2015 HSC Section 1 Book of Articles

Boyette

Displaced fractures of other regions of the mandible can be treated with closed reduction and dental stabilization or open reduction and internal fixation. In general, an attempt at a closed technique is recommended for younger children (<6 years of age), whereas teenagers can be treated with open reduction and internal fixation similar to adults. If closed reduction is successful, there are many methods to achieve stability including traditional arch bars, wire ligatures, or Risdon cables. 1 Acrylic splints fixated with circum-mandibular wires are also a good option if the deciduous dentition does not support wiring. However, the child must undergo general anesthesia up to three times because the mold must first be made, the splint wired in place, and then the splint removed. In general, these types of fixation can be removed after 3 weeks. 57 Open reduction internal fixation is a viable and necessary option in many patients. In general, open reduction internal fixation is applied to displaced fractures of the tooth- bearing portion of the mandible that cannot be properly reduced or stabilized with closed techniques. 57 Multiple fracture sites or comminuted fractures are another indi- cation. 59 As mentioned previously, if the patient has already reached skeletal and dental maturity, open reduction internal fixation can be applied similar to an adult pa- tient. In a recent study, Smith and colleagues 59 report on using open reduction internal fixation on 75% of mandible fractures in children older than 12 years of age. The use of internal fixation in younger children with developing dentition requires that screws be placed to avoid damaging the unerupted teeth ( Fig. 4 ). Single mini- plate fixation is typically all that is necessary for stabilization in children. 57,60 Fixation at the inferior border of the mandible with monocortical screws avoids damaging the unerupted tooth buds. Additional stabilization to prevent rotation at the superior border can be obtained with an arch bar. Avoiding placement of permanent rigid fix- ation across the midline of the mandible in young children is recommended, because there is a potential for growth restriction. 61,62 Although some surgeons recommend hardware removal after a few months, this practice is controversial and objective evidence is lacking. 57,62,63 However, long-term problems with mandibular growth are a major concern. Growth disturbance following mandibular fractures is more commonly encountered with frac- tures of the condyle because this area is considered the primary growth center. 53,58,64 Fractures sustained during the years of active vertical growth have been demon- strated by Demianczuk and colleagues 58 to later require orthognathic surgery in up to 24% of cases. Proffit and colleagues 53 have reported that up to 10% of adult pa- tients with dentofacial deformities have evidence of a condylar fracture in childhood.

Fig. 4. Panorex radiograph demonstrating unerupted tooth buds of the pediatric mandible. Note the particularly low-lying position of the tooth buds in the parasymphaseal region.

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