Children are not just “small versions” of adults, but rather have distinct anatomic and physiologic differences.
Mechanisms of injury and therefore patterns of injury differ in pediatric populations.
As healthcare providers, all practitioners must be vigilant in the prevention of child abuse in pediatric patients.
Treatment (i.e., resorbable fixation) and postoperative protocols may differ in pediatric populations.
Preventative measures (helmets, seat belts, car seats, etc.) can drastically decrease pediatric oral and facial trauma.
3.1 Introduction
Patients with injuries to the face are one of the most challenging populations to rehabilitate. The blend of functional reconstruction while maintaining optimal cosmetic outcomes presents a unique set of problems to maxillofacial surgeons. Pediatric patients also experience the same set of issues but are compounded by the addition of future growth potential as well as a host of other age-specific concerns that must be understood, mastered, and addressed by the reconstructing maxillofacial surgeon. The age-old adage that “children are not little adults” resounds with truth. This chapter identifies some very specific considerations to remember when approaching pediatric patients with traumatic injuries to the face.
3.2 Epidemiology, Economic Burden, and Disparities in Access to Care
According to the Center for Disease Control in the United States head and neck injuries accounted for 17% of hospitalized injuries, 20% of initial visits to EDs, and 15% of injuries reported [1]. Furthermore, children account for nearly 14% of all facial fractures. Studies have shown that pediatric patients who sustain fractures to the face have more severe injuries to the head and chest, resulting in greater hospital lengths of stay, longer stays in critical care units, increased hospital charges, and greater long-term care needs compared with pediatric trauma patients who do not have injuries to the face [2]. Sadly, not all pediatric trauma patients have access to the same comprehensive care. A recent study in the Journal of Pediatrics examined the impact of insurance status on dental practitioner’s willingness to schedule an appointment for a child with a symptomatic fractured permanent tooth. Research assistants posed as mothers of child seeking an urgent dental appointment. Calls were repeated 2 weeks apart and the only difference in the scenario was Medicaid vs. BlueCross dental insurance. The study concluded that dentists, including those participating in the Medicaid program, are less likely to see a child for an urgent dental appointment if the child has public vs. private dental insurance [3]. This highlights the very real disparity that exists in access to care. Almost every pediatric patient that presents to an emergency room with facial trauma will be seen by a consulting surgeon. While there is a host of studies that evaluate the cost of pediatric facial trauma emergency room visits, ignored are the aftercare costs of prescription medication, post-discharge care, outpatient costs, or other costs involved with the management of facial fractures. The long-term reconstructive needs of these patients often surpass the financial resources available to them. Often, close follow-up with an oral and maxillofacial surgeon, orthodontist, or pediatric dentist is warranted and when the ideal soft tissue, bony, and dental rehabilitation requires a significant financial contribution on the part of the patient’s parents, definitive care is delayed or forgotten. A study using a large emergency department all-payer database has shown that only 37.5% of patients who presented with facial fractures had private insurance [4]. In March of 2010, The Patient Protection and Affordable Care Act was signed into law. This radically improved access in the United States to care for pediatric patients by investing an unprecedented $8.3 billion dollars in federal funds to create a minimum of Medicare payments for certain Medicaid services provided by physicians. It also strengthened pediatric primary care, subspecialty, and surgical specialty workforce by offering a new loan repayment program for individuals who pursue full-time employment in pediatric medical and surgical subspecialties. Coverage was expanded to include nearly 32 million more pediatric patients and parents. These changes are monumental in nature and will undergo extensive revision as new political administrations come to power. Time will tell if the changes enacted will have a positive impact on access to care for pediatric patients who experience facial trauma.
All too often facial rehabilitation is viewed as elective treatment and unfortunately in many cases there is no black-and-white restorative treatment algorithm. Practitioners are stuck between offering their time, services, and material for an unsustainable cost or steering treatment to less than ideal options. Further work is needed at the legislative level to ensure appropriate compensation for the practitioners that care for these patients. From a practitioner standpoint, a reminder that a dedication to providing comprehensive rehabilitation for this very vulnerable patient population can reap countless benefits in the doctor’s reputation among the community and healthcare networks they work in.
3.3 Patterns of Injury
While it is well known that pediatric facial trauma contributes to a substantial amount of morbidity and mortality, little attention has been given to describing cause-specific injuries and their associated pattern of trauma. A recent study published in the Journal of Cranio-Maxillofacial surgery looked at the epidemiology and cause-specific outcomes of facial fractures in hospitalized children. The group looked the Kid’s Inpatient Database (KID), which is a component of the Healthcare Cost and Utilization Project (HCUP) that was developed by the Agency for Healthcare Research and Quality (AHRQ). The KID consists of discharge data for patients less than 21 years of age from over 4000 US community hospitals and is the largest all-payer national pediatric database. They identified a total of 21,533 pediatric patients hospitalized due to facial fractures. The three most frequent mechanisms of injury in the pediatric facial trauma population that resulted in inpatient stays were motor vehicle accidents (MVA), intentional trauma (IT), and falls (43, 17, and 11% of patients) [5]. MVA was the most frequently encountered mechanism for all age groups; however falls were more frequent in ages 10 and less and intentional trauma more frequent in ages over 10. They further identified that the IT group was more likely to be older, nonwhite, and male from lower socioeconomic households and covered by Medicaid. Intentional violence being from a largely uninsured or public insurance patient population there is an overall increase in financial burden in this subpopulation. A benefit could be gained by focusing more resources towards hospital-based violence intervention programs, which have been shown to decrease total cost [6].
3.3.1 Bicycle-Related Trauma
Bicycling is one of the most popular activities for children to participate in. While there has been a national push to educate on the benefits of wearing a helmet, little has been done to protect a patient from bike-related facial injuries. Due to the high velocity of impact, inconsistent regulation of helmets, and lack of standard facial protection, there exists a high probability of pediatric patients sustaining significant facial injuries due to biking accidents.
A study in the Journal of Otolaryngology looked at the fracture patterns after pediatric biking accidents [7]. The group searched the National Electronic Injury Surveillance System (NEISS) database for use of the word “mountain bicycles” (code 5033) and “bicycles and accessories excluding mountain bicycles” (code 5040), and then refining their search to involve injuries to the face in pediatric patients from 2010 to 2014. From this data, they found over 178,000 ER visits for facial injuries due to bicycle accidents over this time period. Sixty-three percent of patients sustained lacerations and abrasions/contusions, with facial fractures being the next most common diagnosis. Nasal bone fractures comprised the largest group at 36% followed by mandible fractures at 23%. Orbit and midface fractures comprised only 8% of fractures, likely due to the protection offered by a projected helmet in the more superior aspect of the face. Facial fractures increased in incidence as children became older. This could be due to a softer, more pliable pediatric facial skeleton that hardens as the patient ages. Another consideration is the vector of growth, which results in greater projection of the lower third of the face as it grows down and out. An older pediatric population could be expected to participate in more risky and high-velocity activities as well. The maxillofacial surgeon should maintain a low threshold for the possibility of facial fractures when a soft-tissue injury is associated with a biking-related incident.
There is currently no national law requiring helmets be worn by children while biking. Various attempts during the 1990s and early 2000s have been made at the state level to boost public awareness of the scope of the problem. The Center for Disease Control states that a national survey conducted in 2001–2003 found that only 48% of children aged 5–14 years wore bicycle helmets when riding [8]. The Children’s Safety Network recently concluded that every $10 bicycle helmet generates a $570 savings in cost to society. They also found that every bicycle helmet saves health insurers $57 and auto insurers $17. The overall medical economic burden to society from unhelmeted bike-related accidents is estimated at $197–256 million dollars [9]. A tremendous opportunity exists for maxillofacial surgeons to educate parents during routine office visits on the medical and economic benefits of their children wearing a helmet while biking.
3.3.2 Birth Trauma-Related Facial Injury
A rare but still persistently documented injury is facial nerve paralysis following childbirth. One study documented the rate of facial nerve palsies at 8.6% of birth-related head and neck trauma [10]. Injury to cranial nerve VII is usually associated with seizing the neonate’s head obliquely. Facial nerve paralysis is more frequently found during forceps delivery than during vacuum-assisted delivery [11]. During a forceps delivery the blade exerts pressure on the stylomastoid foramen. It can also compress the bone directly overlying the vertical segment of the facial canal. It is believed though that 33% of cases occur during spontaneous vaginal delivery and likely secondary to compression against the maternal sacral promontory [12]. The overall incidence is believed to be between 1.8 and 7.5/1000 live births. Falco and Eriksson reviewed 92 congenital facial nerve palsies among 44,299 live-birth infants. They found 81 acquired injuries and 74 (91%) were associated with forceps delivery. The prognosis is good with spontaneous recovery often in the first few days of life. Some authors favor early surgical intervention although conventional opinion is to monitor for improvement for 1 year, and up to 2 years if there is documented improvement on electromyography (EMG). A baseline EMG should be obtained early after diagnosis.
3.3.3 Pediatric Facial Burns
Facial burns to a child result in devastating injuries with severe physical and psychosocial implications. Furthermore, the injury is not self-limited, with the subsequent scar formation resulting in severe growth potential restriction. Many principles of burn management that are applied to adults are also relevant in the pediatric population. There are however some significant differences, as outlined by Demircan et al. in the Journal of Burns [13]. Children’s facial skin has a higher density of dermal appendages, leading to improved wound healing and quicker epithelialization following burns. However this is a double-edged sword as the same robust healing capability can overcompensate, causing hypertrophic scarring and devastating contractures in children with severe facial scarring. The amount of donor site availability in severe burns may limit the grafting options available for facial reconstruction in patients with full-thickness burns. A study in 2013 compared the use of allograft (Integra) to autograft skin in facial reconstruction. The authors reviewed a 10-year experience of 160 pediatric patients who underwent facial skin resection and facial grafts and looked at overall aesthetic outcome and need for further reconstruction. The mean burn size was 39% of total body surface area, of which 36% was third-degree burns. Ninety percent of the patients analyzed had their entire faces burned. No difference was noted in the rate of healing between the two materials as well as overall aesthetic outcome. They concluded that when the amount of skin available for autografting is limited, Integra allograft is an acceptable alternative [14].
Facial scarring and contraction after burns result in a host of problems including ectropion, microstomia, skeletal growth restriction, and hypertrophic scarring. A comprehensive discussion of management of these individual problems is beyond the scope of this chapter and requires a multidisciplinary team as well as access to a dedicated burn center. A multimodality approach including skin dermabrasion, laser resurfacing, skin grafting, contracture release, skin expanders, as well as conventional bony osteotomies in the case of skeletal growth disturbance may all be employed. The authors recommend delaying reconstructive surgery for at least 9–12 months until the facial scar completely matures.
3.3.4 Fireworks
July 4th marks a day of celebration in the United States. Each year Americans gather to set off sparklers, cherry bombs, firecrackers, and an arsenal of other consumer explosive devices. The use of recreational explosive devices in combination with the nature of holidays that welcome a day of relaxation and alcohol intake lends itself to an understandably predictable rate of injury. The American Pyrotechnics Association (APA) estimates that the total firework consumption in 2011 was 234.1 million pounds and total firework revenue for 2011 to be over $950 million dollars [15]. In July of 2004 almost 10,000 patients required emergency room care for injuries related to fireworks and 40% were pediatric patients [16]. The most prevalent age group is 10–19-year-old adolescents and males being nearly three times as likely as females to injure themselves from fireworks. Over 42% of all firework-related injuries occur to the head and neck and burn injuries account for the most prevalent pattern, followed by contusions/lacerations, fractures, and sprains. Interestingly, the rate of annual firework-related injuries has steadily decreased from 3.79/100,000 persons per year in 2000 to 2.68/100,000 persons per year in 2010. This can be attributed to a greater understanding of injury pattern and the subsequent increased regulation and enforcement of laws directed towards prohibiting amateur use of the more dangerous types of recreational explosive devices.
Initial management consists of standard facial trauma triage with special consideration for areas of thermal injury. Wounds should be debrided of devitalized tissue and any continued chemical exposure should be promptly and thoroughly washed. Future reconstruction may consist of a multidisciplinary team and may require the use of a burn center if the injury is more thermal than blast in nature. Extensive avulsion of soft tissue is often seen in blast injuries and skin grafts, allografts, and skin expanders may be employed. Of note, the use of blank cartridges is not without risk of injury or permanent disfigurement. Commonly these explosives will result in tattooing and subsequent permanent scarring. Gunpowder particles can be removed under local or general anesthesia. Sterile brushes and pulsating irrigation may aid in cleansing of deeply implanted particles. Afterwards irrigation with antibiotic-infused sterile saline is mandatory. Early treatment of tattooing caused by fireworks or other gunpowder explosives should take place within 24 h to prevent permanent cosmetic disfigurement. Later, residual tattoos and hypertrophic scars may be further augmented by lasers or dermabrasion techniques.
3.4 Legal Considerations/Child Abuse
Unfortunately child abuse will be encountered by practitioners treating pediatric facial trauma. One should be aware of common patterns of injury and a high index of suspicion should remain when a patient’s history does not match their physical exam. Child abuse permeates all ethnic, cultural, and socioeconomic barriers. Mandates in all 50 states require that healthcare professionals be aware of and report instances of child abuse and neglect to the proper state authority. State laws also protect the reporting healthcare professional from civil retribution. As noted by the American Medical Association [17], “[M]ost states also impose criminal penalties for failure to report such cases.”
In 1962, the term “battered child syndrome” was first coined by Kempe et al. [18] The authors suggested that the syndrome should be considered in any child with a combination of multiple fractures, subdural hematoma, and bruises. Fractures associated with child abuse or neglect are more frequently found in younger patients. The older a patient gets the more likely the force required to result in fractures to the facial skeleton would come from accidental trauma. The maxillofacial surgeon should be aware that the diagnosis of a skeletal fracture is incomplete without confirming the etiology of the fracture.
Skull fractures are frequently encountered during the evaluation of pediatric facial trauma. Once accidental trauma is ruled out, the probability of a skull fracture in a child or infant is 0.3. Hobbs et al. [19] concluded that a “growing fracture” that he defined as an enlarged linear fracture could not result from a minor accidental fall and thus abuse is much more likely in those reported events. Furthermore, he concluded that abuse is more likely in depressed, diastatic, or non-parietal bone skull fractures. He considered depressed fractures to be highly indicative of inflicted injury from blunt force trauma. Like Hobbs, Meservy [20] found that multiple or bilateral fractures and fractures that crossed suture lines were significantly associated with abuse.
Infants with head trauma including skull fractures should undergo a skeletal survey; however there is an abundance of opinion in the literature regarding which patients should undergo a complete survey. High-risk infants have been defined as those aged <18 months with isolated skull fractures, significant intracranial injury, retinal hemorrhages, and skeletal injuries. Some data supports the complexity of fracture pattern as an indicator of abuse in children while others show no correlation. A recent study in pediatric radiology concluded “that the majority of children with skull fractures do not require global skeletal imaging assessments, but all infants and young children with skull fractures should have a careful clinical evaluation and if abuse is a serious differential consideration, consultation with a child protection team is appropriate. This multi-disciplinary approach should permit selection of those children in whom a skeletal survey is appropriate” [21].
Other stigmata of abuse are bruising in nonambulatory children; facial or neck bruising in various stages of healing; long bone fractures not consistent with reported mechanism; burn injuries especially when to the hands, feet, and perineum in a symmetric pattern; and blunt abdominal trauma. The most common finding in an abused child with isolated head trauma is a subdural hematoma. Features of a subdural hematoma that are suspicious for non-accidental trauma include (1) the presence of subdural hematoma in the abscess of skull fracture, (2) bilateral subdural hematomas, (3) subdural hematomas of different ages, (4) subdural hematomas in the presence of retinal hemorrhages, and (5) acute interhemispheric subdural or falx hemorrhage [22]. As mandatory reporters of child abuse, the maxillofacial surgeon should have a low threshold for consultation to child protective services when suspicion of abuse is high.
3.5 Anatomy and Physiology of Pediatric Patients
Children are not little adults. There are significant differences in their anatomy and physiology that warrant consideration by the maxillofacial surgeon.
Airway and respiratory system: Anatomical variations include a large head, short neck, and prominent occiput. The tongue is relatively larger compared to their adult counterparts. The larynx is high and anterior at the level of C3–C4 and the epiglottis is long, stiff, and U-shaped. It has been described as “floppy” and tends to rest posteriorly. A standard sniffing position is not as effective in pediatric bag mask ventilation or in visualizing the glottis. The head should remain in a neutral position to accomplish these goals. Neonates preferentially breathe through their nose. They have narrow nasal passages that are easily blocked by secretions and may be damaged by a nasogastric tube or a nasal endotracheal tube. Approximately 50% of all airway resistance is from the nasal passages. The airway is funnel shaped and narrowest at the level of the cricoid cartilage. Here, the epithelium is loosely bound to the underlying tissue. Trauma to the airway easily results in edema. Approximately 1 mm of edema can narrow a baby’s airway by up to 50%. Children have significantly lower respiratory reserve than an adult as well. The chest wall is significantly more compliant than that of an adult. Thus the functional residual capacity (FRC) is relatively lower than an adult.
Normal heart rates (beats\min) and systolic blood pressure (mmHg)
Renal: Pediatric patients have decreased renal blood flow and a lower GFR in the first 2 years of life. Dehydration is not well tolerated and young infants have increased insensible losses as they have a larger surface area relative to weight. Standard urine output should be 1–2 mL/kg/h.
Hepatic: Children’s liver function takes some time to mature and they have an overall lower level of hepatic enzymes. Thus metabolism of opioid medications is delayed.
Temperature control: Babies and children have a larger surface area-to-weight ratio. They have less subcutaneous fat and are more prone to hypothermia than adults. Brown fat deposits are responsible for non-shivering thermogenesis. These stores require more oxygen for metabolism. The optimal temperature to prevent heat loss is 34 °C in premature infants, 32 °C for neonates, and 28 °C in adolescents and adults. Low body temperatures cause respiratory depression, acidosis, decreased CO, increased duration of action of drugs, decreased platelet function, and increased risk of infection [23].
The maxillofacial surgeon should be cognizant of the variations in pediatric anatomy and physiology when compared to adults. This discussion is by no means comprehensive and appropriate triage and care of these facial trauma patients often benefit from consultation with a pediatric ICU and anesthesia specialists. Important also is the patient’s immature psychology and the utmost care should be taken to not cause undue suffering during examination and treatment of these patients.
3.6 Types of Fixation
The pediatric skeleton is more pliable and elastic than that of an adult. Thus fractures tend to be more greenstick or incomplete in nature. Conservative management is more often applied to children than adults due to this. However rigid fixation is still required when fractures are displaced. Over the last 40 years fractures requiring fixation were treated with titanium plates and screws. Titanium fixation hardware is currently the standard in craniomaxillofacial reconstruction. These have the advantage of being strong and lightweight, have good contourability, and are biologically inert. However titanium plates and screws have some distinct disadvantages for pediatric fracture fixation including interference with advanced imaging techniques, palpability, temperature sensitivity, migration of hardware in the growing patient, and most importantly restriction of future growth. This necessitates a secondary procedure to remove the hardware once the patient has achieved a bony union.
More recently an attempt has been made to overcome these inherent disadvantages to traditional metallic fixation and so biodegradable fixation hardware have been developed and are becoming increasingly popular. Biodegradable materials have been clinically tested for the fixation of facial fractures for the last 15 years. The materials commonly in use are poly-α-hydroxyl acids, and polymers and copolymers of poly-l-lactic acid (PLLA), poly-d-lactic acid (PDLA), polyglycolic acid (PGA), and polydioxanone-sulfate (PDS). Currently, copolymers of PLLA, PDLA, and PGA are given preference over pure PLA and PGA, which are associated with adverse reactions. A copolymer of PLLA/PGA acid in a ratio of 82/18% (LactoSorb) was the first commercially available material for the fixation of maxillofacial fractures [24].
Biodegradable polymers combine the benefits of rigid fixation while overcoming the need for a secondary procedure to remove hardware. The ideal resorbable plate will be sufficiently strong and adaptable, and reabsorbs in a predictable time frame. Polylactic acid (PLA) and PGAs are the primary components of most biodegradable plates. The biomechanical and resorptive properties of these plates will vary depending on the ratio of lactic acid isomers and/or glycolic acid [25]. PLA experiences a biphasic degradation. Initially, breakdown will occur via hydrolysis of the materials’ ester bonds [26]. The resulting degradation product then crystallizes and then undergoes a secondary hydrolysis, which is the rate-limiting step. The final end products, CO2 and H2O, are metabolized by the liver. The rate of degradation depends upon the crystallinity and hydrophobic nature of the early by-products. L-isomers form crystalline lattices that are highly hydrophobic and more resistant to degradation than the d-isomers. Different ratios of the two determine their polymer chain organization and orientation. Of note, poly-l-lactic acid crystalline particles have been identified within the cytoplasm of local phagocytic cells years after implantation.
More amorphous polymers, such as PGA, are inherently less hydrophobic, undergo more rapid breakdown, and are susceptible to bulk degradation or fragmentation of the material. PGA is more hydrophilic and undergoes resorption more quickly. PGA is typically used in conjunction with PLA to improve the structural integrity of an implant, as pure PGA does not offer the necessary strength for fracture fixation. These semicrystalline polymers typically exhibit degradation at the outer surface of the material, and are less likely to fragment or undergo bulk degradation [27].
There are some distinct disadvantages of biodegradable fixation. They are inherently weaker than their titanium counterparts. A heat source is required to adapt the hardware to the bone and increased operating room time can be expected. Being prone to fragmentation often results in difficulty with obtaining stable fixation of small comminuted pieces of bone. Due to the local foreign body inflammatory response, there have been multiple documented cases of a “sterile abscess” forming. This can be due to incomplete degradation or a large volume of debris during metabolism. A sterile abscess can require surgical drainage up to 4–5 years after placement. The PLA type of polymer has been implicated more often in sterile abscess formation. Despite these disadvantages biodegradable polymer hardware continues to be an appropriate and desirable alternative to titanium fixation in the growing pediatric facial skeleton.
3.7 Postoperative Management
Postoperative management differs little between adults and pediatric patients with facial trauma. Perhaps the most obvious variance is with patient cooperation during daily examinations, dressing changes, and interaction with a multidisciplinary team. The surgeon should be sensitive to the patient’s heightened fear of strangers and the parent’s appropriate concern with their child’s comfort.
Not only adequate nutrition is important for optimal healing but also familiar foods provide a measure of comfort for young children in an unfamiliar setting. Unfortunately the nature of postoperative management of facial trauma may dictate a liquid or non-chew diet, puree, soft mechanical diet, or even tube feeding. An effort should be made to understand that the abruptly altered diet will not be as easily accepted by pediatric patients. Often children can be finicky eaters and may refuse the limited options provided by the surgeon. In cases of severe facial trauma that warrant a significant change in the patient’s diet, consultation with a pediatric nutritionist is not unwarranted.
Oral hygiene is paramount in cases of maxillomandibular fractures or intraoral lacerations. Children are less likely to cooperate with oral hygiene measures such as brushing their teeth and arch bars. Like adults, chlorhexidine or warm salt water rinses aid in maintaining a clean environment when oral hygiene measures are of limited effort.
Pain management in children often can be easier than with their adult counterparts. Children can be distracted from their discomfort more readily with a host of age-appropriate games, books, and video media. Attention should be paid to what forms of distraction are available in the patient’s room and parents can be encouraged to bring items from home that the patient may miss. Pediatric patients are far less likely than their adult counterparts to have a narcotic tolerance. When facial trauma is severe the surgeon should not hesitate to utilize weight-based narcotic analgesics. These can be quickly weaned as appropriate to various formulations of pediatric nonsteroidal anti-inflammatory drugs.
Antibiotic administration for pediatric facial trauma similarly follows adult guidelines. Clean wounds do not generally require postoperative antibiotics after meticulous debridement and cleansing with sterile saline. Preoperatively, the Surgical Care Improvement Project advises antibiotic administration 1 h prior to incision and procedure-specific antibiotic selection. For head and neck surgery, the antibiotic of choice for a patient <80 kg is cefazolin and in penicillin allergic patients clindamycin ± gentamycin. The recommendation is that all antibiotics be discontinued within 24 h of surgery unless there is a documented infection or suspected infection [27]. Even very young pediatric patients have established oral, sinus, and skin flora. Injuries to the skin with a high risk for infection should cover gram + microorganisms and injuries to the nasosinus region should cover Moraxella and Haemophilus organisms as well. Human and animal bite wounds are discussed elsewhere in this text and antibiotic choice in those cases should cover mixed flora. Lacerations have improved healing when covered in a moist dressing for 2–3 days to allow for optimal reepithelialization. Topical antibiotics such as mupirocin or bacitracin are popular; however simply using a petroleum-based ointment is also appropriate in clean wounds.
3.8 Injury Prevention Strategies
Avoiding injury is always the best strategy to minimize the risk of a significant disruption to a young child’s development. There have been multiple campaign efforts to raise awareness of pediatric facial trauma. The month of April is the national facial protection awareness month. The Centers for Disease Control as well as the American Association of Oral and Maxillofacial Surgeons offer multiple resources online to help educate parents and guardians on the appropriate steps to take to minimize injury.
Sports: Mouth guards are one of the most cost-effective methods for minimizing facial injury. A mouth protector should be evaluated from the standpoint of retention, comfort, ability to speak and breathe, tear resistance, and protection provided to the teeth, gums, and lips. The gold standard is a custom-made bimaxillary occlusal guard. It requires a dental impression and casts that are sent to a lab for fabrication. They offer coverage of all teeth, do not disturb a patient’s ability to speak or breath, and cushion the jaw. The main drawback to a custom mouth guard is its higher cost, which can range from $200 to $500. A sincere talk about all the costs involved with replacing broken teeth with the patient’s parents can often justify this investment. The cheaper alternative is a mouth-formed or “boil-and-bite” guard. These tend to wear quickly, and are not as well adapted. They are also not tolerated as well as they hinder the patient’s ability to speak clearly and can make breathing more difficult. A stock mouth guard is the least desirable option and is poorly tolerated due to an ill fit. It is recommended an occlusal guard be worn during any activity with a high risk for head impact with anything hard such as another child’s head, bat, or ball.
Football helmets should be worn at all times as well as mouth guards. They often have a plastic facemask that may be displaced backwards in high-impact collisions resulting in facial injury. These can be replaced for relatively low cost with carbon-steel wire masks. Baseball catchers should wear full-coverage face shields at all times. Mouth guards are mandatory in the sport of boxing and recently a guard with full coverage and a hole for breathing with a thicker front has been designed. More and more high school sports associations are requiring headgear for wrestlers. These attach via a chin cup and strap. Helmets should be worn during biking, skiing, skateboarding, and horseback riding as well [28].
Seat belts: Fatalities and injury from motor vehicle accidents affect children as well as adult patients. In the United States during 2014 over 121,000 children aged 12 years and younger were injured in vehicle crashes [29]. Of these almost 35% were not wearing seat belts. The CDC advises that buckling passengers in age- and size-appropriate car seats, booster seats, and seat belt reduces the risk of serious and fatal injuries. Based on strong research, the Community Preventative Services Task Force recommends car seat laws and car seat distribution plus education programs to increase restraint use and decrease injuries and deaths to child passengers [30]. A study of five states that increased the age requirement to 7 or 8 years for car seat/booster seats found that fatal or incapacitating injuries decreased by almost 18% [31]. The CDC advises that from birth to 2 years of age, children be restrained in a rear-facing car seat in the back seat of the automobile. When they outgrow this seat, usually from ages 2 to 5 children can be buckled in a forward-facing car seat, still in the back seat. From ages 5 until a seat belt fits appropriately, children should be restrained with a belt positioning booster seat. Restraining belts fit properly when they lay over the upper thigh rather than the abdomen, and the shoulder belt across the chest rather than neck.
Home safety: Parents should be prepared to prevent injuries at home as well. Toxic substances can cause chemical burns when ingested or come into contact with the patient’s skin, resulting in injuries to the mouth or face. Parents should know the nationwide poison control center phone number 1–800–222–1222. Playgrounds are a source of injury to children. Parents should check that they are padded with softwood or rubber chips underneath the equipment. Only age-appropriate equipment should be used and making sure that guardrails are tightly secured can prevent injury. Water burns can be prevented by setting the water heater thermostat at 120° F and using safe cooking habits by never leaving a stove unattended. Railings placed at the top of stairs can prevent falls in young children as well.
3.9 Conclusion
Reconstruction of the pediatric face following trauma often requires a unique approach and one cannot rely exclusively on techniques applied to their adult counterpart. The maxillofacial surgeon should be aware of the anatomical and physiological variations, different methods of fixation, and patterns of injury that are more typically associated with this patient population. Furthermore, the surgeon should be acutely sensitive to disparities in access to care across different geographic, economic, and ethnic populations. Finally, one must be cognizant of the fragile state of the developing child’s mind that is much more susceptible to psychosocial influences. Awareness of these issues will greatly assist the treating surgeon in the myriad of intricacies they will encounter when treating pediatric facial trauma.