Physical Therapy as first therapy to mandibular fracture in a pediatric patient

Mandibular fractures are the most common in children, however with a low incidence because of child anatomy. Among the sites, the condyle is one the most fracture site, being a dilemma to surgeons about your management. The treatment to condyle fracture can be a surgical approach or conservative management. Conservative treatment presents the IMF, appliances, soft diet, and physiotherapy as an option, and these treatments can be applied isolated or associated. Physical Therapy has been a few reported in the literature as isolated therapy, reported as complementing the surgical approach, or after orthodontic/appliances therapy. Promote early mandibular mobility is important to restore function and prevent future complications such as ankylosis. Instruments to perform physiotherapy are Research, Society and Development, v. 11, n. 1, e38111125148, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i1.25148 2 expensive and not accessible to the entire population. Therefore, the present study presents a case of a pediatric patient with condyle fracture treated with a soft diet and physiotherapy with wooden spatula.


Introduction
Mandibular fractures are the most common in children, occurring due to several factors, including traffic accidents, falls, sports accidents, and physical aggression (Wainwright et al., 2019). But the incidence is low due to a larger craniofacial with proportion, increased parental supervision in a younger population, high elasticity of pediatric bone, thicker adipose layer tissue covering them, a high cancellous to cortical bone ratio, and flexible suture lines (Kaban, 1993;Crean et al., 2000;Zimmermann et al., 2005;Youssef et al., 2018;Bansal, 2021). Condylar fractures are the most affected mandibular site however low occurrence of mandibular fractures makes the decision about the approach controversial (Ghosh, 2018;Du, 2021). The different anatomy, the presence of mixed or deciduous dentition, and growth sites are principal factors to be analyzed and make the decision to approach more difficult (Bansal, 2021). Condylar fractures treatments in pediatric patients can be surgical and even conservative. Among the surgical approaches there is the management of reduction and open fixation. Conservatives therapies can guide a liquid diet, splints, traction with Kirschner wire, maxillo-mandibular block, guided occlusion with rubber bands and braces, and physiotherapy, which can be isolated or associated therapies (Kim, 2015;Li, 2020;Vesnaver, 2021).
Physical therapy associated with others has shown favorable results and is well-defended in the literature.
Physiotherapy alone in condylar fractures treatment of pediatric patients is little reported. Therefore, the objective of this paper is to present a case of mandibular fracture in a pediatric patient, conducted only with physical therapy.

Methodology
The present paper consists in a case report of a pediatric patient evaluated in Santa Casa Hospital of Araçatuba, with mandibular fracture conducted only with physical therapy presenting satisfactory results. This study applied the methodology described in Pereira (2018) and a Free and Clarified Term Consent.

Case Report
A 5-year-old male was referred to the oral and maxillofacial surgery Service, of Santa Casa Hospital of Araçatuba (Araçatuba, Brazil) after fell from his bicycle. The initial examination found the normal occlusion with a moderate restriction of mouth opening, sustained an abrasion over the chin that had been evaluated and sutured in the emergency room; crown fractures of upper central incisors. The extraoral assessment presented pain in the preauricular region and deviation to the right side in the mouth opening. The patient presented primary dentition with no significant malocclusion. (Figure 1) Source: Own authorship.
Hence, we recommended conservative treatment rather than surgical treatment. At discharge prescribed him a soft diet and recommended functional exercise. The protocol applied was three sessions/day for three months. At each session, he had to open his mouth for 60 seconds then close it. They had to do this three times (Bandy, 1994). Performed the open mouth with wooden spatulas (2mm) and each week was increased one wooden spatula until 22° spatula (44mm). Complementing the exercises of the open mouth, the patient performed the movements to protrusion and lateral movement. The deviation to the right side in the mouth opening is maintaining. (Figure 3)

Discussion
The conservative management of the mandibular condyle fracture is one of the options for the treatment and it can be used individually or complement the surgical treatment to restore the mandible function (Steed et al. 2016;Cooney, 2020). Soft diet, physiotherapy, intermaxillary fixation (IMF) (Thoren, 2001;Cooney, 2020), and functional appliances are options for these treatments (Staderini, 2020). Some surgeons believe that IMF does not present a benefit to children's condylar fracture.
The management with IMF is complicated by poor patient compliance, difficulty in applying IMF, and, in the case of mixed dentition, lack of sufficient support (Boffano, 2012;Zhao, 2014;Cassi 2017;Cooney, 2020). Likewise, the therapy with functional appliances depend on compliance, self-motivation, parental and peer influence, quality of life impairment and adaptability, wear time, forgetfulness, and interference with daily activities to obtain a good results (El-huni, 2019).
The treatment's limitations with IMF and functional appliances by poor compliance lead to physiotherapy as the option. Physical therapy promotes early mandible mobilization, improves vascular circulation adjacent to the fracture site, and thus accelerates regeneration or remodeling of the fractured condyle (Boffano, 2012). The Therabite®, which is a tool that helps in mouth opening exercises to trauma, radiotherapy, postoperative of mandibular surgeries, but this tool is not available to all patients. Some surgeons use the wooden spatulas, which perform the Therabite® movement as an option to the trismus exercises and obtain the same results and an available treatment option (Lee, 2018). In addition to the mouth opening exercises, the lateral and protrusion movements are important to restore the mandibular movements and were performed and included in our case and protocol promoting good results.
In the mouth opening exercises in cases of important displacement, we have the remodeling of TMJ. Besides the range motion and the condyle remodeling, an author confirmed that anteriorly displaced discs may return to their normal position following closed treatment in cases that condyle do not present an important displacement (Liu et al., 2019). The success results of physiotherapy in radiotherapy, postoperative mandibular surgeries, and condyle fractures restoring range motion and TMJ function depend on the frequency, self-discipline, clearly-set (Lee, 2018;Melchers et al. 2009), and in present case parents and family support to perform the exercises at home. The authors believe that the parents are a tool in the success of the therapy, to complete all the other factors as the frequence exercises, and help the child understand the importance.
The main complication in the failure of these treatments in condyle fracture is the ankylosis in postoperative. Physiotherapy helps restore the integrity of TMJ function and normalize functional movements, avoiding neuromuscular adaptation. The early mobilization does not prevent the fibrous union of the fractured fragments and helps the patients restore the pre-traumatic range of motion. The follow-up is necessary with radiographic control and CT to the early failure diagnosis (Cassi, 2017). In the control needs attention about complications as immobility for insufficient postoperative mandible exercises (Thoren, 2001), asymmetries, and occlusion that can occur in postoperative, being conservative ou surgical approach, and know the moment to forward to the orthodontist (Melchers et al. 2009). Patients can be treated without orthodontics during the first year after trauma, and maintain a good occlusion therefore pediatric patient follow-up is important (Staderini, 2020).
The patient of the present case continues without needing appliances, and in follow-up without complications.

Final Considerations
Therefore the physiotherapy can be the treatment at the first moment after a condyle fracture, but the team should be careful in follow-up to know the moment that present malocclusion and the orthodontic treatment could be necessary. Guide parents and their support is important to instruct their children in therapy and to be successful. The authors consider this therapy good management, but researches and a recent systematic review need to be performed to strengthen our approach.