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