Management of Pediatric Facial Fractures
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.
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
As with all trauma patients, primary survey of the pediatric patient is indicated, specifically ensuring that the airway is patent, the patient is breathing, and vital signs are stable. Airway assessment in the child is of particular importance because the smaller airway of the child increases the relative airway resistance and ease of obstruction, and the threshold for intubating a child with injury or obstruction of the airway should be low. Once the child’s airway and cardiopulmonary status have been stabilized, secondary assessment is completed to identify all areas of injury. In particular, with facial trauma, it is important to rule out neurologic injury.
Prior to examination, a comprehensive history should be obtained. Specific questions focus on the cause of injury, time frame from injury to evaluation, and any history of loss of consciousness. In addition, if dental trauma is suspected, questions regarding loss of dentition are indicated. If teeth were avulsed from the injury, it is important to determine factors such as the location of the teeth, transport medium of the teeth, and whether the teeth were rinsed or swallowed or aspirated. Finally, obtaining a basic past medical history, if feasible, is warranted. The battered child complex must be considered a possibility when the historian’s account does not correlate with the extent of the patient’s injury. This suspicion must be addressed if unexplained bruises, burn marks, or repeated traumatic incidents appear in the child’s medical history or are discovered on physical examination.
Initial examination is focused extraorally by first observing for edema, ecchymosis, or lacerations. Chin lacerations, in particular, are often associated with condylar or symphyseal fractures. Facial edema, periorbital ecchymosis, subconjunctival hemorrhage, subcutaneous emphysema, and nasal bleeding are all indicators of possible facial fracture. Assessment of the trigeminal nerve function can also provide clues about possible injury due to fragments impinging on the peripheral trigeminal nerve branches. Examination should be followed by palpation of the facial skeleton, noting any steps or crepitus. The presence of postauricular ecchymosis (Battle’s sign) or hemotympanum is suggestive of a basal skull fracture. A basic ophthalmologic examination should be completed, if possible, including assessment of pupillary reactivity, visual screening, and extraocular movements. If orbital trauma in suspected, an ophthalmologic consultation is indicated. Identification of intraoral ecchymosis, especially within the mucobuccal folds or sublingual area, should alert the examiner to the probability of facial fractures. Furthermore, palpation for steps intraorally, assessment of occlusion, presence of ecchymosis in the floor of the mouth, and mobility of dental segments are all part of a comprehensive clinical examination. Assessing mandibular range of motion and any deviations may indicate facial fractures—in particular, fractures involving the mandibular condyles. Another often forgotten part of the intraoral examination is assessing the dentition, most importantly counting all teeth and accounting for any missing dentition. If missing dentition is unaccounted for, a chest radiograph is indicated to rule out aspiration of dental hard tissue. A neurosurgical consultation is mandatory if there is loss of consciousness, altered mental status, postauricular ecchymosis, cerebrospinal fluid (CSF) rhinorrhea, facial nerve changes, or hemotympanum. Children are prone to the development of epidural hematomas; it is critical to observe their behavior and level of consciousness following significant facial trauma.
A combination of the clinical examination coupled with a radiographic evaluation allows the clinician to diagnose facial fractures. Radiographs should not be used solely to diagnose facial trauma. In the pediatric population, greenstick fractures are often not visualized by conventional radiographs and developing tooth buds may also obscure fractures on plain films. The simplest radiograph to diagnose mandibular, alveolar, or dental trauma is the panoramic radiograph. This film allows for clear assessment of all aspects of the mandible, assessing dentition and tooth buds, and providing a global view of the maxilla and mandible. Limitations of the panoramic film include its two-dimensional nature, distortion of the anterior maxilla and mandible, and inability to differentiate greenstick fractures from bicortical fractures. When dental trauma or alveolar trauma is suspected, dental radiographs including occlusal films and/or periapical radiographs are helpful.
Panoramic and dental radiographs may not be readily available in the emergency department. If this is the case, another choice is plain radiographs or skull films. A complete facial series of radiographs should include left and right lateral oblique views of the mandible to observe the mandibular body and ramus, a Towne projection to identify condylar injuries, a posteroanterior view to examine the mandible and midface, a Waters view for midfacial and nasal fracture detection, and a submental vertex view for visualization of the zygomatic arches. As technology has evolved, 3-mm axial, coronal, and sagittal computed tomography (CT) for imaging in pediatric facial trauma patients has become routine and is now the standard of care, replacing plain films in many institutions. Sagittal images are particularly useful for evaluating orbital floor trauma. Finally, three-dimensional CT is now readily available and should be performed for all complex facial fractures to assess facial fractures globally from multiple angles and assist with surgical planning. Three-dimensional CT imaging is also preferred to assess postoperative outcomes of reduction and internal fixation, particularly injuries in those areas not well visualized by plain films, such as midface trauma and orbital floor injuries.
Children younger than 6 years have only primary dentition. Children 6 to 12 years of age (or slightly older) will have a mixed dentition of primary and adult teeth. Teenagers and older patients will have adult dentition. Usually, the anterior central incisors are prone to injury due to their position. Trauma to the dentition in the pediatric patient can be divided into primary dentition and secondary dentition. In general, trauma to primary dentition is treated via extraction, although restoration of primary dentition may be warranted if the dental trauma is mild or if there is a concern about space maintenance. If a primary tooth is avulsed, it is not recommended for replantation, unlike permanent dentition. When permanent dentition is injured, treatment is based on the degree of injury. Traumatized adult (secondary) teeth can be classified via the Ellis classification of dental injury:
Ellis types 1 and 2 injuries are typically treated via dental restorations. Ellis type 3 requires root canal therapy followed by dental restoration. Dental subluxation often will require splinting of the subluxed tooth to adjacent teeth for 3 to 4 weeks to stabilize the tooth. The treatment of avulsed teeth is based on the time from injury to treatment. The ideal treatment is to reimplant an avulsed tooth immediately after avulsion. It is important not to wash the tooth to ensure that the periodontal ligament is not washed away. If reimplantation is not immediately feasible, the tooth should be transported ideally in saliva. However, keeping the tooth in the vestibule of the mouth during transport is not advisable in a pediatric patient secondary to risk of aspiration; thus, transporting the tooth in a cup of the patient’s saliva is preferred. If less than 2 hours has passed since avulsion, the tooth may be replanted directly into the site. If more than 2 hours has passed, the tooth should be rinsed off (at >2 hours out of the mouth, the periodontal ligament has most likely necrosed), pulp chamber obturated, and then replanted. In all cases, once replanted, the tooth needs to be splinted for stability and placed out of direct occlusion. It is important to note that once a tooth has been repositioned and splinted, the patient’s occlusion should be checked to ensure that the injured tooth has been repositioned into its pretrauma position.20
Alveolar fractures involve the supporting bone of the dentition. These are considered the most common type of pediatric facial fractures4 and may be often associated with dental trauma or tooth avulsion. Classically, an alveolar fracture may have a segment of teeth that are mobile as a group, with associated soft tissue injury and malocclusion. Primary treatment is conservative, consisting of immobilizing the arch s/>