maxface injuries

Maxillofacial Injuries

in Children

SDM DHARWAD

Dr AJAY CHANDRANDr AJAY CHANDRANLECTURERLECTURER

DEPARTMENT OF OMFSDEPARTMENT OF OMFS

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenPrinciples of treatmentPrinciples of treatment

Soft tissue FracturesSoft tissue Fractures • DebridementDebridement• ClosureClosure• Cover DefectsCover Defects

GrowthGrowthdeformitiesdeformities

SDMSDM DHARWADDHARWAD

displacementdisplacement

treatmenttreatmentInjuryInjury

• ReductionReduction• FixationFixation• RehabilitationRehabilitation

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children

Facial Growth

SDM DHARWAD

‘response to functional needs mediated by soft

tissues’ Moss 1960


AdultAdult ChildrenChildren

RoweRowe 1968 (1500) 1968 (1500) 6% 6%

Morgan Morgan 1972 (300 )1972 (300 ) 4% 4%

Ellis Ellis 1985 (2137)1985 (2137) 1.8%1.8%

Carroll Carroll ** 1987 (10544)1987 (10544) 23 %23 %

Zachariades Zachariades 1990 (200) 1990 (200) 7.7%7.7%

S.D.M. Dharwad (576) S.D.M. Dharwad (576) 10.76%10.76%

IncidenceIncidence

514

620

100

200

300

400

500

600

SDM DHARWAD


4747

1515

MALESMALES FEMALESFEMALES

n = 62n = 62

S.D.M Dharwad (62) 47 : 15S.D.M Dharwad (62) 47 : 15

Posnick Posnick (137) 80 : 57 (137) 80 : 57

Zachariades (202) 140 : 62 Zachariades (202) 140 : 62

Patrikioun (147) 67 : 49Patrikioun (147) 67 : 49

MALE : FEMALEMALE : FEMALE

SDM DHARWAD


EtiologyEtiology3333

2323

33 33

00

55

1010

1515

2020

2525

3030

3535

FALLSFALLS

RTARTA

ALTERCATIONALTERCATION

OTHERSOTHERS



Types of FracturesTypes of Fractures

00

1010

2020

3030

4040

5050

6060

MandibleMandibleNasal BonesNasal BonesSoft TissueSoft Tissue

ZygomaZygomaOrbitOrbitMaxillaMaxilla

5050

7744 22 11

77


McCoy 1966, Hall 1977, Gussack 1987McCoy 1966, Hall 1977, Gussack 1987

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenEtiology & IncidenceEtiology & IncidenceDisparity Adults v/s ChildrenDisparity Adults v/s Children

PreschoolPreschoolParental supervisionParental supervision

Minimal impact fallsMinimal impact falls Thick adipose tissue Thick adipose tissue

Cranium - LargeCranium - LargeProminent foreheadProminent forehead

Absence of frontal sinusAbsence of frontal sinus

Facial skeleton Facial skeleton no air sinusesno air sinuses

elasticity of boneelasticity of bone thick condylar neckthick condylar neck

SDM DHARWAD


Children are not ‘Small Adults’Children are not ‘Small Adults’

Physiological factorsPhysiological factors• Rapid reparative processRapid reparative process• Elasticity of boneElasticity of bone

Psychological factorsPsychological factors• Fear and apprehensionFear and apprehension• Single stage treatment planSingle stage treatment plan

Anatomical factorsAnatomical factorsSDM

DHARWAD


ManagementManagement

‘‘Response to injury different from adult’Response to injury different from adult’ High percentage of associated injuriesHigh percentage of associated injuries Morgan 1972, Gussack 1987Morgan 1972, Gussack 1987

Body Surface area : Mass - High Body Surface area : Mass - High HypothermiaHypothermia Injury severity score Injury severity score Paediatric trauma scorePaediatric trauma score Revised coma scaleRevised coma scale



ManagementManagement Paediatric trauma scorePaediatric trauma scoreScale Scale +2 +1 -1+2 +1 -1WeightWeight >20 10 - 20 <10>20 10 - 20 <10Status of airwayStatus of airway normal maintained not maintainednormal maintained not maintained

Systolic B.PSystolic B.P >90 50 – 90 <50>90 50 – 90 <50CNS CNS (consciousness)(consciousness) awake obtunded comaawake obtunded comaOpen woundOpen wound none minor majornone minor major Skeletal traumaSkeletal trauma none closed open/multiplenone closed open/multiple

SDMSDM

DHARWADDHARWAD


Management: Primary Care Airway Smaller Tongue to oropharynx ratio high

Circulation Turnover rate 3 times more Fluid requirements - 150ml/kg/day Replacement urgent & essential

SDM DHARWAD


Management: Primary Care

Head injury cranium to body mass - high high energy impacts - fatal scalp lacerations - hypotension

Cervical spine flexible interspinous ligaments incomplete articulation flat facet joints SCIWORA

SDM DHARWAD


Management Soft tissue injuries

Healing - rapidScar -

Hypertrophy -

Widening

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Management Soft tissue injuries

Reconstructive procedures

Dense scarring

SDM

DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Management

Soft tissue injuriesReconstructive procedures

Tissue loss

SDM DHARWAD


Fracture DistributionFracture Distribution

00

1010

2020

3030

4040

5050

6060

MandibleMandibleNasal BonesNasal BonesSoft TissueSoft Tissue

ZygomaZygoma

MaxillaMaxilla

5050

7744 22 11

77


McCoy 1966, Hall 1977, Gussack 1987McCoy 1966, Hall 1977, Gussack 1987

OrbitOrbit

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenFractures of the Facial skeleton

Treatment considerations

AgeAnatomic siteComplexity of injuryTime elapsedConcomitant injurySurgical approach

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Facial Fractures

Methods of Fixation

Mono mandibular Maxillomandibular Internal fixation No fixation

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Methods of Fixation Internal fixation Disadvantages Open approach

Limit osteogenic potential of periosteum Scarring Growth deformities ?Advantages

Anatomic reductionNormal oral diet No airway compromiseTolerance SDM

DHARWAD


43

9 84

05

1015202530354045

ParasymphysisAngle

Body

Condyle

Symphysis

1

SITE WISE INCIDENCESITE WISE INCIDENCE SDM DHARWAD

MANDIBULAR FRACTURES

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Fractures of the Mandible

# body gross displacement # lines long & oblique # involve unerrupted teeth

Open reduction? status of dentition

occlusal derangement

SDM DHARWAD

Maxillofacial Injuries in Children

Methods of Immobilization

Orthodontic brackets & elasticsArch barsIvy loop wiringNasomandibular wiring

Immobilization based upon state of development of dentition Rowe 1969

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenFractures of the Mandible: ImmobilizationFractures of the Mandible: Immobilization

Infancy – 2 Years of age / 2 – 4 yearsInfancy – 2 Years of age / 2 – 4 years• Usually symphysial #s Usually symphysial #s • Circum mandibular wiring of splint 2-3 weeksCircum mandibular wiring of splint 2-3 weeks

Fracture angle Fracture angle • Immobilization of mandible Immobilization of mandible • Naso mandibular fixation Naso mandibular fixation

Thoma (1943)Thoma (1943)


Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenFractures of the Mandible: ImmobilizationFractures of the Mandible: Immobilization

5 - 8 years5 - 8 yearsResorbing deciduous teethResorbing deciduous teethIncompletely formed permanent teethIncompletely formed permanent teethOcclusion difficult to establishOcclusion difficult to establishStability of fragments precariously maintainedStability of fragments precariously maintainedMandibular occlusal splint Mandibular occlusal splint Maxillomandibular fixation ‘Pernasal wires’?Maxillomandibular fixation ‘Pernasal wires’?


Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenFractures of the MandibleFractures of the Mandible

9 - 11 years9 - 11 years• Root formation completeRoot formation complete• Arch bar fixationArch bar fixation• Plating possiblePlating possible


Pre-op

Post-op

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenFractures of the MandibleFractures of the Mandible

9 - 11 years9 - 11 years• Root formation complete ?Root formation complete ?• Plating possiblePlating possible•Avoid injury to tooth budsAvoid injury to tooth buds

SDMSDM DHARWADDHARWADPre-op Post-op

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Condylar FracturesCondylar Fractures


Most common siteWell vascularised Short neck‘green stick’ #sHeavy impact

- crush injuries

TMJ ankylosis

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Condylar FracturesCondylar Fractures Incidence – 4 / 62Incidence – 4 / 62

UndisplacedUndisplaced• No active treatment No active treatment

No Occlusal derangement No Occlusal derangement (Unilateral / bilateral #s)(Unilateral / bilateral #s)

• Physiotherapy, analgesicsPhysiotherapy, analgesics Occlusal Derangement Occlusal Derangement (Unilateral / bilateral #s)(Unilateral / bilateral #s)

• Immobilize in centric relationImmobilize in centric relation Open Reduction?Open Reduction?

Mechanical interferenceMechanical interferenceSDMSDM

DHARWADDHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Fractures of the MandibleFractures of the Mandible Most common site - Condyle Most common site - Condyle Immobilization dependsImmobilization depends on state of dentitionon state of dentition Conservative treatment usually the normConservative treatment usually the norm


Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenFractures of the Middle Third of the Face

Cranium to Face ratio - Infant 8 : 1 - Adult 2.5 : 1 Sinuses rudimentary Heavy impact -- death Cranial injures 88% below 5 years 37% 12- 16 years McGraw & Cole 1990

Injuries increase with development of sinusesSDM

DHARWAD


Non existent below 7 years

Magnitude of injury - related to sinus development

SDM DHARWAD


Incidence – 1 / 62 Associated with head injury Minimal displacement conservative management Gross displacement reduction & fixation as adults

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenNasal Bone Fractures

Incidence: 7 / 62

Cartilage disruption

Septal hematoma

‘Open book’ type of fracture

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenNasal Bone Fractures

Treatment: Closed reduction Manipulation

Severe displacement and older fractures Osteotomy Cartilage grafts?

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenNaso-Orbito-Ethmoidal Fractures

Relatively rareTechnically difficult to treatExpansion of cranium via sutures Frontal bone to ethmoidal, lacrimal , maxillary

bones Ethmoidomaxillary suture Naso maxillary suture

Septovomerine suture

Radical approach - accurate anatomical reduction

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenNaso-Orbito-Ethmoidal Fractures

High velocity injuryCT Scan mandatory

Reconstruct

• Nasomaxillary buttress• Orbital rims• Nasal dorsum

Restore normal intercanthal distanceSDM

DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in ChildrenZygomatic Complex Fractures

Incidence 5 / 62 Displaced ZMC #s Elevation: Intra oral / Gillies

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Orbital Fractures

Incidence – 2 / 62 Below 7 years : Roof with frontal extension Treatment indications Displacement Impaired extra-ocular muscle movement Intra cranial injuries Coronal flap Micro plates / Resorbable plates

SDM DHARWAD


Orbital Fractures

Incidence – 2 / 62

Reconstruct floor to prevent enophthalmos & diplopia

SDM DHARWAD

Maxillofacial Injuries in ChildrenMaxillofacial Injuries in Children Uncommon Growth dependent distribution Adaptive demands enormous Primary care critical Treatment ‘conservative’ Rigid fixation - with caution!

SDM DHARWAD

Thank YouThank YouSDM

DHARWAD

maxface injuries

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