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Pediatric Dental Journal

journal homepage: www.elsevier .com/locate /pdj

Case Report

Pediatric mandibular fracture: An unusual etiology

Divesh Sardana*, Krishan Gauba, Ashima Goyal, Satnam S. Jolly

Department of Pediatric Dentistry, Oral Health Sciences Center, PGIMER, Chandigarh, India

a r t i c l e i n f o

Article history:

Received 6 August 2013

Received in revised form

8 November 2013

Accepted 23 December 2013

Keywords:

Pediatric mandibular fractures

Open cap splint

Etiology

Child abuse

* Corresponding author.E-mail addresses: doc_divesh@yahoo.co.i

Please cite this article in press as: Sardan(2014), http://dx.doi.org/10.1016/j.pdj.201

http://dx.doi.org/10.1016/j.pdj.2013.12.0010917-2394/Copyright ª 2014 The Japanese So

a b s t r a c t

Introduction: Mandibular fractures in children are rare and different from adults in terms of

etiology, epidemiology, treatment considerations and associated complications. Thick

adipose tissue, elasticity of the bone and protective nature of the parents have a protective

influence on the prevalence of mandibular fractures in pediatric age group. However, lack

of education may be a factor influencing the etiology of such injuries as shown in the

present case.

Case report: The present case report describes a rare case of mandibular fracture inflicted

unintentionally by his mother in an 18 month old child during drinking of water directly

from the tap in his mouth. The fracture was treated conservatively using custom-made cap

splint and circum-mandibular wiring.

Conclusion: The purpose of this case report is to motivate pediatric dentists that parents

coming to them for treatment of their children should not only be educated regarding the

care of teeth and gums, but should take care of the oral cavity as a whole. Also, through this

paper it is stressed that supervision of the growing child is utmost important to avoid such

injuries.

Copyright ª 2014 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All

rights reserved.

1. Introduction

Maxillofacial region, due to its prominent anatomy, is

amongst themost common area prone to an injury during any

accident. Injury to this area is especially more important

because of its proximity to all major nerves and vessels of

the head and neck region, important organs (like brain) and

also because of esthetic and psychological considerations.

Mandibular fractures are very rare in children; however, still

mandibular fracture is the most common form of facial injury

occurring in pediatric age group [1,2]. Slightly male predilec-

tion has been reported in children subjected to facial trauma

reflecting themore aggressive and risk-taking behavior of pre-

n, manchanda_sheetal@y

a D, et al., Pediatric man3.12.001

ciety of Pediatric Dentist

teen and adolescent boys. Road traffic accidents, fall from

heights and sports injuries have been reported to be the most

common causes of maxillofacial injuries amongst the chil-

dren [3,4]. We report a rare case of mandibular fracture in an

18 month old child inflicted by his mother while she tried to

withdraw the child forcefully from the tap when the child was

drinking water directly with tap in his mouth.

2. Case report

An 18-month-old male child was brought to the Unit of

Pedodontics and Preventive Dentistry, Oral Health Sciences

ahoo.co.in (D. Sardana).

dibular fracture: An unusual etiology, Pediatric Dental Journal

ry. Published by Elsevier Ltd. All rights reserved.

Fig. 1 e Figure depicting the etiology of injury.

Fig. 3 e Antero-posterior radiograph.

p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1e42

Center, Post-graduate Institute of Medical Education and

Research, Chandigarh by his parents with a chief complaint of

bleeding from themouth since few hours. On questioning, the

parents revealed that the child was drinking water directly

from the tap in hismouth; however; he was not able to release

tap from his mouth [Fig. 1]. Subsequently, the mother tried to

forcefully pull her child from the tap thereby injuring the

child, although the injury was unintentional. On examination,

the child was alert but irritable. There were no signs of any

injury elsewhere in the body. There was no history of con-

vulsions, vomiting or nasopharyngeal bleed. Intra-oral ex-

amination was done with difficulty due to un-cooperative

nature of the child; however; mobility of the jaw segment was

noted between unerupted 73 and erupted 72 region along-with

open soft tissue defect in the floor of the mouth [Fig. 2]. The

teeth eruptedwere 51 52 61 62 71 72 81 82 and partially erupted

54 64 74 84 although no tooth was injured. The underlying

permanent tooth buds could not be visualized clinically or

through the defect. Based on clinical examination, provisional

diagnosis of left paraymphysis fracture was reached.

Fig. 2 e Open defect in the floor of the mouth.

Please cite this article in press as: Sardana D, et al., Pediatric man(2014), http://dx.doi.org/10.1016/j.pdj.2013.12.001

Standard anterior-posterior radiograph of the skull was taken

which showed fracture line between left primary mandibular

lateral incisor and unerupted left primary mandibular canine

[Fig. 3]. Neurological and otolaryngologist consultation was

also taken to rule out any other serious injury of associated

hard and soft tissues of the head and neck. The treatment

planning included suturing of the soft tissue defect followed

by closed reduction and stabilization of the fractured seg-

ments using custom-made cap splint and circum-mandibular

wiring under general anesthesia. Upper and lower alginate

impressions of maxilla and mandible were taken in the first

visit and stone cast poured [Fig. 4]. Open cap splint with

reinforced wire (19 gauge) was fabricated on the stone cast

same day and pre-anesthetic clearance for the child was ob-

tained in the mean time. On the subsequent day, patient was

Fig. 4 e Mandibular cast (Note: The defect can be seen).

dibular fracture: An unusual etiology, Pediatric Dental Journal

Fig. 5 e Cap splint in-situ.

Fig. 6 e Cap splint in-situ.

p e d i a t r i c d e n t a l j o u rn a l x x x ( 2 0 1 4 ) 1e4 3

administered general anesthesia and the planned treatment

was carried out [Figs. 5 and 6]. Parents were advised to give

soft diet to the child, maintenance of oral hygiene and follow-

up after every week till one month. The cap-splint was

removed after 4 weeks under conscious sedation and healing

was found to be satisfactory. Follow-up after 3 months

showed adequate functioning of the oral cavity in terms of

speech and mastication. The cusp tip of 73 could be appreci-

ated with no mobility of the fracture line. The parents have

been advised for routine follow up 6 monthly to check for the

status of unerupted deciduous teeth and review the possible

complications if any.

3. Discussion

Both children and adults are subjected to similar type of in-

juries but their etiology, epidemiology, treatment consider-

ations and associated complications are quite different.

Maxillofacial region due to its conspicuous location is most

prone to injury in both children and adults. Themost common

causes of maxillofacial injuries in adults are motor vehicle

accidents or aggravated assaults [5,6]; whereas in children fall

from heights andmotor vehicle accidents are themain causes

of such injuries [3,4,7,8]. Fractures of the maxillofacial region

are very rare under 6 years of age after which the prevalence

rises with the age and becoming parallel to the prevalence in

adults after 12 years [9,10]. Mandible and nasal bones are the

commonest bones to be involved in fractures of the maxillo-

facial region [11,12]. Pediatric mandibular fractures are less

common than adult mandibular fractures probably due to

thick adipose tissue surrounding the mandible, lack of pneu-

matisation, high cancellous-to-cortical bone ratio, flexible

suture lines [13,14]. Also, children especially under 3-years of

age are under parental supervision; hence the chance of any

injury is greatly reduced- this supervision acting as a protec-

tive mechanism for their children. Education and socio-

economic status may have an impact on this protective

mechanismwhichmay prevent serious injuries or very rarely,

itself result in serious injury as shown in the present case.

This unintentional injury caused by lack of parental education

could have been more serious had it involved some major

Please cite this article in press as: Sardana D, et al., Pediatric man(2014), http://dx.doi.org/10.1016/j.pdj.2013.12.001

vessel or gland in the floor of the mouth. The child probably

tried to drink water directly through the tap; however he

didn’t knew how to release the tap from his mouth. The

mother of child tried to free him from the tap forcefully

thereby inflicted the injury. The injury could have been avoi-

ded if the mother could have patiently tried to dis-engage the

child from the tap gently or help him release the tap by

opening his mouth slightly wider. Lack of education is prob-

ably the common contributing factor in all pediatric injuries

(like road traffic accidents, child abuse or any other rare cause

of injury as in present case). Routine dental check-ups for

examination of dental caries and growth problems are

essential and recommended by all pediatric dentists. How-

ever, these visits should also be utilized to guide the parents

about ‘gentle’ handling of their precious children and make

them aware of the possibility of various types and mecha-

nisms of injuries. Also, parents should be advised not to leave

their children unattended and keep small & sharp objects out

of the reach of children. Another factor to be considered in the

present case is the possibility of child abuse or neglect

considering the history and nature of the injury. Child abuse is

actively inflicted by the caretaker to the child and one of the

most common and severe problems encountered in pediatric

dentistry, although most cases go unreported or unnoticed.

The present case in strict sense can be considered a case of

child abuse since it was inflicted actively by the child’s

mother, but since the injury was unintentional and unwanted

by the mother, we would prefer to use the term ‘pseudo-child

abuse’.

The patient in present case was treated with closed

reduction using custom-made open cap splint and circum-

mandibular wiring. Various other methods have been sug-

gested for closed reduction using pre-fabricated cap splints,

modified orthodontic brackets [15], orthodontic resin and

rubber elastics [16], modified orthodontic splint appliance [17].

The advantage of closed reduction over open reduction is its

cost effectiveness, lesser surgical trauma to the patient and

reduced risk of any iatrogenic trauma to the anatomical

structures. Also, the rate of associated complications is less in

cases of closed reduction compared to open reduction [16].

However, the main disadvantage is the difficulty and time

utilized in fabrication of cap splint. The fractures of mandible

in pediatric age group may be associated with long term

complications; hence long-term follow-up is necessary till the

dibular fracture: An unusual etiology, Pediatric Dental Journal

p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 4 ) 1e44

permanent teeth erupts and facial growth is complete. Pedi-

atric mandibular trauma may result in defective formation,

mineralization, discoloration or even failure of eruption of

permanent teeth [16,18]. The patient in present case has

higher chances of development of any of these complications

and has been kept on routine follow-up which will continue

till mandibular growth is complete and all the permanent

teeth have erupted. However, the chances of these compli-

cations in deciduous teeth are minimal in the present case

because when the injury occurred (i.e. 18 months of age), the

enamel completion is expected to be almost complete. Follow-

up radiographs (ideally orthopantomogram) would have pro-

vided ideal means to assess the healing of the bone but

considering the young age of the child and uncooperative

nature, we relied mainly on clinical examination to assess

this. Also, radiographic healing of the bone may take as long

as 6 months to 1 year.

4. Conclusion

The present rare case report describes the occurrence of se-

vere mandibular trauma unintentionally induced by the

mother in an 18-months old child; however, the real etiology

in present case, according to us is the lack of education of the

mother regarding protective care of the child from such un-

fortunate injuries. The fracture was treated conservatively

using custom-made cap splint and circum-mandibularwiring.

Through this case report, it is stressed that parents should not

only be educated regarding the care of teeth and gums, but

should take care of the oral cavity as a whole. Also, supervi-

sion of the growing child is utmost important to avoid such

injuries.

r e f e r e n c e s

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[2] Kaban LB, Troulis JM. Facial trauma II. Dentoalveolar injuriesand mandibular fractures in pediatric oral and maxillofacialsurgery; 2004. pp. 441e61.

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[14] Crean ST, Sivarajasingam V, Fardy MJ. Conservativeapproach in the management of mandibular fractures in theearly dentition phase. A case report and review of theliterature. Int J Paediatr Dent 2000;10:229e33.

[15] Magennis P, Craven P. Modification of orthodontic bracketsfor use in intermaxillary fixation. Br J Oral Maxillofac Surg1990;28:136e7.

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dibular fracture: An unusual etiology, Pediatric Dental Journal