SA1 - Pediatric Mandible Fracture Treatment in a Tertiary Care Facility

Abstract: Statement of the Problem
Pediatric mandible fractures are uncommon when compared to their adult counterparts and management is often more nuanced. The appropriate management of pediatric mandible fractures may depend on a variety of factors, including age, dentition stage, mandible growth, location of the fracture, and cause of injury.1,2

Materials and Methods
This is a retrospective cohort study designed to evaluate the management of mandibular fractures for patients 18 years of age or younger at Boston Children’s Hospital from January 1st, 2000, to January 1st, 2020. Hospital medical records were queried using Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD-10) codes to identify all patients 18 years of age or younger who sustained a mandibular fracture within the study period. The primary predictor variable was age, broken into categories to represent stages of dentition (0 to < 7 years, 7 to < 13 years, and 13 to 18 years). The primary outcome variable was management of the mandibular fracture. Management methods included non-operative treatment, consisting of dietary restrictions, limited physical activity, and close observation; closed reduction; and open reduction internal fixation (ORIF). Additional predictor variables included fracture location and mode of injury. Our secondary outcome measured was complications.

Methods of Data Analysis
Descriptive statistics were calculated. Chi-square, Fisher’s exact, and one-way ANOVA tests were used to analyze associations between variables and outcomes. Results were considered statistically significant when p ≤ 0.05.

Results
A total of 364 subjects were evaluated for a mandibular fracture (72.4% male, mean age of 13.0 ± 4.6 years). There were 50 subjects in the 0 to < 7 years group, 92 subjects in the 7 to < 13 years group, and 222 subjects in the 13 to 18 years group. Management technique significantly varied between age groups, with fractures in younger subjects being managed most often with observation ( < 7 years: 78.4% vs. 7- < 13 years: 71.9% vs. 13-18 years: 30.9%, p< 0.001), compared to subjects 13-18 years of age who were more likely to undergo operative treatment with either closed reduction or ORIF ( < 7 years: 21.7% vs. 7- < 13 years: 38.1% vs. 13-18 years: 69.0%, p< 0.001). Fractures involving the condyle and subcondyle were associated with greater rates of observation (72.5%, < 0.001; and 55.4%, p=0.004, respectively) whereas angle fractures typically underwent closed reduction (40.4%, p< 0.001) and fractures involving the symphysis and parasymphysis were most often managed with ORIF (43.3%, p=0.013; and 35.8%, p< 0.001, respectively). Fractures resulting from falls were more likely to be treated with observation compared to other mechanisms of injury (51.6%, p< 0.001). Fractures from assaults had the highest rate of ORIF (27.6%, p< 0.001). Age of injury was not associated with differences in complications (p>0.243). However, infections and injuries to the inferior alveolar nerve occurred more frequently when fractures were managed with ORIF (1.6%, p=0.047; and 5.5%, p< 0.001, respectively)

Conclusions
Pediatric mandible fractures require a nuanced treatment approach. Younger patients are more likely undergo management with observation while older patients may benefit from an operative approach. Age was not significantly associated with complications. However, ORIF had higher rates of infection and injury to the inferior alveolar nerve compared to other management strategies.

References
1. Irgebay Z, Glenney AE, Cheng L, Li R, Mocharnuk JW, Smetona J, Balasubramani GK, Losee JE, Goldstein JA. Fracture patterns, associated injuries, management, and treatment outcomes of 530 pediatric mandibular fractures. Plast. Reconstr. Surg. 2023.
2. Goth S, Sawatari Y, Peleg M. Management of Pediatric Mandible Fractures. J. Craniofac. Surg. 23(1):47-56, 2012.