Plastic Surgery Research Council
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PSRC 60th Annual Meeting

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Management of Pediatric Condylar and Subcondylar Fractures: The Algorithmal Impact of Concomitant Mandibular Arch Fractures
Ali Ghasemzadeh, BS1, Gerhard S. Mundinger, MD2, Alan F. Utria, BA1, Amir H. Dorafshar, MBChB2.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Johns Hopkins Hospital, Baltimore, MD, USA.

PURPOSE: The management of pediatric condylar and subcondylar fractures (CSC) is complicated by the need to preserve mandibular growth and development, as well as achieve adequate fracture reduction to prevent temporomandibular joint (TMJ) disturbance. This study examines the differences in treatment between isolated CSC fractures and CSC fractures with concomitant fractures of the mandibular arch, defined as fractures of the ramus, angle, body, parasymphysis, and/or symphysis.
METHODS: Retrospective chart review was performed for all patients between the ages of 0 and 18 presenting to the Johns Hopkins Hospital with mandibular CSC from 1990-2010. Demographic, surgical management, hospital course, and complication data was gathered. Computed tomographic (CT) imaging was reviewed for all patients to confirm mandibular fracture pattern, characteristics, and displacement. Identified mandibular fractures were codified and graded using the Strasbourg Osteosynthesis Research Group and Lindahl classification methods. For arch fractures, maximum cortical step-off (either lingual or buccal) was determined in millimeters. Statistical analysis was performed using two-tailed student’s t-tests and chi square tests. Loess curve analysis was used to determine fracture displacement cutoffs. All statistical analyses were performed with STATA 12.0 software.
RESULTS: A total of 55 patients with 77 CSC fractures were identified. 43 additional mandibular arch fractures were found in this patient population (total mandibular fracture n=120). There were 25 (45.5%) patients with isolated CSC fractures and 30 (54.5%) patients with one or more CSC fracture and at least one concomitant mandibular arch fracture. Mandibular arch fracture locations included the ramus (n=2), angle (n=3), body (n=8), parasymphysis (n=20), and symphysis (n=6). Fifteen patients (60%) with isolated CSC fractures were treated with conservative therapy (range of motion exercises and soft diet), compared to only 4 patients (13%) with concomitant fractures of the mandibular arch (p<0.001). Seventeen of 30 patients (57%) with CSC and mandibular arch fractures received ORIF of their mandibular arch fracture(s). Eleven patients (78.5%) with CSC fractures and concomitant mandibular arch fracture with maximum cortical displacement greater than 3mm were treated with open reduction and internal fixation (ORIF) compared to 6 patients (37.5%) with less than 3mm displacement (p<0.001). No patients with isolated CSC fractures were treated with ORIF regardless of level of fracture displacement. Median follow up was 69 days. Differences in complication rates between patients with CSC and arch fractures receiving conservative treatment (n=2, 5.7%), maxillomandibular fixation (MMF, n=1, 2.9%), or arch fracture ORIF (n=5, 14.3%) were not statistically significant (p=0.19).
CONCLUSION: Pediatric CSC can be successfully managed with conservative therapy or a short course of MMF regardless of degree of fracture displacement or the presence of additional mandible fractures. Dental arch fractures with concomitant CSC fractures may require ORIF. In this setting, our data suggests that 3mm of maximum cortical arch displacement is an indication for ORIF, which can be achieved with low morbidity.


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