Injury 51 (2020) 1561–1567 Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury Analysis of pediatric maxillofacial trauma in North China: ✩ ,✩✩ Epidemiology, pattern, and management ∗∗ Wei Zhou, Jingang An, , Yang He, Yi Zhang Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China a r t i c l e i n f o a b s t r a c t Article history: Purpose: To analyze epidemiology, pattern, and management of pediatric maxillofacial trauma in North Accepted 25 April 2020 China. Patients and Methods: Clinical records of patients aged 0–18 years with maxillofacial trauma, from Jan- Keywords: uary 2008 to December 2016 were reviewed. 390 patients with an average age of 9.8 ±5.8 years (range: Children 8 months–18 years) and a male:female ratio of approximately 2:1 were included in the study. Epidemio- Maxillofacial Trauma logical features (age, sex, etiology), characteristics of injuries (locations, types, associated injuries), treat- Pediatric Trauma Fracture ments, and complications were analyzed. Results: Among 55 patients with soft tissue injuries, palate was the most common site (32.7%). Among 335 fracture cases, the most common age group was 16–18 years (25.1%); falls was the main cause (38.2%). Overall, there were 450 fractures (1.78 per capita), primarily mandible (69.3%), followed by zy- goma (12.9%), maxilla (7.7%) and other sites. Multiple fractures occurred in 61.5% of patients. The most common site of mandibular fractures was condyle. The proportion of mid-face fractures to mandibular fractures increased with age (p < 0.01) and stabilized gradually after 12 (approximately 1.14:1). 77.5% of fractures were treated surgically. There was an independent association of surgical intervention with age older than 6 years old (p < 0.05). Absorbable plates were mainly applied to mandibular fractures in patients aged 0–7 and only 1 was removed because of insufficient fixation strength. Conclusions: The primary cause of pediatric maxillofacial fractures in North China was falls; traffic acci- dents led more multiple fractures and associated injuries. Palate and mandible were the most common sites of pediatric maxillofacial soft tissue injuries and fractures, respectively. The proportion of mandibu- lar fractures to mid-face fractures decreased with the increase of age until 12. ©2020 Elsevier Ltd. All rights reserved. Maxillofacial trauma is infrequent in pediatric population [1 , 2] . Management of maxillofacial trauma must be planned by taking Studies have shown that maxillofacial fractures in children un- into account the fact that unlike adults, children are in the growth der 16 years old account for 1%–14% of all fractures, while and development stage. If not appropriately managed, complica- those in children under 5 years old account for only 0.87%–1% tions such as growth disturbances and temporomandibular joint [3 , 4] . This reduced incidence may be explained by the flexibil- (TMJ) ankylosis may occur [8 , 11 , 12] . Therefore, understanding the ity of pediatric skeleton, the large quantities of facial soft tis- characteristics of pediatric maxillofacial trauma can help clinicians sues, the presence of unerupted teeth, the lack of paranasal si- in performing accurate diagnosis and selecting appropriate treat- nus pneumatization, as well as being protected by parents and ment methods [6] . schools [5–10] . Owing to the influence of social, environmental, and economic factors, the characteristics of pediatric maxillofacial trauma are as- sociated with time and region, with a certain degree of variation [7 , 13–15] . Only a few studies have been conducted on pediatric maxillofacial trauma in China in the past decade. The purpose of ✩ Declarations of interest: none this article was to analyze the epidemiology, pattern, and manage- ✩✩ This research did not receive any specific grant from funding agencies in the ment of pediatric maxillofacial trauma treated at our institution in public, commercial, or not-for-profit sectors. ∗ Correspondence author. the past 9 years. Our study was approved by the medical ethics E-mail address: [email protected] (J. An). committee in our hospital. https://doi.org/10.1016/j.injury.2020.04.053 0020-1383/© 2020 Elsevier Ltd. All rights reserved. 1562 W. Zhou, J. An and Y. He et al. / Injury 51 (2020) 1561–1567 Fig. 2. Location of soft injury by percentage. Fig. 1. Annual distribution of patients. Patients and methods Study sample 390 consecutive patients aged 0–18 years with maxillofacial trauma, from January 2008 to December 2016 were eligible for this study. The mean age was 9.8 ± 5.8 years and ranged from 8 months to 18 years. 262 were males and 128 were females, with a male-to-female ratio of approximately 2:1. The medical records of them were retrospectively retrieved and analyzed for prevalence, etiology, pattern, management, and complications of maxillofacial trauma. Fig. 3. Distribution of patients in different age groups by sex. Variables Patients were divided into 6 age groups: 0–3, 4–6, 7–9, 10–12, 13–15, and 16–18 years. The mechanism of trauma included falls, motor vehicle accidents (MVA), bicycle accidents, sports, violence, and others. MVA included car accidents, motorcycle accidents, and car-pedestrian accidents. Trauma was divided into two types: soft tissue injuries and fractures. Soft tissue injuries were classified as injuries in palate, lips, tongue, cheek, and other sites. Fractures were categorized as mandible, maxilla, zygoma, orbit and naso-orbital-ethmoid (NOE). Sites of mandibular fractures included symphysis, parasymphysis, body, angle, ramus, coronoid, condyle, and alveolar process. As a special type of maxillary fracture, Le Fort fracture was separately Fig. 4. Mechanisms of injury by percentage. analyzed. received debridement and sutures. In addition, 7 patients sustained Statistical analysis facial nerve injury, and 6 of them underwent facial nerve anasto- mosis. Two patients experienced parotid duct injury, one of whom Following data were subjected to statistically analysis: age, sex, received parotid duct anastomosis while the other received parotid etiology, location and type of injuries, associated injuries, and duct ligation. treatment methods. Chin-square test was performed using SPSS version 20.0 (SPSS, Chicago, IL), with a 2-sided significance level set at p < 0.05. Maxillofacial fracture Results Fracture was diagnosed in 335 patients. The incidence was highest in the 16–18 years age group (25.1%) and lowest in the 10– There were 55 cases of soft tissue injuries and 335 cases of frac- 12 years age group (9.3%). Two peaks were found at the ages of 6 ≤ tures. Figure 1 shows patient distribution during the entire study and 16–18, respectively ( Fig. 3 ). The male-to-female ratio aged 12 > period. years was 1.6:1, while it increased to 2.9:1 in patients aged 12 years. Maxillofacial soft tissue injury Mechanism of injury Most of the 55 patients with soft tissue injuries were children The primary mechanism of fractures was falls (38.2%), followed aged < 5 years (38/55). The most common site was palate, followed by MVA (19.4%) ( Fig. 4 ). Mechanism of fractures was associated by cheek, lips, tongue, and other sites ( Fig. 2 ). Two patients were with patient age. Falls was the most common etiology in children not treated owing to their general conditions, and the remaining aged ≤6 years (56.5%), while in those aged > 6 years, the leading W. Zhou, J. An and Y. He et al. / Injury 51 (2020) 1561–1567 1563 Table 1 Concomitant Injuries Injured Organ System Type of Injury n % of total Head and neck Cerebral injury 28 12.8 Dental injury 103 47.2 Cervical spine injury 2 0.9 Eye injury 8 3.7 Ear injury 2 0.9 Facial nerve palsy 4 1.8 Parotid duct damage 1 0.5 Thorax Rib fracture 3 1.4 Pneumothorax/hemothorax 7 3.2 Lung contusion 7 3.2 Abdomen Liver 3 1.4 Fig. 5. Distribution of different fractures in each age group. Spleen 1 0.5 Bladder 1 0.5 Gastrointestinal hemorrhage 1 0.5 Upper limbs Upper limb fracture 23 10.6 Lower limbs Lower limb fracture 24 11.0 etiology was MVA (35.7%) (p < 0.001). Isolated fractures were pri- marily caused by falls, while multiple fractures were mostly caused by MVA (p < 0.001). Associated injury In total, 159 (57.9%) patients sustained associated injuries. The Fig. 6. Mandibular symphysis fracture in a 4-year-old boy (fracture line crossing the canine bud). most common associated injury was dental injury (47.2%), which was categorized as avulsion (51.6%), tooth fracture (34.9%), extru- sion (10.3%) and intrusion (3.2%). Other high prevalence of asso- Treatment and outcome ciated injuries included cerebral injury (12.8%), lower limb frac- Among the 335 patients, 77.5% of fractures were treated sur- ture (11.0%), and upper limb fracture (10.6%) ( Table 1 ). Among pa- gically whereas 22.5% of fractures were treated conservatively. tients with associated injuries, MVA was the most common cause Surgical treatment included closed reduction and open reduction (45.9%). ( Fig. 7 ). Conservative treatment consisted of observation, diet man- agement, maxillomandibular fixation (MMF), and splints. Treat- Location and type of fracture ments by fracture sites were summarized in Table 2 . A significant A total of 597 fractures were registered in the 335 study pa- correlation was noted between treatment method and fracture lo- tients (average: 1.78). Of these, 129 patients (38.5%) sustained iso- cation (p < 0.001) ( Table 4 ). The proportion of surgical treatment lated fractures and 206 patients (61.5%) sustained multiple frac- in patients aged ≤6 years was significantly lower compared with tures. The mandible was the most common fracture site (69.3%), those aged > 6 years (p < 0.05) ( Table 5 ).