The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
REFERENCES 1. Bass T. Observation on the misplaced upper canine tooth. Dent Pract Dent Rec 1967;18:25–33 2. Rayne J. The unerupted maxillary canine. Dent Pract Dent Rec 1969;19:194–204 3. Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance. Eur J Orthod 1986;8:133–140 4. Cooke J, Wang H. Canine impactions: incidence and management. Int J Periodontics Restorative Dent 2006;26:483–491 5. Kuroda S, Yanagita T, Kyung HM, et al. Titanium screw anchorage for traction of many impacted teeth in a patient with cleidocranial dysplasia. Am J Orthod Dentofacial Orthop 2007;131:666–669 6. Kokich V, Mathews D. Surgical-orthodontic management of impacted teeth. Dent Clin North Am 1993;37:181–204 7. Jacoby H. The “ballista spring” system for impacted teeth. Am J Orthod 1979;75:143–151 8. Chung KR, Kim SH, Kang YG, et al. Orthodontic miniplate with tube as an efficient tool for borderline cases. Am J Orthod Dentofacial Orthop 2011;139:551–562 9. Lee SJ, Lin L, Chung KR, et al. Survival analysis of a miniplate and tube device designed to provide skeletal anchorage. Am J Orthod Dentofacial Orthop 2013;144:349–356 10. Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial Orthop 2004;126:278–283 11. Park HS, Oh YH. Forced eruption of a labially impacted canine using joined microimplants. J Clin Orthod 2010;44:108–113 12. Seo KW, Ahn HW, Kim SH, et al. Miniplate with a bendable C-Tube head allows the clinician to alter biomechanical advantage without physically moving the skeletal anchorage device. J Craniofac Surg 2014;25:686–689 13. Wei YJ, Kuang SH, Lai YL. Authors’ response. Am J Orthod Dentofacial Orthop 2013;143:5–6 14. Park HS, Kyung HM, Sung JH. A simple method of molar uprighting with micro-implant anchorage. J Clin Orthod 2002;36:592–596 15. Shapira Y, Borell G, Nahlieli O, et al. Uprighting mesially impacted mandibular permanent second molars. Angle Orthod 1998; 68:173–178 16. Becker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod 2013;83:870–876 17. Kare P, Daga A. Management of impacted teeth. J Clin Diagn Res 2011;5:894–898 18. Tanaka E, Kawazo E, Nakamura S, et al. An adolescent patient with multiple impacted teeth. Angle Orthod 2008;78:1110–1118 19. Uematsu S, Uematsu T, Furusawa K, et al. Orthodontic treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and apicoectomy. Angle Orthod 2004;74:132–136 20. Wei YJ, Lin YC, Kaung SS, et al. Esthetic periodontal surgery for impacted dilacerated maxillary central incisors. Am J Orthod Dentofacial Orthop 2012;142:546–551
Conservative Orthodontic Treatment of Mandibular Bilateral Condyle Fracture Goran Gašpar, DMD,* Ivan Brakus, DDS,† Ivan Kovačić, PhD, DMD‡ Abstract: Maxillofacial trauma is rare in children younger than the age of 5 years (range 0.6%–1.2%), and they can require different clinical treatment strategies compared with fractures in the adult population because of concerns regarding mandibular growth and development of dentition. A 5-year-old girl with a history of falling
e488
from a bicycle 7 hours earlier was referred to the department of oral and maxillofacial surgery. Multislice computed tomographic examination demonstrated a bilateral fracture of the mandibular condyle neck associated with minimal fracture of the alveolar ridge of the maxilla. The multislice computed tomographic scan also demonstrated dislocation on the right condyle neck and, on the left side, a medial inclination of approximately 45 degrees associated with greenstick fracture of the right parasymphysis region. In this particular case, orthodontic rubber elastics in combination with fixed orthodontic brackets provided good results in the treatment of bilateral condyle neck fractures associated with greenstick fracture of parasymphysis.
M
axillofacial trauma is rare in children younger than the age of 5 years (range, 0.6%–1.2%), and they can require different clinical treatment strategies compared with fractures in the adult population because of concerns regarding mandibular growth and development of dentition.1 Of all mandibular fractures, the most common are fractures of the angle, condyle, and the subcondylar region. Treatment modalities in young patients range from conservative treatment methods to open reduction with internal fixation.2 Conservative treatment of dislocated condylar process fractures in children results in satisfactory long-term outcome of jaw function despite a high frequency of radiologically noted aberrations.3 Soft diet with immediate mobilization seems to be the treatment of choice..Open reduction and osteosynthesis of the pediatric fracture with titanium plates and screws are thought to have a negative effect on skeletal growth and unerupted teeth and involve a 2-stage surgery because of the need for plate removal after complete healing.4 The technical difficulty of open reduction undoubtedly has been a factor in its lack of general acceptance.5 Maclennan6 reflects the consensus in stating that the critical period for mandibular growth from the condylar growth center is between 1 and 5 years, with particular reference to the age of 2 and a half years and younger. Hence, in children, with few exceptions, closed treatment is preferable, fixation periods should be short, a vigorous post–fixation exercise program is essential, and a patient should have a long-term follow-up.7 We report a conservative orthodontic treatment of a case of mandibular bilateral condyle fracture and greenstick fracture of the right mandibular parasymphysis using an orthodontic therapy with the repositioning of the mandible, bracket bonding on primary molars, and fixation with orthodontic elastics.
BRIEF CLINICAL REPORT A 5-year-old girl with a history of falling from a bicycle 7 hours earlier was referred to the department of oral and maxillofacial surgery. She was found conscious and well oriented in time and space. Extraoral examination revealed chin laceration with difficulties and pain in mouth-opening movements. A slight swelling was noticed in the floor of the mouth near midline. Preauricular regions were tender on palpation. Intraoral examination revealed avulsion of primary anterior teeth (52, 51, 62, 61, and 72). Multislice From the *Dental Polyclinic; Departments of †Oral Surgery, and ‡Prosthodontics, School of Medicine, Study of Dental Medicine, University of Split, Split, Croatia. Received July 2, 2013. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Ivan Brakus, DDS, Papandopulova 9, 21000 Split, Croatia; E mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000904
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
FIGURE 1. Computed tomographic three-dimensional reconstruction and clinical picture before treatment. FIGURE 3. Panoramic x-ray and clinical pictures after 2 years.
computed tomographic (MSCT) examination demonstrated a bilateral fracture of the mandibular condyle neck associated with minimal fracture of the alveolar ridge of the maxilla. The MSCT scan also demonstrated dislocation on the right condyle neck and, on the left side, a medial inclination of approximately 45 degrees associated with greenstick fracture of the right parasymphysis region. The patient could not achieve a normal bite and occlusal contacts in the closing movements of the lower jaw (Fig. 1). Because of the age of the patient, a conservative treatment approach was preferred. The mandible was bimanually repositioned in the caudal direction under general anesthesia. Orthodontic brackets (Dentaurum, Ispringen, Germany) were bonded (Transbond XT Light Cure Adhesive; 3M Unitek, Monrovia, CA) on deciduous first molars on both sides. After the bonding, elastics were used (Forestadent, Pforzheim, Germany) for fixation of the upper and lower first molars on both sides (soft fixation). The patient was discharged from the hospital after 48 hours. The analgesic treatment consisted of acetaminophen suspension (3 times a day, 250 mg) (Calpol; Glaxo-Wellcome) for 2 weeks. The intermaxillary fixation was maintained for 2 weeks, followed by 1 week of active physiotherapy of the jaws by intermaxillary elastics and active movement of the jaws to obtain good occlusion. After that, the brackets were debonded and instructions for mouth opening exercises were given to the patient. The exercises included maximal mouth opening, right and left lateral excursions, as well as protrusive movements. The patient and her parents were instructed to exercise several times a day for 5 minutes. The patient was advised to exercise together with her parents in front of the mirror to avoid or correct possible deviation. After 24 hours, the patient was able to open her mouth normally. The clinical and radiologic evaluation after 6 months showed that both the centric occlusion and healing at the fracture site were excellent (Fig. 2). The clinical and radiologic evaluation after 2 years showed ideal symmetry and normal mouth opening (Fig. 3).
DISCUSSION Bilateral condyle neck fractures can cause asymmetry in vertical, transversal, and horizontal planes. Considering the fact that we never have MSCT of a child before the accident, we can only assume the natural position of the patient's jaws. Recent photographs of the patient's face before the trauma could help us to do the best repositioning possible. In case of asymmetry and skeletal class II, which may be a circumstance of bilateral condyle fracture or a specific growth pattern, orthodontic functional appliance can be the method of choice. Today, such as in the early 70s, medical and dental professionals can provide good results in either open or closed treatment of mandibular condyle fractures in children, so open versus closed treatment is judged individually.5,8 Conservative management (observation, exercises, maxillomandibular fixation, training elastics, bite opening splints) are overwhelmingly
FIGURE 2. Computed tomographic three-dimensional reconstruction and clinical picture after 6 months.
popular because there are minimal complications with good functional outcomes.9 The osteogenic potential of the periosteum in the developing craniofacial skeleton is very high and will lead to somewhat rapid and easier healing, which occurs under the influence of the masticatory stress, even when there is an imperfect apposition of bone surfaces.10 For greenstick undisplaced fractures, conservative closed reduction is the most recommended treatment.11 In our case, the permanent teeth are erupting at this moment. The positive side of such traumas is that we have alliance in nearby growth and development, and orthodontics could help if necessary.
CONCLUSIONS According to the degree of fracture displacement (>35 degrees), the case presented here can be classified as class 3, for which they recommended open reduction.12 Young children have a great osteogenic potential and a high healing rate, so regarding the patient’s age and the short period between trauma and treatment, we opted for conservative approach. In this particular case, orthodontic rubber elastics in combination with fixed orthodontic brackets provided good results in the treatment of bilateral condylar neck fractures associated with greenstick fracture of parasymphysis. However, periodic long-term follow-up is essential for early determination of possible growth disturbances. Only long-term follow-up for more than 10 years will probably provide the data necessary for a meaningful conclusion.
REFERENCES 1. Bataineh AB. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:31–35 2. Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fractures: recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg 2006;35:2–13 3. Thoren H, Hallikainen D, Iizuka T, et al. Condylar process fractures in children: a follow-up study of fractures with total dislocation of the condyle from the glenoid fossa. J Oral Maxillofac Surg 2001;59:768–773 4. Koltai PJ, Rabkin D, Hoehn J. Rigid fixation of facial fractures in children. J Craniomaxillofac Trauma 1995;1:32–42 5. Hoopes JE,Wolfort FG, Jabaley MEM. Operative treatment of fractures of the mandibular condyle in children: using the post-auricular approach. Plast Reconstr Surg 1970;46:357–362 6. Maclennan WD. Consideration of 108 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 1952;5:122 7. Laskin DM. Management of condylar process fractures. Oral Maxillofac Surg Clin North Am 2009;21:193–196 8. Aizenbud D, Emodi O, Rachmiel A. Nonsurgical orthodontic splinting of mandibular fracture in a young child: 10-year follow-up. J Oral Maxillofac Surg 2008;66:575–577 9. Kocabay C, Atac MS, Oner B, et al. The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: a case report. Dent Traumatol 2007;23:247–250 10. Li Z, Zhang W, Li ZB, et al. Mechanism in favorable prognosis of pediatric condylar fractures managed by closed procedures: an experimental study in growing rats. Dent Traumatol 2010;26:228–235 11. Kalia V, Singh AP. Greenstick fracture of the mandible: a case report. J Indian Soc Pedod Prev Dent 2008;26:32–35
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
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12. Bhagol A, Singh V, Kumar I, et al. Prospective evaluation of a new classification system for the management of mandibular subcondylar fractures. J Oral Maxillofac Surg 2011;69:1159–1165
Dental Trauma: Knowledge and Attitudes of Community Health Workers Fábio Wildson Gurgel Costa, DDS, MS,* Elaine Helena de Oliveira, DDS,† Marcelo Ferraro Bezerra, DDS, MS,† Alexandre Simões Nogueira, DDS, MS,† Eduardo Costa Studart Soares, DDS, MS,‡ Karuza Maria Alves Pereira, DDS, MS,§ Background: The international literature emphasizes the importance of evaluating the knowledge of different groups such as teachers, students, dentists, physicians, parents, and athletes regarding dental injuries. In Brazil, community health workers are professionals who can reach a wide variety of people and who have a marked influence on prevention and health promotion strategies. The objective of this study was to investigate the knowledge and attitudes of community health workers regarding dental trauma. Methods: A questionnaire consisting of 19 questions divided into 3 parts was applied: demographic characteristics, knowledge, and attitudes. Data from 206 respondents were analyzed using descriptive statistics and logistic regression models. Results: Approximately 28% of the participants reported to have been called to assist individuals with dental trauma. Only 42 subjects had received education on dental injuries, with 34 of them being instructed by a dentist. In cases of tooth avulsion, only 1.9% of the health workers reported that they would search for the tooth and reimplant it. The most frequently indicated storage media for avulsed teeth were nonphysiological media (69.42%). Conclusions: The educational level of the community health workers somehow influenced their knowledge (P < 0.001) and attitude (P = 0.016) regarding dental injuries. Educational programs for this group are needed to improve the management of traumatic dental injuries.
and are a cause of impaired phonation and esthetics as well as of embarrassment and distress for the patients and their parents or guardians.1 The increase in violence and in the number of traffic accidents and the more frequent participation of children in sports activities contribute to the transformation of traumatic dental injuries into an emerging public health problem.2–4 Various studies on health education strategies have emphasized the importance of evaluating knowledge about traumatic dental injuries in different settings, such as home, schools, and streets, and in different groups that exert a broad influence such as teachers,5,6 students,1 dentists,7–9 physicians,10,11 parents,12,13 and athletes.14,15 In Brazil, community health workers (CHWs) are professionals who can reach a wide variety of people and who have a marked influence on prevention and health promotion strategies in view of their ability to communicate with people and their natural leadership in the work environment.16,17 In addition to Latin America, other countries such as China have been incorporating rural workers, known as barefoot doctors, in their health system since the 1950s, who exert functions similar to those of CHWs,18 a fact demonstrating the importance of inclusion of these professionals in strategies addressing families, communities, and districts that are at risk for not having access to basic healthcare. To our knowledge, there are no studies on dental trauma involving CHWs. Therefore, the objective of the current study was to investigate the knowledge and attitudes of Brazilian CHWs regarding dental trauma.
MATERIALS AND METHODS Study Design and Population A cross-sectional, observational, and quantitative study was conducted between May 2010 and June 2010. At the time of the study, there were 410 CHWs of both sexes who lived in areas attached to the basic health units (BHUs) where they worked. Of these, 215 worked in 20 BHUs of rural districts, and 195 worked in 17 BHUs located in the principal district. The study was conducted in accordance with the Declaration of Helsinki and Resolution 196/96 of the Brazilian National Health Council. The project was approved by the Ethics Committee on Human Research of Universidade Estadual Vale do Acaraú (approval number 27017). Excluded from the study were subjects who did not sign the free informed consent form and those who did not respond to the questionnaire.
Instrument Key Words: Dental trauma, knowledge, attitude, community health workers
T
raumatic dental injuries play an important role in public health because they present economic, psychologic, and social sequelae
From the Divisions of *Oral Radiology, †Oral Surgery, ‡Stomatology and Oral Surgery, and §Oral Pathology, Department of Clinical Dentistry, School of Dentistry, Federal University of Ceará, Fortaleza-CE, Brazil. Received January 2, 2014. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Fábio Wildson Gurgel Costa, DDS, MS, Division of Oral Radiology, School of Dentistry, Federal University of Ceará, Rua João Sorongo, 1016, Apto. 205, Jardim América, CEP: 60416-000, Fortaleza-CE, Brasil; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000916
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A self-administered 2-page standardized questionnaire consisting of 19 questions based on those used in previous studies was developed for data collection. Before the main study, a pilot questionnaire was applied to evaluate the ease of reading and understanding of the questions, and few modifications were introduced after this preliminary evaluation. The CHWs were asked to anonymously complete a questionnaire without consulting with any colleague. In the case of multiplechoice questions, the respondents could choose more than 1 item, if appropriate. For didactic reasons, the questionnaire was divided into 3 parts. The first part consisted of 8 questions about personal characteristics of the respondents, including sex, age, educational level, time of residence in the community where they worked, duration of work in the community assisted, activities performed in the community, number of home visits performed per day of work, and number of families assisted. The second part consisted of 6 questions referring to the knowledge of the respondent about dentoalveolar injuries and the information received by other professionals. The third part consisted of 5 questions that asked the participants about their © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
REFERENCES 1. Bass T. Observation on the misplaced upper canine tooth. Dent Pract Dent Rec 1967;18:25–33 2. Rayne J. The unerupted maxillary canine. Dent Pract Dent Rec 1969;19:194–204 3. Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance. Eur J Orthod 1986;8:133–140 4. Cooke J, Wang H. Canine impactions: incidence and management. Int J Periodontics Restorative Dent 2006;26:483–491 5. Kuroda S, Yanagita T, Kyung HM, et al. Titanium screw anchorage for traction of many impacted teeth in a patient with cleidocranial dysplasia. Am J Orthod Dentofacial Orthop 2007;131:666–669 6. Kokich V, Mathews D. Surgical-orthodontic management of impacted teeth. Dent Clin North Am 1993;37:181–204 7. Jacoby H. The “ballista spring” system for impacted teeth. Am J Orthod 1979;75:143–151 8. Chung KR, Kim SH, Kang YG, et al. Orthodontic miniplate with tube as an efficient tool for borderline cases. Am J Orthod Dentofacial Orthop 2011;139:551–562 9. Lee SJ, Lin L, Chung KR, et al. Survival analysis of a miniplate and tube device designed to provide skeletal anchorage. Am J Orthod Dentofacial Orthop 2013;144:349–356 10. Kokich VG. Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofacial Orthop 2004;126:278–283 11. Park HS, Oh YH. Forced eruption of a labially impacted canine using joined microimplants. J Clin Orthod 2010;44:108–113 12. Seo KW, Ahn HW, Kim SH, et al. Miniplate with a bendable C-Tube head allows the clinician to alter biomechanical advantage without physically moving the skeletal anchorage device. J Craniofac Surg 2014;25:686–689 13. Wei YJ, Kuang SH, Lai YL. Authors’ response. Am J Orthod Dentofacial Orthop 2013;143:5–6 14. Park HS, Kyung HM, Sung JH. A simple method of molar uprighting with micro-implant anchorage. J Clin Orthod 2002;36:592–596 15. Shapira Y, Borell G, Nahlieli O, et al. Uprighting mesially impacted mandibular permanent second molars. Angle Orthod 1998; 68:173–178 16. Becker A, Abramovitz I, Chaushu S. Failure of treatment of impacted canines associated with invasive cervical root resorption. Angle Orthod 2013;83:870–876 17. Kare P, Daga A. Management of impacted teeth. J Clin Diagn Res 2011;5:894–898 18. Tanaka E, Kawazo E, Nakamura S, et al. An adolescent patient with multiple impacted teeth. Angle Orthod 2008;78:1110–1118 19. Uematsu S, Uematsu T, Furusawa K, et al. Orthodontic treatment of an impacted dilacerated maxillary central incisor combined with surgical exposure and apicoectomy. Angle Orthod 2004;74:132–136 20. Wei YJ, Lin YC, Kaung SS, et al. Esthetic periodontal surgery for impacted dilacerated maxillary central incisors. Am J Orthod Dentofacial Orthop 2012;142:546–551
Conservative Orthodontic Treatment of Mandibular Bilateral Condyle Fracture Goran Gašpar, DMD,* Ivan Brakus, DDS,† Ivan Kovačić, PhD, DMD‡ Abstract: Maxillofacial trauma is rare in children younger than the age of 5 years (range 0.6%–1.2%), and they can require different clinical treatment strategies compared with fractures in the adult population because of concerns regarding mandibular growth and development of dentition. A 5-year-old girl with a history of falling
e488
from a bicycle 7 hours earlier was referred to the department of oral and maxillofacial surgery. Multislice computed tomographic examination demonstrated a bilateral fracture of the mandibular condyle neck associated with minimal fracture of the alveolar ridge of the maxilla. The multislice computed tomographic scan also demonstrated dislocation on the right condyle neck and, on the left side, a medial inclination of approximately 45 degrees associated with greenstick fracture of the right parasymphysis region. In this particular case, orthodontic rubber elastics in combination with fixed orthodontic brackets provided good results in the treatment of bilateral condyle neck fractures associated with greenstick fracture of parasymphysis.
M
axillofacial trauma is rare in children younger than the age of 5 years (range, 0.6%–1.2%), and they can require different clinical treatment strategies compared with fractures in the adult population because of concerns regarding mandibular growth and development of dentition.1 Of all mandibular fractures, the most common are fractures of the angle, condyle, and the subcondylar region. Treatment modalities in young patients range from conservative treatment methods to open reduction with internal fixation.2 Conservative treatment of dislocated condylar process fractures in children results in satisfactory long-term outcome of jaw function despite a high frequency of radiologically noted aberrations.3 Soft diet with immediate mobilization seems to be the treatment of choice..Open reduction and osteosynthesis of the pediatric fracture with titanium plates and screws are thought to have a negative effect on skeletal growth and unerupted teeth and involve a 2-stage surgery because of the need for plate removal after complete healing.4 The technical difficulty of open reduction undoubtedly has been a factor in its lack of general acceptance.5 Maclennan6 reflects the consensus in stating that the critical period for mandibular growth from the condylar growth center is between 1 and 5 years, with particular reference to the age of 2 and a half years and younger. Hence, in children, with few exceptions, closed treatment is preferable, fixation periods should be short, a vigorous post–fixation exercise program is essential, and a patient should have a long-term follow-up.7 We report a conservative orthodontic treatment of a case of mandibular bilateral condyle fracture and greenstick fracture of the right mandibular parasymphysis using an orthodontic therapy with the repositioning of the mandible, bracket bonding on primary molars, and fixation with orthodontic elastics.
BRIEF CLINICAL REPORT A 5-year-old girl with a history of falling from a bicycle 7 hours earlier was referred to the department of oral and maxillofacial surgery. She was found conscious and well oriented in time and space. Extraoral examination revealed chin laceration with difficulties and pain in mouth-opening movements. A slight swelling was noticed in the floor of the mouth near midline. Preauricular regions were tender on palpation. Intraoral examination revealed avulsion of primary anterior teeth (52, 51, 62, 61, and 72). Multislice From the *Dental Polyclinic; Departments of †Oral Surgery, and ‡Prosthodontics, School of Medicine, Study of Dental Medicine, University of Split, Split, Croatia. Received July 2, 2013. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Ivan Brakus, DDS, Papandopulova 9, 21000 Split, Croatia; E mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000904
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
FIGURE 1. Computed tomographic three-dimensional reconstruction and clinical picture before treatment. FIGURE 3. Panoramic x-ray and clinical pictures after 2 years.
computed tomographic (MSCT) examination demonstrated a bilateral fracture of the mandibular condyle neck associated with minimal fracture of the alveolar ridge of the maxilla. The MSCT scan also demonstrated dislocation on the right condyle neck and, on the left side, a medial inclination of approximately 45 degrees associated with greenstick fracture of the right parasymphysis region. The patient could not achieve a normal bite and occlusal contacts in the closing movements of the lower jaw (Fig. 1). Because of the age of the patient, a conservative treatment approach was preferred. The mandible was bimanually repositioned in the caudal direction under general anesthesia. Orthodontic brackets (Dentaurum, Ispringen, Germany) were bonded (Transbond XT Light Cure Adhesive; 3M Unitek, Monrovia, CA) on deciduous first molars on both sides. After the bonding, elastics were used (Forestadent, Pforzheim, Germany) for fixation of the upper and lower first molars on both sides (soft fixation). The patient was discharged from the hospital after 48 hours. The analgesic treatment consisted of acetaminophen suspension (3 times a day, 250 mg) (Calpol; Glaxo-Wellcome) for 2 weeks. The intermaxillary fixation was maintained for 2 weeks, followed by 1 week of active physiotherapy of the jaws by intermaxillary elastics and active movement of the jaws to obtain good occlusion. After that, the brackets were debonded and instructions for mouth opening exercises were given to the patient. The exercises included maximal mouth opening, right and left lateral excursions, as well as protrusive movements. The patient and her parents were instructed to exercise several times a day for 5 minutes. The patient was advised to exercise together with her parents in front of the mirror to avoid or correct possible deviation. After 24 hours, the patient was able to open her mouth normally. The clinical and radiologic evaluation after 6 months showed that both the centric occlusion and healing at the fracture site were excellent (Fig. 2). The clinical and radiologic evaluation after 2 years showed ideal symmetry and normal mouth opening (Fig. 3).
DISCUSSION Bilateral condyle neck fractures can cause asymmetry in vertical, transversal, and horizontal planes. Considering the fact that we never have MSCT of a child before the accident, we can only assume the natural position of the patient's jaws. Recent photographs of the patient's face before the trauma could help us to do the best repositioning possible. In case of asymmetry and skeletal class II, which may be a circumstance of bilateral condyle fracture or a specific growth pattern, orthodontic functional appliance can be the method of choice. Today, such as in the early 70s, medical and dental professionals can provide good results in either open or closed treatment of mandibular condyle fractures in children, so open versus closed treatment is judged individually.5,8 Conservative management (observation, exercises, maxillomandibular fixation, training elastics, bite opening splints) are overwhelmingly
FIGURE 2. Computed tomographic three-dimensional reconstruction and clinical picture after 6 months.
popular because there are minimal complications with good functional outcomes.9 The osteogenic potential of the periosteum in the developing craniofacial skeleton is very high and will lead to somewhat rapid and easier healing, which occurs under the influence of the masticatory stress, even when there is an imperfect apposition of bone surfaces.10 For greenstick undisplaced fractures, conservative closed reduction is the most recommended treatment.11 In our case, the permanent teeth are erupting at this moment. The positive side of such traumas is that we have alliance in nearby growth and development, and orthodontics could help if necessary.
CONCLUSIONS According to the degree of fracture displacement (>35 degrees), the case presented here can be classified as class 3, for which they recommended open reduction.12 Young children have a great osteogenic potential and a high healing rate, so regarding the patient’s age and the short period between trauma and treatment, we opted for conservative approach. In this particular case, orthodontic rubber elastics in combination with fixed orthodontic brackets provided good results in the treatment of bilateral condylar neck fractures associated with greenstick fracture of parasymphysis. However, periodic long-term follow-up is essential for early determination of possible growth disturbances. Only long-term follow-up for more than 10 years will probably provide the data necessary for a meaningful conclusion.
REFERENCES 1. Bataineh AB. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:31–35 2. Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fractures: recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg 2006;35:2–13 3. Thoren H, Hallikainen D, Iizuka T, et al. Condylar process fractures in children: a follow-up study of fractures with total dislocation of the condyle from the glenoid fossa. J Oral Maxillofac Surg 2001;59:768–773 4. Koltai PJ, Rabkin D, Hoehn J. Rigid fixation of facial fractures in children. J Craniomaxillofac Trauma 1995;1:32–42 5. Hoopes JE,Wolfort FG, Jabaley MEM. Operative treatment of fractures of the mandibular condyle in children: using the post-auricular approach. Plast Reconstr Surg 1970;46:357–362 6. Maclennan WD. Consideration of 108 cases of typical fractures of the mandibular condylar process. Br J Plast Surg 1952;5:122 7. Laskin DM. Management of condylar process fractures. Oral Maxillofac Surg Clin North Am 2009;21:193–196 8. Aizenbud D, Emodi O, Rachmiel A. Nonsurgical orthodontic splinting of mandibular fracture in a young child: 10-year follow-up. J Oral Maxillofac Surg 2008;66:575–577 9. Kocabay C, Atac MS, Oner B, et al. The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: a case report. Dent Traumatol 2007;23:247–250 10. Li Z, Zhang W, Li ZB, et al. Mechanism in favorable prognosis of pediatric condylar fractures managed by closed procedures: an experimental study in growing rats. Dent Traumatol 2010;26:228–235 11. Kalia V, Singh AP. Greenstick fracture of the mandible: a case report. J Indian Soc Pedod Prev Dent 2008;26:32–35
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e489
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Brief Clinical Studies
12. Bhagol A, Singh V, Kumar I, et al. Prospective evaluation of a new classification system for the management of mandibular subcondylar fractures. J Oral Maxillofac Surg 2011;69:1159–1165
Dental Trauma: Knowledge and Attitudes of Community Health Workers Fábio Wildson Gurgel Costa, DDS, MS,* Elaine Helena de Oliveira, DDS,† Marcelo Ferraro Bezerra, DDS, MS,† Alexandre Simões Nogueira, DDS, MS,† Eduardo Costa Studart Soares, DDS, MS,‡ Karuza Maria Alves Pereira, DDS, MS,§ Background: The international literature emphasizes the importance of evaluating the knowledge of different groups such as teachers, students, dentists, physicians, parents, and athletes regarding dental injuries. In Brazil, community health workers are professionals who can reach a wide variety of people and who have a marked influence on prevention and health promotion strategies. The objective of this study was to investigate the knowledge and attitudes of community health workers regarding dental trauma. Methods: A questionnaire consisting of 19 questions divided into 3 parts was applied: demographic characteristics, knowledge, and attitudes. Data from 206 respondents were analyzed using descriptive statistics and logistic regression models. Results: Approximately 28% of the participants reported to have been called to assist individuals with dental trauma. Only 42 subjects had received education on dental injuries, with 34 of them being instructed by a dentist. In cases of tooth avulsion, only 1.9% of the health workers reported that they would search for the tooth and reimplant it. The most frequently indicated storage media for avulsed teeth were nonphysiological media (69.42%). Conclusions: The educational level of the community health workers somehow influenced their knowledge (P < 0.001) and attitude (P = 0.016) regarding dental injuries. Educational programs for this group are needed to improve the management of traumatic dental injuries.
and are a cause of impaired phonation and esthetics as well as of embarrassment and distress for the patients and their parents or guardians.1 The increase in violence and in the number of traffic accidents and the more frequent participation of children in sports activities contribute to the transformation of traumatic dental injuries into an emerging public health problem.2–4 Various studies on health education strategies have emphasized the importance of evaluating knowledge about traumatic dental injuries in different settings, such as home, schools, and streets, and in different groups that exert a broad influence such as teachers,5,6 students,1 dentists,7–9 physicians,10,11 parents,12,13 and athletes.14,15 In Brazil, community health workers (CHWs) are professionals who can reach a wide variety of people and who have a marked influence on prevention and health promotion strategies in view of their ability to communicate with people and their natural leadership in the work environment.16,17 In addition to Latin America, other countries such as China have been incorporating rural workers, known as barefoot doctors, in their health system since the 1950s, who exert functions similar to those of CHWs,18 a fact demonstrating the importance of inclusion of these professionals in strategies addressing families, communities, and districts that are at risk for not having access to basic healthcare. To our knowledge, there are no studies on dental trauma involving CHWs. Therefore, the objective of the current study was to investigate the knowledge and attitudes of Brazilian CHWs regarding dental trauma.
MATERIALS AND METHODS Study Design and Population A cross-sectional, observational, and quantitative study was conducted between May 2010 and June 2010. At the time of the study, there were 410 CHWs of both sexes who lived in areas attached to the basic health units (BHUs) where they worked. Of these, 215 worked in 20 BHUs of rural districts, and 195 worked in 17 BHUs located in the principal district. The study was conducted in accordance with the Declaration of Helsinki and Resolution 196/96 of the Brazilian National Health Council. The project was approved by the Ethics Committee on Human Research of Universidade Estadual Vale do Acaraú (approval number 27017). Excluded from the study were subjects who did not sign the free informed consent form and those who did not respond to the questionnaire.
Instrument Key Words: Dental trauma, knowledge, attitude, community health workers
T
raumatic dental injuries play an important role in public health because they present economic, psychologic, and social sequelae
From the Divisions of *Oral Radiology, †Oral Surgery, ‡Stomatology and Oral Surgery, and §Oral Pathology, Department of Clinical Dentistry, School of Dentistry, Federal University of Ceará, Fortaleza-CE, Brazil. Received January 2, 2014. Accepted for publication February 10, 2014. Address correspondence and reprint requests to Fábio Wildson Gurgel Costa, DDS, MS, Division of Oral Radiology, School of Dentistry, Federal University of Ceará, Rua João Sorongo, 1016, Apto. 205, Jardim América, CEP: 60416-000, Fortaleza-CE, Brasil; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000916
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A self-administered 2-page standardized questionnaire consisting of 19 questions based on those used in previous studies was developed for data collection. Before the main study, a pilot questionnaire was applied to evaluate the ease of reading and understanding of the questions, and few modifications were introduced after this preliminary evaluation. The CHWs were asked to anonymously complete a questionnaire without consulting with any colleague. In the case of multiplechoice questions, the respondents could choose more than 1 item, if appropriate. For didactic reasons, the questionnaire was divided into 3 parts. The first part consisted of 8 questions about personal characteristics of the respondents, including sex, age, educational level, time of residence in the community where they worked, duration of work in the community assisted, activities performed in the community, number of home visits performed per day of work, and number of families assisted. The second part consisted of 6 questions referring to the knowledge of the respondent about dentoalveolar injuries and the information received by other professionals. The third part consisted of 5 questions that asked the participants about their © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
