|Year : 2017 | Volume
| Issue : 2 | Page : 50-53
Dental sequelae of pediatric maxillofacial trauma
Sanjay Naran1, Liliana Camison2, Brian Lam3, Osama Basri2, Lindsay Schuster2, Brian Martin3, Joseph E Losee2
1 Division of Pediatric Plastic and Reconstructive Surgery, Advocate Children's Hospital, Park Ridge, IL; Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
2 Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
3 Division of Pediatric Dentistry, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
|Date of Web Publication||26-Mar-2019|
Dr. Joseph E Losee
Division Pediatric Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Children's Hospital Drive, 45th and Penn, Pittsburgh, PA 15201
Source of Support: None, Conflict of Interest: None
Purpose: Our goal was to explore dental complications in the pediatric population following facial trauma and identify those at risk. Patients and Methods: We queried children with fractures of tooth-supporting regions presenting from 2000 to 2014. Data elements included demographics, treatment method, and dental outcome measures. Results: A total of 117 subjects were identified. The average age at injury was 10.41 years, and average follow-up was 2.9 years. Fractures were grouped as mandibular (62.39%), maxillary (22.22%), or combination (15.39%). Dentition at time of injury was classified as primary (17.95%), mixed (38.46%), or permanent (43.59%). Conservative management was employed in 41.88%, open reduction and internal fixation (ORIF) in 49.57%, and closed reduction and external fixation in 8.55%. The majority (67.52%) did not experience any dental trauma or sequela. Dental avulsion (10.26%), subluxation (10.26%), dysgenesis (5.13%), and development of a crossbite (5.13%), openbite (3.42%), and occlusal cant (0.85%) were observed. Avulsion was more likely in subjects requiring ORIF (P < 0.05). Development of an openbite, crossbite, or occlusal cant was more likely in subjects requiring ORIF or with combination fractures (P < 0.05). Conclusions: Fracture severity, treatment method, and dental age are all strong predictors for adverse dental complications. Treating specialists should be cognizant of the increase in risk of complication in these patients.
Keywords: Dentition, developing teeth, mandible fracture, open reduction internal fixation, pediatric
|How to cite this article:|
Naran S, Camison L, Lam B, Basri O, Schuster L, Martin B, Losee JE. Dental sequelae of pediatric maxillofacial trauma. J Pediatr Dent 2017;5:50-3
|How to cite this URL:|
Naran S, Camison L, Lam B, Basri O, Schuster L, Martin B, Losee JE. Dental sequelae of pediatric maxillofacial trauma. J Pediatr Dent [serial online] 2017 [cited 2019 Oct 18];5:50-3. Available from: http://www.jpediatrdent.org/text.asp?2017/5/2/50/254832
| Introduction|| |
Management of facial fractures in the pediatric population has long been a topic of interest and debate among surgeons and dentists treating maxillofacial trauma. Although these injuries are relatively uncommon, comprising approximately 3%–6% of all facial fractures, they are of particular concern due to their potential impact on the developing facial skeleton and its associated structures, dentition in particular. Fractures of the alveolar process can account for as much as 60% of all facial fractures in patients under the age of 6 years. As the patient population increases in age, the distribution of fractures tends to take on a notably more inferior pattern with a significantly greater number of fractures seen in the subcondylar, body, angle, and parasymphasis regions of the mandible., By the age of 12 years and the development of the full permanent dentition, fracture patterns become strikingly more similar to those encountered in the adult population. It is also at this point that the prevalence of zygomaticomaxillary complex and LeFort fractures begins to substantially increase. In short, it is clear that developing dentition influences patterns of fracture, but few have examined the impact of maxillofacial fractures, and the interventions required to manage them, on developing dentition. Moreover, few studies have identified predictors for potential complications in dental development following facial fracture. It was the goal of this study to explore the potential adverse complications experienced by pediatric patients who suffer from maxillofacial fractures, especially in the mixed dentition stage (ages 7–11), and to highlight those at greater risk for these complications to optimize collaborative management of these patients.
| Patients and Methods|| |
Our Level-1 pediatric hospital's IRB-approved pediatric facial fracture database was queried for patients who suffered traumatic injury resulting in facial fractures from 2000 to 2014. Inclusion criteria for the study consisted of patients suffering fracture of the tooth-supporting or tooth-enclosing regions of the mandible or maxilla in primary, mixed, or permanent dentitions; patients with initial and follow-up radiographic survey, either panoramic X-ray or computed tomogram; patients with at least 12 months elapsed following initial injury. Specific data elements collected included age, date of injury, date of surgery, gender, ethnicity, surgical and medical history, medication history, as well as follow-up procedures, management, and outcome measures.
Radiographic evaluation was performed independently by two pediatric dentists (OB, BL). Initial and follow-up computed tomograms/panoramic X-rays were used to evaluate the pre- and post-treatment condition of the dental structures, noting any change, damage, or impendence over time. In addition, patients' clinical records were reviewed to determine the degree of fracture displacement, treatment modality used, and any need for additional surgical interventions.
Adverse outcomes with particular attention to dental sequelae were quantified by pediatric dentists. Teeth were referred to using the universal numbering/lettering system [Figure 1]. Adverse dental outcomes were noted for tooth avulsion, subluxation, and dysgenesis of developing dentition (i.e., cyst formation, failure of eruption, tooth agenesis) and the development of a crossbite, openbite, or occlusal cant. Univariate analysis was performed, with statistical significance defined as P < 0.05.
| Results|| |
One hundred and seventeen pediatric facial fracture subjects were identified that met our inclusion criteria [Table 1]. The average age at injury was 10.41 years (range: 1.03–18.68), and average follow-up was 2.9 years (range: 1.00–13.27 years). Fracture types included those of the mandible (62.39%), maxilla (22.22%), or combination (15.39%). Dental development at the time of initial injury was classified as primary (17.95%), mixed (38.46%), and permanent (43.59%). Conservative management was employed in 41.88%, open reduction and internal fixation with or without intermaxillary fixation (ORIF ± IMF) was used in 49.57%, while closed reduction and external fixation (CREF) was used in 8.55% of subjects. The majority of subjects (n = 79, 67.52%) had no adverse outcomes; however, adverse dental outcomes were seen in 32.48% (n = 38) of subjects [Table 2]. Dental avulsion (10.26%), subluxation (10.26%), dysgenesis of developing dentition (5.13%), and the development of a crossbite (5.13%), openbite (3.42%), and occlusal cant (0.85%) were observed. Subjects with more severe fractures, requiring ORIF ± IMF, were significantly more likely to develop dental complications overall. Dental avulsion was more likely in subjects requiring ORIF ± IMF (P < 0.05). Subjects in primary or mixed dentition were more likely to require follow-up dental intervention than those in permanent dentition (P < 0.05). The development of an openbite, crossbite, or occlusal cant was significantly more likely in those who had a combination fracture of the maxilla and mandible or those requiring ORIF ± IMF (P < 0.05).
| Discussion|| |
Traumatic injuries resulting in maxillofacial fractures remain a commonly encountered entity in the pediatric patient population., These fractures in pediatric patients have a unique set of characteristics and challenges, which make them different from their adult counterparts. The developing dentition in the native mandible and maxilla is an important consideration when evaluating and managing these fractures. No study has looked comprehensively at specific dental sequelae following facial fractures during primary and mixed dentition.,,, In our retrospective radiographic evaluation of patients being treated for maxillofacial fractures at our institution, we find that fracture severity, mode of treatment, and patient stage of development are all strong predictive factors for adverse effects on the developing dentition. Our findings suggest that more severe fractures which require ORIF ± IMF are significantly more likely to develop long-term dental complications (P < 0.05). In fact, all patients in this study identified to have developed dental sequelae were treated with ORIF ± IMF. In addition, those patients whose injuries occurred while the patient was in primary and mixed dentition were more likely to require additional dental intervention when compared with those in permanent dentition (P < 0.05).
Our study has several limitations. We concede that it is retrospective and underpowered and is simply a descriptive analysis of a specific cohort of patients. Furthermore, we have a relatively short follow-up period for some patients, with not all primary and mixed dentition patients having been followed into permanent dentition. In an effort to strengthen our data, we limited our review to patients seen before 2014 to gain longer follow-up. However, while 30% of patients had not achieved permanent dentition by the time of last follow-up, we believe that any complication within this group of patients would have already presented within the principal follow-up period.
| Conclusions|| |
These data demonstrate that maxillofacial trauma in the pediatric population can have potentially detrimental effect on the developing dentition. Patients at increased risk will be those who are in primary or mixed dentition at the time of injury; those requiring ORIF ± IMF; and those with combined fractures of the maxilla and mandible. The awareness of these risks can at least warn the treating surgeon that these patients will need more of a team approach, with close dental follow-up to avoid or manage these issues in a timely manner.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grunwaldt L, Smith DM, Zuckerbraun NS, Naran S, Rottgers SA, Bykowski M, et al.
Pediatric facial fractures: Demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg 2011;128:1263-71.
Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA. Management of mandible fractures. Plast Reconstr Surg 2006;117:48e-60e.
Smith DM, Bykowski MR, Cray JJ, Naran S, Rottgers SA, Shakir S, et al.
215 mandible fractures in 120 children: Demographics, treatment, outcomes, and early growth data. Plast Reconstr Surg 2013;131:1348-58.
Smartt JM Jr., Low DW, Bartlett SP. The pediatric mandible: II. Management of traumatic injury or fracture. Plast Reconstr Surg 2005;116:28e-41e.
Goth S, Sawatari Y, Peleg M. Management of pediatric mandible fractures. J Craniofac Surg 2012;23:47-56.
Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg 2009;67:1680-4.
Thorén H, Numminen L, Snäll J, Kormi E, Lindqvist C, Iizuka T, et al.
Occurrence and types of dental injuries among patients with maxillofacial fractures. Int J Oral Maxillofac Surg 2010;39:774-8.
Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with maxillofacial fractures. Dent Traumatol 2013;29:285-90.
Ruslin M, Wolff J, Boffano P, Brand HS, Forouzanfar T. Dental trauma in association with maxillofacial fractures: An epidemiological study. Dent Traumatol 2015;31:318-23.
[Table 1], [Table 2]