Comparison of Nonsurgical Treatment Options in Pediatric Condylar Fractures: Rigid Intermaxillary Fixation Versus Using Guiding Elastic Therapy

Conservative Management of Dislocated Pediatric Unilateral Condylar Fracture Using Orthodontic Treatment and Guiding Elastics

Introduction

Mandibular fractures in children, when compared to adults, are quite less common. Treatment approaches for mandibular fracture differ in children due to their growth and developing dentition. Minimal manipulation of bony architecture is done to achieve a stable position.

Case description

An 8-year-old girl with right-side condylar fracture with dislocation reported to the emergency trauma unit, Post Graduate Institute of Dental Sciences, Rohtak.

Result

The case was well managed by a conservative approach whereby orthodontic treatment along with guiding elastics was used in the reduction of unilateral condylar fractures.

How to cite this article

Goel N, Jha S, Singhal R, et al. Conservative Management of Dislocated Pediatric Unilateral Condylar Fracture Using Orthodontic Treatment and Guiding Elastics. Int J Clin Pediatr Dent 2024;17(2):184-186.

Pediatric Mandible Fractures

The management of pediatric facial fractures requires several considerations by the treating surgeon. Pediatric facial fractures occur less commonly than in adults. Among fracture patterns in children, studies have repeatedly demonstrated that mandible fractures are the most common facial fracture particularly the condyle. Most fractures in children are amenable to nonsurgical or closed treatment; however, certain indications exist for open treatment. The literature describing epidemiology, treatment trends, and long-term outcomes are limited in comparison with adult populations. The purpose of the article is to review the etiology, workup, and management of mandible fractures in children.

Does Dynamic Intermaxillary Fixation With Elastics Improve Outcomes Following Unilateral Condylar Fracture?

PURPOSE

The use of rigid versus semi-rigid intermaxillary fixation (IMF) following subcondylar fractures is controversial. This study aims to investigate whether the "dynamic" elastic fixation technique improves the outcomes, compared to the rigid fixation technique for the treatment of displaced subcondylar fractures in adults.

MATERIALS AND METHODS

This nonblinded randomized clinical trial was performed on adult patients with unilateral displaced mandibular subcondylar fractures. Patients were randomly allocated into two groups (n = 17). The primary predictor variable was wire versus elastic IMF. Changes in primary (mouth opening) and secondary (other clinical and radiological) outcomes were recorded. Data were analyzed with the t test and Mann-Whitney test with SPSS software version 20. P-value < .05 considered as significant.

RESULTS

In this study 34 patients (with mean age of 33.03 ± 1.79, 23.5% females & 76.5% males) in two groups (Elastics & Wire) followed up to 6 months. The Elastics group showed significant improvement in mouth opening (primary outcome) after 1 month of follow-up, but the differences were not significant at the end of the study. In terms of secondary outcomes, the ramus height shortening compared to the opposite side revealed favorable improvement in the Elastics group in the period of study. The differences between the two groups in the lateral movement and protrusive movement were significant in favor of the Elastics group. The differences in pain, fracture displacement, and midline deviation between study groups were not significant at the end of the study. Just 1 case with malocclusion was observed in the Wire group. Patients were more satisfied with dynamic nonrigid IMF with elastics.

CONCLUSIONS

The results of this study showed that using the dynamic IMF technique is more tolerable, and patients have better functional and clinical outcomes during and at the end treatment.

Establishing a Protocol for Closed Treatment of Mandibular Condyle Fractures with Dynamic Elastic Therapy

Treatment of mandibular condyle fractures is controversial. Open treatment achieves anatomic reduction with occlusal stability and faster functional recovery but risks facial nerve injury and jeopardizes joint capsule circulation which can lead to bone resorption. Traditional closed treatment avoids these issues but requires prolonged fixation and risks subsequent facial asymmetry, occlusal disturbance, and ankylosis. Rather than wires, closed treatment with elastics allows for customizable management of a healing fracture with ability to alter vector and degree of traction to restore vertical height and occlusion with less discomfort and decreased risk for ankylosis. In this protocol, unilateral condylar fractures were treated with class II elastics ipsilateral to injury and class I contralaterally. Class III elastics were used contralaterally if additional traction was required and Class II elastics were placed bilaterally for bilateral fractures. Patients were sequentially advanced from fixating to guiding to supportive elastics by titrating elastic vector to any dental midline incongruency or chin deviation. Six patients were treated with this protocol with six-month follow-up. Fracture patterns included displaced and dislocated fractures as well as intracapsular and extracapsular condylar fractures. All patients at completion of the protocol had objective centric occlusion with no subjective malocclusion, chin deviation, facial asymmetry, or temporomandibular joint pain. These early data demonstrate a safe and efficacious innovative protocol for closed treatment of mandibular condylar fractures with dynamic elastic therapy.

The use of mini plates for intermaxillary fixation in a severely comminuted mandibular fracture with bilateral condylar fractures

Intermaxillary fixation (IMF) is an integral technique utilized by maxillofacial surgeons to appropriately reduce and relate maxillary and mandibular fractures to both one another and the facial skeleton. This case report reviews the management of a comminuted mandibular fracture including inoperable bilateral condylar fractures that precluded the use of convention IMF techniques necessitating an alternative technique. This was achieved in the form of modified bony plates extending intraorally. Postoperative review showed favorable results with occlusion and range of motion comparable to the premorbid function and no unforeseen complications.

Physiotherapy Maneuver Is Critical to Recover Mouth Opening After Pediatric Trauma

PURPOSE

A restricted mouth opening (MO) is predominantly a complication of maxillofacial trauma in pediatric patients and develops in 4 to 26.2% of cases. The purpose of the present study was to quantitatively investigate the influence of patient demographic data, fracture characteristics, and regular vigorous physiotherapy, with either voluntary or forcible MO exercises, on the recovery of a post-traumatic restricted MO in pediatric patients.

PATIENTS AND METHODS

A prospective cohort study was performed of pediatric patients with maxillofacial injuries who had been referred to Al-Zahraa and El-Fayoum Hospitals from 2013 to 2015. The predictive variables were patient demographic data, fracture characteristics, and regular vigorous physiotherapy. The patients were treated with a closed technique. The MO measurements were the clinical outcome variables and were recorded at the first week and then monthly for 12 months. Regular vigorous physiotherapy was performed until the patients had returned to their preoperative MO. The data were tabulated and statistically analyzed.

RESULTS

Eighty-six patients were enrolled in the present study. Males predominated. Falls were the most common cause of fracture. Condylar fractures had the greatest incidence. A restricted MO occurred in 81 patients. The results showed no interaction between MO recovery and age, gender, etiology, or fracture site. After physiotherapy, the patients had returned to their preoperative MO at the fourth month, with the measurements fixed at normal values at the sixth month. The recovery rate was nonlinear, with faster improvement in the months closest to the injury.

CONCLUSION

Physiotherapy is more critical in the recovery of the MO and prevention of bony ankylosis than patient data or fracture characteristics in pediatric trauma. We highly advocate the performance of voluntary mouth exercises, even in the absence of fracture. Forcible MO exercises are mandatory to recover a restricted MO. These exercises should be performed under close supervision of the patient's surgeon with the parents motivated to cooperate for at least 6 months.

Condylar Fracture in a Child with Entrapment of the Inferior Alveolar Nerve

The aim of this article is to report the clinical case of a right subcondylar fracture in a 4-year-old boy. The displaced and medial angulated fragmented mandibular condyle in coexistence with an enlarged lateral pterygoid process was compressing the inferior alveolar nerve (IAN) during its course in the area of the infratemporal fossa. This was expressed by exhibiting a rubbing behavior with resulting superficial ulceration at the right lower lip. Hypoesthesia of the lower lip may be a sign of the IAN entrapment after a subcondylar fracture in a child. In contrast to the adults where an open reduction is necessary to relieve the symptoms of hypoesthesia, in pediatric population, a conservative approach seems sufficient.

Open reduction and internal fixation of severely dislocated fractures of condylar neck and base using bioabsorbable miniplate in children: a 3-10 years follow-up study

OBJECTIVE

To evaluate the long-term clinical and radiologic outcomes of treating severely dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth sustained in childhood using bioabsorbable miniplate with open reduction and internal fixation (ORIF).

METHODS

Five children (age ranged from 3 to 11 years old averaged 8.2 years; 3 boys and 2 girls) with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth were treated with ORIF using 1 or 2 bioabsorbable miniplates (through preauricular approach and an oral vestibular approach). All patients have been followed-up clinically and radiographically for a mean of 5.6 years (range, 3-10 years).

RESULTS

All patients were cured satisfactorily with excellent occluding relation without restricted mandibular movement, facial asymmetry, retrognathism and ankylosis. 3-10 years follow-up study did not occur any mandibular development disorder.

CONCLUSION

The results suggested that ORIF using bioabsorbable miniplate was a reliable fixation technique for use in the treatment of severely dislocated fractures of the condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in children when the non-invasive or occlusal therapies were ineffective.