Hanna Thorén

Different patterns of mandibular fractures in children. An analysis of 220 fractures in 157 patients

157 paediatric patients with a total of 220 mandibular fractures were evaluated retrospectively. All patients had been examined with the aid of orthopantomography. 72% of the children had fractures in the condylar region. The patients were divided into four age groups according to the development of the dentition (group A: 0-5 years, B: 6-9 years, C: 10-12 years, and D: 13-15 years). Bicycle accidents and falls were the two main causes of the fractures in all age groups. However, there were significant differences in the causes and location of the fractures between groups A+B and C+D. The proportion of condylar fractures decreased and the proportion of body and angle fractures increased with increasing age; fractures in the horizontal part of the mandible were mainly observed in groups C and D. Both aetiological factors and fracture patterns in the patients older than 10 years of age resembled those of adults. The differences observed should be taken into consideration in studies concerning mandibular fractures in paediatric patients. In this respect the age limit between the adult and child should probably be lowered significantly.

An epidemiological study of patterns of condylar fractures in children

OBJECTIVE To find out how the site and type of condylar fracture are affected by its aetiology and the age and sex of the patient. DESIGN Retrospective study. SETTING Tertiary referral centre, Finland. MATERIAL Radiographs of 101 children (aged 15 years or less) with 119 condylar fractures. MAIN OUTCOME MEASURES Site of fracture and degree of displacement. RESULTS A total of 26 of the 119 fractures were intracapsular (22%) and 93 (78%) extracapsular. Only among patients less than 6 years of age was there a preponderance of intracapsular fractures (7/12 fractures in 10 patients, 58%). In the older children 78% (83/107) were in the condylar neck. There were few subcondylar fractures (5/119, 4%). Only 6 fractures were displaced (5%). Dislocation of the condyle from the glenoid fossa was common in all age groups. CONCLUSION The site of condylar fracture is age related, but not associated with sex or aetiology.

Occurrence and Types of Associated Injuries in Patients With Fractures of the Facial Bones

PURPOSE To identify the occurrence, types, and severity of associated injuries outside the facial region among patients diagnosed with facial fractures, and to analyze whether there are any factors related to associated injuries. MATERIALS AND METHODS This was a cross-sectional study of 401 patients diagnosed with facial fractures during the 2-year period from 2003 to 2004. RESULTS Associated injuries were observed in 101 patients (25.2%). The most common type of injury was a limb injury (13.5%), followed by brain (11.0%), chest (5.5%), spine (2.7%), and abdominal (0.8%) injuries. Multiple associated injuries were observed in 10% and polytrauma in 7.5%. The mortality rate was 0.2%. The occurrence of associated injury correlated significantly with trauma mechanism and fracture type; high-speed accidents and severe facial fractures were significant predictors of associated injury. CONCLUSIONS Associated injuries are frequent among patients who have sustained facial fractures. The results underscore the importance of multiprofessional collaboration in diagnosis and sequencing of treatment, but also the importance of arranging appropriate clinical rotations for maxillofacial residents in training.

Risk factors contributing to symptomatic miniplate removal: a retrospective study of 153 bilateral sagittal split osteotomy patients

Removal of miniplates is a controversial topic in oral and maxillofacial surgery. Originally, miniplates were designed to be removed on completion of bone healing. The introduction of low profile titanium miniplates has led to the routine removal of miniplates becoming comparatively rare in many parts of the world. Few studies have investigated the reasons for non-routine removal of miniplates and the factors that affect osteosynthesis after osteotomy in large numbers of patients. The aim of the present study was to investigate complications related to osteosynthesis after bilateral sagittal split osteotomy (BSSO) in a large number (n=153) of patients. In addition to the rates of removal, emphasis was placed on investigating the reasons and risk factors associated with symptomatic miniplate removal. The rate of plate removal per patient was 18.6%, the corresponding rate per plate being 18.2%. Reasons for plate removal included plate-related complications in 16 patients and subjective discomfort in 13 patients. Half of the plates were removed during the first postoperative year. Smoking was the only significant predictor for plate removal. Patients undergoing orthognathic surgery should be screened with regard to smoking and encouraged and assisted to cease smoking, at least perioperatively.

Changing trends in causes and patterns of facial fractures in children

OBJECTIVE To review the epidemiology of facial fractures in children and to analyze whether it has changed over time. STUDY DESIGN Retrospective review of records of children aged < or = 15 years diagnosed for fracture during 2 10-year periods. RESULTS A total of 378 children were diagnosed with fractures, 187 in 1980-1989 and 191 in 1993-2002. The proportion of children with mandibular fractures decreased by 13.6 percentage-points from the first period to the second, whereas the proportion of patients with midfacial fractures increased by 18.7 percentage-points. Assault as a causative factor increased by 5.5 percentage-points, almost exclusively among children aged 13-15 years, with a high percentage (23.5%). CONCLUSIONS Recognition of a change in fracture patterns over time is probably due to the increased use of computerized tomographic scanning.

Radiologic changes of the temporomandibular joint after condylar fractures in childhood

OBJECTIVE The purpose of this investigation was to study the radiologic outcomes of pediatric condylar fractures. STUDY DESIGN Radiographs of 37 patients with 45 condylar fractures that had been diagnosed at the Department of Oral and Maxillofacial Surgery, Helsinki University Central Hospital were retrospectively reviewed. The frequency and characteristics of incomplete remodeling at an average of 4.1 years after the injury were studied. The influence of age and fracture type on remodeling were considered. RESULTS Incomplete remodeling was observed after 56% of the fractures. The most frequent signs of incomplete remodeling were alteration in the configuration of the surface of the condylar head and deformation of the condylar neck. Incomplete remodeling was frequently (83%) related to fracture dislocation. For this fracture type the radiologic prognosis seems poor in all age groups. A difference in ramus height between the 2 sides was observed in 52% of the fractures, particularly frequently (80%) after fracture dislocation. CONCLUSIONS Radiologic aberrations are frequent after pediatric condylar fractures. Dislocated fractures, in particular, need special attention and long-lasting clinical follow-up.

Does Perioperative Glucocorticosteroid Treatment Correlate With Disturbance in Surgical Wound Healing After Treatment of Facial Fractures? A Retrospective Study

PURPOSE To clarify whether perioperative glucocorticosteroid treatment used in association with repair of facial fractures predisposes to disturbance in surgical wound healing (DSWH). PATIENTS AND METHODS Retrospective review of records of patients who had undergone open reduction, with or without ostheosynthesis, or had received reconstruction of orbital wall fractures during the 2-year period from 2003 to 2004. RESULTS Steroids were administered to 100 patients (35.7%) out of a total of 280. Dexamethasone was most often used, with the most common regimen being dexamethasone 10 mg every 8 hours over 16 hours, with a total dose of 30 mg. The overall DSWH rate was 3.9%. The DSWH rate for patients who had received perioperative steroids was 6.0%, and the corresponding rate for patients who did not receive steroids was 2.8%. The difference was not statistically significant. An intraoral surgical approach remained the only significant predictor to DSWH. CONCLUSIONS With regard to DSWH, patients undergoing operative treatment of facial fractures can safely be administered doses of 30 mg or less of perioperative glucocorticosteroids equivalent to dexamethasone.

Occurrence and types of dental injuries among patients with maxillofacial fractures

The aim of this retrospective study was to clarify the occurrence and types of dental injuries in 389 patients who had been diagnosed with facial fractures, and to analyze whether the occurrence of dental injury correlates to gender, age, trauma mechanism and type of facial fracture. Dental injuries were observed in 62 patients (16%). The most common type of injury was a crown fracture (48%). Dental injuries were multiple in most patients (63%). Almost half (48%) of all injured teeth were severely injured. Most injured teeth (61%) were in the maxilla. The incisor region was the most prevalent site in both the mandible (45%) and the maxilla (56%). The occurrence of dental injury correlated significantly with trauma mechanism and fracture type: motor vehicle accidents and mandibular fracture were significant predictors for dental trauma. The notable rate of dental injury observed in the present study emphasizes the importance of a thorough examination of the oral cavity in all patients who have sustained facial fracture. Referral to a dental practice for further treatment and follow up as soon as possible after discharge from hospital is fundamental.

Symptomatic plate removal after treatment of facial fractures

AIMS To identify the rates and reasons for plate removal (PR) among patients treated for facial fractures. MATERIALS AND METHODS A retrospective review of files of 238 patients. RESULTS Forty-eight patients (20.2%) had plates removed. The reason for removal was objective in 33.3% and subjective in 29.2%. The most common subjective reason was cold sensitivity, and the most common objective reason was wound dehiscence/infection. Women had PR for subjective reasons more often than men (p=0.018). Removal was performed more often for subjective reasons after zygomatico-orbital fractures than after mandibular fractures (p=0.002). Plates inserted in the mandible from an intraoral approach were removed more frequently than extraorally inserted mandibular plates, intraorally inserted maxillary plates, and extraorally inserted plates in other locations (p<0.001). Orbital rim plates had a higher risk of being removed than maxillary or frontal bone plates (p=0.02). CONCLUSIONS Subjective discomfort is a notable reason for PR among Finnish patients, suggesting that the cold climate has an influence on the need for removal. Patients receiving mandibular osteosynthesis with miniplates from an intraoral approach are at risk of hardware removal because of wound dehiscence/infection and loose/broken hardware, reminding us that more rigid fixation devices should not be forgotten despite the widespread use of miniplates.

Policy of routine titanium miniplate removal after maxillofacial trauma.

PURPOSE The literature shows that hardware removal rates after the fixation of maxillofacial fractures with miniplates are not insignificant. The aim of the present survey was to clarify the policies of Finnish oral and maxillofacial consultants for the removal of titanium miniplates after the treatment of facial fractures in adults. Additional aims were to clarify the factors influencing plate removal policy in general, and the reasons for routine plate removal in particular. MATERIALS AND METHODS Twenty-six consultant oral and maxillofacial surgeons responded to a questionnaire about miniplate removal policy after treating 5 types of simple, noncomminuted fractures. RESULTS Overall, routine plate removal was uncommon. However, 12 consultants (46.2%) routinely removed the plate after treating mandibular angle fractures, and simultaneously extracted the third molar because of an increased risk of infection. Most respondents (88.5%) stated that clinical experience guided their plate-removal policy. A policy of routine plate removal was most infrequent among the consultants who had the most experience. CONCLUSIONS The literature provides no definitive answer to the question of whether routine removal of miniplates could or should be indicated, and in what situations. Considering the fairly significant frequency of plate-related complications in general and infection-related complications in particular, long-term follow-up after treatment is indicated.