J. Cranio-Max.-Fac. Surg. 18 (1990) 151

J. Cranio-Max.-Fac. Surg. 18 (1990) 151-153 © Georg Thieme Verlag Stuttgart • New York

Fractures of the Facial Skeleton in Children Nicholas Zachariades, Demetrius Papavassiliou, Fani Koumoura

Oral and Maxillofacial Dept. (Head: N. Zachariades, M.D., D.D.S.), General Peripheral Hospital of Attica-K. A. T. (formerly: "Apostle Paul's" Accidents Hospital), Kifissia, Athens, Greece

Submitted 31.7. 89; accepted 12.9.89

Summary

Among 3.908 patients with fractures of the facial ske- leton hospitalized in a 25-year period, 202 were chil- dren. 69 % were boys and 31% girls. A child is most ac- tive at the age of fourteen. Fractures of the upper alveo- lar bone and the condyle were the most common. We compared the pattern of fractures in children and those in adults recorded at the same period of time.

Key words

Accidents - Children - Maxillofacial injuries - Trau- matology

Introduction

Fractures of the facial skeleton, both in the adult and the child, comprise fractures of the upper and lower jaw, the zygomaticomaxillary complex, the orbit, and the nasal bones. They are often associated with lacerations, particu- larly of the lips, which are penetrated by the patient's teeth, as well as more serious injuries, such as loss of soft tissues, nasal bleeding, C.S.F. rhinorrhoea and otorrhoea, loss of vi- sion, injuries to the cervical spine, cerebral injuries, cranio- facial disruption and others. The facial skeleton is subject to serious injuries, particularly in road traffic accidents when no helmet or seat belts are used. Following the brief enforcement of the law in this country a dramatic decrease of facial fractures was noticed (Braham et al., 1977; Kaban et al., 1977; Tessier, 1979).

Material and Methods

From the Archives of the Oral and Maxillofacial Depart- ment of the General Peripheral Hospital of Attica we col- lected, studied and evaluated the fracture cases that were sustained by patients under the age of 14 years in a twenty- five year period covering the years 1960 through 1984. For technical reasons we omitted all the patients who were treated while hospitalized by other specialities of the Hos- pital or were treated on an out-patient basis, and who would have increased the reported cases by an estimated 10%. Through the 25 years the former category decreased as the latter increased; the past records, however, in earlier years were not adequately accurate on the subject.

Adutts

1.8 fracture per patient

Adul ts

Fig. 1 The facial fractures sex difference in adults and children and the involvement of the mandible vs. the upper middle third in the adult and the child,

Children

35

30

~ 25

U

20

15

t 2 3 t, 5 6 7 8 9 10 11 12 13 14 Children age

Fig.2 Age involvement in children.

1200

110( I

1 oo( I

800

700 I I 6OO

500

400

3OO

200

100

152 J. Cranio-Max.-Fac. Surg. 18 (1990) N. Zachariades et aL

10 20 30 40 50 60 70 80 age

Fig. 3 Involvement of all ages in facial fractures.

Results

During the years 1960-1984 we hospitalized 12,100 pa- tients. 3,908 were patients with fractures of the facial ske- leton. 202 were children under 14 years of age with such fractures. There were 139 boys and 63 girls (Fig. 1). The ae- tiology of fractures is shown in Table 1, while Table2 shows the types of fractures sustained. The age of the pa- tients is shown in Fig. 2.

Table 1 Aetiology of maxillofacial injuries

Adults Children % %

Road traffic accidents 57 5 Falls 20 32 Play 42 Violence 9 Sport 4 5 Industrial 5 Bicycle 9 Gun shot wounds 2 Other 3 7

Table 2 Types of fractures

Children Adults % %

Symphysis 43 15 1141 17 Body 40 14 1021 16 Angle 17 6 747 11 Ramus 11 4 360 6 Condyle 65 23 1155 18 Alveolar process 74 32 414 6 Palate 77 1 Nasal 3 1 138 2 Le Fort I 1 0,5 60 1 Le Fort II 5 2 202 3 Le Fort III 3 1 166 3 Zygomaticomaxillary complex 20 7 1031 16 Coronoid process 53 1

Table 3 Maxillofacial fractures per patient

Adults Children

1.8 1,4

Discussion and Conclusions

The Oral and Maxillofacial Department of K.A.T. Hospital is the oldest of its kind in Greece and until fairly recently the only one. At the beginning of the twenty-five year peri- od that we are covering (which practically corresponds to the opening of the hospital itself) we hospitalized practical- ly all the fractures of the maxillofacial skeleton as they had nowhere else to go. Although at the end of this period we only treated 60% of such cases (it is currently down to 40%) as new maxillofacial facilities were established in Athens and other parts of the country, in absolute numbers the cases we treat each year are ever increasing as the road traffic accidents are continuously on the increase. Indeed, in the decade 1974-1983, according to the National Statis- tical Service, the dead from Road Traffic Accidents (RTA) increased by 67% at an annual rate of 5.5%, while the in- jured rose by 100% with an annual rate of 7.7% for the seri- ously injured and 1.8% for the rest, without a correspond- ing increase in the population. From our archives it is evi- dent that one-third of our admissions were fracture cases with 75% of the latter being men and 25% women. Child- ren comprised 5.2% of the last category with 69% boys and 31% girls. Mthough in older age groups men definitely pre- dominate as they are more prone to automobile, motorcy- cle and industrial accidents as well as injuries resulting from fights, it is interesting that even in children, boys still pre-

dominate, probably because they are more active and play more dangerous games than girls and are, therefore, more prone to accidents and injuries, although not by the same precentage as older ages (Fig. 1). Fig. 2 shows that the most "active" age is fourteen with 16.3% of the cases recorded followed by the ages 9 and 10 years with 12% each. It ap- pears that 14-year-old children are occupied with lots of ac- tivities such as sports, bicycle and motorbike riding and they are, therefore, more prone to injuries. In older age groups (Fig. 3) the ages of 2 1 -3 0 are those most frequently affected. However, as far as aetiology is concerned (Table 1) there is a significant difference between children and adults with most of the former (74%) affected during recreational actMties (play and falls) while the latter being, in most cases (57%) the victims of RTA's. Regarding child- ren involved in RTA's, it has been found (Pappis and Hatji- leonstantas, 1986) that the average child was 8.5 years old, that children in their mother's lap sustained equally as seri- ous injuries as those who did not wear seat belts and that children seated in the back seat sustained more serious inju- ries than those sitting in the front seat when they did not

Fractures of the Facial Skeleton in Children J. Cranio-Max.-Fac. Surg. 18 (1990) 153

wear seat belts; in other words they are not really protected when seated in the back seat if they do not wear seat belts. Unfortunately, not very many people wear seat belts in this country; it has been shown (Papastamatiou et al., 1986; Kontoyannis, 1987) that following the enforcement of a law making the use of seat belts compulsory, 94% of the drivers complied within the cities; that figure dropped to 28% four months later. Fig. 1, Tables 2 and 3 show that there is a difference in the types of fractures sustained by adults and children. In the former the symphyseal, condylar and zygomaticomaxillary complex fractures are more com- mon while in the latter fractures of the upper alveolar bone and the condyle predominate; this is due to the fact that many of the fractures sustained by children are the results of falls; children often fall on their faces. Treatment in children is usually less aggressive and is usually restricted to intermaxillary fixation (Zachariades et al., 1983; Kopel and Johnson, 1985; Arajarvi et al., 1986; Needleman, 1986; Lu- terman et al., 1987).

References

Arajarvi, E., C. Lindqvist, S. Santavirta, J. Tolonen, O. Kiviluoto: Maxillofacial trauma in fatally injured victims of motor vehicle ac- cidents. Brit. J. Oral Maxillofac. Surg. 24 (1986) 251

Braham, R. L., M. W. Roberts, M. E. Morris: Management of dental trauma in children and adolescents. J. Trauma 17 (1977) 857

Kaban, L. B., J. B. Mulliken, J. E. Murray: Facial fractures in child- ren. Hast. Reconstr. Surg. 59 (1977) 15

Kontoyannis, P.: Road traffic accidents; the Greek reality. Gk. Or- thop. Surg. Traumatol. 38 (1987) 5

Kopel, H. M., R. Johnson: Examination and neurologic assessment of children with oro-facial trauma. Endod. Dent. Traumatol. 1 (198s) 159

Luterman, A., K. Rodgers, R. W. Powell, M. L. Ramenofsky: Pediat- ric maxillofacial trauma: unique features in diagnosis and treat- ment. Laryngoscope 97 (1987) 925

Needleman, H. L.: Orofacial trauma in child abuse: types, preval- ence, management, and the dental profession's involvement. Pedi- atr. Dent. 8 (1986) 71

Papastamatiou, L., G. Papadakis, P. Vrachnos, G. Verigos: Road traffic accidents; investigations on the severity of injury and effec- tiveness of the treatment. 15th Annual National Congress of Surg- ery, Thessaloniki, 1986

Pappis, G. D., G. D. Hatjikonstantas: Road traffic injuries in child- ren. The seat belt in the car and the escort in road crossings. Pedi- atrics (Gk) 49 (1986) 146

Tessier, P.: Reflexions sur la chirurgie cranio-faciale d'aujourd'hui et son avenir chez l'enfant. Ann. Chir. Hast. 24 (1979) 109

Zachariades, N., D. Papavassiliou, J. Papademetriou, J. Koundou- ris: Fractures of the facial skeleton in Greece. J. Max-Fac. Surg. 11 (1983) 142

Dr. N. Zachariades, M.D., D.D.S. 40 Papadiamantopoulou St. GR-157 71 Athens Greece