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

Fracture of the lower jaw is more often observed in boys aged 7 to 14 years, ie, during a period of special mobility and activity, when the roots of dairy roots dissolve and the roots of permanent teeth are formed.

Fewer fractures of the lower jaw are observed at the age of 15 to 16 years, when the activity of the boys is somewhat reduced, a permanent bite is already formed, but there is still no wisdom tooth. Much more rarely fractures of the lower jaw occur in boys aged 3 to 6 years, when the eruption of milk teeth has already ended, and permanent - has not yet begun.

[1],

What causes a fracture of the lower jaw in children?

Fractures in girls are observed with accidental injuries equally often in all age groups.

The reasons for fractures of the lower jaw are as follows: bruises, bumps; falling from trees, roofs, stairs, fences; getting under the transport (cars, carts, etc.). The most severe fractures in children occur during travel, sports and street injuries.

In a significant number of children with fractures of the lower jaw, there are craniocerebral injuries, fractures of bones, or damage to the soft tissues of the extremities and trunk.

Diagnosis and symptoms of fracture of the lower jaw in children

Diagnosis of fractures of the mandible in children is difficult, since contact with the child is not always possible. In addition, the child's response to trauma is inadequate, but the adaptive features of the child's body are more pronounced. So, children with fractures of the lower jaw focus on the difficulty of her movements, pain in talking, swallowing. It is difficult to judge the presence of fractures in appearance, as the swelling in the children rapidly increases, smoothing the shape of the face that is characteristic of this or that type of fracture. Therefore, it is much easier to diagnose a fracture in the first hours after the injury, that is, before the development of the edema of the face (because the swelling of the tissues does not allow palpation to diagnose bone damage), when all the reliable symptoms of a mandible fracture in children are easily detected - abnormal mobility of the lower jaws, crepitus, displacement of fragments of the bone, violation of bite (if teeth have already cracked), excessive salivation.

With considerable swelling of the tissues, radiography is performed. But with a subperiosteal fracture or crack, especially in the region of the angle or branch of the jaw, it may not give precise information. In these cases, it is recommended to do x-ray in several projections. It should be borne in mind that, depending on the direction of the rays, the picture of the location of the fragments is to a certain extent distorted, and their displacement on the roentgenogram looks less significant than in reality. Reading the roentgenogram, it is necessary to pay attention to the relationship between the fracture lines and the rudiments of permanent teeth, since the displacement of the tooth rudiments with fragments can subsequently lead to their death or to the anomaly of eruption of permanent teeth.

[2], [3], [4]

Classification of fracture of the lower jaw in children

KA Melnikov divides the fracture of the lower jaw into the following groups.

I. Body fractures:

• A. Single:
  • the central section;
  • lateral section;
  • of the angle region.
• B. Double:
  • the central section;
  • lateral section;
  • central, side or corner area.

II. Fractures of the branch:

• A. Single:
  • actual branches;
  • condylar process;
  • coronoid process.
• B. Double:
  • actual branches;
  • actually branch, condylar or coronoid process.
• C. Two-sided:
  • actual branches;
  • necks of the lower jaw.

III. Combined fractures of the body and branch:

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

Fractures of condylar processes of children are classified not only according to anatomical sign - "high", "low", but also by the degree of dislocation displacement (AA Levenets, 1981), and GA Kotov and MG Semenov (1991 ), based on the interests of the correct choice of the method of treatment and predicting the possible deformities of the child's face in the future, divide them according to the presence or absence of damage to the periosteum, as well as the magnitude of the deformity angle of the process ("insignificant" - up to 25-30 °, "significant" - over 30 ° indicates the presence of fracture-dislocation) and the level of the fracture line ("high" or "low").

Children often have single fractures of the body of the lower jaw (in the central part); much less often - double fractures of the body and combined fractures of the body and branch.

[5], [6], [7]

Treatment of fracture of the lower jaw in children

Treatment of children with fractures of the mandible should begin with the prevention of tetanus, primary surgical treatment with one-stage fixation of fragments and the appointment of intensive care with broad-spectrum antibiotics.

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

In children under the age of 3 years, because of the impossibility of using a tooth wire, tires are used which are made outside the laboratory and in the laboratory. Remove the prints need not plaster, but the impression mass.

In the absence of teeth on the jaw, the gumline tire is combined with a sling-like bandage. In children under the age of one year, the jaw fuses after 2.5-3 weeks. During this period the child wears a tire and eats liquid food.

If the jaw has single teeth, they are used as a support; The bus-kappa is made (by the method of RM Frigof) from bass-hardening plastic.

For fractures in children aged 3 to 7 years, in some cases, metal tires made of fine aluminum (according to the method of SS Tigerstedt) can be used for intermaxillary traction or single-jaw fixation.

Extraoral fixation with devices, like open osteosynthesis, in children should be used only with defects of the jaw's body or in cases where it is impossible to fix and fix fragments of the jaw in another way. In doing so, you need to be as careful as possible, manipulating only in the region of the jaw's body, so as not to damage the dentition and unformed roots of the cut teeth.

Based on the experience of our clinic, it can be considered that in cases of fractures of the muscular processes with a shortening of the jaw branch more than 4-5 cm, indirect (extra-osseous) osteosynthesis is shown with the help of devices for the treatment of fractures of the lower jaw, allowing the lislation and fixation of the fragments.

NI Loktev et al. (1996) with a fractured condylar process with a dislocation of the articular head, a vertical osteotomy of the jaw branch is performed, the posterior fragment and the joint are removed from the wound, the intra-osal securing of the fragments by the needle is performed outside the surgical wound, the implant is fixed to the branch with 1-2 wire seams.

Osteosynthesis with spokes using the device AOCH-3 is shown in children with insufficient number of teeth, during their shift, with bilateral fractures of the lower jaw, fractures with the interposition of muscles between fragments, as well as in mismatched and incorrectly fused fractures. Complications after percutaneous osteosynthesis with metal spokes are half that, and the stay of children in the clinic is less long (on average less for 8 days) than when treated with conservative methods. In addition, the use of spokes does not affect the fusion of the fracture, the growth zone and the development of dental rudiments.

It is noted that bone regeneration in the neck of the fracture occurs faster in those cases when the fracture is located far from the tooth rudiment; If, at the time of the correction of the fragments, the integrity is broken, the rudiment becomes infected, and this can lead to the formation of a cyst or the development of traumatic osteomyelitis.

Treatment of combined fractures of the jaws is carried out on the same principles as in adults, but children often have to resort to the application of bone seams or pinning on the lower jaw, since it is difficult to impose dental tires because of the small size of the tooth crowns.

The upper jaw should be fixed with an individual plastic tire with extraoral thin knitting needles and hooks that allow for intermaxillary traction using plastic hooks (for example, according to VK Pelipas) imposed on the lower jaw.

Outcomes and complications in the treatment of children with injuries of the face, teeth and jaws

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

If untimely and incorrect treatment occurs, there are early or late complications (osteomyelitis, malocclusion, deformation of the jaw contours, stiffness of the lower jaw, ankylosis, etc.). It should be remembered that in children under the age of fixing devices (tires) should be kept 2.5-3 weeks, in children from 1 to 3 years - 3-4 weeks, from 3 to 7 years - 3-5 weeks, from 7 to 14 years - 4-6 weeks, at the age of over 14 years - 6-8 weeks.

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

The favorable outcome of treatment in the immediate after the fracture is not always preserved, since during the development of the teeth and the lower jaw of the child, it is possible to detect a delay in eruption of individual teeth, the development of part or all of the jaw due to damage to the growth zone at the time of injury, osteosynthesis or the onset of inflammatory complications (osteomyelitis of the jaw, arthritis, sinusitis, zygomatitis, phlegmon, ankylosis, etc.). In the area of trauma, rough scars can develop that restrain the development of soft tissues and bones of the face.

All this leads to disruption of the occlusion and contours of the face requiring orthodontic or surgical treatment in combination with orthopedic compensation of lost elements of the chewing system.

Observational data of many authors confirm the advantage of surgical treatment of fractures of the condylar process before the conservative (orthopedic) process.

Prevention of complications in fractures of the mandible in children

Prevention of complications in fractures of the mandible in children should be aimed at preventing complications of the inflammatory nature, violations of growth and development of the lower jaw, 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 the injury and temporary (transport) immobilization of fragments.
2. If possible, early comparison of jaw fragments and their fixation with bandages, sling, head cap and other devices with delayed (as a result of the extremely serious general condition of the victim) permanent immobilization of fragments.
3. Early suturing of the damaged gum (according to indications).
4. Early fixation of fragments of the lower jaw with the help of devices and the use of methods that do not cause additional trauma to the lower jaw, circulatory disorders and innervation (fixation with kappas, teeth, ligature ligature, chin, suture with a gum-gum, osteosynthesis without dissection periosteum or all soft tissues at the ends of fragments).
5. Anti-inflammatory measures - sanitation of the oral cavity (removal of temporary and permanent teeth from the fracture with complicated caries, treatment of temporary and permanent teeth with uncomplicated caries, oral hygiene), rinsing of the fracture with antiseptic solutions, anthiobiotic-novocain blockade (topically), antibiotics (by mouth, intramuscularly or intravenously); desensitizing therapy, physiotherapy.
6. Normalization of impaired blood circulation and innervation in the area of damage by drug treatment (heparin, proserine, dibazol, thiamine, pentoxil and other drugs), the use of physiotherapeutic measures (magnetotherapy), exercise therapy, direct electric stimulation or the use of bio-controlled electrostimulation.
7. Dietotherapy.

Identified by VP Korobov and co-workers. (1989) (and listed in Chapter 1), biochemical changes in the blood of adults with a fracture of the lower jaw are particularly pronounced in children. Therefore, as the authors point out, the use (in the complex treatment of children) of the coamid is especially useful, since it promotes the acceleration of the fusion of bone fragments. The dose of this drug taken by the child inside 3 times a day should be determined by the weight of the child. It is also possible to designate a ceramide, but the coamid more intensively normalizes biochemical disorders than the feramide.

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

1. Perhaps early comparison of fragments of the mandible with fractures in the body and angle to restore the correct anatomical shape and the use of orthodontic devices to fix fragments and compare them in the correct position, if they can not be manually compared.

• A. After correct repositioning of fragments, preventive examinations should be performed twice a year; at detection of deviations in the development of the lower jaw and in case of malocclusion, early orthodontic treatment is prescribed .
• B. When the fragments are fused in the wrong position, orthodontic treatment is carried out either after removal of the fragments fixing fragments and devices, or carried out immediately after refracture.
• B. The duration of orthodontic treatment is determined by the nature of the deformity of the mandible and the state of the occlusion: after restoration of the bite and jaw shape, orthodontic treatment is discontinued, but follow-up is performed prior to the period of formation of the permanent bite; the question of the need for a second course of orthodontic treatment is decided at further stages of observation in accordance with the development of the lower jaw and the location of erupting permanent teeth.
• D. Prior to the formation of a permanent bite, it is necessary to observe 1-2 times a year before the victims reach 15 years of age.

2. Application of fractures of the condylar process (without displacement of fragments or with a slight displacement of them and partial dislocation of the head of the lower jaw) of orthopedic methods of fixing the mandible with early orthodontic treatment and functional load.

• A. Orthodontic devices are applied directly after the injury or 2-3 weeks after it for up to one year.
• B. For orthopedic fixation, the lower jaw should be displaced anteriorly in order to reduce the load on the developing joint head, keep it in the correct position and activate the processes of endochronic osteogenesis.
• B. The increase in the timing of orthodontic treatment or the appointment of a second course is carried out according to the indications depending on the
  effectiveness of the activities carried out in the post-traumatic period.
• D. In these types of fractures of the condylar process in children, prolonged follow-up is recommended until they reach 12-15 years with examination every 6 months.

3. Application of fractures of the condylar process with fractures of its head or comminuted fractures of the head of surgical methods of treatment: osteosynthesis, percutaneous application of the device of the structure M.M. Solov'eva et al. For compression-distraction osteosynthesis, head re-implantation with joint capsule suturing and lateral pterygoid muscle threading according to NA Plotnikov, bone plasty of condylar process with early administration of orthodontic treatment and functional load.

• A. It is recommended to have a maxillary access to the condylar process without flaking of the masticatory and medial pterygoid muscles.
• B. Orthodontic treatment.

4. Preservation of teeth rudiments in the presence of them in the area of fracture of the lower jaw. Remove rudiments should not be earlier than 3-4 weeks after injury with persistent purulent inflammation in the fracture zone (as a result of necrosis of the rudiment of the tooth), confirmed radiologically.

III. Prevention of posttraumatic developmental disorders and eruption of the rudiments of permanent teeth involves the following stages.

1. juxtaposition of jaw fragments in the correct position;
2. anti-inflammatory therapy;
3. dispensary observation and treatment in orthopedic patients in violation of eruption and the arrangement of teeth;
4. remineralizing therapy, the use of fluoride preparations inside or fluoride varnish for dental treatment;
5. control over the development of the nervous apparatus of teeth according to electrodontodiagnostics.

To implement recommendations for the prevention of post-traumatic complications in children with fractures of the mandible, the following measures should be taken:

1. organization of rehabilitation rooms for children's regional (regional), city and inter-district dental clinics or for children's departments of dental clinics in cities and large regional centers;
2. studying sections on providing emergency care for children with injuries of jaws and teeth in regional, regional, city hospitals (specialization courses in surgical dentistry and maxillofacial surgery);
3. organization in cities of the republican, regional (regional) subordination of stationary children's maxillofacial departments for rendering specialized help;
4. organization of cabinets to provide urgent surgical care for children in hospitals of regional (regional) subordination, which include a stationary maxillofacial department;
5. training of dentists for work in the stationary pediatric maxillofacial department in the clinical residency of the pediatric dentistry departments;
6. organization for maxillofacial surgeons of the state, region, the edge of visiting cycles of specialization in children's dentistry and orthodontics.