Facial and dental-related trauma is common in the pediatric population. Appropriate evaluation and management techniques should be followed. Initial evaluation of the medical condition of the patient should be completed with acute management of any medical-related problems as a priority. ABCDE s of pediatric trauma should be followed and a thorough head and neck and oral examination completed with appropriate imaging if indicated. Newer dental trauma treatment protocols developed by the International Association of Dental Traumatology should be followed for best outcomes. Pediatric traumatic dental injuries generally have good prognosis by attempting to retain and stabilize teeth.
Adolescent facial traumatic soft tissue injuries and traumatic dental injuries are commom and facial fractures although uncommon may be associated with other significant injuries including neurological injuries.
Initial management of pediatric facial trauma involves stabilizing the patient from a physilogic standpoint before evaluation or imaging of the facial injuries.
Adolescent facial fractures are often “greenstick” with minimal displacement and may be treated conservatively with observation, while displaced mandible fractures with malocclusion are treated by reestablishing the occlusion with maxillomandibular fixation.
Soft tissue lacerations are evaluated for underlying injuries and repaired following irrigation and debridement.
Traumatic dental injuries, including tooth avulsion, should be treated promptly with the goal of maintaining the tooth with early replantation and splinting with periodic reevaluation for possble endodontic therapy.
Adolescent facial trauma
Trauma affects hundreds of thousands of patients and costs billions of dollars annually in the United States. The pediatric population is a subset that deserves special attention due to multiple factors, including but not limited to anatomy, mechanism of injury, future growth considerations, sex, and age. Despite craniofacial trauma being frequent in pediatric patients, the most common injuries are usually soft tissue and dentoalveolar injuries. Facial fractures in children are relatively infrequent versus adults, but may be associated with severe injuries and significant morbidity and associated disability. Important goals of management of facial trauma in pediatric patients is focused on initially stabilizing the patient, identifying any other concomitant severe injuries, and then diagnosis and management of the facial injuries.
Orofacial trauma demographics
A review of the National Trauma Data Bank of 2016 from the American College of Surgeons gives an overall view of pediatric trauma, highlighting differences in trauma prevalence as follows. Trauma is the leading cause of morbidity and mortality in children, with the head being the most frequently involved and the face the fourth most common affected anatomic region at 24.3% of all cases. Rates of pediatric trauma vary by age, with a mild increase in incidence at the 5 to 7 age range (∼6000 cases) and again at 11 to 18 years of age (∼5000 up to 12,000 cases per year by age 18). These increases can likely be attributed to the increased activity in school-age children 5 to 7 years old and again with ever-increasing levels of activity in pre-teens and teenage patients. There is also a difference by sex, with boys showing a 1.35 to 1.5 times higher incidence of trauma than girls in the 1-year to 9-year age groups. However, male incidence continues to increase during adolescence (ages 11–18) whereas female trauma somewhat levels off. Incidence also can be categorized by intent, with unintentional injury being an overwhelming majority at 88.2% of all pediatric trauma, although potential child abuse must always be considered.
Pediatric craniofacial anatomy must be given special consideration, as the skeletal anatomy changes with growth and development of the child through adolescence. The pediatric facial skeleton has incomplete ossification and compliant suture lines, making it more flexible than the adult facial skeleton. Children also have a larger cranial body-to-mass ratio than adults, and the malar region is protected by a relatively larger malar fat pad. These differences result in a unique distribution of facial injuries in the pediatric population. With the larger cranial size, fractures of the skull vault are more commonly seen in children. Maxillary and midface fractures are also more common in younger children, whereas mandible fractures are more commonly seen in adolescents and adults. Pediatric patients also have a lower incidence of severely displaced facial fractures, as increased skeletal flexibility often resulting in “greenstick” nondisplaced fractures of the face.
Pediatric patients with facial trauma must first be stabilized by Advanced Trauma Life Support protocol with an emphasis on detection and treatment of life-threatening injuries. Pediatric patients have a higher risk for physiologic decompensation due to increased body surface area to blood volume ratios, low blood volume, and higher cardiac output with increased metabolic rate and oxygen demands. Resultant hemodynamic instability makes pediatric patients prone to hypotension, hypoxia, and hypothermia secondary to traumatic injuries. As with any trauma patient, care should be taken to perform an overall assessment of the patient before evaluation of specific facial injuries. Injuries that may require acute intervention may go unnoticed if the provider does not follow the correct sequence of the ABCDE s of acute pediatric trauma evaluation in the following discussion.
Airway assessment and possible establishment of a patent airway. Pediatric airway obstruction is common due to a large flaccid tongue and pharyngeal soft tissue, and possible intraoral hemorrhage or foreign body obstruction. Airway evaluation and treatment, including possible airway repositioning with head tilt chin lift or jaw thrust or use of airway adjuncts such as oral or nasopharyngeal airways, or possible intubation, may be required. Airway evaluation and its management are the first priorities, as pediatric trauma–related airway compromise and respiratory arrest are the most common causes of cardiac arrest in pediatric patients.
Breathing with the ability to ventilate the lungs for oxygenation of blood and removal of carbon dioxide. Pediatric respiratory rates decrease with age, with infants having a rate of 30 to 40 times per minute to 15 to 20 times per minute in teenagers. Lung tidal volume also increases from 4 to 6 mL in infants to 6 to 8 mL/kg in adolescents.
Circulation and control of bleeding . Pediatric craniofacial injuries can result in significant blood loss. Vital signs should be closely monitored for signs of hemodynamic instability and any large bleeding vessels should be controlled with hemostats or gauze pressure. Pediatric patients may often tolerate a loss of up to one-third of total blood volume before developing hypotension due to compensation with tachycardia to maintain systolic blood pressure.
Disability from pediatric head injuries may result, including central nervous system injuries, such as traumatic brain injuries or concussions. Use of the Glasgow Coma Scale ( Table 1 ) with motor, eye-opening, and verbal responses are evaluated and correlated with head injury severity and possible need for immediate treatment, including possible cervical spine immobilization. Concussions are commonly associated with pediatric facial trauma and defined as altered mental status with or without loss of consciousness. Most post–concussion-related symptoms resolve within 3 months and there is no specific directed therapy for concussions.Table 1
Response Scale Score Eye-opening response Eyes open spontaneously 4 Points Eyes open to verbal command, speech, or shout 3 Points Eyes open to pain (not applied to face) 2 Points No eye opening 1 Point Verbal response Oriented 5 Points Confused conversation, but able to answer questions 4 Points Inappropriate responses, words discernible 3 Points Incomprehensible sounds or speech 2 Points No verbal response 1 Point Motor response Obeys commands for movement 6 Points Purposeful movement to painful stimulus 5 Points Withdraws from pain 4 Points Abnormal (spastic) flexion, decorticate posture 3 Points Extensor (rigid) response, decerebrate posture 2 Points No motor response 1 Point
Exposure of the injured with completely undressing and examining the child or adolescent for a full trauma assessment to rule out other injuries while preventing hypothermia of the patient. A fast and reliable method to assess the ABCDE s in age-appropriate pediatric patients is to ask the patient their name and what happened. If the patient is able to verbally respond, this suggests the airway is not compromised, and the patient can breathe well enough for speech production. If the patient is conscious and alert enough to describe what happened, this indicates generalized neurologic stability. Vital signs are continually assessed to ensure adequate cardiac and respiratory function. Failure to respond to these questions in an age-appropriate manner or abnormalities of any vital signs indicate compromised physiologic stability and may warrant acute management.
Once the primary survey has been completed (assessment of the ABCDE s) and the patient is stable, then the secondary survey can begin. The secondary survey is a complete head-to-toe assessment of the patient, which includes physical examination of all body areas and patient history, while continually reassessing vital signs. During this time, a complete neurologic examination is completed and imaging is obtained to rule out any suspected head or neck injuries.
Radiographic imaging should be obtained in most acute trauma cases, unless there are extenuating circumstances that would preclude the patient from having these images taken. Also, in the case of isolated soft tissue injuries secondary to low-impact trauma, imaging is not indicated if the examination is otherwise normal. However, there should be a low threshold for obtaining imaging if there is any suspicion of possible facial fractures or possible foreign bodies in the wound.
In many cases, the most readily available imaging for the practicing dentist will be a panoramic radiograph. This can be useful when the trauma is limited to the mandible and lower midface; however, it will have limited utility when evaluating other regions of the upper facial skeleton. The use of the panoramic radiograph still has some utility, especially for evaluation of the dentition and dentoalveolar fractures.
Computed tomography (CT) imaging with 1-mm to 4-mm slices has multiple advantages over panoramic radiographs, including multiple planes of image, avoidance of superimposed structures, and larger field of view. Axial slice thickness of 1 mm is useful for greater image fidelity as well as reformatting for possible 3-dimensional reconstruction. The use of CT imaging does expose pediatric patients to an increased level of radiation of approximately 1 to 10 millisieverts (mSv), compared with the average person exposed to 3 mSv due to natural ionizing radiation yearly. CT imaging should enhance information from a thorough clinical examination. The increased radiation dose in pediatric patients must be considered, as pediatric patients are more sensitive to radiation than adults, have a longer life expectancy than adults, and increased radiation risk for possible development of brain tumors or leukemia.
Head and neck examination
When evaluating a patient with facial trauma, it is helpful for the provider to have a standardized examination to assess the face by regions, including the cranium/skull base, frontal region, orbits, nose/nasal bones, temporomandibular joint/ears, maxilla and mandible, and intraoral examination.
Starting with the cranium , evaluate for any lacerations, contusions, or obvious fractures. This should include visual examination and digital palpation for palpable defects or depressions. The retro-auricular/mastoid region is assessed for “Battle’s sign” hematoma of mastoid areas of the skull behind the ears associated with skull base fractures. Cranial scalp lacerations may lead to significant blood loss and should be promptly treated.
Attention can then be turned to the frontal region, looking again for any irregularities, including skull defects, depression, or crepitus. Frontal sinus fractures may require treatment if depressed or if there is involvement of the posterior table with possible dural tears and cerebrospinal fluid leak through the nose. Also, V1 trigeminal nerve branch paresthesia/numbness of the forehead region may be present. These findings sometimes can be masked in the acute phase by swelling, so axial CT images are helpful in assessing the anterior and posterior tables of the frontal sinus and nasofrontal outflow tract.
Examination of the orbits then would follow with evaluation for ecchymosis and edema of the periorbital region as well as orbital trauma such as subconjunctival (scleral) hemorrhage or enophthalmos (sunken in eye appearance). Vision defects due to cranial nerve II (optic) and/or extraocular movement defects with cranial nerves III (oculomotor), IV (trochlear), or VI (abducens) involvement resulting in limited eye gaze or diplopia (double vision) require an ophthalmology consultation. Orbital floor “blow-out” fractures are common in pediatric facial trauma patients as a protective mechanism to prevent injury to the eye. Orbital floor fractures may result in limited upward eye gaze due to inferior rectus muscle entrapment of the affected eye resulting in diplopia. Orbital floor fractures with entrapment require inferior rectus muscle release within 48 hours to prevent muscle atrophy or fibrosis and repair of the orbital floor fracture with an implant via a transconjunctival inner eyelid incision.
The nasal region examination can be concurrent with orbital examination. The external nose is inspected for gross deviation from the facial midline or bony steps or crepitus of the thin nasal bones or nasal septum. As previously discussed, nasal bone or nasal septal fractures are a common pediatric facial fracture with possible functional and nasal airflow, deviation, or cosmetic defects, which are anatomically reduced by closed reduction with possible internal and/or external nasal splinting. Evaluation for naso-orbital ethmoidal (NOE) fractures should be performed and may result in traumatic telecanthus (increased intercanthal width of the eyes) and widened and flattening of the superior nasal bridge area. Axial view on CT imaging will be helpful in evaluation of the degree of displacement and comminution of the fractures. Any nasal septal hematomas should be evacuated to prevent possible necrosis of the septal cartilage and loss of nasal support. Significant NOE fractures are treated with open reduction with rigid internal fixation with miniplates and screws or transnasal wiring to prevent traumatic telecanthus and widening of the upper nose.
Maxillary assessment begins during the orbital examination, looking for any fractures by palpation for step defect depressions of the inferior orbital rim. The malar and zygomatic regions should also be examined visually and palpated for fractures and depressions that may not be detected on physical examination due to acute swelling. Some zygomaticomaxillary (ZMC) fractures can impinge on the mandibular coronoid process, resulting in trismus (limited mandibular opening), flattening of the malar eminence or cheek, and may result in a unilateral trigeminal nerve V2 branch paresthesia of the upper teeth and lip, lateral nose, and cheek. Nondisplaced fractures of the zygomatic arch or ZMC may be observed with the patient to maintain a soft diet and avoiding any contact or trauma to the face or head for 6 to 8 weeks. LeFort fractures can cause mobility of the maxilla, nasal, and zygomatic areas, which can be tested by grasping the maxilla bilaterally apical to the anterior teeth and checking for maxillary mobility. A mobile dentoalveolar fracture involving multiple tooth segments may be present with fracture of the alveolar bone and associated teeth and require stabilization with bonded splinting of the teeth or possible open miniplate fixation.
The mandible should be examined with palpation for step defects of the inferior border, crepitus of bone with palpation, malocclusion with open bite, premature contacts or posterior edge-to-edge cusp occlusion, trismus, deviation of the mandibular dental midline with opening, mandibular gingival tears, and vestibular or floor of the mouth ecchymosis. The mandibular examination should include a thorough temporomandibular joint (TMJ) examination to evaluate for TMJ pain, clicking, crepitus, dysfunction, or trismus possibly associated with mandibular condylar process or subcondylar fractures. Condylar process or subcondylar fractures may result in deviation to the side of the fracture due to associated loss of posterior vertical dimension on the side of the fracture. If the mandible fracture involves the inferior alveolar canal with displacement of the fracture, the patient may have a V3 paresthesia (altered sensation of numbness or tingling) of the lower lip on the side of the fracture.
Previously the panoramic radiograph was the standard for evaluation of mandible fractures often due to availability, although often CT imaging is obtained in the hospital and provides 3-dimensional images of mandible fractures. The vector of force to the mandible may result in specific fracture patterns. For example, if a patient is struck on the left body of the mandible, the resultant fracture pattern is often a left-sided angle, body, or parasymphyseal fracture with a contralateral condylar process or subcondylar fracture. Another example would be a fall in which the patient strikes their chin on the ground, which can often result in bilateral condylar process or subcondylar fractures.
The ear should be examined for hematoma formation and laceration. Any hematomas of the ears should be evacuated to prevent necrosis of the underlying ear cartilage and lacerations are repaired with sutures and covered with a pressure dressing to prevent hematoma formation. Care also should be taken to look for the presence of exudate from the external auditory canal, including blood or clear fluid, which may indicate a cerebrospinal fluid leak. A gross hearing test for each ear to evaluate cranial nerve VIII (vestibulocochlear) and tympanic membrane function should be completed.
Mandibular fracture treatment
When considering treatment of facial fractures, one must consider the type, location, and severity of the fracture. There are also multiple patient-based factors, including patient age, activity level, and compliance to proposed treatment. Some mandibular fractures in the adult population may warrant open reduction with internal rigid plate and screw fixation, whereas the same fractures in the pediatric population may require conservative treatment with observation, a soft non-chew diet, or maintenance of occlusion by closed reduction techniques, as discussed next.
Mandibular closed reduction methods
Closed reduction of mandibular fractures with maxillomandibular fixation (MMF) or intermaxillary fixation (IMF) are used interchangeably and may be completed by several common methods to establish and maintain the pretrauma dental occlusion. In certain cases, closed reduction with MMF or IMF may be the only treatment required for many mandibular fractures. A variety of closed reduction techniques may be used and can be performed in either an inpatient or outpatient setting, under local anesthesia or with sedation or general anesthesia if needed. Care should be taken to not disturb the developing tooth buds of the permanent dentition while treating pediatric mandibular fractures. MMF or IMF are techniques that avoid trauma to the developing tooth buds and may require circummandibular symphysis wire and a piriform nasal aperture wire for attachment. Then they are connected with a fixation wire for MMF or IMF.
Ivy loop fixation uses stainless steel wires around 2 adjacent teeth in each quadrant using circumdental 24-gauge wires with a buccal wire loop. A 24-gauge fixation wire is then passed through both the maxillary and mandibular loop and tightened to place the patient in MMF. This is a simple, low-cost, effective treatment, especially for pediatric patients who are easy to place under local or possible deep sedation/general anesthesia. The image in Fig. 1 demonstrates placement and configuration of Ivy loops.