|Year : 2014 | Volume
| Issue : 1 | Page : 10-13
Evaluation of facial trauma in pediatric population
Pushkar P Waknis1, Samrat Sabhlok1, RS Dolas1, Gandhali Limaye2
1 Department of Oral and Maxillofacial Surgery, Dr. D Y Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India
2 Dental Surgeon, Dr. D Y Patil Dental College and Hospital, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||31-Jan-2014|
Department of Oral and Maxillofacial Surgery, Dr. D Y Patil Dental College and Hospital, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to retrospectively evaluate the incidence and treatment rendered for fractures in pediatric population over a period of 13 years. Materials and Methods: Surgical data over 13 years were evaluated for age, type of fracture, and treatment rendered. Out of a total of 423 trauma cases operated, a total of 38 pediatric trauma cases were seen, with 30 patients requiring at least some type of surgical intervention. The etiology of most of the fractures was road traffic accidents. Results: The eight cases of dentoalveolar and undisplaced parasymphysis trauma were managed by wiring and four cases of soft tissue injury treated by suturing while 18 cases required surgery in the form of osteosynthesis. Bioresorbable plating system was used in 11 cases while Titanium plates were used in seven patients, which were removed within 3 months.Conclusion: We recommend the use of open reduction internal fixation with bioresorbable plating system in children above 10 years of age and arch bar fixation for dentoalveolar trauma.
Keywords: Bioresorbable plates, pediatric facial trauma, pediatric fractures
|How to cite this article:|
Waknis PP, Sabhlok S, Dolas R S, Limaye G. Evaluation of facial trauma in pediatric population. J Dent Res Rev 2014;1:10-3
|How to cite this URL:|
Waknis PP, Sabhlok S, Dolas R S, Limaye G. Evaluation of facial trauma in pediatric population. J Dent Res Rev [serial online] 2014 [cited 2019 Dec 14];1:10-3. Available from: http://www.jdrr.org/text.asp?2014/1/1/10/126157
| Introduction|| |
In surgical terms, trauma may be defined as a physical force that results in injury. The etiology of maxillofacial trauma varies with road traffic accidents accounting for 40.3% in India. 
The common age group involved for pediatric trauma is 7-12 years with a peak incidence of 10 years. Injuries occur predominantly in boys and are normally due to motor vehicle collisions, falls, violence, and sports-related trauma. Falls at home predominate in children younger than 6 years, and sports injuries are more prevalent during adolescence. , If not managed properly, these injuries can have a significant impact on future growth and development. The increased ratio of the cranial mass relative to the body leaves younger patients more vulnerable to craniofacial trauma. The indications for the management of patients with maxillofacial trauma in childhood are different from those of the adult patient. When compared with injuries with other parts of the body, the healing process for the facial region is much quicker and encompasses fewer complications in children than older patients. 
There are many reasons though that make children unique for trauma. Children are difficult to examine both clinically and radiologically. It is difficult to make use of teeth for fixation as deciduous teeth may be insufficient in number and in stages of root resorption. The shape of the deciduous crown is bell shaped with little undercut area not being favorable for the retention of wires and splints.  It is thus a difficult task for the surgeon to satisfactorily treat these patients. The potential psychological effect of the trauma must be taken into account as well. Hospitalization has been shown to disrupt feeding patterns, alter circadian rhythms, and lead to behavioral disturbances in children who have had a traumatic injury. Therefore, minimizing pain and discomfort of the child is of utmost importance. 
So the treatment of pediatric facial fractures is actually a surgeons dilemma as deciding on the correct treatment is often more difficult than administering the treatment itself.
The purpose of this review was to describe the protocol for assessment of pediatric patients who have had a maxillofacial injury and to review the specific therapies available for treatment of these conditions.
| Materials and Methods|| |
All the pediatric trauma cases reporting to Dr D.Y. Patil Dental College and Hospital and other private hospital attachments of the authors, from January 2000 to November 2013 were included in the study. Personal records of patients operated for facial fractures were searched for with a specific interest in the pediatric age group, up to 16 years of age. Details of hospitalization, age of patient, etiology of trauma [Table 1], and treatment rendered were recorded [Table 2]. A total of 423 patients were operated from 1 st January 2000 to 30 th November 2013 that included 38 patients in the specified pediatric age group. All patients admitted to the hospital were first evaluated by a pediatrician and a neurosurgeon for general physical status. A CT scan of the brain was done in cases of facial fractures to rule out head injury and to visualize fractures.
All patients did not require active surgical intervention. Surgery was carried out depending on the type required, only after detailed preoperative laboratory investigations and medical fitness for surgery. Thirty patients had to undergo surgical intervention with 18 of them requiring open reduction internal fixation (ORIF), eight of them requiring closed reduction and four were treated with debridement and suturing. All cases were operated under general anesthesia with administration of antibiotics prophylactically and then continued for two days intravenously after surgery. The patients were started on liquid diet 48 h after surgery and shifted to soft diet later. Wire removal in cases of dento-alveolar fractures was done on an out-patient basis under local anesthesia after 6 weeks and removal of titanium plates and screws done after 3 months.
| Results|| |
The treatment carried out in our series is as tabulated [Table 2]. No complications were noted in any of the patients operated in the study. There was no incidence of loss of tooth vitality requiring endodontics later.
The fracture of the mandible, which was undisplaced and treated with arch bars, healed without any problems. The patients with the facial soft tissue injury were recalled for suture removal 7 days later and showed adequate soft tissue healing in subsequent follow-ups.
In cases of the patients operated for bilateral fracture of the mandible with Titanium osteosynthesis, the hardware was removed after 3 months and showed good fracture consolidation at the time of surgery with an uneventful healing and satisfactory occlusion one year after surgery [Figure 1]a-c.
|Figure 1: (a) Preoperative CT scan, (b) Postoperative radiograph, (c) Postoperative occlusion|
Click here to view
The patients operated with bioresorbable osteosynthesis showed adequate stability of fractures and no complications [Figure 2]a-d.
|Figure 2: (a) Preoperative CT scan, (b) Fixation of the angle of mandible, (c) Fixation of parasymphysis, (d) Postoperative radiograph|
Click here to view
| Discussion|| |
The care of children affected with trauma is a unique proposition for the surgeon as whole family of the patient is also emotionally involved. Establishment of trust should be the prime goal as the trust that is established is transferred to the parents who will help in the uncomfortable stage of examination and treatment and lend support during convalescence. This trust also helps dealing with the psychological aftermath felt by the patient.
The experience of most clinicians in pediatric fractures is limited as the incidence of fractures in children is very low.  The incidence of pediatric facial fractures among Indians is 5.5%.  But in our study the incidence of pediatric facial fractures was found to be slightly higher at 8.9%. There is a noticeable increase in facial injuries in children in summer months.  This can be understood by the fact that there is more of traveling to places by vehicles and more of play time involved leading to an increase in chance of trauma. During the first years of life, close parental supervision helps children avoid serious mishaps. Falls are mostly trivial in nature and are well absorbed by thicker subcutaneous tissues, pliant bones, and cartilaginous growth sites. As the child grows, supervision lessens and play becomes more adventuresome. In our study there were 27 boys and 11 girls indicating boys more prone to trauma. Twenty (67%) patients suffered from trauma due to road traffic accidents in our study. The injury in a 1-year-old boy occurred due to parental ignorance and eagerness to make the child walk by putting him in a walker. The walker is a very unstable device and not recommended by pediatricians for various reasons and this had caused the trauma in the child leading to a displacement of anterior teeth that required the need of a horizontal tie wire for stabilization. In our study, the injuries caused due to road traffic accidents were also due to pure parental neglect as in most of the cases the children were sitting unprotected on the lap of the adult in the front seat of the vehicle already crowded with eight or nine adults. In the case of a collision the child hits the dashboard or in unfortunate cases succumbs to the trauma. A great deal of awareness amongst parents, stricter law enforcement and curbing of speeding tendency would greatly help prevent the incidence of death in road traffic accidents.
The presence of tooth buds in the jaws has been suggested as a contributing factor to fracture. If one looks at the distribution of fractures in children younger than 10 years of age the only place this hypothesis holds true is in the vicinity of the mandibular permanent canine. 
Soft tissue injuries of the face are common in children and range from minor intraoral lacerations and bruises to major alveolar wounds. All wounds must be debrided meticulously after considerations of history of tetanus vaccinations otherwise tetanus toxoid must be administered. The wounds ideally must be closed within 12 h of injury though this may not be practically possible due to head injury status. Tissue vascularity is excellent and traumatic flaps must be maintained and sutured unless they are nonviable. The soft tissue injuries need classic routine procedures of cleaning the wound and removing any particles from dermis using magnification if required.  Antibiotics depend on the severity of trauma, contamination of the wound, and type of injury. Other than meticulous surgery the only treatment shown to reduce scar hypertrophy and keloid formation are silicone sheeting and intralesional steroids. The treatment of intraoral wounds does not differ from operative techniques and resorbable sutures must be used. The treatment of maxillofacial trauma is described using local anesthesia alone or with sedation or general anesthesia. The author prefers the use of general anesthesia for trauma as a meticulous treatment is possible under general anesthesia and is more beneficial in avoidance of psychological trauma to the child. Most of the cases of dentoalveolar trauma were treated by arch bar fixation  or stabilization was done with horizontal interdental wires. Only in one case, where the baby was 1-year old, a thinner 28 gauge wire was used to stabilize the deciduous central incisors as a thicker wire would have avulsed them. Dental trauma is one of the most frequent reasons for admissions of children to the pediatric emergency department.  The teeth most generally affected are the maxillary incisors as was consistent with our finding.
We have not encountered any patient with mid facial fractures in our hospitals. Fractures of the mandible occur with greater frequency than those of the midface. Displaced fractures of the mandibular angle require an open reduction as the proximal fragment cannot be controlled. Care should be taken when screw holes are drilled and the screws are kept short to prevent damage to developing teeth buds.  The superficial underlying tooth bud can be easily identified and avoided as they appear slightly raised, pale blue areas of bony cortex. Microplate and miniplate systems using monocortical screws were the first step toward applications of osteosynthesis of the mandible in children.  The development of small micro-osteosynthesis plate systems enables the more frequent use in mandibular fractures. There are other authors who recommend broader screws (2 mm) that are much more retentive in pediatric bone than microscrews. A mandibular arch bar or interdental wire may be combined with a single plate and screw fixation for added stability.  In children less than 10 years of age we have used a 1.5 mm titanium plates with screws of 4 mm in length that was removed after 3 months. In children older than 10 years broader plates of 2 mm have been used for fixation. Application of arch bars in mixed dentition is difficult and stability was achieved by passing ivy loops of 26 gauge wire along with interdental wires across fracture sites. A clear guideline of the concept of fracture treatment in the growing mandible has been documented.
Concept of fracture treatment on the growing mandible 
Condyle : Conservative
Mandibular Ramus: Conservative
Mandibular Ramus: Operative
(8-16 years) Microplates/miniplates/resorbable plates
The osteosynthesis technique follows the principles for adult facial skeleton. In pediatric patients younger than 16 years of age, plates must be removed before the end of the third month  as was done in our cases treated with titanium plates and screws.
The impact of open reduction and internal fixation on subsequent facial growth is not clear. Studies have demonstrated altercations in craniofacial anatomy after plating across cranial sutures in animals. 
The advantages of bioresorbable plating system are that there is no need for second surgery for removal of implants, it is made of inert material, avoidance of potential odontogenic injury, does not interfere with growth and it does not affect CT and MRI scans.  Eleven patients treated with bioresorbable plates and screws in our study showed excellent postoperative recovery.
It is safe to say that pediatric patients may well benefit from resorbable internal fixation as it enables faster rehabilitation without the need for a second operation to remove the plates. We therefore recommend the use of bioresorbable plates where possible to avoid the need for the second surgery.
| References|| |
|1.||Ward Booth P, Schendel SA, Haugman JE. Maxillofacial Surgery. 2 nd ed., Vol. 1. London: Churchill-Livingstone Elsevier; 2007. p. 2,3. |
|2.||Kumarswamy SV, Nanjappa M, Keerthi R, Deora SS. Pediatric injuries in maxillofacial trauma: A 5 year study. J Maxillofac Oral Surg 2009;8:150-3. |
|3.||Ryan ML, Thorson CM, Otero CA, Ogilvie MP, Cheung MC, Saigal GM, et al. Pediatric facial trauma: A review of guidelines for assessment, evaluation, and management in the Emergency Department. J Craniofac Surg 2011;22:1183-9. |
|4.||Kaban LB. Diagnosis and treatment of fractures of the facial bones in children 1943-1993. J Oral Maxillofac Surg 1993;51:722-9. |
|5.||Oji C. Fracture of the facial skeleton in children. A survey of patients under the age of 11 years. J Craniomaxillofac Surg 1998;26:322-5. |
|6.||Fonseca RJ, Walker RV, Betts NJ, Barber HD, Powers MP. Oral and Maxillofacial Trauma. 3 rd ed., Vol. 1. Philadelphia: Elsevier Saunders; 1997. p. 421. |
|7.||Sawhney CP, Ahuja RB. Faciomaxillary facrure in north India: A statistical analysis and review of management. Br J Oral Maxillofac Surg 1988;26:430-4. |
|8.||Posnick J, Wells M, Pron G. Pediatric facial Fractures: Evolving patterns of treatment. J Oral Maxillofac Surg 1993;51:836-44. |
|9.||Thoren H, Iizuka T, Hallikainen D, Lindquist C. Different patterns of mandibular fractures in children: An analysis of 220 fractures in 157 patients. J Craniomaxillofac Surg 1992;20:292-6. |
|10.||Ward Booth P, Schendel SA, Haugman JE. Maxillofacial Surgery. 2 nd ed., Vol. 1. London: Churchill-Livingstone Elsevier; 2007. p. 224. |
|11.||Fonseca RJ, Walker RV, Betts NJ, Barber HD, Powers MP. Oral and Maxillofacial Trauma. 3 rd ed., Vol. 1. Philadelphia: Elsevier Saunders; 1997. p. 432. |
|12.||Ward Booth P, Schendel SA, Haugman JE. Maxillofacial Surgery. 2 nd ed., Vol. 1. London: Churchill-Livingstone Elsevier; 2007. p. 225. |
|13.||Yaremchuk M, Posnick J. Resolving controversies related to plate and screw fixation in the growing craniofacial skeleton. J Craniofac Surg 1995;6:525-38. |
|14.||Yerit KC, Hainich S, Enislidis G, Turhani D, Klug C, Wittwer G, et al. Biodegradable fixation of mandibular fractures in children: Stability and early results. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:17-24, 1183-9. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]