods

Fifty-nine patients aged from 14 months to 16 years formed the basis for this study. All of them were patients with mandibular frac- tures admitted to the Department of Max- illofacial Surgery and Stomatology of the University Hospital "Virgen del Rocio", Se- ville, Spain, between June 1988 and Decem- ber 1990. Patients with mandibular fractures who died because of other associated injuries and those with isolated alveolar and dental fractures were excluded from this study. The

patient data recorded included age at the time of injury, cause of injury, anatomic site of fracture, associated injuries, radiographs, mode of treatment, complications, and re- sults obtained. The sample was divided into three groups to compare the variables in dif- ferent age groups. Group A comprised pa- tients aged 14 months to 5 years; group B, patients aged 6-11 years; and group C, pa- tients aged 1~16 years.

Results

There were 99 mandibular fractures treated during the period studied. The patients ranged in age from 14 months to 16 years (mean 11.5 years). The num- ber of c a s e s (30) w a s greatest for group C (51%). Group B accounted for 22 c a s e s (37%) and group A for seven c a s e s

(12%). Of the 59 patients studied, 37

330 In fan te Cossio et al.

(63%) were boys and 22 (37%) were girls (a ratio of 2.9: 1). There was a predomi- nance of boys in all age groups.

The causes of the fractures are shown in Table 1. The most common cause of mandibular fracture in our series was a motor vehicle accident. This repre- sented 44% (26 patients) in all groups. C o m m o n falls were the cause in 24% of the cases (14 patients). Pedestrians hit by motor vehicles comprised 13.5% of the patients (9). Other less frequent causes were sports injuries, bicycle acci- dents, fights, gunshot, and horse kick.

The cause of the injury varied ac- cording to the age group. The most common cause of mandibular fracture in group A was motor vehicle accidents and in group B falls and being hit by motor vehicles while walking. In group C, the most common cause of mandibu- lar fractures was motor vehicle acci- dents, motorcycle accidents being

characteristic o f this age group. All fractures caused by sports accidents, fights, gunshot, and horse kick oc- curred in group C.

The anatomic location of fractures in each age group is depicted in Table 2. The most common site of injury in all age groups was the condyle in 55.9% of cases, both alone or in com- bination with other fractures. Condy- lar fractures occurred in 43.25% of the cases. Less commonly noted were sym- physial area (24.25%), angle (20.25%), and mandibular body (12.25%). No ramus or coronoid process fractures were seen.

Twenty-nine (49%) patients presented with multiple fractures of the mandible, with a mean of 1.7 fractures per patient. Multiple fractures were more common in group C (60%) than in groups A (42.9%) and B (36.4%). Seven patients presented three fracture sites in the

Table 1. Causes of mandible fractures in various age groups

Group A Group B Group C Total

Motor vehicle accidents 5 4 17 26 (44%) Common falls 2 10 2 14 (24%) Pedestrians struck by motor vehicles 5 3 8 (13.5%) Bicycle accidents 3 3 (5.1%) Sports accidents 3 3 (5.1%) Fights 3 3 (5.1%) Gunshot 1 1 (1.6%) Horse kick 1 1 (1.6%)

Total 7 22 30 59 (100%)

Table 2. Anatomic location of mandible fractures in various age groups

Group A Group B Group C Total

Symphysial - 9 15 24 (24.25%) Body 3 3 6 12 (12.25%) Angle 2 5 13 20 (20.25%) Condyle 5 t7 21 43 (43.25%) Ramus - 0 Coronoid process - - : 0

Total 10 34 55 99 (100%)

Table 3. Associated injuries in various age groups

Group A Group B Group C

Intracerebral trauma 4 6 10 Soft-tissue injuries 3 9 8 Facial fractures

Nasal 1 - 1 Middle third 1 1 2 Malar - 1 1 Orbital floor - 1 2

Extremity fractures - 3 6 Visceral lesions - - 1

Liver

mandible, and two children had more than three fractures.

In 44 children studied (71%), injuries associated with the mandibular fracture were present. Younger children were clearly shown to have a higher incidence of associated injuries (Table 3). In group A, 6/7 (86%) patients sustained other injuries in addit ion to the man- dibular fractures, and two patients even required intubation and treatment in the intensive care unit. Sixteen of 22 (73%) patients in group B and 20/30 (67%) patients in group C had associ- ated injuries. Only one patient in group B and one in group C required endotra- cheal intubation.

Dental fractures and dental avulsions were noted in 2/7 (28.5%) patients in group A, 5/22 (22.7%) patients in group B, and 6/30 (20%) patients in group C. No patients had aspirated a broken or lost tooth.

Most of the patients underwent a closed reduction of the fracture and in- termaxillary fixation (IMF). In 32 cases, I M F was done with archbars, in 14 with internal skeletal wires from the pyriform rim to a circummandibular wire, and in four with Ivy loops. In group A, two children required an acrylic splint on the lower arch fixed with circummandibular wires. Open reduction of the temporo- mandibular joint was done in one pa- tient. In group A, no open reduction and internal fixation of the fracture segments was done. One child in group B and six children in group C underwent open re- duction and internal fixation with mini- plate osteosynthesis.

In groups A and B, I M F was removed after 3 weeks or less in all patients. For group C, a 4-6-week period of immobil- ization was maintained in all fractures except condylar fractures, for which a 3- week period of fixation was used.

All patients were followed up for 6 months. Follow-up was extended to 2 years in ca~es of condylar fractures. A satisfactory result was obtained in most patients (90%). Few complications de- veloped in children. One patient had malocclusion and another had a com- bined malocclusion and residual de- formity. One patient had a postopera- tive infection related to a circttmmandi- bular wire fixation. Temporomandi- bular joint ankylosis and retarded facial growth were detected in one patient.

Discussion

A lower incidence of mandibular frac- tures in children than adults has been

Mandibular fractures in children 331

found in several studies reporting simi- lar data varying 1 5% 1'3'4'15, depending on the age studied. The incidence in- creases gradually from birth through 16 years o f age 6,16, as in this study. The sex distribution shows a dominance of boys in all age groups. This trend increases with age, as shown in this series and in others 1,4,10,14j6.

The most common cause of man- dibular fractures was motor vehicle ac- cidents, as reported elsewhere 2,4,17. Nevertheless, in some European coun- tries and in the USA, this percentage has been decreasing because of laws re- quiring seat belts for chiidren 5,16. In our study, no case of mandibular fracture caused by abuse was found. Some authors have reported such cases, mainly arising from violence to silence a crying child 12,16.

Other injuries associated with man- dibular fractures were common, show- ing a percentage (71%) similar to that reported by other authors 5. The inci- dence of these injuries decreases with increasing age 13,16. Most fractures caused by traffic accidents in children younger than 5 years of age are associ- ated with intracerebral t rauma or other facial injuries. In total, 4/59 patients re- quired airway control by endotracheal intubation, al though no t racheotomy was done.

The mean of mandibular fractures per patient was 1.7, a figure agreeing with those reported by other authors 16,17. These data emphasize the necessity of searching for a second frac- ture site when one fracture is dis- covered.

The most common fracture site was the condyle, with a total of 43 (55.9%) fractures. The percentage is similar to those reported by other authors 16. The higher incidence of condylar fractures in children than adults may be e x - plained by the higher propor t ion of medullary bone with only a thin r im of cortex 5,6. The second most common location of fractures in this series was the mandibular angle.

Mandibular fractures in children were treated according to the basic methods as reported in the literature 5,s. In most patients, adequate immobiliza- tion with archbars and eyelet wiring or by skeletal suspension wiring from the

bony pyri form rim to a circummandib- ular wire can be obtained 9. In younger children, we have also successfully used acrylic splints attached to the mandible by circummandibular wires, avoiding the necessity of I M F 5. In some older children with unfavorable fractures, we used direct osteosynthesis with mini- plates. A miniplate can be placed at the mandibular inferior border by directing the screws away from the developing rootsl l .

The short period of follow-up in this study makes it impossible to draw any conclusions about possible alterations in facial growth. Ankylosis of the tem- poromandibular joint as a complication of condylar fracture was observed in one patient. This complication might be avoided with a shorter period of im- mobilization. The period of immobil- ization in young children, who have a high osteogenic potential, should not be longer than 2-3 weeks 1. In addition to a short period of immobilization, early mobil izat ion and rehabilitation should be done. Low condylar neck fractures may be treated with immediate rigid fixation with micro- or miniplates to mobilize the joint as soon as possible.

The remaining complications ob- served in the patients were of less im- portance and were similar to those pre- viously reported 5,16. They were mainly related to the delay of adequate treat- ment. There was no damage to the teeth or germs in those patients receiving internal fixation. We had no occlusal problems, and the mouth opening in all children was within normal limits. Non- unions were not observed in any of the patients, and only one patient had a postoperative infection, which was cured with antibiotics.

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Address: Dr Pedro Infante Cossio Department of Maxillofacial Surgery and

Stomatology Virgen del Rocio University Hospital Manuel Siurot Avenue 41013-Seville Spain