Shahid R. Aziz and Vincent B. Ziccardi

Outline

Anatomic Considerations

The primary differences in craniomaxillofacial trauma in the pediatric or growing patient compared with the adult patient are based on developmental anatomy. At birth, the cranium-to- face ratio is 8 : 1. This decreases to 4 : 1 by age 5 and 2.5 : 1 as an adult.¹ As such, in infants, a large cranium protects the face, although infants are more susceptible to cranial trauma. As the child grows older, the cranium-to-face-ratio decreases, making the child more susceptible to facial fractures, in particular midface fractures.² The orbits reach skeletal maturity early in life (5 to 7 years of age); therefore, the lower third of the face is relatively protected during childhood. During the mixed dentition years, the mandibular growth catches up with the rest of the facial skeleton in an anterior and downward pattern. Skeletal maturity of the facial skeleton occurs at approximately 14 to 16 years of age in females and 16 to 18 years of age in males.³ Palatal, midaxillary, and premaxillary suture growth are completed by age 12 years.⁴

Unique to the jaw of growing patients is the consideration of dental development and the potential complications and morbidity that arise from surgical manipulation in the region of developing teeth. By the age of 2 years, chin prominence develops and the primary dentition begins to erupt. Transverse maxillary growth is complete with palatal, premaxillary, and midline maxillary suture growth complete and obliterated by ages 8 to 12 years.⁵ The deciduous dentition starts with the replacement of the permanent dentition by 6 years, representing a period of mixed dentition. As the mandible continues to grow, it lengthens and widens to accommodate developing teeth. Growth of the mandible continues by deposition posterior and resorption anterior to the ramus.⁶

The pediatric maxillofacial complex is also malleable, because there is a greater cancellous-to-cortical ratio. As such, greenstick fractures of the facial skeleton occur more frequently in children compared with adults. The consistency of the growing patient’s bone (more cancellous than cortical) is less conducive to the use of screw or wire fixation to fixate fractures internally. For these reasons, closed reduction is a viable option for most facial fractures in the growing patient. The osteogenic and bone remodeling potential of a child exceed that of an adult. Fractures of the maxilla and mandible that are not reduced within several days of injury often cannot be adequately reduced because of the rapid bone healing that occurs.

The contour heights of the crowns of deciduous teeth are below the gingival level, which does not lend itself well to circumdental wiring when arch bars are necessary to stabilize fractures during childhood. In addition, resorption of roots and attrition of deciduous teeth make these teeth less stable in keeping arch bars in place. It is often necessary to supplement circumdental wiring with skeletal wiring (e.g., piriform aperture, circumzygomatic, or circummandibular) to maintain adequate fixation of arch bars or splints when relying on the deciduous or mixed dentitions.⁷ When placing these skeletal wires, care must be taken not to pull them through the child’s soft bone and the position of the developing canine must be considered in the piriform region. In addition to skeletal fixation, the clinician can use Risdon wires in the pediatric patient with complete primary dentition or in the case of mixed dentition.

Epidemiology of Facial Fractures

Approximately 8.5 million children are evaluated annually in emergency rooms in the United States.⁸ An estimated 11.3% of pediatric emergency room visits overall are a result of craniofacial injuries.⁹ Facial fractures are less common in the growing patient than in adults. In an analysis of 1500 facial fractures by Rowe,¹⁰ 5% of all facial injuries occurred in children younger than 12 years and less than 1% of these fractures occurred in children younger than 6 years. Midface fractures in children accounted for less than 1%, with 4% of these fractures being variations of Le Fort type I, in part attributed to follicular crypts and developing dentition in the maxilla for children younger than 6 years.¹¹ The lower incidence of fractures in children compared with adults is also secondary to the underdeveloped facial skeleton in children as well as increased support form unerupted dentition. A 2008 survey from the National Trauma Data Bank (2001 to 2005) identified 277,008 pediatric trauma patient admissions, including 12,739 (4.6%) who sustained facial fractures. Of the 12,739 patients, 32.7% sustained mandibular fractures, 30.2% nasal bone fractures, and 28.6% maxillary-zygomatic fractures. Nasal and maxillary fractures were the most common in patients younger than 1 year; mandibular fractures were the most common among teenagers. Of those with mandible fractures, symphyseal, angle, and body were most common areas of fracture; 25% of all these patients required operative intervention. Finally, 68% of pediatric fracture patients were male; motor vehicle accidents (MVAs) accounted for 55% of pediatric facial fractures, followed by assault (14.5%), and falls (8.6%).¹² Literature on the incidence of pediatric facial trauma has indicated that 1.5% to 8% of all facial fractures occur in children younger than 12 years and 1% or less of such trauma occurs in children younger than 5 years.¹³ A 2008 Swiss survey of 291 pediatric maxillofacial trauma patients found that 64% were secondary to falls, 22% were secondary to MVAs, and 9% were sports-related accidents.¹⁴

Dental trauma in the growing patient, as isolated injuries or associated with facial fractures, has been studied extensively. Andreasen, examining a European population, estimated that one in every other child suffered dental injury by the age of 14 years.¹⁵ In the American population, age-specific, population-based incidence of dental trauma to the incisor teeth between the ages of 6 and 50 years has been estimated to be 24.9%.¹⁶

A 2011 study of 772 patients from the University of Pittsburgh found that the 69% of pediatric facial trauma patients were male, with an average age of 10.7 years. In children younger than 5 years, 56.4% sustained orbital fractures. Falls were the most common mechanism of injury. In children between the ages of 6 to 11 years, orbital fractures were the most common fracture type, with MVAs as the most common mechanism of injury. The 12- to 18-year-old age group comprised almost half of patients in this study. Orbital fractures were again the most common injury, primarily attributed to interpersonal violence. Of the 772 patients, 55% had associated injuries, particularly cervical spine and neurologic trauma (primarily concussions). The incidence of associated neurologic injury decreased as the age of the patient increased. This study also demonstrated the importance of seat belt and helmet use; 45% of pediatric patients injured in this study from MVAs were unrestrained and 67% of patients involved in bicycle and all-terrain vehicle (ATV) accidents were not wearing helmets.¹⁷ In addition, young children using seat belts too soon, rather than other more appropriate means of car restraints, sustained facial fractures 1.6 times more than those appropriately restrained for their age. Of pediatric facial fractures observed in MVAs, 51.4% were nasal fractures, 15.5% were mandibular fractures, 11.6% were orbital fractures, and 8.7% were fractures in the zygoma and maxillary bones.¹⁸ In addition, Winston et al have found that of 13,853 children between the ages of 2 and 5 years involved in MVAs, those inappropriately restrained in seat belts rather than child safety seats, suffered a fourfold increased chance of having significant head trauma.¹⁹

Diagnosis

Types of Fractures