ISSN 0970 - 4388
Management of facial trauma in children: A case report DAS U. M.a, NAGARATHNA C.b, VISWANATH D.c, KEERTHI R.d, GADICHERLA P.e
Abstract Children are uniquely susceptible to cranio facial trauma because of their greater cranial mass to body ratio. Below the age of 5, the incidence of pediatric facial fractures in relation to the total is very low ranging from 0.6-1.2%. Maxillo-facial injuries may be quite dramatic causing parents to panic and the child to cry uncontrollably with blood, tooth and soft tissue debris in the mouth. The facial disfigurement caused by trauma can have a deep psychological impact on the tender minds of young children and their parents. This case reports documents the trauma and follow up care of a 4-year-old patient with maxillofacial injuries. Key words: Pediatric facial trauma, maxillofacial injuries, dento alveolar fracture
Introduction
For Fractures of the body of mandible in pediatric patients the fracture lines extend downwards and forwards from the upper border of mandible. Where as in the adult direction of fracture line is usually downward and backwards.[1]
Paradoxically, facial injuries in children are much less common than in adults, particularly during the first 5 years of life.[1] The incidence is low, ranging from 0.6-1.2% [Table 1]
Case Report Amongst the facial fractures, nasal fractures are the most common. Mandibular fractures are the second most common fractures reported in hospitalized pediatric trauma patients.[2] Mid face fractures are rare in case of children because of retrusive position relative to prominent Calvaria.[3,4]
A 4 year old patient reported to the department with a history of fall from the 4th floor of a building while playing [Figure 1 and 2]. The mother was feeding the second baby when this incident occurred. The patient was conscious, not well oriented with dressings in the lower jaw. There was no history of convulsions or vomitting.
The purpose of this article is to provide an insight on maxillofacial injuries in pediatric patient and to assist the clinician in the management of this unique and highly specialized area of traumatology.
On examination Extra oral examination revealed, diffuse facial oedema. Right eye showed periorbital echymosis (black eye), and sub conjunctival haemorrhage. Pupillary reflexes were normal. Bleeding from mouth, nose and ears (soft tissues) was evident [Figure 2]. Intra oral examination revealed complete set of deciduous dentition. Because of fear, apprehension radiographic examination had to be done under sedation
In pediatric patients the angle,condyle and the sub condylar region account for approximately 80% of mandibular fractures. Symphysis and parasymphysis fractures account for 15-20%. Body fractures are rare.[5] In the early years of life the cranium is relatively large, with forehead prominent and unprotected by frontal sinuses hence, any impact is primarily sustained by the frontal bone frequently resulting in child’s death.[6]
CT scan revealed
Other factors accounting for comparative rarity of jaw fractures in children include: 1. Elasticity of bones 2. Short thick condylar neck, which tends to resist fracture
However, a high tooth –to-bone ratio encourages fracture through the developing tooth crypts but it is seldom necessary to remove them.[6]
Small petechial haemmorhages in right postero-superior parietal white matter. Mild cerebral oedema Fracture of Nasal bone Fracture of Anterior wall of left maxillary sinus ant wall of left max sinus. No sub dural or extra dural haemorrhage.
Provisional diagnosis of dento-alveolar fracture with 51,52,53, fracture of right zygoma, which is inferiorly displaced, fracture of nasal bone, right parasymphysis fracture was made [Figure 3, 4].
a,b,c
M. D. S., dM. D. S. (Oral Maxillofacial Surgery), eP. G. Student, Dept. of Pedodontics, V. S. Dental College and Hospital, K. R. Road V. V. Puram, Bangalore - 560 004, Karnataka, India 157
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Management of facial trauma in children Table 1: Statistical evidence to support the very low incidence of facial fractures in children less than 5 years of age Authors Mac Lennan (1956) Donaldson (1961) Hagan and Huelke(1961) Rowe and Killey (1968) Morgan et al. (1972) Sawhney, Ahuja (1988)[3,4]
Age group (years) 0-5 0-5 0-5 0-5 0-6 0-70
Total in series 187 335 319 1500 300 262
Percentage of children 1.0 1.0 1.2 0.87 1.3 5.5
Figure 1: Pre operative photograph (Before)
Figure 3: View showing: Parasymphysis fracture
Figure 2: Pre operative photograph (Before)
Figure 4: P.N.S. View showing: Fracture of right zygoma
Management
dard procedure.
Management of mandibular fractures in children differs from that of adults because of anatomic variation, rapidity of healing, degree of cooperation from and the potential for interference with mandibular growth.
Maxillary fracture was digitally reduced and 51,52 had to be extracted and the labial lacerations were sutured with mersilk 3-0 and zinc oxide eugenol pack placed. A 30 size stainless steel wire was used to stabilize 61,62 and 53,54 [Figure 7].
The patient was shifted to the O.T. after pre-medication. The patient was laid on the O.T. table and induction of General Anesthesia was done by I.V route and maintenance through naso-tracheal intubation using an endo-tracheal tube. The surgical area was scrubbed and painted and the patient was draped in the usual stanJ Indian Soc Pedod Prev Dent - September 2006
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The mandibular arch was reduced and stabilized with Prefabricated Mac Lennan type cap splints or (stents) [Figure 5] and circum mandibular wiring was done by placing a small stab incision on the inferior border of mandible on right and left side 4-5 cm from midline.
Management of facial trauma in children
Figure 5: Upper and lower cast with cap splints
Figure 8: Post operative photograph
Figure 6: Post operative photograph showing circum mandibular wiring, zinc oxide eugenol pack in place with good healing
Figure 9: Post operative photograph (After)
side [Figure 6]. Management principle for soft tissue injuries are much the same except that treatment should be initiated within hours because healing occurs sooner. Although immature collagen in the child’s soft tissue provides very cosmetic results vast majority of times hypertrophic scars and keloids may form in this patient population.[8] Lower lip lacerations were then debrided and wound edges were freshened and sutured with vicryl 4-0. Nasal injuries in children Figure 7: Post operative OPG showing splintiing of 53, 54 and 61, 62. Healed fracture site. Occlusion normal
Mandibular bone awl was used to enter lingually along the body of the mandible and piercing lingual mucosa the wire was fed and passed onto buccal sulcus along the body of the mandible. Wire held together and stent stabilized by winding wire in clockwise direction at 83,84 region. Same procedure was repeated on left
A blow from the front may fracture both nasal bones transversely, or the bones may separate in the midline a so-called “open book” fracture.[2] The nasal bones here were elevated and reduced with an ash forceps
Children have greater osteogenic potential and faster healing rates than adults.[2] Three weeks is generally sufficient to ensure union and any discrepancy in alignment is auto159
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Management of facial trauma in children
matically adjusted by later bone growth [Figure 7]. 4.
In conclusion facial trauma in children can often be challenging to manage with long-term consequences involved. The pure joy and satisfaction derived after treating such children is unparalleled.
5.
6.
Acknowledgement 7.
Staff and P. G’s Department of Pedodontics and Oral Surgery 8.
References 1.
2. 3.
James D. Maxillofacial injuries in children. In: Rowe NL, Williams JL, editors. Maxillofacial Injuries. Churchill Livingstone: p. 538-58. Facial trauma I: mid face fractures. In: Kaban LB: Pediatric Oral Maxillofacial Surgery. W.B Saunders Co: 1990. p. 210-2. Kaban LB. Diagnosis and treatment of fractures of facial bones
in children. J Oral Maxillofac Surg 1993:51:722-9. Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofacial Surg 1993;51:836-44. Bataineh AB. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:31-5. Haugrh, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34. Bamjee Y, Lownie JF, Cleaton Jones PE, Lownie MA. Maxillofacial injuries in a group of South Africans under 18 years of age. Br J Oral Maxillofacial Surg 1996:34:298-302. Sawhney CP, Ahuja RB. Faciomaxillary fractures in North India, a statistical analysis and review of management. Br J Oral Maxillofac Surg 1988;26:430-4.
Reprint requests to: Usha Mohan Das, Dept of Pedodontics and Preventive Dentistry, K. R. Road, V. V. Puram, Bangalore - 560 004, Karantaka, India
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