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FRATURAS MANDIBULARES EM CRIANAS* MANDIBULARS FRACTURES IN CHILDRENS

Clvis MARZOLA * Joo Lopes TOLEDO-FILHO ** Cludio Maldonado PASTORI *** Daniel Luiz Gaertner ZORZETTO ****

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* Professor Titular de Cirurgia aposentado da USP de Bauru. Professor do Curso de Especializao e Residncia da APCD Regional de Bauru e do Hospital de Base da Associao Hospitalar de Bauru. ** Professor Titular de Anatomia da FOB-USP de Bauru e Professor do Curso de Especializao e Residncia da APCD Regional de Bauru e do Hospital de Base da Associao Hospitalar de Bauru. *** Professor do Curso de Especializao e Residncia da APCD Regional de Bauru e do Hospital de Base da Associao Hospitalar de Bauru. **** Professor do Curso de Especializao e Residncia da APCD Regional de Bauru e do Hospital de Base da Associao Hospitalar de Bauru.

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RESUMO
As fraturas mandibulares em crianas no representam um acidente muito raro dentro da Traumatologia Buco maxilo facial, embora j tenha ocorrido caso de morte. Comparando-se com os adultos, esse trauma foi observado somente em acidentes ocorridos com bicicletas e, nos esportes, no sendo, contudo, verificados muitos trabalhos que investigaram a incidncia dessa alterao. Para o tratamento cirrgico das fraturas da mandbula em crianas, fixao interna rgida (FIR) pode ser utilizada com inteiro sucesso, muito embora a grande maioria desses autores a tenham realizado somente em adultos. O processo de reparo desse tipo de trauma, tambm, tem sido objeto de estudo, para ser avaliado corretamente qual o melhor mtodo para a reduo das fraturas. Esse mtodo da FIR para a reduo de fraturas da mandbula em crianas, j est sendo utilizado em pacientes atendidos no Hospital de Base da Associao Hospitalar de Bauru, sendo que no perodo compreendido entre agosto de 1993 a maro de 1997, foram colocadas 20 miniplacas. O objetivo primordial do presente trabalho, alm da reviso histrica sobre todos os mtodos j utilizados para a reduo de fraturas mandibulares em crianas, a sua incidncia, indo at as complicaes advindas de algum tipo de tratamento, materiais utilizados, at o processo de reparo e, ainda com a apresentao de alguns casos cirrgicos, que venham esclarecer o leitor sobre as vantagens da utilizao das miniplacas nesse tipo de traumatismo.

ABSTRACT
The mandibular fractures in children very do not represent an accident rare inside of the Buco maxillofacial Traummatology, even so already have occurred death case. Comparing themselves with the adults, this trauma was only observed in accidents occurred with bicycles and, in the sports, not being, however, verified many works that had investigated the incidence of this alteration. For the surgical treatment of the mandibular fractures in children, rigid internal fixation (FIR) can be used with entire success, much even so the great majority of these authors has carried through it only in adults. The healing of this type of trauma, also, has been study object, to be evaluated which correctly the best method for the reduction of the fractures. This method of the FIR for the reduction of mandible fractures in children already is being used in patients taken care of in the Hospital of Base of the Hospital Association of Bauru, being that in the period understood between August of 1993 the March of 1997, 20 miniplates had been placed. The primordial objective of the present work, beyond the historical revision on all the used methods already for the reduction of mandibular fractures in children, its incidence, going until the happened complications of some type of treatment, materials used, until the healing and, still with the presentation of some surgical cases, that they come to clarify the reader on the advantages of the use of the miniplates in this type of trauma. Unitermos: Fraturas mandibulares, Crianas, Incidncia, Tratamento cirrgico, Processo de reparo, Fixao interna rgida, Casos clnicos.

Uniterms: Mandibles fractures, Children, Incidence, Surgical Treatment, Healing process, Internal rigid fixation, Clinical Cases.

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INTRODUO
As fraturas mandibulares em crianas no representam um acidente muito raro dentro da Traumatologia Buco maxilo facial, embora j tenha ocorrido caso de morte (25). Comparando-se com os adultos, esse trauma foi observado somente em acidentes ocorridos com bicicletas (169) e, nos esportes (23), no sendo, contudo, verificados muitos trabalhos que investigaram a incidncia dessa alterao (01, 15, 56, 68, 78, 96, 126, 127, 135, 154, 170) . Os traumatismos do tero mdio da face, desde que iniciaram seus estudos e treinamentos com LE FORT (82) (1900), sempre incidiram de maneira bastante freqente, destacando-se os traumas no corpo e ramo da mandbula, alm de tipos de tratamentos investigados (03, 04, 05, 07, 09, 10, 12, 14, 18, 19, 20, 21, 22, 24, 25, 28, 29, 30, 31, 35,
36, 37, 38, 39, 40, 41, 44, 47, 49, 51, 52, 54, 55, 57, 59, 61, 63, 66, 64, 69, 70, 72, 73, 76, 77, 83, 84, 86, 88, 90, 91, 94, 95, 100, 101, 102, 103, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 119, 121, 122, 123, 128, 129, 130, 131, 136, 137, 138, 140, 141, 145, 146, 149, 151, 152, 156, 158, 159, 160, 161, 162, 165, 167, 168, 169, 171, 172, 174)

, bem como

aqueles ocorridos no cndilo da mandbula 118, 134, 143, 146, 150, 151, 155, 157, 168) . Destacam-se, tambm, as fraturas da mandbula em crianas, associadas ao trauma dental (06, 87), que podem atingir grandes propores. Fazendose uma comparao com os adultos, as complicaes ocorridas relacionadas com as fraturas de mandbula em crianas, so muito raras, haja vista a escassez de trabalhos encontrados na literatura (4, 120, 142). Para o tratamento cirrgico das fraturas da mandbula em crianas, tambm a fixao interna rgida (FIR) pode ser utilizada com inteiro sucesso (02, 11, 13, 17, 26, 28, 32, 42, 43, 46, 48, 50, 58, 62, 65, 67, 75, 80, 81, 85, 98, 116, 125, 132, 133, 147, 148, 151, 153, 163, 164, 166, 175) , muito embora a grande maioria desses autores a tenham realizado somente em adultos. O processo de reparo desse tipo de trauma, tambm tem sido objeto de estudo, para ser avaliado corretamente qual o melhor mtodo para a reduo das fraturas (34, 93, 124, 139, 144, 151, 173). Esse mtodo da FIR para a reduo de fraturas da mandbula em crianas, j est sendo utilizado em pacientes atendidos no Hospital de Base da Associao Hospitalar de Bauru, sendo que no perodo compreendido entre agosto de 1993 a maro de 1997, foram colocadas 20 miniplacas. O objetivo primordial do presente trabalho, alm da reviso histrica sobre todos mtodos j utilizados para a reduo de fraturas mandibulares em crianas, a sua incidncia, indo at as complicaes advindas de algum tipo de tratamento, materiais utilizados, at o processo de reparo. Alm disso, a apresentao de alguns casos cirrgicos, que poderiam esclarecer o leitor sobre as vantagens da utilizao das miniplacas nesse tipo de trauma. Justifica-se sua apresentao, pelos esclarecimentos que traro comunidade cientfica, no sentido de alert-la sobre as vantagens e desvantagens da utilizao das miniplacas, nessa ocorrncia, sobre o treinamento que o profissional dever adquirir anteriormente sua prtica diuturna e, as conseqncias de um tratamento mal planejado.

(08, 16, 27, 33, 45, 53, 59, 60, 71, 74, 79, 89, 92, 97, 99, 105,

APRESENTAO DE CASOS CLNICO-CIRRGICOS

CASO 1: Paciente: V. M. O. com 9 anos de idade, gnero masculino, leucoderma, vitima de acidente de bicicleta, deu entrada no Pronto Socorro

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Municipal com tontura, sinais vitais normais, mas um pouco confuso. Foi internado no Hospital de Base da Associao Hospitalar de Bauru aos cuidados do Servio de Cirurgia e Traumatologia Buco Maxilo Facial, tendo sido avaliado pelo neurologista para verificao do seu grau de comprometimento neurolgico. Realizada tomografia computadorizada de crnio o paciente foi liberado pelo neurologista para o tratamento cirrgico. Depois dos exames clnicos e radiogrficos, foi constatada a fratura na regio da snfise mandibular. Realizados os exames laboratoriais pr-operatrios - hemograma e coagulograma completos - alm da avaliao pr-anestsica, a cirurgia foi marcada aps 3 dias ao trauma. Inicialmente foi efetuada a reduo da fratura sinfisria, com a colocao de miniplaca de titnio e parafusos (Engimplan-Prolig), utilizando-se o acesso intra-oral. A fixao foi feita com miniplaca na base da regio sinfisria e a contra fora atravs de uma odontossntese nos elementos 31, 32, 41 e 42. Este caso foi controlado, sendo que aps 60 dias pde-se observar um aspecto clnico e, de ocluso, com resultado bastante satisfatrio (Figs. 1 a 4).
A

Figs. 1 (A e B) Imagem radiogrfica pr-operatria pstero-anterior para mandbula evidenciando a fratura na snfise, notando-se a linha de fratura durante o transcirrgico.

Figs. 2 (A) Reduo da fratura sinfisria e (B) atravs da fixao com miniplaca e parafusos de titnio, o complemento da reduo.

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A B

Figs. 3 (A) Aspecto clnico no ps-operatrio e (B) vista do local do trauma.

Figs. 4 (A e B) Vistas laterais no ps-operatrio.

CASO 2: Paciente: A. C. S. com 8 anos de idade, gnero masculino, leucoderma, vitima de acidente automobilstico, deu entrada no Pronto Socorro Municipal com tontura, sinais vitais normais, mas um pouco confuso. Foi internado no Hospital de Base da Associao Hospitalar de Bauru aos cuidados do Servio de Cirurgia e Traumatologia Buco Maxilo Facial, tendo sido avaliado pelo neurologista para verificao do seu grau de comprometimento neurolgico. Realizada tomografia computadorizada de crnio o paciente foi liberado pelo neurologista para o tratamento cirrgico. Depois dos exames clnicos e radiogrficos, foram constatadas fraturas bilaterais parasinfisrias na mandbula. Realizados os exames laboratoriais pr-operatrios - hemograma e coagulograma completos - alm da avaliao pr-anestsica, a cirurgia foi marcada aps 3 dias ao

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trauma. Foi efetuada a seguir a reduo das fraturas parasinfisrias, com a colocao de miniplaca de titnio e parafusos (Engimplan-Prolig), utilizando-se o acesso intraoral. A fixao foi feita com miniplaca na base da regio sinfisria e a contrafora atravs de outra miniplaca. Este caso foi controlado, sendo que aps 60 dias pde-se observar um aspecto clnico e de ocluso, com resultado bastante satisfatrio (Figs. 5).
A B

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Figs. 5 (A L) Fraturas bilaterais parasinfisrias da mandbula numa criana de 8 anos, notando-se a teraputica cirrgica intrabucal com a colocao das miniplacas e a estabilizao com a Barra de Erich. Pode-se constatar o sucesso da interveno aps alguns meses tanto clnica quanto radiograficamente.

CONCLUSES
Pode-se concluir que: 1. A fixao interna rgida (FIR) possibilita melhor conteno das fraturas, bem como uma estabilizao em longo prazo, quando comparada com a osteossntese com o fio de ao. 2. Um menor tempo de reparao ssea, evitando-se a formao de calo fibroso e, portanto um restabelecimento funcional precoce. 3. Diminuio do edema ps-operatrio, e do tempo de permanncia do paciente no ambiente hospitalar. 4. Higienizao oral facilitada e melhorada, por haver sido evitada a fixao intermaxilar (FIM ou BIM). 5. Alimentao melhorada no ps-operatrio, evitando-se a queda de resistncia, e como conseqncia as infeces oportunistas. 6. Evita complicaes ps-operatrias imediatas, como a broncoaspirao pelo bloqueio intermaxilar. 7. Est indicada em pacientes que necessitam um restabelecimento da funo mastigatria imediata, bem como naqueles pacientes que no cooperam como os alcolatras, dependentes de drogas, epilpticos, desdentados totais, etc.

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8. o mtodo mais eficaz para o tratamento das fraturas mandibulares, desde que os cirurgies buco maxilo faciais tenham conhecimento, treinamento e habilidade do sistema, na sua manipulao.

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* De acordo com as normas da ABNT.

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