detail description of age changes anatomy of head and neck with detailed management modalities for pediatric trauma

1. Pediatric
TRAUMA
1
Presented by :
Dr Preeti Sharma
Dept. of Oral and Maxillofacial Surgery

2. According to WHO
• Premature Newborns < 38 weeks
• Term Newborns > 38 weeks
• Neonate 0 – 30 days of age
• Infant 1 month – 2 years
• Young Child 2 – 6 years
• Child 6 – 12 years
• Adolescent 12 – 18 years
2

3. Unique features of the pediatricpatient
• Ratio between cranial volume and facial volume
At birth - 8:1
By age 5 - 4:1
Adult - 2.5:1
• Facial fractures in children occur less frequently than in adults and they are
more often minimally displaced
3

4. • End of 1st year : two mandibular halves have joined in the midline.
• At age 2: complete symphysis fusion from the inferior border to the alveolus
and most of the transverse maxillary growth is complete (followed by vertical
and then anteroposterior)
• By 6th year : mixed dentition phase
antrum are present and well developed
orbit skeletal maturity
• By ages 8 to 12 : Palatal, premaxillary
and midline maxillary sutural growth are
complete with suture obliteration
• By ages 12 to 13 : adult dentition is present
• Skeletal maturity of facial skeleton: 14-16 year- females
16-18 year -males
4

5. • High cancellous-to-cortical bone ratio
• Osteogenic and bone remodeling
potential: child>adult
• Contour heights of crowns of deciduous
teeth
• Primary and mixed dentition
• Higher surface-to-body volume ratio,
metabolic rate, oxygen demand and
cardiac output
• Lower total blood and stroke volumes
• Eustachian tube of the infant and young
child is short and relatively horizontal
5

6. • Nose:Infants are obligate nose breathers
• Tongue:
a.Large in comparison to the size of infant’s/young child’s oral cavity.
Gradually improves as the child grows
b.By the age of 10 the tongue is more proportional to an adult’s oral cavity
(Potts & Mandleco, 2012)
6

7. • Epiglottis
• Larynx
• Cricoid
7

8. Trachea
8

9. Epidemiology
• analysis of 1500 facial fractures by Rowe:
-5% of all facial injuries occurred in children younger than 12 years and
less than 1% of these fractures occurred in children younger than 6 years.
• National trauma data bank survey in 2008 on 277,008 pediatric trauma
9

10. • Peak in incidence occurs during puberty and adolescence with increased
unsupervised physical activity and sports.
• Seasonal variations are reported with peak frequencies during summer
months when outdoor activity is greatest
• Gender
boys >girls worldwide and in all age groups
In younger age groups, gender differences are less significant and the
etiologies are similar in both sexes.
10

11. Etiology
36%
25%
12%
10%
1%
16%
fall motor vehicle accident pedestrians bicycles motor cycle injuries others
11

12. Primary survey andearly management
PRIMARY SURVEY
 Airway assessment
 Cardiopulmonary status
 Neurologic injury
SECONDARY EXAMINATION
 Comprehensive history
- cause of injury
-time frame
-loss of consciousness
-dental trauma
12

13. 13

14. A-Airway with cervical spine protection
• Assess the airway while protecting the cervical spine
14

15. • If the child is stable and the airway is patent:
• If the child is unstable:
Check for signs of possible airway obstruction
(use of accessory muscles, cyanosis, visible swelling of the
tongue/pharynx or neck, facial trauma, any obvious foreign bodies in
the oral cavity).
Listen for any upper-airway noises such as stridor
15

16. • Attempt simple airway maneuvers if required
• Jaw thrust maneuver (best way to open the airway and protect the cervical
spine)
• The oral cavity can be suctioned with a Yankauer catheter to remove
secretions.
• Care must be taken to avoid stimulating the gag reflex.
16

17. ARTIFICIAL AIRWAY
• Oropharyngeal: only be inserted if the
child is unconscious, and should not
be used if a gag reflex is present
• Size : ranges from 00-5 (determined
by measuring from the corner of the
mouth to the angle of the jaw. An
incorrect size can obstruct the airway.
• Nasopharyngeal (nasal)
airways:diameter and length range
from 16-32 Fr French gauge)
• Small-diameter nasopharyngeal
airway may be obstructed easily by
secretions, and may need frequent
suctioning (AHA, 2015)
17

18. INTUBATION
• Patient should be provided with 100% oxygen prior to an
intubation attempt.
• The alignment of cervical spine should be maintained, and the
patient’s heart rate and oxygen saturation should be monitored
during the intubation attempt (AHA, 2015).
• Uncuffed endotracheal (ET) tubes:children <8 years of age.
• Length based tapes, such as the Broselow® Pediatric Tape,
provide a guide to selecting appropriate ET tube sizes.
• Pediatric ET tube sizes :range from 3.0 – 7.0 mm.
• Formulas for calculating ET tube sizes include:
18
Uncuffed endotracheal tube internal diameter (mm) = 4 + (age/4)
Cuffed endotracheal tube internal diameter (mm) = 3.5 + (age/4)

19. B-BREATHING
• A need for respiratory support include nasal flaring, unusual breath sounds
that are unequal/diminished/absent, unequal chest rise, and an oxygen
saturation of <90%
• A chest x-ray can confirm complications, and life-threatening thoracic
injuries such as pneumothorax, hemothorax which must be immediately
treated (AHA 2015)
• Oxygen should be placed on all trauma patients via nasal cannula or
facemask, even if there are no signs of airway or respiratory compromise.
• A pulse oximeter should be placed to measure oxygen saturation
continuously and to maintain oxygen saturation greater than 96%.
• For the apneic or bradypneic child, rescue breathing should be initiated with
a bag-valve-mask using 100% oxygen
19

20. C-Circulation
• Hypovolemia- most
common cause of
shock
• If intravenous access is
difficult, obtain
intraosseous access
20

21. • If circulation is inadequate:
(tachycardia, hypotensive, cool peripheries etc)
-administer a fluid bolus of 20 mL/kg of 0.9% normal saline
If circulation continues to be unstable:
-repeat the fluid bolus using 20 mL/kg normal saline
-If the response is inadequate, administer a bolus of packed red blood cells of
20 mL/kg
Minimum cross-match requirements for major trauma patients are:
Infants: 2 units
Small child: 4 units
Large child: 6 units
21

22. • Maintenance fluid:
-Use the following formulae to calculate normal daily fluid requirements in
children up to 30kgs:HOLLIDAY-SEGARD NOMOGRAM
•Up to 10kgs – 100ml/kg/day
•10-20 kgs – 1000mls plus 50ml/kg/day for each kg over 10kgs
•20-30 kgs – 1500mls plus 20ml/kg/day for each kg over 20kgs
Hypoglycaemia may be present in injured infants.
-5 mL/kg of 10% dextrose (0.5g/kg) IV, followed by a glucose infusion (NaCl +
5% or 10% dextrose) at ‘maintenance’ rates.
-Never give large volume infusions of 5% or 10% dextrose in water, as
hyponatremia may occur
22

23. D-Disability: neurological status
23

24. E-EXPOSURE
• Pediatric patients are prone to hypothermia due to increased heat loss
from their larger body surface area, and trauma can also increase
susceptibility to hypothermia.
• The pediatric patient should be covered as much as possible, exposing only
needed body surface areas during any assessment or procedure.
• To prevent hypothermia, all wet clothing or sheets should be removed, and
a warming blanket, and/or a radiant heat source can be used.
• Active warming may be initiated by using warmed IV fluids and blood to
increase the core temperature
24

25. MANAGEMENT- SOFT TISSUE INJURIES
• Tetanus status:The full basic course of immunisation against tetanus toxiod
consists of three primary doses of 0.5ml at least four weeks apart, followed
by booster doses at 18 months, 5 years, 10 years and 16 years and then
every 10 years.
25

26. • Debridment and closure : within 12 hr of injury
• Ecchymoses and contusions : cold application / no treatment
• Hematoma : incised and evacuated
• Deep wounds: closed in layers , skin approximation using fine nylon or
prolene sutures
• Lacerations : reapproximation and appropriate closure using sutures
• In case of tissue loss: reconstruction with appropriate grafts
26

27. DENTAL TRAUMA
• Common location: anterior maxilla >anterior mandible
• Children with protrusive maxillary teeth are particularly at risk for repeated
dentoalveolar trauma
• Intrusion and avulsion of teeth are common dentoalveolar injuries in young
children
• In general, trauma to primary dentition is treated via extraction, although
restoration of primary dentition may be warranted if the dental trauma is mild
or if there is a concern about space maintenance.
• primary tooth is avulsed:
not recommended for replantation
27

28. CLASSIFICATION OF DENTAL INJURIES
• Andreasen described a classification of traumatic dental injuries based on the
specific structures involved
• 1. Hard dental tissues and pulp:
a. Fractures of the crown: enamel alone; enamel and dentin; enamel, dentin,
and pulp (complicated crown fracture)
b. Fractures of crown and root: enamel, dentin,cementum without pulpal
exposure; enamel,dentin, cementum with pulpal exposure
c. Root fracture: dentin, cementum, and pulp
• 2. Periodontal tissues: concussion without loosening,loosening without
displacement (subluxation),loosening with partial displacement (extrusive or
lateral luxation), complete avulsion, retained root
• 3. Alveolar bone: fractures of the alveolus, with or without comminution
28

29. CLASSIFICATION OF DENTAL INJURIES
29

30. MANAGEMENT- DENTAL TRAUMA
• Ellis types 1 and 2 injuries are typically treated via dental restorations.
• Ellis type 3 requires root canal therapy followed by dental restoration.
• Dental subluxation often will require splinting of the subluxed tooth to
adjacent teeth for 3 to 4 weeks to stabilize the tooth.
30

31. • The treatment of avulsed teeth is based on the time from injury to treatment.
The ideal treatment is to reimplant an avulsed tooth immediately after
avulsion.
• It is important not to wash the tooth to ensure that the periodontal ligament is
not washed away.
• If reimplantation is not immediately feasible, the tooth should be transported
ideally in saliva or HBSS medium.
• Tooth should be splinted to the adjecent tooth
for 2-3 months to allow healing and uptake.
31

32. ALVEOLARFRACTURES
• Alveolar fractures involve the supporting bone of the dentition.
• Most common type of pediatric facial fractures.
• Frequently associated with dental trauma or tooth avulsion.
• Clinically, an alveolar fracture may have a segment of teeth that
are mobile as a group, with associated soft tissue injury and malocclusion.
32

33. MANAGEMENT
• Primary treatment is conservative, consisting of immobilizing the arch
segment using an arch bar, wire ligation, or a composite supported
orthodontic wire extended to stable teeth in the injured arch.
33

34. NASAL FRACTURES
• Nasal fractures are the second most common type of pediatric facial fractures.
• Prominent skeletal structure and the fragile nasal bones makes it more
susceptible to injury
• CLINICAL FINDINGS
• Ecchymosis
• overlying skin lacerations, swelling,
• epistaxis,
• septal hematoma, or intranasal lacerations.
• Palpable bony irregularities
• Intranasal speculum examination is important to rule out a possible septal
hematoma, which (if present) requires emergent evacuation to avoid septal
cartilage necrosis or resorption, resulting in a saddle nose deformity. 34

35. • Intramembranous ossification begins during the third month of fetal life.
• Nasal bones flexible so usually do not comminute.
• Lateral blow to the nose displaces the nasal bone medially, and the opposite
nasal bone may override the frontal process of the maxilla.
• Blow from the front may fracture both nasal bones transversely, or the bones
may separate in the midline, a so-called open book fracture.
• RADIOGRAPHS
• Lateral nasal projection
• Waters' view at 30 to 45 degrees
• CT Scan
35

36. MANAGEMENT
• Fractures of the nasal structures in children should be managed like those in
the adult.
• Epistaxis is common with nasal trauma and can be controlled by local means
by pinching the nostrils for 5 to 10 minutes, with the head slightly elevated
• Although rare, local means of control may fail and the surgeon must
surgically cauterize the region with silver nitrate or minimal electrical
cauterization or by placement of a balloon inflation catheter, or ligation of
vessels.
36

37. CLOSED REDUCTION - success rates of 60% to 90%.
• Indicated for simple non comminuted fractures.
• The fundamental principle is to apply a force opposite to the vector of trauma
to achieve fracture reduction
• Depressed segments of nasal bone can
be reduced using an elevator or
Walsham's forceps, Ash forceps,
Kelly clamp, can be inserted into the
nasal cavity and rotated laterally to
pull out fracture the bones.
37

38. • Septal base should be repositioned into the
vomerine groove.
• Intranasal packing and a splint are used to
stabilize the reduction and provide
hemostasis
• The splint is made to cover the nose only
because of the forward projecting frontal
bone in children causes a splint to ride off
the nose if it is secured to the forehead.
• Splint for 7 days should be given in all nasal
bone reductions
• It help hold bones in place and reminds the
patient and others around them to be careful
as the bones can quite easily displace again.
Internal nasal packing
with thermal plastic
splint applied for
stabilization
38

39. • A septal hematoma must be drained on an
emergent basis to avoid resorption of the
cartilage, which causes the associated saddle
nose deformity.
• Most frequent long-term complication
of nasal injury is a compromised airway
caused by deviation and thickening of
the septum or widening of the dorsum.
• Most closed reductions do not require internal
splints, but they may be used in comminuted
fractures, septal dislocation, and with inwardly
collapsing nasal bones.
INTERNAL NASAL
SPLINT
39

40. 40

41. • OPEN REDUCTION:
• after 4 to 6 months after the initial
injury to allow tissues to settle before
formal open septorhinoplasty can be
considered.
• Indicated for fractures that cannot be
reduced by closed techniques.
• Complex injuries between bones and
cartilages and fixing one without the
other will leave the patient with ongoing
nasal breathing issues.
• Advantage: Greater exposure and direct
visualization allowing better reduction.
41

42. ZYGOMATICCOMPLEX FRACTURES
• Zygomatic complex fractures - up to 41% of all pediatric midface fractures.
• Include fractures of the zygoma, zygomatic maxillary complex, zygomatic
orbital complex, and zygomatic arch.
• FZ and ZT sutures are particularly weak and susceptible to disruption
• CLINICAL FINDINGS
• Lacerations, Periorbital edema, Epistaxis
• Infraorbital nerve hypoesthesia
• Flattening of the malar process
• Palpable bony steps, crepitus, pain
• Possible trismus if the arch is fractured and displaced
• Associated orbital fracture (ophthalmologic examination must be carried out)
• Diplopia 42

43. • Minimally displaced zygomatic fractures may be masked in young children
by their subcutaneous fat and because poor cooperation immediately after the
acute injury makes examination difficult.
• Asymmetry becomes evident with time, when the swelling goes down and
some of the fat on the injured side atrophies.
• Entrapment of extraocular muscle limits the upward gaze of the patient.
• DIAGNOSIS:
• Waters‘ and submental vertex view radiographs
• CT Scan and 3D CT
43

44. MANAGEMENT
AIM
• Restore normal contour of face
• Relieve pain
• Precise anatomical reduction of the fractured fragment
• Stable fixation of the reduced fragment
• Correct diplopia
• Remove any interference in range of mandibular movement
• Relieve pressure from infraorbital nerve
NOTE:
• Reduction of the fractured arch of the zygoma is performed only if a cosmetic
deformity exists or if notable trismus, or nerve impingement is present in
minimally displaced or undisplaced fractures. 44

45. • Greenstick or minimally displaced arch fractures in
the pediatric patient are treated conservatively by
observation, diet modification and analgesics.
• Open reduction and rigid internal fixation is
necessary for significantly displaced or
comminuted fractures.
• Like the adult patient, three-point stabilization is
ideal(zygomaticofrontal process, infraorbital rim,
and zygomatic buttress) are reduced and rigidly
fixated.
• Treatment should be carried out 5 to 7 days after
the injury, after the swelling has resolved but
before the fracture consolidates. 45

46. • The frontozygomatic region is explored through an upper eyelid (supratarsal
fold) incision“. This approach allows clear visualization of the suture, access
for elevation of the zygoma, and room for placement of a miniplate.
• ln children, most of these fractures are stable with one plate,because of the
short distance (short lever arm) from the frontozygomatic suture to the
infraorbital rim.
46

47. • Care should be taken when placing the rigid fixation in the zygomatic buttress
region to avoid damaging any underlying tooth buds.
• Isolated zygomatic arch fractures can be treated via an extraoral (Gilles) or
intraoral (Keane) approach.
• In both cases, rigid fixation is not required. The reduced arch must be protected
postoperatively from any trauma or pressure during the initial postoperative
period to ensure that the reduced arch does not displace.
47

48. • Resorbable plate systems are preferred an alternative to titanium plates and
screws in the pediatric trauma population.
• The resorbable systems eliminate the need to remove plates and screws for
fear of future problems or interference with growth and second surgery for
their retrieval.
Resorbable microminiplates and screws
Resorbable miniplates and screws
Resorbable miniplates and screws
48

49. ORBITAL FRACTURES
• < 7 years: mostly in the orbital roof, with extension to the frontal sinus. This
is due to the underdevelopment of the sinuses.
• > 7 years: injury to the orbital roof, medial and lateral walls, floor, and frontal
sinus are more frequent. Because most growth of the orbits is complete after
the age of 7.
• Fractures of the orbit in children 7 years or older should be managed like
those in the adult, without concern for growth disturbances.
DIAGNOSIS:
• Complete ophthalmologic examination
• CT scan (coronal, axial, sagittal, and three-dimensional reconstructions)
• Child may refuse to move the eye because of pain, and a forced duction test is
usually not possible in an awake child. – sedation or general anesthesia are
required to make the diagnosis of entrapment. 49

50. CLINICAL FINDINGS:
• Periorbital ecchymosis,
• Edema and hematoma,
• Enophthalmos
• Infraorbital nerve paresthesia
• Extraocular muscle dysfunction
(may be difficult in a pediatric patient)
50

51. • Radiologic findings may be minimal because of the elasticity of the orbital
floor. Tissue herniation into the maxillary sinus (tear drop sign) may not be
evident in a blow out fracture because of overlap of the fractured segment
called a trapdoor fracture.(entrapment of the left inferior rectus muscle)
• When a child has diplopia and restriction of vertical gaze and little or no
clinical evidence of soft tissue trauma (e.g.,edema, ecchymosis), this fracture
is referred to as white eyed blowout.
WHITE EYED BLOWOUT TEAR DROP SIGN
51
TRAPDOOR FRACTURE

52. • Oculocardiac reflex consists of the triad of bradycardia, nausea, and syncope.
• Nausea and vomiting may be a vagally mediated response to pain or other
sensory feedback associated with extraocular muscle traction.
52

53. • Type 1: Pure Orbital Fractures
• 1a—floor fractures
• 1b—medial wall fractures
• 1c—roof fractures
• 1d—lateral wall fractures
• 1e—combined floor and medial wall
fractures
• Type 2: Craniofacial Fractures
• 2a—growing skull fractures
• Type 3: Orbital Fractures Associated
With Common Facture Patterns
• 3a—fractures of floor in inferior orbital
rim
• 3b—zygomatic maxillary complex
fractures
• 3c—naso-orbital-ethmoid (NOE)
fractures
• 3d—other fracture pattern
Classification of Orbital Fractures (Losee JE, Afifi A, Jian S, et al 2008)
53

54. MANAGEMENT
• Most common type of pediatric orbital fracture is the type 1 fracture. For
which conservative management is recommended.
• Type 2 fractures (orbital fractures occurring in conjunction with the
craniofacial skeleton) should also be treated conservatively.
• INDICATIONS FOR SURGICAL INTERVENTION
• Evidence of entrapment,
• Enophthalmos
• Vertical orbital dystopia
• Type 3 fractures that occur in conjunction with other facial fractures.
54
Vertical orbital dystopia

55. • Approaches to the orbit are similar to those for the adult and have similar
complications, including the subciliary incision and/or transconjunctival
incisions.
• Orbital fractures in children with evidence of muscle entrapment be treated
sooner to avoid necrosis of the extraocular musculature and associated
oculorotary dysfunction.
• Trapdoor fracture or a white-eyed blowout should be operated as soon as
possible (within 24 to 48 hours): to prevent fibrosis thereby enhancing muscle
recovery.
• If delayed ischemic necrosis of the entrapped tissue occurs.
• Orbital fractures with a large orbital floor defect,without restriction in eye
motility, can be explored in 5 to 7 days (when edema subsides).
55

56. MANDIBULAR FRACTURE
CLINICAL EXAMINATION:
• History:fall or blunt injury to chin
• Laceration
• Pain to TMJ(fracture or haemarthrosis)
• Occlusal disturbance
-unilateral subcondylar # :ipsilat. Premature occlusion with cross bite or
contralateral open bite
-bilat. Subcondylar # : open bite/retrognathism
• Limitation in mouth opening
-unilat. Condylar # :Jaw deviates towards the fracture on open
Premature/crossbite
56

57. • Hematoma and ecchymosis at buccal sulcus and floor of mouth in fracture
area
57
SUBLINGUAL HEMATOMA

58. RADIOGRAPH
• OPG: TMJ ,Ramus ,angle
body,symphysis of mandible
• Occlusal radiograph:symphyseal fracture
• Towne’s view(AP Plane):position and
deviation of condyle is seen
• PA view ,left and right lat. Oblique
• 3D CT:postion of proximal segment of
condyle and subcondyle #
A, Posteroanterior radiograph
of a left angle fracture
B, Towne's view of a right
subcondylar fracture
58

59. Mandibular fractures in 3-year-old boy.
(a) Three-dimensional CT reconstruction: displaced right mandibular and bilateral subcondylar fractures (arrows).
(b) Coronal computed tomography (CT) scan cut showing bilateral displaced subcondylar fractures.
(c) Axial CT scan showing oblique displaced right mandibular fracture extending through buccal and lingual plates.
59

60. MANAGEMENT
• Undisplaced #
-Unless mechanical interference:no surgical intervention
-Muscle training
if severe pain: a day rest with headcap or chin strap
-If occlusal disturbace:Immobilization in centric relationship for 2-3
weeks followed by active excercise
60

61. • Rowe in 1969: methods of immobilization depending on state of dentition
at the time of injury
61

62. 0-2 year
Circumferential wiring
•Treat as edentulous patient
(MacLennan 1956)
•Prefabricated acrylic lower gunning
splint
•Splint retained in place by 2
circumferential wire on each side of the
# line (symphysis region)
•Angle:
-Transosseous wiring followed by
maxillomandibular fixation using
gunning splint
62

63. 2-4 year
CAP SPLINT
•Deciduous teeth are present, and
stable
•Options
-Interdental eyelet wiring
-Cap splints
•Further support if needed
•circummandibular wires and wires
through the pyriform aperture
63

64. 5-8 years
•Deciduous tooth roots resorb
•Permanent teeth are erupting
Multiple permanent teeth available for standard
arch bar placement
•May also use orthodontic devices for fixation as well
•Gunning type splint :premature extraction of teeth due
to caries or trauma
GUNNING SPLINT
64

65. 9-11 year
• Cap splint
• Transosseous wiring (in case of compound fracture)
65

66. BODY , SYMPHYSIS ,ANGLE:
Nondisplaced #
-majority(elasticity of the mandible and embedded tooth bud)
-observation-close follow up,
-blenderized diet,
-avoidance of physical activity
• Displaced #
- body and symphysis fracture:splinting
close reduction (acrylic splint)and immobilization or Open reduction and
miniplate screw fixation
-angle
Cant do MMF or splint(proximal segment reduction)
Transosseous wiring (close to lower border ) 66

67. CONDYLE
Aim
• Pain free mouth opening beyond 40mm in adulthood
• Good movement of jaw in all excursions
• Normal occlusal rerationship with time and growth
• Stable TMJ ,Good facial height and jaw symmetry
67

68. CLASSIFICATION
• Based on location: intracapsular(condylar) or extracapsular(subcondylar)
• Unlateral or bilateral
• Relationship of the proximal fragment to the glenoid fossa and the
mandible.
The fractures may be
- nondisplaced or displaced in fossa (referred to as medial and lateral
override depending) ,
-dislocated, meaning the proximal head is out of fossa
68

69. Difference between adult and child condyle
69

70. • ORIF not indicated unless there is mechanical obstruction
• In intracapsular fracture or crush injury : early mandibular exercise and jaw
exercise (children less than 3years).Duration of IMF should not exceed 3-
4days
• Exercise -3months followed by every 3 months follow up for 12 months
• If orthodontic appliance is indicated –should started within 2-4 weeks of
injury
• Primary or mixed dentition : conservative treatment
• Permanent dentition : in unilateral or bilateral #
IMF for 7-10days followed by open reduction
70

71. • It is not advocated to perform orthodontic aftercare as a routine action
in all patients.
• High condylar intracapsular fractures show good evidence of
regeneration (64%)
• While low condylar intracapsular fractures may give rise to some
asymmetry.
• It is concluded that nonsurgical management of condylar fractures of
the mandible in children is still the method of choice
Int. J Oral Maxillojac. Surg.
1999; 28." 429~140
71

72. • Both groups demonstrated primary bone healing. Minor complications
were similar in both groups. The metallic group involved secondary
operations for plate removal. Mandibular growth was satisfactory in
both groups.
• Resorbable plates cost more than the metallic ones; however, when the
secondary operations are included in the total cost, resorbable plates
were favourable. As mandibular growth and complication parameters
are similar in both groups, resorbable plates are favored due to
avoidance of potential odontogenic injury, elimination of long-term
foreign body retention and provision of adequate stability for rapid bone
healing
Ulus Travma Acil Cerrahi Derg,
November 2015, Vol. 21, No. 6
72

73. Complications
• Immediate complication
-Edema
-Pain
-Infection
• Late complication
-Growth disturbances
-Ankylosis
-dentition and final occlusion disturbance
-medial canthal displacement
-Enopthalmos
73

74. REFERENCES
INTERNET RESOURCES
74

75. 75