Review Article
Maxillofacial injuries in the pediatric patient*

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Abstract

Approximately 22 million children are injured in the United States annually. Children are uniquely susceptible to craniofacial trauma because of their greater cranial-mass-to-body ratio. The pediatric population sustains 1% to 14.7% of all facial fractures. The majority of these injuries are encountered by boys (53.7% - 80%) who are involved in motor vehicle accidents (up to 80.2%). The incidence of other systemic injury concomitant to facial trauma is significant (10.4% - 88%). The management of the pediatric patient with maxillofacial injury should take into consideration the differences in anatomy and physiology between children and adults, the presence of concomitant injury, the particular stage in growth and development (anatomic, physiologic, and psychologic), and the specific injuries and anatomic sites that the injuries affect. This comprehensive review, based on the last 25 years of the world’s English-speaking surgical literature, presents current thoughts on the anatomic and physiologic differences between adults and children, a synopsis of childhood growth and development, and an overview of state-of-the-art management of the pediatric patient who has sustained maxillofacial injury. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34)

Section snippets

The epidemiology of pediatric maxillofacial injury

Approximately 22 million children are injured in the United States annually. This represents 1 of every 3 individuals in this age group.1, 2, 3 Injuries surpass all other major diseases of children in frequency and consequence.1, 2, 3 A review of current literature has shown great statistical variation regarding pediatric maxillofacial injury. Estimates regarding the incidence of pediatric facial fractures range between 1% and 14.7% for victims under the age of 16 (Table I), and 0.87% to 1% for

Psychological development

The greatest concern when treating the pediatric patient is the effect of the injury or treatment on growth and development. This is both anatomically and psychologically important and may have various effects on management for the different stages of psychological development as delineated in the introduction. During infancy, hospitalization, trauma, and surgery will disrupt established patterns of feeding and sleeping. Thus, behavioral disturbances and nutrition are a concern during this

Anatomic differences between children and adults, and their consequences in trauma

In general, children tend to have a smaller body mass than adults, which during a traumatic episode, results in a greater force per unit of body area. The child’s incompletely calcified skeleton is close to the internal organs with less fat and more elastic connective tissue. These factors result in multiple internal organ injuries, often without external signs. Children have a higher surface-area-to-body volume ratio, which makes them prone to the quick development of hypothermia and can

The battered or abused child

Of significance to the clinician who treats pediatric maxillofacial injuries is the battered or abused child. The challenges in the management of this form of trauma extend beyond mere physical injury and include psychological management and medico-legal considerations. Fifty percent of the physical injury in the battered or abused child is to the head and neck. Profiles of battered children are typically of newborn or preschool boys, whereas sexually abused children are typically 11-year-old

General considerations for the pediatric maxillofacial trauma victim

As with all trauma victims, initial assessment and resuscitation should follow the “ABCs” of advanced trauma life support, with a focus on the unique differences in pediatric anatomy and physiology (Table III).1, 2, 3, 52, 53, 54 The high incidence of multisystem injuries concomitant with maxillofacial injuries should be the initial management focus. The diagnosis of facial fractures is based on a clinical examination and is confirmed with imaging. Because of the incompletely calcified areas of

Fixation considerations

When formulating a plan of treatment for pediatric patients with facial trauma, a number of elements must be considered. These include the age of the patient (to maximize growth and development), the anatomic site (to optimize form and function), the complexity of the injury (displacement, comminution, and the number of sites), the time elapsed since injury (ideal to treat within 4 days), concomitant injury (fitness for anesthesia and duration of surgery), and the surgical approach (closed

Dental and dentoalveolar injury

Dental and dentoalveolar injury is frequently overlooked in surveys that review pediatric maxillofacial injury. This has occurred because some authors consider this area inconsequential compared with other forms of injury, and accurate data regarding incidence or frequency are only represented by hospital admissions. Offices, emergency departments, or other sites for ambulatory management have not had their records scrutinized for these forms of injury like hospital records have been. Those

Mandibular condyle

Although mandibular fractures have been reported to occur with a greater incidence (15%-86.7%) than other pediatric facial fractures, it is the condyle that is the most frequently injured region of the mandible (14.5%-60%) (Table I, Table IV). This type of injury, especially in the pediatric age group, is amenable to less aggressive therapy. Open reduction should be considered when the occlusion cannot be reestablished because of the position of the fractured condylar segment, when the segment

Mandibular angle, body, ramus, or symphysis injury

Injuries to the mandible other than the condyle or alveolus have been reported to occur with varying degrees of frequency (Table IV). Therapy for these forms of injury adhere to the principles discussed previously in the section entitled Fixation Considerations. Generally, observation and soft diet are preferred in the patient under 2 years of age and in those with greenstick or minimally displaced fractures. Young children (those without a complete dentition) may be effectively treated with

Maxillary injury

The maxilla is the least frequently injured pediatric facial bone (1.2%-20%) (Table V).11, 13, 14, 15, 20, 24, 27, 28, 29, 30, 31, 33, 37, 39, 42, 43, 44 Absolute anatomic reduction is necessary under these circumstances to ensure proper growth and development with attention directed to the nasofrontal and frontomaxillary sutures, as well as to the septum. The septovomerine suture has been associated with midfacial growth disturbances subsequent to trauma.40, 77, 78 Maxillary injury is

Zygoma injuries

Zygomatic fractures occur with relative frequency in the pediatric facial fracture population (7%-41%) (Table V). Treatment of this form of injury is generally straightforward. Only observation is required for greenstick or minimally displaced fractures, whereas displaced fractures require an open approach. Intraoral and Giles approaches are effective for displaced arch fractures, and transconjunctival incisions with lateral canthotomy extensions are effective for most other zygomatic injuries.

Nasal injury

With the exception of alveolar injuries (5%-65%), those to the nose are the most frequently encountered midfacial injury in children (1%-45%) (Table V). When evaluating nasal injury, attention must be paid to the nasal bones and to the cartilaginous structures as well. Nasal fractures are frequently masked in children by edema. If edema obscures initial diagnosis, refracture or osteotomy of the healing malunion and definitive treatment by intranasal packing and external splinting should be

Naso-orbital-ethmoidal injury

Naso-orbital-ethmoidal injuries are among the most technically difficult injuries to treat in children and perhaps the most potentially deforming in the growing patient. They occur with relative infrequency (1%-8%) (Table VI).8, 19, 20, 21, 24, 25, 27, 30, 39, 42, 43, 44, 79In the highly unusual situation that a fracture occurs in this region and is nondisplaced, observation is acceptable. Yet if any suspicion exists regarding displacement, an open approach and anatomic reduction are required.

Orbital and frontal bone injury

Fronto-orbital injury has been reported to occur with a frequency ranging between 2.9% and 35% in the pediatric facial fracture population (Table VI). Isolated orbital injury occurs with a frequency between 10% and 13%. The floor is affected 25% to 58% of the time, the roof 18% to 35%, and the medial wall 5% to 28%. Although these numbers reflect relative frequency for the total pediatric population, the various forms of injury are age-specific. Before age 7, because of the presence of only

Soft tissue injuries

Pediatric soft tissue injuries are frequently overlooked when discussing pediatric trauma. Yet they occur in association with facial fractures 29% to 56% of the time. Management principles are much the same as for adults except that treatment should be initiated within hours because healing occurs sooner. Although immature collagen in the child’s soft tissues provides very cosmetic results the vast majority of the time, hypertrophic scars and keloids may form in this patient population.

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    *

    Reprint requests: Richard H. Haug, DDS, Division of Oral and Maxillofacial Surgery, College of Dentistry, D-508, Lexington, KY 40536-0297

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