Pediatric Craniofacial Trauma

J Oral Maxillofac Surg 66:58-64, 2008

Pediatric Craniofacial Trauma Nicole M. Eggensperger Wymann, MD, DMD,* Alexander Hölzle, DMD,† Zacharias Zachariou, MD,‡ and Tateyuki Iizuka, MD, DDS, PhD§ Purpose: Maxillofacial and skull fractures occur with concomitant injuries in pediatric trauma patients.

The aim of this study was to determine the causes and distributions of maxillofacial and skull fractures as well as concomitant injuries of pediatric patients in Switzerland. Results were compared with worldwide studies. Materials and Methods: A retrospective review was conducted of 291 pediatric patients with maxillofacial and skull fractures presenting to a level-I trauma center over a 3-year span. Data concerning the mechanism of the accident and the topographic location of the injuries were analyzed. Results: The most common causes were falls (64%), followed by traffic (22%) and sports-related accidents (9%). Fifty-four percent of the fractures occurred in the skull vault and 37% in the upper and middle facial third. One third of the patients (n ⫽ 95) suffered concomitant injuries, mostly cerebral concussions (n ⫽ 94). Conclusions: The spectrum of craniofacial injuries is related to the specific developmental stage of the craniofacial skeleton. It is probable that national prevention programs will have a positive effect on reducing the incidence of falls. Standardization of studies is needed for international comparison. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:58-64, 2008 Children are uniquely susceptible to craniofacial trauma because of their greater cranial mass-to-body ratio. However, only 1% to 15% of all facial fractures occur in the pediatric population.1-7 This reduced incidence of pediatric facial fractures, compared with adult facial fractures, is probably because of the flexibility of the facial bone, the lack of pneumatization of the paranasale sinus, and the protection of the malar region by the prominent buccal fat pad in infants.8 Furthermore, young children are less often involved in occupational or violence-related accidents that are typical features of adult facial fractures.9-11 The causes and incidence of maxillofacial injuries in children vary widely as a result of social, cultural, and environmental factors, as reported in previous publications.12-25 The main causes worldwide are traf-

fic accidents, falls, violence, and sports-related accidents (Table 1). Skull vault fractures have recently been reported to be the most frequent fractures in the young pediatric patient,23,26,27 whereas mandibular and midfacial fractures are predominantly seen in older children.25,26 However, no previous study has compared causes, incidences, and patterns of pediatric maxillofacial fractures worldwide. An understanding of the cause, severity, and temporal distribution of maxillofacial and skull vault trauma and associated injuries in children can assist in establishing clinical and research priorities for prevention and effective treatment of these injuries. Because there were no Swiss studies of maxillofacial injuries in a large series of pediatric patients, we retrospectively analyzed the characteristics of head fractures treated at our clinic from January 2001 to December 2003, to determine their principal causes and craniofacial distribution. We also studied associated injuries. Finally, an exhaustive literature review was performed to compare our results with those from countries around the world.

Received from the University of Bern, Inselspital, Bern, Switzerland. *Resident, Department of Cranio-Maxillofacial Surgery. †Student, Department of Cranio-Maxillofacial Surgery. ‡Head of Department, Department of Surgical Pediatrics. §Professor and Senior Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery. Address correspondence and reprint requests to Dr Eggensperger Wymann: Department of Cranio-Maxillofacial Surgery, University of Bern, Inselspital, CH-3010 Bern, Switzerland; e-mail: [email protected]

Materials and Methods The present study was conducted at the Department of Cranio-Maxillofacial Surgery, University of Bern, Inselspital, Bern. This is the only trauma center that provides treatment of cranio and maxillofacial injuries around the clock, 365 days a year in central Switzerland. The region

© 2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6601-0010$34.00/0 doi:10.1016/j.joms.2007.04.023

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EGGENSPERGER WYMANN ET AL

Table 1. LITERATURE REVIEW

Study

Continent

Country/City

Holland et al, 20018 Tanaka et al, 19931 Adekeye, 198012 Oji, 199911 Chidzonga, 198713 Bamjee et al, 199614 Jaber and Porter, 199715 Qudah et al, 200216 Porter, 19873

Australia

Sydney

Asia Africa Africa Africa Africa

Anderson, 199517

Europe

No. of Years* Patients

Etiologies Traffic (%)

Falls (%)

Violence (%)

Sports (%)

Ratio

Others† (%)

Mean Age (yr)

Male (%)

Female (%)

10

67

33

to 15 to 13 to 11 to 16 4

69 68 73 72 70

31 32 27 28 30

4

46

63

17

0

0

20

Japan Nigeria Nigeria Zimbabwe South Africa

13 6 12 2 4

81 85 40 18 326

20 54 28 11 29

28 32 65‡ 22 23‡

25 6 7 61 48

18 1 0 6 0

26 7 0 11 0

Africa

Libya

14

209

48

50

0

0

2

6

53

47

Middle East

Jordan

5

227

20

52

17

8

3

11

70

30

Europe

United Kingdom United Kingdom United Kingdom Austria

5

40

50

12

6

20

12

12§

63

37

10

139

23

40‡

10

27

0 to 13

74

26

5

241

34

43

4

14

5

0 to 16

77

23

10

381

30

24‡

14

17

15

10

66

34

5

Carroll et al, 1987

Europe

Gassner et al, 200418 Zerfowski and Bremerich, 199819 Guven, 199220 Zachariades et al, 199021 Stylogianni et al, 199122 Gussack et al, 19877 McGraw and Cole, 199023 Thaller and Huang, 199224 Posnick et al, 199325 Present study, 2000-2003

Europe Europe

Germany

Europe Europe

㛳

1 0 0 0

3

1,358

15

47

15

10

13

8

63

37

Turkey Greece

1 25

83 202

29 14

67‡ 74‡

0 0

0 5

4 7

7 0 to 14

69 69

31 31

Europe

Greece

8

116

79

8

5

5

3

0 to 13

58

42

USA

Alabama

2

30

64

10

13

0

13

11

60

40

USA

Texas

5

72

67

2

14

10

7

10

60

40

USA

California

1

53

55

11

11

9

14

0 to 16

74

26

USA

Washington

4

137

50

23

0

20

7

10

63

37

Europe

Switzerland

3

291

22

64

5

9

0

6

60

40

*Duration of observation. †Gunshots, pets, traumatic birth delivery etc. ‡Including playing accidents. §Median. 㛳Including soft tissue and dental injuries. Eggensperger Wymann et al. Pediatric Craniofacial Trauma. J Oral Maxillofac Surg 2008.

has 1.6 million inhabitants, representing 22% of the country’s total population. Eighteen thousand injured children, aged 0 to 16 years, presented at the hospital’s pediatric emergency department from January 2001 to December 2003. Of those, the emergency and hospital records of children with maxillofacial and skull vault fractures were reviewed in the Department of CranioMaxillofacial Surgery. The children included in the present study (n ⫽ 291) were divided into 3 groups according to age (under 6 years, 6 to 11 years, and 12 to 16 years). Cause of injury fell under 4 main categories: 1) falls, 2) road traffic accidents (RTA), 3) violence, and 4) sporting injuries. Fractures were determined from computed tomography scans and operative reports.

Fractures of the maxilla and midface were classified according to the system delineated by Le Fort,28 and those involving the mandibular and zygomatic complex according to that of Killey.29 They were further subclassified according to patient gender, monthly distribution of the traumas, circumstances and mechanisms of injury, and absence/presence of systemic injuries. Treatment data were also collected. Numerical data are presented as mean values ⫾ the standard deviation of the mean.

Results Patient ages at the time of accident ranged from 0 to 16 years, with a mean of 6.1 years. Fifty-two per-

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PEDIATRIC CRANIOFACIAL TRAUMA

FIGURE 1. Yearly distribution of accidents. Forty-six percent of accidents occurred in the period from February to May. Eggensperger Wymann et al. Pediatric Craniofacial Trauma. J Oral Maxillofac Surg 2008.

cent (n ⫽ 151) of the patients were under 6 years (infants and preschool), 27% (n ⫽ 80) were between 6 and 11 (school age), and 21% (n ⫽ 60) were between 12 and 16 years (adolescents). Male patients (60%; n ⫽ 174) outnumbered female patients (40%; n ⫽ 117) consistently in all age groups. The number of facial fractures tended to increase in the winter and spring months; 46% of all fractures occurred between the months of February and May (Fig 1). The causes of injury are shown in Figure 2. Sixtyfour percent (n ⫽ 188) of the patients were injured by falls. These patients were predominantly of preschool age and incurred their injuries mostly by falling on the floor when playing indoors or outdoors, falling from beds, chairs and stairs, or falling from a ladder or a wall. RTAs were the second most frequent, accounting for 22% (n ⫽ 63) of facial fractures. They were caused by cyclists (11%; n ⫽ 32), automobiles (9%; n ⫽ 25), and motorcycles (2%; n ⫽ 6; Table 2) and were predominantly found in the school age patients. Sports accounted for 9% (n ⫽ 26) of accidents, which occurred mostly while skiing and horseback riding. Finally, violence accounted for 5% (n ⫽ 14) of injuries. The distribution of fractures is presented in Figure 3. Most fractures occurred in the skull vault (54%; n ⫽ 192). Upper and middle facial bone fractures made 37% (n ⫽ 132) and mandibular fractures 32 (9%) of all

fractures. Single fractures were present in 251 patients (86%), and 2 or more fractures were seen in 40 patients (14%). There was no obvious predominance for the left or right side. Ninety-five patients (33%) suffered a total of 208 associated injuries (Table 3). Two thirds (n ⫽ 66) had only 1 concomitant injury and the others (n ⫽ 29) more than 1. Most associated injuries were cerebral concussions (n ⫽ 94; 45% of injuries). Of these, 50% were because of falls and 30% were traffic-related. Two hundred forty patients (82%) were treated conservatively by observation alone; 12 patients (4%) received closed reduction and 39 patients (13%) underwent surgery involving open reduction and osteosynthesis. The mean duration of the hospital stay was 6.3 days (range, 1 to 58 days).

Discussion The purposes of this investigation were: 1) to analyze pediatric facial and skull bone fractures treated in our department, and their associated injuries, and 2) to compare findings with relevant studies worldwide (Table 1). In this study, patients’ mean age was in the lower range of other studies (Table 1), which is no doubt the reason for our study’s high incidence of fall injuries. However, the peak incidence of facial fractures is

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EGGENSPERGER WYMANN ET AL

FIGURE 2. Different causes of injuries according to the children’s age. Falls are the most common cause of injury (64%) especially in young children (0 to 5 years). Traffic accidents (22%) and sports-related accidents (9%) were predominantly seen in the older children (6 to 16 years). Eggensperger Wymann et al. Pediatric Craniofacial Trauma. J Oral Maxillofac Surg 2008.

difficult to compare because other studies used different upper age limits in their samples. In this study, the peak incidence was 6 years, but all fracture types were more common in patients aged less than 6 years. In contrast to other studies,1,3,6,11,12,14,16,19,21,25,26 we found a decrease of incidence of facial fractures with increasing age. The high incidence reflects the young child’s inclination to explore the world with immature physical abilities. Our highest incidence of maxillofacial injuries was among males (60%), which agrees with findings worldwide, where males account for 53% to 77%. This is probably because of the more aggressive risk-taking behavior of boys and is reported by authors from Greece,21 Turkey,22 the United States,26 Australia,8 and Nigeria.11,12 These results showed an increased incidence of facial fractures in the period from February to May, which covers the snowy winter–spring months in

Switzerland. Snow and ice may be responsible especially for the high incidence of falls but also for the sports accidents of the adolescent pediatric patients. In contrast to our results in Switzerland, a study from Washington, DC25 described the highest incidence of facial fractures in the summer months. The same was reported in the United Kingdom5 and in Austria,18 and could be explained by the long evenings and school vacations in July, when children have more freedom to indulge in outdoor activities. Thus, differing distri-

Table 2. TRAFFIC ACCIDENTS RESULTING IN CRANIOFACIAL FRACTURES (N)

Age (yr)

0 to 5

Cyclists 2 Vehicle passengers 5 Motorbikers 0 Total (%) 7 (3)

6 to 11 12 to 16 Total (%) 17 13 14 6 0 6 31 (11) 25 (9)

32 (11) 25 (9) 6 (2) 63 (22)

Eggensperger Wymann et al. Pediatric Craniofacial Trauma. J Oral Maxillofac Surg 2008.

FIGURE 3. Distribution of pediatric facial fractures at the Inselspital, University of Bern 2001 to 2003. Records show a total of 192 fractures of the skull vault, 132 fractures of the upper and middle facial third, and 32 fractures of the mandible. Absolute numbers of fractures are listed with percentages in parentheses. Eggensperger Wymann et al. Pediatric Craniofacial Trauma. J Oral Maxillofac Surg 2008.

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PEDIATRIC CRANIOFACIAL TRAUMA

Table 3. ASSOCIATED INJURIES

Number of Injuries (n) Associated Injuries Dental Cerebral Thorax Abdominal Extremities

Luxation* Fracture† Avulsion Concussion Pneumocephalus Hydrocephalus Upper Lower

Total (%)

Sport

7 5 3 12 1 0 2 2 3 1 36 (17)

Traffic

5 2 7 28 4 0 6 6 10 12 80 (38)

Falls

2 6 0 47 0 1 5 9 12 3 85 (41)

Violence

0 0 0 7 0 0 0 0 0 0 7 (4)

Total (%)

14 (7) 13 (6) 10 (5) 94 (45) 5 (2) 1 (1) 13 (6) 17 (8) 25 (12) 16 (8) 208 (100)

*Intrusion and lateral luxation. †Root or crown fracture. Eggensperger Wymann et al. Pediatric Craniofacial Trauma. J Oral Maxillofac Surg 2008.

butions of pediatric facial fractures to some extent reflect differences owing to geographic area and seasonal activities. In this study falls were the most common cause of maxillofacial injury (64%), occurring most frequently in pre-school ages. This high percentage of falls may also be because of uncertainty of motion and lack of coordination, which prevent young children from adequately shielding themselves from a blow or turning their head aside. The injured zone is therefore concentrated in a relatively small area, which might be the reason for our high percentage of single fractures (86%). The older children are mostly occupied with a multitude of activities such as sports and bicycle and motorbike riding. This is why our second most frequent cause of facial fractures was RTAs involving children mainly as cyclists and vehicle passengers (22%). However, compared with other studies,3,7,8,12,15,22-24 our percentage for traffic accidents as causes is rather low, which can be explained by the speed limit on Swiss roads and high penalties for disregarding seat belt regulations. According to our literature search, several European studies reported a high incidence of maxillofacial injuries because of falls.5,17,19-21 In particular, those studies that also listed play accidents under falls showed high numbers with this cause.20,21 On the other hand, other European countries show RTAs to be a major problem. In Austria,18 the United Kingdom,3 and in Greece,22 30% to 80% of pediatric facial injuries occur because of RTAs. The high incidence in Greece is explained by the fact that children are not prohibited from sitting in the front seat and safety belts are not frequently used. In contrast to our results, in which pediatric victims were predominantly car passengers and cyclists, other studies found a high percentage of children involved in RTAs to be pedes-

trians.8,17,22 However, facial injuries caused by RTAs are probably because of the generally increasing road traffic in Europe and can be expected to increase further in the future. Most of the American studies were conducted in urban areas, and therefore also showed a high percentage of RTAs as causes (Table 1). Studies from Texas and Alabama revealed that about 65% of injuries were traffic-related and only 2% to 10% were owing to falls.7,23 Also, in Washington, DC,25 despite improvements in protective devices for vehicle occupants, motor vehicle accidents remain the leading cause of injury (50%). This high percentage of RTAs in the US, compared with some European or African countries, may be attributed to the greater use of automobiles versus public transport in the former. In Australia, RTAs also cause 63% of maxillofacial injuries in children.8 The causes of maxillofacial fractures in Africa differ depending on the social and economic situations in the countries investigated. For example, in South Africa and Zimbabwe injuries were predominantly due to violence (48% and 61%, respectively).13,14 Zimbabwe showed only 11% of pediatric injuries to be traffic-related. Mode of transport (few Zimbabweans own motor vehicles) and socializing habits are probably responsible for these findings. In contrast, a study from Libya reported that falls and RTAs each account for about 50% of maxillofacial injuries.15 One reason for this high rate of injury from traffic accidents might be that children do not have to be strapped into the seats of moving vehicles. Furthermore, a dramatic increase in imported used cars, badly maintained roads, and driver carelessness could contribute to traffic-related injuries in pediatric patients in Libya. In Asia and the Middle East, most studies concerning facial fractures unfortunately only report on adult patients.30-35 One study from India mentions that 50% of all accidents involving adults

EGGENSPERGER WYMANN ET AL

and children are traffic-related. This may be because of the widespread use of motorcycles in India. A study from Japan reports that falls and violence are the most common causes of children’s facial fractures.1 In Jordan, 52% of injuries are caused by falls and 20% are traffic-related. The latter might be because of poor compliance with safety belt use.33 The etiology of maxillofacial fractures in the pediatric patient appears to vary from one country to another. Physicians must therefore be actively involved in developing strategies to decrease the occurrence of falls by counseling parents of small children to increase their supervision of play activities and to keep children from playing unsupervised on stairs, ladders, and walls. Legislative measures to enforce safety, as well as the development of protective devices, could lead to long-term benefits in reducing injuries caused by falls. On the other hand, the high percentage of RTAs in a number of countries indicates that further informational and educational measures for both parents and children may be required to improve both compliance in the use of safety features and parental supervision of vehicle use. In terms of injury location in our patients, the skull vault was injured about twice as often as the midface and 6 times more often than the mandible. This is understandable because a small, flat midface, an even smaller mandible, and a prominent frontal bone and cranium characterize the infant’s face. With increasing age, the midface (especially the mandible) enlarge and thus assume a more vulnerable position. We found only 35% midface/skull base fractures and only 9% mandibular fractures. In view of the risk of maldevelopment of the condylar and septal growth center, there were, fortunately, only a few (n ⫽ 22; 6%) condylar fractures and only 1 nasal septum fracture. However, for medico-legal reasons, parents of such patients should be informed about the risk of maldevelopment. In Europe, most studies report a percentage of mandibular fractures between 60% and 86% of pediatric maxillofacial fractures.3,17-22 This is probably because the peak incidence among pediatric patients is in the older age group, thus involving patients with a more developed and larger mandible than in our study. Furthermore, skull vault fractures were often not included, which makes comparison with our results even more difficult. According to our results, a study from Texas also found a high incidence of skull vault fracture, occurring especially in the youngest patients between birth and 5 years of age.23 Their findings were explained by the increased elasticity and stability of facial bones in young children. This stability requires greater force to elicit maxillofacial fractures and can transmit forces to the children’s skull vault. Another study from Ohio26

63 confirmed these findings and statements. A study from Washington25 found mostly mandibular fractures, but this was because cranial vault fractures (which outnumber mandibular fractures) were primarily seen by the neurosurgical team and therefore not included. An Australian study showed most fractures to be in the midface,8 whereas in Jordan16 and Japan1 mainly mandibular fractures were found. In the African countries of South Africa,14 Nigeria,11,12 and Zimbabwe,13 the mandible was the most frequently injured maxillofacial bone. There, the low incidence of diagnosis of fractures of the middle third of the face is probably because of the lack of modern radiological techniques such as computed tomography. In addition, alveolar fractures, nasal fractures, and zygomatic fractures are often treated in the outpatient setting. Craniomaxillofacial trauma may sometimes be associated with related injuries to other body regions. Mechanism of injury plays a key role in predicting potential concomitant injury, which can be grouped into low-energy (falls, violence, and sports-related accidents) and high-energy (traffic accidents) categories. In our study, a higher incidence of injury to other organ systems associated with the former category is clearly observable. Associated head injuries were more common in the young patients who suffered predominantly from falls. This might be because of the larger craniofacial ratio and frontal prominence of these patients. Therefore, neurosurgical consultation should always be considered when dealing with pediatric maxillofacial trauma, especially in children less than 6 years of age. In Texas23 and Alabama,7 73% to 88% of patients with maxillofacial fractures suffered associated head injuries because high-velocity traffic accidents make up about 65% of all trauma cases. This was confirmed by a study from Australia.8 In contrast, a comparatively low incidence of associated injuries was observed in the United Kingdom17 and Greece,22 although traffic accidents were the most frequent cause. Low incidences were also reported in Nigeria12 and South Africa,14 probably because of the predominance of low-energy causes, such as falls and violence. When planning treatment in children’s fractures, all of the following should be taken into account: the age of the patient, the anatomic site and complexity of the fracture, the time elapsed since injury, and concomitant injuries. Internal fixation implies an open approach with subsequent subperiostal dissection, which interrupts the osteogenic potential of the periosteum and creates scarring, which may further restrict growth.24,36,37 Therefore, conservative treatment of the growing bone is preferred whenever possible. In our study, maxillofacial and skull vault fractures were treated with observation in 82% of

64 cases, and in only 12% with open reduction. No displacement of the fractures and reproducibility of adequate occlusion were the criteria utilized in conservative treatment. Comparing these figures with the European literature, we find the range of conservative treatment of maxillofacial fractures between 30% and 75% in the United Kingdom,3,5,17 whereas in Greece22 most fractures were treated by closed reduction and intermaxillary fixation. In the American literature, conservative treatment varies between 24% in Alabama,7 28% in Texas,23 and 30% in Washington, DC.25 This low incidence might be because of the high percentage of high-energy traffic accidents, which are often responsible for complex fractures and therefore need an open approach. In Australia, conservative treatment was possible in 43% of children,8 and in as many as 92% of patients in Jordan16 and Japan.1 On the other hand, in Nigeria12 only 27% of patients received conservative treatment, with none in Libya.15 The range of conservative treatment might be because of the different distribution of fracture types, but it also seems to indicate that there is still no consensus on the treatment of maxillofacial and vault fractures in pediatric patients worldwide. This might be due to the varying experience of surgeons with different treatment techniques, but also due to social and referral habits. The findings of this retrospective analysis show that craniofacial fractures in infants are most often in the young child’s skull vault and associated with cerebral concussion. To decrease the occurrence of these craniofacial traumas, more intensive instructions of parents by physicians, legislations concerning infant’s role in the traffic, and developing safer head-protecting devices are necessary. Comparison of international studies can contribute to our understanding of the circumstances and mechanism of pediatric head trauma. To make comparison meaningful, standardization of studies would be needed.

References 1. Tanaka N, Uchide N, Suzuki K, et al: Maxillofacial fractures in children. J Craniomaxillofac Surg 21:289, 1993 2. Rowe NL: Fractures of the facial skeleton in children. J Oral Surg 26:505, 1968 3. Porter SR: Facial fractures in children. Br Dent J 163:144, 1987 4. Haug RH, Foss J: Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:126, 2000 5. Carroll MJ, Mason DA, Hill CM: Facial fractures in children. Br Dent J 163:289, 1987 6. Koltai PJ, Rabkin D: Management of facial trauma in children. Pediatr Clin North Am 43:1253, 1996 7. Gussack GS, Luterman A, Powell RW, et al: Pediatric maxillofacial trauma: Unique features in diagnosis and treatment. Laryngoscope 97:925, 1987 8. Holland AJ, Broome C, Steinberg A, et al: Facial fractures in children. Pediatr Emerg Care 17:157, 2001

PEDIATRIC CRANIOFACIAL TRAUMA 9. Starkhammar H, Olofsson J: Facial fractures: A review of 922 cases with special reference to incidence and aetiology. Clin Otolaryngol 7:405, 1982 10. Voss R: The aetiology of jaw fractures in Norwegian patients. J Maxillofac Surg 10:146, 1982 11. Oji C: Jaw fractures in Enugu, Nigeria, 1985-95. Br J Oral Maxillofac Surg 37:106, 1999 12. Adekeye EO: Pediatric fractures of the facial skeleton: A survey of 85 cases from Kaduna, Nigeria. J Oral Surg 38:355, 1980 13. Chidzonga MM: Facial fractures in children. Cent Afr J Med 33:274, 1987 14. Bamjee Y, Lownie JF, Cleaton-Jones PE, et al: Maxillofacial injuries in a group of South Africans under 18 years of age. Br J Oral Maxillofac Surg 34:298, 1996 15. Jaber MA, Porter SR: Maxillofacial injuries in 209 Libyan children under 13 years of age. Int J Paediatr Dent 7:39, 1997 16. Qudah MA, Bataineh AB: A retrospective study of selected oral and maxillofacial fractures in a group of Jordanian children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:310, 2002 17. Anderson PJ: Fractures of the facial skeleton in children. Injury 26:47, 1995 18. Gassner R, Tuli T, Hachl O, et al: Craniomaxillofacial trauma in children: A review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg 62:399, 2004 19. Zerfowski M, Bremerich A: Facial trauma in children and adolescents. Clin Oral Invest 2:120, 1998 20. Guven O: Fractures of the maxillofacial region in children. J Craniomaxillofac Surg 20:244, 1992 21. Zachariades N, Papavassiliou D, Koumoura F: Fractures of the facial skeleton in children. J Craniomaxillofac Surg 18:151, 1990 22. Stylogianni L, Arsenopoulos A, Patrikiou A: Fractures of the facial skeleton in children. Br J Oral Maxillofac Surg 29:9, 1991 23. McGraw BL, Cole RR: Pediatric maxillofacial trauma. Age-related variations in injury. Arch Otolaryngol Head Neck Surg 116:41, 1990 24. Thaller SR, Huang V: Midfacial fractures in the pediatric population. Ann Plast Surg 29:348, 1992 25. Posnick JC, Wells M, Pron GE: Pediatric facial fractures: Evolving patterns of treatment. J Oral Maxillofac Surg 51:836, 1993 26. Chan J, Putnam MA, Feustel PJ, et al: The age dependent relationship between facial fractures and skull fractures. Int J Pediatr Otorhinolaryngol 68:877, 2004 27. Lallier M, Bouchard S, St-Vil D, et al: Falls from heights among children: A retrospective review. J Pediatr Surg 34:1060, 1999 28. Le Fort R: Etude experimentale sur les fractures de la machorie superieure. Rev Chir 123:208, 1901 29. Killey HC: Killey’s fractures, in Banks P: Fractures of the Mandible. London: Wright; 1988 30. Jarupoonphol V: Surgical treatment of Le Fort fractures in Ban Pong Hospital: Two decades of experience. J Med Assoc Thai 84:1541, 2001 31. Tan WK, Lim TC: Aetiology and distribution of mandibular fractures in the National University Hospital, Singapore. Ann Acad Med Singapore 28:625, 1999 32. Iida S, Kogo M, Sugiura T, et al: Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 30:286, 2001 33. Bataineh AB: Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86:31, 1998 34. Motamedi MH: An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, 2003 35. Klenk G, Kovacs A: Etiology and patterns of facial fractures in the United Arab Emirates. J Craniofac Surg 14:78, 2003 36. Rowe NL: Fractures of the facial skeleton in children. J Oral Surg 26:505, 1968 37. Waite DE: Pediatric fractures of jaw and facial bones. Pediatrics 51:551, 1973