Mandibular fracture: clinical guidelines

List of Abbreviations

BP – blood pressure

HBO – hyperbaric oxygenation

SSI – surgical site infection

MFT – facial bones

GI – gastrointestinal tract

LFA – lower facial area

PAP – perioperative antibiotic prophylaxis

MFR – maxillofacial region

MFT – maxillofacial trauma

TBI – traumatic brain injury

Con – concussion

TBI – traumatic brain injury

Terms and Definitions

Anterograde amnesia – loss of memory for events, experiences, and facts occurring in the period following the acute phase of the illness, often against the background of lingering impaired consciousness from the acute stage.

Congrade amnesia – complete or partial loss of memory for events of the acute phase of the illness (the period of impaired consciousness).

Retrograde amnesia – loss of memory for impressions and events preceding the acute period of the illness or injury.

Anisocoria – a condition characterized by unequal pupil sizes, sometimes accompanied by slight pupillary distortion.

Intraoral access is a type of surgical approach performed by sequential dissection of the oral mucosa, periosteum, and sometimes deeper layers of soft tissues to visualize the jaw.

Oral hygiene is a set of measures aimed at reducing the amount of dental deposits.

Closed fracture of the mandible – a type of fracture in which the fracture line does not communicate with the external environment through a skin wound, a wound (tear) of the oral mucosa, or through the periodontal space of a tooth.

Fracture line is a planar image of the fracture plane on a radiograph.

External access is a type of surgical approach performed by sequential dissection of the skin, subcutaneous adipose tissue, and deeper layers of soft tissues to visualize the jaw.

Osteosynthesis is the connection of bone fragments during a fracture or reconstructive surgery using various types of hardware (wire suture, bone miniplate, etc.)

Extra-focal osteosynthesis – osteosynthesis in which the fixation device is located outside the fracture line.

Open osteosynthesis is osteosynthesis with dissection of soft tissues and exposure of the bone in the fracture area.

Focal osteosynthesis – osteosynthesis in which the fixation device crosses the fracture line.

Open fracture of the mandible – a type of fracture in which the fracture line communicates with the external environment through a skin wound, a wound (tear) of the oral mucosa, or through the periodontal space of a tooth.

Bone fragment reposition is a procedure aimed at aligning the fragments of a fractured bone

Positive loading sign is the appearance of sharp pain in the fracture area due to the displacement of fragments and irritation of the damaged periosteum when pressing on a knowingly undamaged area of the jaw.

Epiphysiolysis is a disruption of bone integrity along a line that completely or partially passes through the cartilaginous epiphyseal plate (growth plate).

Subperiosteal fracture, "greenstick" fracture — a transverse tear (fracture) of the cortical layer on one side of the jaw (more often the ramus) without fracturing the opposite cortical layer.

Pathological fracture is a fracture resulting from a force that does not exceed physiological levels (chewing food), in the event of decreased bone strength due to thinning in certain conditions (neoplasms, cysts, fibrous dysplasia, chronic odontogenic osteomyelitis, etc.)

Traumatic fracture occurs as a result of a force exceeding the plastic limits of the bone tissue.

Jaw immobilization is the fixation of jaw fragments in the correct position for the period necessary for their fusion (consolidation), i.e., until callus formation.

1. Brief information on the disease or condition

In the prenatal period, the mandible consists of two halves connected by connective tissue. After birth, in the neonatal period, fusion of the mandible begins, which ends approximately by the end of the first year of life. By this time, the mandible has a body and an alveolar process, but due to the absence of teeth, it is poorly developed. The ramus of the jaw is wide and short, and the condylar process is located almost at the level of the alveolar process. Subsequently, simultaneously with the body of the jaw, the rami develop and the condyles form [76,80,104].

In terms of its chemical composition, a child's bone tissue is characterized by a high content of water and organic substances, and a lower content of minerals. The ratio of compact to spongy substance of the jawbone varies at different age periods. Before birth, this ratio is 1:3, and after birth, 1:4. The fibrous structure and chemical composition provide greater elasticity of bones during compression and bending, and lower brittleness compared to adults. The periosteum in children is thicker, especially its inner layer, which is why fractures are often "subperiosteal," of the greenstick type (when the inner dense bone fragment "breaks" and the periosteum is peeled off), which is the most typical fracture of the mandible in younger age groups [83,104].

In newborns and infants, radiographs show a well-defined structure of the jaw body and its rami, and main bone trabeculae can be distinguished. The spongy substance of the jaws in a 6-month-old child is located in the area of deciduous molar tooth buds. The area of spongy bone is small, and the substance itself is poorly differentiated. Accelerated growth of the spongy substance occurs between the ages of 6 months and 3 years, i.e., during the eruption of primary teeth. At 1-2 years of age, signs of functional structural remodeling of the bone appear, and it noticeably increases in size. From 3 to 9 years, intensive remodeling of the spongy substance takes place. The thickness of the compact bone substance of the jaw steadily increases as the child grows and reaches 2 mm by the age of 6. By 13-15 years, the amount of compact substance increases by 2–3 times. From this age, the ratio of compact to spongy bone substance begins to shift towards an increase in compact substance.

The growth of the jawbones is uneven: most intensively during periods of tooth eruption. Pronounced growth of the mandible is observed at the age of 2.5 to 4 and 9 to 12 years. The mandibular ramus grows intensively at the ages of 3-4 and 9-11 years. The growth of the frontal sections of the alveolar processes basically ends by 6-7 years, when the eruption of permanent teeth begins.

Further growth of the jaw occurs mainly in the lateral sections and the ramus region, basically ending by 15-17 years, when tooth eruption and the formation of the permanent occlusion are completed. At this time, the bone structure of the jaw reaches the highest degree of differentiation. By the time the third permanent molars erupt, jaw growth is already complete. The main growth zones of the mandible are the condyles, the posterior parts of the jaw body (in the area of the molars), the angles, and the upper parts of the ramus [77, 92,104,105].

1.1 Definition of the disease or condition

A jaw fracture is defined as a violation of the integrity of all its bone structures.

Trauma (from Greek "trauma" — wound) refers to the impact of environmental factors on the human body that disrupt the anatomical integrity and physiological functions of organs and tissues, accompanied by local and general reactions of the body. [4,5,7,75,76].

Maxillofacial trauma in children is accompanied not only by significant damage in the acute period, but also by consequences associated with delayed development and growth of facial and jaw tissues, causing persistent post-traumatic deformities [79,83].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

All parents sooner or later encounter childhood injuries. A child may receive their first maxillofacial injury during childbirth as a result of mechanical damage; such an injury is called a birth injury. The cause can be precipitous or prolonged labor, a large fetal head size relative to the pelvis, artificial delivery assistance, or any methods of labor augmentation. Typical injuries of the newborn include fractures of the skull and maxillofacial bones, soft tissue injuries of the face and head, as well as facial nerve injury [80,82,84].

M.P. Vodolatsky states that 0.86% of newborns in the maternity hospital are diagnosed with maxillofacial tissue injuries, including mandibular fractures, especially in the condylar process region; a number of other authors point to similar data [80,86,87,92,97].

The nature of maxillofacial injuries largely depends on the child's age. Unlike an adult, a child has a lower body weight and height, which softens the impact of the traumatic force. Children's bones are thinner and less durable, but more elastic than those of adults; therefore, bone fractures from falls occur more frequently in adults. Elasticity and flexibility are due to a lower mineral salt content in the child's bones, as well as increased extensibility of the periosteum, which in children is thicker and has an abundant blood supply. The periosteum forms an elastic sheath around the bone, providing it with greater flexibility and "protecting" it during trauma. These anatomical features, on the one hand, prevent and reduce the frequency of bone fractures in children, and on the other hand, determine skeletal injuries typical of childhood: subperiosteal (greenstick) fractures, epiphysiolysis, and osteoepiphysiolysis.

Among the causes of maxillofacial trauma in children, domestic injuries rank first in prevalence. This is due to the fact that safe conditions for a child are not always created at home, and children require special attention and control from parents because they lack sufficient skills in handling surrounding objects and household appliances, and cannot realistically assess a hazardous situation. Road traffic accidents rank second [78,79,103].

Older children, especially adolescents, are characterized by falls from a height, motor vehicle accidents, falls from scooters and bicycles, sports injuries, as well as injuries resulting from blows to the face due to hooliganism. Gunshot fractures of the jawbones, like other facial bones, are not typical for childhood and have been noted in isolated observations [76,83].

The mechanisms of mandibular fracture occurrence are: bending, less commonly compression and shear, and extremely rarely avulsion.

A traumatic fracture of the mandible usually occurs as a result of an impact force that exceeds the physical capacity of the bone tissue.

Four mechanisms of mandibular fracture are distinguished: bending, shear, compression, avulsion.

The mandible, having an arched shape, experiences increased stress in its most curved or thin areas under mechanical impact. Within the mandible, these are: the base and neck of the condylar process, the angle of the jaw, the region of the mental foramen and canine, and less commonly the symphysis of the jaw. It is in these vulnerable "weak" spots that the fracture of the jaw occurs due to its bending.

The shear mechanism is realized when a force is applied to a section of bone that lacks support—that is, counteraction to the force—and it is displaced (sheared) relative to another section of this bone that has support. As a result of shear, a longitudinal fracture of the mandibular ramus occurs if a force directed from bottom to top is applied to the base of the mandible anterior to its angle on a narrow section (in the projection of the coronoid process). The anterior part of the mandibular ramus is displaced upwards relative to the posterior part, which has support in the articular fossa. This is possible in the absence of molars and premolars on the mandible or their antagonists (on the fracture side), as well as in the complete edentulism of the upper and lower jaws and if at the moment of impact the patient's mouth was semi-open. The shear mechanism is also possible in fractures of the mandibular body. If a force is applied to the base of the jaw from bottom to top in an edentulous area, lacking support, it may be displaced upwards relative to the area that has teeth and, consequently, support.

The compression mechanism can manifest if the acting and reacting forces are directed towards each other. When a blow is delivered from bottom to top to the base of the mandibular body in the angle region over a wide area, the mandibular ramus, fixed in the articular fossa, undergoes compression, as a result of which it breaks transversely—most commonly in the middle section. The avulsion mechanism can manifest when the impact force is directed from top to bottom onto the chin region while the patient's teeth are tightly clenched. In this case, a reflexive contraction of all masticatory muscles occurs. The powerful temporalis muscle, being attached to the thin coronoid process over a significant area, tears it away from the mandibular ramus. Not all authors recognize the plausibility of such a mechanism of coronoid process fracture.

Sometimes the jaw breaks under the influence of a force that does not exceed physiological limits (e.g., during chewing). This is possible in cases of bone thinning due to certain conditions (malignant tumor, cystic neoplasm, dysplasia, chronic osteomyelitis, etc.). In this situation, the fracture is defined as pathological.

1.3 Epidemiology of the Disease or Condition

Maxillofacial tissue injuries in children rank second in frequency after inflammatory diseases, accounting for up to 25% of all emergency patients requiring inpatient treatment. Jaw fractures in children are noted at all age periods, but the majority of them occur in the late and partially early middle school age period (6–12 years)—over 60%.

In the preschool age period (3–6 years) and especially the early childhood period (1–3 years), jaw injuries are noted less frequently—collectively no more than 25%. Subperiosteal fractures are more typical for younger age groups and are practically absent in children over 10–11 years of age. Single mandibular fractures are noted in 80% of observations, double in 15%, and the rest account for triple and multiple jaw fractures [83].

1.4 Features of Coding the Disease or Condition

According to ICD-10

S02.6 Fracture of mandible

S02.60 Closed fracture of mandible

S02.61 Open fracture of mandible

According to ICD-11

NA02.70 Fracture of condylar process of mandible

NA02.71 Fracture of subcondylar process of mandible

NA02.72 Fracture of coronoid process of mandible

NA02.73 Fracture of ramus of mandible

NA02.74 Fracture of angle of mandible

NA02.75 Fracture of alveolar border of mandible

NA02.76 Fracture of symphysis of mandible

NA02.7Y Other specified fractures of mandible

NA02.7Z Fracture of mandible, unspecified

1.5 Classification of the disease or condition

Classification by B.D. Kabakov and V.A. Malyshev [15].

A. By localization:

I. Fractures of the body of the jaw:

a) with a tooth present in the fracture line,

b) in the absence of a tooth in the fracture line.

II. Fractures of the ramus of the jaw:

a) of the ramus proper,

b) of the coronoid process,

c) of the condylar process: base, neck, head.

B. By the nature of the fracture:

a) without displacement of fragments, with displacement of fragments,

b) linear, comminuted.

This classification can also be taken as a basis in pediatric practice.

Depending on the direction of the fracture line, it is subdivided into longitudinal, transverse, oblique, and fenestrated. In addition, it can be large- and small-comminuted.

A fracture may occur at the site of force application, in which case it is called direct; if it occurs at some distance from the impact site or on the opposite side, it is indirect or reflected.

By quantity, single, double, and multiple fractures are distinguished. They can be located on one side of the jaw (unilateral) or on both sides (bilateral). Single fractures are more common than double ones, and multiple fractures are less common than single and double ones.

Fractures within the body of the mandible within the dental arch are generally open, since the mucous membrane of the alveolar part of the jaw is immobile and, in the event of fragment displacement, is damaged along with the periosteum, with the fracture line communicating with the oral cavity. In addition, if the fracture passes through the tooth socket, its periodontium is partially or completely ruptured, leading to tooth dislocation (root fracture is also possible). In this case, the bone wound always communicates with the oral cavity through the periodontal space. However, in children with subperiosteal jaw fractures, disruption of the integrity of the oral mucosa does not occur. Fractures of the mandibular ramus are usually closed. In the presence of a wound in the soft tissues surrounding the bone, they can also be open. In fractures of the condylar process, localization distinguishes fractures of the base, neck, and head of the jaw.

The most well-known classifications of jaw fractures in children were proposed by V.S. Dmitrieva (1966), V.A. Falaleev (1981), A.A. Levenets (1982), and several other authors. The working classification of jaw fractures in children is based on the classifications proposed by G.A. Kotov (1973) and M.G. Semenov (1993) [83,84].

The generally accepted division of pediatric mandibular fractures into two large groups is:

• "subperiosteal" (incomplete, greenstick fractures)

• fractures with disruption of periosteal integrity (complete).

Comments: Fractures of the mandibular condylar process in children deserve special attention, which is associated both with the high frequency of fractures of this localization in childhood and the significant impact of the injured condylar head—the main growth zone of the jaw in children—on the formation of the mandible and the entire facial skeleton.

Clinical and radiological classification of fractures of the mandibular condylar process in children [83].

1. Fractures of the mandibular condylar process without disruption of periosteal integrity ("subperiosteal" fractures).

1.1. Subperiosteal fractures with minor deformation of the condylar process

1.2. Subperiosteal fractures with significant deformation of the condylar process

2. Fractures of the mandibular condylar process with disruption of periosteal integrity.

2.1. Fractures without displacement of jaw fragments.

2.2. Fractures with displacement of jaw fragments

2.3. Fracture-dislocations of the condylar process.

2.3.1. "Low" fracture-dislocations.

2.3.2. "High" fracture-dislocations.

3. Fractures of the mandibular condylar process with damage to the articular surface of the condylar head.

3.1. Intra-articular fractures (including epiphyseolysis).

3.2. Intra-extra-articular fractures.

The AO/ASIF classification of mandibular fractures, improved by A.S. Pankratov and T.G. Robustova (2001), can also be used in pediatric practice, especially in adolescence.

Category F (fracture):

• F 0 – incomplete fracture

• F 1 – simple fracture, including:

• F 1-0 (oblique) oblique fracture:

• F 1-5 (surface) oblique split fracture:

• F 2 – double and multiple unilateral fractures;

• F 3 – comminuted fracture;

• F 4 – fracture combined with bone defect formation.

Category T (tooth):

• T 0 – the mandibular fracture line does not pass through teeth;

• T 1 – the fracture line passes through an intact tooth;

• T 2 – the fracture line passes through a tooth affected by:

• T 2 – caries;

• T 2 pu – pulpitis:

• T 2 pe – periodontitis;

• T 2 R – the fracture line passes through a residual tooth root;

• T 2 par – due to periodontal disease, there is marked bone destruction in the area of the tooth through which the fracture line passes;

• T 3 - the mandibular fracture line is combined with a tooth fracture or dislocation.

For categories T1–T3, the dental formula must be recorded immediately after the letter and number designation. In category O 2 (see below), the designation T 0 is not included in the diagnosis.

Category L (localization):

• L 1 – fracture localized in the incisor region;

• L 2 – fracture localized in the canine region;

• L 3 – fracture located in the region from the first premolar to the second molar;

• L 4 – fracture localized in the angle of the mandible region:

• L 5 – fracture localized in the mandibular ramus region;

• L 6 – fracture localized in the condylar process region:

• L 6 H – intra-articular fracture of the mandibular head;

• L 7 – fracture localized in the coronoid process region;

• L 8 – fracture of the alveolar part of the mandible;

Category D (dislocation):

• D 0 – absence of fragment displacement;

• D 1 – presence of fragment displacement;

• D 2 – fragment displacement combined with dislocation of the mandibular articular head.

Category O (occlusion):

• O 0 – absence of occlusal disturbances;

• O 1 – presence of disocclusion;

• O 2 – absence of occlusal relationships:

• O 2 – AL (atrophy): in the fracture area – class I atrophy of the mandibular body (its height is 20–16 mm);

• O 2 – ALL: in the fracture area – class II atrophy of the mandibular body (height 15–10 mm);

• O 2 – ALL: in the fracture area – class III atrophy of the mandibular body (height less than 10 mm).

When the fracture of the mandibular body is localized within the dentition, the O designation is not included in the diagnosis, as it is replaced by category D,

Category O may include patients who have a few teeth, but with

an absence of occlusal relationships.

Category S (soft tissue):

S 0 – closed fracture of the mandible;

S 1 – open fracture of the mandible communicating with the oral cavity;

S 2 – open fracture of the mandible combined with damage

to the integumentary tissues;

S 3 – mandibular fracture open both intra- and extraorally;

S 4 – open fracture of the mandible combined with a soft tissue defect.

Category I (infection):

I 0 – absence of inflammatory signs in the fracture area;

I 1 – presence of purulent discharge from the fracture cleft;

I 2 – formation of abscesses and phlegmons of the soft tissues adjacent to the

fracture zone.

In category S 0, the designations of subsection I are not included in the diagnosis.

Category A (associated):

A 0 – absence of associated trauma;

A 1 – presence of associated trauma.

1.6 Clinical presentation of the disease or condition

The clinical presentation of a mandibular fracture depends on the localization and character of the fracture, the presence or absence of jaw fragment displacement, the degree of soft tissue damage, and the presence of associated trauma, especially traumatic brain injury (TBI). It is advisable to distinguish three main age groups of children with the corresponding occlusion. Preschool age (up to 6 years) is characterized by primary dentition; the early school and partially middle school period (7–11 years) is characterized by mixed dentition; and middle and older school age (12 years and older) is characterized by permanent dentition.

In children, along with complete jaw fractures typical of adults, "subperiosteal" (or greenstick-type) fractures and epiphysiolysis occur. In "subperiosteal" fractures, the symptoms of injury are mildly expressed; they are mainly found in toddlers (up to 3 years), preschoolers (up to 6 years), and early school-age children up to 10 years (average age – 6 years). Fractures of the condylar process with a disrupted periosteum, without displacement and with fragment displacement, were noted more frequently in early and middle school age (average age – 12 years).

Most characteristic signs of a mandibular fracture:

• Soft tissue trauma of the maxillofacial region, pronounced swelling of the lower third of the face

• Pain, "step" sign and "crepitus" detected along the lower border of the mandible.

• Malocclusion, tears of the alveolar process mucosa, tooth mobility, and minor bleeding from the oral mucosal wound.

• Pathological mobility of the mandible.

• Neurological disorders resulting from inferior alveolar nerve injury.

• Violation of the integrity of the mandibular bone tissue.

• An effective diagnostic sign of a mandibular fracture, including in children, is the indirect load symptom.

Comments: when examining a child with a suspected fracture of the maxillofacial region, especially for symptoms that provoke pain (indirect load symptom, bone crepitus in the fracture area), the examination should be performed very carefully, particularly in younger age groups. If there is no doubt about the presence of a fracture, it is better to refrain from this type of examination altogether.

Features of the clinical presentation of mandibular fractures in children compared to adults:

Single fractures of the body and ramus of the mandible in younger children quite often occur as a "greenstick" fracture, while complete fractures are relatively less common with displacement of bone fragments and malocclusion. As a result of trauma, children rapidly develop pronounced edema and hematoma at the point of impact, which can mask any facial deformity.

Fractures of the mandibular ramus itself are rare, usually without fragment displacement. Palpation along the posterior border of the ramus may reveal a discontinuous bone contour. Hemorrhage in the retromolar triangle area can be detected in the oral cavity.

Condylar process fractures most commonly occur from a blow to the chin or mandibular ramus area. The younger the child, the more likely the diagnosis is a greenstick fracture. In this case, medial displacement of the condylar head most often occurs at a specific angle, the sides of which are formed by the inner surface of the displaced condylar process and the inner surface of the mandibular ramus, and the apex is the zone where the cortical plate of the bone is deformed but retains its integrity, preventing the head from significant displacement and separation from the ramus. The magnitude of the deformation angle can range from 5–6 degrees to 25–30 degrees; in the latter case, the condylar head may completely or partially dislocate out of the articular fossa.

Another characteristic feature of condylar process fractures is a significant number of fracture-dislocations of the condylar head. Such fractures occur in cases where, under the action of a powerful traumatic force, the periosteum on the inner side of the base and neck of the condylar process can no longer hold the process (with a deformation angle greater than 25–30 degrees), resulting in its avulsion and displacement along the inner surface of the mandibular ramus. Frequently, this dislocation is also accompanied by its displacement under the cranial base. After a short period of time (3–4 days), the developing spasm of the lateral pterygoid muscle attached to the condylar head fixes its position and prevents any possibility of conservative reposition [85]. Subsequently, partial or, much less frequently, complete resorption (osteolysis) of the condylar head is possible. Months later, under the influence of masticatory load in the area of the ramus stump, some degree of "remodeling" occurs with the formation of a pseudoarthrosis. Mandibular movement in children is preserved almost in full, with deviation of the jaw toward the affected side upon mouth opening. In subsequent years until the completion of facial growth, post-traumatic micrognathia develops in the child, which often requires bone-reconstructive treatment in the future. In the acute and early post-traumatic periods, the clinical symptoms of a fracture-dislocation are determined by the level (height) of the fracture line on the neck of the condylar process. The lower the fracture line, the more pronounced the decrease in articular height and the more striking the clinical symptoms of trauma: facial asymmetry, malocclusion, and degree of deviation upon mouth opening [85]. Consequently, manifestations of post-traumatic condylar mandibular micrognathia become more pronounced in the future as the child grows. These manifestations are most prominent in unilateral condylar process fractures.

Double fractures of the mandibular body in children are more common than in adults and are frequently bilateral. Fragment displacement is greater the further the fracture site is from the midline. Rapidly increasing soft tissue edema of the floor of the mouth, profuse salivation, and stress in the child can lead to asphyxia. Double mandibular fractures are frequently combined with traumatic brain injury [78, 83, 98, 101].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

A mandibular fracture in children is diagnosed based on

1. complaints

2. anamnestic data

3. physical examination

4. laboratory examinations

5. instrumental examination

2.1 Complaints and Anamnesis

• When taking the medical history, it is recommended to clarify whether there was dizziness, nausea, vomiting, or anterograde, congrade, or retrograde amnesia, since a significant proportion of children with traumatic brain injury are admitted in moderate, severe, or even extremely severe condition, one of the symptoms of which is various types of amnesia [11, 20, 78, 88, 89].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

2.2 Physical Examination

During the examination of children, the principle of maximum informativeness with minimal invasiveness must be observed.

All children with maxillofacial trauma are recommended to undergo a physical examination to clarify the diagnosis and determine treatment tactics:

• assessment of the patient's general condition;

• examination of the maxillofacial region and oral cavity;

• palpation and percussion of the maxillofacial region [78, 79, 80, 83]

GCR CLEL 5Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade C (Level of Evidence – 5).

Comments: The physician moves their fingers along the posterior border of the mandibular ramus and the base of its body in the direction from the condylar process to the midline or vice versa. In this process, a bone prominence, bone defect, or painful point can be detected under the finger, most often – in the area of most pronounced soft tissue edema or hematoma.

Next, the load test (pain sign) is checked. It is used to identify a painful bone area corresponding to the suspected fracture site. During the examination, the physician presses on a knowingly uninjured area of the patient's mandible, which causes sharp pain in the fracture area due to the load applied along the axis of the bone. The essence of the examination is explained to the patient beforehand. Using one finger, the patient must indicate the projection of the pain point on the facial skin. As a rule, it coincides with the previously identified bone prominence and swelling (hematoma) in the soft tissues [78, 91].

Comments: to do this, the physician inserts the second or fifth finger into the patient's external auditory meatus on both sides and presses them against the anterior wall of the meatus. The patient is asked to open and close the mouth and move the mandible to the right and left. By palpating the mandibular heads, the presence or absence of synchronous movement of the heads and the adequacy of the range of motion of the condylar processes are assessed. In case of a fracture of the latter, the movement of the mandibular head may be absent or its range will be significantly smaller compared to the healthy side. The findings can be confirmed by palpating the mandibular head anterior to the tragus of the auricle[2, 15, 18, 88].

Comments: Determination of the degree of mouth opening and restriction of mandibular mobility. Displacement of the chin towards the fracture side when opening the mouth may be noted. Attention is paid to the occlusion, which is most often disrupted in mandibular fractures. Tooth percussion is performed – percussion of the teeth between which the fracture line runs may be painful. When a fracture of the mandibular body occurs in the oral vestibule and on the lingual side of the alveolar part, a hematoma is often detected, which is a diagnostic sign, since with soft tissue contusion, a hematoma occurs only from the vestibular side. Sometimes a laceration of the alveolar mucosa extending into the interdental space can be found in the oral cavity, indicating the location of the fracture line. A reliable sign of fracture is the symptom of fragment mobility. [2, 7, 21].

Comments: This method is used to determine a fracture within the dental arch. There is an increase in the interdental space or the mucosal wound of the alveolar part due to the displacement of fragments and a change in the height of adjacent teeth [4, 7, 19].

Comments: This method is used when the fracture line is localized in the angle of the mandible [2, 7, 12, 15].

2.3 Laboratory Diagnostics

• laboratory diagnostic tests are recommended for all children with mandibular fractures (complete blood count, urinalysis) [14, 18, 84, 88].

GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: All fractures of the mandible within the dentition are infected with the pathogenic microflora of the oral cavity, predominantly staphylococci and streptococci. [83,84].

2.4 Instrumental Diagnostics

Instrumental diagnostic methods are used to clarify the clinical diagnosis, evaluate treatment efficacy, and assess rehabilitation [20, 21, 23, 99].

The most widely used and one of the most informative imaging methods in jaw fractures is radiography [8, 9, 25,

90,96,100, 105].

Comments: Radiography of the facial bones (in anteroposterior and lateral projections) visualizes the entire mandible, superimposed by the image of the cervical spine; the bones of the cranial vault, the pyramids of the temporal bones, the maxilla, the orbital opening, the walls of the nasal cavity, and the lower parts of the maxillary sinuses are visible. On the radiograph of the mandible in an oblique projection, the angle and ramus of the mandible with processes and the lower molars are determined. Sometimes the zygomatic arch of the adjacent side can be projected into the mandibular notch [22, 25, 90, 100].

Comments: using this method, it is possible to diagnose fractures of the mandible in the region of the condylar process, ramus, body, and chin quite accurately. Of particular value is the clear identification of the fracture line in the mental region of the jaw, which is poorly visualized on conventional radiographs [25, 100].

Comments: The software of modern computed tomographs allows determining both linear and angular parameters of the skull. This technique makes it possible to obtain a 1:1 scale image of the skull, which has high diagnostic value [7, 89, 90].

2.5 Other Procedures

Damage to internal organs

Craniocerebral trauma

Comments: Concussion of the brain is characterized by loss of consciousness (from a few seconds to 20 minutes). Sometimes – congrade, retrograde, anterograde amnesia. Nausea or a single bout of vomiting may occur. Patients report headache, dizziness, weakness, tinnitus, sweating, facial flushing, sleep disturbances. Pain with eye movement and reading, divergence of eyeballs, and vestibular hyperesthesia may occur. Mild concussion presents with miosis, while severe concussion presents with mydriasis. Sometimes – anisocoria [5, 82, 87]. Contusion of the brain, depending on severity, is characterized by loss of consciousness (from minutes to hours and weeks), headache, nausea, vomiting (including repeated), con-, retro-, and anterograde amnesia, bradycardia or tachycardia, elevated blood pressure, tachypnea [78, 87, 89, 95].

It should be borne in mind that in TBI, the described symptoms, including loss of consciousness, may be absent to varying degrees, indicating a "lucid interval," which is especially characteristic of younger children. The younger the child, the more likely these symptoms will be partially or completely absent due to the neurophysiological characteristics of childhood. This can lead to underestimation of the severity of the child's condition in the first hours (days) after the injury. Dynamic monitoring of the patient is required.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Dental wire splints in children are generally recommended to be used after 11 years of age. This is due to the fact that children under 11 years of age do not have a sufficient number of stable teeth due to incomplete formation or physiological resorption of tooth roots. In addition, the anatomical neck of primary teeth is poorly expressed and unreliable for fixing wire ligation on it [80, 84, 104].

• In children, surgical methods for treating mandibular fractures are recommended for limited indications. Surgical methods include the use of titanium wire (230990 Titanium suture material, monofilament) for osseous suture, osteosynthesis with a Kirschner wire, and plates. Indications for surgical treatment methods include the inability to reduce and fixate bone fragments using orthopedic methods [76, 80, 83].

Comments: In children, it is recommended to extract all deciduous teeth, permanent teeth with periapical foci of infection, teeth with compromised root structure integrity, etc., located within the fracture line of the jaw within the dental arch. If there is no fracture of the permanent tooth (crown or root), teeth without signs of chronic odontogenic foci of infection should be preserved whenever possible, leaving them under observation and for subsequent endodontic treatment if necessary. Permanent tooth germs located in the fracture line should be preserved, except in rare cases where they interfere with the reposition of jaw fragments. [79, 83].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

3.1. Orthopedic Treatment

1. Fractures of the mandibular body.

The orthopedic method of treating jaw fractures in children is the primary one. It is recommended for use in all patients with "subperiosteal" jaw fractures, fractures without displacement, as well as in a significant portion of patients with mandibular fractures with fragment displacement within the dental arch, outside it (the mandibular "angle"), and in the area of the mandibular condylar process without displacement or with minor displacement of its fragments [58, 76, 80, 83, 85].

The most common individual dental splints are splints for maxillofacial fracture fixation (S.S. Tigerstedt type) [58, 59, 79, 85]. In some cases, in adolescents (over 12 years old), standard Vasilyev ribbon splints can be used.

In patients with unilateral "subperiosteal" fractures of the mandible within the dental arch, especially in preschool age, it is quite reasonable to recommend applying a chin-vertex bandage for 7–10 days, accompanied by appropriate symptomatic therapy and diet therapy. In older children with isolated fractures without fragment displacement, it is recommended to use an occlusal splint as an immobilizing structure, with an additional chin-vertex bandage if necessary [59, 66, 76, 78, 83].

In complete fractures with periosteal disruption and minor fragment displacement (without malocclusion) within the dental arch, immobilization of the mandible with a dental double-jaw wire or ribbon splint may be recommended. In double fractures of the mandibular body in middle school-aged children and older, two-jaw immobilization with individual wire or standard ribbon splints using intermaxillary elastic traction must be performed [44, 76, 83, 85]. It should be kept in mind that if the orthopedic method of jaw immobilization does not provide the necessary stability of the bone fragments—for example, outside the dental arch (the "mandibular angle"), in bilateral or comminuted fractures of the mandibular body, etc.—it is necessary to recommend either a combined surgical-orthopedic method or open reduction and osteosynthesis of the jaw [78, 79, 83].

• In children during the mixed dentition period, as well as preschool (4–6 years) and early childhood (under 3 years) ages, the use of dental orthopedic splints is difficult or even impossible. Therefore, it is recommended in this group of patients, when indicated by the nature of the jaw fracture (see below), to perform fixation of bone fragments via open reduction using various types of on-bone fixation plates for craniofacial surgery (non-resorbable, resorbable) [78, 83].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: In certain cases, in children with mandibular fractures during the mixed dentition period when dental splints cannot be used and there is no significant displacement of jaw fragments, immobilization of the mandible can be achieved by applying intermaxillary elastic traction from the maxilla to orthodontic anchorage screws inserted into the interdental spaces or (if absent) screws from an osteosynthesis set. [83, 84].

Comment: it should be remembered that splinting structures applied to the upper and lower dental arches with elastic intermaxillary traction provide fixation of the mandible to the fixed maxilla. In this case, especially in younger age groups, constant monitoring by adults is required to ensure proper oral hygiene, the neglect of which can lead to inflammatory complications [79, 80, 84].

Comment: The technique of using a bone wire to fix the mandible to a fast-curing plastic dental splint-cap (adjustable dental occlusal splint) in pediatric practice is as follows:

Under general anesthesia, manual reduction of mandibular fragments is performed, along with primary surgical debridement of wounds associated with maxillofacial region injuries if necessary, and in young and very restless children, an impression of the mandibular dental arch is taken. Then, a plaster model of the patient's mandible is made, and a fast-curing plastic dental splint-cap (adjustable dental occlusal splint) is constructed on it. Under repeated general anesthesia, the splint-cap is fixed to the mandibular dental arch using two, less frequently – three circumferential wire ligatures passed around the body of the jaw. The circumferential ligatures are placed on both sides of the mandibular fracture line [83].

Comments: The maxillofacial fracture fixation splint (smooth splint) is used to treat children with linear mandibular fractures within the dental arch without fragment displacement, or with easily reducible fractures, or with fractures of the alveolar part of the mandible, provided that there are at least 2 stable teeth on the jaw fragments.

The maxillofacial fracture fixation splint (splint with a spacer bend) is used for mandibular fractures without displacement or with easily reducible fragments if the fracture line passes through an edentulous alveolar part, with a dental arch defect of no more than 1–2 teeth. A splint with a spacer bend can be used if there are at least 2 stable teeth on the fragment. The spacer bend prevents lateral displacement of the fragments.

In the treatment of children over 11–12 years of age with unilateral (with displacement), bilateral, double, and multiple mandibular fractures, maxillofacial fracture fixation splints (dental wire or standard ribbon splints with traction hooks) are used within the dental arch, provided there are at least 2 stable teeth on the fragments. Additionally, such splints with traction hooks can sometimes (not always) be used in children of this age group for jaw fractures outside the dental arch [79, 80, 83].

• The duration of jaw immobilization with dental splints is individual, but the general rule is that the younger the child, the shorter the immobilization period compared to older children (adolescents), given the high bone tissue regeneration potential in children and the relatively weak masticatory muscle force. For unilateral jaw fractures, immobilization with splints is recommended for 3–5 weeks; for bilateral fractures, up to 5–6 weeks [83].

Comments: In pediatric practice, it is recommended to remove all deciduous teeth, permanent teeth with periapical foci of infection, teeth with compromised root structure, etc., located within the fracture line of the jaw. If there is no fracture of the permanent tooth (crown or root), teeth without signs of chronic odontogenic foci of infection should, whenever possible, be preserved, keeping them under observation and providing subsequent endodontic treatment if necessary. Permanent tooth germs located within the fracture line should be preserved, except for rare cases where they interfere with the reposition of the jaw fragments [76,80,83].

2. Unilateral or bilateral fracture of the condylar process of the jaw.

• In children with a unilateral or bilateral "subperiosteal" fracture of the condylar process of the jaw with a "deformation angle" of the condylar neck in the lateral direction up to 5-15 degrees, or a fracture of the process with a disrupted periosteum without fragment displacement, it is recommended to limit treatment to the application of a chin-vertex bandage for 7-10 days, a soft diet, symptomatic, medical, and physiotherapeutic treatment. As the "deformation angle" increases in a "subperiosteal" fracture of the process, with complete or partial protrusion of the head from the articular fossa, or in a complete fracture of the process with fragment displacement (but not dislocation) of the jaw, or in an intra-articular fracture, it is recommended to perform orthopedic treatment via slow reposition of the condylar process (or its fragments in an intra-articular fracture) using a disposable custom-made splint on the fracture side between the molars of the jaws, creating intermaxillary elastic traction in the anterior regions of the upper and lower jaw. These manipulations aim for a complete or partial gradual reposition of the jaw head along the required vector generated by the elastic traction and the patient's masticatory muscles [83,85].

GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: performing a complete reposition of a significantly deformed condylar process in a "subperiosteal" fracture, or even a slightly displaced one in a complete fracture, is quite difficult. This is due to the lack of stable teeth, especially during the mixed dentition period, for fixing dental splints and a custom intermaxillary pad, as well as the very limited timeframe (no more than 6-8 days) during which the head can be repositioned by the patient's masticatory muscles "guided" by the physician-created intermaxillary elastic traction and custom pad. Nevertheless, even a partial reposition of the condylar process, taking into account its subsequent remodeling during the child's growth and, if necessary, orthodontic treatment, will help prevent the development of pronounced post-traumatic mandibular micrognathia [83,84,85].

3.2. Surgical treatment

Indications:

1. Inability to reposition displaced bone fragments using orthopedic methods in fractures of the jaw body.

2. Lack of a sufficient number of stable teeth for the stable fixation of bone fragments of the jaw using orthopedic methods.

3. Interposition of soft tissues in the jaw fracture line.

4. Comminuted fractures of the jaw body.

5. Condylar process fractures with significant displacement, including fracture-dislocations of the condylar process.

Contraindications:

1. Severe general somatic pathology in the stage of decompensation.

2. Acute traumatic brain injury causing a severe (extremely severe) condition of the patient.

Operations in the area of the jaw body

• It is recommended to use surgical methods for fixing jaw fragments in patients of all age groups with a mandibular fracture when orthopedic methods do not yield the desired result and/or cannot provide stable immobilization to restore the occlusion and align the fragments to the original bone shape [28,29,30,31,32,33,34,35,36,39,102,103].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comments: there are a number of conditions in which surgical methods for fixing bone fragments of the jaw, including in children, have no alternative due to the unstable position of the jaw fragments associated with orthopedic treatment methods. These include the localization of jaw fractures outside the dentition; fractures within the dentition with an insufficient number of stable teeth on the jaw fragments; significant displacement under the action of masticatory muscles; comminuted fractures of the body and ramus of the jaw, and a number of other conditions [28,29,30,31,32,33,34,35,36,37,39].

Theoretical calculations using mathematical modeling [27,40,41] have demonstrated that the fixation of lower jaw fractures using on-bone plates best complies with the principles of optimal stability [30,34,40,43,44,49].

Comment: as a method of fixing jaw fractures during osteosynthesis in children, an on-bone wire suture (rarely) in various modifications is used, even less frequently a polyamide thread, an on-bone wire suture with a metal pin, and biodegradable plates. The optimal type of fixation is titanium on-bone miniplates. The use of various metal osteosynthesis methods in children has a number of significant limitations associated with the anatomical features of the lower jaw (the possibility of damaging permanent tooth germs, the mandibular canal), the need for a second surgery to remove the fixing structure, etc.

The use of an intraoral approach makes the surgical intervention less traumatic. The volume of traumatized tissue is minimized. The risks of bleeding and facial nerve injury are sharply reduced. The patient's rehabilitation period is shortened. The intraoral approach makes it easier to remove the miniplate in the postoperative period. The intraoral approach is most commonly used to fix fragments in the area of the jaw body. The disadvantage of this technique can be considered the risk of bone wound infection in case of inadequate oral hygiene [78,79,87,97,98,101].

2. Operations in the area of the condylar process

Operations aimed at open reposition of condylar process fragments in case of its fracture in children must be strictly justified. The physician must clearly assess both the risk of the surgical intervention itself and the consequences of surgical trauma on the further growth of the jaw, and weigh this against the consequences of uncorrected reposition of the condylar process with significant displacement, including the extreme stage—fracture of the process with dislocation of the head from the articular fossa.

Comment Surgical technique: the surgery is performed via submandibular and retromandibular, and in some cases preauricular approaches, under combined endotracheal anesthesia using muscle relaxants. After exposing the mandibular ramus, the head of the mandible is identified by palpation, freed from the surrounding tissue mass, and sometimes from fairly dense impaction and compression in the area of the inner cortical plate of the mandibular ramus and the spastic lateral pterygoid muscle. Reduction and osteosynthesis of the fragments with plates are performed; if such reduction is impossible, the condylar head is extracted from the wound for subsequent replantation. During this stage of surgery, damage to blood vessels and nerve trunks is possible, so manipulations are performed with utmost care. Various non-absorbable or absorbable craniomaxillofacial fixation plates and non-absorbable or absorbable craniomaxillofacial bone screws, as well as their combinations, are used as fixing devices. In addition to this consideration, the choice of the fixing device is also determined by the level of the condylar process fracture line. The higher the fracture line level, the more difficult and less reliable is the use of bone wire or non-absorbable/absorbable craniomaxillofacial fixation plates and non-absorbable/absorbable craniomaxillofacial bone screws. In these cases, preference should also be given to various combinations of intramedullary Kirschner wire osteosynthesis and wire suture osteosynthesis, and in some instances, to the surgical technique proposed in 1985 by A.A. Zhilonov. The disadvantage of using pins for any localization of mandibular fracture is that they are inserted largely blindly, which increases the likelihood of vascular and nerve damage and does not guarantee stable fixation of bone fragments in the correct anatomical position.

The attempt to create a “universal and optimal fixing device” for the fixation of condylar process fragments is very appealing to maxillofacial surgeons. In recent years, several designs have been proposed that allow osteosynthesis or replantation to be performed. However, all known osteosynthesis devices suffer from either insufficient fixation rigidity, complexity and invasiveness of placement and removal of the metal fixation structure, or its “bulkiness” [38,42,45,46,47,48,53,67,94].

3.3. Prevention of Surgical Site Infections

Comments: The choice of regimen and protocol for antimicrobial prophylaxis (AMP) is based on national and international guidelines for SSI prevention [24,68,69,70,71].

Comments: in case of a high risk of complications, prolongation of antibiotic prophylaxis for 24-48 hours in the postoperative period is permitted. Prolongation of antibiotic prophylaxis after surgery does not increase its efficacy, but increases the risk of selecting antibiotic-resistant strains and complications, in particular, Clostridioides difficile-associated diarrhea.

• For type IV wounds (“infected wounds”) in cases of old trauma, prior infection, presence of purulent discharge, or non-viable tissues, antibiotic therapy is recommended [23,68,69,70,72,73,74].

GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments: type IV wounds include old traumatic wounds with non-viable tissues, as well as postoperative wounds in areas where infection was already present. It is implied that microorganisms capable of causing SSI were present in the surgical area before the operation. Thus, prolongation of antibiotic prophylaxis for more than 48 hours is possible, combined with the prevention of dysbiosis. [23,68,69,70,71].

GCR CLEL 5Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade C (Level of Evidence – 5).

Table 1. Antibacterial drugs for AMP in patients with mandibular fractures

¹ allergy to beta-lactam antibacterials: penicillins, high risk of MRSA.

² 120 minutes before incision.

Comment: The single dose of antibiotics for AP in pediatric surgery is calculated individually for each child, depending on body weight.

Amoxicillin+[Clavulanic acid]**

this drug is used in accordance with the instructions for medical use.

Cefazolin**

this drug is used in accordance with the instructions for medical use.

Metronidazole**

this drug is used in accordance with the instructions for medical use.

Cefuroxime**

this drug is used in accordance with the instructions for medical use.

Vancomycin**

this drug is used in accordance with the instructions for medical use.

#Clindamycin**

For children at a single dose of 10 mg/kg.

Route of administration: IV. [70].

3.4. Pain Management

Comments: Mandibular reposition and osteosynthesis surgeries are usually performed under general combined endotracheal anesthesia with nasotracheal intubation or combined anesthesia.

3.5 Other treatments

3.5.1. Diet Therapy

A patient with a jaw fracture cannot consume food of normal consistency or chew it. This hinders normal bone tissue repair processes due to inadequate intake of proteins, fats, carbohydrates, micronutrients, and vitamins, and also impairs gastrointestinal function. Thus, organizing adequate nutrition for patients with mandibular fractures is one of the primary tasks determining the treatment outcome.

Comments: The first jaw-diet menu has the consistency of cream. Tube feeding is performed by physicians or nursing staff. The tube is inserted into the stomach through the inferior nasal meatus. The remaining external part must be of sufficient length to be secured to the patient's head [3,18].

3.5.2. Physiotherapy

Comment: to prevent secondary deforming osteoarthritis, children with fractures of the mandibular condylar process are prescribed potassium iodide electrophoresis (A17.03.001 electrophoresis of medications for bone pathology), ultrasound or hydrocortisone phonophoresis (A17.30.034 medical ultraphonophoresis), systemic antibacterial drugs, etc.

Hyperbaric oxygenation (HBO) is a method of general strengthening therapy. Its use ensures improved tissue microcirculation, promotes regeneration, and serves as a preventive measure against anaerobic infection development. A positive effect on the healing of a mandibular bone wound is exerted by exposure to direct electric current (A17.03.006 exposure to ultra-high frequency currents in bone pathology), vacuum therapy (A17.30.010 Vacuum exposure), laser irradiation (A17.30.027 Laserophoresis), UHF therapy (A17.30.017 Exposure to ultra-high frequency electric field (UHF EF)), etc.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Medical rehabilitation is recommended for all patients with mandibular fractures after therapeutic immobilization of bone fragments has been performed, with the aim of achieving complete physical and social recovery of the victim [7,8,9,60,64,65,78].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment After removing the splints, mechanotherapy (A19.03.003.003 Mechanotherapy for bone fracture) and physical therapy aimed at preventing the development of extra-articular muscular contracture of the jaw and secondary deforming osteoarthritis are prescribed.

5. Prevention and Dispensary Observation

Dispanserization (clinical follow-up) of children with mandibular fractures is recommended for the entire childhood period, until the growth of the facial bones of the skull is complete.

After fractures of the jaw bones, consultations and, if necessary, treatment by an orthodontist and a pediatric dentist, as well as other specialist physicians if necessary, are mandatory, taking into account possible complications and consequences of the trauma [54,55,78,83].

• All children with a mandibular fracture are recommended to undergo a follow-up X-ray examination of the facial bones of the skull 4 weeks after surgery to confirm the correct position of the fragments, the onset of their consolidation, and to exclude a post-traumatic inflammatory process [78, 80,83].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comments: Rehabilitation of children who have suffered maxillofacial bone fractures combined with maxillofacial trauma does not end with the child's discharge from the hospital [78]; follow-up clinical appointments must be scheduled at 2–4 weeks, 3 months, 6 months, and 1 year.

Comments: Teeth with chronic periapical lesions are always potentially dangerous in terms of developing inflammatory complications. The same category includes teeth with a root fracture, mobility, extensive exposure of the root cementum, or tooth luxation from the socket. Temporary teeth in the fracture line must always be removed [79,80,83,84].

6. Organization of Medical Care

Indications for emergency hospitalization in the maxillofacial surgery department:

1. presence of a mandibular fracture with displacement of its fragments.

2. presence of a mandibular fracture without fragment displacement with a duration of up to 1-2 weeks after the injury.

3. presence of a mandibular fracture without fragment displacement with a duration of more than 2 weeks with complications in the ENT organs and/or the organ of vision, central or peripheral nervous system.

Comments: In any maxillofacial injuries in children and suspected traumatic brain injury (TBI), injuries to other systems and organs, when they cannot be ruled out in the emergency department, hospitalization of the child is indicated to clarify the diagnosis. [80,92].

Comments: when fractures of the facial bones of the skull are suspected upon hospitalization, temporary transport immobilization of the jaw bones must be ensured using a chin-parietal bandage, a plaster chin sling, etc. [1,2,79,80].

Indications for planned hospitalization in the Department of Maxillofacial Surgery:

No indications.

Comment: mandibular fracture is an emergency condition; hospitalization for emergency indications is recommended for all patients with this condition.

7. Additional Information

7.1 Temporary immobilization.

Comments: From a practical standpoint, patients with TBI combined with facial bone fractures are divided into four groups.

1) Group 1 – severe TBI (severe and moderate cerebral contusion, intracranial hematomas) and severe facial bone fractures (midface fracture, simultaneous fracture of the upper and lower jaws, etc.). Half of such patients develop traumatic shock. Temporary immobilization in Group 1 patients is possible immediately after resuscitating them from shock. Therapeutic immobilization using orthopedic methods is recommended on days 2–5 from the moment of injury and recovery from the shock state; osteosynthesis is performed no earlier than the seventh day. 2) Group 2 – severe TBI and mild facial bone trauma (Le Fort III maxillary fracture, unilateral fractures of the upper and lower jaws, zygomatic bones, etc.). Therapeutic immobilization in Group 2 patients is recommended within 1–3 days. 3) Group 3 – mild TBI (cerebral concussion, mild cerebral contusion) and severe facial bone injuries. The severity of the patients' condition is mainly due to the trauma to the facial skeleton. Therapeutic immobilization, including osteosynthesis, is recommended as early as the first day after the injury. 4) Group 4 – mild TBI and mild injuries of the facial skeleton. Immobilization of fragments can be performed within the first hours after the injury. Early specialized treatment not only does not worsen the patient's condition, but also reduces the risk of developing intracranial inflammatory phenomena [81,67,68].

Indications for jaw immobilization: stabilization of blood pressure at 90–95 mm Hg, pulse rate < 90/min, respiratory rate < 20/min.

7.2. Oral Hygiene

Comments: Medical treatment of the oral cavity consists of thorough cleaning of splints and teeth from food debris by irrigating and rinsing the oral vestibule with antiseptic and disinfectant solutions. Rinsing is performed by irrigating with a jet of antiseptic and disinfectant solutions from a syringe. After rinsing, splints are cleaned from food debris stuck between the splint, teeth, gums, ligatures, and rubber rings. During dressings, it is necessary to check the position of the splint, hook loops, and the state of wire ligatures. If there are pressure sores from the loops on the mucous membrane of the lips, gums, or cheeks, they must be bent back to an appropriate position. Loose ligatures are tightened and bent toward the teeth.

Comments: The patient should rinse the mouth with antiseptics, including using electric oral irrigators, not only after every meal, but also between meals and before bedtime. The patient should brush their teeth with a toothbrush and toothpaste, and use interdental brushes to remove food debris remaining after brushing.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Semyonovich Mikhail Georgievich – MD, Professor, Member of the LLC "Association of Maxillofacial Surgeons".

2. Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.

3. Braylovskaya T.V. – MD, Professor, Executive Secretary of the Association of Maxillofacial Surgery Specialists.

4. Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

5. Ivanov S.Yu. – Corresponding Member of the RAS, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists.

6. Drobyshev A.Yu. – MD, Professor, Vice-President of the Association of Maxillofacial Surgery Specialists.

7. Yaremenko A.I. – MD, Professor, Vice-President of the Association of Maxillofacial Surgery Specialists.

8. Roginsky V.V. – MD, Professor, Member of the Association of Maxillofacial Surgery Specialists.

9. Belchenko V.A. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists.

10. Topolnitskiy O. Z. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.

11. Sysolyatin P. G. – Doctor of Medical Sciences, Professor, Board Member of the Association of Specialists in Maxillofacial Surgery.

12. Durnovo E. A. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.

13. Lepilin A. V. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.

14. Tarasenko S. V. – MD, PhD, Professor, Member of the Association of Maxillofacial Surgeons.

15. Epifanov S. A. – MD, PhD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

16. Pankratov A.S. – MD, Professor, Member of the LLC "Association of Maxillofacial Surgeons".

17. Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".

18. Baranov, I.V. – PhD in Medical Sciences, Member of the LLC "Association of Specialists in Maxillofacial Surgery".

19. Bambarykova A.I. – Member of the LLC "Association of Maxillofacial Surgeons".

20. Sviridenko, A.D. – Member of the LLC "Association of Specialists in Maxillofacial Surgery".

21. Stolyarenko, P.Yu. – PhD in Medical Sciences, Associate Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".

All members of the working group are members of the All-Russian Public Organization "Association of Specialists in Maxillofacial Surgery". There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Maxillofacial surgeons

2. Dentists

3. Trauma and orthopedic surgeons

4. Neurosurgeons

5. Mid-level medical personnel

6. Healthcare organizers

7. Medical insurance experts (including conducting medical and economic expertise)

8. Medical students, residents, postgraduate students

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Article 76 of Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation," regarding the development and approval of clinical guidelines (treatment protocols) for the provision of medical care by medical professional non-profit organizations;

2. Order of the Russian Ministry of Health No. 422n dated June 14, 2019, "On Approval of the Procedure for Providing Medical Care in the Field of 'Maxillofacial Surgery'";

3. Federal Law of the Russian Federation No. 326-FZ dated November 29, 2010 (as amended on July 3, 2016), "On Compulsory Medical Insurance in the Russian Federation";

4. Order of the Russian Ministry of Health No. 422an dated July 7, 2015, "On Approval of Criteria for Assessing the Quality of Medical Care";

5. Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care".

6. Order of the Ministry of Health and Social Development of the Russian Federation No. 565n dated May 17, 2012 (as amended on November 23, 2020) "On Approval of the Procedure for Medical Organizations to Inform Internal Affairs Organs about the Admission of Patients in Respect of Whom There Are Sufficient Grounds to Believe That Harm to Their Health Was Caused as a Result of Illegal Actions"

7. Federal Law No. 178-FZ dated July 17, 1990 (as amended by Federal Laws No. 345-FZ dated December 8, 2010, No. 345-FZ, No. 169-FZ dated July 1, 2011, No. 133-FZ dated July 28, 2012, No. 258-FZ dated December 25, 2012, No. 99-FZ dated May 7, 2013, No. 104-FZ dated May 7, 2013, No. 185-FZ dated July 2, 2013, No. 317-FZ dated November 25, 2013) "On State Social Assistance".

8. Federal Law No. 124-FZ dated July 24, 1998, "On Basic Guarantees of the Rights of the Child in the Russian Federation"

9. Order of the Ministry of Health and Social Development of the Russian Federation No. 1024n dated December 17, 2015, "On the Classification and Criteria Used in Medical and Social Expertise of Citizens by Federal State Institutions of Medical and Social Expertise"

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Pediatric traumatism – is a serious problem that entails injuries of varying severity, up to life-threatening conditions. As children grow older, the danger increases, especially when the child begins to move independently. At the same time, the nature of injuries changes: the number of burns decreases, while the number of wounds, contusions, and fractures increases. The main cause of accidents is adult negligence. Maxillofacial trauma leads to severe anatomical, functional, and neurological disorders that may require a series of reconstructive surgeries.

When sustaining a maxillofacial injury accompanied by a mandibular fracture and loss of consciousness, one must immediately seek medical care at a hospital and call an ambulance team. Treatment of patients with fractures of the facial bones of the skull must necessarily be carried out in a specialized pediatric maxillofacial inpatient facility that is part of a multidisciplinary children's hospital.

Upon confirmation of the diagnosis of "Mandibular fracture," children are hospitalized without fail. Depending on their general condition and the extent of the injury, a decision is made regarding which department to admit the child to and when to perform surgical treatment.

Parents should be aware that visible clinical and radiological well-being upon the child's discharge from the hospital or the completion of active outpatient treatment does not exclude the possibility of long-term complications, including post-traumatic dentofacial deformities. All children who have suffered a maxillofacial trauma must be placed on dispensary follow-up.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not used