Fractures of the lower jaw in children: causes, symptoms, diagnosis, treatment

A fracture of the lower jaw is most often observed in boys aged 7 to 14 years, i.e. during a period of particular mobility and activity, when the roots of baby teeth are resorbed and the roots of permanent teeth are formed.

Somewhat less frequently, a fracture of the lower jaw is observed at the age of 15 to 16 years, when the activity of boys is somewhat reduced, the permanent bite has already formed, but there are no wisdom teeth yet. Much less frequently, fractures of the lower jaw occur in boys aged 3 to 6 years, when the eruption of baby teeth has already ended, and permanent teeth have not yet begun.

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What causes jaw fracture in children?

Fractures in girls are observed as a result of accidental injuries equally often in all age groups.

The causes of lower jaw fractures are as follows: bruises, blows; falling from trees, roofs, ladders, fences; being hit by transport (cars, carts, etc.). The most severe fractures in children occur when being hit by transport, sports and street injuries.

A significant number of children with mandibular fractures have traumatic brain injury, bone fractures, or soft tissue damage to the extremities and trunk.

Diagnosis and symptoms of a fracture of the lower jaw in children

It is difficult to diagnose fractures of the lower jaw in children, since it is not always possible to establish contact with the child. In addition, the child's reaction to the injury is inadequate, but the adaptive features of the child's body are more pronounced. Thus, children with fractures of the lower jaw pay primary attention to the difficulty of its movements, pain when talking, swallowing. It is difficult to judge the presence of fractures by appearance, since swelling quickly increases in children, smoothing out the shape of the face, characteristic of a particular type of fracture. Therefore, it is much easier to diagnose a fracture in the first hours after the injury, i.e. before the development of facial edema (since tissue swelling does not allow palpation diagnostics of bone damage), when all reliable symptoms of a fracture of the lower jaw in children are easily detected - abnormal mobility of the lower jaw, crepitus, displacement of bone fragments, malocclusion (if teeth have already erupted), profuse salivation.

In case of significant tissue swelling, radiography is performed. However, in case of a subperiosteal fracture or crack, especially in the area of the angle or branch of the jaw, it may not provide accurate information. In these cases, it is recommended to perform radiography in several projections. It should be taken into account that, depending on the direction of the rays, the picture of the location of the fragments is distorted to a certain extent, and their displacement on the radiograph looks less significant than in reality. When reading the radiograph, it is necessary to pay attention to the relationship of the fracture lines and the rudiments of permanent teeth, since the displacement of the tooth rudiments by fragments can subsequently lead to their death or to anomalies in the eruption of permanent teeth.

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Classification of mandibular fracture in children

K. A. Melnikov divides fractures of the lower jaw into the following groups.

I. Fractures of the body:

• A. Singles:
  • central area;
  • lateral section;
  • corner areas.
• B. Double:
  • central area;
  • lateral section;
  • central, lateral section or corner area.

II. Branch fractures:

• A. Singles:
  • branches proper;
  • condylar process;
  • coronoid process.
• B. Double:
  • branches proper;
  • the actual branch, condylar or coronoid process.
• C. Bilateral:
  • branches proper;
  • necks of the lower jaw.

III. Combined fractures of the body and branch:

• A. One- and two-sided:
  • bodies and branches of the jaw;
  • body and condylar or coronoid process.

Fractures of the condylar processes in children are classified not only by anatomical features - "high", "low", - but also by the degree of displacement of fragments (A. A. Levenets, 1981), and G. A. Kotov and M. G. Semenov (1991), based on the interests of the correct choice of treatment method and prediction of possible deformations of the child's face in the future, divide them by the presence or absence of damage to the periosteum, as well as by the magnitude of the angle of deformation of the process ("insignificant" - up to 25-30 °; "significant" - over 30 ° indicates the presence of a fracture-dislocation) and by the level of the fracture line ("high" or "low").

In children, single fractures of the body of the mandible (in the central area) are most common; much less common are double fractures of the body and combined fractures of the body and branch.

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Treatment of fracture of the lower jaw in children

Treatment of children with fractures of the lower jaw should begin with tetanus prophylaxis, primary surgical treatment with immediate fixation of fragments and prescription of a course of intensive therapy with broad-spectrum antibiotics.

The choice of the method of immobilization of fragments is determined by the location and nature of the fracture (linear, comminuted, multiple with displacement of fragments, etc.), the age of the child, the presence of stable teeth on the jaw fragments, the general condition of the victim, etc.

In children under 3 years of age, due to the impossibility of using dental wire splints, splint-caps are used, manufactured outside the laboratory and in the laboratory. Impressions should be taken not with plaster, but with impression mass.

If there are no teeth on the jaw, the gum splint is combined with a sling bandage. In children under one year of age, the jaw grows together in 2.5-3 weeks. During this period, the child wears a splint and eats liquid food.

If there are single teeth on the jaw, they are used as a support; the splint-mouthguard is made (according to the method of R. M. Frigof) from quick-hardening plastic.

In case of fractures in children aged 3 to 7 years, in some cases, metal splints made of thin aluminum can be used for intermaxillary traction or single-jaw fixation (according to the S.S. Tigerstedt method).

Extraoral fixation with devices, like open osteosynthesis, should be used in children only in case of jaw body defects or in cases where it is impossible to adjust and fix jaw fragments in another way. In this case, it is necessary to observe maximum caution, manipulating only in the area of the edge of the jaw body, so as not to damage the tooth rudiments and unformed roots of erupted teeth.

Based on the experience of our clinic, it can be assumed that in case of fractures of the muscular processes with a shortening of the jaw branch of more than 4-5 cm, indirect (extrafocal) osteosynthesis is indicated using devices for the treatment of fractures of the lower jaw, which allow for the removal and fixation of fragments.

N. I. Loktev et al. (1996) in case of a fracture of the condylar process with dislocation of the articular head perform a vertical osteotomy of the jaw branch, remove its posterior fragment and articular head from the wound, perform (outside the surgical wound) intraosseous fastening of the fragments with a pin, and fix the replant to the branch with 1-2 wire sutures.

Osteosynthesis with pins using the AOCh-3 device is indicated in children with an insufficient number of teeth, during their change, with bilateral fractures of the lower jaw, with fractures with interposition of muscles between fragments, as well as with comminuted and improperly healed fractures. Complications after percutaneous osteosynthesis with metal pins are twice as few, and children's stay in the clinic is shorter (on average, 8 days less) than with treatment using conservative methods. In addition, the use of pins does not affect the healing of the fracture, growth zones and the development of tooth rudiments.

It has been noted that bone regeneration in the fracture gap occurs faster in cases where the fracture is located far from the tooth germ; if, however, at the time of reduction of the fragments, its integrity is compromised, the germ becomes infected, and this can lead to the formation of a cyst or the development of traumatic osteomyelitis.

Treatment of combined jaw fractures is carried out according to the same principles as in adults, however, in children it is more often necessary to resort to the application of a bone suture or pinning on the lower jaw, since it is difficult to apply dental splints due to the small size of the tooth crowns.

The upper jaw should be fixed with an individual plastic splint with extraoral thin whisker-shaped spokes and hooks, which allow intermaxillary traction using plastic splints with hooks applied to the lower jaw (for example, according to V.K. Pelipas).

Outcomes and complications in the treatment of children with facial, dental and jaw injuries

If specialized treatment is started in a timely manner (within the first 24-48 hours after the injury) and the method is chosen correctly, recovery occurs within the usual time frame (from 2.5 to 8 weeks, depending on the complexity of the fracture).

If treatment is not timely or is incorrect, early or late complications may occur (osteomyelitis, malocclusion, jaw contour deformations, lower jaw stiffness, ankylosis, etc.). It should be remembered that in children under one year, fixing devices (splints) must be kept in place for 2.5-3 weeks, in children aged 1 to 3 years - 3-4 weeks, from 3 to 7 years - 3-5 weeks, from 7 to 14 years - 4-6 weeks, and over 14 years of age - 6-8 weeks.

The duration of fixation is determined by the nature of the fracture and the general condition of the child.

A favorable outcome of treatment in the immediate period after a fracture does not always persist in the future, since in the process of development of the child's teeth and lower jaw, a delay in the eruption of individual teeth, development of part or the entire jaw can be detected due to damage to the growth zone at the time of injury, osteosynthesis or an inflammatory complication (osteomyelitis of the jaw, arthritis, sinusitis, zygomatitis, phlegmon, ankylosis, etc.). Rough scars can develop in the area of injury, inhibiting the development of soft tissues and facial bones.

All this leads to malocclusion and facial contours, requiring orthodontic or surgical treatment in combination with orthopedic compensation for lost elements of the masticatory system.

Observational data from many authors confirm the advantage of surgical treatment of fracture-dislocations of the condylar process over conservative (orthopedic) treatment.

Prevention of complications in fractures of the lower jaw in children

Prevention of complications in fractures of the lower jaw in children should be aimed at preventing complications of an inflammatory nature, growth and development disorders of the lower jaw, and developmental disorders and eruption of the rudiments of permanent teeth.

I. Prevention of post-traumatic complications of an inflammatory nature includes the following measures:

1. Local anesthesia (conduction or infiltration) immediately after injury and temporary (transport) immobilization of fragments.
2. If possible, early alignment of jaw fragments and their fixation with bandages, a sling, a head cap and other devices with delayed (as a result of the extremely severe general condition of the victim) permanent immobilization of fragments.
3. Early suturing of damaged gums (as indicated).
4. Early fixation of lower jaw fragments using devices and methods that do not cause additional trauma to the lower jaw, circulatory and innervation disorders (fixation using mouth guards, dental splints, wire ligature ligature, chin sling, wrapping suture with a dental-gingival splint, osteosynthesis without cutting the periosteum or all soft tissues at the ends of the fragments).
5. Anti-inflammatory measures - oral cavity sanitation (removal of temporary and permanent teeth with complicated caries from the fracture gap, treatment of temporary and permanent teeth with uncomplicated caries, oral hygiene), rinsing the fracture gap with antiseptic solutions, antibiotic-novocaine blockades (locally), antibiotics (orally, intramuscularly or intravenously); desensitizing therapy, physiotherapy measures.
6. Normalization of impaired blood circulation and innervation in the area of injury through drug treatment (heparin, proserin, dibazol, thiamine, pentoxyl and other drugs), the use of physiotherapy measures (magnetic therapy), exercise therapy, direct current electrical stimulation or the use of the method of biocontrolled electrical stimulation.
7. Diet therapy.

The biochemical changes in the blood of adults with a fracture of the lower jaw, identified by V. P. Korobov et al. (1989) (and listed in Chapter 1), are especially pronounced in children. Therefore, as the authors point out, the use (in the complex treatment of children) of coamide is especially useful, since it promotes the acceleration of the fusion of bone fragments. The dose of this drug, taken orally by the child 3 times a day, should be determined by the child's weight. Feramide can also be prescribed, but coamide normalizes biochemical disturbances more intensively than feramide.

II. Prevention of post-traumatic disorders of growth and development of the lower jaw involves several points:

1. It is possible to perform early alignment of fragments of the lower jaw in case of fractures in the area of the body and angle in order to restore the correct anatomical shape and to use orthodontic devices to secure the fragments and align them in the correct position if it is impossible to align them manually.

• A. After correct repositioning of the fragments, preventive examinations are recommended to be carried out twice a year; if deviations in the development of the lower jaw and malocclusion are detected, the earliest possible orthodontic treatment is prescribed.
• B. When fragments fuse in an incorrect position, orthodontic treatment is carried out either after removing the devices and appliances that fix the fragments, or is carried out immediately after refraction.
• B. The duration of orthodontic treatment is determined by the nature of the deformation of the lower jaw and the state of the bite: after the restoration of the primary bite and the shape of the jaw, orthodontic treatment is stopped, but dispensary observation is carried out until the period of formation of the permanent bite; the question of the need for a repeat course of orthodontic treatment is decided at further stages of observation in accordance with the development of the lower jaw and the location of the erupting permanent teeth.
• G. Until the permanent bite is formed, observation is necessary 1-2 times a year until the victims reach 15 years of age.

2. The use of orthopedic methods of fixation of the lower jaw with early orthodontic treatment and functional loading in case of fractures of the condylar process (without displacement of fragments or with minor displacement of them and partial dislocation of the head of the lower jaw).

• A. Orthodontic devices are applied immediately after the injury or 2-3 weeks after it for up to one year.
• B. During orthopedic fixation, it is necessary to achieve anterior displacement of the lower jaw in order to reduce the load on the forming joint head, maintain it in the correct position and activate the processes of enchondral osteogenesis.
• B. An increase in the duration of orthodontic treatment or the appointment of a repeat course is carried out according to indications, depending on the
  effectiveness of the measures carried out in the post-traumatic period.
• G. For the indicated types of condylar process fractures in children, long-term dispensary observation is recommended until they reach 12-15 years of age with examination every 6 months.

3. Application of surgical treatment methods for fractures of the condylar process with dislocation of its head or comminuted fractures of the head: osteosynthesis, percutaneous application of the apparatus designed by M. M. Solovyov et al. for performing compression-distraction osteosynthesis, replantation of the head with suturing of the joint capsule and suturing of the lateral pterygoid muscle according to N. A. Plotnikov, bone grafting of the condylar process with early prescription of orthodontic treatment and functional loading.

• A. A retromandibular approach to the condylar process without detaching the masseter and medial pterygoid muscles is recommended.
• B. Orthodontic treatment.

4. Preservation of tooth rudiments if they are present in the area of the lower jaw fracture. The rudiments should be removed no earlier than 3-4 weeks after the injury in case of persistent purulent inflammation in the fracture area (as a result of necrosis of the tooth rudiment), confirmed by radiography.

III. Prevention of post-traumatic disorders of development and eruption of permanent teeth rudiments involves the following stages.

1. alignment of jaw fragments in the correct position;
2. anti-inflammatory therapy;
3. outpatient observation and treatment by an orthodontist in case of problems with the eruption and positioning of teeth;
4. remineralizing therapy, the use of fluoride preparations or fluoride varnish for treating teeth;
5. monitoring the development of the dental nervous system using electroodontodiagnostics data.

To implement recommendations for the prevention of post-traumatic complications in fractures of the lower jaw in children, it is necessary to carry out the following measures:

1. organization of rehabilitation rooms at children's regional (provincial), city and inter-district dental clinics or at children's departments of dental clinics in cities and large regional centers;
2. study of sections on providing emergency care to children with injuries to the jaws and teeth in regional, provincial, and city hospitals (specialization courses in surgical dentistry and maxillofacial surgery);
3. organization in cities of republican and regional (oblast) subordination of inpatient children's maxillofacial departments to provide specialized care;
4. organization of offices for the provision of emergency surgical care to children at hospitals of regional (oblast) subordination that have an inpatient maxillofacial department;
5. training dentists to work in the inpatient pediatric maxillofacial department in the clinical residency of the pediatric dentistry departments;
6. organization of visiting cycles of specialization in pediatric dentistry and orthodontics for maxillofacial surgeons of the state, region, and territory.