The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: a case report

Abstract –  The use of rigid fixation in children is controversial and may cause growth retardation along cranial suture lines. Intermaxillary fixation for mandibular fractures should be used cautiously as bony ankylosis in the temporomandibular joint (TMJ) and trismus may develop. The high osteogenic potential of the pediatric mandible allows non-surgical management to be successful in younger patients with conservative approaches. In this case, successful conservative treatment of mandibular fracture of a 3-year-old patient is presented.     

铸造个别牙弓夹板在下颌骨前段骨折中的应用

目的:评价铸造个别牙弓夹板在下颌骨前段骨折治疗中的作用。方法:制取牙模型,在骨折线处锯开下颌模型,再按上下颌关系重新行模型拼对、联结,在联结后的模型上制取颊舌侧个别牙弓夹板代型,完成个别牙弓夹板的铸造,将其安放于经手法复位后的下颌牙弓的颊舌侧并结扎固定,以恢复牙弓的连续性及咬合关系。结果:经上述方法治疗的18例下颌骨骨折患者,4周后拆除个别牙弓夹板,6～8周后咬合关系完全恢复正常。结论:铸造个别牙弓夹板是治疗下颌骨前段线性骨折的有效方法。     

牵引钉植入与牙弓夹板行颌间牵引固定治疗单纯髁状突骨折的疗效比较

目的　比较两种颌间牵引固定方法治疗单纯髁状突骨折的临床疗效。方法　将单纯髁状突骨折的患者随机分成牵引钉植入组（23例）和牙弓夹板组（21例）,并行相应的颌间牵引固定治疗,分别检测两组术后患者的咬合关系恢复情况、操作时间的长短以及在五个不同时间点测定的DI、GI、CPITN指数,对二组在疗效、操作的难易和牙周状况的变化进行比较。结果　牵引钉植入术与牙弓夹板行颌间牵引固定均能达到较好的临床治疗效果,在术后最大开口度及颞下颌关节检查方面无统计学意义（P>0.05）,但使用牵引钉植入操作时间明显缩短（P<0.05）,且颌间牵引治疗期间及颌间牵引装置拆除后,两组在DI、GI及CPITN方面的差异有统计学意义（P<0.05）。结论　牵引钉植入术是一种新的微创、快捷、安全有效的治疗髁状突骨折的方法,值得在临床上推广使用。     

Management of mandibular fractures in children with a split acrylic splint: a case series

Five children with mandibular fractures were treated with a split acrylic splint, which secured the fracture by wiring around the mandible. The occlusion was satisfactory, without infection or malocclusion. None required revision, and there was no deviation of the mandible, ankylosis, or disturbances of growth.     

快速成型帽状夹板在下颌骨骨折中的应用

目的 寻求迅速、简便、有效的下颌骨骨折的固定方法。方法 真空成型牙列套的帽状夹板，利用其弹性来复位骨折片。结果 治疗骨折线位于牙列内的单发、多发下颌骨骨折11例，取得良好效果。此方法不影响进食，骨折端稳定。结论 快速成型帽状夹板在下颌骨骨折治疗中有较好固定效果。     

Clinical and radiological outcomes after treatment of sagittal fracture of mandibular condyle (SFMC) by using occlusal splint in children

This study was designed to investigate the effects of occlusal splints in the treatment of sagittal fractures of the mandibular condyle in children. From January 1995 to December 2011, 37 sagittal fractures of the mandibular condyle in 30 patients aged 4–8 years old were included in this study. All the patients were treated with 1–2 mm occlusal splints in the molar region. The mouths of the patients were kept slightly open by the occlusal splints for 3–6 months, and we reviewed the clinical and radiological remodelling of the affected condyles after treatment. Excellent (n = 20) and good (n = 10) clinical outcomes were achieved with full radiological remodelling seen in 19 and partial remodelling in 11. Treatment with occlusal splints is effective in delivering good results and function with minimal morbidity in children with sagittal fractures of the condyle, while permitting ongoing remodelling and growth in the short term.     

����ʽ��֬���������а����������岿�����ڹ̶���������ϵ��ٴ���Ч�о�

目的探讨应用联结式树脂金属牙弓夹板防治下颌骨颏体部骨折内固定术后错位愈合和错畸形的临床疗效。方法对2001年10月至2008年12月福建省建阳市立医院收治的50例下颌骨颏体部骨折患者,随机分为两组,试验组(29例)采用内固定术+联接式树脂金属牙弓夹板固定联合治疗,对照组(21例)采用单纯内固定术治疗,术后3～6个月复查咬合关系和X线片,观察两组患者错位愈合和错畸形的发生情况。结果两组患者术后均无感染,术后3～6个月开口度均大于37mm;咬合关系复查,试验组出现2例错(6.9%),对照组出现8例(38.1%),经卡方检验,两组术后错的发生率差异有统计学意义(P<0.05)。X线复查,试验组所有患者下颌骨均未见错位愈合、骨愈合不良和假关节形成,对照组1例患者下颌骨出现错位愈合。结论内固定术+联结式树脂金属牙弓夹板固定联合的方式可以有效防治下颌骨颏体部骨折内固定术后错的发生。     

The lingual splint: an often forgotten method for fixating pediatric mandibular fractures

Maxillofacial fractures are uncommon in the pediatric population, and their treatment is unique due to the psychological, physiological, developmental and anatomical characteristics of children. We present the case of a boy who was treated in an outpatient dental clinic using a lingual splint for the reduction, stabilization and fixation of a mandibular body fracture. This technique is a reliable, noninvasive procedure that dentists may consider in selected cases by referral to an oral and maxillofacial surgeon. It also limits the discomfort and morbidity that can be associated with maxillomandibular fixation or open reduction and internal fixation in pediatric patients.     

Successful minimally invasive intervention in a primary central incisor after root fracture: A case report

Root fractures vary in severity, extent, and location, according to the physical and mechanical aspects of the accident. Root fractures are rare in primary teeth and they affect dentin, cementum, periodontal ligament and the pulp. This paper reports a case of a two-and-a-half-year-old baby who had a root fracture of the upper right primary central incisor (tooth 51) as a consequence of trauma that was managed with minimally invasive intervention. After clinical and radiographic examinations, the presence of tooth mobility, pain, bleeding and a horizontal apical root fracture was diagnosed on tooth 51. The treatment of choice was splinting for 120 days, which can deliver excellent results regardless of the patient's age. The tooth was preserved without needing endodontic intervention until its physiologic exfoliation and normal eruption of its permanent successor. As sequelae to the fractured tooth 51, there was some coronal color alteration and dystrophic calcification of the root canal. This tooth did not develop ankylosis or mobility during the follow-up period. After 57 months of follow-up, repositioning and splinting were appropriate ways to manage this horizontal root fracture in the apical third of this primary tooth. It allowed the tooth to be preserved in the arch with normal function.     

Open cap splint with circummandibular wiring for management of pediatric mandibular parasymphysis/symphysis fracture as a definitive treatment modality; a case series

Abstract –  Management of pediatric maxillofacial injuries is mainly governed by their psychological, physiological, developmental, and anatomical characteristics. Pediatric mandibular fractures can have variable etiologies but have similar manifestations as those in adult patients. There are various treatment modalities to treat mandibular parasymphysis/symphysis fractures in children, which have their own limitations and complications. We currently describe our experience with open cap splint as a treatment modality which involves fewer risks in treating 10 pediatric parasymphysis/symphysis mandibular fractures.     

Lateral compression open cap splint with circummandibular wiring for management of pediatric mandibular fractures: a retrospective audit of 10 cases

Introduction

Mandibular fractures are relatively less frequent in children when compared to adults. Pediatric patients present a unique challenge to maxillofacial surgeons in terms of their treatment planning and in their functional needs. We currently describe our experience with lateral compression open cap splint with circummandibular wiring as a treatment modality which involves fewer risks in treating pediatric symphysis/parasymphysis/body mandibular fractures.

Materials and methods

A retrospective analysis of pediatric patients with mandibular symphysis/parasymphysis/body fractures operated from January 2007 to January 2012 was performed. Clinical photographs and orthopantomogram assessment at the time of presentation, after treatment, and at 6 months postoperatively were evaluated.

Results

All the 10 patients were followed up until the period of 6 months, and none of them had any major complications. Postoperatively, there was satisfactory healing and union of fracture fragments in all the patients. Only one patient developed infection at submental region. The 6-month follow-up showed good occlusion, without interference in teeth eruption and no signs of temporomandibular joint problems.

Conclusions

Lateral compression open cap splints for treatment of pediatric mandibular symphysis/parasymphysis/body fractures are reliable treatment modalities with regard to occlusion-guided fracture reduction.     

Conservative treatment of paediatric mandibular fracture by the use of orthodontic appliance and rubber elastics: report of a case

Abstract –  Treatment principles of paediatric mandibular fractures may differ from the treatment of the adult population in that a conservative approach is in most cases advocated before the use of internal rigid fixation with plates and screws. This is because of a relative high risk of disturbed facial skeletal growth and risk of damaging unerupted teeth. Knowledge of conservative treatment options is essential in order to minimize these risks and one option is presented in this paper.
This case report describes a 5-year-old girl that sustained an open fracture of the mandible and who was successfully treated by the means of applying orthodontic brackets and an arch bar combined with ligatures and rubber elastics.     

Open versus closed treatment for unilateral mandibular extra-capsular condylar fractures: A meta-analysis

PurposeTo compare the functional outcomes between open reduction and internal fixation (ORIF) and closed reduction (CR) for unilateral mandibular extra-capsular condylar fractures in patients over 12 years old.Materials and methodsA comprehensive electronic search of PubMed, Embase and the Cochrane Library databases was conducted up to October 31, 2018. The evaluated functional outcomes included malocclusion, temporomandibular joint (TMJ) pain, protrusion, laterotrusion, maximum inter-incisal opening and lateral deviation during maximum inter-incisal opening.ResultsFourteen studies appeared to meet the inclusion criteria. Statistically significant differences between ORIF and CR treatment were observed for the outcomes of malocclusion (P = 0.001), maximum inter-incisal opening (P = 0.0008), lateral deviation during maximum inter-incisal opening (P = 0.007) and laterotrusion (P < 0.0001), but not for the outcomes of protrusion (P = 0.33) and TMJ pain (P = 0.29).ConclusionsORIF treatment of unilateral mandibular extra-capsular condylar fractures provides better functional outcomes in comparison to CR treatment with regard to occlusion, maximum inter-incisal opening, lateral deviation during maximum inter-incisal opening and laterotrusion, whereas there was no statistically significant difference between ORIF and CR group with regard to protrusion and TMJ pain.     

Outcomes of anterior disc displacement and condylar remodelling for sagittal fracture of the mandibular condyle in children after closed treatment

The aim of this study was to evaluate the outcomes of temporomandibular joint (TMJ) anterior disc displacement and condylar remodelling for sagittal fracture of the mandibular condyle (SFMC) in children. Disc displacement was observed in 20 patients with 24 SFMCs (age 4–12 years) via magnetic resonance imaging. After 6 months of closed treatment (T1), the joints were categorized based on the displaced disc status as complete reduction (DCR) or incomplete reduction (DICR). Moreover, condylar remodelling was compared between the groups using cone beam computed tomography images of the TMJ obtained at T1 and at the 1-year follow-up (T2; 15 patients with 18 displaced SFMCs). At T1, 17 of 24 joints with SFMC were assigned to the DCR group and six to the DICR group; one unilateral SFMC case developed ankylosis. Condylar depth and height differed significantly between the groups at T1, but not at T2. Intra-group comparison exhibited significant changes in the condylar depth and height over time in the DICR group. Thus, most of the anteriorly displaced discs (17/24, 70.8%) achieved reduction following closed treatment. Although sustained anterior disc displacement was associated with an increased depth and reduced height of the condyle, no clinical impairment was noted unless ankylosis developed.     

Feasibility of carbon-fiber-reinforced polymer fixation plates for treatment of atrophic mandibular fracture: A finite element method

The objective of this study was to conduct a computer assessment of the biomechanical stability of locking fixation plates of different thicknesses, made of titanium alloy and carbon-fiber- reinforced polyetheretherkotone (CFR-PEEK) in Class III atrophic mandibular fractures. Class III atrophic mandibular models were constructed using three-dimensional finite element models. After simulation of fracture on the left side, plates with different thicknesses (1.0, 1.5, 2.0, and 2.5 mm) were adapted to the models and three locking screws on each side of the fracture were used for fixation. Titanium alloy and CFR-PEEK material properties were assessed for all plate models. Von Mises stress values decreased gradually with an increase in plate profile thickness. Von Mises stress values for screws and plates were lower in models using CFR-PEEK plates. An increase in plate profile enhanced the load-sharing performance of the fixation systems, with rigid titanium alloy plates sharing the load among the screws more evenly. 1.0 mm, 1.5 mm, and 2.0 mm CFR-PEEK plates produced strain values of 2–10%, which promote proper healing via formation of callus in the fracture line. In terms of investigated biomechanical parameters, and with a Young's modulus similar to that of cortical bone, CFR-PEEK materials appear to be suitable for the treatment of atrophic mandibular fractures.     

Comparative evaluation of 2.0-mm locking plate system vs 2.0-mm nonlocking plate system for mandibular fracture: a prospective randomized study

This study evaluated the efficacy of a 2.0-mm locking plate/screw system compared with a 2.0-mm non-locking plate/screw system in mandibular fractures. A prospective randomized clinical trial was conducted. Patients were randomly assigned to receive 2.0-mm locking plates (group A) or 2.0-mm nonlocking plates (group B). All patients were followed up for 12 weeks postoperatively. Complications were analysed according to the type of plate used and the site of fracture. Fifty patients with 76 fractures met the inclusion criteria. Thirty-six fracture sites were treated with 2.0-mm locking plates and 40 with 2.0-mm nonlocking plates. The number of patients requiring postoperative maxillomandibular fixation was significantly higher in group B (p < 0.01); seven complications occurred representing 9% of the total. Two complications occurred in the locking group and five in the nonlocking group with complication rates equalling 6% and 13%, respectively. When comparing the overall complication rates according to plates used, the χ² test showed no statistically significant difference between the locking and nonlocking plates (p > 0.05). In conclusion, mandible fractures treated with 2.0-mm locking plates and 2.0-mm nonlocking plates present similar short-term complication rates.     

Biomechanical analysis of poly‐L‐lactic acid and titanium plates fixated for mandibular symphyseal fracture with a conservatively treated unilateral condylar fracture using the three‐dimensional finite element method

The purpose of this study was to investigate stress on poly‐L‐lactic acid (PLLA) plates with a thickness of 1.4 mm and titanium plates with a thickness of 1.0 and 1.4 mm placed for mandibular symphyseal fractures with or without conservatively treated, unilateral condylar fractures using finite element analysis. The symphyseal fracture region was defined by the following three conditions: the defect, the callus, and the contact condition. Stress on the plates was analyzed by an applying occlusal force of 478.1 N on the first molar of the non‐condylar fracture side. In the model of isolated symphyseal fracture, the maximal stresses were below the material strength in all plate types and conditions. In the models with condylar fracture, the maximal stresses on these plates were much higher than those in the models of isolated symphyseal fracture, especially for the defect condition. Although the maximal stresses on all types of plates in the contact condition were below the material strengths, some of those in the defect condition were higher than these strengths. These results suggest that a PLLA plate can theoretically withstand stress under good reductions of symphyseal fractures, even for condylar fractures; however, both the PLLA plate and titanium miniplate may be at risk of fracture under poor reduction.     

Endoscopically assisted computer-guided repair of internal orbital floor fractures: an updated protocol for minimally invasive management

BackgroundPerforming accurate anatomical reconstruction is a challenging task in the treatment of internal orbital floor fractures. Compared with traditional transcutaneous incisions, endoscopic transmaxillary approaches have the advantage of avoiding complications related to external scars, and provide direct access to the orbital floor. Autogenous bone provides the ideal material for defect reconstruction, but determination of the correct size and shape of the graft is crucial for a stable support. This study introduces a new protocol for the treatment of internal orbital floor fractures that combines endoscopy, virtual reality, and 3D printing. The authors also investigated the impact of computer-aided surgery (CAS) on the overall accuracy of reconstruction in aiming to achieve the triple objective of restoring anatomy, volume, and function.Materials and methodsFourteen patients with orbital floor fractures were recruited for this study. High-resolution CT scans provided appropriate imaging for detailed orbital floor defect visualization. A virtual reconstruction of the orbital floor defect was developed and a 3D printed template was fabricated to provide intraoperative guidance in the graft harvesting phase, according to the orbital defect. Virtual analyses were conducted to evaluate the accuracy of reconstruction both in terms of graft size and graft orientation.ResultsPostoperative CT scans showed that in all cases orbital floor reconstruction was successfully performed, resulting in restoration of the correct globe position. No intraoperative complications occurred. Correspondence of graft size was evaluated using color-coded maps and RMSE, while comparison of angular measurements allowed the authors to relate simulated and actual reconstruction.ConclusionsOrbital floor reconstruction performed via transmaxillary endoscopy is a safe technique, which allows for detailed visualization of the fracture rim, avoids external scars, and permits an easier reduction of the prolapsed orbital content into the overlying orbital cavity. Virtual planning plays an important role in defining the appropriate geometry of the bone graft and establishing the optimal reconstruction strategy. Our preliminary results indicate that virtual planning and 3D printing should become part of an integrated protocol for the endoscopic treatment of orbital floor fractures.