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Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 39-42

Comprehensive management of pediatric mandibular fracture caused by an unusual etiology

1 Department of Oral Health Sciences, Unit of Pedodontics and Preventive Dentistry, Oral Health Sciences Center, Post-graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Oral Health Sciences, Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Center, Post-graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication26-Aug-2014

Correspondence Address:
Divesh Sardana
Unit of Pedodontics and Preventive Dentistry, Oral Health Sciences Center,
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1597-1112.139469

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Mandibular fractures in children are rare due to thick adipose tissue, resiliency of bone and protective and care taking nature of the parents. These fractures carry different etiology and treatment considerations with them when compared with similar types of injuries in adults. Furthermore, the associated complications may have long lasting effect on the growth and development of the child's face and developing teeth. The purpose of this case report is to highlight the occurrence of mandibular fracture in 7-year-old caused by horse-kick and its subsequent management by open cap-splint with circum-mandibular wiring.

Keywords: Circum-mandibular wiring, fracture, mandibular, pediatric

How to cite this article:
Sardana D, Gauba K, Goyal A, Rattan V. Comprehensive management of pediatric mandibular fracture caused by an unusual etiology. Afr J Trauma 2014;3:39-42

How to cite this URL:
Sardana D, Gauba K, Goyal A, Rattan V. Comprehensive management of pediatric mandibular fracture caused by an unusual etiology. Afr J Trauma [serial online] 2014 [cited 2024 Mar 2];3:39-42. Available from: https://www.afrjtrauma.com/text.asp?2014/3/1/39/139469

  Introduction Top

Maxillofacial region, due to its prominent anatomy, is one of the most common regions to be injured in any type of accident. Injury to this region is also important because it may be associated with partial or complete; temporary or permanent loss of one of the important functions of the oral cavity such as speech, esthetics, or mastication. The region becomes all the more important in the pediatric age group because of growth and development taking place at the time of injury and its potential consequences in the future. The purpose of this paper is to present a case of comprehensive management of pediatric mandibular fracture caused by horse-kick and demonstrate its healing after 6 months.

  Case Report Top

A 7-year-old boy was referred to the Department of Pediatric Dentistry, PGIMER, Chandigarh from Government Hospital, Saharanpur with the chief complaint of pain in the right side of the face since 4 days. There was a history of trauma due to a hit by a horse-kick, while the child was playing with it. There was no history of convulsions, vomiting, or nasopharyngeal bleed. On examination, the patient was alert and responsive with no sign of trauma elsewhere in the body except for the maxillofacial area. Intra-orally the patient was in mixed dentition stage with avulsed 51, 52, 53, and mobility of the jaw segment between 81 and 82 [Figure 1]. Teeth 74 and 84 were found to be carious proximo-occlusally. Based on the clinical examination, provisional diagnosis of right parasymphysis fracture was reached. Investigations included orthopantogram (OPG) and three-dimensional computed tomography scan, which confirmed the diagnosis of parasymphysial fracture [Figure 2] and [Figure 3]. The treatment planning included closed reduction and stabilization of the fracture segment using custom-made cap-splint and circum-mandibular wiring under general anesthesia. Upper and lower alginate impressions of maxilla and mandible were taken and stone cast poured. The cast was split with a saw at the fracture site and the segments brought into normal alignment and stabilized. Open cap-splint with reinforced wire (19 gauge) was fabricated on this modified cast and retained on the patient's mandible by circum-mandibular wiring after adequate reduction of the fracture under general anesthesia [Figure 4] and [Figure 5]. Parents were advised for maintenance of oral hygiene of the child and follow-up after every week. The cap-splint was removed after 4 weeks under deep sedation and antibiotics prescribed; however, the patient developed swelling subsequent to removal of cap-splint on the 3 rd day [Figure 6] due to cellulitis for which incision and drainage was done by giving small incision in the right inferior border of the mandible and keeping the patient on antibiotics for 5 days. For avulsed 51, 52, and 53, a flexible removable partial denture was delivered and carious 74 and 84 were restored with stainless steel crowns [Figure 7] and [Figure 8]. Six months follow-up OPG [Figure 9] demonstrated satisfactory healing of the fractures site and the patient has been kept on routine follow-up thereafter to monitor the eruption of permanent teeth at the fracture site.
Figure 1: Pretreatment intra - oral view (Note: The step deformity)

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Figure 2: Computed tomography scan demonstrating fracture line

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Figure 3: Pretreatment orthopantomogram

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Figure 4: Cap-splint in situ

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Figure 5: Intra - oral view of cap - splint in situ

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Figure 6: Swelling on right side of face 3 days after removal of cap-splint

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Figure 7: Posttreatment with flexible removable partial dentures

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Figure 8: Posttreatment frontal view

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Figure 9: Posttreatment orthopantogram (6 months)

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  Discussion Top

Mandibular fractures are very rare in children; however, still mandibular fracture is the most common form of facial injury occurring in pediatric age group. [1],[2] The low incidence of pediatric mandibular fractures may be due to thick adipose tissue in maxillofacial region, elasticity of the bone and protective nature of the guardians (teachers and parents). Slightly male predilection has been reported in children subjected to facial trauma reflecting the more aggressive and risk-taking behavior of preteen and adolescent boys. Road traffic accidents, fall from heights and sports injuries have been reported to be the most common causes of maxillofacial injuries amongst the children. [3],[4] However, children are more vulnerable to any trauma due to their small body size with less weight. The injury in the present case occurred due to a hit by horse-kick, which could have been more serious if it could have been on vital structures like eye-ball or skull.

The patient in present case was treated with closed reduction using custom-made open cap-splint and circum-mandibular wiring. Various other methods have been suggested for closed reduction using prefabricated cap-splints, modified orthodontic brackets, orthodontic resin and rubber elastics, modified orthodontic splint appliance. [5],[6],[7] The advantage of closed reduction over open reduction is its cost-effectiveness, lesser surgical trauma to the patient and reduced risk of any iatrogenic trauma to the developing teeth and other anatomical structures. Furthermore, the rate of associated complications is less in cases of closed reduction compared to open reduction. [6] However, the main disadvantage is the difficulty and time utilized in fabrication of cap-splint. Furthermore, in the present case removal of cap-splint was associated with development of cellulitis probably due to improper maintenance of oral hygiene by the parents of the child. The cellulitis was managed by conservative incision and drainage and prescription of antibiotics and antiinflammatory medications. The restoration of avulsed teeth was done by delivery of flexible removable partial denture, which was well-accepted by the child due to restoration of esthetics. 6 months postoperative follow-up demonstrated adequate healing of the fracture site with all associated functions intact. The main disadvantage associated with removable partial denture was that it had to be changed after 6 months due to change in arch dimensions. Injuries in the mandibular region may be associated with defective formation, mineralization, discoloration or even failure of eruption of permanent teeth. [6],[8] The patient in present case has although unpredictable, but higher chances of development of any of these complications and has been kept on routine follow-up which will continue until mandibular growth is complete and all the permanent teeth have erupted.

  References Top

1.Iida S, Matsuya T. Paediatric maxillofacial fractures: Their aetiological characters and fracture patterns. J Craniomaxillofac Surg 2002;30:237-41.  Back to cited text no. 1
2.Kaban LB, Troulis JM. Facial trauma II. Dentoalveolar injuries and mandibular fractures. In: Pediatric Oral Maxillofacial Surgery. Saunders, Philadelphia, Pennsylvania; 2004. p. 441-61.  Back to cited text no. 2
3.Rowe NL. Fractures of the jaws in children. J Oral Surg 1969;27:497-507.  Back to cited text no. 3
4.Tanaka N, Uchide N, Suzuki K, Tashiro T, Tomitsuka K, Kimijima Y, et al. Maxillofacial fractures in children. J Craniomaxillofac Surg 1993;21:289-93.  Back to cited text no. 4
5.Magennis P, Craven P. Modification of orthodontic brackets for use in intermaxillary fixation. Br J Oral Maxillofac Surg 1990;28:136-7.  Back to cited text no. 5
6.Aizenbud D, Hazan-Molina H, Emodi O, Rachmiel A. The management of mandibular body fractures in young children. Dent Traumatol 2009;25:565-70.  Back to cited text no. 6
7.Aizenbud D, Emodi O, Rachmiel A. Nonsurgical orthodontic splinting of mandibular fracture in a young child: 10-year follow-up. J Oral Maxillofac Surg 2008;66:575-7.  Back to cited text no. 7
8.Ben Bassat Y, Fuks A, Brin I, Zilberman Y. Effect of trauma to the primary incisors on permanent successors in different developmental stages. Pediatr Dent 1985;7:37-40.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

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