ORIGINAL ARTICLE

Pediatric Mandibular Fractures

A Free Hand Technique
Steven P. Davison, DDS, MD; Matthew S. Clifton, MD; M. Nora Davison, PA-C;
Marc Hedrick, MD; George Sotereanos, DMD

Background: The treatment of pediatric mandibular
fractures is rare, controversial, and complicated by
mixed dentition.
Objectives: To determine if open mandibular fracture
repair with intraoral and extraoral rigid plate place-
ment, after free hand occlusal and bone reduction, with-
out intermaxillary fixation (IMF), is appropriate and to
discuss postoperative advantages, namely, maximal early
return of function and minimal oral hygiene issues.
Patients: A group of 29 pediatric patients with a man-
dibular fracture were examined. Twenty pediatric pa-
tients (13 males and 7 females) with a mean age of 9 years
(age range, 1-17 years) were treated using IMF. All pa-
tients were treated by the same surgeon (G.S.).
Results: Surgical time for plating was reduced by 1 hour,
the average time to place patients in IMF. The patients
who underwent open reduction internal fixation with-
out IMF ate a soft mechanical diet by postoperative day
3 compared with postoperative day 16 for those who un-
derwent IMF. Complication rates related to fixation tech-
nique were comparable at 20% for those who did not un-
dergo IMF and 33% for those who did.
Conclusions: We believe that free hand reduction is a
valuable technique to reduce operative time for pediat-
ric mandibular fractures. It maximizes return to func-
tion while minimizing the oral hygiene issues and hard-
ware removal of intermaxillary function.
Arch Facial Plast Surg. 2001;3:185-189

From the Divisions of Plastic
Surgery, Georgetown
University Medical Center,
Washington, DC (Drs Davison
and Clifton and Ms Davison),
and Surgery, University of
Pittsburgh, Pittsburgh, Pa
(Drs Hedrick and Sotereanos).
P
EDIATRIC mandibular frac-
tures are rare and their treat-
ment controversial. Manage-
ment is complicated by
mixed dentition that is in-
herently dynamic and unstable. In re-
ports of large case series of maxillofacial
trauma, children younger than 6 years con-
stitute 1% of the fractures.1,2 The inci-
dence of pediatric mandibular fractures in-
creases to 5% at the ages 6 years or older;
this is because the relative size of the cra-
nium decreases.3 As the pediatric man-
dible is more malleable, a fracture in-
volves significant force, with motor vehicle
injuries consistently being the most fre-
quent mechanism of injury.3-5
See Editorial Comment
at end of article
The ideal treatment approach is un-
clear as the number of patients to study are
few and follow-up study difficult because
it disturbs growth. Treatment options in-
clude soft diet, intermaxillary fixation (IMF)
with eyelet wires, arch bars, circumman-
dibular wiring, or stents. Alternative op-
tions include open reduction and internal
fixation through either an intraoral or ex-
traoral approach. Isolated condyle frac-
tures have been successfully treated with
closed functional therapy.6,7 The closed
treatment of ramus, body, and symphysis
fractures may require extended periods of
IMF from 3 to 5 weeks8-10; however, un-
recognized and untreated fractures can lead
to increased rates of orthodontic and cra-
niofacial surgery for facial asymmetry.11
To improve postoperative occlusion
results with IMF in an inherently un-
stable dentition, suspended circumman-
dibular wire fixation was devised.12 To re-
duce the length of IMF, it has been
combined with miniplate osteosynthetic
open reduction internal fixation (ORIF).2
Two recent large case series by Norholt et
al6 and Posnick et al3 have treated up to
65% of noncondylar fractures with ORIF
because of multiple concomitant fracture
sites. Those techniques still require ini-
tial fracture reduction with IMF that may
be retained as a tension band.2,13 Studies
performed on the adult population have
shown that a reduction in operative time
can be attained using a free hand tech-

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PATIENTS AND METHODS
A retrospective review of oromaxillofacial trauma
treated at a tertiary care pediatric hospital from Janu-
ary 18, 1992, to March 31, 1997, identified 39 mixed
dentition pediatric mandibular fractures. Twenty pe-
diatric patients (13 males and 7 females) with a mean
age of 9 years (age range, 1-17 years) were treated
with ORIF after the mandibles were reduced and sta-
bilized with a bimanual technique without IMF. These
were compared with 9 patients treated with IMF. All
patients were treated by one of us (G.S.).
Diagnostic data were collected from hospital
medical records, operative and dietary notes, and ra-
diographic studies (including panoramic tomogram
[Panorex] and computed tomographic scans). Clini-
cal follow-up was recorded from office notes, pan-
oramic tomograms, and clinical examination. All pa-
tients and their families were surveyed by telephone
using a questionnaire on function modified from
Norholt et al.6
The anatomical site of the mandibular fracture
was identified, the surgical approach documented, and
the number and type of plate were recorded. The sur-
geon’s operative time for comparison with a sample-
matched group treated with IMF was isolated. Post-
operative clinical examination noted occlusion,
malocclusion, masticatory function, oral opening,
tooth loss or damage related to plate placement, and
facial growth retardation. The treated fractures were
separated into those whose fractures were reduced
with a free hand and bimanual technique or IMF pre-
operatively, intraoperatively, or postoperatively.
nique in the absence of IMF, with no increase in occlusal
discrepancies.14
We describe a technique of internal fixation in the
pediatric population, after free hand occlusal and bone
reduction without IMF. It emphasizes bone reduction un-
der direct vision while eliminating the time and diffi-
culty of applying IMF to an unstable dentition. We docu-
ment the efficacy, efficiency, and complication of this
technique and compare it with a group of patients treated
with IMF. The purpose of this study was to illustrate the
reduction in surgical time by eliminating concurrent IMF
and to discuss postoperative advantages, namely, maxi-
mal early return of function and minimal oral hygiene
issues.
SURGICAL TECHNIQUE
The distinguishing difference in the free hand tech-
nique is the emphasis on bone reduction. Adequate ex-
posure via an intraoral or extraoral approach is accom-
plished and the fracture site prepared for the insertion
of a plate, wires, or lag screws. An assistant, positioned
cephalad, bimanually manipulates the dentition into the
patient’s centric occlusion. Under direct vision, the bone
edges are manipulated into the ideal position, tripoding
the fracture with the occlusion. The fractures are then
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fixated with plates, wires, lag screws, or a combination
of these, focusing on bone reduction. The technique uses
no intraoperative or postoperative IMF (Figure 1).
RESULTS
A total of 39 fracture sites in 20 pediatric patients (13
males and 7 females) were treated with a free hand tech-
nique. These patients had a mean age of 9 years (age range,
1-17 years). The mechanism of injury was motor vehicle/
all-terrain vehicle crash in 9 patients (45%), playing sports
in 8 patients (40%), assault or abuse in 2 patients (10%),
and fall in 1 patient (5%). The surgical approach for place-
ment of a total of 45 plates was intraoral in 11 patients
(55%), extraoral in 7 patients (35%), or combined in 2
patients (10%).
The site of fracture was parasymphyseal in 8 (41%)
of 20 patients or condylar or subcondylar in 9 patients
(43%). The body and ramus constituted the fracture sites
in 3 patients (16%). Surgical time for plating averaged
21⁄2 hours. The average time for the placement of the IMF
alone was 1 hour.
Functional results were reviewed at an average of
19 months’ follow-up (Table 1). Complications were
also listed (Table 2). Complications were considered
to be related to reduction techniques either free hand or
IMF when they affected occlusion, trismus, or function.
In the free hand group 4 complications in 3 patients were
related to the reduction technique. In the group who un-
derwent IMF, 3 complications in 3 patients were related
to the reduction technique.
Cephalometric and panographic examination re-
vealed no facial growth disturbance or asymmetry. Four
patients underwent elective plate removal to avoid fa-
cial growth retardation or plate exposure for a total pa-
tient reoperation ratio of 7:20 (35%). Of the patients
treated with IMF, 6 (67%) of 9 needed general anaes-
thetic and reoperation to remove arch bars.
COMMENT
Many factors complicate the management of pediatric
mixed-dentition mandibular fractures: tooth eruption,
short roots, developing tooth buds, and growth issues.
One major factor is the inherent instability of the occlu-
sion in the mixed deciduous-permanent tooth phase.
These fractures are rare and a vast treatment experience
is hard to gather. Because there are no controlled stud-
ies, there is a lack of agreement in the ideal treatment.
There are 2 philosophical approaches to management.
One is conservative therapy with soft diet, and/or mini-
mal functional IMF.2,13 This relies on the plasticity of the
pediatric occlusion. The second approach, used in more
complex fracture patterns1,4 in both the very young and
the more adult patient, uses techniques standard to adult
management. This includes rigid IMF and ORIF. Our tech-
nique, a free hand occlusal and bone reduction without
IMF, is discussed as it combines the benefits of ORIF (early
motion, rapid advancement of mastication, and hy-
giene) with the advantage of a malleable dentition.
The descriptive portion of this study mirrors find-
ings found in other large case series.1,3,6,10 Pediatric man-
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 A B

C D

Figure 1. A, Intraoperative bony stabilization using a bimanual technique. B, Bimanual reduction to establish clinical occlusion. C, Emphasis on bony reduction
rather than occlusal reduction in this pediatric population with unstable dentition. D, Bony fixation with open reduction internal fixation of the bone.

Table 1. Time Elapsed for Return Table 2. Complications Associated

of Dental and Hygiene Function* With Open Technique vs Closed Technique*

Function Free Hand Technique, d IMF Technique, d
Liquids 1.2 1
Soft diet 3 16
Hygiene 3 18
*Free hand technique indicates occlusal and bone reduction without
intermaxillary fixation (IMF); IMF technique, IMF with arch bars,
circummandibular or eyelet wires, or stents.
dibular fractures require significant force to occur. Mo-
tor vehicle injuries are the most common causes, followed
by high-velocity sports injuries, although in Europe a re-
cent study found falls a greater problem, reflecting cul-
tural differences.13 Children riding all-terrain vehicles are
also at high risk of mandibular fractures; these fractures
(3 of 20 patients) were associated with the most severe
upper facial and cranium fractures. A recent treatise
emphasizes the risks to the craniofacial skelton in all-
terrain vehicle use.
The pediatric mandibular fractures in this case se-
ries were seen at the parasymphyseal and condylar or
subcondylar region. A common combination was the
parasymphyseal and condylar fracture.15 This is differ-
ent from the pattern of parasymphyseal and angle frac-
tures seen in adults. The controversy of open treatment
vs closed treatment of pediatric mandibular fractures
remains. However, the recent literature2,3,15,16 shows a
Free Hand Technique IMF Technique
Complication (n = 20) (n = 9)
Malocclusion 1 2
Trismus 1 1
Mastication 2 0
Reoperation 7 6
*Free hand technique indicates occlusal and bone reduction without
intermaxillary fixation (IMF); IMF technique, with arch bars,
circummandibular or eyelet wires, or stents. All data given as number
of patients.
change in using ORIF in fracture stablilization. The
risks of facial growth disturbance in ORIF has not been
supported.6 In contrast, no treatment in unrecognized
mandibular fractures leads to a high incidence of or-
thognathic surgery and craniofacial treatment.11 The
potential damage to tooth roots17 and follicles can be
minimized with a careful technique, which places bi-
cortical screws in the lower mandibular border with
monocortical screws placed in more superior plates
(Figure 2). This case series of patients with limited
(19-month) follow-up showed no facial growth or
tooth eruption problems. The most significant compli-
cation was a traction injury of the facial nerve in 1 pa-
tient who had a subcondylar fracture that subsequently
improved with aggressive therapy. After primary repair

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Figure 2. Monocortical screw placement above the tooth roots.
B technique without the disadvantages of a closed tech-
Figure 3. Radiographic view of open reduction internal fixation without
intermaxillary fixation (A) and with intermaxillary fixation (B).
and aggressive physical therapy, this patient’s condition
improved to a grade IV/VI Glasgow scale score for facial
motion.
Our free hand technique concentrates on the re-
duction of the bony fragments under ideal visualization
to achieve less than 1 mm of gapping. The occlusion is
held in place manually. This relies on experienced as-
sistance, but there is also the fact that in children small
occlusal discrepancies will be rapidly compensated for
by the plasticity of the mixed dentition and future erup-
tion patterns. A large case series by Fordyce et al14 has
already established that the use of anatomical reduction
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Figure 4. Fixed braces make ideal intermaxillary fixation while requiring no
additional surgical time.
Figure 5. Example of a bilateral parasymphyseal fracture in an adolescent
patient with horizontal separation of the alveolar bone off the basilar bone.
This reduction requires intermaxillary fixation.
over IMF requires less intraoperative time with no long-
term increase in malocclusion in the adult population.
Our technique maximizes the advantages of an ORIF
nique with IMF because it eliminates 1 hour of surgical
time and additional general anaesthetic for obtaining
impressions18 or IMF removal. One case series of IMF/
ORIF treatment required a 6% reoperation rate to revise
IMF.15 This series illustrates that in pediatric patients
the reoperative rate is much higher (66%) with IMF. Pe-
diatric patients are less able to tolerate removal of IMF
in the physician’s office. This rate was higher for the 7
of 20 patients who were reoperated on in the free hand
group for any reason, infection, scar revision, or plate
removal (Figure 3). One clinical caveat is that which
occurs when patients already have existing orthodontic
devices in place. Fixed braces make ideal rapid IMF,
and removable appliances and expanders function as
tension bands (Figure 4).
In addition, the patients who were treated using the
free hand technique quickly return to functional masti-
cation. Drinking liquids was delayed by 0.2 days com-
pared with IMF secondary to surgical pain and swell-
ing. However, the patients who underwent the free hand
technique ate a soft diet and performed oral hygiene at 3
days which was 13 and 15 days, respectively, earlier than
those who underwent IMF. This has implication for nor-
mal condylar growth and normal joint function. The re-
sults of condylar function have been improved with early
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 motion.18 When the free hand technique is compared with
IMF, the rate of mastication or occlusion difficulties was
similar. This is important as an ORIF was used in a more
severely injured group.
This study was not a comparison between open and
closed techniques, but rather between free hand fixa-
tion and IMF. The group who were treated with IMF in-
cluded patients treated with ORIF. The group with free
hand ORIF had complications not directly related to re-
duction, including scar formation, postoperative infec-
tion, and nerve injury. In the free hand group, 5 com-
plications were in 2 patients with multiple associated
midfacial or basilar skull injuries. This may suggest that
they were better candidates for IMF with ORIF or would
have had complications regardless of fixation modality.
The free hand technique is best suited to surgeons
experienced in working with the facial skeleton and re-
quires the presence of appropriately skilled assistants since
there is potential for the incorporation of occlusal discrep-
ancy in unskilled hands. However, the plasticity of the pe-
diatric occlusion and dentofacial architecture reduces this
risk. Some fracture patterns are not ideal for this bi-
manual technique, such as horizontally unfavorable frac-
tures that tip the alveolar bone lingually off the basilar bone
(Figure 5). Often, a lingual acrylic splint is needed to
maintain arch contour in these situations. Fortunately, this
fracture pattern is not often seen in children. Although this
technique reduces operative time, cost, and reoperation
to remove IMF, it is not easier than placing arch bars, and
in certain circumstances requires more skill and experi-
ence. A notable improvement in eating a soft diet and tooth
brushing and oral hygiene, particularly on the lingual tooth
surface, is quickly appreciated.
CONCLUSIONS
We describe a technique for free hand occlusal and bone
reduction without IMF in pediatric patients with mixed-
dentition mandibular fractures. When an open tech-
nique is used for reduction, it emphasizes the bony re-
duction relying on the plasticity of pediatric occlusion. This
free hand technique reduces surgical time by 1 hour and
accelerates soft diet intake and oral hygiene capability by
2 weeks when compared with techniques that incorpo-
rate IMF. This technique can be successfully used when
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dentition has not yet erupted or is in a mixed phase and
poorly able to support IMF. It does, however, require pro-
viding skilled assistance to the primary surgeon and as such
is more applicable to a tertiary care center.
Accepted for publication February 8, 2001.
Corresponding author and reprints: Steven P. Davi-
son, DDS, MD, Division of Plastic Surgery, Georgetown Uni-
versity Medical Center, 3800 Reservoir Rd NW, Washing-
ton, DC 20007.
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