Year : 2007 | Volume
: 25 | Issue : 4 | Page : 183--186
Management of dentoalveolar injuries in children: A case report
UM Das, D Viswanath, V Subramanian, M Agarwal
Department of Pedodontics and Preventive Dentistry, VS Dental College and Hospital, KR Road, VV Puram, Bangalore 560 004, Karnataka, India
U M Das
Department of Pedodontics and Preventive Dentistry, V. S. Dental College and Hospital, K. R. Road, V. V. Puram, Bangalore-560 004, Karnataka
Children aged 6-15 years old experience more injuries to their teeth and the injuries sustained are more serious as evidenced by a higher percentage of luxations, avulsions, fractures and dislocations. The mandible is the most frequently fractured facial bone and mandibular alveolar injuries have been reported to range between 8.1-50.6%. Those with mandibular or midface fractures have a higher incidence of associated chest, extremity, abdomen and cervical spine injuries. The growing patient with facial injuries presents the clinician with a series of thought-provoking circumstances. Dentoalveolar and mandibular injuries are especially important to understand because of the potential complications related to tooth eruption, alveolar development, occlusion and facial growth. However, the principles involved in the treatment for children need to be modified by certain anatomical, physiological and psychological factors specifically related to childhood.
This case report documents the trauma, management and follow-up care of an 11-year-old boy who sustained undisplaced infraorbital, nasal fractures and mandibular dentoalveolar fracture along with other associated injuries of the extremities.
|How to cite this article:|
Das U M, Viswanath D, Subramanian V, Agarwal M. Management of dentoalveolar injuries in children: A case report.J Indian Soc Pedod Prev Dent 2007;25:183-186
|How to cite this URL:|
Das U M, Viswanath D, Subramanian V, Agarwal M. Management of dentoalveolar injuries in children: A case report. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2020 Jul 12 ];25:183-186
Available from: http://www.jisppd.com/text.asp?2007/25/4/183/37015
Trauma is described as injury resulting from an external force. It is the leading health problem that children are facing today.  It has no significant predictable pattern of intensity and may not only leave physical scars but also has a psychological impact on the victim. 
Facial fractures in children occur with less frequency than in adults, the most common being minimally displaced nasal fractures. Mandibular fractures are the second most common facial skeletal fractures reported in hospitalized, pediatric trauma patients.  The incidence increases gradually from birth to 16 years of age. The gender wise distribution shows a higher prevalence among boys of all age groups.  Among all cases of pediatric maxillofacial trauma, the majority accounts for dentoalveolar trauma and soft tissue injuries, whereas the frequency of facial bone fractures is considerably low.  The reported incidence of tooth avulsion ranges from 1-16% of all traumatic injuries to the permanent teeth and from 7-13% of injuries to the primary dentition. The maxillary central incisors are the most frequently avulsed teeth in both the permanent and primary dentition. 
Traumatic orofacial injuries demand the application of basic fracture management principles, namely diagnosis, reduction, fixation and rehabilitation while accomplishing the goals of restoring function, occlusion and esthetics.
This case report focuses on the evaluation, diagnosis and effective management of a child who sustained injuries to the orofacial region and specifically to the permanent teeth and their supporting structures.
A 11-year-old boy reported to our department with the chief complaint of pain and swelling over the face. The child gave a history of fall from the first floor of a building while playing. The patient was moderately built and well nourished, conscious and cooperative with dressings on the left eyebrow, nose and right cheek region. While there was no history of convulsions or vomiting, there was a positive history of bleeding from the nose and the mouth and momentary loss of consciousness for two minutes.
On examination [Figure 1]
Extraoral examination revealed diffuse facial edema (left side), left eye showed periorbital ecchymosis, (black eye) and subconjunctival hemorrhage and periorbital edema of the right eye. Pupillary reflexes were normal, bleeding from mouth, nose and ears (soft tissues) was evident, abrasions on the nose, chin and left infraorbital region were also seen. Swelling of upper and lower lips with tenderness on palpation and limited mouth opening (1.5 cm) were noticed.
Intra Oral Examination [Figure 2]
Intraoral examination revealed avulsed 21, 22 and 63; deranged occlusion of the lower arch and Ellis Class I fracture of 12, 32, 41. Grade I mobility was found in 11 and Grade II mobility was noted with 31, 32, 41 and 42. Contusion on the lower labial mucosa and sutures on the upper labial frenum and labial mucosa were seen.
Computed tomography (CT) scan
No focal intracranial injury was seen although left nasal bone fracture and left premaxillary, prenasal, preseptal, prefrontal, pericranial soft tissue contusions with periorbital soft tissue emphysema were reported. X-Ray of the forearm revealed fractures of the distal end of the radius with epiphyseal injury and of the base of the third metacarpal of the right hand. PNS view revealed [Figure 3] an undisplaced left infraorbital fracture. OPG showed [Figure 4] a dentoaIveolar fracture line medial to left lower central incisor extending up to the apex. A provisional diagnosis of mandibular dentoalveolar fracture, left nasal fracture, undisplaced infraorbital fracture with the associated right radius and metacarpal fracture was made.
The principles of treating alveolar fractures are partly related to the treatment of jaw fractures and partly to that of tooth luxations. As a general rule, conservative therapy should be favored when treating facial trauma during childhood, especially in tooth-bearing regions and long-term follow-up is important. The mandible in children is characterized by a high cancellous to cortical bone ratio, giving more elasticity to the bone. The high osteogenic potential associated with a greater potential for healing in children is responsible for low complication rate. 
Fractured or missing anterior teeth have a negative effect on a child's physical attractiveness that can affect his/her self esteem. Hence, the management of pain caused by traumatic injury is not only the main concern when the trauma affects the appearance of the teeth. After a thorough assessment, a treatment plan was formulated for the patient described in this case report. Immediately after injury, the teeth were managed with a minimal amount of manipulation. Treatment for undisplaced nasal and infraorbital fractures was limited to observation.
After proper repositioning (closed reduction) of the alveolar fragment with digital pressure under local anesthesia (bilateral inferior alveolar nerve block), a semirigid, wire-composite splint using a 0.7 mm stainless steel wire was applied to ensure bone healing. Care was taken so that the splint did not impinge on the gingiva and/or prevent maintenance of oral hygiene in that area. The duration of the splint was three weeks [Figure 5]. The treatment of choice for enamel fracture of 12, 32 and 41 was an adhesive composite resin restoration with minimal tooth preparation using an acid-etch technique [Figure 6].
This case includes tooth avulsion of permanent maxillary left central and lateral incisors and primary canines which the patient could not locate. As the patient had missing 21, 22 and 63, he desired an esthetic restorative replacement. When a traumatic injury causes the loss of a child's tooth, the anatomic considerations of the size of the pulp, continuing soft tissue changes as the teeth continue to erupt and any other growth and development that will occur preclude the use of a crown-fixed, partial prosthesis.
A provisional removable partial denture replacing the missing teeth was fabricated which provides an esthetic replacement of the missing teeth [Figure 7],[Figure 8]
Pediatric maxillofacial fractures are not common and demonstrate different clinical features when compared with adults. They also need different treatments due to the differences in their facial bones and skulls. Fractures of the alveolar process are common while midfacial fractures are less common in children. These characteristic fracture patterns are a consequence of the anatomical characteristics of the pediatric facial skeleton such as the elasticity of the developing jaws, lack of sinus pneumatization (Posnick et al . 1993), mixed dentition (Tanaka et al. 1993), a prominent forehead (Kaban,1993) as well as the etiology of the trauma.  Gordy, stated that children aged 6-15 years experience more injuries to the teeth and the injuries sustained were more serious, as evidenced by the higher percentage of luxations, avulsions, fractures and dislocations. Injury to a young child's teeth and face is not only traumatic in the physical sense but also in the emotional and psychological sense. Hence, it seems appropriate to have noninvasive criteria when treating a child with acute dental trauma.  The patient who has sustained a traumatic dental injury must undergo posttreatment evaluations to assess the initial therapy provided, proceed with an additional phase of treatment for additional problems and/or to prevent or treat complications. 
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