Dual support technique for pediatric palatal fracture: 1.5 mm transmucosal titanium plates along with acrylic splint backing

Discussion

Facial fractures are uncommon in paediatric population. Thaller and Huang did a retrospective study concluding that less than 1% of maxillofacial fractures occurred in children younger than 5 years of age.5 Not only the anatomical variation in younger individuals but also the protected environment under parental supervision is the cause of less major injuries. The facial skeleton is flexible due to elasticity of the bones and fat pads acts as cushion to overcome traumatic forces.

There is more frontal projection of the cranium in younger children which saves the midface and mandible from injuries but can sustain skull fracture due to frontal impact. The cranial-to-facial proportion at birth is approximately 8:1, whereas in adults it is approximately 2:1.6 Moreover, relative lack of development of paranasal sinuses and unerupted permanent tooth buds further supports the midface.

The median palatine suture ossifies much later than other facial sutures and is seldom complete before the third decade, explaining the cause of higher incidence of sagittal palatal fractures in adolescence and early adulthood. The sagittal palatal split lead to lateral splaying of palatal shelves leading to facial widening. Therefore, management of sagittal split of palate is very important to control transverse facial width.

Treatment of paediatric facial fractures should be non-invasive whenever possible. Various surgical techniques include Kirschner wire fixation,2 interosseous wiring, palatal acrylic splints and titanium plates.3 4 For the sagittal split, Manson et al recommended both open reduction and internal fixation, and intermaxillary fixation with a palatal splint. Gruss and Mackinnon concluded that wide exposure of the palatal fracture was necessary for accurate reduction.7 8 Hendrickson et al advised rigid internal fixation of the palate through a midline incision or pre-existing laceration.9 Moreover, in view of contusion head injury, postoperative maxillomandibular fixation was also not preferred choice.

There have been reports in literature about screw loosening from palatal implants leading to hardware failure.10 This can be very risky in case of children who can aspirate or ingest these. After repair of hard palate cleft, undergrowth of the maxilla is well described in patients who have had periosteal elevation.11 Open reduction and fixation of palatal shelves, hence, should not be advocated. Transmucosal fixation is a better option than Open Reduction and Internal Fixation (ORIF).12 The periosteum is essential for blood supply to the bone; it is osteoinductive and following elevation it can form a scar. Traumatic stripping of the periosteal tissues either from direct trauma or surgical repair may potentially cause growth disturbances.

Reduction of palatal shelves usually require Hayton Williams forceps in adults which can be destructive for children, worsening the situation if inadvertent force is applied. So, minimal forces are to be used in children. For making traditional acrylic splint, mock surgery is to be done on casts which causes waste of time and manpower. But immediate splint can be made by fixing the palatal shelves with plates and then taking the impression with putty. The plates can be backed up with acrylic splint for more support decreasing chances of failure either in the form of malocclusion or residual oronasal fistula or transmucosal screw loosening. If not, it may require second surgery.

So, we through this case report are emphasising on dual support for management of paediatric palatal fracture. It is of utmost importance that surgeons involved in paediatric patient care understand the differences between children and adult fracture patterns and the potential long-term effects on the growth of the paediatric skeleton and management of these problems when they occur.