International Journal of Pediatric Otorhinolaryngology 75 (2011) 62–64

Mandibular fractures in children: Analysis of 61 cases and review of the literature

Michael Glazer a, Ben Zion Joshua b, Yitzhak Woldenberg c, Lipa Bodner c,*a Division of Anesthesiology and Critical Care, Soroka University Medical Center and Ben Gurion University of the Negev, Beer-Sheva, Israelb Department of Otolaryngology Head and Neck Surgery, Soroka University Medical Center and Ben Gurion University of the Negev, Beer-Sheva, Israelc Department of Oral and Maxillofacial Surgery, Soroka University Medical Center and Ben Gurion University of the Negev, Beer-Sheva, Israel

A R T I C L E I N F O

Article history:

Received 24 August 2010

Received in revised form 21 September 2010

Accepted 1 October 2010

Available online 29 October 2010

Keywords:

Mandible

Jaw bone

Trauma

Fracture

Children

A B S T R A C T

Objective: The purpose was to evaluate the incidence, etiology, site and patterns, management and

treatment methods, and outcome of pediatric patients with mandibular fractures.

Methods: Pediatric patients (1.5–16 years old) with mandibular fractures, treated at the Soroka

University Medical Center were included in the study. Age, gender, etiology, site and type of fracture,

associated injuries, mode of treatment, outcome, complications, and follow up were evaluated. The cases

were divided into 3 age groups: Group A: 1.5–5 years, Group B: 6–11 years, and Group C: 12–16 years.

Results: Sixty one patients were included in the study. The male to female ratio was 2:1. Motor vehicle

accident was the most common cause. Associated trauma was more common in young children. The

condyle was involved in 54% of the fractures. Closed reduction and intermaxillary fixation was the most

common treatment used. Complications were rare.

Conclusion: Management of mandibular fracture in the pediatric age group is a challenge. The

anatomical complexity of the developing mandible and teeth strongly suggest the use of surgical

techniques that are different from those routinely used in adults. The conservative approach is

recommended. Whenever possible closed reduction should be the treatment of choice.

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1. Introduction

Fractures of the facial skeleton in children occur less frequentlythan in adults and they are more often minimally displaced. Thereason for this is because a thicker layer of adipose tissue coversthe more elastic bones and the suture lines are flexible. Also, theretruded position of the face relative to the neurocranium is animportant reason for the lower incidence of midface andmandibular fractures and greater incidence of cranial injuries inyoung children [1–3]. With increasing age and facial growth indownward and forward directions, the midface and mandiblebecome more prominent and the incidence of facial fracturesincreases, while cranial injuries decrease [4].

Less than 15% of all facial fractures occur in the pediatricpopulation. They are very rare below the age of five. The incidencerises as children begin school and peaks during puberty andadolescence, with increased unsupervised physical activity andsports [1,5,6]. Boys are more commonly affected than girls in allage groups. The male predilection has been attributed to moredangerous physical activities among boys [3,7].

* Corresponding author at: Department of Oral and Maxillofacial Surgery, Soroka

University Medical Center, P.O. Box 151, Beer-Sheva 84101, Israel.

Tel.: +972 8 640 0505;:fax: +972 8 640 3651.

E-mail address: lbodner@bgu.ac.il (L. Bodner).

0165-5876/$ – see front matter � 2010 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.ijporl.2010.10.008

Falls, sports-related injuries, and road traffic accidents (RTA) arethe most frequent causes of facial injuries in children [1,8].Although rare, facial fractures are also seen among victims of childabuse, mainly in newborns, infants, and preschool children [9].

Social, cultural, and environmental factors vary from onecountry to another and influence the incidence and etiology ofmandibular trauma. Limited information is available regarding theincidence and characteristics of pediatric mandibular fractures inIsrael.

The purpose of the present report is to evaluate the incidence,etiology, site and patterns, management and treatment methods,and outcome of 61 pediatric patients with mandibular fractures.

2. Materials and methods

The records of a series of 61 children and adolescents up to 16years of age, treated for mandibular fractures during a period of 17years (1993–2010) were reviewed. Patients with mandibularfractures who died due to other associated injuries and those withisolated alveolar and dental fractures were excluded from thisstudy. Patients were divided into 3 age groups in accordance withprevious studies, Group A: 18 months–5 years, Group B: 6–11years, and Group C: 12–16 years.

Data were collected regarding age, gender, etiology, site andtype of fracture, associated injuries, mode of treatment, outcome,complications, and follow up.

Table 3Concomitant injuries in various age groups (N = 61).

Group A Group B Group C Total

Neuro-cranial injuries 5 6 10 21 (34.4%)

Soft tissue lacerations 3 9 9 21 (34.4%)

Extremity fractures 3 7 10 (16.4%)

Facial fractures 3 5 8 (13%)

Abdominal injuries 1 1 (1.6%)

Total 8 21 33 61

M. Glazer et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 62–64 63

The data were tabulated and analyzed. The Student-Newman-Keuls test was used for statistical analysis at the p = 0.05 level forsignificant differences.

3. Results

There were 61 children with 85 mandibular fractures. Patients’age ranged from 18 months to 16 years (mean 11.2 years). Therewere 9 (15%) patients in Group A, 22 (36%) in Group B, and 30 (49%)in Group C. Of the 61 patients, 41 (67%) were boys and 20 (33%)were girls. There was a statistically significant (p < 0.05) predomi-nance of boys in all age groups.

The etiologies are shown in Table 1. The most common causewas motor vehicle accident (MVA), representing 37 patients (60%)in all groups. Common falls were the cause in 14 patients (23%).Horse kicks were the cause in 8 patients (13%).

Other less frequent causes were bicycle and sports injuries. Thedifference between MVA and the other causes was significant(p < 0.05).

The site and type of mandibular fractures in each age group aredescribed in Table 2. The most common site in all age groups wasthe condyl in 38 out of 85 (45%) of the fractures, either solitary or incombination with other fractures. The condylar fracture aloneoccurred in 27 (44%) of the patients. The incidence of condylarfracture was significantly different than the other sites (p < 0.05).Less common fracture sites were symphysis/parasymphysis area(26%), angle (21%), and body (8%). Twenty-eight (46%) patientspresented with multiple fractures of the mandible, with a mean of1.39 fractures per patient. Multiple fractures were more commonin Group C (62%) than in Groups A (35%) and B (25%). The differencebetween Group C and Groups A and B was significant (p < 0.05).Multiple fractures usually involved the condyle of one side and thebody/angle of the other side of the mandible; when horse kick wasthe etiology, in 7 out of the 8 cases both fractures were on the sameside of the jaw.

The concomitant injuries are listed in Table 3. In 40 children(65%) concomitant injuries were present. Children in Group A had agreater incidence of neuro-cranial associated injuries, compared tothose in Groups B and C. This difference was significant (p < 0.05).Facial soft tissue lacerations were mainly adjacent to the fracturesite.

Closed reduction was the most common treatment method(87%). These include intermaxillary fixation (IMF) with archbars in34 (56%) cases (1, 11and 22 cases in Groups A, B and C,respectively), Ivy loops in 11 (18%) cases (6, 3 and 2 cases in

Table 1Causes of mandibular fractures in various age groups (N = 61).

Group A Group B Group C Total

Motor vehicle accident 6 9 22 37 (60%)

Common falls 3 10 1 14 (23%)

Horse kick 3 5 8 (13%)

Bicycle accidents 1 1 (2%)

Sports accidents 1 1 (2%)

Total 9 22 30 61 (100%)

Table 2Site of mandibular fractures in various age groups (N = 85).

Group A Group B Group C Total

Condyl 4 16 18 38 (45%)

Symphysis/parasymphysis 8 14 22 (26%)

Angle 2 4 12 18 (21%)

Body 1 3 3 7 (8%)

Total 7 31 47 85 (100%)

Groups A, B and C, respectively), and acrylic splint on the mandiblefixed with circummandibular wires in 8 (13%) cases (7, and 1 casesin Groups A and B, respectively). Open reduction and internalfixation (ORIF) was done for one patient in Group B and 7 patientsin Group C. No ORIF was done in Group A.

In Groups A and B, the IMF was removed after 3 weeks or less.For Group C, a 4–6-week period of immobilization was maintainedin all fractures except condylar fracture, for which a 3-week periodof fixation was used.

The follow-up period was at least 6 months for all patients, andwas extended to 2 years in cases of condylar fracture. Asatisfactory result was obtained in most patients (90%) in termsof facial symmetry, occlusion, maximal mouth opening, lateraljaw movements, neurological dysfunction, and bone healing. In 6patients (10%) there were some complications. These includedmalocclusion, malocclusion associated with residual deformity,postoperative infection of the circummandibular wire, temporo-mandibular joint (TMJ) ankylosis, and retarded facial growth. Nodifference was noted regarding age, fracture site or method oftreatment.

4. Discussion

Numerous reports on pediatric facial trauma patients have beenpublished. A lower incidence of mandibular fractures in childrenthan adults has been found in several studies reporting similardata, varying from 1% to15%, depending on the age studied [3,10].The incidence increases from birth to 16 years of age [11], as foundin our study. The sex distribution shows a dominance of boys in allage groups. This trend increases with age, as shown in our study,similar to other reports [8].

The most common cause of mandibular fracture was MVA, asreported by others [10]. This cause has been decreasing due to lawsrequiring seat belts and car seats for children. A relative highincidence of fractures due to horse kick was found in our series,probably because the hospital is located in a huge agriculturalregion, where the outdoor activity of the children is on farms,unsupervised and adjacent to animals.

In our study, no case of mandibular fracture due to child abusewas found. Some authors have reported such cases, mainly as aresult of violence to silence a crying child [9].

Twenty-eight patients (46%) presented with multiple frac-tures of the mandible, with a mean of 1.39 fractures per patient, afigure agreeing with those reported by other authors [10,12,13].This should emphasize the necessity of searching for a possiblesecond fracture site when one fracture is discovered. While inmost cases with multiple fractures, one was condylar and theother was body/angle of the opposite side; in cases of horse kick,both fractures occurred on the same side, probably due to thedirect low-velocity force.

The most common fracture site was the condyle, with a total of38 (45%) fractures. This percentage is similar to those reported byothers [7,10]. The greater incidence of condylar fractures inchildren than adults may be explained by the higher proportion ofmedullary bone with only a thin rim of cortex in children [11].

M. Glazer et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 62–6464

Concomitant injuries in the present series were found in 65% ofthe children. This is in agreement of other reports, whereassociated injuries are seen in 25–75% of the children with facialfractures [4,14]. These include neuro-cranial injuries; soft tissuelacerations; other facial fractures; extremity fractures; andabdominal, thoracic, spine, and dental injuries. Children in GroupA had a greater incidence of neuro-cranial associated injuriescompared to Groups B and C. This is due to the ratio betweencranial volume and facial volume. At birth, the ratio is approxi-mately 8:1, whereas by completion of growth this ratio becomes2.5:1 [15]. Consequently, the incidence of facial fractures increaseswith age, while cranial injuries decrease [4].

The treatment goals of mandibular fracture in children arebasically similar to that in adults, but the management isdifferent. The specific age-related status of the growingmandible and dentition development should be a majorconsideration when choosing the mode of treatment. Regardlessof age, the pre-injury skeletal and dentoalveolar anatomy andfunction have to be re-established by anatomic reduction offractures based on the occlusion. Children have greaterosteogenic potential and faster healing rates than adults.Therefore, anatomic reduction must be accomplished soonerand immobilization time should be shorter (2 weeks versus 4–6weeks in adults) [16]. Immobilization and fixation can beachieved by IMF or internal skeletal fixation or a combination ofthese. In younger children an acrylic splint attached to themandible with circummandibular wire can successfully avoidthe use of IMF. Using IMF, via the teeth, may be more difficult inchildren than in adults due to fewer teeth available, resorbedroots of deciduous teeth. Also, the crown of deciduous teeth andpartially erupted permanent teeth may be less favorable for thefixation of interdental wires and arch bars.

Mandibular fracture without displacement and malocclusionare managed by close observation, a liquid to soft diet, avoidance ofphysical activities and analgetics [5,17,18].

Displaced mandibular fracture needs to be reduced andimmobilized. When ORIF is the treatment of choice, a miniplatecan be placed at the inferior border of the mandible by directingthe screws away from the developing buds. When tooth budswithin the mandible do not allow ORIF, fixation can be achievedwith an IMF, or by a mandibular splint fixed to the teeth and to themandible with circummandibular wire.

Most condylar fractures are treated by observation or closedreduction and a short period of IMF, for 7–10 days, followed by aperiod of physical therapy to prevent ankylosis [19]. Low condylarneck fractures may be treated with immediate ORIF using micro-or mini-plates to mobilize the joint as soon as possible. Also,minimally invasive techniques such as ORIF of condylar fracturesunder endoscopic visualization is interesting and may gainacceptance [20].

Currently, ORIF with resorbable plates and screws is increas-ingly used for children. These biodegradable materials canguarantee sufficient rigidity and stability to enable bone healingof the broken mandible, followed by eventual degradation,resorption, and elimination from the body [21]. The advantagesof this system include:

(a) it does not interfere with radiodiagnostic techniques due totheir radiolucency,

(b) as the plate and screws are biodegradable, there is no need forsecondary surgery for plate removal.

All patients were followed up for at least 6 months. Follow upwas extended to 2 years in cases of condylar fractures. Asatisfactory result was obtained in most patients (90%) in termsof facial symmetry, occlusion, maximal mouth opening, lateral jaw

movements, neurological dysfunction, and bone healing. In 6patients (10%) there were some complications. These includedmalocclusion, malocclusion associated with residual deformity,postoperative infection of the circummandibular wire, temporo-mandibular joint (TMJ) ankylosis, and retarded facial growth.

Ankylosis of the TMJ as a complication of condylar fracturemight be avoided by a shorter period of immobilization. Inaddition, early mobilization associated with physical therapyconsisting of mandibular opening exercises should be done. Theremaining complications observed in our series were of lessimportance and were similar to those previously reported [22].

In conclusion, management of mandibular fracture in thepediatric age group is a challenge to the operating clinician. Theanatomical complexity of the developing mandible and teethstrongly suggest the use of surgical techniques that are verydifferent from those routinely used in adults. The conservativeapproach is recommended. Whenever possible closed reductionshould be the treatment of choice.

Conflict of interest

None.

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