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CASE REPORT
Year : 2006  |  Volume : 24  |  Issue : 3  |  Page : 161-163
 

Management of facial trauma in children: A case report


Dept. of Pedodontics, V. S. Dental College and Hospital, K. R. Road V. V. Puram, Bangalore - 560 004, Karnataka, India

Correspondence Address:
U M Das
Dept of Pedodontics and Preventive Dentistry, V. S. Dental College and Hospital, K. R. Road, V. V. Puram, Bangalore - 560 004, Karantaka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.27900

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   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 report documents the trauma and follow up care of a 4-year-old patient with maxillofacial injuries.


Keywords: Dento alveolar fracture, maxillofacial injuries, pediatric facial trauma


How to cite this article:
Das U M, Nagarathna C, Viswanath D, Keerthi R, Gadicherla P. Management of facial trauma in children: A case report. J Indian Soc Pedod Prev Dent 2006;24:161-3

How to cite this URL:
Das U M, Nagarathna C, Viswanath D, Keerthi R, Gadicherla P. Management of facial trauma in children: A case report. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2018 Dec 15];24:161-3. Available from: http://www.jisppd.com/text.asp?2006/24/3/161/27900



   Introduction Top


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]

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]

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.

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]

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]

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]


   Case Report Top


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][Figure - 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.

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

CT scan revealed

  • 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
  • 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][Figure - 4].

Management

  • 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.

    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 standard procedure.

    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 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. 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 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 [Figure - 8][Figure - 9].[8]

Lower lip lacerations were then debrided and wound edges were freshened and sutured with vicryl 4-0.

Nasal injuries in children

  • 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 automatically adjusted by later bone growth [Figure - 7].

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.


   Acknowledgement Top


Staff and P. G's Department of Pedodontics and Oral Surgery

 
   References Top

1.James D. Maxillofacial injuries in children. In : Rowe NL, Williams JL, editors. Maxillofacial Injuries. Churchill Livingstone: p. 538-58.  Back to cited text no. 1    
2.Facial trauma I: mid face fractures. In : Kaban LB: Pediatric Oral Maxillofacial Surgery. W.B Saunders Co: 1990. p. 210-2.  Back to cited text no. 2    
3.Kaban LB. Diagnosis and treatment of fractures of facial bones in children. J Oral Maxillofac Surg 1993:51:722-9.  Back to cited text no. 3    
4.Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofacial Surg 1993;51:836-44.  Back to cited text no. 4    
5.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.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Haugrh, Foss J. Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34.  Back to cited text no. 6    
7.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.  Back to cited text no. 7    
8.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.  Back to cited text no. 8  [PUBMED]  


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]

    Tables

[Table - 1]


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    Abstract
    Introduction
    Case Report
    Acknowledgement
    References
    Article Figures
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