Centers for Disease Control and Prevention

DU Rosenthal

J Lustmann

J Palmer

JC Collyer

K Wolff

L Cascarini

L Stylogianni

LE Pinckney

MM Chidzonga

N Zachariades

PC Modayil

R Rapuano

RJ Presutti

RV Aghababian

S Iida

T De Keuster

TWM Walker

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Dog bite- fracture of the mandible in a 9 month old infant: a case 
report
TWM Walker*, PC Modayil, L Cascarini and JC Collyer
Address: Department of Oral & Maxillofacial Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, RH19 3DZ, UK
Email: TWM Walker* - tomwmw@hotmail.com; PC Modayil - princemodayil2000@yahoo.co.in; L Cascarini - lcascarini@hotmail.com; 
JC Collyer - jeremy_collyer@doctors.org.uk
* Corresponding author    
Abstract
Background: We present the case of a fractured mandible due to a dog bite in a 9 month old
female. Dog bites in this age group are rare as are fractured mandibles. There are only two
reported cases of fractured mandibles due to dog bites in the literature. This is the youngest. The
other reported cases were in a 1 year old and also in a 4 year old.
Case Presentation: A 9 month old female was brought by her parents to the Emergency
Department after sustaining a dog bit to the face. This was assessed by the emergency physicians
and deemed to be superficial. The patients wounds were irrigated, and she was given oral
antibiotics. She was transferred to our department were she was assessed under anaesthetic. A
fracture of her mandible was discovered and treated with open reduction and internal fixation.
Conclusion: The case presentation highlights the important of proper assessment of facial
lacerations for not only neurovascular status and the parotid duct, but also the hard tissues. The
case also highlights the difficulty of treating children and infants with fractures of the mandible and
the importance of follow-up to monitor growth.
Background
Bite wounds are among the most common trauma to
which man is subject to. In urban areas the main suspects
are dogs, cats and humans [1]. Dog bites have a recog-
nised mortality and there are at least 15 deaths per year in
the United States [2]. In the young the most documented
injuries have been to the face, head and neck areas [3]. In
older children and adults the bites are most commonly on
the limbs. Dog bites are frequently complicated with a
crush injury as a result of the high masticatory forces that
can be delivered by certain breeds; 310 – 31790 KPa
depending on the breed [4,5]. Mandibular fractures in
infants are rare. In reported jaw fractures in children under
10 years old 0.9–2.6% occur in the age group 0–1 year [6-
8]. They are almost unheard of in neonates [4]. They are
between 1.6 – 6 times more common in male children. In
children, fractures are most common in the condylar
region (36%), followed by the canine region (23%) [9].
The reported causes of fractured mandibles in infants and
neonates have been due to road traffic accidents, non acci-
dental injuries, traumatic delivery, bicycle accidents and
falls.
Our literature search using mandible, fracture, child,
infant, dog bite and animal bite found only 2 cases of frac-
tures of the mandible due to dog bites in the English lan-
guage publications available through med line and
Google search engines [10,11]. One case report was
Published: 12 January 2009
Cases Journal 2009, 2:44 doi:10.1186/1757-1626-2-44
Received: 8 September 2008
Accepted: 12 January 2009
This article is available from: http://www.casesjournal.com/content/2/1/44
© 2009 Walker et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:44 http://www.casesjournal.com/content/2/1/44regarding a four year old and the other a 1 year old. Frac-
tures of other skull bones due to dog bites have been
reported in children as young as 4 months old [12]. We
present what we believe to be the youngest patient pre-
senting with a fractured mandible due to a dog bite.
Case Presentation
On the 24th April 2006 a 9 month old girl was brought to
the Emergency Department of a hospital which routinely
refers patients to us. She had sustained a dog bite to her
face 30 minutes previously. She was seen by the emer-
gency physicians and was found to have received multiple
lacerations to her face over the right zygoma, right parana-
sal area, right cheek, left eye lid, left paranasal area, left
lower cheek and over her left body of her mandible. She
was fully examined and found to have no wounds else-
where however due to the circumstances of patient and
parental distress, intra-oral examination was not possible.
The initial work up did not include radiographic investi-
gations as it was felt by the emergency physicians that
only a soft tissue injury was sustained. On the advice of
the on-call maxillofacial team she had her facial wounds
cleaned with aqueous iodine solution and she was started
on an oral course of Co-Amoxiclav and paracetamol. An
examination by the ophthalmologist revealed no ocular
injury.
She was transferred to our unit the following day, fasted
in preparation for an examination under general anaes-
thesia and primary closure of her facial lacerations. Dur-
ing the procedure it was found that she had sustained an
open fracture of her left mandible consistent with a dog
bite. (fig 1). This was treated via a trans-oral approach
with a five hole 1.2 mm titanium plate and four 3 mm
screws. (fig 2). She had her facial laceration copiously irri-
gated with normal saline and chlorhexidine and primarily
closed in with a fine nylon suture. She was discharged
home the next day. Seven days later she attended for
removal of sutures under a general anaesthetic and exam-
ination of her jaw. The facial wounds were healing well
and there was no movement at the fracture site. Ten weeks
after the first operation she was admitted for removal of
her mandibular plate under general anaesthetic. There
was good bony union and the plate was removed with no
complications (fig 3). She will continue to be reviewed in
clinic to monitor dentoalveolar development and man-
dibular growth.
Conclusion
Dog bites account 250,000 minor injury and emergency
unit attendances in the UK each year and 740 people per
100,000 are bitten by dogs 18. However only a minority
seek medical attention. Overall 2.6/100,000 require hos-
pital admission. The annual incidence of dog bites in chil-
dren aged under 15 is 22/1000 [13]. In the United States
Intraoperative view of fracture mandibleFigure 1
Intraoperative view of fracture mandible.
 
Intraoperative view of mandibular mini-plate in situ on man-dibleFigure 2
Intraoperative view of mandibular mini-plate in situ 
on mandible.
 
Intraoperative view of healed mandibular fractureFigure 3
Intraoperative view of healed mandibular fracture.
 
 Page 2 of 3
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of America, the annual mortality is 7.1/100 million pop-
ulation, with 57% occurring in children under the age of
10 years. In children, however 76% of bites are to the lips,
nose or cheeks [14].
Dog bites causing mandibular fractures are extremely rare.
There are only two cases previously reported. In one case
a 4 year old boy sustained a right mandibular body frac-
ture that was treated with elastic intermaxillary fixation
[11]. In the other case a 1 year old girl sustained a fracture
at the left angle and right body resulting in an avulsed free
segment of bone that required extensive reconstructive
surgery [10].
This case is interesting for several reasons; firstly dog bites
in this age group are rare, secondly fractures of the mandi-
ble due to dog bites are extremely unusual and thirdly this
seems to be the youngest in the literature [8,9,11,14,15].
There are a number of options with regards to treatment
of mandibular fractures in children and infants [16]. The
surgical principles differ from that in adults due to
unerupted or incompletely formed teeth, and the rela-
tively soft, growing mandible as well as the poorly differ-
entiated cortical bone. However, any slight discrepancy in
alignment of the mandibular bone will be compensated
for in future growth. There is a risk of damaging the
unerupted dentition and disturbing facial skeletal growth.
We opted for open reduction and internal fixation with a
titanium mini plate and screws, over the lower boarder of
the mandible, with subsequent removal of these after 10
weeks. We considered the use of resorbable fixation, how-
ever the smallest resorbable mini plate would have been
too large for the small size of the mandible. The fracture
was mobile and displaced thus needing rigid fixation. IMF
was contraindicated due to absence of erupted dentition
in the region of the fracture.
The child is still under regular clinic review and is being
followed up with regards to scar maturation and dental
and facial growth.
This case highlights the importance of intra oral examina-
tion in facial trauma victims for clinical signs of facial frac-
tures.
Consent
We confirm that informed written consent was obtained
from the patients parents to publish the case presentation
and the non identifiable intra oral photos of the patient.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
TWMW – Literature Search, Wrote Report, PCM – Litera-
ture Search, Wrote Report, LC – First Edit, Wrote Conclu-
sion, JCC – Final Edit and General Advice.
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Dog bite- fracture of the mandible in a 9 month old infant: a case report

Crossref

A: Epidiemology of dog bites: a Belgian experience of canine behaviour and public health concerns. Vet J

Conte JE: Mammalian bite wounds. Ann Emerg Med

Disease Control and Prevention: Dog bite-related fatalities–United states,

Disease Control and Prevention: Nonfatal dog biterelated injuries treated in Hospital Emergency Departments-United States,

Dog bites of the face: a fifteen year review. Br J Plast Surg

Fractures of the Infant Skull Caused by Animal Bites. AJR

Koumoura F: Fractures of the facial Skeleton in Children. J Cranio-Max-Fac Surg

Management of animal bite injuries of the face: experience in 94 patients. J Oral Maxillofac Surg

Mandibular Fracutre in a neonate: Report of a Case. Int J Oral Maxillofac Surg

Matsuya T: Paediatric maxillofacial fractures: their aetiological characters and fracture patterns.

Milhem I: Mandibular fractures in infants. Review of the literature and report of seven cases.

Patrikiou A: Fractures of the facial Skeleton in Children. Br J Oral Maxillofac Surg

Prevention and treatment of dog bites.

Report of Fractured Mandible in a child aged 1 year [http://www.aofoundation.org/portal/wps/portal/!ut/p/_s.7_0_A/ 7_0_3K7?contentUrl=/aca/cas/case_of_the/2006/08/ ex_alumni_cases_0000024.jsp]. Accessed on 15/10/2006.

Stratigos GT: Mandibular fracture resulting from a dog bite: Report of Case. J Oral Surg

When K-9s cause chaos: an examination of police dog policies and their liabilities. New York Law School of Human Rights

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2630302

Dog bite- fracture of the mandible in a 9 month old infant: a case report

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