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CASE REPORT
Year : 2018  |  Volume : 36  |  Issue : 2  |  Page : 220-222
 

Arrested root growth and concomitant failure of eruption of a developing tooth following open reduction and internal fixation of a pediatric mandibular fracture


1 Oral Health Sciences Centre, Unit of Pedodontics and Preventive Dentistry, PGIMER, Chandigarh, India
2 Oral Health Sciences Centre, Unit of Oral and Maxillofacial Surgery, PGIMER, Chandigarh, India

Date of Web Publication2-Jul-2018

Correspondence Address:
Morankar Rahul
Room. No 202, Unit of Pedodontics and Preventive Dentistry, Oral Health Sciences Centre, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_228_17

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   Abstract 


Mandible is one of the commonly fractured bone in children during maxillofacial trauma. These factures are usually managed conservatively but sometimes require open reduction and internal fixation (ORIF). Management of mandibular fracture in children is influenced by the presence of developing permanent tooth buds, minimal anchorage from primary teeth and facial growth and development. Although, there have been technical and material advancements with ORIF, it is still associated with complications related to growth and damage to developing teeth. This case report describes a case of mandibular parasymphyseal fracture managed successfully with open reduction and internal fixation using a miniplate and a consequent cessation of root growth and eruption failure of a mandibular canine present in the fixation area.


Keywords: Mandibular fracture, open reduction and internal fixation, complications, root growth


How to cite this article:
Rahul M, Ashima G, Akshat G. Arrested root growth and concomitant failure of eruption of a developing tooth following open reduction and internal fixation of a pediatric mandibular fracture. J Indian Soc Pedod Prev Dent 2018;36:220-2

How to cite this URL:
Rahul M, Ashima G, Akshat G. Arrested root growth and concomitant failure of eruption of a developing tooth following open reduction and internal fixation of a pediatric mandibular fracture. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Dec 5];36:220-2. Available from: http://www.jisppd.com/text.asp?2018/36/2/220/235682





   Introduction Top


Maxillofacial fractures are relatively uncommon in a pediatric population. Children because of their light weight and a small size of facial skeleton are less severely affected by maxillofacial trauma. A greater cranial volume compared to their facial skeleton in children make them less susceptible to facial fractures.[1] The mandible is the second most commonly fractured facial bone in pediatric patients after the nasal bone. The treatment of mandibular fractures in children is influenced by several factors such as developing permanent tooth germ, shorter roots of primary teeth, and facial growth and development.

Pediatric mandibular fractures can be treated by a variety of fixation methods. The goal of any treatment should be the accurate reduction and restoration of preexisting form and function. Incomplete and undisplaced fractures as well as fractures involving subcondylar region are usually managed conservatively with closed reduction methods.[2] However, displaced fractures show better outcome with open reduction and internal fixation (ORIF) techniques. Although rigid fixation techniques for the management of facial fractures have been evolved since long, their use in children is somewhat controversial. There are evidence suggesting the use of nonresorbable plates in the mandible of a growing child lead to disruption of the functional bone matrix and mandibular growth centers.[3] ORIF has the potential to cause disturbance in permanent tooth development due to damage to their pulp and interference with their root growth.[4],[5] Therefore, the decision to use an invasive approach in children should be considered with great caution and only if other means of reduction and fixation are not possible.

The present case report describes a case of pediatric mandibular fracture managed by ORIF using a miniplate leading to a retarded root growth and failure of eruption of a permanent mandibular canine.


   Case Report Top


An 8-year-old child reported to the Oral Health Sciences Center, PGIMER, Chandigarh, with the chief complaint of inability to open mouth and swelling on the right side of the face. The patient had met with a road traffic accident 2 weeks back leading to trauma to the maxillofacial region. The trauma had resulted in bleeding from mouth and exfoliation of mandibular primary incisor teeth. There was no history of unconsciousness, vomiting, or seizures. The patient immediately consulted at a local hospital where primary stabilization of fracture was carried out with help of interdental wiring and intermaxillary fixation (IMF). The IMF was removed after 12 days; however, facial swelling still persisted and a reduction in the mouth opening had occurred since trauma, for which patient reported to the Oral Health Sciences Center, PGIMER, Chandigarh. Extraoral examination revealed swelling involving the right side of face leading to facial asymmetry. There was deviation of the chin to the right side on closing. Intraoral examination revealed protrusion of upper incisors and deranged occlusion. The primary mandibular incisors were missing and 42 was displaced and mobile due to trauma. The radiographic examination [Figure 1] revealed a malunited mandibular right parasymphyseal fracture with bone loss.
Figure 1: Three-dimensional facial computed tomography showing right mandibular parasymphysis fracture

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Considering the malunion of fracture and bone loss at the fracture site, it was decided to refracture the mandible followed by ORIF with miniplate [Figure 2] under general anesthesia. A single miniplate (1.8 mm, Ortho Max locking type, 4 holed) was fixed with four screws (1.8 mm system, 6 mm length) along the inferior border of the mandible at the fracture site. Extraction of 42 was carried out due to its poor prognosis.
Figure 2: A single miniplate fixed along right mandibular parasyphysis at inferior border

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The patient was kept under follow-up and oral hygiene instructions were given. The follow-up radiograph [Figure 3] after 5 years revealed complete healing of fracture site with bone formation. The miniplate with screws was fixed very close to the developing tooth germ of 43 which did not show any signs of root development and eruption thereafter compared to contralateral 33 which has erupted with normal development.
Figure 3: An arrested root development and failure of eruption with mandibular permanent right canine (43) compared to contralateral left canine after 5 years of follow-up

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The miniplate remained fixed in the jaw for almost 5 years and as the parents wanted the miniplate to be removed and not left in the jaw permanently, it was decided to remove the miniplate under general anesthesia. At the same time, 43 was also extracted as it was neither showing any root development nor any sign of eruption during 5-year follow-up period. The extracted 43 show an abnormal root morphology with deformation [Figure 4] in the apical half of the root.
Figure 4: Miniplate with screws after removal. An arrested apical half of the root with abnormal morphology

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   Discussion Top


Waldron et al. were the first to set a paradigm for the conservative management of facial fractures in children.[6] However, in children, the treatment of facial fracture today is different than it was in 1943. The principles, techniques, and materials have attained great development over the past 74 years. Therefore, the type of treatment modality to be used for the management of mandibular fracture in pediatric population is debatable. One has to choose between conservative options such as arch bars, acrylic splints, interdental wiring, and among ORIF methods. Those advocate conservative methods for the management of pediatric mandibular fractures are of the opinion that open reduction can put the growing patient at an increased risk. Nevertheless, some consider the precise anatomic reduction and internal fixation to be the best method for complex facial trauma in children.[7]

Although there have been advancements in the techniques and materials used for ORIF, it is still associated with a number of complications including increased risk of damage to the developing teeth and disturbance related to the growth centers.[8] The child in the present case report was brought to us 12 days after the trauma. An attempt had already been made in trying to fix the fracture by conservative means leading to malunion and deranged occlusion. Thus, it was necessary to refracture the mandible so that it could be reduced and stabilized in its correct position. The fracture was comminuted with bone loss and avulsion of multiple primary teeth. Conservative management by the means of arch bar or open cap splint was not possible. The malunited site was refractured and stabilized with ORIF using miniplate. This promised precise anatomic reduction and internal fixation compared to other conservative means of reduction which would have resulted in contour deformities and malunion necessitating the subsequent need of secondary reconstruction.

In the present case, complications related to root development and eruption of 43 could be a result of direct physical damage to Hertwig's epithelial root sheath caused by the screws used for miniplate fixation. The results of this case report revealed that open reduction and fixation method using miniplate and screws for the management of mandibular fracture in a child patient can damage the developing tooth buds and lead to an arrested root growth. Conservative methods of management should the preference in the pediatric population, but in situ ations where ORIF methods are absolutely necessary, the position of developing tooth buds must be evaluated before fracture fixation.


   Conclusion Top


ORIF can be successfully used for management of mandibular fractures in children. The possible complications related to its use in a pediatric population should be weighed against its advantages before treatment planning to achieve maximum benefit with minimum postoperative complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wong GB. Paediatric mandibular fracture treated by rigid internal fixation. J Can Dent Assoc 1993;59:759-64.  Back to cited text no. 1
[PUBMED]    
2.
Kaban LB. Diagnosis and treatment of fractures of the facial bones in children 1943-1993. J Oral Maxillofac Surg 1993;51:722-9.  Back to cited text no. 2
[PUBMED]    
3.
Aizenbud D, Hazan-Molina H, Emodi O, Rachmiel A. The management of mandibular body fractures in young children. Dent Traumatol 2009;25:565-70.  Back to cited text no. 3
[PUBMED]    
4.
Crean ST, Sivarajasingam V, Fardy MJ. Conservative approach in the management of mandibular fractures in the early dentition phase. A case report and review of the literature. Int J Paediatr Dent 2000;10:229-33.  Back to cited text no. 4
[PUBMED]    
5.
Ranta R, Ylipaavalniemi P. The effect of jaw fractures in children on the development of permanent teeth and the occlusion. Proc Finn Dent Soc 1973;69:99-104.  Back to cited text no. 5
[PUBMED]    
6.
Waldron CW, Balkan SG, Peterson RG. Fractures of the facial bones in children. J Oral Surg 1943;1:215-8.  Back to cited text no. 6
    
7.
Posnick JC, Wells M, Pron GE. Pediatric facial fractures-evolving patterns of treatment. J Oral Maxillofac Surg 1993;51:836-44.  Back to cited text no. 7
[PUBMED]    
8.
Khitab U, Khan A, Khan MT. The outcome of rigid internal fixation of mandibular fractures – A retrospective study. Pak Oral Dent J 2009;29:207-10.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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