Maxillary Dentoalveolar Fracture in a Child: Case Report and Review

INTRODUCTION

Pediatric maxillofacial fractures are not common and carry different clinical features when compared with adults¹. Depending on the age, these differences include the small size of the bones, the small volume of the paranasal sinuses, the growth potential, the presence of tooth germs in the jaws during the primary and the mixed dentition, a quicker healing process, as well as difficulty in cooperation and the need for general anaesthesia in more cases than in adults². The ratio of boys to girls is 2:1 and the largest age subgroup is 15-years old. The most common cause of injury is bicycle accidents (26%), followed by falls (25%). Mandibular fractures are the most common (56%), followed by fractures of the alveolar process (31%). The maxilla is the least frequently injured pediatric facial bone (1.2%-20%)³ , reflecting the fact that the facial skeleton and paranasal sinuses of the preadolescent child are underdeveloped, leading to craniofacial disproportion, and that the unerupted dentition provides additional strength to the maxilla. Children also have many fat pads around the upper and lower jaws, which cushion any impact⁴. 

Traumatic injuries to the dentofacial complex in children often cause tooth fractures, luxation, avulsion, or alveolar process fractures, maxillary central incisors being the most frequently affected. Injuries to children's teeth can be very distressing for children as well as their parents.¹⁰

The management techniques should be modified to address the child's particular stage of anatomical, physiological, or psychological development. Diagnosis of any dentoalveolar fracture requires a good clinical and radiological examination. Current methods of stabilizing dentoalveolar fractures involve the application of arch bars or the newer acid etch techniques. Regardless of the stabilization technique selected, the splinting methods must meet specific criteria. These include easy fabrication, maintenance of only passive force on the teeth, lack of irritation to soft tissues, maintenance of normal occlusion, allowance of good oral hygiene, access for subsequent orthodontic treatment and easy removal. Hence, techniques may have to be modified to suit individual needs. Acrylic splints are a well-known tool used to manage mandibular fractures in the young and elderly⁵. The purpose of this case report was to describe an unusual case of dentoalveolar fracture of the posterior maxillary segment requiring treatment modification in the form of cap acrylic splint using GIC.

CASE REPORT

A five year old boy reported to department of oral and maxillofacial surgery with a complaint of swelling on the right side of face and pain upon closing the mouth. He had sustained trauma while playing 3 days back. Extra orally there was no abnormality detected. Intra orally occlusion was disturbed, upper right canine was avulsed, lateral incisor was grade I mobile, vestibular sulcus was obliterated. The dentoalveolar segment from mesial of lateral incisor to distal of second molar displaced occlusally and palatally causing open bite on the contralateral side. Mouth opening was normal. Patient was unco-operative for intra oral periapical radiograph. Orthopantamogram was taken and it revealed fracture line extending from mesial aspect of deciduous right lateral incisor running above the apices of deciduous molars till distal aspect of second molar displacing the dentoalveolar fragment downward. (Fig- 1,2)

Treatment:

Maxillary and mandibular impression was made. Cast was prepared and mock surgery was carried out and acrylic cap splint was fabricated after fracture reduction. Under general anesthesia, the fragment was reduced using digital pressure, and a prefabricated, custom-made splint was seated in position. The splint was secured in place using GIC. Fracture reduction and stabilization was satisfactory, as evidenced by the postoperative occlusion (Figure 4). Recovery from general anesthesia was uneventful, and the patient was discharged on the second postoperative day with instructions for a soft diet and maintenance of good oral hygiene. A 5-day course of antibiotic and analgesic syrup was also prescribed. The child was recalled on a weekly basis to check for stability of the splint. At the end of 3 weeks, the splint was removed. The consolidation of the fracture was confirmed clinically and radiographically (Figure 4 and 5). Satisfactory occlusion and healing was observed. 

DISCUSSION

There are some general considerations one should follow when managing pediatric facial fractures. First, pediatric facial bones tend to heal much faster than adults, thus intervention, if required, must be performed earlier. Most pediatric facial fractures can be managed through observation or closed techniques alone with fairly good results. If open reduction and internal fixation are necessary, then one should obtain proper alignment of all suture lines and avoid extensive periosteal elevation as this may lead to growth disturbances¹¹.

Treatment of fractures of the alveolar process involves reduction and immobilization of the involved segment and stabilization for at least 2 to 4 weeks. There are many modalities available like Arch bars, cap splints, IMF can be used for stabilization in adults, but in children it is not feasible due to the size of the teeth and mixed dentition. The contour heights of the crowns of deciduous teeth are below the gingival level, and circumdental wiring may result in extrusion of deciduous teeth. Taking support from newly erupted permanent teeth is also contraindicated due to the incomplete root formation. ^{10, 11}

Among the commonly used treatment options, acrylic cap splints are ideal. They not only take support from the adjacent teeth, but also from bone. They are easy to fabricate and are economical. Routinely, these are used in stabilizing mandibular fractures, as they can be stabilized by the use of circum-mandibular wires. Interdental wiring can be done to secure the maxillary splint in place to facilitate adequate stabilization of the fractured segment⁵. Modified method of securing splint was using GIC to stabilize the splint which was atraumatic and easy¹²

Fractured deciduous teeth that cannot be restored should be extracted. Intruded primary teeth should be allowed to reerupt. Luxated teeth should be repositioned and stabilized for 2 to 4 weeks. Wire, acrylic, and arch bars offer satisfactory methods of stabilization. Avulsed primary teeth should not be replaced, whereas avulsed adult teeth should be re-implanted within 2 hours (preferably 30 minutes) and stabilized for 4 weeks ^5,6. In our case the right primary canine was avulsed post fracture reduction pt was reffered to deptatment of pedodontics for space maintainer, as it has to be maintained pt is 10-11 yrs.

Maintaining the splint in position until satisfactory consolidation of the fracture is important. Following splint placement and during the entire period of the splint in place, a diet restriction like Liquid or semisolid diet was advised initially and hard foods was completely avoided. Maintenance of oral hygiene poses a problem, particularly with children and more so with the splint in place. The child is advised to use regular mouthrinses containing 0.2% chlorhexidine.

Following removal of the splint, a careful examination of the teeth and the fractured fragment is carried out to confirm satisfactory healing of the fracture. Patient was reffered to deptatment of pedodontics for space maintainer, as it has to be maintained till the permanent canine erupts arround 10-11 yrs.^5-9

CONCLUSION

Pediatric trauma can cause panic regarding the treatment and about growth in parents. Early re-establishment of the preinjury skeletal anatomy is essential to facilitate normal growth of the craniofacial complex. This would minimize or avoid the ill effects of delayed or no treatment such as malunion, deranged occlusion, and an impending dentofacial deformity. Depending on the stage of development, dentoalveolar injury may lead to dental growth disturbances ranging from dilaceration to ankylosis with an altered eruption sequence So early intervention and proper care and atrumatic treatment protocol can reduce the anxiety and futher followup to facilitate proper eruption of permanent teeth.