Fractures of the facial skeleton in children

Pediatric Maxillofacial Trauma: Insights into Diagnosis and Treatment of Mandibular Fractures in Pediatric Patients

Aim

To assess the diagnostic and therapeutic approaches in pediatric mandibular fractures with regards to fracture pattern and localization.

Patients and methods

This retrospective study included patients under the age of 17 years that presented to the Department of Oral and Maxillofacial Surgery at Charité-Universitätsmedizin Berlin with mandibular fractures over an 11-year long period (2010-2020). Medical records were analyzed for age, gender, injury mechanism, clinical presentation, imaging modalities, fracture pattern, and fracture management. Statistical analyses included descriptive statistics, normality testing, and Mann-Whitney U tests.

Results

A total of 91 pediatric patients (23 females and 68 males) presented with mandibular fractures. The majority of mandibular fractures occurred in patients aged 13-16 years (67.0%, n = 61). The main causes were activities of daily life (34.1%), followed by assault (25.3%). Malocclusion and pain upon mandibular joint compression were documented in 72.5% and 51.7% of patients, respectively. The most frequently applied radiological diagnostic tool was a panoramic X-ray (49.5%). The main fracture patterns were single (42.9%) and double fractures (48.4%). An age-adapted surgical approach using open reduction and internal fixation (ORIF) was the most frequent management (61.5%). A conservative approach was favored in cases of condylar head fractures. Resorbable plates were used in eight cases of ORIF (8.8%).

Conclusion

Treatment regimens should be carefully selected based on the unique anatomy of the pediatric patient with regards to centers of growth and dentition phase, to restore stomatognathic function and to maintain adequate skeletal growth and eruption of teeth.

Clinical significance

This study illustrates the challenges of mandibular fracture management in the pediatric patient.

How to cite this article

Hofmann E, Koerdt S, Heiland M, et al. Pediatric Maxillofacial Trauma: Insights into Diagnosis and Treatment of Mandibular Fractures in Pediatric Patients. Int J Clin Pediatr Dent 2023;16(3):499-509.

Absorbable Fixation Devices for Pediatric Craniomaxillofacial Trauma: A Systematic Review of the Literature

BACKGROUND

The purpose of this study was to investigate surgical outcomes with the use of resorbable plating systems for the repair of craniomaxillofacial trauma in the pediatric population.

METHODS

A systematic review of the literature was performed. A descriptive analysis, operative technical data, outcomes, and postoperative complications with the use of absorbable plating systems for craniomaxillofacial trauma were included.

RESULTS

The systematic literature review identified 1264 abstracts, of which only 19 met inclusion criteria. From these 19 studies, 312 clinical cases with 443 facial fractures that were treated with absorbable fixation systems were extracted for analysis. The review identified only level III/IV (n = 17) and level V (n = 2) studies. Minor and major complications were rare, occurring in 5.45 percent (n = 17) and 3.21 percent (n = 10) of cases, respectively. The most common complications were surgical-site infections (n = 4) and plate extrusion (n = 4).

CONCLUSIONS

This report is, to the authors' knowledge, one of the first comprehensive reports on the use of absorbable plating systems for pediatric craniomaxillofacial trauma. Their analysis suggests that the use of absorbable fixation devices for pediatric craniomaxillofacial trauma is relatively safe, with a low-risk profile. Outcome studies with longer follow-up periods specifically investigating facial growth, reoperation rates, standardized surgical outcome metrics, and cost are necessary to effectively compare these fixation devices to titanium alternatives for craniomaxillofacial trauma.

Tessier 30 Median Mandibular Hard and Soft Tissue Cleft, One-Stage Reconstruction Using a Template-Guided Resorbable “U”-Shaped Plate

Midline clefts of the lower lip, tongue, and mandible are a rare type of facial cleft classified as “Tessier 30.” We present the case of a female patient with an isolated Tessier 30 facial cleft affecting the tongue, lower lip, and mandibular symphysis with ankyloglossia. This was reconstructed with a template-guided resorbable “U”-shaped plate at 10 months of age. The procedure was carried out in one stage, which avoided the need for a repeat general anesthetic for the patient. We had a successful outcome with normal dental eruption and we believe such an approach could be considered as a relevant treatment modality for future cases.

Orofacial trauma in rural India: A clinical study

PURPOSE

Orofacial trauma is becoming a leading medical problem worldwide. Most of the studies pertaining to orofacial trauma have been done in urban areas but very little scientific literature is available for rural areas.

METHODS

A prospective medical institute-based study of orofacial injury patients was carried out from May 2013 to April 2016 (36 Months). Data regarding incidence, age and sex distribution, causes, types and site of injury, treatment modalities and trauma associated complications were collected and analysed.

RESULTS

A total of 784 patients were studied. Males outnumbered females by a ratio of 2.9:1. Age range was 9 months-75 years with the peak incidence in the age-group of 18-34 years. Most injuries were caused by road-side accidents (72.7%), followed by assault and falls in 11.6% and 8% respectively. Soft tissue injuries and mandibular fractures were the most common type of injuries. Head/neck (50.29%) and limb injuries (27.2%) were the most prevalent associated injuries. Surgical debridement and soft tissue suturing was the most common emergency procedure. Closed reduction was performed in 61% of patients and open reduction and internal fixation in 30% of cases and 9% were managed conservatively. Complications occurred in 6.88% of patients, mainly due to infection and malocclusion. The mean duration of hospital stay was (10.12 ± 6.24) days.

CONCLUSION

This study highlights the importance of department of dental surgery along with other disciplinaries in the management of orofacial injuries. Road-side accident remains the major etiological factor of orofacial injuries in our setting.

Pediatric Facial Fractures: A 10-year Study

Aims and Objectives

The aim of the study is to retrospectively analyse the incidence of facial fractures along with age, gender predilection, etiology, commonest site, associated dental injuries and any complications of paediatric patients operated in Craniofacial unit of SDM college of dental sciences and hospital.

Materials and Methods

This retrospective study was conducted at the department of OMFS, SDM College of Dental Sciences, Dharwad from January 2003-December 2013. All the patients below 15 years of age were included in the study. Data were recorded for the cause of injury, age and gender distribution, frequency and type of injury, localization and frequency of soft tissue injuries, dentoalveolar trauma, facial bone fractures, complications, concomitant injuries and different treatment protocols.

Results

A total of 68 cases of paediatric fracture were treated during these 10 years. Boys were commonly injured than girls with a ratio of 2.9:1, the commonest cause of trauma was fall (59 %), mandible was the commonest bone to be fractured (83 %), treatment protocols were dependant on the age, region and type of fracture but in most of the cases closed reduction was the choice of treatment, dental injuries were seen in 26 % patients and the commonest injury was avulsion.

Conclusion

This study was done not only to analyse the different types of facial fractures and the pattern of fracture of paediatric cases admitted at this centre, but also to act as a contributional data which will help us to take preventive measures to avoid such injuries and make the appropriate treatment plan and execute it to achieve the pre-injury status of form and function.

Characteristics of temporomandibular joint structures after mandibular condyle fractures revealed by magnetic resonance imaging

Background

This study aimed to evaluate the structural changes of temporomandibular joint immediately after condylar fractures with magnetic resonance imaging (MRI).

Method

We evaluated 34 subjects of condylar fractures with MRI. The position, shape, and signal intensity of the condyle, disc, and retrodiscal tissue were analyzed with MR images.

Results

Immediately after trauma, the disc was displaced with the fractured segment in almost all cases. And, the changes of signal intensity at the retrodiscal tissue were found but less related to the degree of fracture displacement. And, the high signals were observed almost at all fractured joint spaces and even at some contralateral joints.

Conclusions

The displaced disc as well as the increased signal intensity of the joint space, condylar head, and retrodiscal tissue demands more attention to prevent the possible sequela of joint.

Management of Symphysis and Parasymphysis Mandibular Fractures in Children Treated with MacLennan Splint: Stability and Early Results

Objective: The aim of this study was to assess the safety and efficiency of MacLennan splint in symphysis and parasymphysis mandibular fractures in children.

Study design: Six patients (four boys and two girls, mean age 3 years, range between 2 and 5 years) were operated on parasymphysis fractures of children. The mean follow-up time was 12 months. MacLennan splint was applied in these case upto 3 weeks.

Results: Primary healing of the fractured mandible was observed in all patients. Postoperative complications were minor and transient. The outcome of the operation was not endangered. Adverse tissue reaction like infection, malocclusion, swelling and growth restrictions did not occur during observation period.

Conclusion: MacLennan splint is having various advantages like faster mobilization and the avoidance of secondary removal operations. Based on this preliminary results MacLennan splints are safe and efficient in the treatment of pediatric mandible fracture.

How to cite this article: Khairwa A, Bhat M, Sharma A, Sharma R. Management of Symphysis and Parasymphysis Mandibular Fractures in Children Treated with MacLennan Splint: Stability and Early Results. Int J Clin Pediatr Dent 2015;8(2):127-132.

Pediatric Maxillofacial Trauma Outcomes Based on a Survey of 65 Patients: A Prospective Study of Etiology, Incidence and Methods of Treatment

BACKGROUND

The purpose of this study was to assess the etiology, incidence, and various methods of treatment of maxillofacial injuries in children presenting at our centre and to compare our findings with literature.

PATIENTS AND METHODS

We carried out prospective study of 65 pediatric maxillofacial trauma patients treated from January 2011 to October 2012 at our centre. Data was collected on age, gender, etiological factors, anatomic site and treatment methods. Follow-up was performed by recall survey.

RESULTS

Out of 65 patients 17 (26.15 %) presented with isolated soft tissue injuries and 48 (73.84 %) patients reported with 81 craniomaxillofacial fractures. Falls were most common mode of injury with 53 fractures (81.53 %). Treatment for fractures in our series comprised of periodic observation for non-displaced fractures (46.15 %), closed reduction (maxillomandibular fixation with IMF screws, acrylic cap splints) for minimally displaced fractures (15.38 %) and open reduction and internal fixation (ORIF) for grossly displaced fractures (12.30 %).

CONCLUSION

Paediatric maxillofacial trauma can be managed conservatively and surgical treatment by ORIF is required in a very small group of children with grossly displaced fractures as a result of high velocity injuries.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Nonfatal sport-related craniofacial fractures: characteristics, mechanisms, and demographic data in the pediatric population

BACKGROUND

Few reports exist on sport-related craniofacial fracture injuries in the pediatric population. Most patients with craniofacial injuries are adults, and most studies on pediatric sport injuries do not focus specifically on craniofacial fractures. The authors' goal was to provide a retrospective, descriptive review of the common mechanisms of sport-related craniofacial injuries in the pediatric population, identifying the characteristics of these injuries and providing a description of the demographics of this population.

METHODS

The study population included children between the ages of 0 and 18 years who were seen in the emergency department at Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center between 2000 and 2005. Of the 1508 patients identified, 167 had injuries caused by sport-related trauma (10.6 percent).

RESULTS

After evaluation in the emergency department, 45.5 percent were hospitalized, and 15.0 percent of these were admitted to the intensive care unit. The peak incidence of sport-related injuries occurred between the ages of 13 and 15 years (40.7 percent). Nasal (35.9 percent), orbital (33.5 percent), and skull fractures (30.5 percent) were most common, whereas fractures of the maxilla (12.6 percent), mandible (7.2 percent), zygomaticomaxillary complex (4.2 percent), and naso-orbitoethmoid complex (1.2 percent) were observed less frequently. Baseball and softball were most frequently associated with the craniofacial injuries (44.3 percent), whereas basketball (7.2 percent) and football (3.0 percent) were associated with fewer injuries. The most common mechanisms of injury were throwing, catching, or hitting a ball (34.1 percent) and collision with other players (24.5 percent).

CONCLUSION

These data may allow targeted or sport-specific craniofacial fracture injury prevention strategies.

Pediatric maxillofacial injuries - if a new look is required?

OBJECTIVE

Maxillofacial injuries in children always present a challenge in respect of their diagnosis and management. The phenomenal increase in automotives on the road has led to a tremendous rise in the number of road traffic accidents leading to facial injuries, of which children are the most unfortunate victims. The purpose of this retrospective study was to evaluate the epidemiology, etiology and pattern of facial injuries and also to access the most feasible method for the management of facial injuries in children without hampering the facial growth.

METHODS

The records and radiographs of 110 patients within the age range of 0-16 years were retrospectively reviewed who have presented with maxillofacial injuries to our department from October 2008 to June 2012. The information extracted from patient's case records included patient's gender (male/female), age, etiology, fracture type (single fractures and multiple fractures), occlusal status, fracture site and treatment performed.

RESULTS

Patient's age at the time of accident ranged from 0 to 16 years, with a mean of 6.1 years. 54.54% (n = 60) of the patients were under 6 years (infants and preschool), 31.82% (n = 35) were between 6 and 11 (school age), and 13.64% (n = 15) were between 12 and 16 years (adolescents). Road side accident was the most frequent cause of injury. Most fractures occurred in the mandible (54.54%; n = 60). The fractures with minimal or no occlusal disturbance were managed by liquid diet alone.

CONCLUSION

We believe that even after so much advancement in surgical techniques and armamentarium, conservative treatment is still the most reliable approach in managing maxillofacial injuries in children.

Open versus closed reduction: mandibular condylar fractures in children

PURPOSE

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of mandibular condylar fractures (MCFs) in children.

METHODS

An electronic search in PubMed was undertaken in May 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies published in English or German from the last 20 years (from 1992 onwards) reporting clinical series of MCFs in children and adolescents until the age of 18.

RESULTS

The search strategy initially identified 542 studies. The references from 1992 onwards totaled 339 articles. Twenty-seven studies were identified without repetition within the selection criteria. Additional hand-searching yielded two additional papers.

CONCLUSIONS

Pediatric MCFs require thoughtful consideration in management to avoid significant growth disturbance. Early treatment is indicated in order to improve the chances for favorable development. Long-term follow-up is required, in order to properly treat late complications that may appear. Coronal computed tomography is helpful in substantiating the correct final diagnosis. Many studies show that conservative treatment (CTR) has satisfactory long-term outcome of jaw function, occlusion, and facial esthetics, despite a high frequency of radiological aberrations. Surgery before puberty should be reserved for exceptional cases such as missile injuries, in cases with extensive dislocation and lack of contact between the fragments, in cases with multiple midfacial fractures, in which the mandible has to serve as a guide to reposition the midfacial bones, and in cases which the dislocation of the fractured stump creates a functional impediment that cannot be resolved by CTR. As the craniofacial skeleton becomes more adult-like in its form at about 12 years of age, the decreased remodeling capacity in the adolescents may occasionally result in abnormally shaped condylar heads or shortened ramus heights that may lead to persistent malocclusion. Thus, the indication of open reduction and internal fixation increases with age.

Mandibular fractures in children: analysis of 61 cases and review of the literature

OBJECTIVE

The purpose was to evaluate the incidence, etiology, site and patterns, management and treatment methods, and outcome of pediatric patients with mandibular fractures.

METHODS

Pediatric patients (1.5-16 years old) with mandibular fractures, treated at the Soroka University Medical Center were included in the study. Age, gender, etiology, site and type of fracture, associated injuries, mode of treatment, outcome, complications, and follow up were evaluated. The cases were divided into 3 age groups: Group A: 1.5-5 years, Group B: 6-11 years, and Group C: 12-16 years.

RESULTS

Sixty one patients were included in the study. The male to female ratio was 2:1. Motor vehicle accident was the most common cause. Associated trauma was more common in young children. The condyle was involved in 54% of the fractures. Closed reduction and intermaxillary fixation was the most common treatment used. Complications were rare.

CONCLUSION

Management of mandibular fracture in the pediatric age group is a challenge. The anatomical complexity of the developing mandible and teeth strongly suggest the use of surgical techniques that are different from those routinely used in adults. The conservative approach is recommended. Whenever possible closed reduction should be the treatment of choice.

Epidemiologia das fraturas de face em crianças num pronto-socorro de uma metrópole tropical

OBJETIVO: Realizar um estudo epidemiológico das fraturas de face em crianças em um serviço de urgência. MÉTODOS: Estudo retrospectivo de quarenta e dois pacientes com idades variando entre zero a 17 anos, portadores de fraturas de face, tratados no Setor de Cirurgia Buco-Maxilo-Facial da Santa Casa de São Paulo, no período de janeiro de 2000 a dezembro de 2003. Os dados foram tabulados através das informações colhidas dos prontuários dos pacientes, tais como: idade, gênero, tipo de fratura, etiologia e sazonalidade. RESULTADOS: Entre os resultados encontrados, houve predominância do gênero masculino com 81% da casuística, a fratura de mandíbula foi a mais prevalente, com mais de 70% dos casos, os acidentes de trânsito e as quedas foram os agentes etiológicos que mais causaram fraturas. O verão foi a época do ano com mais casos de fratura e mais de 80% destas necessitaram de intervenção cirúrgica para o seu tratamento. CONCLUSÃO: É necessária uma política de prevenção com uma atenção especial aos acidentes de trânsito e às quedas, que foram os agentes etiológicos que mais causaram fraturas faciais.

Incidence and patterns of mandibular condyle fractures

PURPOSE

The aim of the present study was to retrospectively evaluate the epidemiologic characteristics of the prevalence, type, and treatment modalities of condylar fractures of the mandible.

PATIENTS AND METHODS

Data were collected from patients during an 8-year period (1999 to 2007). The data recorded included demographic data, etiology, diagnosis, type, dislocation, use of protective devices, state of the dentition, associated facial and general trauma, soft tissue lesions, treatment methods, and the interval between trauma and treatment. Data analysis included a descriptive analysis, chi(2) test, Fisher's exact test, t test, and Kruskal-Wallis test.

RESULTS

During the 8-year period, 209 unilateral fractures and 54 bilateral fractures were treated, with a male/female ratio of 3.05:1 and a mean age of 28.4 years, for a total of 317 condylar fractures. Male gender was significantly associated with the presence of a condylar fracture (P < .05). The most common cause of condylar fractures was road traffic accidents (57.8%). Of the 317 fractures, 300 were classified as simple fractures, and 249 fractures were not displaced. Protective devices significantly decreased the number of condylar fractures occurring from road traffic accidents (P < .05). Symphysis fractures were significantly associated with both unilateral and bilateral fractures of the mandibular condyle (P < .05). Subcondylar displaced fractures were significantly associated with surgical treatment (P < .05).

CONCLUSIONS

Young adults were involved in most of the accidents. Road traffic accidents were the main cause of condylar fractures. The mandatory use of safety helmets and seatbelts and education of those using the road are essential to decrease the number of facial fractures.

The use of a single titanium microplate in displaced pediatric parasymphysial mandibular fractures

OBJECTIVE

The objective of this study was to evaluate the use of one titanium microplate in the fixation of displaced pediatric parasymphysial mandibular fractures.

MATERIALS AND METHODS

The study was conducted on 7 children in the mixed dentition stage with displaced parasymphysial fracture. Patients' age ranged between 5 years 9 months and 8 years 4 months with an average of 7 years 1 month. Fractured bone segments were exposed, reduced and then fixed using 1.5 linear microplates at the inferior border of the mandible using monocortical screws, with 1.5 mm in diameter and 5 mm in length. Stainless steel wire was used as a tension band by ligating the teeth around the fracture line. Patients were followed up for occlusion and stability clinically and radiographically (panoramic X-ray and CT).

RESULTS

According to clinical and radiographic post-operative follow-up, none of the patients showed displacement of the fixed bony segments.

CONCLUSION

The present study concluded that using one microplate with 1.5 monocortical microscrews and dental tension band by a stainless steel wire could be adequate for fixing displaced pediatric parasymphysial mandibular fractures. This technique has the following advantages: decreases the amount of titanium used, decreases the risk of injury of the roots and teeth buds, and decreases the cost and time of surgery.

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

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.

Pediatric craniofacial trauma

PURPOSE

Maxillofacial and skull fractures occur with concomitant injuries in pediatric trauma patients. The aim of this study was to determine the causes and distributions of maxillofacial and skull fractures as well as concomitant injuries of pediatric patients in Switzerland. Results were compared with worldwide studies.

MATERIALS AND METHODS

A retrospective review was conducted of 291 pediatric patients with maxillofacial and skull fractures presenting to a level-I trauma center over a 3-year span. Data concerning the mechanism of the accident and the topographic location of the injuries were analyzed.

RESULTS

The most common causes were falls (64%), followed by traffic (22%) and sports-related accidents (9%). Fifty-four percent of the fractures occurred in the skull vault and 37% in the upper and middle facial third. One third of the patients (n = 95) suffered concomitant injuries, mostly cerebral concussions (n = 94).

CONCLUSIONS

The spectrum of craniofacial injuries is related to the specific developmental stage of the craniofacial skeleton. It is probable that national prevention programs will have a positive effect on reducing the incidence of falls. Standardization of studies is needed for international comparison.

Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals

INTRODUCTION

The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) or intracapsular, undisplaced, deviated, displaced or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and the dental occlusion, and the surgeon's experience.

PURPOSE

This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment.

MATERIAL AND METHODS

The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted.

RESULTS

Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively.

CONCLUSIONS

Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with 'medical problems' where intermaxillary fixation is not recommended.

Pediatric facial fractures: recent advances in prevention, diagnosis and management

During the last 25 years, there have been considerable advances in the prevention, diagnosis and management of craniomaxillofacial injuries in children. When compared to adults, the pattern of fractures and frequency of associated injuries are similar but the overall incidence is much lower. Diagnosis is more difficult than in adults and fractures are easily overlooked. Clinical diagnosis is best confirmed by computed tomographic (CT) scans. Treatment is usually performed without delay and can be limited to observation or closed reduction in non-displaced or minimally displaced fractures. Operative management should involve minimal manipulation and may be modified by the stage of skeletal and dental development. Open reduction and rigid internal fixation is indicated for severely displaced fractures. Primary bone grafting is preferred over secondary reconstruction and alloplastic materials should be avoided when possible. Children require long-term follow-up to monitor potential growth abnormalities. This article is a review of the epidemiology, diagnosis and management of facial fractures in children.

Pediatric facial fractures: recent advances in prevention, diagnosis and management

During the last 25 years, there have been considerable advances in the prevention, diagnosis and management of craniomaxillofacial injuries in children. When compared to adults, the pattern of fractures and frequency of associated injuries are similar but the overall incidence is much lower. Diagnosis is more difficult than in adults and fractures are easily overlooked. Clinical diagnosis is best confirmed by computed tomographic (CT) scans. Treatment is usually performed without delay and can be limited to observation or closed reduction in non-displaced or minimally displaced fractures. Operative management should involve minimal manipulation and may be modified by the stage of skeletal and dental development. Open reduction and rigid internal fixation is indicated for severely displaced fractures. Primary bone grafting is preferred over secondary reconstruction and alloplastic materials should be avoided when possible. Children require long-term follow-up to monitor potential growth abnormalities. This article is a review of the epidemiology, diagnosis and management of facial fractures in children.

Pediatric craniofacial fractures: long-term consequences

Pediatric craniofacial fractures are distinct from adult fractures because of the anatomical differences that result in unique fracture patterns and challenges in management. The unanswered question remains the outcome with regards to subsequent growth and development. Upon review of all primary craniofacial fractures treated at the Children's Hospital of Philadelphia, the authors find that the majority are associated with favorable long-term outcome. Severe centrofacial bony and cartilaginous injury may result ingrowth and developmental anomalies in up to 40% of patients.

A comparative study of 2 imaging techniques for the diagnosis of condylar fractures in children

PURPOSE

We sought to compare the sensitivity and specificity of panoramic radiographs with those of coronal computed tomography (CT) scans in the diagnosis of mandibular condylar fractures in the pediatric population.

METHODS

Medical, dental, and radiographic records of patients who presented between 1995 and 2000 were evaluated for injuries involving the mandibular condyle. The sample included 22 males and 15 females with ages ranging from 2 to 15 years (mean, 8 years). Control subjects were added and matched by age and gender. The panoramic radiographs were blocked to allow separate evaluation of each condyle. Representative images from the CT scans were selected and individually photographed for projection. Both sets of images were evaluated by 4 groups of examiners: oral and maxillofacial (OMF) surgeons who regularly deal with pediatric trauma (n = 2), community OMF surgeons who had been out of training for at least 5 years (n = 6), OMF radiologists (n = 3), and OMF surgery residents (n = 6). Each image was shown for 20 seconds and the examiners were given 3 options to choose: 1) fracture, 2) no fracture, and 3) uncertain.

RESULTS

The overall diagnostic accuracy of CT scanning was 90% (sensitivity, 92%; specificity, 87%), and that of panoramic radiographs was 73% (sensitivity, 70%; specificity, 77%). Of interest, the most experienced clinicians were also those most likely to respond that panoramic films were not diagnostic. Statistical analysis of the results was performed using chi(2) analysis. The differences for sensitivity measurements using the CT scan were not statistically significant (P >.1). However, the differences in sensitivity measurements using the panoramic radiographs and the specificity measurements using both the CT and panoramic radiographs were statistically significant (P <.05).

CONCLUSIONS

CT scans provide consistently greater accuracy of diagnosis, sensitivity, and specificity than panoramic radiographs in the assessment of children suspected of having condylar fractures. In view of the high rate of false-negative and false-positive results associated with panoramic radiographs, coronal CT scans should be considered routine investigation in these patients.

Intracapsular fractures of mandibular condyle: diagnosis, treatment, and anatomical and pathological evaluations

The aim of this study was to attempt to establish a correlation between condylar localized fracture, onset of anatomicopathological lesions of the articular structures, and determination of ankylosis so as to define appropriate diagnostic and therapeutic procedures. Clinical, arthroscopic, and histological studies were carried out in two patients with a severe temporomandibular joint disorder after a condylar localized fracture. Treatment included removal of the displaced fragments, condylar surface remodeling, suture of retrodiskal perforations, and diskal repositioning. The histological study of the condylar specimens revealed signs of osteoarthrosis of the articular surface and chondroid metaplasia of the bilaminar zone with early onset of ankylosis. Results of this study confirmed the presence of causal relations between condylar localized fracture and ankylosis with alterations in retrodiskal tissue. These relations are found in 1) tissue damage caused by bony fragments remaining in the articular cavity (underestimated and poorly treated fractures), 2) the lesion that occurs in association with mechanical trauma; and, particularly, c) the disk and retrodiskal impairments caused by catabolic and degenerative osteoarthrotic changes secondary to condylar marrow damage. Thus, timeliness and accuracy of the diagnosis of condylar localized fracture are most important, as are correct diagnosis and treatment before the onset of degenerative anatomicopathological lesions.

Mandibular fractures in children: long term results

Mandibular fractures in children treated in our department between March 1994 and January 2001 were retrospectively studied. Age, sex, type of fracture, etiology and evolution after treatment, functional mobility and maximal mouth opening were recorded. The population consisted of 19 patients who sustained 30 fractures. The patients ages ranged from 1.5 to 18 years. The mean time of follow up was 28 months. The male to female ratio was 1.7:1. Traffic and bicycle accidents were the main causes of the fractures. The condyle was involved in 16% of the cases, the subcondylar region in 28%. Fractures were multiple in half of the cases. Isolated fractures of the condyloid joint were treated conservatively. For isolated subcondylar fractures, maxillomandibular fixation was the treatment in 40% of the cases. Otherwise, conservative functional treatment was used. Children with a combination of body and condyle fractures were treated by open reduction and maxillomandibular fixation. Neither infection nor retarded facial growth was observed. Only one case of ankylosis of the temporomandibular joint (TMJ) and one case of temporomandibular pain syndrome were recorded. Associated lesions might concern the extremities, the brain and the cervical spine.

Paediatric maxillofacial fractures: their aetiological characters and fracture patterns

OBJECTIVE

Paediatric maxillofacial fractures are not common and carry different clinical features when compared with adults. To clarify the differences of aetiology and patterns of fractures in paediatric patients, a clinical retrospective analysis was performed.

PATIENTS

One hundred seventy-four paediatric patients younger than 16 years of age treated in the First Department of Oral and Maxillofacial Surgery, Osaka University Dental Hospital during a 15-year period were analysed.

STUDY DESIGN

Age, sex, fracture patterns, incidence, common locations of the mandibular fractures and treatment were studied according to the patients' charts and radiographs.

RESULTS

The ratio of boys to girls was 2:1 and the largest age subgroup was 15-years old. The most common cause of injury was bicycle accidents (26%), followed by falls (25%). The distribution of causes and ages revealed that the incidence of the fall-related injuries decreased in patients older than 10 years, and assaults became a common cause in patients older than 12 years. The yearly distribution showed a decrease of the group between 6 and 10 years and of bicycle-related accidents in the last 5-year period (1992-1996). Mandibular fractures were most common (56%), followed by fractures of the alveolar process (31%). Condylar fracture was common in children younger than 14 years, especially in those below 6 years. Fractures of the mandibular angle were the most common in those above 13 years.

CONCLUSION

These results document that the aetiological characters and patterns of paediatric maxillofacial fractures gradually shifted towards those found in adolescents.

Maxillofacial injuries in the pediatric patient

Approximately 22 million children are injured in the United States annually. Children are uniquely susceptible to craniofacial trauma because of their greater cranial-mass-to-body ratio. The pediatric population sustains 1% to 14.7% of all facial fractures. The majority of these injuries are encountered by boys (53.7% - 80%) who are involved in motor vehicle accidents (up to 80.2%). The incidence of other systemic injury concomitant to facial trauma is significant (10.4% - 88%). The management of the pediatric patient with maxillofacial injury should take into consideration the differences in anatomy and physiology between children and adults, the presence of concomitant injury, the particular stage in growth and development (anatomic, physiologic, and psychologic), and the specific injuries and anatomic sites that the injuries affect. This comprehensive review, based on the last 25 years of the world's English-speaking surgical literature, presents current thoughts on the anatomic and physiologic differences between adults and children, a synopsis of childhood growth and development, and an overview of state-of-the-art management of the pediatric patient who has sustained maxillofacial injury.

Análise de 126 fraturas de face em crianças menores de 12 anos

As fraturas da face em crianças são infreqüentes e a melhor forma de tratamento ainda é a prevenção. Com isso nosso estudo busca caracterizar epidemiologicamente as fraturas de face em crianças enfatizando os sítios principais. Analisamos 126 fraturas de face em 98 crianças atendidas no HC-FMUSP, entre janeiro de 1990 e julho de 1996. A causa mais freqüente foi a queda de alturas e o osso da face mais acometido foi a mandíbula (29%), seguida do osso nasal (24%). Das fraturas da mandíbula, o corpo foi a região mais envolvida (31%), seguido do côndilo (27%). Traumas associados estiveram presentes em 24% dos casos, sendo traumatismo crânio-encefálico o mais freqüente. Os acidentes domésticos são as principais causas de fraturas de face em crianças, portanto, medidas preventivs simples podem ser adotadas objetivando diminuir o número desses acidentes.

Mandibular fractures in children. A retrospective study of 99 fractures in 59 patients

Fifty-nine children younger than 16 years with mandibular fractures were studied by age, sex, type of fracture, cause, methods of treatment, and complications. The cases were divided into three age groups. The male-to-female ratio was 2.9:1. Motor vehicle accidents were the most common cause of mandibular fractures. Associated injuries were more common in young children. The condyle was involved in 43.3% of fractures. Intermaxillary fixation was the most common treatment used. Complications appeared to be rare.

Mandibular fractures in infants: review of the literature and report of seven cases

Mandibular fractures in infants are rare. During the last 50 years, only 13 cases have been recorded in the literature. In this study seven cases of mandibular fractures in infants treated within a period of 3 years are reported. The male-to-female ratio was 6:1. All fractures were caused by short falls, and in all cases the symphysis region was the injured site. The treatment approach was conservative, without any active intervention. The results were satisfactory; perfect alignment of the fractured bone segments was achieved in all cases.

Maxillofacial fractures in children

A clinico-statistical and long-term follow-up study was performed on 81 pediatric fractures seen during the 14 years between 1977 and 1990. Of all maxillofacial fractures, the incidence of pediatric fractures was 14.7%. The ratio of boys to girls was 2.1:1, and the highest incidence involved boys over 13 years of age. Fractures of the upper alveolar bone and mandible were common. Conservative therapy, such as maxillomandibular fixation using orthodontic brackets was usually performed and was found to be successful. The long-term follow-up study revealed that 5 out of 21 patients with alveolar fractures complained of malocclusion and it is suggested that a longer duration of intramaxillary fixation and long-term follow-up might be needed for alveolar fractures in children.

Different patterns of mandibular fractures in children. An analysis of 220 fractures in 157 patients

157 paediatric patients with a total of 220 mandibular fractures were evaluated retrospectively. All patients had been examined with the aid of orthopantomography. 72% of the children had fractures in the condylar region. The patients were divided into four age groups according to the development of the dentition (group A: 0-5 years, B: 6-9 years, C: 10-12 years, and D: 13-15 years). Bicycle accidents and falls were the two main causes of the fractures in all age groups. However, there were significant differences in the causes and location of the fractures between groups A+B and C+D. The proportion of condylar fractures decreased and the proportion of body and angle fractures increased with increasing age; fractures in the horizontal part of the mandible were mainly observed in groups C and D. Both aetiological factors and fracture patterns in the patients older than 10 years of age resembled those of adults. The differences observed should be taken into consideration in studies concerning mandibular fractures in paediatric patients. In this respect the age limit between the adult and child should probably be lowered significantly.