CLINICAL STUDY

Maxillofacial Injuries in Infants and Preschools: A 2.5-Year Study Rong-tao Yang, PhD, DDS, Zhi Li, PhD, DDS, and Zu-bing Li, PhD, DDS Purpose: This study aims to evaluate the epidemiology of maxillofacial injuries in infants and preschools. Patients and Methods: The data from 110 infants and preschools with maxillofacial injuries from October 2010 to March 2013 were analyzed retrospectively. Results: The male-to-female ratio was 1.89:1. The peak age was 1 to 3 years (53.64%). Accident falls (76.36%) were the major cause. A total of 166 soft-tissue injuries were found in 103 patients, 102 dental traumas in 36 patients, and 53 maxillofacial fractures in 33 patients. The most common sites of soft-tissue injuries included the gingiva (17.47%), lower lip (13.86%), upper lip (13.25%), and chin (12.05%), and the majority were lacerations (77.71%). Dental traumas occurred mainly in incisors (81.37%) and the lower arch (60.78%). Of the 53 fractures, the most common sites were the condyle (45.28%), symphysis (22.64%), and mandibular body (16.98%); 28 (52.83%) were treated by operation and 25 (47.17%) by conservative treatment. Conclusions: Maxillofacial injuries in infants and preschools exhibit specific epidemiological features. These are related to anatomic, physiologic, and psychologic development in infants and preschools. Key Words: Maxillofacial injuries, infants, preschools, children (J Craniofac Surg 2014;25: 964–967)

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hildren are special populations in maxillofacial injuries, owing to their undeveloped physiologic and psychologic status. Maxillofacial injuries in children may lead to developmental malformations, facial deformities, and functional disorders, which people especially their parents are concerned. Many studies related to maxillofacial injuries in pediatric patients have been reported, and these mainly focus on epidemiology and treatment modality of maxillofacial injuries in children or pediatric patients whose age younger than 19, 18, 16, 15, or 12 years.1–6 The special population whose age is younger than 6 years is often mentioned in the studies on pediatric maxillofacial injuries. Usually, the newborn to 1 year of life is defined as infant, and the age between 2 and 6 years is defined as preschool.1 Infants and From the State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, People’s Republic of China. Received August 31, 2013. Accepted for publication January 13, 2014. Address correspondence and reprint requests to Zu-bing Li, PhD, DDS, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, 237# Luoyu Road, Wuhan City 430079, Hubei Province, People’s Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000760

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preschools get injured easily because their specific features in anatomic, physiologic, and psychologic development. They have a relatively large head with a high center of gravity and develop poor motor coordination; these increase the incidence of maxillofacial injuries.7 In addition, the deciduous dentition, the high degree of bone elasticity, and the thick soft-tissue layer of the face also contribute to the characteristics of maxillofacial injuries in infants and preschools.7,8 To our knowledge, no study focusing on maxillofacial injuries in infants and preschools has been reported. This study was designed to evaluate the age, gender, etiology, injury site and type, and treatment modality of maxillofacial injuries in infants and preschools over a 2.5-year period, and also to summarize the experience of diagnosis and treatment on maxillofacial injuries in infants and preschools.

PATIENTS AND METHODS A total of 110 infants and preschools with maxillofacial injuries were treated in the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, China from October 2010 to March 2013. The epidemiological information including age, sex, etiology, injury site and type, treatment details, and follow-up results were tabulated for the present study. Maxillofacial injuries were classified as soft-tissue injuries, dental traumas, and maxillofacial fractures. For soft-tissue injuries, debridement and suture were performed when necessary, and flaps from the adjacent area were prepared for soft-tissue defects during the primary debridement and suture process. For dental traumas, fixation with sutures or wires was performed when necessary. For maxillofacial fractures, observation, soft diet, splint, screw-based semi-rigid intermaxillary fixation, and open reduction and internal fixation (ORIF) were applied according to the fracture site and type. The institutional review board of Wuhan University approved the protocol, survey, and consent forms used.

RESULTS Age and Gender Distribution Of the 110 patients, 72 were male and 38 were female; the male-to-female ratio was 1.89:1. The patient age ranged from 8 months to 6 years, with an average of 2.99 years. Only 4 patients (3.64%) were infants, whereas 106 (96.36%) were preschools. The highest incidence rates were found in the age groups of 1 to 3 years (59, 53.64%) (Fig. 1).

Time of Injury Figure 2 demonstrates the distribution of injuries by week, with a peak in Sunday (n = 30, 27.3%), and the distribution by hour showed the peak lasted from 10:00 to 21:00. The time interval from injury to department visit ranged from 1 hour to 45 days (median, 5 hr; mean, 2.25 d). Eighty-four (76.36%) patients visited our department in 24 hours and 62 (56.36%) in 6 hours.

The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014

Maxillofacial Injuries in Children

breakage or failure of the resorbable plates and screws were observed. Of the 24 condylar fractures, 14 were by screw-based semirigid intermaxillary fixation combined with an occlusal splint,9 4 by removal of the fracture fragments, 1 by ORIF with resorbable plates, 2 by ORIF with titanium microplates, and 3 by observation or soft diet.

Follow-Up

FIGURE 1. Age distribution of 110 infants and preschools.

Etiology Overall, the most common etiology was an accident fall (84, 76.36%), followed by motor vehicle accidents (11, 10%), falls from height (5, 4.55%), bites (4, 3.64%), and others (6, 5.45%) (Table 1). Of the 84 accident falls, 47 slipped or tripped on the ground, 16 bumped against furniture or other hard structures after falls, 9 punctured by hard or sharp objects after falls, 6 slipped from the stairs, and 6 related to baby carriages. Of the 4 bites, 3 were bit by oneself and 1 by a dog.

Injury Sites and Types A total of 166 soft-tissue injuries were found in 103 patients (93.64%), 102 dental traumas in 36 patients (32.73%), and 53 maxillofacial fractures in 33 patients (30.00%). Of the 110 cases, isolated injuries accounted for 60%; combined injuries, 40% (Table 1). Among the 166 soft-tissue injuries, the most common site was the gingiva (29, 17.47%), followed by the lower lip (23, 13.86%), the upper lip (22, 13.25%), the chin (20, 12.05%), the tongue (14, 8.43%), the palate (10, 6.02%), and the frenulum of upper lip (10, 6.02%) (Fig. 3). Of these cases, 129 were lacerations, 23 were abrasions, and 14 were contusions. Table 2 displays the distribution of the 102 dental traumas; the most common tooth position was the central incisor (48, 47.06%), followed by the lateral incisor (35, 34.31%). Sixty-two (60.78%) dental traumas occurred in the lower arch and 40 (39.22%) in the upper arch. Of these cases, 22 were avulsions, 15 were extrusions, 7 were intrusions, 44 were tooth concussions with mobilities, and 14 were crown fractures. Of the 33 patients with bone fractures, the vast majority (30, 90.90%) sustained mandibular fractures, and only 4 (3.92%) sustained midfacial fractures. Among the 53 fractures, the most common site was the mandibular condyle (24, 45.28%), followed by the symphysis (12, 22.64%) and the mandibular body (9, 16.98%). In all, 24 condylar fractures were found in 19 patients. According to the level of condylar fractures, 14 were intracapsular fractures, 8 were condylar neck fractures, and 2 were subcondylar fractures.

The duration of follow-up ranged from 3 to 24 months. All the soft-tissue injuries healed well. Of the dental traumas, 3 intruded teeth dropped within 2 weeks after the restoration and fixation. All the fractures healed without complications; the growth disturbance of mandible, midline mandibular deviation, facial nerve injuries, malocclusion, malunion, and non-union were not observed during the follow-up period. The patient’s maximal mouth opening increased to a mean of 36.2 mm. Titanium plates were removed 3 to 6 months after ORIF.

DISCUSSION Clinically, maxillofacial injuries in infants and preschools are not uncommon in oral and maxillofacial surgery. However, the literature focusing on the special population is limited. Owing to the difference between these people and adults in anatomic, physiologic, and psychologic development, maxillofacial injuries in infants and preschools deserve exclusive attention and study. According to the reanalysis of previous studies on pediatric maxillofacial injuries, the incidence of maxillofacial injuries in infants and preschools ranged from 5.2% to 17.6%.3,5,10 In the present study, 110 infants and preschools suffered from maxillofacial injuries in a 2.5-year period, and there were 1087 recorded maxillofacial traumas in the same period at our department. Thus, 10.12% injured patients were younger than 6 years, and this is consistent with previous reports. The male-to-female ratio was 1.89:1 in this study, perhaps because of the active nature of the boys. This confirms that boys are more susceptible to injury than girls, adding weight to the existing publications.1,3,6,11 The age distribution peaked at 1 to 3 years of age, accounting for 53.63% of the 110 cases in this study. Other studies also reported that the peak age of maxillofacial injuries in infants and preschools was 1 to 2 or 1 to 4 years of age.5,7 The most common cause of maxillofacial injuries in infants and preschools was accident fall (76.36%), and this is consistent with other reported figures.7,12 However, in pediatric cases, the major causes were motor vehicle accidents, bicycle-related accidents, accident falls, assaults, and sports-related accidents in the literatures; their incidences differed and were primarily dependent on social, cultural, and environmental factors.2–4,8,13 In general, children in the infant and preschool age learn to walk and run; they are prone to get injured by accident falls due to poorly developed motor coordination and less concern for environmental hazard.7

Treatment Of the 103 patients who sustained soft-tissue injuries, 82 patients with lacerations were treated by debridement and suture, and 12 with abrasions and 9 with contusions were treated by observation or drug therapy. Of the 36 patients with dental traumas, 11 were stabilized by wires, 9 by absorbable sutures, 5 by edgewise arch wires, and 11 with slight mobilities by soft diet. For 53 maxillofacial fractures, 24 were treated by ORIF with titanium microplates (10 fractures) or resorbable plates (14 fractures), 4 with removal of the fracture fragment, and the rest by conservative treatment. Of the 14 fractures treated by resorbable plates, no

FIGURE 2. Week distribution of 110 infants and preschools.

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Yang et al

TABLE 1. The Etiology and Injury Type of 110 Maxillofacial Injuries in Infants and Preschools Injury Type Maxillofacial injuries Soft-tissue injuries Dental traumas Maxillofacial fractures Soft-tissue injuries + dental traumas Soft-tissue injuries + maxillofacial fractures Dental trauma + maxillofacial fractures Soft-tissue injuries + dental trauma + maxillofacial fractures

Accident Falls

Motor Vehicle Accidents

Falls From Height

Bites

Others

Subtotal

84 53 0 1 13 4 3 10

11 1 1 1 0 2 0 6

5 0 0 1 0 3 0 1

4 4 0 0 0 0 0 0

6 4 0 0 1 0 0 1

110 62 1 3 14 9 3 18

The incidence of soft-tissue injuries in infants and preschools was frequently overlooked in the literatures. In pediatric maxillofacial injuries, there was a high incidence of soft-tissue injuries, accounting for 34.7% to 92.3%.2,3,5,10,14,15 In the present study, soft-tissue injuries occurred in 93.63% of the 110 infants and preschools. The site distribution of soft-tissue injuries was mainly located at the gingiva, lower lip, upper lip, chin, and tongue. A possible explanation for the high incidence of soft-tissue injuries in the lower face could be due to the relative protrusion of the lower face. In addition, 77.71% of soft-tissue injuries in infants and preschools were lacerations; the incidence is higher than that in pediatrics.5 It is possible that the majority of contusions, abrasions, or hematomas were managed as outpatients, and the rest involving dental traumas or fractures and lacerations were admitted for active intervention.15 Usually, debridement and suture were performed for soft-tissue injuries. For injuries caused by animal bites, soft-tissue defects often occurred and could be corrected by flaps from adjacent area during the debridement and suture process. The most common tooth position was the incisor, accounting for 81.37% of the dental traumas. Incisors are at the front of the maxilla and mandible, and injuries usually occur in the lower face; these probably contribute to the high incidence of incisors in dental

traumas. In addition, primary teeth of the lower arch erupt earlier than that of the upper arch, and this may lead to the prevalence (60.78%) of dental trauma in the lower arch. In contrast to the reported figures, the most common type of dental trauma was tooth concussion with mobility, instead of crown fractures,16extrusions,5 or avulsions.3 As parts of dental traumas were managed as outpatients, it resulted in different incidences of dental traumas. The retrospective studies for hospitalized patients were not sufficient to analyze the accurate incidence, and a prospective study is needed to perform in infants and preschools. For dental traumas, fixation with sutures or wires is applied when necessary. When accompanying with mandibular fractures, dental traumas are recommended to be stabilized by wires, and when accompanying with dentoalveolar fractures, stabilization with edgewise arch wires is recommended. The major fracture site in infants and preschools was the mandible, accounting for 90.90% of maxillofacial fractures. Combining with results mentioned above, we found that maxillofacial injuries occurred mainly in the lower face—the most common sites of soft-tissue injuries were the gingiva, lip, and chin; the most common fracture site was the mandible; and the most common dental trauma was located in the incisors. In addition to the anatomic factors, these were probably related to the major cause of accident falls. When infants and preschools fall on the ground, their lower face will crash on the ground first, and subsequently, the gingiva, lip, chin, incisor, and the mandible will be injured. Of the mandibular fractures in this study, condyle and symphysis were the major fracture sites. Anatomically, condyle and symphysis are weak points of the mandible, and they easily fracture when attacked. When the chin crashes on the floor, this leads to direct forces on the symphysis, and then the forces are transmitted through the body and ramus to the condyle, resulting in condylar fractures.17 Moreover, accident falls usually are low-velocity forces, and always result in intracapsular condylar fracture and greenstick fracture of the mandible. These findings were well correlated in our study. Clinically, the condyle usually fractures accompanying with chin injuries. In the present study, of the 19 condylar fractures,

TABLE 2. Site Distribution of 102 Dental Traumas in 36 Patients Upper Arch

FIGURE 3. Site distribution of 166 soft-tissue injuries in 103 patients.

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Lower Arch

Tooth Position

Left

Right

Left

Right

Subtotal

Central incisor Lateral incisor Canine First molar Second molar Subtotal

12 7 1 2 0 22

10 5 1 1 1 18

14 12 2 2 1 31

12 11 2 2 4 31

48 35 6 7 6 102

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014

14 sustained chin injuries; of the 22 chin injuries, 14 occurred condylar fractures, including 5 bilateral fractures. Owing to the lack of cooperation from infants and preschools, chin injuries would be an important clue for the possibility of condylar fractures. Computed tomography should be applied when necessary. The condyle is related to mandibular growth and development, and condylar fractures in infants and preschools need proper management. For condylar fractures, we followed these treatment principles: (1) for condylar fractures without obvious displacement and malocclusion, soft diet and observation were recommended; (2) for condylar fractures with slight malocclusion or displacement, the screw-based intermaxillary fixation with a designed splint was applied for 1 month9; (3) for condylar fractures with obvious displacement or malocclusion and comminuted condylar fractures, ORIF or removal of the fracture fragment was performed. Conservative treatment was considered as the most reliable approach in managing pediatric maxillofacial fractures.11 However, less than half of maxillofacial fractures in infants and preschools received conservative treatment in the present study; this is obviously less than the reported proportion in pediatric patients.7,11 In the largest tertiary referral specialized hospital in central China, serious and complicated maxillofacial fractures are more common, and this might lead to a higher proportion of open surgery. ORIF with resorbable or titanium plate was performed in parts of these cases. In fact, both resorbable and titanium plates are suitable materials for ORIF; each type has its benefits and disadvantages. Resorbable plates avoid the second removal surgery and benefit for mandibular development; however, the low intensity, large size, inflammation during the resorb process, and the high price limit the application.18 Titanium plates provide enough burden for fractures; however, the negative effects on development are still controversial. Thus, to prevent the influence of titanium plates on mandibular growth, removal of the titanium plates was recommended.18 No matter which site, type, and treatment modality of maxillofacial fractures, continuous follow-up for facial development should be insisted until they reach adulthood.

CONCLUSIONS Maxillofacial injuries in infants and preschools exhibit specific epidemiological features. These are related to anatomic, physiologic, and psychologic development in infants and preschools. Chin injuries in infants and preschools indicate condylar fractures. The choice of treatment methods should consider the influences of treatment on the development for infants and preschools.

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2. Kumaraswamy SV, Madan N, Keerthi R, et al. Pediatric injuries in maxillofacial trauma: a 5 year study. J Maxillofac Oral Surg 2009;8:150–153 3. Munante-Cardenas JL, Olate S, Asprino L, et al. Pattern and treatment of facial trauma in pediatric and adolescent patients. J Craniofac Surg 2011;22:1251–1255 4. Qing-Bin Z, Zhao-Qiang Z, Dan C, et al. Epidemiology of maxillofacial injury in children under 15 years of age in southern China. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:436–441 5. Gassner R, Tuli T, Hachl O, et al. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg 2004;62:399–407 6. Zhou HH, Ongodia D, Liu Q, et al. Incidence and pattern of maxillofacial fractures in children and adolescents: a 10 years retrospective cohort study. Int J Pediatr Otorhinolaryngol 2013;77:494–498 7. Yamamoto K, Matsusue Y, Horita S, et al. Maxillofacial fractures in children. J Craniofac Surg 2013;24:153–157 8. Thoren H, Iso-Kungas P, Iizuka T, et al. Changing trends in causes and patterns of facial fractures in children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:318–324 9. Wu Y, Long X, Fang W, et al. Management of paediatric mandibular condylar fractures with screw-based semi-rigid intermaxillary fixation. Int J Oral Maxillofac Surg 2012;41:55–60 10. Osunde OD, Amole IO, Ver-or N, et al. Pediatric maxillofacial injuries at a Nigerian teaching hospital: a three-year review. Niger J Clin Pract 2013;16:149–154 11. Singhal R, Singh V, Bhagol A, et al. Pediatric maxillofacial injuries—if a new look is required? Int J Pediatr Otorhinolaryngol 2013;77:1333–1336 12. Cavalcanti AL, Melo TR. Facial and oral injuries in Brazilian children aged 5–17 years: 5-year review. Eur Arch Paediatr Dent 2008;9:102–104 13. Bamjee Y, Lownie JF, Cleaton-Jones PE, et al. Maxillofacial injuries in a group of South Africans under 18 years of age. Br J Oral Maxillofac Surg 1996;34:298–302 14. Kotecha S, Scannell J, Monaghan A, et al. A four year retrospective study of 1,062 patients presenting with maxillofacial emergencies at a specialist paediatric hospital. Br J Oral Maxillofac Surg 2008;46:293–296 15. Rahman RA, Ramli R, Rahman NA, et al. Maxillofacial trauma of pediatric patients in Malaysia: a retrospective study from 1999 to 2001 in three hospitals. Int J Pediatr Otorhinolaryngol 2007;71:929–936 16. Iso-Kungas P, Tornwall J, Suominen AL, et al. Dental injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofac Surg 2012;70:396–400 17. Yang R, Zhang C, Liu Y, et al. Why should we start from mandibular fractures in the treatment of panfacial fractures? J Oral Maxillofac Surg 2012;70:1386–1392 18. Turvey TA, Proffit WP, Phillips C. Biodegradable fixation for craniomaxillofacial surgery: a 10-year experience involving 761 operations and 745 patients. Int J Oral Maxillofac Surg 2011;40:244–249

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Maxillofacial injuries in infants and preschools: a 2.5-year study.

This study aims to evaluate the epidemiology of maxillofacial injuries in infants and preschools...
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