Pediatric Intermaxillary Fixation in a Child with Isolated Subcondylar Fracture under Local Anesthesia: A Technical Note and Case Report.

Pediatric subcondylar jaw fractures in the mixed dentition phase present a unique challenge as immobilization of the jaw is indicated but arch bars are contraindicated due to fear of damage to underlying tooth buds. No definite guidelines are present in the management of pediatric subcondylar jaw fractures. We report a case in which a patient in mixed dentition with undisplaced fracture of neck of condyle which was managed with Intermaxillary fixation. How to cite this article: Tirupathi SP, Rajasekhar S, Ganesh M, et al. Pediatric Intermaxillary Fixation in a Child with Isolated Subcondylar Fracture under Local Anesthesia: A Technical Note and Case Report. Int J Clin Pediatr Dent 2022;15(1):119-120.

Introduction

Jaw fractures are an infrequent occurrence in children and account for 15% of pediatric facial fractures. Out of maxillaofacial fractures in children, mandibular fractures account for 20-50% based on literature reports. Mandibular fractures are reported to be more prevalent in the mixed dentition phase as compared to the primary dentition phase, the reason being alteration in the proportion of the cranium to facial bones. Management of mandibular fractures in pediatric patients in mixed dentition is a unique challenge. Proper guidelines for intermaxillary fixation in this age group are nonexistent.[1,2]

Among all pediatric mandibular fractures, condylar and subcondylar fractures require special attention. The condyle is one of the most important growth sites. Classification of condylar fractures at different ages and different locations is important for treatment planning consideration. Few authors consider that there is a relationship between age and the site of condylar fracture. In younger children, intracapsular fractures are more common whereas extracapsular fractures are more common in older children.[3-5]

Classification of Condylar Fractures

Intracapsular fractures: Fractures of condyle are classified based on their location neck, head, and base.[6] The condylar head fractures can be further sub-divided into lateral, central, and medial fractures (types A, B, C, respectively).[7]

Extracapsular fractures: Extracapsular fractures are classified as non-displaced greenstick fracture, deviation, displacement, and dislocation (MacLennan's class I, II, III, IV). Displacement can be further classified as mild, moderate, or severe based on the extent. Condylar head remains inside the glenoid fossa in nondisplaced green-stick fracture and deviation and displacement. The condylar head is out of the glenoid fossa in dislocation. Overlap of the distal and proximal segment can be found in displacement. Discontinuity is found in deviation and displacement.[8]

Isolated condylar fractures are rare in occurrence, they are most commonly associated with other sites such as symphysial, parasymphyseal, body angle, and ramus fractures. Management of condylar fractures can be surgical (open reduction and internal fixation) or nonsurgical (closed reduction, conservative management).[3]

The following case report describes the management of a unilateral condylar fracture of a child in mixed dentition.

Case Description

A 9-year-old male patient reported a chief complaint of pain on the opening of the mouth. The patient sustained a fall from a wall while he was playing. No other abnormalities were detected. On clinical extraoral examination, only a bruise was present over the middle of the mental region. Asymmetry is evident as a swelling on the left side. Palpation of TMJ elicited pain on the left side. On opening a slight mandible shift to the right side is evident. The interincisal distance of maximum opening was also compromised (less than 20 mm). An OPG was advised. Radiographic evaluation revealed a unilateral undisplaced fracture on the neck of the left condyle (Figs 1 and 2).

Fig. 1

Clinical picture of the patient

Fig. 2

Preoperative OPG

Immobilization is the mainstay of treatment for condylar fractures. Intermaxillary fixation was planned under local anesthesia. The lower right first primary molar was mobile so extraction was done. Arch bar fixation was planned using firm teeth as anchors for intermaxillary fixation. Four permanent central incisors I (two maxillary, two mandibular) and four primary second molars (E's) (two maxillary, two mandibular) were used as anchor points for maxillo-mandibular fixation. A soft diet was advocated. The patient was recalled for follow-up after 3 weeks. Healing was observed in OPG. Arch bar removal was accomplished (Figs 3 and 4).

Fig. 3

Mouth opening after 3 weeks postoperatively

Fig. 4

Postoperative OPG

In the third-week postoperative follow-up visit, the patient has improved mouth opening and no deviation on opening which shows the improved signs of healing. No evidence of TMJ ankyloses was observed in this case. No adverse outcomes were reported. Arch bar fixation can be safely accomplished in the mixed dentition phase also with firm deciduous teeth and partially erupted permanent teeth. Semirigid fixation using arch bars also greatly improves the outcome in the healing of condylar fractures in children in the mixed dentition phase.

Conclusion

Conservative treatment option of Intermaxillary Fixation (IMF) using Primary molars in the posterior region and permanent incisors in the anterior region can be a cost-effective and less invasive treatment option for pediatric subcondylar fractures in the mixed dentition phase.