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European Maxillofacial Trauma (EURMAT) in children: A multicenter and prospective study Paolo Boffano, MD,a Fabio Roccia, MD,b Emanuele Zavattero, MD,b Emil Dediol, MD PhD,c Kovacic, MD,d Ales Vesnaver, MD, PhD,d Vedran Uglesic, MD, PhD,c Ziga Vitomir S. Konstantinovic, DDS, MD, PhD,e Milan Petrovic, DDS, MD,e Jonny Stephens, MMedSci,f Amar Kanzaria, BChD, MFDS, RCS,f Nabeel Bhatti, MFDS, RCS, MRCS,f Simon Holmes, FDS, RCS, FRCS,f Petia F. Pechalova, DDS, MD, PhD,g Angel G. Bakardjiev, DDS, PhD,g Vladislav A. Malanchuk, MD, DDS, PhD,h Andrey V. Kopchak, DDS, PhD,h Pål Galteland, MD, DDS,i Even Mjøen, MD, DDS,i Per Skjelbred, MD, DDS, PhD,i Fanny Grimaud, MD,j Fabien Fauvel, MD,j Julie Longis, MD,j Pierre Corre, MD,j Sigbjørn Løes, DDS, PhD,k Njål Lekven, DDS,k Sean Laverick, FDS, FRCS,l Peter Gordon, MFDS, MRCS,l Tiia Tamme, MD, PhD,m Stephanie Akermann, DDS,m K. Hakki Karagozoglu, MD, DDS,a Sofie C. Kommers, MD, DDS,a Brigitte Meijer, MD, DDS,a and Tymour Forouzanfar, MD, DDS, PhDa Objective. The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year. Study Design. The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years. Results. The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures. Conclusions. Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-6)
a Department of Oral and Maxillofacial Surgery/Pathology, VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands. b Department of Maxillofacial Surgery, University of Turin, Turin, Italy. c Department of Maxillofacial Surgery, University Hospital Dubrava, Zagreb, Croatia. d Maxillofacial Department, UKC Ljubljana, Ljubljana, Slovenia. e Clinic of Maxillofacial Surgery, School of Dentistry, University of Belgrade, Belgrade, Serbia. f Department of Oral and Maxillofacial Surgery, Royal London Hospital, Barts Health NHS, London, UK. g Department of Maxillofacial Surgery, Medical University, Plovdiv, Bulgaria. h Department for Oral and Maxillofacial Surgery, Bogomolets National Medical University, Kiev, Ukraine. i Department of Maxillofacial Surgery, Oslo University Hospital, Oslo, Norway. j Service de Stomatologie et Chirurgie Maxillo-faciale, Chu de Nantes, France. k Department of Maxillofacial Surgery, University of Bergen, Bergen, Norway. l Department of Oral and Maxillofacial Surgery, NHS Tayside, University of Dundee, Dundee, UK. m Department of Maxillofacial surgery, Stomatology Clinic, Tartu University, Tartu, Estonia. Received for publication Sep 25, 2014; returned for revision Nov 1, 2014; accepted for publication Dec 12, 2014. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2014.12.012
Maxillofacial injuries in children are proportionally rare compared with adult facial fractures. The flexibility of the facial bones, the lack of pneumatization of the paranasal sinuses, and the protection allowed by the prominent buccal fat pad in infants may be some of the reasons for such a low incidence, in spite of the children’s greater cranial mass/body ratio.1-3 However, the causes and incidence of maxillofacial injuries in children vary widely because of social, cultural, and environmental factors.1,2 Moreover, trauma remains the leading cause of morbidity and mortality in children.4 Therefore, the knowledge of the causes, severity, and epidemiology of pediatric maxillofacial trauma is crucial for the establishment of appropriate clinical and research priorities for prevention measures.2,5,6 To our knowledge, no prospective multicenter study about pediatric maxillofacial trauma has been published. Therefore, several European centers that already
Statement of Clinical Relevance Falls can be acknowledged as the most important cause of facial trauma during the first years of life, whereas great attention should be paid to prevention measures during sport activities. 1
ORAL AND MAXILLOFACIAL SURGERY 2 Boffano et al.
had research experience in maxillofacial trauma7-24 decided to collaborate to start a prospective multicenter study of facial fracture epidemiology in Europe. The aim of this study is to present and discuss the results of this European scientific collaboration on a multicenter prospective study about pediatric maxillofacial trauma epidemiology during 1 year.
MATERIALS The present study was conducted at several European departments of oral and maxillofacial surgery: The Department of Oral and Maxillofacial Surgery/Pathology at the VU University Medical Center and Academic Centre for Dentistry Amsterdam (Amsterdam, The Netherlands), the Department of Maxillofacial Surgery at the University of Turin (Turin, Italy), the Department of Maxillofacial Surgery at the University Hospital Dubrava (Zagreb, Croatia), the Maxillofacial Department at the UKC Ljubljana (Ljubljana, Slovenia), the Clinic of Maxillofacial Surgery of the School of Dentistry at the University of Belgrade (Belgrade, Serbia), the Department of Oral and Maxillofacial Surgery of the Royal London Hospital at Barts Health National Health Service (NHS; London, UK), the Department of Maxillofacial Surgery at the Medical University (Plovdiv, Bulgaria), the Department for Oral and Maxillofacial Surgery at the Bogomolets National Medical University (Kiev, Ukraine), the Department of Maxillofacial Surgery at the Oslo University Hospital (Oslo, Norway), the Service de Stomatologie et Chirurgie Maxillo-faciale at the Chu de Nantes (Nantes, France), the Department of Maxillofacial Surgery at the University of Bergen (Bergen, Norway), the Department of Oral and Maxillofacial Surgery at NHS Tayside and University of Dundee, (Dundee, UK), and the Department of Maxillofacial surgery, Stomatology Clinic, Tartu University (Tartu, Estonia). This study is based on a systematic computerassisted database that allowed study collaborators to prospectively and continuously record all patients hospitalized with maxillofacial fractures in the involved maxillofacial surgery units across Europe from Monday, December 31, 2012, to Sunday, December 29, 2013. The following data were recorded for each patient: gender, age, etiology, etiology subtypes, site of facial fractures, Facial Injury Severity Score (FISS),25 date of injury, timing of intervention, type of intervention, length of hospital stay. For this study, only patients aged 15 years or younger were considered. The children included in the present study were divided into 3 groups according to age (younger than 6 years, 6-10 years, and 11-15 years). The following categories of cause of injury were considered: falls, road traffic accidents (RTA), assaults, sport injuries,
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and other causes. Sport injuries were analyzed and divided according to the type of sport. Road traffic accidents were classified according to the mechanism of injury (car accident, motorbike accident, pedestrian). Fractures were determined from radiographs or computed tomography scans (if they were considered necessary) at admission to hospital and classified in fractures of the mandible, orbito-zygomatic-maxillary complex (OZM), orbit, nose, LeFort, frontal sinus, and naso-orbital-ethmoidal (NOE). Orbital fractures were subclassified according to the involved walls, and LeFort fractures were divided according to LeFort I, II, and III types. Frontal sinus fractures were divided according to the involvement of the anterior or posterior tables. Mandibular fractures included fractures of the symphysis, body, angle, ramus, coronoid, extraarticular condyle, and intra-articular condyle. Data regarding the type of performed intervention (whether closed reduction or open reduction and internal fixation [ORIF]) were collected. Patient characteristics were analyzed using descriptive statistics. This study was approved by the Institutional Review Board (IRB) of the leading institution (Turin, Italy). We followed Helsinki Declaration guidelines.
RESULTS Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a total of 130 fractures and an average of 1.1 fractures per patient. On the whole, 82 patients were male and 32 were female, with a male/female ratio of 2.6:1. Mean age was 10.9 years (range, 1-15 years; median, 12; standard deviation, 3.8). Most patients were included in the age group 11 to 15 years (72/114, 63%), followed by the 6 to 10 years group (Table I). The male/female ratio progressively increased with age from a value of 1.3:1 in the youngest group to 3.8:1 in the oldest group. The most common cause of injury was fall with 36 patients, followed by sport injuries (31), RTA (17), other causes (16), and assaults (14) (Figure 1). According to age groups (Table II), sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. According to gender (Table III), assaults and sport were mainly responsible for maxillofacial injuries in boys, whereas falls and RTAs had a more uniform distribution between genders (although with a predominance for males). Football-associated facial injuries were the most common sport injuries (10 patients), followed by bicycle-, combat sportse, and rugby-associated fractures. As for RTAs, 7 children were injured while they were in a car, 6 reported facial injuries as pedestrians,
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Table I. Demographic characteristics of the study population
Table III. Etiology according to gender of patients Gender
Assaults
Falls
RTA
Sport
Other
Total
Age groups
Males Females Total
13 1 14
22 14 36
11 6 17
24 7 31
12 4 16
82 32 114
Males
Females
Total
M:F
8 17 57 82
6 11 15 32
14 28 72 114
1.3:1 1.5:1 3.8:1 2.6:1
0-5 6-10 11-15 Total
RTA, road traffic accidents.
RTA, road traffic accidents.
Fig. 1. Percentages of causes of injury in the whole study population.
Fig. 2. Percentages of sites of fractures in the whole study population.
Table II. Etiology according to age groups Age groups 0-5 6-10 11-15 Total
Assaults
Falls
RTA
Sport
Other
Total
1 13 14
8 12 16 36
2 4 11 17
5 26 31
4 6 6 16
14 28 72 114
RTA, road traffic accidents.
2 children reported an accident while they were on a motorcycle, and the remaining 2 patients reported other mechanisms of injury. The most commonly observed fracture involved the mandible with 47 fractures, followed by orbital (22), nose (21), OZM (19), LeFort (12), frontal sinus (6), and NOE fractures (3) (Figure 2). As for the mandible, 18 condylar fractures were recorded (14 extra-articular, 4 intraarticular), followed by 12 body fractures, 11 fractures of the symphyseal region, 4 angle fractures, and 2 fractures of the ramus (Figure 3). On the whole, 12 orbital floor fractures, 6 medial wall fractures, 2 lateral wall fractures, and 2 orbital roof fractures were detected. Out of the 12 LeFort fractures, 4 Le Fort I, 5 Le Fort II, and 3 Le Fort III fractures were recorded. FISS mean score in the study population was 2.1 (range, 1-12; median, 1; standard deviation, 1.7). The analysis of dates of injury allowed us to calculate a month distribution of injuries (Figure 4): A mild predominance of summer months can be noted, with August as the most represented month, although a quite uniform distribution among all months is noted, with few exceptions (February, September). Timing of intervention varied widely: In 40 cases treatment was performed within 24 hours from injury; in
Fig. 3. Percentages of subsites of mandibular fractures in the whole study population.
35 cases treatment was performed within 72 hours (but after 24 hours) from injury; and the remaining 39 patients underwent treatment beyond 72 hours. On the whole, 75 children underwent ORIF, whereas in 39 children a closed reduction was performed. Mean hospital stay was 3.1 days (range, 1-11; median, 1; standard deviation, 1.7).
DISCUSSION Clinical features of pediatric maxillofacial trauma change because of social, cultural, and environmental factors: They vary from one country to another and even within the same country.1,6 Furthermore, the incidence and etiology of pediatric maxillofacial injuries are also strictly affected by age-related activities.1 In literature, facial fractures in children are reported to be less than 15% of all facial fractures.1 This is widely confirmed by our multicenter study population, which confirmed that just 3.3% of maxillofacial trauma patients during the year were children aged 15 years or younger. Such a low incidence of pediatric injuries may be partially explained by the flexibility of the facial
ORAL AND MAXILLOFACIAL SURGERY 4 Boffano et al.
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Fig. 4. Month distribution of injuries.
bones, the lack of pneumatization of the paranasal sinuses, and the protection allowed by the prominent buccal fat pad in infants, as aforementioned. An important factor is also the higher craniofacial ratio in children (8:1) compared with adults (2:1). However, the progressive increase of European mean age and the aging of its population may play an important role too. In agreement with previous studies,1,26,27 we found that facial injuries are rare before the age of 5 years, whereas their incidence progressively increases with the beginning of school and adolescence. In fact, in our study population most patients (63%) were in the 11-15 years group, whereas just about the 12% of children were 5 years old or younger. The general male/female ratio of our study population was 2.6:1, in agreement with the results of previous articles.4,6 However, the male/female ratio progressively increased with age from a value of 1.3:1 in the youngest group to 3.8:1 in the oldest group. This may be due to a progressive change in everyday and physical activities between boys and girls after 5 years of age. In fact, as Tables II and III show, assaults and sport accidents (which present a strong male predominance) are almost limited to the oldest group of age, thus explaining this progressively increasing trend of male/ female ratio. Instead, during the first years of life, most children are under the care of parents and their major activity context is the family house. In fact, in the youngest age group (0-5 years), the most commonly observed cause of facial injuries is falls, which show a more uniform distribution between genders. Falls may be due to the uncertainty of motion and lack of coordination in the first years that would prevent young children from adequately shielding themselves from a blow.2,5 Finally, it is worthy to remember that the use of car seat restraints for infants and young children may
contribute to the lower frequency of RTA-associated pediatric facial trauma.3 Therefore, our multicenter prospective study confirms that falls are the primary source of trauma in children. Assaults and sport injuries are more uncommon causes of facial fractures in children, and they are seen in older age groups. In the present study, a total of 130 fractures with an average of 1.1 fractures per patient were recorded. The mandible was the most common fracture site in children (36%), followed by the orbital walls (17%), the nose (16%), and the zygomatic complex (15%), in agreement with previous studies.3,26 In particular, the condyle (extra-articular and intra-articular) was the most common mandibular fracture site with a whole percentage of 39%, thus confirming the results of several authors.27,28 The anterior and middle regions (symphysis and body) of the mandible were the next most involved areas. The low incidence of angle fractures may be partially explained by the absence of a third molar and therefore with the continuity and integrity of the superior cortical border in correspondence of the angle region. Unfortunately, the incidence of nasal fractures still present an important bias, because in some hospitals of the present study they are also seen and treated by otolaryngology divisions, thus possibly underestimating their real incidence in this study. As for the monthly distribution of injuries, a mild predominance of summer months can be observed, with August as the most involved month, although a quite uniform distribution among all months is noted with few exceptions (February, September). Of course, this trend with a higher incidence during June, July, and August may be related to the long evenings and school vacations in summer months, when children can perform outdoor activities more easily.3
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Timing of intervention varied widely: In 40 cases treatment was performed within 24 hours from injury; in 35 cases treatment was performed within 72 hours (but after 24 hours) from injury; and the remaining 39 patients underwent treatment beyond 72 hours. On the whole, 75 children underwent ORIF, whereas in 39 children a closed reduction was performed. Treatment of pediatric facial fractures depends on the type and site of fractures and on the skeletal and dental development.1 In children, conservative treatment is sometimes preferred in comparison with adult patients, although there is still no consensus on the treatment of maxillofacial fractures in pediatric patients.3 However, the aim of our scientific collaboration was focused on epidemiology of maxillofacial trauma. Therefore, the collected data mainly related to incidence and etiology of facial fractures.
CONCLUSIONS This scientific collaboration among European institutions allowed us to perform the first prospective multicenter study on maxillofacial trauma epidemiology in a pediatric population in Europe. Our results may be the first step in the establishment of appropriate clinical and research priorities for prevention measures in children. A thorough knowledge of mechanisms of trauma may be crucial for both prevention and treatment of maxillofacial trauma, and further multicenter studies may provide an important contribution for this purpose. Falls can be acknowledged as the most important cause of facial trauma during the first years of life, whereas great attention should be paid to prevention measures during sport activities. In fact, the high incidence of sport accidents after age 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most common fracture site. Again, a consensus on the management of condylar fractures in children would be crucial to inform and improve their treatment. REFERENCES 1. Ogunlewe MO, James O, Ladeinde AL, Adeyemo WL. Pattern of paediatric maxillofacial fractures in Lagos, Nigeria. Int J Paediatr Dent. 2006;16:358-362. 2. Eggensperger Wymann NM, Hölzle A, Zachariou Z, Iizuka T. Pediatric craniofacial trauma. J Oral Maxillofac Surg. 2008;66: 58-64. 3. Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN. Facial fractures in children and adolescents: a retrospective study of 3 years in a hospital in Belo Horizonte, Brazil. Dent Traumatol. 2010;26:262-270. 4. Gassner R, Tuli T, Hächl O, Moreira R, Ulmer H. 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.
ORIGINAL ARTICLE Boffano et al. 5 5. Rahman RA, Ramli R, Rahman NA, Hussaini HM, Idrus SM, Hamid 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. 6. Li Z, Li ZB. Characteristic changes of pediatric maxillofacial fractures in China during the past 20 years. J Oral Maxillofac Surg. 2008;66:2239-2242. 7. Ahmad Z, Nouraei R, Holmes S. Toward a classification system for complex craniofacial fractures. Br J Oral Maxillofac Surg. 2012;50:490-494. 8. Al-Qamachi LH, Laverick S, Jones DC. A clinico-demographic analysis of maxillofacial trauma in the elderly. Gerodontology. 2012;29:E147-149. 9. Bakardjiev A, Pechalova P. Maxillofacial fractures in Southern Bulgariada retrospective study of 1706 cases. J Craniomaxillofac Surg. 2007;35:147-150. 10. Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T. Bicycle-related maxillofacial injuries: A doublecenter study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:275-280. 11. Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T. Diplopia and orbital wall fractures. J Craniofac Surg. 2014;25: E183-185. 12. Corre P, Arzul L, Khonsari RH, Mercier J. Facial trauma and multiple trauma. Soins. 2013;778:43-45. 13. Dediol E. The role of three-dimensional computed tomography in evaluating facial trauma. Plast Reconstr Surg. 2012;129: 354e-355e. 14. Konstantinovic VS, Puzovic D, Anicic B, Jelovac DB. Epidemiologic, clinical, and forensic aspects of chainsaw, circular saw, and grinding saw injuries in the maxillofacial region. J Craniofac Surg. 2010;21:1029-1032. 15. Laverick S, Patel N, Jones DC. Maxillofacial trauma and the role of alcohol. Br J Oral Maxillofac Surg. 2008;46:542-546. 16. Lekven N, Neppelberg E, Tornes K. Long-term follow-up of mandibular condylar fractures in children. J Oral Maxillofac Surg. 2011;69:2853-2859. 17. Malanchuk VO, Kopchak AV. Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area. J Craniomaxillofac Surg. 2007;35:57-62. 18. Skjelbred P. Management of facial injuries. Tidsskr Nor Laegeforen. 1992;112:1032-1037. 19. Tamme T, Soots M, Kulla A, et al. Odontogenic tumours, a collaborative retrospective study of 75 cases covering more than 25 years from Estonia. J Craniomaxillofac Surg. 2004;32:161-165. 20. Uglesic V, Virag M, Aljinovic N, Macan D. Evaluation of mandibular fracture treatment. J Craniomaxillofac Surg. 1993;21: 251-257. 21. van den Bergh B, Heymans MW, Duvekot F, Forouzanfar T. Treatment and complications of mandibular fractures: a 10-year analysis. J Craniomaxillofac Surg. 2012;40:e108-e111. 22. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg. 2012;40:E165-169. 23. Vesnaver A, Ahcan U, Rozman J. Evaluation of surgical treatment in mandibular condyle fractures. J Craniomaxillofac Surg. 2012;40:647-653. 24. Vesnaver A, Gorjanc M, Eberlinc A, Dovsak DA, Kansky AA. The periauricular transparotid approach for open reduction and internal fixation of condylar fractures. J Craniomaxillofac Surg. 2005;33:169-179. 25. Bagheri SC, Dierks EJ, Kademani D, et al. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg. 2006;64:408-414.
ORAL AND MAXILLOFACIAL SURGERY 6 Boffano et al. 26. Oji C. Fractures of the facial skeleton in children: a survey of patients under the age of 11 years. J Cranio-Maxillofac Surg. 1998;26:322-325. 27. Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofac Surg. 1993;51: 836-844. 28. Iida S, Matsuya T. Paediatric maxillofacial fractures: their aetiological characters and fracture patterns. J Craniomaxillofac Surg. 2002;30:237-241.
OOOO Month 2015 Reprint requests: Dr. Paolo Boffano, MD Department of Oral and Maxillofacial Surgery/Pathology VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057 1007 MB Amsterdam The Netherlands [email protected]
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European Maxillofacial Trauma (EURMAT) in children: A multicenter and prospective study Paolo Boffano, MD,a Fabio Roccia, MD,b Emanuele Zavattero, MD,b Emil Dediol, MD PhD,c Kovacic, MD,d Ales Vesnaver, MD, PhD,d Vedran Uglesic, MD, PhD,c Ziga Vitomir S. Konstantinovic, DDS, MD, PhD,e Milan Petrovic, DDS, MD,e Jonny Stephens, MMedSci,f Amar Kanzaria, BChD, MFDS, RCS,f Nabeel Bhatti, MFDS, RCS, MRCS,f Simon Holmes, FDS, RCS, FRCS,f Petia F. Pechalova, DDS, MD, PhD,g Angel G. Bakardjiev, DDS, PhD,g Vladislav A. Malanchuk, MD, DDS, PhD,h Andrey V. Kopchak, DDS, PhD,h Pål Galteland, MD, DDS,i Even Mjøen, MD, DDS,i Per Skjelbred, MD, DDS, PhD,i Fanny Grimaud, MD,j Fabien Fauvel, MD,j Julie Longis, MD,j Pierre Corre, MD,j Sigbjørn Løes, DDS, PhD,k Njål Lekven, DDS,k Sean Laverick, FDS, FRCS,l Peter Gordon, MFDS, MRCS,l Tiia Tamme, MD, PhD,m Stephanie Akermann, DDS,m K. Hakki Karagozoglu, MD, DDS,a Sofie C. Kommers, MD, DDS,a Brigitte Meijer, MD, DDS,a and Tymour Forouzanfar, MD, DDS, PhDa Objective. The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year. Study Design. The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years. Results. The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures. Conclusions. Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;-:1-6)
a Department of Oral and Maxillofacial Surgery/Pathology, VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands. b Department of Maxillofacial Surgery, University of Turin, Turin, Italy. c Department of Maxillofacial Surgery, University Hospital Dubrava, Zagreb, Croatia. d Maxillofacial Department, UKC Ljubljana, Ljubljana, Slovenia. e Clinic of Maxillofacial Surgery, School of Dentistry, University of Belgrade, Belgrade, Serbia. f Department of Oral and Maxillofacial Surgery, Royal London Hospital, Barts Health NHS, London, UK. g Department of Maxillofacial Surgery, Medical University, Plovdiv, Bulgaria. h Department for Oral and Maxillofacial Surgery, Bogomolets National Medical University, Kiev, Ukraine. i Department of Maxillofacial Surgery, Oslo University Hospital, Oslo, Norway. j Service de Stomatologie et Chirurgie Maxillo-faciale, Chu de Nantes, France. k Department of Maxillofacial Surgery, University of Bergen, Bergen, Norway. l Department of Oral and Maxillofacial Surgery, NHS Tayside, University of Dundee, Dundee, UK. m Department of Maxillofacial surgery, Stomatology Clinic, Tartu University, Tartu, Estonia. Received for publication Sep 25, 2014; returned for revision Nov 1, 2014; accepted for publication Dec 12, 2014. Ó 2015 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2014.12.012
Maxillofacial injuries in children are proportionally rare compared with adult facial fractures. The flexibility of the facial bones, the lack of pneumatization of the paranasal sinuses, and the protection allowed by the prominent buccal fat pad in infants may be some of the reasons for such a low incidence, in spite of the children’s greater cranial mass/body ratio.1-3 However, the causes and incidence of maxillofacial injuries in children vary widely because of social, cultural, and environmental factors.1,2 Moreover, trauma remains the leading cause of morbidity and mortality in children.4 Therefore, the knowledge of the causes, severity, and epidemiology of pediatric maxillofacial trauma is crucial for the establishment of appropriate clinical and research priorities for prevention measures.2,5,6 To our knowledge, no prospective multicenter study about pediatric maxillofacial trauma has been published. Therefore, several European centers that already
Statement of Clinical Relevance Falls can be acknowledged as the most important cause of facial trauma during the first years of life, whereas great attention should be paid to prevention measures during sport activities. 1
ORAL AND MAXILLOFACIAL SURGERY 2 Boffano et al.
had research experience in maxillofacial trauma7-24 decided to collaborate to start a prospective multicenter study of facial fracture epidemiology in Europe. The aim of this study is to present and discuss the results of this European scientific collaboration on a multicenter prospective study about pediatric maxillofacial trauma epidemiology during 1 year.
MATERIALS The present study was conducted at several European departments of oral and maxillofacial surgery: The Department of Oral and Maxillofacial Surgery/Pathology at the VU University Medical Center and Academic Centre for Dentistry Amsterdam (Amsterdam, The Netherlands), the Department of Maxillofacial Surgery at the University of Turin (Turin, Italy), the Department of Maxillofacial Surgery at the University Hospital Dubrava (Zagreb, Croatia), the Maxillofacial Department at the UKC Ljubljana (Ljubljana, Slovenia), the Clinic of Maxillofacial Surgery of the School of Dentistry at the University of Belgrade (Belgrade, Serbia), the Department of Oral and Maxillofacial Surgery of the Royal London Hospital at Barts Health National Health Service (NHS; London, UK), the Department of Maxillofacial Surgery at the Medical University (Plovdiv, Bulgaria), the Department for Oral and Maxillofacial Surgery at the Bogomolets National Medical University (Kiev, Ukraine), the Department of Maxillofacial Surgery at the Oslo University Hospital (Oslo, Norway), the Service de Stomatologie et Chirurgie Maxillo-faciale at the Chu de Nantes (Nantes, France), the Department of Maxillofacial Surgery at the University of Bergen (Bergen, Norway), the Department of Oral and Maxillofacial Surgery at NHS Tayside and University of Dundee, (Dundee, UK), and the Department of Maxillofacial surgery, Stomatology Clinic, Tartu University (Tartu, Estonia). This study is based on a systematic computerassisted database that allowed study collaborators to prospectively and continuously record all patients hospitalized with maxillofacial fractures in the involved maxillofacial surgery units across Europe from Monday, December 31, 2012, to Sunday, December 29, 2013. The following data were recorded for each patient: gender, age, etiology, etiology subtypes, site of facial fractures, Facial Injury Severity Score (FISS),25 date of injury, timing of intervention, type of intervention, length of hospital stay. For this study, only patients aged 15 years or younger were considered. The children included in the present study were divided into 3 groups according to age (younger than 6 years, 6-10 years, and 11-15 years). The following categories of cause of injury were considered: falls, road traffic accidents (RTA), assaults, sport injuries,
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and other causes. Sport injuries were analyzed and divided according to the type of sport. Road traffic accidents were classified according to the mechanism of injury (car accident, motorbike accident, pedestrian). Fractures were determined from radiographs or computed tomography scans (if they were considered necessary) at admission to hospital and classified in fractures of the mandible, orbito-zygomatic-maxillary complex (OZM), orbit, nose, LeFort, frontal sinus, and naso-orbital-ethmoidal (NOE). Orbital fractures were subclassified according to the involved walls, and LeFort fractures were divided according to LeFort I, II, and III types. Frontal sinus fractures were divided according to the involvement of the anterior or posterior tables. Mandibular fractures included fractures of the symphysis, body, angle, ramus, coronoid, extraarticular condyle, and intra-articular condyle. Data regarding the type of performed intervention (whether closed reduction or open reduction and internal fixation [ORIF]) were collected. Patient characteristics were analyzed using descriptive statistics. This study was approved by the Institutional Review Board (IRB) of the leading institution (Turin, Italy). We followed Helsinki Declaration guidelines.
RESULTS Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a total of 130 fractures and an average of 1.1 fractures per patient. On the whole, 82 patients were male and 32 were female, with a male/female ratio of 2.6:1. Mean age was 10.9 years (range, 1-15 years; median, 12; standard deviation, 3.8). Most patients were included in the age group 11 to 15 years (72/114, 63%), followed by the 6 to 10 years group (Table I). The male/female ratio progressively increased with age from a value of 1.3:1 in the youngest group to 3.8:1 in the oldest group. The most common cause of injury was fall with 36 patients, followed by sport injuries (31), RTA (17), other causes (16), and assaults (14) (Figure 1). According to age groups (Table II), sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. According to gender (Table III), assaults and sport were mainly responsible for maxillofacial injuries in boys, whereas falls and RTAs had a more uniform distribution between genders (although with a predominance for males). Football-associated facial injuries were the most common sport injuries (10 patients), followed by bicycle-, combat sportse, and rugby-associated fractures. As for RTAs, 7 children were injured while they were in a car, 6 reported facial injuries as pedestrians,
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Table I. Demographic characteristics of the study population
Table III. Etiology according to gender of patients Gender
Assaults
Falls
RTA
Sport
Other
Total
Age groups
Males Females Total
13 1 14
22 14 36
11 6 17
24 7 31
12 4 16
82 32 114
Males
Females
Total
M:F
8 17 57 82
6 11 15 32
14 28 72 114
1.3:1 1.5:1 3.8:1 2.6:1
0-5 6-10 11-15 Total
RTA, road traffic accidents.
RTA, road traffic accidents.
Fig. 1. Percentages of causes of injury in the whole study population.
Fig. 2. Percentages of sites of fractures in the whole study population.
Table II. Etiology according to age groups Age groups 0-5 6-10 11-15 Total
Assaults
Falls
RTA
Sport
Other
Total
1 13 14
8 12 16 36
2 4 11 17
5 26 31
4 6 6 16
14 28 72 114
RTA, road traffic accidents.
2 children reported an accident while they were on a motorcycle, and the remaining 2 patients reported other mechanisms of injury. The most commonly observed fracture involved the mandible with 47 fractures, followed by orbital (22), nose (21), OZM (19), LeFort (12), frontal sinus (6), and NOE fractures (3) (Figure 2). As for the mandible, 18 condylar fractures were recorded (14 extra-articular, 4 intraarticular), followed by 12 body fractures, 11 fractures of the symphyseal region, 4 angle fractures, and 2 fractures of the ramus (Figure 3). On the whole, 12 orbital floor fractures, 6 medial wall fractures, 2 lateral wall fractures, and 2 orbital roof fractures were detected. Out of the 12 LeFort fractures, 4 Le Fort I, 5 Le Fort II, and 3 Le Fort III fractures were recorded. FISS mean score in the study population was 2.1 (range, 1-12; median, 1; standard deviation, 1.7). The analysis of dates of injury allowed us to calculate a month distribution of injuries (Figure 4): A mild predominance of summer months can be noted, with August as the most represented month, although a quite uniform distribution among all months is noted, with few exceptions (February, September). Timing of intervention varied widely: In 40 cases treatment was performed within 24 hours from injury; in
Fig. 3. Percentages of subsites of mandibular fractures in the whole study population.
35 cases treatment was performed within 72 hours (but after 24 hours) from injury; and the remaining 39 patients underwent treatment beyond 72 hours. On the whole, 75 children underwent ORIF, whereas in 39 children a closed reduction was performed. Mean hospital stay was 3.1 days (range, 1-11; median, 1; standard deviation, 1.7).
DISCUSSION Clinical features of pediatric maxillofacial trauma change because of social, cultural, and environmental factors: They vary from one country to another and even within the same country.1,6 Furthermore, the incidence and etiology of pediatric maxillofacial injuries are also strictly affected by age-related activities.1 In literature, facial fractures in children are reported to be less than 15% of all facial fractures.1 This is widely confirmed by our multicenter study population, which confirmed that just 3.3% of maxillofacial trauma patients during the year were children aged 15 years or younger. Such a low incidence of pediatric injuries may be partially explained by the flexibility of the facial
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Fig. 4. Month distribution of injuries.
bones, the lack of pneumatization of the paranasal sinuses, and the protection allowed by the prominent buccal fat pad in infants, as aforementioned. An important factor is also the higher craniofacial ratio in children (8:1) compared with adults (2:1). However, the progressive increase of European mean age and the aging of its population may play an important role too. In agreement with previous studies,1,26,27 we found that facial injuries are rare before the age of 5 years, whereas their incidence progressively increases with the beginning of school and adolescence. In fact, in our study population most patients (63%) were in the 11-15 years group, whereas just about the 12% of children were 5 years old or younger. The general male/female ratio of our study population was 2.6:1, in agreement with the results of previous articles.4,6 However, the male/female ratio progressively increased with age from a value of 1.3:1 in the youngest group to 3.8:1 in the oldest group. This may be due to a progressive change in everyday and physical activities between boys and girls after 5 years of age. In fact, as Tables II and III show, assaults and sport accidents (which present a strong male predominance) are almost limited to the oldest group of age, thus explaining this progressively increasing trend of male/ female ratio. Instead, during the first years of life, most children are under the care of parents and their major activity context is the family house. In fact, in the youngest age group (0-5 years), the most commonly observed cause of facial injuries is falls, which show a more uniform distribution between genders. Falls may be due to the uncertainty of motion and lack of coordination in the first years that would prevent young children from adequately shielding themselves from a blow.2,5 Finally, it is worthy to remember that the use of car seat restraints for infants and young children may
contribute to the lower frequency of RTA-associated pediatric facial trauma.3 Therefore, our multicenter prospective study confirms that falls are the primary source of trauma in children. Assaults and sport injuries are more uncommon causes of facial fractures in children, and they are seen in older age groups. In the present study, a total of 130 fractures with an average of 1.1 fractures per patient were recorded. The mandible was the most common fracture site in children (36%), followed by the orbital walls (17%), the nose (16%), and the zygomatic complex (15%), in agreement with previous studies.3,26 In particular, the condyle (extra-articular and intra-articular) was the most common mandibular fracture site with a whole percentage of 39%, thus confirming the results of several authors.27,28 The anterior and middle regions (symphysis and body) of the mandible were the next most involved areas. The low incidence of angle fractures may be partially explained by the absence of a third molar and therefore with the continuity and integrity of the superior cortical border in correspondence of the angle region. Unfortunately, the incidence of nasal fractures still present an important bias, because in some hospitals of the present study they are also seen and treated by otolaryngology divisions, thus possibly underestimating their real incidence in this study. As for the monthly distribution of injuries, a mild predominance of summer months can be observed, with August as the most involved month, although a quite uniform distribution among all months is noted with few exceptions (February, September). Of course, this trend with a higher incidence during June, July, and August may be related to the long evenings and school vacations in summer months, when children can perform outdoor activities more easily.3
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Timing of intervention varied widely: In 40 cases treatment was performed within 24 hours from injury; in 35 cases treatment was performed within 72 hours (but after 24 hours) from injury; and the remaining 39 patients underwent treatment beyond 72 hours. On the whole, 75 children underwent ORIF, whereas in 39 children a closed reduction was performed. Treatment of pediatric facial fractures depends on the type and site of fractures and on the skeletal and dental development.1 In children, conservative treatment is sometimes preferred in comparison with adult patients, although there is still no consensus on the treatment of maxillofacial fractures in pediatric patients.3 However, the aim of our scientific collaboration was focused on epidemiology of maxillofacial trauma. Therefore, the collected data mainly related to incidence and etiology of facial fractures.
CONCLUSIONS This scientific collaboration among European institutions allowed us to perform the first prospective multicenter study on maxillofacial trauma epidemiology in a pediatric population in Europe. Our results may be the first step in the establishment of appropriate clinical and research priorities for prevention measures in children. A thorough knowledge of mechanisms of trauma may be crucial for both prevention and treatment of maxillofacial trauma, and further multicenter studies may provide an important contribution for this purpose. Falls can be acknowledged as the most important cause of facial trauma during the first years of life, whereas great attention should be paid to prevention measures during sport activities. In fact, the high incidence of sport accidents after age 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most common fracture site. Again, a consensus on the management of condylar fractures in children would be crucial to inform and improve their treatment. REFERENCES 1. Ogunlewe MO, James O, Ladeinde AL, Adeyemo WL. Pattern of paediatric maxillofacial fractures in Lagos, Nigeria. Int J Paediatr Dent. 2006;16:358-362. 2. Eggensperger Wymann NM, Hölzle A, Zachariou Z, Iizuka T. Pediatric craniofacial trauma. J Oral Maxillofac Surg. 2008;66: 58-64. 3. Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN. Facial fractures in children and adolescents: a retrospective study of 3 years in a hospital in Belo Horizonte, Brazil. Dent Traumatol. 2010;26:262-270. 4. Gassner R, Tuli T, Hächl O, Moreira R, Ulmer H. 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.
ORIGINAL ARTICLE Boffano et al. 5 5. Rahman RA, Ramli R, Rahman NA, Hussaini HM, Idrus SM, Hamid 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. 6. Li Z, Li ZB. Characteristic changes of pediatric maxillofacial fractures in China during the past 20 years. J Oral Maxillofac Surg. 2008;66:2239-2242. 7. Ahmad Z, Nouraei R, Holmes S. Toward a classification system for complex craniofacial fractures. Br J Oral Maxillofac Surg. 2012;50:490-494. 8. Al-Qamachi LH, Laverick S, Jones DC. A clinico-demographic analysis of maxillofacial trauma in the elderly. Gerodontology. 2012;29:E147-149. 9. Bakardjiev A, Pechalova P. Maxillofacial fractures in Southern Bulgariada retrospective study of 1706 cases. J Craniomaxillofac Surg. 2007;35:147-150. 10. Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T. Bicycle-related maxillofacial injuries: A doublecenter study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:275-280. 11. Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T. Diplopia and orbital wall fractures. J Craniofac Surg. 2014;25: E183-185. 12. Corre P, Arzul L, Khonsari RH, Mercier J. Facial trauma and multiple trauma. Soins. 2013;778:43-45. 13. Dediol E. The role of three-dimensional computed tomography in evaluating facial trauma. Plast Reconstr Surg. 2012;129: 354e-355e. 14. Konstantinovic VS, Puzovic D, Anicic B, Jelovac DB. Epidemiologic, clinical, and forensic aspects of chainsaw, circular saw, and grinding saw injuries in the maxillofacial region. J Craniofac Surg. 2010;21:1029-1032. 15. Laverick S, Patel N, Jones DC. Maxillofacial trauma and the role of alcohol. Br J Oral Maxillofac Surg. 2008;46:542-546. 16. Lekven N, Neppelberg E, Tornes K. Long-term follow-up of mandibular condylar fractures in children. J Oral Maxillofac Surg. 2011;69:2853-2859. 17. Malanchuk VO, Kopchak AV. Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area. J Craniomaxillofac Surg. 2007;35:57-62. 18. Skjelbred P. Management of facial injuries. Tidsskr Nor Laegeforen. 1992;112:1032-1037. 19. Tamme T, Soots M, Kulla A, et al. Odontogenic tumours, a collaborative retrospective study of 75 cases covering more than 25 years from Estonia. J Craniomaxillofac Surg. 2004;32:161-165. 20. Uglesic V, Virag M, Aljinovic N, Macan D. Evaluation of mandibular fracture treatment. J Craniomaxillofac Surg. 1993;21: 251-257. 21. van den Bergh B, Heymans MW, Duvekot F, Forouzanfar T. Treatment and complications of mandibular fractures: a 10-year analysis. J Craniomaxillofac Surg. 2012;40:e108-e111. 22. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg. 2012;40:E165-169. 23. Vesnaver A, Ahcan U, Rozman J. Evaluation of surgical treatment in mandibular condyle fractures. J Craniomaxillofac Surg. 2012;40:647-653. 24. Vesnaver A, Gorjanc M, Eberlinc A, Dovsak DA, Kansky AA. The periauricular transparotid approach for open reduction and internal fixation of condylar fractures. J Craniomaxillofac Surg. 2005;33:169-179. 25. Bagheri SC, Dierks EJ, Kademani D, et al. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg. 2006;64:408-414.
ORAL AND MAXILLOFACIAL SURGERY 6 Boffano et al. 26. Oji C. Fractures of the facial skeleton in children: a survey of patients under the age of 11 years. J Cranio-Maxillofac Surg. 1998;26:322-325. 27. Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving patterns of treatment. J Oral Maxillofac Surg. 1993;51: 836-844. 28. Iida S, Matsuya T. Paediatric maxillofacial fractures: their aetiological characters and fracture patterns. J Craniomaxillofac Surg. 2002;30:237-241.
OOOO Month 2015 Reprint requests: Dr. Paolo Boffano, MD Department of Oral and Maxillofacial Surgery/Pathology VU University Medical Center and Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057 1007 MB Amsterdam The Netherlands [email protected]
