2.
5
Pediatric Mandible Fractures
BACKGROUND
The topic of pediatric mandible fractures covers a wide range of patients
with multiple clinical variables. Patients can range from a neonate with
a mandible fracture stemming from birth trauma to an 18-year-old
with full permanent dentition and multiple fractures. Because of this
range of differences, the “pediatric” population in regards to mandible
fractures can be further divided into the following:
Neonate/infants – 0 to 1 year of age (developing/unerupted dentition)
Toddlers – 1 to 3 years of age (erupting primary dentition)
Children – 4 to 12 years of age (primary and mixed dentition)
Adolescents – 12 to 18 years of age
Fractures of the mandible can be characterized as favorable or unfavor-
able, or according to site; however, the crucial information in pediatric
mandible fractures is the stage of the dentition. Whether the patient
has primary, mixed or permanent dentition can drastically affect the
overall treatment plan. The pediatric mandible is the storage warehouse
for the developing teeth. Developing tooth buds that exist in the growing
patient will add complexity to a case, as the routine methods to control
occlusion (intermaxillary fixation) and apply fixation can prove to be
difficult, or even impossible. Unfortunately, pediatric mandible fractures
are a common problem.
The incidence of pediatric mandible fractures, as demonstrated
in Imahara’s review of the National Trauma Data Bank from 2001
to 2005, is not insignificant. Imahara found that of 12,739 pediatric
patients diagnosed with facial fractures, the most common fracture
was that of the mandible (32.7%).1 A recent review of the Healthcare
Cost and Utilization Project’s National Emergency Department Sample
demonstrated mandible fractures (defined as fractures in patients 18
years of age and younger) to have a 4 : 1 male to female ratio and
an overall mean age of 14 years. The major etiologies of mandible
fractures in this study included falls (17%), motor vehicle collisions
(13%), and assault (8%). The mechanism of trauma varies according
to age, with the leading cause in both females and males in patients
under 12 years of age being falls, while male and older adolescent (≥12
years) patient populations had assault as their leading cause of mandible
fracture.2
The site of fracture also varies according to age. Owusu and col-
leagues reviewed more than 1200 mandible fractures in pediatric patients,
revealing that the most commonly fractured anatomic sites of the man-
dible varied depending on age.2 This is likely a result of two factors:
first, the developing dentition, which would provoke changes in the
mandible’s weak points as teeth develop and erupt, and second, the
change in the mechanisms based on the common activities specific to
each age group. Young patients (≤12 years of age) most commonly
fractured the condyle (27.9%) while older patients’ most common site
of fracture was the angle (17.6%).2 Several additional studies have dem-
onstrated that while many pediatric mandibular condylar fractures will
Lewis C. Jones, Robert L. Flint
occur in isolation, up to 20% will present with bilateral condylar
fractures.3–5 Mandible fractures also occur with concomitant injuries
in regions other than the face in 11%–65% of trauma patients.6,7 Forces
that are significant to fracture a pediatric mandible have a high likeli-
hood of concomitant injury. Injuries associated with mandible fractures
include other facial fractures (13%), facial soft tissue injury (34%),
C-spine (0.9%–4.4%), neurocranial (8.5%–34%), extremity (9.1%–
16.4%), chest (1.8%), and abdominal injuries (1.6%).2,6,7 Concomitant
injuries vary based on the mechanism of injury. While ER visits involving
facial fractures are relatively uncommon (0.03%),2 all surgeons are
mandatory reporters of suspected child abuse—any suspicion of the
mechanism/injury should provoke notification through the proper
channels for investigation and any necessary intervention.
EMBRYOLOGY AND GROWTH OF THE MANDIBLE
The mandible develops by intramembranous ossification and is derived
from the first branchial cleft with contributions from the proximal
portion of Meckel’s cartilage. By the sixth week of embryologic devel-
opment, the bilateral mandibular processes have fused to form a fibrous
symphysis. The mandible is then the second site (after the clavicle) to
undergo ossification.8,9 Ossification continues throughout the first year
of life.
The growth of the mandible is a complex, multifactorial process.
Its growth is influenced by the growth of the alveolar process, the devel-
oping dentition, the associated muscular processes, and the mandibular
condyle. Disruptions in growth (either due to congenital factors or due
to trauma) can lead to abnormal development, with significant cosmetic
and functional consequences, including asymmetries and malocclusions
(Fig. 2.5.1).
The importance of the relationship of the developing dentition to
alveolar growth cannot be overstressed. In patients with congenitally
missing dentition (such as ectodermal dysplasia), the alveolar process
is undeveloped. The growth of the alveolar process mirrors the eruption
sequence. After tooth eruption, the mechanical forces of mastication
and parafunctional habits exert forces on the alveolar bone that will
also influence development and maintenance of bone. While this complex
process has not been fully elucidated, it is imperative that the surgeon
understands the interactive role the developing dentition plays in alveolar
bone development and does everything possible to minimize disruption
during the treatment of mandible fractures.
The position of the mental foramen changes relative to the man-
dibular body throughout mandibular growth. At age 3 it lies between
the deciduous canine and first molar and is near the inferior border.
By age 6, the mental foramen is posterior and superior in its relative
position, eventually residing inferior to the first or second premolar
and is no longer near the inferior border, but is often equidistant between
the inferior and superior aspect of the mandibular body.10
323
324 SECTION 2 Pediatric Facial Injury
Infant mandible
Adult mandible
Fig. 2.5.1 Artist rendition of pediatric versus adult mandible.
The muscles of mastication play a role in the development of both
the coronoid process and mandibular angle (which grow by periosteal
apposition). However, disruption of these regions with fractures rarely
impacts the overall growth of the mandible.
The mandibular growth derived from the condylar process is complex
and fracture of this region can impede growth and result in asymmetry
and malocclusion.10 While other growth mechanisms exist within the
mandible, the condyle is a major contributing source of both vertical
and horizontal growth of the mandible. The growth of the condylar
process is linked to the presence of secondary cartilage in this location.11
The direction of this growth of the condyle is influenced by the man-
dibular posture, condyle/fossa relationship, and a multitude of mechanical
factors.12 Fractures of the condyle can have a significant impact on
normal mandibular growth/development and will be discussed later in
this chapter.
ANATOMY OF THE MANDIBLE
The bony mandible is comprised of the following anatomic subunits:
the condyle, condylar neck, ramus, angle, body, and symphysis. Use of
these terms in describing the injury is paramount in helping a practi-
tioner understand the problem at hand – as fractures of the mandible
are treated differently based on the age of the patient and the anatomic
subunit involved (Fig. 2.5.2).
The third division of the trigeminal nerve (cranial nerve V) provides
sensory innervation to the mandible after exiting the foramen ovale.
This nerve also provides innervation to the muscles of mastication
(masseter, temporalis, and medial/lateral pterygoid muscles). The major
arterial supply to the mandible is the inferior alveolar artery (a branch
of the internal maxillary artery). The associated inferior alveolar vein
completes the neurovascular bundle that enters at the mandibular
Condylar head
Condylar neck
Parasymphysis
Symphysis
Ramus
Angle
Body
Fig. 2.5.2 Artist rendition of anatomic regions of the mandible.
foramen proximally and divides at the first molar region into an incisive
branch that continues anteriorly within the mandible and a mental
branch that exits at the mental foramen. The orientation of the neu-
rovascular bundle is that the vein (or veins) reside superior to the nerve,
and the artery is located lingual to the nerve.13
The mandible is a bone suspended in space by its musculature. The
paired muscles that help with mastication are the medial and lateral
pterygoids, masseter, temporalis, with some contribution from the
digastric muscles. The medial aspect of the mandibular body is the site
of attachment for the mylohyoid and the anterior lingual aspect provides
the site of attachment for the digastric, the genioglossus, and geniohyoid
muscles. The mandible is also the site of attachment for the paired
muscles of the mentalis (anteriorly) and buccinator (superiorly at the
posterior body), as well as the platysma (along the inferior border).
This complex musculoskeletal unit provides the ability for basic life
functions such as speech and mastication. An injury to the mandible
can lead to compromise, and its proper repair is necessary in reestab-
lishing both form and function.
STAGES OF DENTITION
Understanding the dentition and its stages is crucial in the treatment
of pediatric mandible fractures. In general, pediatric mandible fractures
can be divided into three simple groups: primary dentition, mixed
dentition, and permanent dentition stages. The dentition phase, as well
as the condition of the dentition, will significantly affect the treatment
plan for mandible fractures.
The tooth buds for the primary teeth are present in utero with the
dental lamina from which they develop present as early as 12 weeks in
utero.14 The first teeth to erupt are most often the lower central incisors
at 6–10 months of age. The primary dentition is comprised of 20 teeth
that most often erupt prior to age 3 (Fig. 2.5.3). Primary teeth have
crowns that are more bulbous than their permanent counterparts, and
have roots with increased divergence, which allows space for the devel-
opment of permanent tooth buds inferiorly. The roots of primary teeth
will resorb as the permanent teeth develop and begin to erupt, ending

Fig. 2.5.3 Primary dentition in a 4-year-old patient with Risdon cables
in place.
Fig. 2.5.4 Mixed dentition: panoramic image of mixed dentition (age
11) – note the eruption of permanent first molars and incisors. The
developing canines and premolars (and second and third molars) have
yet to erupt.
with the exfoliation of the primary teeth. Primary teeth should have
some spacing between all of the teeth, although spacing between the
primary teeth will close with the eruption of the first permanent molar,
which ushers in the beginning of the mixed dentition phase.15
The mixed dentition phase begins around age 6 and extends until
approximately age 12 when the final primary tooth exfoliates (Fig. 2.5.4).
The mixed dentition presents significant challenges in establishing the
maxillomandibular relationship due to unerupted or partially erupted
permanent teeth, loose deciduous teeth that have not exfoliated, and
discrepancy in crown size of the newly erupted permanent dentition
adjacent to smaller, retained primary teeth. These challenges can impede
the placement of secure maxillomandibular fixation (MMF) for both
closed and open procedures to correct alignment of a mandible fracture.
Similarly to the primary dentition phase, existing unerupted tooth buds
within the mandible can present challenges when open reduction/rigid
fixation is required.
Following the exfoliation of the final primary tooth, the dentition
is considered to be in the permanent dentition phase (Fig. 2.5.5). It
is at this point that the methods of treatment for a mandible frac-
ture begin to mirror the treatments rendered in the adult population.
The fracture patterns of the mandible also resemble that of the adult
population.
FRACTURE PATTERNS IN
PEDIATRIC POPULATIONS
Fracture patterns in pediatric populations vary based on the stage of
the dentition of the patient as both the activities a child/youth/adolescent
CHAPTER 2.5 Pediatric Mandible Fractures 325
Fig. 2.5.5 Early permanent dentition (age 13) with developing third
molars.
is involved in and the weak points of the mandible vary with age. In
various studies evaluating the distribution of mandible fractures in
pediatric patients, the condylar (condylar neck or condylar head) region
is consistently the most frequently fractured structure (7%–45%), the
parasymphysis is the second most frequently injured (20%–32%), the
percentage of angle fractures ranges from 4.4% to 45%, with an increased
incidence during the teenage years, coinciding with third molar devel-
opment. Siegel et al. demonstrated that children in mixed dentition
aged 7–12 have increased risk of mandibular body fractures (20%)
compared to younger children aged birth to 6 (4.4%) or those aged
13–18 years (9.7%). Patients often presented with multiple fractures
(28%–59%).7,16,17
EVALUATION
Evaluation of the mandible during the secondary trauma survey (fol-
lowing ATLS protocol) should replicate the exam in an adult patient
– however, it will often require patience and ingenuity. A thorough
evaluation of the mandible will include examination of the temporo-
mandibular joints, bony continuity at the posterior/inferior border,
dentition, occlusion, and the associated soft tissue.
The temporomandibular joint (TMJ) should be assessed for appro-
priate range of motion, tenderness overlying the joint, pop/click/crepitus,
and deviation on opening. From the TMJ region, the practitioner should
palpate for bony steps or irregular surface along the posterior border
of the ramus and inferior border of the body and symphysis region,
also noting any discrete regions of tenderness. The dentition should be
inspected for loose or missing teeth as well as “steps” in the occlusal
plane. The occlusion with the maxillary dentition (if intact) should be
evaluated for a stable/repeatable occlusion, as alterations in occlusion
can be indicative of fracture or TMJ hemarthrosis/edema. The overlying
attached and unattached gingival tissues require inspection for lacera-
tions and bleeding, which often harbor fragments of traumatized denti-
tion (or entire teeth).
Imaging of the mandible for suspected fractures/injury is best
performed with a combination of images.18 Imaging of the mandible
can be accomplished with a single panoramic image (Fig. 2.5.6). This
single image allows visualization of the mandible and dentition in its
entirety on a single image with minimal radiation exposure. Unfor-
tunately, young patients may not be tall enough or remain motion-
less long enough for this image to be obtained, and many emergency
rooms and trauma centers are not equipped to provide this image as
it is most often employed in a dental setting. AP and lateral mandible
films can be helpful in augmenting the panoramic image (Fig. 2.5.7).
They may be used alone to demonstrate fractures, but can be difficult to
interpret if the practitioner is not accustomed to viewing these images
and non-displaced fractures or greenstick fractures (more common
326 SECTION 2 Pediatric Facial Injury

Fig. 2.5.6 Fracture from between teeth 22 and 23 extending to sym-

physis detected on panoramic radiograph (age 18).

Fig. 2.5.7 AP plain film of infant with left body fracture due to forceps
delivery.

in pediatric populations) can be missed. For all of the above reasons,

further characterization of mandible fractures is most often provided
by a non-contrast computerized tomogram (CT) of the mandible (Fig.
2.5.8). Appropriate imaging ensures extension of the area imaged from
the glenoid fossa to the inferior border of the mandible. Finally, sur-
geons who have cone beam technology available to them can utilize this
method of imaging to decrease radiation dose, while still affording axial,
coronal and sagittal slices for three-dimensional evaluation of the injury,
but like a panoramic image they require a patient to remain motion-
less in an upright position for the period of time it takes to obtain the
image.
TREATMENT
The treatments described below are directed toward the growing patient,
and for the purposes of this chapter, treatments for patients where
growth cessation has already occurred are not discussed – as these
patients should be treated consistent with “adult” modalities. The major
“take-home” point from any chapter on pediatric fractures should be
the role for conservative therapy, which often occupies a much larger
spectrum than in the adult population. This is due to the pediatric
B
Fig. 2.5.8 Coronal CT of 2-year-old male with left parasymphysis fracture
(ATV accident) – coronal (A) and axial (B) views.
patient’s ability to heal more rapidly, as well as avoidance of potential
complications associated with open management of a growing/developing
bony structure. The discussion of management is divided into anatomic
regions and includes fractures of the condylar/subcondylar region, angle,
and the body/symphyseal region.
Fractures of the Condyle/Subcondylar Region
Condylar fractures in pediatric patients are almost always managed
closed; these patients have proven regenerative/healing potential and
the risk of growth disturbance usually precludes open treatment.19 The
indications for open treatment of condylar fractures, introduced by
Zide,20 also apply to pediatric patients as there are few scenarios outside
of these in which the benefits of an open procedure would outweigh

Fig. 2.5.9 Bilateral subcondylar fracture in a 9-year-old male.
the risks. These indications, as outlined in the 1983 paper, include the
following scenarios:
1. Displacement of the condyle into the middle cranial fossa or external
auditory canal
2. Lateral extracapsular dislocation.
3. Contaminated open joint wound.
4. Inability to obtain adequate occlusion.
It should be noted that in pediatric patients, there may exist a much more
loose definition of what defines adequate occlusion. In the primary and
mixed dentition phase, the developing dentition can often compensate
for discrepancies introduced by a condylar fracture. In situations where
occlusion is difficult to determine, a set of dental models can often
prove useful as it can allow the practitioner to evaluate the occlusion
with some manipulation of the models and thus help determine the
necessity for opening a condylar fracture. When in doubt, it is prudent
to err on the side of conservative treatment. In general, conservative
therapy is preferred for treating pediatric condylar fractures – even
in bilateral cases (Fig. 2.5.9). Several practitioners have demonstrated
good results in published reports.21,22 Conservative therapy for condylar
and subcondylar fractures includes a soft diet and antiinflammatory
medications. The soft diet should be adhered to for 4–6 weeks and the
antiinflammatory medications should be prescribed for the first 5–7
days in patients where contraindications do not exist. Both unilateral
and bilateral fracture patients require close observation for persistent
decreased range of motion that may indicate a patient on the path
to ankylosis. Early referral to a physical therapist to increase range
of motion is advised. Patients are also observed for development of
growth disturbances with resultant asymmetry (Figs. 2.5.10A–D). The
traumatized condyle may cease to grow while the unaffected condyle
continues to grow normally resulting in obvious asymmetry with a
compensatory occlusal cant. Appropriate follow-up and early refer-
ral to an orthodontist for evaluation and intervention is paramount
(Fig. 2.5.10E).
Like condylar fractures, subcondylar fractures should also be managed
conservatively. These fractures are contained within the pterygomas-
seteric sling and as such will most often heal without complication.
The healing of a subcondylar fracture is facilitated by light function
with Risdon cables and elastics in primary and mixed dentition, and
CHAPTER 2.5 Pediatric Mandible Fractures 327
Erich arch bars with elastics in the growing patient with permanent
dentition (Figs. 2.5.11 and 2.5.12).
In all cases, it is important to maintain long-term follow-up to
observe the developing mandible after a fracture of the condyle. Frac-
tures in young patients can take years to manifest the developing
asymmetry.
Angle Fractures
Fractures of the mandibular angle increase with the development of the
third molar – thus inducing a weak point at the angle of the mandible.23–26
As such, only 4% of mandible fractures in children <12 years of age
were angle fractures, versus almost 18% of patients over age 12 who
presented with mandibular angle fractures.2 These fractures can be
treated with MMF as described above with the use of Risdon cables
or Erich arch bars and wire MMF for a period of 2–3 weeks followed
by elastics for an additional 2–4 weeks depending on the patient’s age
and severity of the fracture. Open reduction and internal fixation of
angle fractures can be addressed with the use of 3D or “ladder” plates, a
single superior lateral border plate, a plate on the external oblique ridge
(“Champy technique”), or with an inferior border plate27 (Fig. 2.5.13).
Several circumstances will impact the decision-making process regard-
ing the technique to be employed, such as the nature of the fracture,
the presence or absence of a third molar, and the need for extraction
of the third molar (if present) at the time of fixation.
Fractures of the Mandibular Body/Symphysis
Fractures of the body and symphysis region (dentate portion) of the
mandible should be assessed for mobility. If no mobility is noted and
imaging is consistent with a greenstick fracture (which is common in
pediatric populations), then soft diet and follow-up are recommended.
Minimal mobility or displacement may be amenable to Risdon cables/
arch bar placement with a short (2–3 week) period of MMF followed
by elastics for an additional 2–4 weeks depending upon the severity of
the fracture. The severity of the fracture is based upon bony displace-
ment and subsequent occlusal stability. Alternatively, a lingual splint
can be used to stabilize the fracture with the aid of circumdental wires
(Fig. 2.5.14). However, this usually necessitates multiple trips to the
operating room for impressions, followed by pouring of dental stone
models and fabrication of a lingual splint, which is then wired into
place. This laborious process is generally avoided as a technique. Frac-
tures of the body which are oblique in nature may be amenable to
circumdental wiring, which is another effective technique that is rarely
employed (Fig. 2.5.15).
Grossly displaced fractures often require open reduction and internal
fixation. Resorbable plates are not FDA-approved for use in mandible
fractures, but have been utilized with some success.28 If used, they may
require placement of two plates and therefore placement of the second,
more superior plate can cause damage to developing tooth buds in
primary and mixed dentition patients. A single mandibular miniplate
at the inferior border with the use of a superior “tension band” of a
Risdon cable or Erich arch bar is often sufficient and minimizes injury
to tooth buds and/or the inferior alveolar nerve (Figs. 2.5.16 and 2.5.17).
The plate can be removed after adequate healing has taken place. This
can usually be accomplished in conjunction with removal of the arch
bars/wires at 6–8 weeks after injury.
Conservative, nonoperative management of the pediatric mandible
fracture is often the preferred method of treatment. Open treatment
of the symphysis, body, or ramus is typically indicated when there is
significant skeletal displacement resulting in malocclusion, limited range
of motion, inhibition of proper function, and/or the possibility of airway
compromise. Rarely, if ever, is open treatment performed for a pediatric
Text continued on p. 332
328 SECTION 2 Pediatric Facial Injury

A B

D
E
Fig. 2.5.10 (A) Patient in mixed dentition phase (age 7) with history of left condylar fracture at age 2. Some
mild to moderate asymmetry can be seen at the inferior border of the mandible. (B) Same patient at age 13
with worsening asymmetry due to condylar fracture at age 2. (C) Intraoral view exhibiting occlusal cant and
mandibular asymmetry with left posterior crossbite present. Severe dental midline discrepancy also exists.
(D) Anteroposterior facial view of patient at age 13 with noted asymmetry. Note the significant chin point
deviation toward the affected left side and the dental midline discrepancy is also present. (E) Patient with
orthodontic appliance in place. This appliance is fabricated and worn in order to help inhibit right maxillary
tooth eruption and promote continued eruption of that on the left. This will help prevent development of a
compensatory maxillary occlusal cant.
 CHAPTER 2.5 Pediatric Mandible Fractures 329

A B

C D

E
Fig. 2.5.11 (A) Risdon cables are placed by first placing a circumdental wire around a stable molar. The wire
is then twisted to the length appropriate to reach the contralateral molar and a loop can be placed around
this molar as well. (B) Circumdental wires are then placed around each tooth in the arch, securing it to the
initial cable. (C) This is done in the maxilla and mandible both in order to obtain maxillomandibular fixation.
(D) The final product should appear similar to this – with rosettes placed to avoid additional trauma to adjacent
soft tissues. (E) Elastics can then be placed bilaterally for elastic MMF to allow for light function through the
convalescent period.
330 SECTION 2 Pediatric Facial Injury

Fig. 2.5.12 Erich arch bars are applied similarly to Risdon cables. Note
that Erich arch bars are more able to maintain stability with wire MMF
compared with Risdon cables.

Fig. 2.5.14 Lingual splint fabricated from acrylic for stabilization of left
mandibular body fracture. Note the holes placed for stabilization with
circumdental wires.

A B

C
Fig. 2.5.13 (A) 3D/Ladder plate at angle with removal of third molar (#17). Note the empty four holes over
the region of fracture. The screws at the angle are monocortical. Note that arch bars remain in place and
single mandibular reconstruction plate was used for the symphysis fracture. (B) Superior lateral border plate
can be used for fixation of an angle fracture. This is a 14-year-old female with angle fracture. Tooth #32 was
removed due to displacement and six-hole monocortical plate was placed with three screws on each side
of the fracture. (C) One disadvantage of a 3D or a superior border plate is the necessity for a transbuccal
trocar for placement of proximal screws. Several types of transbuccal retractors exist for use with the trocar.
Pictured below is the blade cheek retractor (KLS Martin). (D) Champy plate at left angle fracture with third
molar remaining in place. Rigid fixation achieved at contralateral fracture with reconstruction plate at inferior
border. This plate can most often be placed with a transoral approach.
 CHAPTER 2.5 Pediatric Mandible Fractures 331

B
A

C
Fig. 2.5.15 Placement of circum-mandibular wire is accomplished with the aid of an awl which is passed first
on the lingual aspect (A), the wire is secured through the hole on the awl and then brought inferiorly (taking
care not to exit the skin) and reintroduced at the buccal aspect. The fracture is then reduced by twisting
the wire into place (B). (C) Panoramic image after placement of the circum-mandibular wire pictured in (B).

A
Fig. 2.5.16 (A,B) Single four-hole plate at the inferior border of the posterior left mandibular body. This will
ideally be below the developing tooth buds. As evidenced on the panoramic image, the plate appears to be
placed at the inferior aspect of the developing #20 follicle.
332 SECTION 2 Pediatric Facial Injury
A
Fig. 2.5.17 (A,B) Fracture of the parasymphysis region with developing tooth buds in place. A single inferior
border four-hole plate was placed for stabilization.
condyle fracture unless the condyle is displaced into the middle cranial
fossa.
Treatment of the Associated Dentition
Tooth buds that are displaced and in the line of fracture preventing
reduction should be replaced within the alveolus, where possible. If
preventing fracture reduction, the tooth bud should be removed – with
clear communication to the patient’s dentist/pedodontist for space
maintenance, where appropriate. Avulsed primary teeth should never
be replaced. Primary teeth loose enough to present an aspiration risk
should be removed. Permanent teeth that have been avulsed or luxated
should be reimplanted, reduced, and splinted/stabilized appropriately
and referred to a dentist/endodontist for vitality testing to determine
the necessity of root canal therapy.
MAJOR COMPLICATIONS AND MANAGEMENT
Ankylosis
This is a complication that is often described but seldom seen in the
pediatric patient. Trauma to the TMJ region that results in fracture of
the condyle or high subcondylar region can lead to bone formation in
and around the condylar head/glenoid fossa. Inadequate reduction of
mandible fractures can lead to fixation with resultant mandibular wid-
ening and a condyle that functions lateral to the glenoid fossa. These
scenarios can result in bony ankylosis, which is a difficult problem to
successfully treat. Treatment of ankylosis may involve resection of the
bony ankylosis followed by reconstruction with a costochondral graft
or distraction osteogenesis. Growth of the costochondral graft is quite
variable and requires a delay in initiation of physical therapy for 10–14
days following reconstruction (while distraction patients can begin
immediately). Preventing reankylosis is best accomplished by adequate
bony resection combined with postoperative physical therapy, which
is crucial in preventing reankylosis (Fig. 2.5.18). This therefore requires
the surgery to be performed in an age-appropriate patient who can
participate in postoperative physical therapy.29 The techniques in pedi-
atric bony ankylosis release and reconstruction have been well described
by Kaban et al.30
Growth Disturbance
Thankfully, like bony ankylosis, growth disturbance following trauma
to the mandible is an uncommon complication (Figs. 2.5.10A–D). One
retrospective study evaluating adverse outcomes in pediatric popula-
tions noted that 2 of 57 patients (3.5%) with isolated mandible fractures
exhibited post-injury mandibular hypoplasia.31 Pediatric mandible
fractures, especially those in the condylar/subcondylar region, should
be followed as they continue to grow to evaluate for disturbance in
growth. This is most often noted as chin point deviation and dental
midline discrepancies. A panoramic radiograph (orthopantomogram)
will confirm clinical suspicion for hypoplasia of the mandible following
trauma. Treatment will be dependent upon age and severity of the
asymmetry – most often, surgical correction will include orthodontics
in conjunction with orthognathic surgery. According to a single center,
retrospective study at the Hospital for Sick Children (Toronto, Canada)
of 88 patients with mandible fractures, the children most likely to require
orthognathic surgery after mandible fracture were those between ages
4 and 7 (22%) and 8 and 11 (17%). As expected, these growth distur-
bances most often resulted from condylar trauma.29
Internal fixation hardware in the pediatric mandible fracture, although
controversial as to its impact on skeletal growth, can easily be removed
at the time of MMF hardware removal. Since bony healing is so rapid
in the pediatric population, a short course of 6–8 weeks is often all that
is necessary for internal fixation. Removal at that time will reduce bony
overgrowth of the hardware, which may make plate removal more dif-
ficult at a later date, and will also alleviate the concern for growth
restriction.
Malunion/Malocclusion
Typically, pediatric patients that develop or have persistent malocclusion
following a fracture with or without operative intervention are observed
without further operative intervention until growth is completed. Refer-
ral to an orthodontist with a combined approach for correction is often
the best solution. Some minor malocclusions can be amenable to orth-
odontic correction alone, while other more severe presentations will
require a combined effort to correct the underlying problem (Figs.
2.5.19 and 2.5.20).
 CHAPTER 2.5 Pediatric Mandible Fractures 333

E
Fig. 2.5.18 (A) Panoramic image of 16-year-old male with bilateral ankylosis from untreated condylar fractures
from a fall at a young age. (B–C) Three-dimensional renderings of CT scan demonstrating ankylosis. (D)
Coronal slice of CT of same patient. (E) Coronal image with costochondral grafts in place. (Photos courtesy
of Drs. Waite and Louis, Univeristy of Alabama at Birmingham.)
334 SECTION 2 Pediatric Facial Injury
CONCLUSION
The evaluation, diagnosis, and treatment of mandible fractures in the
pediatric trauma patient differs from that of an adult. It requires a
complete knowledge of the growth and development of the dentition,
and the mandible and its subunits. The surgeon should also compre-
hend tooth development and the difficulties that are often encountered
in the mixed dentition stage. The application of all of this informa-
tion, along with understanding of the various techniques available for
fracture management, is integrated to make the final recommendation
regarding treatment in an effort to avoid both short- and long-term
complications.
EXPERT COMMENTARY
This chapter contains much valuable classification and thought organization,
including a comprehensive description of “ages” of mandibular growth and
development, organized to guide treatment considerations. Development and
anatomical regions are further used to guide surgery/treatment planning in
the regions, and growth considerations are well managed.
The long-term follow-up of pediatric patients is notoriously difficult, however
the authors do as good a job with this as anyone I have read, and offer a
reliable guide to the practice of pediatric mandibular trauma.
Fig. 2.5.19 This 19-year-old patient was referred by his orthodontist
after he had previously undergone ORIF of his angle fracture 3 months
prior to referral. He exhibited a posterior open-bite from inadequate
reduction at the time of surgery. Note the difference in interocclusal
distance with increase on right compared with left.
A
Fig. 2.5.20 (A) 14-year-old female with angle fracture with third molar (#32) that impeded adequate fracture
reduction with a Champy technique. Again, note the increased interocclusal distance on right compared with
left. (B) This patient returned to the OR on postop day 1, the plate was removed, the third molar extracted,
and a superior border plate placed for reduction. Adequate occlusion achieved with small gap at inferior
border.
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