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Mandibular fracture in a neonate: Report of a case
MANDIBULAR
1452 by excessive screw length and penetration through the lingual cortical plate a distance of 4 to 5 nun into the soft tissue near the alveolar crest in the third molar area. Report of Case A 15-year-oldhealthy, white boy was referred for orthognathicsurgeryto correctmandibularhypoplasiaanda Class II malocclusion.Bilateral mandibular sagittal split ramus osteotomieswere performedwithout complications.The osteotomieswere rigidly stabilizedbilaterally with threebicortical screwsplacedat the superiorborder. During drill hole preparationand screwplacement,care was taken to retract the lingual mucoperiostealflaps,usinga Freer elevator. The patient was dischargedthe day of surgery and was seenon a regular basisthereafter. Three weeks after surgery, the patient complainedfor the first time of bilaterallingual nerve parasthesiaand ageusia,which wereimmediatelyconfirmed by clinical examination,includingpinprick, brushstroke,and two-point discrimination. A posteroanteriorradiographof the mandible(Fig 1) showedthat the centerbicortical screws on each sidehad penetratedthe lingual cortex 4 to 5 mm. The patient was scheduledfor surgery the following week for bilateral lingual nerve exploration and repair, and either removal or shorteningof the protruding screws. The lingual nerveswere located in the paralingualsulci medial to the mandibularrami, 0.5 to 1 cm inferior to the superiorborder in the third molar region. Both were firmly attachedto the lingual mandibularperiosteum.In each instance,the overextendedbicortical screwswere found to penetratethe body of the nerve. On the patient’sright side, the free nerve endswere identified and anastamosed with 8-O Vicryl suture.On the left, the nerve wasdissectedfrom the screwand treatedonly by neurolysis.Both screwswere shortenedto a position Aush with the lingual cortex of the mandible.At 8 monthspostoperatively,the patient reported return of sensationin both lingualnervesthat he describedas “nearly normal.” Furthermore,he wasnot able to perceive differencesin stimuli betweenthe right and left nerves.
FRACTURE
Discussion This report describesthe occurrence of bilateral lingual nerve injury as a complication of bicortical screw stabilization of sagittal ramus split osteotomies. The clinical findings suggestthat the causeof these injuries may have been the overpenetration of the bone screws through the lingual cortex, with subsequentimpingement of the lingual nerve on the screws as the soft tissueshealed and became reattached to the mandible. Surprisingly, the patient did not complain of lingual nerve paresthesia until about 3 weeks after surgery, even though he had been counseled preoperatively about this potential complication. Overpenetration of bicortical screws used to stabilize sagittal ramus osteotomies is capable of causing lingual nerve injury. During surgery, care must be taken to minimize penetration into the lingual soft tissues adjacent to the mandible when preparing screw holes and when placing bicortical bone screws. Screws should be of adequate length to engage the lingual cortex, but should not extend beyond it. References 1. White RP Jr, Peters PB, Costich ER, et al: Evaluation of sagittalsplit-ramus osteotomy in 17 patients. J Oral Surg 27:851, 1969 2. Schendel SA, Epker BN: Results after mandibular advancement surgery, and analysis of 87 cases. .I Oral Surg 38:265, 1980 3. Hegtvedt AK, Zuniga JR: Lingual nerve injury as a complication of rigid fixation after sagittal ramus osteotomy. J Oral Maxillofac Surg 48:647, 1990 4. Meyer RA: Protection of the lingual nerve during placement of rigid fixation after sagittal ramus osteotomy. J Oral Maxillofat Surg 48:1135, 1990 [Letters to the Editor] 5. Blakey GH III, Zuniga JR: Lingual nerve injury associated with superior border wire fixation. Int J Adult Orthod Orthognath Surg 7: 115, 1992
J Oral Maxillofac Surg 54:1452-1454, 1996
Mandibular Fracture in a Neonate: Report of a Case M.M. CHIDZONGA,
*Department of Surgery, University of Zimbabwe, School of Medicine, Avondale, Harare, Zimbabwe. Address correspondence and reprint requests to Dr Chidzonga: Department of Surgery, University of Zimbabwe, School of Meditine, Box A178, Avondale, Harare, Zimbabwe. 0 1996 American Association 0278-2391/96/5412-0012$3.00/O
of Oral and Maxillofacial
Surgeons
BDS, FFD, RCSI” The frequency of iaw fractures in children tends to increase with age. In the 0- to l-year age-group (infants), the frequency has been reported to range from 0.9% to 2.6%.’ Although there have been a number of articles written on the management of fractures in children,‘-’ very little has been written on the neonate.“” A review of the literature since 1946r showed
M.M.
CHIDZONGA
only eight cases, in six of whom the cause of the fracture was a traumatic delivery, in one a cesarean section, and in the other the cause was unknown. The purpose of this report is to present the management of a fracture of the mandible in a IO-hour-old neonate using an acrylic splint and circummandibular wiring. Report
of Case
On June 23, 1995, a neonatewas brought to the Neonatal Unit at Harare Hospital, Harare, Zimbabwe, with a complaint of bleeding from the mouth that had started at birth at approximately 3:00 AM that morning. Examination showed that the baby had sustained a gingival laceration along with a fracture of the mandible just to the left of the midline (Fig 1). Radiographs confirmed the fracture (Fig 2). The fracture was grossly displaced, and the fragments were freely moveable. There was hematoma in the floor of the mouth. The history showed that the baby had been born at home. The mother was alone at the time of delivery after 7 hours of labor. Immediately after delivery the child was taken to the local clinic, where bleeding from the oral cavity was noted, and the baby was transferred to the hospital. On admission to hospital, 6 hours later, the baby’s birth weight was recorded as 2.66 kg. All findings confirmed that this was a full-term, healthy baby after an uneventful pregnancy. Further questioning of the mother indicated that she had intended to kill the baby soon after delivery (product of an unwanted pregnancy). She had attempted to suffocate the baby by firmly pressing her hand across the baby’s mouth. This resulted in the fracture of the mandible. The infant was saved by the timely appearance of the housemaid, who alerted the neighbors and rushed both the mother and infant to the local clinic. Preoperatively an alginate impression was made using custom-made wax trays. This was poured in plaster of Paris. The models were sectioned to the desired mandibular position, and an acrylic splint was fabricated using heat-cured acrylic resin. Under general anesthesia, the fracture was re-
FIGURE fracture.
2.
Lateral
oblique
view
of the mandible
showing
the
duced and fixed with the acrylic splint, which was secured by circummandibular wiring on either side of the mandible in the molar region. The left deciduous tooth bud, which was in the fracture line, was removed. No maxillomandibular fixation was used. The patient was placed on antibiotics and analgesics. The splint was removed after 4 weeks, at which time successful union had been achieved. No mobility could be elicited at the fracture line. The infant is feeding well and gaining weight satisfactorily.
Discussion The incidence of jaw fractures in infants (0- to lyear age-group) is very low, and does not exceed 2.6% of all jaw fractures observed during the first decade.‘,4.7 As of a 1994 literature review, only 13 fully documented cases had been reported within a period of almost 50 years, an average of one reported caseevery 4 years. Seven more new cases were recently added to the list. Six of the reported caseswere newborns who were injured during traumatic delivery. The current report is of a newborn (10 hours old on admission to hospital) whose mandible was fractured as a result of an attempted infanticide. This is the first reported case of fractured mandible in a neonate with such a cause. No other injuries were noted, possibly becauseof the timely intervention of the housemaid. The fractured mandible in the child was diagnosed clinically on the basisof the step deformity, hematoma in the floor of the mouth and on the alveolar ridge, as well as the mobility of the fractured segments.Unlike other reported
FIGURE 1. Clinical view the mandible on admission.
showing
grossly
displaced
fracture
of
cases, the clinical
signs and symptoms
were strikingly evident. Infants
are not cooperative,
their
clinical
examina-
1454
SIMPLE
tion is difficult, and the taking of radiographs of good or even reasonable quality is troublesome and sometimes impossible. The current patient is likely to suffer damage to developing tooth germs, both deciduous and permanent, because of the fracture. Because most children described in other reports were followed for 1 year at most, comprehensive comparative assessment of the effects of trauma on dental development has not been possible.” In a case followed for 9 years by Mektubjian,” the mandible developed symmetrically with only loss of the lower left deciduous lateral incisor, a deformed crown of the left central incisor, and absence of the left lateral incisor. Variations in odontogenesis can be expected after trauma, and more aggressive therapy in handling fractures of the neonatal mandible can cause even more serious problems.7-9 The current case is under close follow-up to assess the effect of the trauma on both the mandible and the dentition.
BONE
CYST
OF
THE
MANDIBULAR
CONDYLE
1. Lustman J, Milhem .I: Mandibular fractures in infants: Review of literature and report of seven cases. .I Oral Maxillofac Surg 52:240, 1994 2. Zachariades N, Papavassiliou D, Koumoura F: Fractures of the facial skeleton in children, J Cranio Maxillofac Surg 18:1, 1990 3. Stylogianni L, Arsenopoulos A, Patrikiou A: Fractures of the facial skeleton in children. Br J Oral Maxillofac Sum- 29:23, 1991 4. Keniry AJ: A survey of jaw fractures in children. Br J Oral Surg 8231, 1971 5. Morgan WC: Pediatric mandibular fractures. Oral Surg 40:270, 1975 6. Adekeye EO: Pediatric fractures of the facial skeleton: A survey of 85 cases from Kaduna, Nigeria. J Oral Surg 38:355, 1975 7. Carroll MJ, Hill CM, Mason DA: Facial fractures in children. Br Dent J 163:23, 1987 8. Kaban LB, Mulliken JB, Murray JE: Facial fractures in children: An analysis of 122 fractures in 109 patients. Plast Reconstr Sure 59:15, 1977 9. Priest ?H: Treatment of a mandibular fracture in a neonate. J Oral Maxillofac Surg 47:77, 1989 10. Mektubjian SR: Mandibular fracture in a five-week-old infant. J Oral Maxillofac Surg 43:814, 1985
J Oral Maxillofac Surg 54:1454-1458, 1996
Simple Bone Cyst of the Mandibular Condyle: Report
of a Case
HISASHI TANAKA, MD,* PER-LENNART WESTESSON, MD, PHD, DDS,t AND AMIR H. MARASHI, DDS§ FRED G. EMMINGS, DDS, PHD,$ Different terms have been used to describe the simple bone cyst. These include traumatic bone cyst,’ solitary bone cyst,’ hemorrhagic bone cyst,3 progressive bone cavity: and unicameral bone cyst.’ Most simple bone cysts of the jaw are located in the body or symphysis of the mandible.6 Only a few cases have been reported in the condyle.7-‘4 We encountered a 14-yearold patient with a simple bone cyst in the mandibular Received from the University of Rochester Medical Center, Rochester, NY. * Visiting Assistant Professor, Department of Radiology. 7 Professor, Department of Radiology. $ Professor, Department of Clinical Dentistry. Q Formerly Chief Resident, Oral and Maxillofacial Surgery; currently, in private practice, Mankato, MI. Address correspondence and reprint requests to Dr Tanaka: Department of Radiology, Osaka University, Medical School, Yamadaoka 2-2 Suita, Osaka 565, Japan. 0 1996 American
Association
0278-2391/96/5412-0013$3.00/O
of Oral and Maxillofacial
Surgeons
condyle presenting with a pathologic fracture. This report describes the clinical, radiographic, surgical, and pathologic findings of the case. Report
of Case
The patient was a 14-year-old girl with acute onset of severe pain in the right temporomandibular joint (TMJ). Before this she had been completely asymptomatic. At the time of occurrence she heard a pop in front of the right ear while eating, which was followed by constant sharp pain. On physical examination the next day there was focal tenderness over the right TMJ, without swelling. Mouth opening was painful but not limited. Magnetic resonance (MR) images were obtained with proton density and T2-weighted imaging sequences in the sagittal and coronal planesI and these showed a cystic enlargement (2 x 2 X 2 cm) of the right mandibular condyle and thinning of the cortical outline (Figs 1, 2). The lesion showed homogeneous intermediate signal intensity on proton density-weighted images (Fig 1). On the T2-weighted image, it showed homogeneous high signal
1452 by excessive screw length and penetration through the lingual cortical plate a distance of 4 to 5 nun into the soft tissue near the alveolar crest in the third molar area. Report of Case A 15-year-oldhealthy, white boy was referred for orthognathicsurgeryto correctmandibularhypoplasiaanda Class II malocclusion.Bilateral mandibular sagittal split ramus osteotomieswere performedwithout complications.The osteotomieswere rigidly stabilizedbilaterally with threebicortical screwsplacedat the superiorborder. During drill hole preparationand screwplacement,care was taken to retract the lingual mucoperiostealflaps,usinga Freer elevator. The patient was dischargedthe day of surgery and was seenon a regular basisthereafter. Three weeks after surgery, the patient complainedfor the first time of bilaterallingual nerve parasthesiaand ageusia,which wereimmediatelyconfirmed by clinical examination,includingpinprick, brushstroke,and two-point discrimination. A posteroanteriorradiographof the mandible(Fig 1) showedthat the centerbicortical screws on each sidehad penetratedthe lingual cortex 4 to 5 mm. The patient was scheduledfor surgery the following week for bilateral lingual nerve exploration and repair, and either removal or shorteningof the protruding screws. The lingual nerveswere located in the paralingualsulci medial to the mandibularrami, 0.5 to 1 cm inferior to the superiorborder in the third molar region. Both were firmly attachedto the lingual mandibularperiosteum.In each instance,the overextendedbicortical screwswere found to penetratethe body of the nerve. On the patient’sright side, the free nerve endswere identified and anastamosed with 8-O Vicryl suture.On the left, the nerve wasdissectedfrom the screwand treatedonly by neurolysis.Both screwswere shortenedto a position Aush with the lingual cortex of the mandible.At 8 monthspostoperatively,the patient reported return of sensationin both lingualnervesthat he describedas “nearly normal.” Furthermore,he wasnot able to perceive differencesin stimuli betweenthe right and left nerves.
FRACTURE
Discussion This report describesthe occurrence of bilateral lingual nerve injury as a complication of bicortical screw stabilization of sagittal ramus split osteotomies. The clinical findings suggestthat the causeof these injuries may have been the overpenetration of the bone screws through the lingual cortex, with subsequentimpingement of the lingual nerve on the screws as the soft tissueshealed and became reattached to the mandible. Surprisingly, the patient did not complain of lingual nerve paresthesia until about 3 weeks after surgery, even though he had been counseled preoperatively about this potential complication. Overpenetration of bicortical screws used to stabilize sagittal ramus osteotomies is capable of causing lingual nerve injury. During surgery, care must be taken to minimize penetration into the lingual soft tissues adjacent to the mandible when preparing screw holes and when placing bicortical bone screws. Screws should be of adequate length to engage the lingual cortex, but should not extend beyond it. References 1. White RP Jr, Peters PB, Costich ER, et al: Evaluation of sagittalsplit-ramus osteotomy in 17 patients. J Oral Surg 27:851, 1969 2. Schendel SA, Epker BN: Results after mandibular advancement surgery, and analysis of 87 cases. .I Oral Surg 38:265, 1980 3. Hegtvedt AK, Zuniga JR: Lingual nerve injury as a complication of rigid fixation after sagittal ramus osteotomy. J Oral Maxillofac Surg 48:647, 1990 4. Meyer RA: Protection of the lingual nerve during placement of rigid fixation after sagittal ramus osteotomy. J Oral Maxillofat Surg 48:1135, 1990 [Letters to the Editor] 5. Blakey GH III, Zuniga JR: Lingual nerve injury associated with superior border wire fixation. Int J Adult Orthod Orthognath Surg 7: 115, 1992
J Oral Maxillofac Surg 54:1452-1454, 1996
Mandibular Fracture in a Neonate: Report of a Case M.M. CHIDZONGA,
*Department of Surgery, University of Zimbabwe, School of Medicine, Avondale, Harare, Zimbabwe. Address correspondence and reprint requests to Dr Chidzonga: Department of Surgery, University of Zimbabwe, School of Meditine, Box A178, Avondale, Harare, Zimbabwe. 0 1996 American Association 0278-2391/96/5412-0012$3.00/O
of Oral and Maxillofacial
Surgeons
BDS, FFD, RCSI” The frequency of iaw fractures in children tends to increase with age. In the 0- to l-year age-group (infants), the frequency has been reported to range from 0.9% to 2.6%.’ Although there have been a number of articles written on the management of fractures in children,‘-’ very little has been written on the neonate.“” A review of the literature since 1946r showed
M.M.
CHIDZONGA
only eight cases, in six of whom the cause of the fracture was a traumatic delivery, in one a cesarean section, and in the other the cause was unknown. The purpose of this report is to present the management of a fracture of the mandible in a IO-hour-old neonate using an acrylic splint and circummandibular wiring. Report
of Case
On June 23, 1995, a neonatewas brought to the Neonatal Unit at Harare Hospital, Harare, Zimbabwe, with a complaint of bleeding from the mouth that had started at birth at approximately 3:00 AM that morning. Examination showed that the baby had sustained a gingival laceration along with a fracture of the mandible just to the left of the midline (Fig 1). Radiographs confirmed the fracture (Fig 2). The fracture was grossly displaced, and the fragments were freely moveable. There was hematoma in the floor of the mouth. The history showed that the baby had been born at home. The mother was alone at the time of delivery after 7 hours of labor. Immediately after delivery the child was taken to the local clinic, where bleeding from the oral cavity was noted, and the baby was transferred to the hospital. On admission to hospital, 6 hours later, the baby’s birth weight was recorded as 2.66 kg. All findings confirmed that this was a full-term, healthy baby after an uneventful pregnancy. Further questioning of the mother indicated that she had intended to kill the baby soon after delivery (product of an unwanted pregnancy). She had attempted to suffocate the baby by firmly pressing her hand across the baby’s mouth. This resulted in the fracture of the mandible. The infant was saved by the timely appearance of the housemaid, who alerted the neighbors and rushed both the mother and infant to the local clinic. Preoperatively an alginate impression was made using custom-made wax trays. This was poured in plaster of Paris. The models were sectioned to the desired mandibular position, and an acrylic splint was fabricated using heat-cured acrylic resin. Under general anesthesia, the fracture was re-
FIGURE fracture.
2.
Lateral
oblique
view
of the mandible
showing
the
duced and fixed with the acrylic splint, which was secured by circummandibular wiring on either side of the mandible in the molar region. The left deciduous tooth bud, which was in the fracture line, was removed. No maxillomandibular fixation was used. The patient was placed on antibiotics and analgesics. The splint was removed after 4 weeks, at which time successful union had been achieved. No mobility could be elicited at the fracture line. The infant is feeding well and gaining weight satisfactorily.
Discussion The incidence of jaw fractures in infants (0- to lyear age-group) is very low, and does not exceed 2.6% of all jaw fractures observed during the first decade.‘,4.7 As of a 1994 literature review, only 13 fully documented cases had been reported within a period of almost 50 years, an average of one reported caseevery 4 years. Seven more new cases were recently added to the list. Six of the reported caseswere newborns who were injured during traumatic delivery. The current report is of a newborn (10 hours old on admission to hospital) whose mandible was fractured as a result of an attempted infanticide. This is the first reported case of fractured mandible in a neonate with such a cause. No other injuries were noted, possibly becauseof the timely intervention of the housemaid. The fractured mandible in the child was diagnosed clinically on the basisof the step deformity, hematoma in the floor of the mouth and on the alveolar ridge, as well as the mobility of the fractured segments.Unlike other reported
FIGURE 1. Clinical view the mandible on admission.
showing
grossly
displaced
fracture
of
cases, the clinical
signs and symptoms
were strikingly evident. Infants
are not cooperative,
their
clinical
examina-
1454
SIMPLE
tion is difficult, and the taking of radiographs of good or even reasonable quality is troublesome and sometimes impossible. The current patient is likely to suffer damage to developing tooth germs, both deciduous and permanent, because of the fracture. Because most children described in other reports were followed for 1 year at most, comprehensive comparative assessment of the effects of trauma on dental development has not been possible.” In a case followed for 9 years by Mektubjian,” the mandible developed symmetrically with only loss of the lower left deciduous lateral incisor, a deformed crown of the left central incisor, and absence of the left lateral incisor. Variations in odontogenesis can be expected after trauma, and more aggressive therapy in handling fractures of the neonatal mandible can cause even more serious problems.7-9 The current case is under close follow-up to assess the effect of the trauma on both the mandible and the dentition.
BONE
CYST
OF
THE
MANDIBULAR
CONDYLE
1. Lustman J, Milhem .I: Mandibular fractures in infants: Review of literature and report of seven cases. .I Oral Maxillofac Surg 52:240, 1994 2. Zachariades N, Papavassiliou D, Koumoura F: Fractures of the facial skeleton in children, J Cranio Maxillofac Surg 18:1, 1990 3. Stylogianni L, Arsenopoulos A, Patrikiou A: Fractures of the facial skeleton in children. Br J Oral Maxillofac Sum- 29:23, 1991 4. Keniry AJ: A survey of jaw fractures in children. Br J Oral Surg 8231, 1971 5. Morgan WC: Pediatric mandibular fractures. Oral Surg 40:270, 1975 6. Adekeye EO: Pediatric fractures of the facial skeleton: A survey of 85 cases from Kaduna, Nigeria. J Oral Surg 38:355, 1975 7. Carroll MJ, Hill CM, Mason DA: Facial fractures in children. Br Dent J 163:23, 1987 8. Kaban LB, Mulliken JB, Murray JE: Facial fractures in children: An analysis of 122 fractures in 109 patients. Plast Reconstr Sure 59:15, 1977 9. Priest ?H: Treatment of a mandibular fracture in a neonate. J Oral Maxillofac Surg 47:77, 1989 10. Mektubjian SR: Mandibular fracture in a five-week-old infant. J Oral Maxillofac Surg 43:814, 1985
J Oral Maxillofac Surg 54:1454-1458, 1996
Simple Bone Cyst of the Mandibular Condyle: Report
of a Case
HISASHI TANAKA, MD,* PER-LENNART WESTESSON, MD, PHD, DDS,t AND AMIR H. MARASHI, DDS§ FRED G. EMMINGS, DDS, PHD,$ Different terms have been used to describe the simple bone cyst. These include traumatic bone cyst,’ solitary bone cyst,’ hemorrhagic bone cyst,3 progressive bone cavity: and unicameral bone cyst.’ Most simple bone cysts of the jaw are located in the body or symphysis of the mandible.6 Only a few cases have been reported in the condyle.7-‘4 We encountered a 14-yearold patient with a simple bone cyst in the mandibular Received from the University of Rochester Medical Center, Rochester, NY. * Visiting Assistant Professor, Department of Radiology. 7 Professor, Department of Radiology. $ Professor, Department of Clinical Dentistry. Q Formerly Chief Resident, Oral and Maxillofacial Surgery; currently, in private practice, Mankato, MI. Address correspondence and reprint requests to Dr Tanaka: Department of Radiology, Osaka University, Medical School, Yamadaoka 2-2 Suita, Osaka 565, Japan. 0 1996 American
Association
0278-2391/96/5412-0013$3.00/O
of Oral and Maxillofacial
Surgeons
condyle presenting with a pathologic fracture. This report describes the clinical, radiographic, surgical, and pathologic findings of the case. Report
of Case
The patient was a 14-year-old girl with acute onset of severe pain in the right temporomandibular joint (TMJ). Before this she had been completely asymptomatic. At the time of occurrence she heard a pop in front of the right ear while eating, which was followed by constant sharp pain. On physical examination the next day there was focal tenderness over the right TMJ, without swelling. Mouth opening was painful but not limited. Magnetic resonance (MR) images were obtained with proton density and T2-weighted imaging sequences in the sagittal and coronal planesI and these showed a cystic enlargement (2 x 2 X 2 cm) of the right mandibular condyle and thinning of the cortical outline (Figs 1, 2). The lesion showed homogeneous intermediate signal intensity on proton density-weighted images (Fig 1). On the T2-weighted image, it showed homogeneous high signal