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Mandibular (jaw) fractures in children

Mandibular (jaw) fractures in children
Literature review current through: Jan 2024.
This topic last updated: Mar 25, 2022.

INTRODUCTION — This topic will discuss the evaluation and treatment of jaw fractures in children. Dental trauma in children is discussed separately. (See "Evaluation and management of dental injuries in children".)

RELEVANT ANATOMY — The mandible is a U-shaped bone composed of the following paired regions (figure 1) [1]:

Anterior coronoid

Posterior condyle

Ramus

Angle

Body

Symphysis

Alveolus

The anterior coronoid and the posterior condyle articulate with the glenoid fossa of the skull to form the temporomandibular joint (figure 2). The alveolus is the region for tooth eruption in the mandible [1]. The mandible is innervated by the inferior alveolar branch of the mandibular branch of the trigeminal nerve and derives its vascular supply from the inferior alveolar artery.

As the child develops, the mandible grows downward, forward, and laterally [2,3]. Infants up to two years of age have a short, thick condylar neck that resists fracture, unless significant force is applied but a highly vascular condylar head that is prone to crush injury. In older children, the condylar neck becomes more vulnerable to fracture. In adolescents, the angle of the jaw replaces the condyle as the most likely fracture site [3]. The mandible is fully developed by about age 14 to 16 years in girls and 16 to 18 years in boys.

Because of the elastic nature of the bone in children, they typically sustain greenstick or incomplete fractures and are less likely to have comminuted fractures [3]. Fracture lines tend to run inferiorly and anteriorly because of developing dentition. Remodeling of significantly displaced condylar fractures commonly occurs in children younger than 12 years of age [2]. In adolescence, new bone formation is greater than in adults but remodeling of the condyle becomes limited.

Relative to school-age children and adolescents, infants and young children are less likely to sustain a mandibular fracture. Protective factors of the developing mandibular anatomy in these young patients include:

Thick, short, elastic condyles

Thick adipose tissue surrounding the mandible

During falls, decreased force of impact due to smaller size and weight

Large cranium-to-facial ratio that creates a relative micrognathia, so that the force of impact is directed to the forehead or skull rather than the mandible

EPIDEMIOLOGY — Mandible fractures account for approximately one-third of all facial fractures in children [4]. They occur more commonly in older children and adolescents because of their greater exposure to significant traumatic forces (eg, motor vehicle collisions) and high-risk activities, such as fighting, collision sports, or bicycle riding [5]. In addition, children younger than five years of age have anatomical protection provided by their immature skeleton and bone characteristics. (See 'Relevant anatomy' above.)

The typical mechanisms of injury depend upon age and sex. Falls and motor vehicle collisions (MVCs) account for most fractures in infants, children, and adolescent girls; assault and MVCs are most common in adolescent males [4,6]. In infants younger than one year of age, child abuse is also an important etiology [4]. Overall, the male-to-female ratio for mandibular fractures is approximately 4:1 [4]. Condylar fractures predominate in children younger than 10 years, while fractures of the angle are most frequent in adolescents [6].

Associated injuries such as facial lacerations, intracranial injury, and cervical spine fractures may occur at any age, especially in victims of MVCs [6]. However, because of the higher degree of force necessary to fracture their relatively stable mandible, infants and young children are more likely to have serious injuries in addition to mandibular fractures.

CLINICAL FEATURES — Common mechanisms of injury include a fall onto the chin, direct blow to the jaw (eg, assault or recreational injury), or facial trauma sustained during a motor vehicle collision [6].

Children with mandibular fractures present with one or more of the following findings [2,7-9]:

Facial swelling

Ecchymoses

New malocclusion

Chin lacerations

Tongue lacerations

Holding the jaw to one side

Jaw or temporomandibular pain

Difficulty opening or closing the mouth

Pain upon biting or chewing

Numbness of the lower lip and chin

Ear pain (high condylar fractures)

On physical examination, the diagnosis of mandibular fracture is supported by [2]:

Malocclusion

Deviation of the chin to the fractured side (displaced condylar fracture)

Ecchymosis or laceration of the floor of the mouth

Preauricular swelling and tenderness (condylar fractures)

Gross malalignment or mobility of mandibular segments

Posterior displacement of the mandible (bilateral fractures)

Tenderness or swelling over the fracture site (figure 1)

Inability to bite down and hold a tongue depressor with the teeth

Tooth fracture

Mucosal or gingival lacerations

INITIAL STABILIZATION — Children with mandibular fractures in association with high force multiple trauma should undergo initial stabilization according to the principles of Advanced Trauma Life Support (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey'.)

Maintaining the airway in a multiple trauma patient with mandibular fracture can pose significant challenges because of intraoral bleeding and/or hematoma, limitation of mouth opening, posterior displacement of the jaw with airway obstruction, direct airway injury, and the requirement to maintain cervical spine motion restrictions. These patients are at higher risk for having a difficult airway and requiring establishment of a surgical airway.

Essential actions for these patients include the following:

Patients with neck pain or a high-risk mechanism (eg, diving accident, high-risk motor vehicle collision, serious head or face injury, or multiple trauma) warrant institution of spinal motion restriction and evaluation for cervical spine injury. (See "Pediatric cervical spinal motion restriction" and "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Evaluation'.)

In patients with jaw fractures and associated heavy bleeding, large intraoral hematoma, or hematoma extending into the neck, an emergency call for an anesthesiologist and otolaryngologist to assist with securing the airway should be made.

Supine trauma patients with heavy bleeding or oral debris from jaw injuries are at risk of aspiration and airway compromise. While an assistant provides manual in-line cervical spine motion restriction, the patient should be log rolled onto their side (figure 3) and the oropharynx cleared of all blood, secretions, teeth, and bone fragments using two, large-bore Yankauer or wide-bore tonsil tip suction catheters. For patients at risk for spinal column injury, the backboard may be tilted in a manner that reduces the risk of aspiration after initial suctioning.

Children with severe oropharyngeal bleeding who do not require spinal immobilization should be allowed to assume a position of comfort. They can sit leaning forward and undergo frequent suctioning by a caregiver or assistant; cooperative older children and adolescents may suction themselves.

When endotracheal intubation is indicated, clinicians should anticipate difficulty in patients with heavy bleeding or evidence of direct airway injury. Simultaneous preparation for oral intubation and cricothyrotomy (ie, double set-up) is prudent in such cases. (See "The difficult pediatric airway for emergency medicine", section on 'Airway management' and "Rapid sequence intubation (RSI) in children for emergency medicine: Approach", section on 'Approach' and "Needle cricothyroidotomy with percutaneous transtracheal ventilation" and "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

Intraoral bleeding may be profuse and should be controlled by gauze pressure packs when possible. Only large gauze with radiopaque markers should be used, and a "handle" portion of each piece should be drawn out and positioned so it is visible outside the mouth for monitoring and ease of removal. Small (eg, 2 x 2 inches) or unmarked gauze is an aspiration hazard and should never be used for this purpose.

During airway assessment, avulsed, very loose, or dangling teeth should be removed and properly stored. Once the patient is stabilized, permanent teeth should be reimplanted (table 2). (See "Evaluation and management of dental injuries in children", section on 'Replantation and dental treatment'.)

IMAGING — Patients with normal range of motion, no acute malocclusion, and no bony tenderness, including no condylar tenderness throughout full range of motion on palpation via the external meatus, are at very low risk for significant mandibular injury.

All other patients with a suspected mandibular fracture warrant multidetector computed tomography (CT) of the facial bones and mandible. Three-dimensional reconstruction is also desirable if midface injury is suspected [10]. The U-shape of the mandible and the presence of adjacent bony structures make it impossible to isolate the mandible on a flat radiograph film. Therefore, simple radiographs of the mandible are less sensitive for detecting fractures than CT or panoramic radiographs (ie, Panorex) and can miss fractures of the condyle. CT is preferred for the evaluation of mandibular fractures because it has higher sensitivity than panoramic radiographs, provides necessary information to the surgeon for planning fracture management, and better detects associated facial fractures [10].

When available and when the patient is cooperative, panoramic radiographs in addition to CT are often helpful to identify associated dental fractures [10]. Cervical spine injury must be excluded prior to imaging because this study requires that the child be seated in a steady upright position.

Common sites of fracture on imaging include:

Condylar fractures (most common) – Condylar fractures include low subcondylar fractures, high condylar neck fractures, and crush fractures of the condylar head (figure 1). Low subcondylar fractures are most frequent. They often are incomplete "greenstick" fractures [11]. These injuries are commonly associated with a chin laceration [8,9,12].

Fractures of the body of the mandible – These fractures are often displaced. Single body fractures, particularly those lateral to the symphysis, are frequently associated with contralateral condylar fractures.

DIAGNOSIS — Mandibular fractures should be clinically suspected in any child with trauma to the face, jaw, or chin; and findings of localized swelling, tenderness, malocclusion, difficulty opening the mouth, jaw deformity, or deviation of the jaw to one side. (See 'Clinical features' above.)

Mandibular fractures are diagnosed by appropriate imaging, usually multidetector computed tomography of the mandible. (See 'Imaging' above.)

Mandible fractures may be missed more often in younger children than in teenagers and adolescents because the only obvious clinical finding may be a soft tissue injury in the jaw or chin area [13]. Unlike adolescents and school-age children, younger children may be unable to describe symptoms that suggest mandibular fractures such as occlusal or neurosensory changes in the mouth. Restricted mouth opening is an important finding of mandibular fracture that was present in 70 percent of children with missed mandibular fractures in one retrospective observational study [13].

DIFFERENTIAL DIAGNOSIS — Once proper imaging is obtained, the diagnosis of a mandibular fracture is straightforward. Mandibular fractures are commonly associated with chin lacerations, dental avulsion or fractures, temporomandibular joint dislocation, and/or facial fractures.

Multiple trauma patients with mandibular fractures frequently have associated facial, intracranial, and cervical spine injury.

INDICATIONS FOR SPECIALTY CONSULTATION OR REFERRAL — All children with mandibular fractures warrant evaluation and treatment by an oral and maxillofacial surgeon or dentist with pediatric expertise.

MANAGEMENT

General principles — The management of children with mandibular fractures should be directed by a plastic or oral and maxillofacial surgeon with pediatric expertise. Rapid healing may cause malunion if stabilization is delayed beyond five days. Thus, timely specialist consultation and referral are imperative. Definitive treatment depends upon the patient's age, location and mobility of the fracture, dental development, presence of concomitant injuries, patient and caregiver adherence, and experience and judgement of the treating surgeon.

Incomplete or nondisplaced fractures may be managed with a period of soft diet, especially in very young patients. Children with early mixed dentition (eg, age six to eight years) and minimal occlusal changes may also be treated this way, or with a short period (two to three weeks) of elastic occlusal control. Elastic control is placed using one of several dental wiring techniques, depending on the dental development and stable anchorage available [14]. (See 'Unilateral condylar fractures' below.)

More severely displaced, freely mobile, or multiple mandible fractures may require immobilization, typically by maxillomandibular fixation using arch bars or other dental wiring techniques. Elastic fixation between the arches may achieve comparable results to wire fixation, with fewer risks [15]. Successful immobilization with maxillomandibular fixation requires teeth that are firmly supported in the alveolar bone [16]. The degree of support varies by age (and stage of dental development) as follows:

0 to 2 years – There is little dentition to immobilize the mandible

2 to 4 years – The deciduous teeth can provide support

5 to 8 years – The deciduous molars can be used for support

9 to 11 years – Permanent molars and incisors can be used for support

>11 years – The dentition supports fixation

In most pediatric cases, closed reduction is preferred over open reduction to avoid formation of growth-inhibiting scar tissue or injury to developing permanent teeth caused by fixation screws. Furthermore, placing internal fixation hardware during open reduction may require a second operation for its removal to prevent growth inhibition or migration [14].

Open reduction with internal fixation is reserved for fractures unlikely to remain stable after closed reduction and immobilization. Titanium miniplates with monocortical screws are commonly used. Resorbable plates appear to be well tolerated and effective in some settings, and they avoid the need for a second operation for hardware removal [5,17,18]. Another advantage of resorbable plates, which metal cannot provide, is that they provide adequate strength initially to permit bone healing, then decrease in strength so that there is increasing physiological force transference to the bone. External pin fixation is rarely used for pediatric mandible fractures.

By about age 11 to 12 years, most children have a nearly complete adult dentition and are approaching final mandibular growth. Mandible fractures in patients this age or older are managed more like adult injuries, although with shorter immobilization times because of the osteogenic capacity of the immature skeleton [3]. Immobilization for three to four weeks is typically sufficient to permit adequate healing [12].

Treatment of selected injuries

Unilateral condylar fractures — The management of unilateral condylar fractures varies by the presence of malocclusion:

No malocclusion – Children who have unilateral condylar fractures and no associated malocclusion are treated with analgesia, a liquid to soft diet, and observation for one to two weeks. They should have follow-up within one to two weeks; radiographs should be obtained at the time of follow-up.

Malocclusion – Children who have open bite deformities with retrusion of the mandible and limitation of movement or malocclusion are treated with 7 to 10 days of immobilization by intermaxillary fixation or maxillomandibular fixation followed by guiding elastics and movement exercises [11,19,20].

Bilateral condylar fractures — The management of bilateral condylar fractures, with or without an associated fracture of the symphysis, can be difficult. The goal of treatment is to overcome the loss of mandibular height that can cause class II dental malocclusion (eg, the mandibular molars and canines are behind the maxillary first molars and canines) or anterior open bite. In most cases, recommended treatment includes a brief 7 to 10 days of immobilization followed by elastic guidance into the desired occlusion for several weeks. Long-term follow-up is recommended, as occlusal changes can occur months or years later due to growth disturbance. When late occlusal problems develop, orthodontic management is indicated [21].

Fractures of the symphysis, body, and angle — Symphysis fractures are usually treated conservatively because of the risk of injury to unerupted tooth buds and the remodeling potential from subsequent growth. Open reduction with fixation is reserved for severely displaced or comminuted fractures [22].

Fractures of the body and angle of the mandible often are incomplete in children; occlusion and jaw movement are unaffected. These incomplete fractures are frequently treated with soft diet and analgesia for one to two weeks, but caregivers must be instructed to return immediately if a malocclusion develops. Follow-up evaluation and repeat imaging with panoramic mandible radiographs should occur within one to two weeks.

The treatment for displaced fractures of the body or angle depends upon the degree of distraction and the dentition. Intermaxillary fixation is usually adequate, but open reduction and internal fixation may be necessary. Miniplates or microplates that are necessary for intermaxillary fixation should be placed on the inferior border of the mandible, as far away from the unerupted tooth buds as possible [22].

Dental injuries — Dental avulsion, fracture, and/or intrusion commonly accompany mandibular fractures. An overview of the clinical findings and treatment is provided separately (table 3). (See "Evaluation and management of dental injuries in children".)

Wound management — Facial and intraoral wounds require debridement, irrigation, and, depending upon size, closure. Management of facial and intraoral wounds is discussed separately. (See "Assessment and management of facial lacerations" and "Assessment and management of lip lacerations" and "Evaluation and repair of tongue lacerations".)

Tetanus prophylaxis — Tetanus prophylaxis should be provided for all wounds as indicated (table 4).

Antibiotic prophylaxis — Patients who have open mandibular fractures, dental injuries, and multiple trauma with higher injury severity are at increased risk for developing surgical site infections after open reduction and internal fixation and may receive preoperative antibiotic prophylaxis selected to cover oral flora (eg, penicillin, amoxicillin, cephalexin, or in penicillin-allergic patients, clindamycin) [23]. Observational evidence does not suggest additional benefit from postoperative antibiotic prophylaxis.

With respect to patients with mandibular fractures and associated lacerations, antibiotic prophylaxis is also suggested for through-and-through lip lacerations. Although evidence is lacking to suggest antibiotics prevent infection in patients with intraoral and tongue lacerations, many experts also routinely provide prophylaxis for these patients. (See "Assessment and management of lip lacerations", section on 'Prophylactic antibiotics' and "Evaluation and repair of tongue lacerations", section on 'Complications'.)

Evidence does not support the use of antibiotic prophylaxis for clean facial or lip lacerations that do not involve mucosal surfaces. (See "Assessment and management of facial lacerations", section on 'Prophylactic antibiotics'.)

COMPLICATIONS — The complications of mandibular fractures include growth disturbance with facial asymmetry, malocclusion, poor mastication osteomyelitis, tooth bud damage, temporomandibular joint dysfunction, salivary disorders, obstructive sleep apnea, and chronic pain [24]. Nonunion occurs rarely [16,25]. Open reduction is a risk for tooth bud damage.

Condylar fracture may disturb mandibular growth and cause facial asymmetry [26]. Pediatric patients with condylar fractures complicated by additional arch fractures or temporomandibular joint dislocation are at especially high risk for these complications [26-28]. Thus, all children with condylar fractures, and particularly those who fracture the condyle before they reach five years of age, should have long-term follow-up with a plastic or oral-maxillofacial surgeon [11]. Follow-up should begin within one week of the injury and continue yearly until the mandible has completed growth.

Temporomandibular joint ankylosis, a bony fusion of the joint causing severe trismus, complicates condyle fractures within the joint itself [29]. Ankylosis may cause facial asymmetry in the growing child if it is not surgically corrected in a timely fashion [12]. Even after surgical correction, control of growth in the reconstructed ramus/condyle unit may be unpredictable [19].

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of acute fracture management".)

(See "General principles of definitive fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Acute pain management" and "Society guideline links: Pediatric trauma".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Facial fractures (The Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Common mechanisms of injury for mandibular fractures include a fall onto the chin, direct blow to the jaw (eg, assault or recreational injury), or facial trauma sustained during a motor vehicle collision. Child abuse is an important consideration in children younger than one year of age or when the injury does not match the reported mechanism. (See 'Epidemiology' above and 'Clinical features' above.)

Clinical manifestations – Clinical manifestations of mandibular fractures include (see 'Clinical features' above):

Facial swelling

Jaw or temporomandibular tenderness and swelling over the fracture site

Ecchymoses

New malocclusion

Chin lacerations

Inability to bite down and hold a tongue depressor with the teeth

Deviation of the chin to the fractured side (condylar fracture)

Gross malalignment or mobility of mandibular segments

Posterior mandibular displacement in patients with bilateral fractures

Tooth fracture

Mucosal or gingival lacerations

Initial stabilization – Children with mandibular fractures in association with high-force multiple trauma should undergo initial stabilization according to the principles of Advanced Trauma Life Support (table 1). Maintaining the airway in a multiple trauma patient with mandibular fracture can pose significant challenges. Essential actions include:

Cervical spine motion restriction as indicated

Suctioning of intraoral blood, secretions, teeth, and bone fragments

Control of intraoral bleeding

For patients with heavy intraoral bleeding, large intraoral hematoma, or hematoma extending into the neck, an emergency call to an anesthesiologist and otolaryngologist to assist with securing the airway.

During airway assessment, avulsed, very loose, or dangling teeth should be removed. Once the patient is stabilized, permanent teeth should be reimplanted (table 2). (See 'Initial stabilization' above.)

Diagnosis and imaging – Mandibular fractures are diagnosed by appropriate imaging obtained based upon suggestive findings on physical examination. All patients with a suspected mandibular fracture warrant multidetector computed tomography (CT) of the facial bones and mandible. Three-dimensional reconstruction is also desirable if midface injury is suspected. When available and when the patient is cooperative, panoramic radiographs in addition to CT are often helpful to identify associated dental fractures. Cervical spine injury must be excluded prior to imaging because this study requires that the child be seated in a steady upright position. (See 'Imaging' above and 'Diagnosis' above.)

Associated injuries – Mandibular fractures are commonly associated with chin lacerations, dental avulsion or fractures, temporomandibular joint dislocation, and/or facial fractures. Multiple trauma patients with mandibular fractures frequently have associated facial, intracranial, and cervical spine injury. (See 'Diagnosis' above and 'Differential diagnosis' above.)

Indications for specialty consultation – All children with mandibular fractures warrant evaluation and treatment by an oral and maxillofacial surgeon or dentist with pediatric expertise. Rapid healing may cause malunion if stabilization is delayed beyond five days. Thus, timely specialist consultation and referral are imperative. (See 'Indications for specialty consultation or referral' above and 'General principles' above.)

Management – Specific treatment depends upon the patient's age, location and mobility of the fracture, dental development, presence of concomitant injuries, patient and family adherence, and experience and judgement of the treating surgeon (see 'General principles' above):

Incomplete or nondisplaced fractures may be managed with a period of soft diet, especially in very young patients. Children with early mixed dentition and minimal occlusal changes may also be treated this way, or with a short period (two to three weeks) of elastic occlusal control. Elastic control is placed using one of several dental wiring techniques, depending upon the dental development and stable anchorage available.

More severely displaced, freely mobile, or multiple mandible fractures may require immobilization, typically by maxillomandibular fixation using arch bars or other dental wiring techniques. Elastic fixation between the arches may achieve comparable results to wire fixation, with fewer risks. Successful immobilization with maxillomandibular fixation requires teeth that are firmly supported in the alveolar bone.

In most pediatric cases, closed reduction is preferred over open reduction to avoid formation of growth-inhibiting scar tissue or injury to developing permanent teeth caused by fixation screws. Open reduction with internal fixation is reserved for fractures unlikely to remain stable after closed reduction and immobilization.

Treatment of selected mandibular injuries is provided above. (See 'Treatment of selected injuries' above.)

Associated dental fractures – Dental avulsion, fracture, and/or intrusion commonly accompany mandibular fractures. An overview of the clinical findings and treatment are provided separately (table 3). (See "Evaluation and management of dental injuries in children".)

Wound management – Minor wounds that require closure frequently accompany mandibular fractures. Tetanus prophylaxis should be provided for all wounds as indicated (table 4). The use of prophylactic antibiotics depends upon the location of the wound. Patients with mandibular fractures that require open reduction and internal fixation should receive antibiotic prophylaxis selected to cover oral flora (eg, penicillin, amoxicillin, cephalexin, or in penicillin-allergic patients, clindamycin). (See 'Wound management' above and 'Tetanus prophylaxis' above and 'Antibiotic prophylaxis' above.)

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References

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