Conservative treatment of bilateral condylar fractures in children: case report and review of the literature

Conservative management and follow-up of bilateral condylar fractures in pediatric patients: A case report

Key Clinical Message

Conservative treatment of bilateral condylar fractures, including intermaxillary fixation using arch bars and elastic bands, yields satisfactory results in pediatric patients. Therefore, the conservative approach should be considered the first line of treatment for bilateral condylar mandibular fractures in pediatric patients.

Abstract

Road traffic accidents (RTAs) are considered the leading cause of mortality and morbidity of children and adults in Saudi Arabia. Head injuries and fractures are the most common form of injuries resulting from RTAs, with mandibular fractures being the most common head injury; condylar fractures are the most frequent type of mandibular fracture. A review of the literature reveals diverse opinions about the best approach for treating bilateral condylar fractures in pediatric patients. The findings of the literature review are reported in this study. The case presented here shows the result of adopting a conservative approach to treating a bilateral extracapsular displaced condylar fracture. An elastic band was fixed onto intermaxillary fixation (IMF) screws at the midline upper and lower jaws; the patient was followed up for almost 3 years. The conservative approach yielded excellent results, as both condyles were fully repositioned and healed, without causing any deviation or limitation of the mouth opening. The results of this case support considering the conservative approach as the first line of treatment for bilateral condylar mandibular fractures in pediatric patients.

Photoacoustic imaging for characterization of radiofrequency ablated cardiac tissues

Photoacoustic (PA) imaging is an emerging technique being explored for various clinical applications. PA imaging offers a portable, inexpensive, stand-alone modality for evaluating optical contrast agents. PA signals are well-correlated with tissue physical parameters and can quantify various physiological variables (e.g., oxygenation of hemoglobin). Moreover, radiofrequency (RF) ablation is a promising treatment for certain cardiac arrhythmias. Assessment of RF-ablated lesions is of clinical importance. The purpose of this study is to elaborate the PA imaging to characterize RF-ablated cardiac tissues. Specifically, we describe the application of PA imaging to identify, characterize, and quantify cardiac RF lesions, highlighting the fundamental principles and unique benefits of this optical imaging technique. Potential future clinical application of PA imaging that reveals additional information about structural damage in RF-treated cardiac tissue are also anticipated.

Treatment of pediatric bilateral condylar fractures: A comprehensive analysis

Pediatric bilateral condylar fractures (PBCF) is a rare clinical pathology, where the management is carried out with both conservative and surgical approaches. The purpose of this study was to analyze and compare these two treatment approaches and their associated long term complications in PBCF. An extensive literature review- through the search of online databases- was conducted to survey, collect, analyze and compare the reported outcomes of different treatment modalities for PBCF. The number of studies presenting PBCF case reports was 16, while the number of such retrospective studies included here was 19. Analyses of these studies revealed that the conservative treatment is preferred in PBCF patients younger than 12 years of age. Moreover, a composite approach where the open reduction and internal fixation (ORIF) is carried out for one side while the intermaxillary fixation (IMF) for the contralateral side is frequently reported for the management of PBCF cases; this approach appears effective in improving daily functioning of temporomandibular joint and reducing long term complications. Performing ORIF for one side while IMF for the contralateral side seems the most common treatment approach in PBCF. This study may help in rapid decision making for treatment selection of PBCF patients while minimizing the risk for late complications.

Customizable interdental splinting for repair of pediatric mandibular fractures in children with mixed dentition: A novel technique

OBJECTIVE

Repair of pediatric mandibular fractures (PMFs) can be challenging due to the lack of permanent dentition for immobilization, and the presence of unerupted teeth and growth plates in the mandible limiting the space for fixation. Interdental splinting (IDS) has been advocated to provide temporary fixation without the need for mandibular plating; however, there is sparse description of the surgical methodology, and data on long term outcomes are even more limited. The aim of this study is to present our technique and outcomes using a novel technique for IDS repair of pediatric mandible fractures.

STUDY DESIGN

Observational retrospective chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

Pediatric patients requiring operative repair for mandibular fracture at our tertiary care institution between 2004 and 2021 were included. Patients over 18 years of age, those who died due to associated injuries, or those who underwent non-IDS repairs were excluded. Subjects with at least 3 months of follow-up were assessed for efficacy of surgical repair and short-term adverse outcomes, and at least 1 year for long-term adverse events. Descriptive statistics were obtained.

RESULTS

Twenty-three children were included in the study with an average age of 7.4 years (range 2-17 years). Fifty-two percent (52.2%) were female. The most common fracture site was the condyle, occurring in 16 children (70%). The indication for operative repair in all cases was malocclusion. The average duration of maxillomandibular fixation (MMF) with the novel IDS was 21 days (range 12-42 days). The average length of follow up was 1.6 years (range 3 months-11 years). All children had restored, functional occlusion at follow up with none requiring further orthodontic or dental intervention. Three children of the total cohort (13.0%) had prolonged hospitalization beyond 48 h for poor oral intake. Five children (21.7%) experienced minor long-term complications including persistent temporomandibular joint pain (n = 1, 4.3%), infection (n = 2, 8.7%), hypertrophic scar (n = 1, 4.3%) and exposure of hardware (n = 1, 4.3%).

CONCLUSION

PMFs resulting in malocclusion are safely and effectively managed with operative repair utilizing a customizable IDS, with few observed short- and long-term complications.

Change of the Inclination Angle in a Pediatric Bilateral Condylar Fracture Treated With Intermaxillary Fixation and an Occlusal Stop

ABSTRACT

This paper presents the outcomes of a pediatric bilateral condylar fracture treated with intermaxillary fixation (IMF) and an occlusal stop.A 6-year-old girl presented with the complaint of pain on her chin. She had fallen down, whereas riding a bicycle and her face hit the road. She had limited mouth-opening (10 mm). Panoramic radiography and computed tomography confirmed a bilateral condylar fracture. The inclination of the fractured condyle (IFC) was 39.2° and 42.4° on the left and right sides, respectively. On the third post-trauma day, arch bars were applied and IMF was performed with a prefabricated wafer (occlusal stop) and rubber bands. The rubber bands were changed to wires on post-IMF day (PMF) 4.Immediately after IMF, the IFCs increased (left: 50.1° and right: 68.1°). On PMF 1, the IFCs had improved (44.5° and 46.9°, respectively). On PMF 3, 12, 28, and 35, the left and right IFCs were 46.9° and 70.7°, 38.9° and 72.0°, 38.0° and 56.5°, and 36.4° and 44.6°, respectively. On PMF 42, the IFCs had changed to 34.5° and 36.1°, and wires were changed to rubber bands. On PMF 49, the IFCs were 34.0° and 36.5°, and rubber bands were applied at night only. On PMF 56, the IFCs had improved to 35.0° and 34.8°, and the arch bars were removed. The changes of IFC were fitted to an exponential regression model (left: y = 44.134e-0.005x and right: y = 11.378e-0.043x).This case shows that pediatric bilateral mandibular condyle fractures can be treated by vertical lengthening using an occlusal stop and IMF.

Restoration of Ramus Height in Child Patients With Extracapsular Condylar Fractures: Is This Mission Almost Impossible to Accomplish?

OBJECTIVE

This study aimed to assess whether ramus height is restored in children with extracapsular condylar fractures treated by conservative or surgery procedures.

METHODS

The sample consisted of 35 children (collected consecutively) less than 12 years old who presented with extracapsular condylar fractures and treated within an 8-year period (June 2011 to April 2019). Data on the age, gender, date of injury, mechanism of trauma, location and pattern of mandibular condylar fracture, associated injuries and treatment methods were recorded and analyzed. Ramus height restoration is the main evaluation indicator during the follow-up period.

RESULTS

Within the 8-year record retrieval, the 35 children sustained 41 extracapsular condylar fractures. For the sample size, 10 (24.4%) and 31 (75.6%) had condylar neck and base fractures, respectively. Deviation and green-stick fracture were the predominant types in condylar neck and base fractures, accounting for more than 3 quarters (31, 75.6%). The majority (33, 80.5%) of patients were treated with nonsurgical treatment, and 8 (19.5%) were treated by open reduction and internal fixation (ORIF). During the follow-up period (1-1419 days, average time of 110.6 days), only 1 patient (with bilateral extracapsular condylar fractures) had their ramus height restored (follow-up period, 256 days). Most members of the ORIF group (5 of 8, 62.5%) postoperatively showed bended ramus (deviated angularly/fragment angulation).

CONCLUSION

Conservative treatment could hardly restore the ramus height of children with extracapsular condylar fractures. Anatomically or totally restoring the ramus height is difficult even with the surgical treatment of ORIF; however, surgical treatment of ORIF can substantially restore the ramus height for dislocated fractures or seriously displaced fractures.

Classification and treatment strategies for condylar fractures in children

In this study, we aimed to describe a classification method (position and displacement (PD) classification) and the corresponding treatment strategies for condylar fractures in children, based on the anatomical position and displacement of the fractures. Moreover, we aimed to explore the effect of the treatment strategies for condylar fractures in children. Such fractures were classified into the following three types by PD classification: condylar head fracture (type A), mildly displaced condylar neck and base fracture (type B), and severely displaced condylar neck and base fracture (type C). According to this classification, we proposed the corresponding treatment strategy of closed treatment for types A and B fractures and open treatment for type C fractures. Eighty-four patients who had 123 condylar fractures (type A = 97, type B = 16, type C = 10) were included in this study. Type A fractures showed the restoration of normal function with favourable remodelling in the condyles. Types B and C fractures had good function and symmetry in the condylar angle and height of the condylar neck. The PD classification and corresponding treatment strategies may serve as a better option for the clinical treatment of condylar fractures in children.

Mandibular condylar fractures in children and adolescents: 5-Year retrospective cohort study

OBJECTIVE

This study aimed to evaluate and compare the demographic characteristics of mandibular condylar fractures between children and adolescents.

METHODS

The sample was composed of all children (less than 12 years) and adolescents (between 13 and 18 years old) who presented with mandibular condylar fractures within a 5-year period (January 2011 to April 2016). The age, gender, time of injury, mechanism of trauma, location and pattern of fracture, associated injuries and treatment methods were recorded and analysed. Data analysis included chi-square test and Fisher exact test. Differences at p less than 0.05 were considered significant.

RESULTS

A total of 111 children and 39 adolescent patients with condylar fractures were registered and compared. More children than adolescents were involved in falls from a height (p = 0.007), but nearly no relationship was observed between the trauma aetiology and type of condylar fracture in the two patient groups. Condylar head fractures occurred most frequently in the children and adolescents, especially in the children (p < 0.05). Condylar neck fractures were more frequently observed in the adolescent patients (p < 0.001) than in the children. Green-stick fractures occurred only in the child patients (p = 0.005). The patients who fractured other sites of the mandible tended to show a decreased frequency of dislocation (condylar head was out of the glenoid fossa) (p = 0.024). Symphysis/para-symphysis fractures were highly common in the children who sustained unilateral condylar fractures, compared to adolescents (p < 0.05). The patients with bilateral condylar fractures were more frequently associated with other mandibular fractures (children, p = 0.001; adolescents, p = 0.011), especially the fracture of the mandibular body or symphysis. The children who sustained extracapsular fractures were more prone to fractures of other mandibular sites (p = 0.009), especially fracture of the symphysis/para-symphysis (p = 0.014). Intracapsular fractures in children were treated non-surgically more frequently than surgically (p < 0.001). The extracapsular fractures (mild and serious fractures) in children were also treated non-surgically more frequently (p < 0.05).

CONCLUSIONS

The trauma mechanisms, incidence, pattern and treatment of condylar fractures in children substantially differ from those in adolescents. This study was conducted to enable the understanding of the differences in condylar fractures between children and adolescents. Accordingly, preventive measures and treatment plans in children or adolescents should be applied differently.

Clinical, retrospective case-control study on the mechanics of obstacle in mouth opening and malocclusion in patients with maxillofacial fractures

This study aims to identify and distinguish various factors that may influence the clinical symptoms (limited mouth opening and malocclusion) in patients with maxillofacial fractures. From January 2000 to December 2009, 963 patients with maxillofacial fractures were enrolled in this statistical study to aid in evaluating the association between various risk factors and clinical symptoms. Patients with fractured posterior mandibles tended to experience serious limitation in mouth opening. Patients who sustained coronoid fractures have the highest risk of serious limitation in mouth opening (OR = 9.849), followed by arch fractures, maxilla fractures, condylar fractures, zygomatic complex fractures and symphysis fractures. Meanwhile, the combined fracture of zygomatic arch and condylar process results in normal or mild mouth opening. High risks of sustaining malocclusion are preceded by the fracture of nasal bone (OR = 3.067), mandible, condylar neck/base, combined fracture of zygomatic arch and condylar process, mandibular body, bilateral condylar, dental trauma, mandibular ramus, symphysis, mandibular angle and mid-facial. Patients who experienced serious limitation in mouth opening are treated with surgery more frequently (OR = 2.118). No relationship exists between the treatment options and the patients with malocclusion.

Risk factor analysis and idiographic features of mandibular coronoid fractures: A retrospective case-control study

This study aimed to identify and distinguish various factors that may influence the occurrence of mandibular coronoid fractures. From January 2000 to December 2009, a total of 1131 patients with maxillofacial fractures were enrolled in this statistical study to evaluate the association between mandibular coronoid fractures and other risk factors. Among these patients, 869 had mandibular fractures, and 25 sustained a total of 25 coronoid fractures. More than half (13 of 25 patients, 52%) of the coronoid fractures in these patients were caused by motor vehicle accidents. Among these coronoid fractures, seven were associated with other mandibular fractures, and 23 (92.0%) were related to midfacial fractures. The most common site of midfacial fracture was the zygomatic arch (20 patients, 80%). Multivariate logistic regression analysis revealed that the most important influencing factor was the zygomatic arch fracture (odds ratio, 9.033; 95% confidence interval, 1.658, 49.218; p = 0.011). The majority of coronoid fracture fragments (19 of 25, 76%) were removed during operation. The most commonly used incision is hemicoronal or bicoronal approach (16 of 19, 84.2%).