Pediatric Mandibular Disorders and Condylar Fractures
Congenital Mandibular Aplasia and Agenesis
Congenital Aplasia or Mandibular Agenesis is often associated with abnormalities of the first branchial arch.
First Branchial Arch Syndromes
Pierre Robin Syndrome: Characterized by micrognathia, cleft palate, and tongue retraction (glossoptosis with pseudomacroglossia).
Treacher Collins Syndrome (Mandibulofacial Dysostosis): Features include micrognathia, deafness, hypoplasia of the average lower third of the face, coloboma in the lower eyelid, ear malformations, and cleft palate.
First and Second Branchial Arch Syndromes
Goldenhar Syndrome: Also known as hemifacial microsomia or unilateral mandibular hypoplasia. This congenital condition accompanies ear alterations and is caused by a default in the migration of neural crest cells.
Juvenile Rheumatoid Arthritis (JRA)
Juvenile Rheumatoid Arthritis is an autoimmune disease characterized by chronic synovitis with the destruction of joint tissue. It affects large and multiple joints and evolves into outbreaks of fever and arthritis with an increased ESR (Erythrocyte Sedimentation Rate). In over 50% of children, rheumatoid arthritis produces destruction of the articular cartilage and condyles.
Patients may develop:
- Micrognathia
- Mandibular asymmetry
- Unilateral open bite
- Reduced capacity for mouth opening
Treatment for JRA
Systemic Treatment: Includes NSAIDs and the steroid Prednisone.
Local TMJ Treatment: Use of an undirected occlusal splint to reduce stress and pain in the condyles. This requires an occlusal reassessment every 6 months, including occlusal cover components.
Classification of Condylar Fractures
- Direct: The trauma occurs directly at the level of the condyle.
- Indirect: The stroke occurs at the chin due to forced mouth opening or cervical traction.
- Subcondylar: Located at the condylar neck. This is a frequent occurrence.
- Greenstick: Common in childhood; these often go unnoticed and are usually caused by indirect mechanisms, such as a fall while cycling.
- Condylar: Located at the head of the condyle. Intracapsular fractures are more problematic, while extracapsular fractures are considered normal.
Rare direct actions in intracapsular fractures may lead to complications such as ankylosis, inhibited lower jaw growth, and craniomandibular dysfunction syndrome. This produces a fracture of the condylar head with no displacement of the fracture fragment.
Treatment Protocols for Condylar Fractures
Subcondylar Greenstick Fractures
Typically occurring in children under 8 years of age, treatment involves immobilization for 20 days, a liquid diet, and analgesics. No intermaxillary fixation (IMF) is required. After 20 days, the patient starts a soft diet with early and progressive mobilization.
Fractures in Children Under 10 Years
- With Displacement: Closed reduction and immobilization for a short period (7–14 days), followed by 6 to 8 weeks of elastic therapy.
- Without Displacement: No surgical intervention or cutting is required.
Fractures in Children Over 10 Years
Treatment is less conservative but retains spontaneous correction capability. Intermaxillary fixation is typically required for 2 to 3 weeks.
Temporomandibular Dysfunction Syndrome
This involves TMJ (Temporomandibular Joint) malfunction, characterized by muscle or articular pain, joint sounds (clicking or popping), and limitation of mobility.