DISCUSSION
According to a study performed by Grunwaldt et al. in 772 pediatric
patients, the age range of 0–5 years is the age group in which facial
fractures are the least common [7]. This is because they are under
adult supervision, and fractures in this age group are due to daily
activities. Children between the ages of 6 and 11 are the second group
in which fractures are most common, and maxillofacial fractures
generally result from motor vehicle accidents, games, and bicycle
accidents in this age group. The age group of 12–18 years is the group
in which facial fractures are most commonly detected in pediatric
patients due to starting to drive cars, participation in sports
activities and involvement in incidents of violence are often
encountered in this age group [7, 8].
In the present study, 22 of 87 children were girls (25.3%) and 65 of
them were boys (74.7%). When the patients were divided into 3 different
groups according to the same age ranges, the most commonly operated
patient group was the age group of 12–18 years (49.4%), and the least
commonly operated group was the age group of 0–5 years (24.1%). These
results are similar to those seen in the study by Grundwalt et al. In
addition, the most common cause of fracture of the facial bones in these
patients was falls, which is consistent with the literature.
It is difficult to perform an optimal examination in pediatric patients,
especially because of lack of patient cooperation and communication at
young ages. For this reason, imaging methods are important in the
evaluation of fractures and computed tomography is usually used.
Following an appropriate physical examination and stabilization of the
patient, it is performed by taking into account intracranial and
cervical spinal injuries, cranial bone fractures, soft tissue incisions
and abrasions, as well as body and extremity injuries. In this age
group, CT examination should be requested at the slightest suspicion of
a fracture [8, 9]. Unlike adults, cranial and cervical spinal
injuries are rare in this age group. In a study conducted by Xun et al.,
2966 pediatric patients with craniomaxillofacial trauma have been
examined and accompanying cervical spinal damage has been detected in
only 5 of them (0.169%), and the rarity of this condition in this age
group compared to adults has been associated with anatomical differences
[10]. We did not find any cervical spinal nerve damage in our
patient group.
Considering the rapid healing of the facial skeleton, mostly
conservative approaches are recommended in the literature for orbital
and zygomatic fractures in children. In non-displaced or minimally
displaced fractures, conservative treatment and follow-up is sufficient
without surgical treatment. In the displaced, early fractures, closed
reduction alone can be sufficient [11, 12]. We treated 2 of our
patients with closed reduction alone at this site. Patients with
complete dissociation were treated with similar principles in adult age.
In zygomatico-orbital fractures, open reduction, and internal fixation
should be applied if diplopia and/or endophthalmitis is seen or if there
is orbital wall changes [9]. Orbital trapdoor fractures are orbital
floor fractures that limit eye movements, lead to diplopia, and are
characterized by herniation and compression of orbital contents. Early
treatment is often recommended in these fractures. According to a study
conducted by Gerbino et al., in the long-term follow-up of 24 patients
operated for diplopia, residual diplopia has been detected in only 1 of
12 (8.3%) patients operated within the first 24 hours, and residual
diplopia has been detected in 4 of 4 (100%) patients operated after 96
hours and later [13]. According to the results of this study, they
have suggested that pediatric orbital trapdoor fractures are a surgical
emergency that should be operated within the first 24 hours. Our
approach to these fractures is to treat them as soon as the general
condition of the patient allows. Since recovery is rapid in children,
repair is recommended to be performed within the first 4 days [9].
It should be kept in mind that late repairs, especially in the
zygomatico-orbital region, may result in reduced treatment success and
make recovery more difficult. In the reconstruction of the orbital floor
fractures, non-resorbable alloplastic materials such as porous
polyethylene, titanium mesh, polyester urethane or resorbable
alloplastic materials such as poly-L-lactide are used as well
as autogenous tissues [14-17]. Because porous polyethylene implant
(Medpor) is durable, it is used very often in orbital reconstruction.
However, complications including inflammation, infection, cyst and
abscess have been widely reported in the long-term [18-20]. Although
titanium mesh has advantages such as high biocompatibility and easy
shaping, complications including orbital adhesion, limitation in eye
movements, and diplopia have been reported [21-23]. We used
autogenous cartilage graft in 2 of the 4 patients that we operated due
to orbital floor fracture, and we used a porous polyethylene implant in
2 of them. Residual diplopia was observed in 1 patient and ectropion,
which improved following massage was found in 1 patient.
In order to avoid bone development problems in the future, it is
important to make minimal intervention to the periosteum and muscle
adhesions while treating fractures of the facial bones in children.
Approaches in which fractures can be reduced and stabilized with minimal
dissection should be adopted as a basic principle [11, 24]. If rigid
fixation has been applied in pediatric patients, the issue of removing
plate screws is very controversial. In some publications, plate screws
have been reported to cause regional growth restriction and removal is
therefore needed, while in other publications it has been reported that
removal would be unnecessary [11, 12, 24, 25]. Haug et al. have
reported that microplates can be used in periorbital fractures and that
the growth of periorbital region ceases after 2 years of age and the
microplates used in this region do not need to be removed [24]. We
use microplates in zygomatico-orbital fractures and do not remove the
plates. In maxilla and mandible fractures, we performed secondary
surgery for removal of the plates.
The maxilla is the least commonly injured bone in pediatric facial
traumas [26]. Due to greater flexibility of the facial bones,
immature sinuses and differences in teeth and tooth development,
pediatric maxilla fractures are not similar to classical LeFort fracture
types as in adults [27]. Treatment of maxilla fractures is based on
two basic requirements. The first is to avoid damaging bone growth, and
the second is to achieve a sufficiently stable fixation. During patient
evaluation prior to treatment, life-threatening conditions are addressed
with priority, as in any trauma. Airway, breathing, and circulation are
evaluated. Head, neck, cervical spine, and soft tissues are examined.
Bleeding control and intervention are performed. Greenstick fractures of
the maxilla are more common in children, and a good recovery can be
achieved with a conservative approach [27]. In the treatment of
minimally displaced fractures, 2-3 weeks of closed reduction with
maxillomandibular fixation is sufficient. Ivy loop is used to ensure
occlusion. Semirigid fixation should be applied in displaced fractures
[11, 28, 29]. We performed closed reduction with ivy loop or arch
bar in minimally displaced maxilla fractures, and open reduction
internal fixation with titanium microplates in displaced fractures. We
performed the operations with as little dissection as possible, using
minimal plate screws and trying not to damage the teeth. Since ivy loop
and arch bar applications damage the teeth and gums, we have been
recently performing intermaxillary fixation by placing a bracket system
in older children.
Mandibular fractures are the most common fractures in pediatric facial
traumas [30, 31]. Fracture was detected in at least one mandibular
region in 54 of 87 patients treated in our clinic (panfacial fractures
were evaluated independently from this group). The most common location
for fracture of the mandible is condyle in children. In our series, 24
of 54 patients with mandibular fractures have at least one fracture in
condylar area (27.5% of all fractures). Children under the age of 3
with condylar trauma are at high risk of joint ankylosis. Inadequate
treatment in condylar fractures can cause growth restriction, while
excessive immobilization may lead to mandibular hypomobility [32].
Open reduction should be performed if occlusion cannot be achieved due
to the fractured condylar segment, the condylar segment has been
displaced toward the middle cranial fossa, or in the presence of a
foreign body. Conservative approach may be applied in greenstick and
minimally displaced fractures [33-36]. In addition, if the fracture
is intracapsular, our approach is observation, soft diet and physical
therapy. In the greenstick and minimally displaced fractures of the
mandibular angulus, body, ramus and symphysis regions other than the
condyle , we recommend observation and soft diet as in the basic
approaches. We use monocortical rigid fixation in displaced fractures.
In recent years, bioabsorbable plates made of polyglycolic acid and
polylactic acid have been used in pediatric patients. These plates are
preferred to prevent growth restriction in the facial bones, and because
there is no need for a second surgery to remove them [24]. In a
study by Eppley, it is reported that fixation with a 1.5 mm
bioabsorbable plate and at least 2 screws can be sufficient for
stabilization in mandibular fractures. However, the difficulties in
shaping bioabsorbable plates and their lower resistance make it
difficult to use them in mandibular fractures. In zygomatic and orbital
fractures, the large size of bioabsorbable plates makes it more
difficult to use them [37]. Another factor that prevents the use of
bioabsorbable plates is their high cost. The total cost of a single
bioabsorbable plate (450 USD/piece) and 2 bioabsorbable screws (125
USD/piece) is 700 USD for a simple mandibular fracture. The approximate
cost of a titanium plate (30 USD/piece) and 2 titanium screws (10
USD/piece) that can be used in the same type of fracture is 50 USD. We
prefer titanium plates due to the high cost of bioabsorbable plates and
we perform second surgery to remove the plates.
In conclusion, pediatric maxillofacial traumas are less common than in
adults. In this patient group, the primary treatment approach is
conservative, and if surgical treatment is indicated, the simplest and
most effective method should be chosen. In order to avoid problems in
bone development in the subsequent years, it is necessary to cause
minimal damage to the tissues, to perform minimal dissection, and to
protect especially the locations of adhesion of the muscles and the
periosteum as much as possible. In recent years, the use of
bioabsorbable plates in the internal fixation of maxillofacial fractures
has become widespread. However, these plates cannot be used in our
clinic due to their high costs; titanium plates are preferred instead,
and these plates are removed in a secondary surgery after 2-3 months.
ACKNOWLEDGMENTS: None