Conservative Management Favored for Most Pediatric Mandibular Fractures

By Marilynn Larkin

June 24, 2019

NEW YORK (Reuters Health) - In young children with mandibular fractures, conservative management with observation or maxillomandibular fixation (MMF) and soft diet is more common than open reduction internal fixation (ORIF), researchers say.

"Pediatric mandible fractures are a relatively under-studied population, and management patterns to date have been ill-defined," Dr. Taha Shipchandler of Indiana University School of Medicine in Indianapolis told Reuters Health by email. "What our study aimed to do is examine the treatment patterns over the past eight to 10 years for different age groups in the pediatric population. Our follow-up of these patients determined whether the treatment patterns were successful or unsuccessful."

Dr. Shipchandler and colleagues studied data on patients up to age 17 diagnosed with mandible fractures at their institution from 2010 through 2016.

As reported online June 6 in JAMA Facial Plastic Surgery, 150 patients with 310 mandible fractures were identified. Patients' mean age was 12.8 years; 72% were male; 71.3% were white; and 72.7% had two or more mandible fractures.

Fractures included 78 condylar or subcondylar (60 patients), 75 ramus or angle (69 patients), 69 body (62 patients), 78 symphyseal or parasymphyseal (76 patients), and 10 coronoid (10 patients).

Assault and battery, motor vehicle collisions, falls or play and sports were the most common mechanisms of injury, and 25% of patients were treated with observation and a soft diet.

ORIF or ORIF with MMF was used with increasing frequency with age by group, in two of 18 children younger than six years (11.1%), six of 33 ages six to 11.99 (18.2%), and 36 of 99 ages 12 or older (36.4%).

The reverse was true of observation: children younger than six years were more likely to be observed.

Among 112 patients treated with surgery, 63 (56.2%) were treated with MMF, 24 (21.4%) with ORIF, and 20 (17.9%) with both MMF and ORIF. Nonabsorbable plating was used in all but one of the ORIF procedures.

Among 44 patients who received ORIF or ORIF and MMF, five (11.4%) were followed for more than six months and eight (18.2%) underwent plating hardware removal; hardware was in place for a mean of 180 days.

Sixty of the overall cohort (40.0%) had some form of follow-up for a mean of 90 days after initial presentation.

Summing up, Dr. Shipchandler said, "In patients under seven years of age, using rigid titanium plates to stabilize mandible fractures is rarely necessary. Typically, conservative management with rubber band maxillomandibular fixation for a few weeks is more than adequate."

"If a fracture is very displaced or separated, then absorbable, non-titanium plating systems work well," he noted. "Using conservative measures limits the amount of interference in mandibular growth a child may experience as they get older."

"As children get older (ages 8-11 or 13), use of titanium plating increases as greater distraction forces from nearby muscles separate fractures out more," he said. "Oftentimes plates were removed 6-9 months postoperatively in order to decrease the negative effects on mandibular growth. Children over 13 years of age were effectively treated like adults, with titanium plates being very common."

"The management patterns we analyzed should hopefully positively affect the treatment of children with these common fractures of the mandible. Conservative management without rigid plating worked very well for the majority of patients," Dr. Shipchandler concluded.

Dr. Christopher Michael Runyan, Assistant Professor, Plastic and Reconstructive surgery at Wake Forest Baptist Health in Winston-Salem, North Carolina, commented by email, "It is my experience that pediatric mandible fractures are more commonly non-displaced and thus may be treated with conservative management."

"The reason for this is likely multifactorial," he told Reuters Health. "Depending upon the patient's age, the pediatric mandible has both baby teeth and unerupted adult teeth. The presence of these teeth in the body of the mandible make it less likely for displacement to occur with a fracture."

"Pediatric patients often have thicker soft tissue over their mandible than adults," he added. "They are also less likely to be involved in assaults and high-energy trauma."

"In patients with displaced pediatric mandible fractures, I prefer to use absorbable fixation rather than titanium, to avoid potential complications of retained hardware later in life," Dr. Runyan concluded.

SOURCE: http://bit.ly/2x9DVpE

JAMA Facial Plast Surg 2019.

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