A 9-year-old female came to the emergency room after tripping at school and falling straight down onto a tiled floor. A teacher had witnessed the fall and reported that the child had seemingly been wiped off her feet landing with a great deal of force straight onto her chin. The teacher said there was no loss of consciousness. Her mother brought her to the emergency room after being called by school personnel. She reportedly had blood in her mouth originally but this had stopped and she was having pain at the point of the chin and by the temperomandibular joint on the left side. The past medical history was non-contributory.
The pertinent physical exam showed a female in some pain. Her vital signs were normal including growth parameters that were in the 10-25%. HEENT showed a laceration underneath her chin that was 2 cm in length that was through the skin. After cleaning it was found to be easily approximated. Her ear exam was negative. She refused to open her mouth fully and when she tried she complained of some pain with palpation anterior to the left ear. Her oral exam was grossly normal without pain on tapping of teeth that could be reached and there was a minor laceration inside the left cheek without bleeding. Her neck exam and rest of her head examination was normal. Her neurological examination was negative with her being alert and oriented but refusing to open her mouth fully. The rest of her examination was negative. The diagnosis of probable mandibular trauma along with other possible intraoral trauma was made. The pediatric dentists were consulted. They did not find any significant intraoral trauma. The radiologic evaluation of a panorex of the maxilla and mandible revealed the diagnosis of a left mandibular condylar fracture. She was begun on a no chew diet after repair of the chin laceration and her clinical course showed radiographic and clinical improvement after 3 weeks. She was to continue on the diet until another 3 week followup.
The most common mandibular fractures are condylar fractures (30-40%) followed by fractures of the symphysis, angle and body respectively. Mandibular condyle fractures also account for 11-16% of all facial fractures. The causes of mandibular fractures are motor vehicle accidents, falls and sports. Pain, edema, malocclusion, hematoma and bruising, crepitus, trismus, decreased movement and lost sensation are common presenting signs and symptoms. Patients are diagnosed by history and radiographs (usually a CT scan). Potential complications of condylar fractures include decreased movement, muscle spasms, pain, malocclusion, facial asymmetry, ankylosis and osteonecrosis. Complicated mandibular fractures can have permanent tooth damage, facial asymmetry, and nerve damage. Mandibular fractures can also be isolated or part of neurocranial or multi-organ system trauma.
“Whereas absolute reduction and fixation of fractures is indicated in adults, concern for minimal manipulation of the facial skeleton is mandated in children. The small size of the jaw, existing active bony growth centers and the contained, overwhelmingly crowded deciduous teeth with permanent tooth buds located in great proximity to the mandibular and mental nerves, all significantly increase the therapy-related risks of pediatric mandibular fractures and their growth related abnormalities. Intact active mandibular growth centers are important for preserving mandibular function, which have a significant influence on future facial development. Thus, restoration of the mandibular continuity after fracture is important not only for immediate function but also for future craniofacial development.”
Options for treatment of mandibular fractures include:
- Close observation with analgesics, liquid-to-soft diets and no activities that present risks such as sports.
This is usually used for greenstick fractures without displacement or malocclusion.
- Splints – prefabricated acrylic splints, staples or orthodontic devices. These have the advantage of being relatively easy to apply and remove, can be done in an outpatient setting or with decreased general anesthesia time.
- Open reduction (including wiring of the jaws) is used for more complicated fractures including those that are significantly displaced.
Questions for Further Discussion
1. Besides dentists, what other professionals may be helpful in managing mandibular fractures?
2. How are the nutritional needs of a patient with a mandibular fracture met?
- Disease: Mandibular Fracture | Jaw Injuries and Disorders
- Symptom/Presentation: Pain
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Jaw Injuries and Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Aizenbud D, Hazan-Molina H, Emodi O, Rachmiel A. The management of mandibular body fractures in young children. Dent Traumatol. 2009 Dec;25(6):565-70.
Goth S, Sawatari Y, Peleg M. Management of pediatric mandible fractures. J Craniofac Surg. 2012 Jan;23(1):47-56.
Chrcanovic BR. Open versus closed reduction: mandibular condylar fractures in children. Oral Maxillofac Surg. 2012 Sep;16(3):245-55.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital