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Why is Oral & Maxillofacial Surgical Care different in Children?

Paediatric Oral & Maxillofacial Surgery is an evolved subspecialty of Oral & Maxillofacial Surgery that deals with managing the specific dental needs of neonates, infants and growing children. It involves the care of patients with congenital craniofacial anomalies, cleft lip and palate, trauma, abnormal jaw growth, temporomandibular joint disorders and dentoalveolar anomalies. 

Children have different oral physiology and anatomy due to the presence of tooth buds and growth potential. Hence, Oral & Maxillofacial Surgeons must assess the long term impact of the injury and the surgical interventions on the developing facial skeleton and dentition of the young patients. 

In lieu of Children’s Day, MedPiper Technologies and JournoMed along with the Association of Oral & Maxillofacial Surgeons of India (AOMSI), Tamilnadu & Puducherry Branch, had conducted a webinar on 14th November, 2021 on how why the Oral & Maxillofacial surgical care in children is different to that of adults. The speakers were Dr. J Naveen Kumar, Professor and Head of Department of Oral & Maxillofacial Surgery, Sri Ramachandra Faculty of Dental Sciences, Chennai and Dr. R Rammohankumar, a Consultant Oral & Maxillofacial Surgeon. The event was moderated by Dr. P Senthil Murugan, Associate Professor at Saveetha Dental College and Hospital, Chennai. Dr. S Jimson, Hon. State Secretary of AOMSI, TN & Puducherry Branch, coordinated the event. 

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The speakers offered their insights on the causes of paediatric oral and maxillofacial deformities and injuries along with the corresponding treatment options through various case studies. The first cause being neglected dental care. 

Dental issues are often dismissed and can give rise to various fatal complications if not addressed. Sometimes, a severe swelling of the face can spread to the orbital and intraorbital regions. If the swelling is not immediately diagnosed,  it can lead to cavernous sinus thrombosis (blood clot in the hollow spaces located under the brain), which is more fatal in the paediatric population. The surgeons have to identify the cause of the swelling and remove the affected area by incision and drainage of the abscess followed by treatment with intravenous antibiotics. 

Facial and Dental Fractures

The speakers then discussed how various kinds of physical trauma (dental or facial) during childhood can greatly impact the mobility of the jaw as the child ages. The presence of the tooth buds and a fragile jaw can aggravate a mandibular fracture thus affecting the eruption of permanent teeth. Avulsed tooth (a tooth that has been dislodged from its socket) is a type of dental trauma that requires immediate treatment. Dental wiring and splints can help to implant the tooth back into its socket. 

For jaw fractures in adults, wiring and screws are used for the correction process. However, the same invasive strategies cannot be used for treating jaw fractures in children as they can damage the tooth buds. Dr. Rammohankumar suggested a non-invasive approach called circum mandibular wiring to treat paediatric mandibular injuries. In this approach, an impression of the patient’s teeth is taken and molded into a model. The model is then fixed and placed along with a splint and non-invasive wiring onto the patient’s jaw for six months. This enables healing of the fracture without disrupting the tooth buds. 

Dr. Naveen Kumar stated how fractures to the chin can also impact the joints of the face specifically between the condyle and the cranial base. Any kind of injury or concussion to these joints can cause temporomandibular joint ankylosis. Ankylosis is when a blood clot (caused by an injury) forms a bone which then fuses with other bones leading to restricted growth and severe pain. This can be prevented through extensive physical rehabilitation i.e. early mobilisation of the jaw during the healing process. In extreme cases of ankylosis, surgical intervention is required. 

Congenital and Genetic Disorders

Cleft Palate or Cleft Lip are the second most common congenital deformity in children after clubbed feet and is diagnosed antenatally. The doctors must give prenatal counselling to the parents in order to ease their psychological unrest and get rid of any kind of social stigma and also reassure the parents that the child will be able to lead a healthy and normal life. 

The causes for cleft palate are multifactorial in origin and the child has problems with breathing, feeding, speech and restricted midface growth. Five to six surgeries are required to correct these problems with the first surgery being conducted as early as between 3-6 months of age to correct the cleft lip followed by the cleft palate surgery done between 10-18 months of age to improve speech. Alveolar Bone Graft, Osteotomy and Rhinoplasty are done as the child grows older. 

Craniofacial Syndromes are a class of facial deformities that occur when there is premature fusion of the cranial plates thus preventing the brain from expanding. As a result, there is no proper development of the midface. The inward growth of the mid face can lead to breathing issues and obstructive sleep apnea. Surgeries to fix these conditions include trans zygomatic pin fixation or distraction which are extensive and should be planned out using 3-D printed models or AR-VR technologies

Oral & Maxillofacial Surgery encompasses various procedures ranging from dental extraction to extensive facial reconstruction. Hence these surgeons play a pivotal role in treating the various dental, facial and obstructed airway issues a person faces. 

In order to make these services easily available and affordable to people under government schemes, including those below the poverty line Dr. Murugan requests the respective authorities and the insurance companies to include the discussed procedures under the maxillofacial fraternity as they are not listed as separate services. “Thus helping to improve the quality of lives of the affected young patients”, says Dr. Murugan.

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