Pattern and Treatment of Facial Trauma in Pediatric and Adolescent Patients

ORIGINAL ARTICLE Pattern and Treatment of Facial Trauma in Pediatric and Adolescent Patients Jose Luis Muñante-Cárdenas, DDS, MS, Sergio Olate, DDS, MS, PhD, Luciana Asprino, DDS, MS, PhD, Jose Ricardo de Albergaria Barbosa, DDS, MS, PhD, Márcio de Moraes, DDS, MS, PhD, and Roger W. F. Moreira, DDS, JD, MS, PhD Abstract: Pediatric maxillofacial trauma is a challenge for surgeons. There are no completely defined protocols, and sometimes, the initial management could be complex. The aim of this research was to perform a retrospective study to analyze the pattern and treatment of maxillofacial fractures in pediatric and adolescent patients. We reviewed the clinical records of 2986 patients treated at the Oral and Maxillofacial Surgery Division of Piracicaba Dental School between 1999 and 2008. Seven hundred fifty-seven patients were younger than 18 years and were divided into 3 groups according to age; the age and sex of the patients, etiology, fractures and associated injury, treatment, and complications were evaluated. Five hundred thirty boys (70.01%) and 227 girls (29.99%) were treated for injuries with major prevalence in adolescents. The most common injury causes were bicycle accidents (29.06%) and falls (28.40%). The mandible was the most fractured bone (44.8%); associated injuries were lacerations of the soft tissue and dental trauma. Surgical treatment was performed in 75 cases (30%) with minor complications (10% of surgical patients). We conclude that maxillofacial trauma in child is associated to fall and bicycle accidents; the mandible is more affected than other maxillofacial structures, and frequently, nonsurgical treatment is performed. Key Words: Pediatric trauma, pediatric injuries, treatment (J Craniofac Surg 2011;22: 1251Y1255) Facial fractures are uncommon injuries in children. Pediatric maxillofacial fractures are present in 1% to 15% of all facial fractures, 1Y3 showing different clinical features when compared with adult patients. 4 The flexibility of the facial skeleton in children, the relative protection offered by the lack of pneumatization of paranasal sinus, and the protection of the malar region by the prominent buccal fat pad in children contribute to reduce the frequency of these fractures. 3,5 From the Division of Oral and Maxillofacial Surgery, Piracicaba Dental School, State University of Campinas, Campinas, Brazil; and the Division of Oral and Maxillofacial Surgery, School of Medicine, University of La Frontera, Temuco, Chile. Received September 20, 2010. Accepted for publication December 5, 2010. Address correspondence and reprint requests to Prof Dr Roger W. F. Moreira, Division of Oral and Maxillofacial Surgery, State University of Campinas, Av Limeira 901, Caixa Postal 52-CEP 13414-903, Piracicaba-SP, Brazil; E-mail: roger@fop.unicamp.br The authors report no conflicts of interest. Copyright * 2011 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31821c696c Worldwide, the major causes of fractures in children are vehicle accidents, falls, violence, and sports-related accidents 1,3,6 ;their incidence is influenced by social, cultural, and environmental factors 7 because the rates of fractures are different between countries. On the other hand, the treatment has changed in the last years. In Brazil, maxillofacial fractures have been studied in adult patients, 8Y10 with limited information regarding facial trauma in children from 0 to 18 years. The aim of this research was to review and compare the etiology, frequency, and distribution of maxillofacial fractures and analyze the changes in the last 10 years in pediatric and adolescent patients treated at the Division of Oral and Maxillofacial Surgery of Piracicaba Dental School, Sao Paulo, Brazil. PATIENTS AND METHODS Data were collected from patients attended at the Division of Oral and Maxillofacial Surgery of State University of Campinas, Brazil, from April 1999 to December 2008. The information was obtained from clinical notes and surgical records using a standardized data collection form. Subjects 18 years or younger were included in the admission and were divided into 3 groups according to ages: group 1 (0Y5 years, infants), group 2 (6Y12 years, schoolaged children), and group 3 (13Y18 years, adolescents). The data record included patient s sex and age, etiology and location of the fracture, associated injury, treatment, and complications. The etiology of trauma was related to bicycle accidents, vehicle accidents (car and motorcycle), pedestrian accidents, sportsrelated accidents, falls, and violence. The fractures were associated to mandible, maxillae, isolated nasal bone, frontal bone, zygomatic bone, and nasal-orbital-ethmoid complex. The classifications of the fractures were based on conventional radiographic study and computed tomographic examinations, and the segment displacement was evaluated with clinical and imaging techniques. They were classified in nondisplaced and displaced. Sign and symptoms of the patient were evaluated as pain, neurologic disturbance of infraorbital nerve, asymmetry with evaluation of osseous fragment displacement, occlusion alteration, and diplopia. The surgical and nonsurgical treatments were evaluated, and the patient had to submit to at least 3 months of postoperative follow-up. Exclusion criteria were charts that did not had complete information about the trauma, unacceptable postoperatively reduction of fracture (evaluated with computed tomography), and postsurgical follow-up less than 3 months. RESULTS Etiology, Age, and Sex Distribution In 120-month review, 2986 patients (from 1 to 97 years) were treated for facial injuries at the Division of Oral and Maxillofacial Surgery of Piracicaba Dental School. Seven hundred fifty-seven patients (25.35%) who are 18 years or younger were included (mean The Journal of Craniofacial Surgery & Volume 22, Number 4, July 2011 1251

Muñante-Cárdenas et al The Journal of Craniofacial Surgery & Volume 22, Number 4, July 2011 TABLE 1. Distribution of Etiology of Injuries According to Sex Etiology Female Male Total % Car accident 23 40 63 8.32 Motorcycle 9 24 33 4.36 Bicycle 60 160 220 29.06 Pedestrian accident 21 36 57 7.53 Sports-related 10 51 57 8.06 Violence 14 47 61 8.06 Falls 77 138 215 28.40 Others 13 34 47 6.21 Total 227 530 757 100 age, 11.1 years). There were 530 boys (70.01%) and 227 girls (29.99%), in a ratio of 2.3:1. The incidence of maxillofacial injury increased with age: 156 cases in infants and preschool (20.61%), 257 in school-aged children (33.95%), and 344 in adolescent group (45.44%; Table 1). The causes of injuries were bicycle accidents (29.06%), falls (28.40%), vehicle accidents (8.32%), and violence (8.06%). Falls were the first cause of facial injuries in children younger than 6 years with 103 cases (66.03%). For other groups (school-aged children and adolescents), bicycle accidents were more common (Table 2). Location and Type Maxillofacial fractures were reported in 250 cases (33.02%; Table 3). The most common fracture was the mandibular fracture with 108 cases (43.20%) followed by nasal bone fractures, 77 cases (30.80%). Midfacial fractures were observed in 58 cases (23.20%) that included fractures of the zygomatic complex, isolated zygomatic arch, Le Fort I, Le Fort II, and blow-out fractures. Mandibular and midfacial fractures were present in 4 cases (1.6%), and nasal and midfacial associated fractures, in 3 cases (1.2%). Other maxillofacial fractures such as frontal, nasal-orbital-ethmoid complex, or Le Fort III fractures were not observed (Table 4). In mandible, 139 fractures in 112 patients were observed, distributed by condyle (43.17%), parasymphysis (18.70%), body and angle with 21 cases each (15.11%), 9 cases in the symphysis (6.47%), and 2 cases of mandibular ramus (1.44%; Table 5). TABLE 2. Distribution of Etiology of Injuries According to Age Group Age Group,* y Etiology 0Y5 6Y12 13Y18 Total Car accident 6 19 38 63 Motorcycle 0 2 31 33 Bicycle 18 82 120 220 Pedestrian accident 10 32 15 57 Sports-related 2 21 38 61 Violence 4 15 42 61 Falls 103 65 47 215 Others 13 21 13 47 Total 156 257 344 757 1252 TABLE 3. Distribution of Patient According to Maxillofacial Fractures Bone Fracture Fractures, n % Mandible 108 43.20 Middle third 58 23.20 Nasal bone 77 30.8 Mandible and middle third 4 1.6 Nasal bone and middle third 3 1.2 Total 250 100 Associated Injuries In patient with maxillofacial trauma, soft-tissue injury was present in 334 patients (44.12%), lacerations of perioral and intraoral tissue being more frequent (mainly in tongue and mucosal lips); 216 patients presented dental trauma with 261 injured teeth. The most common etiology was bicycle accidents (37.96%), falls (34.26%), pedestrian accidents (9.26%), and car accidents (5.09%). The most common dental injury was avulsion (29.88%), lateral luxation (16.09%), crown fracture (14.18%), and intrusive luxation (12.64%). Treatment Maxillofacial fractures were present in 250 patients, and 75 (30%) of them underwent surgical treatment (13 school-aged children and 62 adolescents). In 18 patients with maxillofacial fractures in group 1, conservative treatment was performed with diet management and analgesic therapy. These patients had fragments with little or no displacement, and the occlusion was not compromised, presented limited occlusion alterations that did not warrant any surgical treatment. Of 112 patients with mandible fractures, 55 patients (45.53%) were subjected to an open reduction and internal fixation. Surgical treatment of bilateral condylar fracture was performed in 4 cases, with reduction and fixation of the one affected side (exclusively for group 3), and open reduction of midfacial fractures was performed in 20 patients (30.65%; exclusively for group 3). Postsurgical complications were observed in 7 patients (9.3%) showing dehiscence (1 patient), postoperative bleeding (1 patient), eye movement restriction (1 patient), and facial paresthesia (3 patients) (only group 3). One patient with infection related to internal fixation in group 2 was recorded. DISCUSSION Sociodemographic Situation and Etiology of Trauma Several investigations about pediatric maxillofacial injuries have been performed to recognized their patterns and treatments. Some factors such as geographical location and socioeconomic status are related to the causes of injuries (Table 6). In this research, we evaluated patients from 0 to 18 years, as reported in other studies. 11Y13 The World Health Organization considers children as those with ages ranging from 0 to 18 years. However, there are differences within this group related to age, such as the etiology of trauma and its treatment. Children younger than 5 years live in a protected family environment, which contributes to the low frequency of accidents. 11 On the other hand, the face is protected by the frontal prominence with a small projection of the face mainly by the lack of development of the paranasal sinuses and the presence of temporary teeth. 12 * 2011 Mutaz B. Habal, MD

The Journal of Craniofacial Surgery & Volume 22, Number 4, July 2011 Pediatric Maxillofacial Trauma TABLE 4. Distribution of 138 Patients With Midfacial Fractures Region of Fracture Age,* y Fracture 1 Fracture 2 0Y5 6Y12 13Y18 Total % Zygomatic complex V 4 13 28 45 32.61 Zygomatic Arch V 0 0 2 2 1.45 Zygomatic complex Le Fort II 0 0 2 2 1.45 Zygomatic complex Zygomatic arch 0 0 1 1 0.72 Zygomatic complex Nasal 0 0 3 3 2.18 Zygomatic complex Le Fort I 0 1 0 1 0.72 Zygomatic complex Orbital floor 0 0 1 1 0.72 Nasal V 5 24 48 77 55.80 Le Fort I V 0 0 6 6 4.35 Total 9 38 91 138 100 V indicates that there was no fracture 2. With increasing age and development of paranasal sinuses, the face becomes less flexible and less protected. In fact, for a child patient, the cranium-face ratio is 8:1, whereas for an adult patient, this ratio decreased to 2:1. Given this relationship, if the infant receive a direct trauma, he is more likely to present a fracture of the cranium when compared with an older child or adolescent who will likely to present a face fracture. 12 On the other hand, in maxillofacial trauma, some research showed that boys were more affected than girls with ratios ranging from 2:1 to 6:1. 1,11,14 The results of our study are consistent with these previous reports (Table 2). Our results showed an increase of maxillofacial fractures according to age, with a high frequency in the adolescent group. The etiology of lesion also presented relationship with age: in patients younger than 6 years, the trauma presented low or middle energy (falls), whereas in patients older than 12 years, the trauma was related to high-energy trauma (transport vehicles). These results are in agreement with other researches. 1,11,14Y16 In European countries, vehicular accidents represent 30% to 80% of maxillofacial trauma, 17 whereas that in Africa, 11 the principal cause of maxillofacial trauma was violence. In our sample, bicycle accidents and falls were the most common causes of maxillofacial injury (29.06% and 28.40%, respectively) with higher incidence in boys; interpersonal violence was present mainly in adolescent males. For bicycle accidents, the use of safety devices is still very limited or simply not respected by parents or by the same person, showing deficiencies in the programs for education and accident prevention. 16 Our results showed only 4 patients younger than 6 years with facial fractures that could be associated to interpersonal violence. TABLE 5. Distribution of the 112 Patients With Mandible Fracture Region of Fracture Age,* y Fracture 1 Fracture 2 0Y5 6Y12 13Y18 Total % Mandible angle V 1 0 10 11 9.82 Mandible angle Mandible body 0 0 5 5 4.46 Mandible angle Parasymphysis 0 1 4 5 4.46 Condylar process V 7 7 32 46 41.07 Condylar process Parasymphysis 2 0 3 5 4.46 Condylar process Symphyisis 3 0 1 4 3.58 Condylar process Mandible body 0 1 4 5 4.46 Mandible body V 1 1 6 8 7.14 Mandible body Parasymphysis 1 2 0 3 2.68 Parasymphysis V 0 3 8 11 9.82 Symphysis V 0 2 1 3 2.68 Mandible ramus V 0 0 2 2 1.79 Symphysis Zygomatic complex 0 0 2 2 1.79 Parasymphysis Zygomatic complex 0 0 2 2 1.79 Total 15 17 80 112 V indicates that there was no fracture 2. * 2011 Mutaz B. Habal, MD 1253

Muñante-Cárdenas et al The Journal of Craniofacial Surgery & Volume 22, Number 4, July 2011 TABLE 6. Literature Reviews About Maxillofacial Injuries in Pediatric Patient Etiologies, % Reference Country Years No. Patients MVA Falls Violence Sports Others Mean Age, y Tanaka et al 1 Japan 13 81 20 28 25 18 26 1Y15 Qudah et al 15 Jordan 5 227 20 52 17 8 3 11 Bamjee et al 11 South Africa 4 326 29 23 48 0 0 1Y18 Gassner et al 17 Austria 10 381 30 24 14 17 15 10 Posnick et al 13 United States 4 137 50 23 0 20 7 10 Zachariades et al 19 Greece 25 202 14 74 0 5 7 0Y14 Gussack et al 22 United States 2 30 64 10 13 0 13 11 Oji 6 Nigeria 12 40 28 65 7 0 0 0Y11 Current study, 1999Y2008 Brazil 10 757 12* 28 8 7 6 0Y18 *Including road traffic and motorcycle accidents. MVA indicates motor vehicle accident. Domestic violence is an important medical-legal situation and should be approached in a critical way. Our maxillofacial surgery department has established protocols for handling these cases, including psychologic and legal support. Treatment and Complications The choice of treatment for pediatric patient will depend on the characteristics of fracture, complexity, age of the patient, concomitant injuries, and teething stage. Internal fixation and subperiosteal dissection can alter the osteogenic potential of periosteum with internal or external scarring that may further restrict growth. So when possible, a conservative treatment should be preferred, particularly in patients with osseous growth phase. 18 In our sample, conservative treatment was used in 175 cases of fractures (70%), which is consistent with previous researches. 1,19 This treatment was indicated for minimum or absent displacement of fracture (image study) and adequate reproduction of occlusion. Midface fractures in pediatric patients are uncommon (0.5% to 17%) because the mandible and cranium provide protection and absorb most of the impact. 18 Our results showed 21 cases of midface fractures due to vehicular accidents (high-energy impact) of which 8 (36.84%) were present in groups 1 and 2. These results support the hypothesis that exists in a positive relationship between midface fractures and the pneumatization grade of paranasal sinuses. 20 Isolated fractures of the nasal bones represented the 30.08% of fractures (77 cases) and were the second most affected facial bone. The high incidence is probably due to higher projection of this bone structure. 21 Most cases of nasal fractures in our study were treated in a conservative way because of the interference in the respiratory function that was not presented or the patient aesthetics. The mandible is the most vulnerable facial bone, probably because of its mobility, projection, and anatomy 13 ; in these patients, mandible fractures could be caused by low-energy trauma, such as falls or bicycle accidents. 14,15 The high incidence of condylar fractures is 1 characteristic of the pediatric mandible fractures. 14,19 In fact, in the research of Iida and Matsuya, 4 condylar fractures were the most common (36% of mandible fractures). In contrast, condylar fractures are less common in adult patients 15 ; our results showed that there is a higher incidence of condylar fractures (60 cases) in the adolescent group. Seventy-five patients (30%) were submitted to open reduction and rigid internal fixation. The great osteogenic potential of a child with high rates of healing may be related to the reduced need for surgical treatment. 18,22 Postsurgical complications were associated 1254 to the surgical site, suture dehiscence, infection, and paresthesia. Any other kind of complication, such as temporomandibular joint ankylosis, visual dysfunctions, growth disorders, or aesthetic complications, was not observed; we believe that physiotherapy applied in surgical and nonsurgical patients is very important to the success of treatment and for minor complications. Zachariades et al 19 showed that early mobilization is the key in the management of surgical and nonsurgical patients and is important for the reduction of complications such as ankylosis or altered growth. This research revealed interesting features about the etiology of the pediatric maxillofacial injuries that were associated to high occurrence of fall and bicycle accidents. We consider that it is important to inform parents about the care that must be adopted for the prevention of domestic accidents in infants and recommend the obligatory use of safety devices in cyclists. 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