Combined Symphyseal and Condylar Fractures: Considerations for Treatment in Pediatric Patients

Abstract

BACKGROUND: Combined symphyseal-condylar mandible fractures represent a unique, unstable injury pattern that can cause significant morbidity in pediatric patients. However, this particular mandibular injury pattern has not been well characterized in children. Given the complex biomechanics of the mandibular symphysis and the importance of the condyles in long-term mandibular growth and occlusal development, focused study of pediatric symphyseal-condylar fractures is important.1,2 This study investigated the etiology and management of symphyseal-condylar fractures in pediatric patients, in order to provide treatment recommendations to improve long-term outcomes. METHODS: This was a retrospective cohort study of pediatric patients with symphyseal-condylar mandibular fractures both at our institution between 1990 and 2019 and nation-wide (identified in the Healthcare Cost and Utilization Project Kid Inpatient Database) between 2000 and 2016. Two-tailed Mann–Whitney U and Fischer’s exact analyses were used to compare demographic and clinical factors as well as incidence of complications between patients in each dentition stage in our institutional dataset. Also, multiple logistic regression with forward stepwise selection of predictor variables was used to generate adjusted odds ratios for complications, and a treatment algorithm was proposed. National data on pediatric symphyseal/condylar fractures between 2012 and 2016 abstracted from Healthcare Cost and Utilization Project Kid Inpatient Database were used to confirm recommendations in the proposed treatment algorithm using chi square analyses. Additionally, a logistic regression model was used to evaluate the proposed treatment algorithm, by predicting odds of complications based on adherence or nonadherence to the algorithm for patients in each dentition stage. Concordance statistics were used to evaluate model robustness. RESULTS: Twenty-one patients at our institution and 1,708 national database patients met inclusion criteria. At our institution, 26.7% of deciduous dentition patients underwent ORIF, 40% underwent closed treatment (MMF), and 33.3% were treated with soft diet. All mixed dentition patients underwent either ORIF or closed treatment (MMF); all permanent dentition patients underwent ORIF. In the national cohort, most permanent dentition patients (88.7%) underwent ORIF, while most mixed dentition patients (79.2%) underwent closed treatment. Among deciduous dentition patients in the national cohort, 53.5% patients were treated with soft-diet and 38% with closed treatment. At our institution, the overall post-treatment complication rate was 62.5% among ORIF patients, 14.3% among closed treatment patients, and 16.7% among patients treated with soft diet. The most common complications were temporomandibular joint dysfunction (50%) and malocclusion (37.5%). A treatment algorithm was developed using study data; algorithm adherence significantly decreased odds of complications (odds ratio, 0.03; 95% CI, 0.001–0.6; P = 0.03). CONCLUSIONS: Symphyseal-condylar fractures were associated with substantial morbidity in children. Using the data from both our institution as well as from review of a national database, we proposed a treatment algorithm, stratified by dentition stage, in order to guide treatment for children who present with this complex fracture type. REFERENCES: 1. Wolfswinkel EM, Weathers WM, Wirthlin JO, et al. Management of pediatric mandible fractures. Otolaryngol Clin North Am. 2013;46:791–806. 2. Cole P, Kaufman Y, Hollier L. Managing the pediatric facial fracture. Craniomaxillofacial Trauma Reconstr. 2009;2:077–083.