CME

The Pediatric Mandible: II. Management of

Traumatic Injury or Fracture
James M. Smartt, Jr., M.A., M.D., David W. Low, M.D., and Scott P. Bartlett, M.D.
Philadelphia, Pa.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the changing epidemiology
of mandibular fractures in children and adolescents. 2. Discuss the appropriate use of internal fixation in the treatment
of pediatric mandibular fractures. 3. Describe the difficulties posed by the deciduous dentition in the use of interdental
wiring. 4. Understand reasons why techniques specific to adult fractures may not be applicable to the growing mandible.
5. Understand the etiology and epidemiology of pediatric mandibular fractures. 6. Understand the reasons for conser-
vative (closed) versus aggressive (open) treatment of mandibular injury.

Management of pediatric mandibular frac-

Background: Fractures of the pediatric
mandible are complicated by the anatomic
complexity of the developing mandible, par-
ticularly by the presence of tooth buds and
the eruption of deciduous and permanent
teeth. Traditional methods of fracture reduc-
tion and fixation employed in adults have
little applicability in the pediatric population.
Methods: The authors describe the surgical
techniques that have been used at their in-
stitution and those that can be used safely in
the pediatric setting.
Results: In most cases, “conservative” man-
agement is the preferred option, especially in
the treatment of condylar fractures. In cases
requiring surgical intervention, interdental
wiring, drop wires in combination with cir-
cummandibular wires, and acrylic splints are
suited well to specific phases of dental mat-
uration.
Conclusion: Open reduction and internal
fixation using monocortical screws and mi-
croplates or resorbable plates and screws are
acceptable techniques in the pediatric pa-
tient, but they require special safeguards. Al-
gorithms are presented to simplify manage-
ment of these complicated injuries. (Plast.
Reconstr. Surg. 116: 28e, 2005.)
tures is predicated upon an understanding of
the developmental anatomy of the lower jaw.
This information was presented in Part I
of this article in the July 2005 issue of this
Journal. We apply this knowledge to the de-
velopment of specific age-dependent treat-
ment protocols.
EPIDEMIOLOGY, ETIOLOGY, AND DISTRIBUTION
The distribution of fracture patterns at vari-
ous stages of development follows logically
from an understanding of mandibular anato-
my.1 While, for the majority of childhood, the
mandible is small compared with the rapidly
growing neurocranium, its undeveloped struc-
ture makes it vulnerable to a variety of insults.
Given the protected environment provided
most children during early life, it is not surpris-
ing that fractures of the mandible comprise a
small percentage of facial trauma as a whole.
Most series report the incidence of pediatric
facial fractures as 1 to 15 percent of all facial
fractures occurring in adults and children.2– 8
However, within the pediatric subpopulation,
mandibular fractures are relatively prominent.
The majority of large series of pediatric pa-
tients report the incidence of mandibular frac-
tures at approximately 20 to 50 percent of all

From the Division of Plastic Surgery, Department of Surgery. The University of Pennsylvania Medical Center, The Children’s Hospital of
Philadelphia, and the Edwin and Fannie Gray Hall Center for Human Appearance. Received for publication May 28, 2004; revised December 10, 2004.
DOI: 10.1097/01.prs.0000173445.10908.f8
28e
Vol. 116, No. 2 / THE PEDIATRIC MANDIBLE
childhood facial fractures.9 –11 Earlier studies by
McCoy et al. and Hall found the incidence of
mandibular fractures to be 20.7 to 40.8 percent
of all pediatric facial fractures.10,12 Later studies
by Posnick et al. and Tanaka et al. largely have
confirmed these earlier studies with rates of 34
and 46.9 percent, respectively.2,13 In all studies,
fractures of the mandible are more common in
boys and increase in frequency until they reach
15 years of age.2,5,13
The mechanisms of injury vary from series to
series, with motor vehicle accidents, falls, and
sports-related injuries contributing significant-
ly.5,11,13–15 In a series of 81 patients reviewed by
Posnick et al., motor vehicle accidents ac-
counted for 50 percent of all mandibular frac-
tures, with falls (23 percent) and sports-related
injuries (15 percent) accounting for the major-
ity of the remaining fractures.2 Siegel et al.,
reporting on a series from our institution,
found altercations to be the most common
cause of injury (35 percent), along with motor
vehicle accidents (28 percent), bicycle acci-
dents (12 percent), and falls (7 percent).5 In
most series, the proportion of injuries attribut-
able to altercations and sports-related injuries
increased with age. Strikingly, a large propor-
tion of patients with mandibular fractures (30
to 60 percent) also experience a serious asso-
ciated intra-abdominal, neurocranial or ortho-
pedic injury—attesting to the force required to
effect such injuries.9,11,16
Fracture patterns also vary with age. Multiple
studies in pediatric patients have found that the
incidence of condylar fractures is initially high
and decreases with age. Conversely, fractures of
the body and angle are initially infrequent, but
increase with age.5,8,17 Pediatric patients are more
likely than adults to sustain greenstick or incom-
plete fractures. This is because of the relatively
high elasticity of the mandible’s thin cortical
bone and thick surrounding layer of adipose tis-
sue. Furthermore, because of the presence of
tooth buds and developing crypts, pediatric frac-
tures are often long and irregular in character,
with the fracture generally running inferiorly
and anteriorly.12 Pediatric fractures are less likely
to have multiple comminutions compared with
those in adults.
SPECIAL CONSIDERATIONS IN THE MANAGEMENT OF
PEDIATRIC MANDIBULAR FRACTURES
The anatomical complexity of the develop-
ing mandible, and concerns regarding the bio-
compatibility of implanted hardware, often
29e
mandate the use of surgical techniques that
differ markedly from those used in adults.
While anatomic reduction utilizing wide expo-
sure and rigid internal fixation has been the
standard of care in adults for a long time, this
method of treatment is seldom useful in chil-
dren. In fact, given the pediatric skeleton’s
capacity for remodeling and the high inci-
dence of minimally displaced or greenstick
fractures, conservative therapy alone often is
effective.8,16,18 Clinical evidence suggests that
many fractures in children remodel with little
or no intervention.19 –21 This is especially true of
the many minimally displaced greenstick frac-
tures of the condylar necks that occur early in
childhood. Consequently, a decision to under-
take surgical reduction of a mandibular frac-
ture can only be made after having assessed the
age of the patient and the severity of the frac-
ture.
When surgical management is indicated, a
few basic guidelines are likely to make therapy
more efficacious. First, the least possible
amount of the fracture site should be exposed
during treatment. Recent evidence suggests
that soft-tissue undermining incurred during
surgery can adversely affect craniofacial
growth.22,23 These studies reaffirm Moss’s orig-
inal assertion regarding the importance of the
“functional matrix” in normal growth.24 De-
spite these findings, however, it has been noted
that patients undergoing extensive craniofacial
reconstruction for simple suture synostosis
seem to attain relatively normal growth param-
eters.25 While conflicting reports exist, a more
conservative approach to manipulation of the
periosteum and its muscular attachments
seems warranted until definitive evidence is
available.
Finally, the pediatric dentition presents a
formidable challenge to traditional surgical
techniques. Arch bars used for intermaxillary
fixation in adults may be of little value in the
pediatric patient as the primary teeth and par-
tially erupted secondary teeth are not a suffi-
ciently stable foundation. In fact, the pressure
exerted in intermaxillary fixation may avulse
the primary teeth. The conical shape of the
primary teeth, with their wide cervical margins
and tapered occlusal surface, makes the place-
ment of eyelet wires or arch bars technically
challenging. Some authors have indicated that
intermaxillary fixation using arch bars is safe in
younger children, especially those older than
9.16,26,27 Other studies have used “mini arch
30e
bars,” which exert less strain on the developing
teeth.28 In our experience, intermaxillary fixa-
tion with arch bars can only safely be used in
patients older than 11 whose permanent den-
tition has been able to form adequate roots.29
Before this age, one may utilize interdental
wiring techniques, such as the use of eyelet
wires. These techniques take advantage of in-
dividualized tooth anatomy, and, when wired
to an adjacent tooth, are less prone to avulsion
or tearing of the periodontal ligament.
The presence of tooth buds in the pediatric
mandible further complicates treatment. As
discussed earlier, during the majority of child-
hood, tooth buds nearly approximate the infe-
rior border of the mandible. Previous reports
suggest that tooth damage and pulp oblitera-
tion are not uncommon at mandibular frac-
ture sites.30 Disruption of these tooth buds, or
the developing teeth, with any form of internal
stabilization can result in maldevelopment of
permanent teeth.31,32 Consequently, if internal
fixation is used, the surgeon must be careful to
avoid the developing structures. Débridement
and manipulation of tooth fragments and bone
chips also should be kept to a minimum.
Despite these concerns, a few characteristics
of the developing craniofacial skeleton make
therapy somewhat easier in children than in
adults. Given the high metabolic rate of most
developing tissues and the increased osteo-
genic capacity of the periosteum, rates of heal-
ing are much higher in children. As a result,
for even complex mandibular fractures, 2 to 3
weeks of immobilization may be all that is re-
quired for union.18 This tenet holds true for
nearly any form of surgical therapy that might
be used. Fibrous union during the healing pro-
cess is very uncommon and excellent remodel-
ing of fracture sites is standard. This remains
true even in the setting of masticatory stresses
and imperfect apposition of the bone surfaces.
Consequently, a much greater degree of toler-
ance is allowed in the alignment of bone frag-
ments and the restoration of occlusion than in
the treatment of adults.33
NONSURGICAL TREATMENT STRATEGIES
The first question that must be answered in
the treatment of any child’s fracture is whether
or not to undertake surgical intervention. As
discussed previously, the ability of the develop-
ing facial skeleton to remodel to normal pro-
portions in the absence of treatment has been
observed both clinically and experimental-
PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005
ly.19,20,34 Conservative management has many
advantages, including a decreased immobiliza-
tion time, decreased muscular atrophy, better
oral hygiene, and a decreased risk of anky-
losis.35 This is especially true of condylar frac-
tures and nondisplaced or greenstick fractures
of the body and ramus in which normal occlu-
sion is present following injury.36,37 While the
literature on condylar fractures suggests that
affected children may have an increased risk of
growth disturbances, no particular surgical
therapy has been demonstrated to be more or
less efficacious in preventing these prob-
lems.19,38 Conservative management is further
supported by clinical and experimental evi-
dence that documents the uncomplicated heal-
ing of various mandibular fractures, including
those of the condyles.6,7,9,13,39 In our experi-
ence, conservative management of intracapsu-
lar condylar fractures, high fractures of the
condylar neck, and coronoid fractures is war-
ranted when the occlusion is normal and no
barriers to movement exist.40,41
However, in the case of fractures low in the
condylar neck with significant displacement,
open reduction and internal fixation should
definitely be considered— especially in chil-
dren more than 9 years of age. Fractures of the
body and angle may be treated conservatively
when displacement is minimal and the patient
is without functional deficits or malocclusion.
After a proper radiological assessment (includ-
ing Panorex films and/or axial and coronal
computed tomography scans) and physical ex-
amination for normal occlusion, the imposi-
tion of a soft diet, rigorous physiotherapy,
avoidance of rigorous physical contact, and
symptomatic pain control may be an adequate
treatment plan for a wide variety of mandibular
fractures. Nonetheless, as the literature on pe-
diatric condylar fractures attests, the effect of
fractures on growth is unpredictable, making
long-term follow-up essential.38,42
SURGICAL MANAGEMENT
Interdental Wiring
In many cases, the use of interdental wiring
is a relatively noninvasive and safe method of
fracture reduction. Through this method,
wires are placed around the cervical margins of
stable teeth on either side of the fracture site.
These wires may be attached to individual
teeth or looped around a series of teeth in a
bridle wire fashion. In either case, a pre-
Vol. 116, No. 2 / THE PEDIATRIC MANDIBLE
stretched, 15-cm-long, 26-gauge, soft stainless
steel wire can be used. After placement, the
wire is tightened around the neck of the tooth
through twisting. In the case of interdental
wiring of individual teeth, a 3-cm tail should be
left so as to facilitate connections with adjoin-
ing structures (Fig. 1). When bridle wires are
used, shorter tails may be utilized, as they are
rarely attached to other structures at the tail
itself. To avoid soft-tissue trauma, the cut ends
of any tails should be bent into the interdental
spaces. The wires should be left in place for 2
to 3 weeks and can sometimes be removed in
the office, without the need for general anes-
thesia.
The benefits of these methods are not uni-
versal. Sufficient reduction using these tech-
niques presupposes the presence of stable den-
tition, preferably of permanent teeth. As a
consequence, this method is often not a viable
option in children younger than 3 years of age.
FIG. 1. Interdental Wiring. (Above) Bridle wires around
multiple teeth. Note the placement of the wire near or at the
gumline to ensure good purchase on the deciduous teeth.
(Below) The use of wiring around individual teeth. These
individual wires can be connected to one another to form a
system of interdental stabilization.
31e
Between the ages of 3 and 12, it can be appli-
cable, but the stability of anchoring teeth must
be checked in the operating room through
bimanual examination. For patients between
the ages of 3 and 7, the deciduous molars often
provide a stable surface for immobilization.
Between the ages of 8 and 13, the permanent
incisors and molars often can be used.16
This technique also can be problematic in
children with stable deciduous dentitions. The
shape of deciduous teeth differs markedly
from their permanent counterparts.43 The cer-
vical margins of permanent teeth are narrower
than their occlusal surface. Consequently, the
teeth provide more purchase for the place-
ment of any form of interdental wiring or in-
termaxillary fixation. The deciduous teeth
have a tapered shape that is sometimes widest
at the cervical margin. As a result, dental wires
and arch bars are often difficult to apply, and
may slip. When used, care must be taken to
place such hardware well below the gumline.
Given the large percentage of only mini-
mally displaced or greenstick fractures of the
pediatric mandible, this somewhat conservative
approach is often sufficient to provide normal
occlusal relations and anatomic reduction.
This includes many fractures of the body, es-
pecially those in the alveolar regions. In addi-
tion, interdental wiring can be used in con-
junction with any of the following techniques
to gain additional stabilization of complex or
oblique fractures.
Occlusal Splints with Circummandibular Wires
The use of occlusal splints is a versatile tech-
nique that can be used for a wide range of ages.
While the composition of these splints varies,
catalyst-activated acrylic has been the choice at
our institution because of its ease of use. Frac-
ture reduction is generally first performed bi-
manually in a closed fashion, or with a combi-
nation of interdental wiring and direct
monocortical wires at the fracture site. Splints
should be constructed so that the occlusal sur-
face makes contact with the maxilla or maxil-
lary dentition, and maintains a normal vertical
dimension. After contouring and curing in the
operating room with the patient under general
anesthesia, the splint is applied to the lower
dental arch and monomaxillary fixation
achieved using two to four circummandibular
wires (Fig. 2).40
Nishioka et al. have correctly emphasized the
careful placement of circummandibular wires
32e
FIG. 2. (Above) The application of occlusal splints using
circummandibular wires. Note the placement of circumman-
dibular wires both proximal and distal to the fracture itself.
(Below) Axial view of the occlusal splint. Care should be taken
to form the splint only after complete fracture reduction has
been achieved. Furthermore, the splint should encompass
both the lingual and buccal surfaces of the existing dentition.
Note that the use of splints such as these is possible in nearly
every stage of dental maturation and mandibular growth.
so as to avoid injury to the mental nerve.27
Wires should not be placed near the mental
foramen (under the first deciduous molar, or
first and second permanent premolars) or en-
gage the fracture line (Fig. 2). In addition, care
must be taken not to apply excessive force in
the application of these (or any) wires as they
can easily cut into the immature cortical bone.
Schweinfurth and Koltai have noted the impor-
tance of thinning the posterior portion of the
splint overlying the molars to prevent prema-
ture closure resulting in an open bite.16 The
acrylic splint should be left in place for 2 to 3
weeks and can usually be removed in the office,
or in the operating room under light sedation.
The use of splints can be particularly advan-
tageous in a few clinical situations. In patients
less than 3 years of age, with few stable dental
structures, the use of splints is encouraged. In
these cases, even markedly displaced fractures
of the body or angle can be stabilized ade-
quately with these techniques. Splints also pro-
vide an acceptable way to ensure normal occlu-
PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005
sion in the face of dental instability, especially
between the ages of 5 and 12. The use of splints
is helpful in many situations in which interden-
tal wiring is not acceptable. In addition, use of
acrylic materials circumvents the time-consum-
ing process of splint construction using plaster
casts of the upper and lower dental arches.
Splints constructed of this material can be
made in any size—a feature that can be of
particular value when inclusion of the molars is
desired. Finally, the use of monomaxillary
acrylic splints obviates the use of “Gunning-
type” splints and encourages early jaw mobili-
zation, thus further decreasing the risk of an-
kylosis. Nonetheless, despite these advantages,
splints also have drawbacks that make their use
difficult for some practitioners. The creation of
splints often increases operative time, and may
not be appropriate in the presence of maxillary
fractures. Splints often are unnecessary in com-
plex fractures in which some form of internal
fixation is used. In such cases, intermaxillary
fixation can be provided through the use of
suspensory wires attached to the piriform ap-
erture in combination with an intermediate
connecting wire.
Drop Wires and Circummandibular Wires
Drop wires, or a set of superiorly anchored
wires attached at the midface, in combination
with circummandibular wiring, offer another
method of fracture reduction and fixation in
children. The literature has provided various
descriptions of drop wires, all using slightly
different techniques. Nishioka et al. advocated
the use of circummandibular, piriform rim sus-
pension, arch bars, and a bridle wire in the
treatment of isolated fractures of the mandi-
ble.27 After the initial application of a maxillary
arch bar, a bridle wire is placed to reduce the
mandibular fracture at the level of the denti-
tion and alveolar bone. A mandibular arch bar,
circummandibular wires, and drop wires sus-
pended from the lateral piriform apertures are
placed and further reduction is performed.
Fixation and normal occlusal relations are
achieved when the maxillary and mandibular
portions are connected through the use of an
intermediate wire (Fig. 3). Renner et al. used a
single drop wire suspended from the nasal
spine in combination with two circumman-
dibular wires in the treatment of pediatric
mandibular fractures.44 Unlike Nishioka, these
authors used bimanual reduction, drop wires,
and circummandibular wiring without the use
Vol. 116, No. 2 / THE PEDIATRIC MANDIBLE
FIG. 3. Intermaxillary fixation using drop wires with the
application of mini arch bars, circummandibular wires, and
an intermediate wire.
of arch bars. Lastly, Eppley has described the
use of a large, circummandibular suture in the
treatment of condylar fractures and nondis-
placed fractures of the body and angle.45
After placement of resorbable screws in each
zygomatic body, a large (2-0), nonresorbable
monofilament suture is passed around each
side of the mandible using an awl guided
through a small submandibular incision. The
suture is then tied, leaving a knot high in the
vestibule. With a cooperative patient, the su-
ture can be removed in the office setting, leav-
ing the screw to be resorbed over time.
At our institution, we have used drop wires in
combination with circummandibular wires in a
number of patients. Ideally, we prefer to sus-
pend the drop wires from the lateral piriform
aperture (Fig. 4). In patients in whom reduc-
tion can be achieved with normal occlusion, we
prefer to use the procedure without adjunctive
measures such as splints or arch bars. However,
the use of an interdental acrylic splint may be
necessary to effect proper reduction of condy-
lar fractures with occlusal deformities without
the use of intermaxillary fixation. More specif-
ically, fracture reduction is achieved in the op-
erating room using bimanual manipulation.
When possible, pre-installed orthodontic appli-
33e
FIG. 4. Drop wires using circummandibular wires, piri-
form rim suspension, and intermediate wires. (Above) The
application of circummandibular wires using an awl. To insert
the wires, a small stab incision is placed under the anterior
surface of the inferior mandibular border. (Below) Circum-
mandibular wires are then pulled around the inferior man-
dibular border and pushed superiorly through the lingual
mucosal layer of the oral cavity. The buccal and lingual ends
of the wires can then be tightened through gaps in the ex-
isting dentition. Intermediate wires of a lighter gauge are
used to ensure that wire failures can be repaired without the
need for additional invasive wiring.
ances (braces) can be used for temporary in-
termaxillary fixation to attain normal occlu-
sion.
After reduction, a small, submandibular in-
cision is made and a prestretched, 25-gauge
wire run on the lingual and buccal side of the
mandible using an awl (Fig. 4). The wires are
then tightened around the mandibular corpus,
taking care to avoid damage to the mental
nerve. The wires are tightened enough to pro-
vide proper reduction and fixation of the frac-
ture, but not so much as to damage the devel-
oping bone. Moderate tension will provide
adequate force to stabilize most fractures of the
body, even oblique fractures in which it is im-
portant to realign both the buccal and lingual
cortices. The exact number of circummandibu-
lar wires used depends on the extent of the
fracture and the number of sites involved.
Ideally, two wires should be place in the
para-symphyseal region distal to the fracture
and at least one additional wire proximal to the
34e
fracture itself. Exposure of the piriform rim is
then performed through a high vestibular in-
cision. A subperiosteal dissection is performed,
with adequate release of any attachments to
the anterior floor of the nose and nasal spine.
A transosseous hole is then created in each
piriform aperture using a 1-mm drill. A single,
26-gauge, prestretched wire is placed on each
side and twisted down on an instrument with
the distal portion of the wire extending just
through the mucosal incision. Subsequently, a
smaller, 28-gauge, intermediate wire is placed
connecting the circummandibular wires (up to
two within each intermediate wire) and those
in the piriform aperture. Using this intermedi-
ate wire, tension is increased gradually, bring-
ing both dental arches into proper occlusion
while simultaneously providing enough force
to stabilize any underlying fracture. Use of a
smaller gauge connecting wire assures that if
wire failure occurs it is usually in the connect-
ing wire itself. Therefore, if replacement is nec-
essary, it can be done without opening of the
vestibular incision or placement of additional
circummandibular wires.
The use of drop wires offers many advan-
tages not possible with other techniques. First,
the amount of operative time is significantly
decreased since the splint-making procedure is
not necessary. There also is significantly less
surgical exposure than that which accompa-
nies open reduction and internal fixation. The
risk to developing tooth buds is minimized, as
the mandible itself is never penetrated. Also,
this technique is acceptable as an adjunct for
use with other methods such as splitting, inter-
dental wiring, or the use of internal fixation. As
Nishioka et al. have indicated, this method is
often effective in oblique displaced fractures
where the fabrication of dental splints is com-
plicated by a poor fit.27 Drop wires also can be
effective in treating fractures of the condyles,
coronoid, and body. For instance, unilateral
condylar fractures with occlusal deformities
and bilateral condylar fractures with a posteri-
orly displaced open-bite deformity are two
problems that can be treated effectively using
occlusal splints such as these. When used
alone, the technique may not be appropriate
for the treatment of angle fractures in which
dentition is unavailable for proximal reduction
using circummandibular wires.
This technique also has many potential draw-
backs. The maintenance of proper occlusal re-
lations is contingent upon the presence of
PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005
some stable dentition, preferably the decidu-
ous molars or permanent teeth. In the case
where such dentition does not exist, occlusal
splinting or internal fixation is probably a bet-
ter option. This criticism applies to all of the
techniques reviewed above. The attachment of
drop wires to different locations on the mid-
face is also potentially problematic. Drop wires
should never be placed around the zygomatic
arch, as the wires will likely cut through the soft
bone.40 While Renner et al. mention the use of
their nasal spine technique in children,44 we
question the ability of this structure to support
the pressure exerted by intermaxillary fixation.
The technique may be viable in adults, but
should be applied with caution in children.
Eppley’s use of a nonresorbable suture should
be reserved primarily for patients with nondis-
placed or condylar fractures and the dental
stability to maintain proper occlusion.45 More
generally, drop wires may not be efficacious in
the treatment of fractures posterior to the den-
tition, such as fractures of the angle. Finally,
the use of drop wires requires a period of
immobilization and impairs oral hygiene.
Open Reduction and Internal Fixation
While the use of internal fixation is increas-
ingly widespread, few studies inform the prac-
titioner about its application in the treatment
of pediatric mandibular fractures. Early discus-
sions emphasized the importance of avoiding
developing dental structures, but provided few
technical details.16,46,47 While the use of open
reduction and internal fixation with and with-
out intermaxillary fixation was indicated as a
treatment modality in some publications, tech-
nical methods were not specifically ad-
dressed.2,5,6,13,48
Wong’s case description of a 5-year-old child
treated with open reduction and internal fixa-
tion and arch bars was the first discussion to
provide technical details.26 Subsequently, Davi-
son et al. were the first to undertake a larger
clinical study of internal fixation of pediatric
mandibular fractures. In their series of 29 pe-
diatric patients, the authors compared more
traditional methods of intermaxillary fixation
(using arch bars, eyelet wires, circummandibu-
lar wires, or splints) with a “free hand tech-
nique” that used open bimanual reduction and
internal fixation using a combination of plates,
wires, and screws. The authors noted numer-
ous advantages of using internal fixation with-
out intermaxillary fixation, including de-
Vol. 116, No. 2 / THE PEDIATRIC MANDIBLE 35e
creased immobilization time, quicker
resumption of a soft diet, and a quicker return
to normal dental hygiene habits. They also ob-
served similar rates of adverse events, including
malocclusion, trismus, and the need for reop-
eration.49 Hardt and Gottsauner also docu-
mented the use of internal fixation in a subset
of patients in their study of fracture treat-
ment.28 Unfortunately, while offering support
for the role of internal fixation without inter-
maxillary fixation in the treatment of children,
the articles fail to provide specific technical
details related to the use of internal fixation or
long-term follow-up regarding efficacy and
complications.
At our institution, we have found that open
reduction and internal fixation, when used ju-
diciously, are indispensable in the treatment of
specific subsets of mandibular fractures, in-
cluding displaced fractures of the body or an-
FIG. 5. Monocortical plating of the developing mandible
gle, fractures of the condylar neck with signif-
using miniplates and screws. (Above) Note the relatively su-
icant barriers to movement, complex fractures, perficial movement of the monocortical screw at the inferior
and fractures in non–toothbearing areas. In mandibular border. (Below) Again, placement of plate and
general terms, the use of internal fixation screw fixation at the inferior mandibular border. Despite the
should follow the guidelines already discussed use of these conservative fixation techniques, note the prox-
imity of the monocortical screws and the unerupted tooth
in this series. Open reduction should be per- buds.
formed cautiously, with minimal manipulation
of overlying soft tissues. When possible an in-
inferior border and developing teeth is suffi-
traoral approach should be used to minimize
ciently large.
the potential for visible scarring that can be
One exception to this rule might be symph-
significant in these cases. In addition, external
yseal fractures, in which it may be safe to use
appliances requiring skin incisions should be bicortical screws in patients older than 8. Dur-
avoided whenever possible. Given the pediatric ing the placement of screws of any type, passive
mandible’s capacity to remodel properly in the adaptation of the plate to the bony surface
face of small discrepancies in occlusion, we always should be achieved. As discussed by
believe that some fractures safely can be re- Luhr, failure to do so can result in separation
duced bimanually without intermaxillary fixa- of the cortices and spurious fracture reduction
tion. with lingual gaps.46 In addition, when fixation
Metallic internal fixation can be achieved of the superior mandibular border is required,
through the use of interosseous wiring or plate interdental wiring or splints should be used
fixation. Recent evidence suggests that soft- cautiously to avoid damage to tooth roots.
tissue undermining incurred during surgery While some authors have advocated the use of
can adversely affect craniofacial growth; there- monocortical screws above the inferior border
fore, the fracture site should only be exposed of tooth roots, we caution against their use
to the extent that exposure is required for because of the risk of damage to the develop-
treatment.22,23,50 In patients less than 9 years of ing teeth (Fig. 6).49 Furthermore, to prevent
age, plates should be placed only on the man- plate “migration” and the potential for the in-
dible’s inferior border using monocortical terference with growth, interval removal of any
screws (Fig. 5). Drill holes always should be hardware is recommended in patients less than
placed at the most inferior position and di- 10 years of age.
rected posteromedially, not superiorly. The When performed properly, open reduction
use of transosseous wiring and bicortical screws and internal fixation is probably a safe and
should be reserved for patients older than 11 versatile treatment modality. In addition to the
to 13, when the space between the mandible’s benefits outlined by Davison et al.,49 internal
36e
fixation decreases operative time, produces sta-
bilization in more complicated cases, and pro-
vides a means of fixation in non–toothbearing
areas of the mandible. Furthermore, as we have
discussed elsewhere, microplates act more to
FIG. 6. Compressive plate fixation at the inferior mandib-
ular border, though not damaging to the teeth, has contrib-
uted to eruption of a permanent canine well below the al-
veolus. (Above) Application of monocortical plate fixation to
the inferior mandibular border following fracture of the man-
dibular body. (Center) Panorex of a patient at 2-month follow-
up. (Below) Patient at 1-year follow-up.
PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005
stabilize fractures than to provide rigid internal
fixation. As such, they act more like interosse-
ous wires and should, in theory, be less likely to
adversely affect facial growth. Nonetheless, the
scale of the plates used warrants discussion.
While the biomechanical forces generated by
children during mastication are often of
smaller magnitude than those generated by
adults, we have observed clinically that chil-
dren are less apt to “test” the repair by early
chewing of hard food.51 Hence, 1.3-mm, 1.5-
mm, and 2.0-mm (midface) plates have been
utilized. We have never witnessed plate bend-
ing, fracture, or displacement. This is espe-
cially true if combined with a period of inter-
maxillary fixation. If using plates for children,
a rough guideline might include a 1.0 or 1.3
system plate in those less than 3 years of age;
1.5 system plates in patients aged 4 to 9, and
1.5 or 2.0 system plates in preadolescents and
teenagers. This recommendation is experien-
tial rather than based on experimental studies.
The use of resorbable plates also is an in-
creasingly attractive option in the treatment of
a variety of conditions affecting the pediatric
craniofacial skeleton, including mandibular
fractures. Recent experimental studies suggest
that poly-L-lactide resorbable plates may be
used effectively for treatment of mandibular
fractures or osteotomies in the mature cranio-
facial skeleton.52,53 Studies using a variety of
mandibular fracture models in animals indi-
cate that resorbable plates and screws may be
used successfully in surgical management.54,55
The use of resorbable plates and screws has
been supported further by successful reports of
their clinical use in the treatment of mandibu-
lar fractures in adults.56,57 Unfortunately, to
date, the use of resorbable plates and screws
has not been investigated in the treatment of
pediatric mandibular fractures. However, given
the decreased force exerted during mastica-
tion in children, the use of resorbable plates
and screws may, in theory, be used most effica-
ciously in the pediatric setting. There is little
evidence to suggest that poorly placed resorb-
able screws have any less deleterious effect on
the developing dentition.
It also must be remembered that, due to the
biomechanics of the resorbable plates them-
selves, the strength of equally sized resorbable
and metallic plates is not equivalent. A 1.5 -mm
system resorbable plate probably provides
much less stability than a 1.5-mm titanium
plate. In light of this, we believe that resorbable
Vol. 116, No. 2 / THE PEDIATRIC MANDIBLE 37e

FIG. 7. Algorithm 1. Management of body and angle fractures. CMW, circummandibular wires; IDW, inter-
dental wiring; IMF, intermaxillary fixation; ORIF, open reduction and internal fixation.

plates likely have the role of helping to main-
tain fracture reduction and alignment, but
must be utilized with additional methods (such
as wires, splints, and intermaxillary fixation).
Large-scale resorbable plates (greater than 2.0
mm system) may have a role in fractures pos-
terior to the dentition in older children, but
until more experiences are published, judg-
ment must be reserved.
The possible deleterious effects of open re-
duction and internal fixation in children have
been well documented in the literature. Exper-
imental evidence provided by Lin et al. has
demonstrated that plates and screws of the size
used in managing adult fractures may, to a
limited extent, adversely affect facial growth.58
The “migration” of such implanted hardware
also has been observed both clinically and ex-
38e PLASTIC AND RECONSTRUCTIVE SURGERY, August 2005

FIG. 8. Algorithm 2. Management of condylar and coronoid fractures. PRS, piriform rim suspension; CMW,
circummandibular wires; IDW, interdental wiring; IMF, intermaxillary fixation; ORIF, open reduction internal
fixation.

perimentally.59,60 The fate of developing teeth
in fracture lines remains a controversial sub-
ject, and has great significance to surgical ther-
apy. Kamboozia and Punnia-Moorthy have re-
ported an increased incidence of devitalized
teeth adjacent to mandibular fractures treated
with plates when compared with interosseous
wiring.31 While this study is cause for concern,
it should be noted that grossly displaced frac-
tures are more likely to be treated with plates—
making it difficult to draw conclusions regard-
ing the modality’s actual effect on tooth
vitality. While Davison et al.’s study of the “free-
hand technique” provides some vindication for
Vol. 116, No. 2 / THE PEDIATRIC MANDIBLE
the use of open reduction and internal fixation
without intermaxillary fixation in pediatric pa-
tients, its conclusions should be viewed with
skepticism until sufficient, long-term follow-up
(19 months in their study) of facial growth,
occlusion, and dental vitality is provided.49
Given all the considerations stated above,
which include age, fracture type, and location
variables, as well as treatment materials, we
believe it is difficult to construct an absolute
treatment algorithm for these often-compli-
cated injuries. Nevertheless, we have included
here a treatment proposal realizing that flexi-
bility in its application is the watchword, and
modification may be necessary as more clinical
reports detailing specific treatment modalities
emerge. As a point of departure, refer to Fig-
ures 7 and 8.
SUMMARY
The treatment of the fractured pediatric
mandible represents a therapeutic challenge to
the surgeon. Treatment is complicated by the
dynamic nature of the developing mandible,
the presence of tooth buds, and dental insta-
bility. In the majority of cases of minimally
displaced or greenstick fractures in pediatric
patients, conservative management, possibly
with a brief period of intermaxillary fixation, is
appropriate. When surgical management is in-
dicated, interdental wiring, occlusal splints,
drop wires, and monocortical plates and screws
are all legitimate treatment options. The two
treatment algorithms presented here are not
absolute in their applicability and mandate in-
dividualization of treatment. Furthermore,
with the addition of resorbable systems to the
surgeon’s armamentarium and the growing lit-
erature documenting the efficacy of various
treatment strategies, flexibility in the surgical
management of these complicated injuries re-
mains paramount.
Scott P. Bartlett, M.D.
Division of Plastic Surgery
The University of Pennsylvania and The
Children’s Hospital of Philadelphia
The Edwin and Fannie Grey Hall Center for
Human Appearance
Wood Building, First Floor
34th and Civic Center Boulevard
Philadelphia, Pa. 19104
scottbartlett@uphs.upenn.edu
39e
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