Injuries to jaws and teeth in children: causes, symptoms, diagnosis, treatment

In peacetime, injuries to the maxillofacial region in children account for 6-13% of all injuries. In the period from 1984 to 1988, children with injuries accounted for 4.1%. Almost half of them (47%) were delivered by ambulance; 5.5% were referred by medical institutions, and 46.8% sought help on their own. There were 96.6% of urban residents, 2.5% of rural residents, and 0.9% of non-residents. Boys were injured more often than girls - on average 2.2 times. In 59.1% of cases, there was a domestic injury, in 31.8% - street injury, in 2.4% - road traffic injury, in 3.2% - school injury, and in 3.5% - sports injury. There were 1.2% of children with bite wounds. The nature of the injuries was distributed as follows: soft tissue injuries were observed in 93.2% of cases, dental injuries in 5.7%, facial bone fractures in 0.6%, and temporomandibular joint injuries in 0.5%.

As an analysis of the work of the trauma center in recent years has shown, the flow of injured children from Kiev has a tendency to decrease: if in 1993 2574 children were delivered to it, then in 1994 - 2364, and in 1995 - "only" 1985 children. This encouraging trend is partly due to the fact that among women from Kiev there are more unemployed mothers and grandmothers, fathers and grandfathers who can spend more time at home and pay more attention to their children and grandchildren.

All injuries to the maxillofacial region in children can be divided into the following groups:

1. damage to soft tissues (bruises, abrasions, ruptures of the skin, facial muscles and tongue, mucous membranes, nerves, salivary glands and their ducts);
2. damage to teeth (damage to the integrity of their crown, root; dislocation of the tooth from the alveolus);
3. damage to the jaws (fracture of the body or processes of the upper and lower jaws, fracture of both jaws);
4. fracture of the zygomatic bone, zygomatic arch;
5. damage to soft tissues, facial bones and teeth;
6. combination of damage to the maxillofacial region with closed craniocerebral trauma;
7. damage to the temporomandibular joints;
8. a combination of damage to the maxillofacial region with damage to the limbs, chest organs, abdominal cavity, pelvis and spinal column. Jaw and tooth fractures in children occur mainly as a result of accidental falls and bruises (during fast running, sports, playing with ungulates or horned animals), or when hit by street transport.

In early childhood, children fall and bruise more often, but fractures of the facial bones occur relatively rarely; in older children, fractures of the jaws and nasal bones occur more often, which is due to a decrease in the layer of subcutaneous tissue in the facial area, an increase in the force of impact when falling (due to increased growth and more rapid movement), a decrease in the elasticity of bones (due to a gradual increase in their inorganic component), a decrease in the resistance of bones to traumatic effects, since in connection with the resorption of baby teeth and the eruption of permanent teeth, the bone plate of the compact substance of the bone decreases.

To properly provide assistance to children with maxillofacial trauma, it is necessary to take into account its anatomical and topographic features.

Anatomical, physiological and radiological features of the maxillofacial region in children that affect the nature and outcome of damage

1. Continuous but abrupt growth of the child's skeleton and adjacent soft tissues (during periods of temporary growth retardation, intensive differentiation of tissues and organs and their formation occurs).
2. Significant differences in the anatomical structure of the face and jaws (especially in newborns and young children).
3. The presence of a large mass of pronounced subcutaneous tissue on the face (especially the fat pad of the cheek).
4. The facial nerve is located more superficially than in adults, especially between the stylomastoid foramen and the parotid gland.
5. Low location of the parotid duct, its indirect course.
6. Absence of closure of the gums of the upper and lower jaws in newborns and small children, which is caused by underdevelopment of the alveolar processes and prolapse of the mucous membrane and fat pad of the cheek into the gap between the gums. Over time, during the eruption of teeth, this non-closure of the jaws is gradually eliminated.
7. Weak development of the upper jaw vertically (horizontally it grows in accordance with the rate of development of the base of the skull), as a result of which the oral cavity borders on the lower wall of the orbit.
8. The comparatively weak development of the lower jaw (a kind of physiological microgenia), due to which it seems to not keep up with the rate of development of the brain section of the skull and the upper jaw closely adjacent to it.
9. Flat shape of the palate, insignificant volume of the oral cavity, flattened and elongated shape of the tongue, which has not yet been included in “labor activity” (sucking the breast, sound production).
10. The gradual eruption of baby teeth, starting in the middle of the first year, and then their replacement by permanent teeth. Due to this, the volume and height of the alveolar processes gradually increase.
11. Frequent inflammation of the gums due to teething (hyperemia, swelling, infiltration), which in themselves can sometimes complicate the injury.

In addition to the listed anatomical and topographic features, one should also take into account the features of the radiological characteristics of the maxillofacial region in children.

1. The alveolar process of the maxilla in newborns and young children is projected at the same level as the palatine processes.
2. The rudiments of the upper teeth in infants are located on the radiograph directly under the eye sockets, and as the upper jaw grows in the vertical direction, they gradually project lower.
3. The upper contour of the maxillary sinuses in children under 3 years of age is defined as a narrow slit, and the lower contour is lost against the background of dental rudiments and erupted teeth. Up to 8-9 years, the bottom of the sinuses is projected at the level of the bottom of the nasal cavity, i.e. the lower edge of the piriform aperture.
4. The size of the shadow of baby teeth is small, the pulp chamber is relatively large and clearly defined; enamel, dentin and cement, not having such a density as in adults, cause a less intense shadow than in permanent teeth. In the area of the apex of the not yet formed root of the baby tooth, a defect filled with the remainder of the "growth granuloma", i.e. the dental sac, is clearly visible.
5. Considering that the tooth germ in the process of its development is capable of moving not only vertically and horizontally, but also around its longitudinal axis, the displaced position detected on the radiograph should not be regarded as permanent and pathological.

Touching upon the rate of change of the radiographic characteristics of teeth in children, E. A. Abakumova (1955) distinguishes two stages: an unformed apex of the tooth and an unclosed apex. The first is characterized by the fact that the parallel walls of the root canal are clearly visible in the image, which are thinned at the apex and diverge in the form of a bell, forming a funnel-shaped expansion of the already wide opening of the apex of the tooth. In the second stage, the walls of the root canal, although fully formed along their length, have not yet closed at the apex, so in such cases a fairly wide opening of the apex of the tooth is clearly visible.

At the age of 6-7 years, an X-ray of a child shows both generations of teeth (20 baby teeth and 28 permanent teeth), located in 3 rows (the first - erupted baby teeth, the second - unerupted permanent teeth, the third - canines).

The process of replacing baby teeth with permanent teeth ends at 12-13 years of age, however, the radiographic image of permanent teeth for a long time is distinguished by the unformed apex of the tooth root or the failure to close the opening of the apex of the tooth.

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