Penetrating toothbrush injury in a child: an unusual presentation

We present an unusual case of a penetrating toothbrush injury in a 6-year old child. The injury was sustained due to a fall at home and resulted in accidental implantation of an adult toothbrush in the facial soft tissues. The toothbrush was removed under general anaesthesia without any complications. This case highlights a rare presentation involving extra oral penetration of a toothbrush which is not reported previously in the literature.

Mandibular fractures in different pediatric age groups and their current management modalities

A number of cases of growing age trauma within oro-facial region have been observed in Pakistan, unlike developed countries of world. Mandibular fractures occur in greater frequency than those of the middle third of the face in children, later being very small and plastic comparative to mandible. These fractures of mandible do not demonstrate different clinical features as compared to adults but there is relative difference in treatment management due to, different patterns and plasticity of the facial bones in children, developing tooth buds at different levels in the jaws, mixed dentition, shedding deciduous teeth and incomplete roots of anterior teeth. The causes and patterns of fracture in children older than 12 years resemble to those found in adults. Mandibular fractures are common in Pakistan and commonly related etiology is accidental fall. 57 patients presented with mandibular fractures at Oral and Maxillofacial Surgery department of Punjab Dental Hospital and Children Complex Hospital, Lahore from September 2003 to September 2005. The age of the patients ranged from infancy to early teenage [6 month to 15 years]. After confirming diagnosis, the children were divided into following four groups; Group "A" [Infants], Group "B" [Pre-school], Group "C" [School] and Group "D" [Teenage]. All patients were treated with one of the following treatment modalities, depending upon the site of fracture and age group of the patients; Micro and miniplates, Eric arch bar splints, Acrylic splints, Ivy eyelet wires, Trans-osseous wiring and Conservative treatment. Group "A" of only 3 patients was managed with open reduction and microplate rigid fixation. Six months follow up showed healing without any complications. Group 'B' with 60% males, had mostly body fractures, was treated with acrylic splints and circummandibular wires. Two bilateral body fractures, with avulsed few teeth, were fixed with rigid fixation. Five patients of about age 3 with minimally displaced body fractures were man aged with Eric arch bar fixation alone. Two bilateral condylar bowing fractures were treated conservatively [no active treatment] with no TMJ complications during follow up. The mandibular trauma was noticed exceedingly high in group 'C' with overall 50.87% and exclusively in males [90%]. Acrylic splints were utilized to treat either condyle with body fractures or condyles alone. Two children had postoperative ipsilateral jaw deviation on opening, which was improved with reverse elastic exercises during follow up. Five patients of high condylar fractures with either no or minimum occlusal disturbance, were conservatively managed. Early mobilization was the prime concern in them to avoid late complications. 17.54% patients were of group 'D' with again high male [90%] ratio. Two horizontally unfavorable angle fractures were managed by trans-osseous wires. Five with minimum displacement were managed with miniplates rigid fixation. All others' with associated condylar fractures were treated with Eric arch bar splint with one plate at body and intermaxillary fixation for two weeks. The patterns and management modalities of pediatric mandibular fractures vary in different age groups. The pediatric fractures should be managed as early as possible to avoid complications. Majority of trauma results in school going and teenage groups with definite high male proportion. High condylar fractures should be treated with extra care, keeping in mind of post traumatic TMJ ankylosis. Acrylic splints showed ideal results in body and condylar fractures, whereas, microplates may be the treatment of choice in infants with no or few deciduous teeth. No serious complications were observed during 6 months follow up

Prevalent age group, cause and site of pediatric facial bone trauma at two tertiary units in Pakistan

The pediatric oro-facial trauma is observed in Indian Subcontinent as well as in developing countries. The school group and teenage group children are frequently involved. Dento-alveolar fractures are common comparative to mandibular fractures whereas middle third of the face is exceedingly rare. The mandible is fractured at variety of sites in pediatric facial trauma. The condylar cartilage, developing permanent teeth and advancing growth, all result in injury at different sites of the mandible and hence the various treatment modalities are required to manage these fractures. In majority, the causes of fractures are accidental falls and road traffic accident [RTA]. 141 patients presented at Oral and Maxillofacial Surgery Department of Punjab Dental and Children Complex Hospitals, Lahore from September 2003 to December 2005. The age of the patients ranged from infancy to early teenage [>0 years to 15 years] with facial bone injuries. The children were divided into four groups; Group "A " [Infants], Group "B" [Pre-school], Group "C" [School] and Group "D" [Teenage]. After initial examination, different radiographs [orthopantomograph, posterioanterior mandible and occipitomentalis views] were utilized to confirm the site and diagnosis. Different treatment modalities depending upon the site, bone involved and age group of the patients were used to manage the fractures. Few patients were managed conservatively. The dento-alveolar trauma was noticed frequently in group "C" and "D" and it is 50.35% of the total facial bone trauma. The cause of the trauma in majority of the patients was by accidental falls. 40 patients were of maxillary dento-alveolar trauma and nine were of mandible. Twenty-two children had bi-maxillary dento-alveolar trauma. It was observed that the maxillary trauma was common in skeletal /dental class II div I cases. The next common bony trauma was of the mandible [45.39%]. 50% of total mandibular fractures were from group "C". The site of the fracture in these patien ts was the body of the mandible and frequently associated with mandibular condyles [29%] whereas 9.37% of them had unilateral condylar fractures. This group had the highest frequency of mandibular fractures among facial bone fractures. Group 'D' [20.31%] of total mandibular fractures had high male prevalence [80%]. Maxillary fractures were 2.83% of the total facial bone trauma. The patients had Le Fort I or high Le Fort I fractures while one patient [presented 15 days after trauma] had Le Fort III fracture. The Le Fort III patient had fall from double story building and had head injury too. Two patients had trauma due to automobile RTA. All patients of maxillary fracture were from early age group "C" and there was no associated mandibular fracture in these patients. Zygomatic fractures were 1.41% of the total facial bone trauma. One patient had fracture from fall [stairs] and other had RTA. The patterns and sites of pediatric facial bone fracture vary within age groups. Majority of facial bone tr auma results in school going and early teenage groups with definite male predominance. Dento-alveolar and mandibular fractures are frequent with negligible mid face fractures. The pediatric facial bone fractures should be managed at their earliest to avoid complications

Treatment of unilateral temporomandibular joint ankylosis with silastic interpositional arthroplasty

Ankylosis is a very common condition developed mainly after damage to mandibular condyles or temporomandibular joint [TMJ] at a growing age. Different autogenous and alloplastic interpositional materials have been attempted after the resection of the ankylotic bone to achieve desirable results. This condition is relatively common in Pakistan. We treated TMJ ankylosis with alloplastic medical grade silicone "silastic" interpositional arthroplasty. Eight joints accompanied ipsilateral or contralateral coronoidectomy to achieve desirable results. All patients were presented at Punjab Dental Hospital Lahore. Sixty-one joints with unilateral TMJ ankylosis were underwent surgery after careful examination and final radiographic confirmation. The preoperative CT scan was also performed in few patients. The postoperative measurements of the interincisal opening with lateral and protrusive jaw movements were criteria for success of surgery. The lateral and protrusive jaw movements were assessed as excellent, good and poor. Less than 25 mm interincisal opening was considered as poor jaw opening. The overall success rate was 98.4 "Ai with 84% desirable interincisal jaw opening. Less than 5% patients were observed with poor jaw opening. The immediate late complications were transient and were included oedema, weakness of a branch of the facial nerve on the operated side. Two implants were infected along with one wire in the first month of surgery and were removed under local anesthesia without further complication

Management of pediatric temporomand bular joint ankylosis: use of costochondral rib graft with interpositiona, temporalis myofacial flap

The posttraumatic ankylosis of the temporomandibular joint [TMJ] is frequently seen in children in Pakistan. The factors which favour in the development of this condition are; the children exhibit much more liability to emergency management, greater difficulty in clinical and radiological examination, state of mixed dentition, faster rate of healing, non-availability of specialists and low socioeconomic status of the patient. Different autogenous and alloplastic interpositional materials have been attempted after the resection of the ankylotic bone to achieve desirable results. All patients were presented at Punjab Dental and Children Complex Hospitals Lahore. Twenty-three children [age 1 to 15years] with 28 joints underwent costochondral arthroplasty with interpositional temporalis myofacial flap, out of which 6 were of re-ankylosis after surgery at other centres. The costochondral graft was fixed by tripod screws with remaining ramus condylar unit. The surgery was planned after caref ul examination and final radiographic confirmation. The preoperative CT scan was also performed in few patients. The surgical protocol is used to achieve the desirable interincisal jaw opening [>30mm] that was also the postoperative criteria for successful surgery. Five patients with bilateral ankylosis were operated and one patient with additional ipsilateral coronoidectomy. Less than 30mm interincisal opening was considered as unsatisfactory jaw opening. The overall success rate was 96% with only one patient was observed with less than 30mm opening. The lateral and protrusive jaw movements were assessed as excellent, good and poor. The immediate postoperative complications were transient. The ankylosis develops mainly after damage to mandibular condyles or TMJ at a growing age. Results with the procedure were encouraging without noticeable complications during an average follow up of one year