American Journal of Otolaryngology–Head and Neck Medicine and Surgery 42 (2021) 102874

Contents lists available at ScienceDirect

American Journal of Otolaryngology–Head and Neck

Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Maxillofacial trauma in children: Association between age and mandibular

fracture site
Chelsea N. Cleveland a, Andrew Kelly a, Jason DeGiovanni a, b, Adrian A. Ong a, b,
Michele M. Carr a, b, *
a
Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States
b
Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: To describe the association between age and location of facial fractures in the pediatric population.
Pediatric facial trauma Materials and methods: A retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) from the
Facial fracture 2016 Kids’ Inpatient Database (KID) in children aged ≤18 years was conducted. International Statistical Classi­
Mandible fracture
fication of Diseases, 10th Revision (ICD-10) codes were used to extract facial fracture diagnoses. Logistic regression
Maxillofacial trauma
was used to evaluate and compare the contribution of various demographic factors among patients who had
Kids’ inpatient database
different types of facial fractures.
Results: A total of 5568 admitted patients were identified who sustained any type of facial bone fracture. Patients
who had facial fractures were significantly more likely to be male (68.2% versus 31.8%; p<0.001) and were older
with a mean age of 12.86 years (95% confidence interval [CI]: 12.72–12.99). Approximately one-third of patients
with a facial fracture had a concomitant skull base or vault fracture. Maxillary fractures were seen in 30.9% of
the cohort while mandibular fractures occurred in 36.9% of patients. The most common mandibular fracture site
was the symphysis (N=574, 27.9% of all mandibular fractures). Condylar fractures were more common in
younger children while angle fractures were more common in teenagers. Regression analysis found that age was
the only significant contributor to the presence of a mandibular fracture (β=0.027, p<0.001) and race was the
only significant contributor to maxillary fractures (β=− 0.090, p<0.001).
Conclusions: Facial fractures increase in frequency with increasing age in children. The mandible was the most
commonly fractured facial bone, with an age-related pattern in fracture location.

1. Introduction Accounts of pediatric mandibular fractures broken down by anatomical

Pediatric facial fractures are uncommon injuries that can require
immediate medical attention and extensive intervention. Children ac­
count for up to 15% of all facial fractures, and they are susceptible to a
number of concomitant injuries such as concussion, cervical spine
fracture, and skull base fracture [1–5]. The mechanism of injury usually
associated with pediatric facial fracture varies in the literature, although
reports cite motor vehicle accidents, assault, and falls as the most
common antecedent conditions [4,6]. Isolated nasal bone fractures may
be encountered more often clinically, however these fractures may be
underreported in the literature [7–9]. Instead, fractures of the mandible
are reported in the literature more often than any other facial structure,
making up between 24% and 44% of all pediatric facial fractures [2,10].
subunits are inconsistent, although they tend to suggest a higher inci­
dence of condylar and subcondylar fractures along with symphyseal and
parasymphyseal fractures [6,10–12].
While the incidence of pediatric facial fractures is well documented,
there are a scarcity of data reporting how these injuries change as
children age. A study of 215 patients by Smith et al. reports discrep­
ancies in mandibular fracture rates across age groups, with younger
children being more susceptible to condylar head fractures and older
children being more susceptible to condylar neck and angle fractures
[8]. Understanding the varying types of facial trauma on a more gran­
ular level can assist clinicians in their assessment of the pediatric facial
trauma patient. The goal of our study is to elucidate epidemiologic
factors associated with subsets of craniofacial trauma across age groups

* Corresponding author at: Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New
York, 1237 Delaware Avenue, Buffalo, NY 14209, United States.
E-mail address: mcarr@buffalo.edu (M.M. Carr).

https://doi.org/10.1016/j.amjoto.2020.102874
Received 4 October 2020;
Available online 29 December 2020
0196-0709/© 2020 Elsevier Inc. All rights reserved.

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C.N. Cleveland et al.
in the pediatric population using a large national database.
2. Materials and methods
This study was approved by the University at Buffalo Institutional
Review Board. We used the Kids’ Inpatient Database (KID), a nationwide
sample of pediatric inpatient records [13]. It is part of the Healthcare
Cost and Utilization Project (HCUP), a group of health care databases
developed via a Federal-State-Industry partnership and sponsored by the
Agency for Healthcare Research and Quality. HCUP databases merge
data collection efforts of state data organizations, hospital associations,
private data organizations, and the United States federal government to
create a national information resource of encounter-level health care
data. The HCUP KID for 2016 was searched for the International Statis­
tical Classification of Diseases, 10th Revision (ICD-10) diagnosis for facial
fractures which is summarized in Table 1. All patients aged 18 or
younger with facial fractures denoted by these codes were included.
Demographic information including gender, race, primary payer
status, median household income, region of the country, month of injury
as well as ICD-10 diagnosis codes were extracted from the database.
Descriptive statistics were utilized for all outcome variables. Non-
parametric methods were used to describe the population. Logistic
regression analysis was used to evaluate predictive factors for mandib­
ular and maxillary fractures. Statistical analysis was completed using
SPSS version 26 (IBM Corp., Armonk, NY). A p-value of <0.05 denoted
statistical significance.
3. Results
A total of 5568 patients between ages 0 and 18 years were identified.
Mean age was 12.86 years (95% confidence interval [CI]: 12.72–12.99)
and, in general, the frequency of facial fractures increased with age
(Fig. 1). Distribution of gender, race, primary payer, median household
income, region, and month of injury was significantly different in this
group (p<0.001), as seen in Table 2. There were fewer fracture admis­
sions between December and February and more between April and
October.
The mandible was the most commonly fractured facial bone in this
dataset, occurring in over one-third of patients (36.9%). The maxilla was
the second most commonly fractured facial bone (30.9%), which was
followed by fractures of the nasal bone (27.3%) and orbital floor
(19.4%). Approximately one third of children with facial fractures had a
concomitant skull vault or skull base fracture (Table 3).
The distribution of different sites of mandible fractures is listed in
Table 4 with the mandibular symphysis being the most common
mandibular fracture site. Condylar fractures were more common in
younger children with children less than 1 year of age having the highest
incidence of condylar fractures (16.9%). In children aged 13–18 years,
fractures of the condyle accounted for between 5.2% and 7.8% of
mandible fractures while in children less than 13 years old these frac­
tures accounted for between 6.2% and 16.9% of mandible fractures. By
contrast, angle fractures were more common in teenagers. In teenagers
greater than 14 years old, fractures of the angle accounted for between
12.2% and 14.2% of mandible fractures, while fractures of this subsite in
children younger than this age accounted for between 0% and 7.5% of
Table 1
ICD-10 diagnosis codes.
Fracture type ICD-10 code (first 4 or 5 digits only)
Vault of skull S02.0
Skull base S02.1
Nasal S02.2
Orbital floor S02.3
Maxilla S02.4
Mandible S02.6
Unspecified facial fracture S02.92
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 42 (2021) 102874
mandible fractures. Children younger than 2 years of age did not have
any fractures of the angle. There were no other significant age-related
correlations with fracture site. The frequency of condylar and angle
fractures in each age group is depicted in Fig. 2.
Logistic regression was used to evaluate the contribution of age,
gender, race, month of injury, and region of the country to the presence
of a mandibular fracture, and only age was a significant contributor
(β=0.027, p<0.001). With the same factors, race was significantly
associated with the presence of a maxillary fracture (β=− 0.090,
p<0.001).
4. Discussion
The current study found the incidence of facial fractures increasing
with age among pediatric patients. This increasing frequency can be
explained by the craniomaxillofacial development of the pediatric pa­
tient, and is consistent with previous literature [14–19]. Early cranio­
facial development is thought to contribute to reduced susceptibility to
facial fractures in infants compared to older children and adults. Infants
have a proportionately larger cranium at birth, with a craniofacial ratio
of 8:1 as compared to a ratio of 2:1 in adult [20]. The proportionally
larger cranial to maxillofacial skeleton predisposes infants to skull
fractures rather than facial fractures as the facial skeleton is retro­
displaced relative to the cranium [9,15]. However, as the child grows,
the lower face lengthens and widens eventually representing a greater
proportion of the craniofacial skeleton, approaching adult proportions.
In the early stages of development, the immature facial bones have not
undergone significant pneumatization of the paranasal sinuses or bone
mineralization [21]. In adults, the paranasal sinuses are theorized to
provide a “crumple zone” on impact leading to fracture of facial bones in
order to protect nearby vital structures [17]. As pneumatization and
mineralization progress, the facial bones become less compliant and
more susceptible to fracture. Furthermore, the presence of primary
dentition with tooth germs, which provides further structural stability to
the pediatric maxillofacial skeleton, and infantile facial fat pads confer
additional protection from fracture [15,22].
Additionally, children have a number of behavioral factors that may
contribute to a lower incidence of craniofacial trauma than adults. While
both adults and children are subject to injury from violent behavior,
sports, and road accidents, children are normally under supervision and
have fewer opportunities to produce significant forces that would pre­
cipitate these injuries with the majority of pediatric facial fractures
being caused by falls. However, there is a reported increase in cranio­
facial trauma as children age and begin to learn skills like bicycle riding
and driving [6,23]. In addition, their participation in sports activities
and driving predispose older children to more frequent craniofacial
trauma [5,6,10,18]. As in adulthood, male children have a greater
predilection for injury, with most studies showing two to threefold
greater risk of facial fracture [5,6,10]. This may be explained by
increased interpersonal violence in the male population which remains a
rare cause of facial fracture, however more prevalent in adolescents
[19].
Eggensperger et al. conducted a retrospective review of pediatric
patients presenting to a level 1 trauma center for evaluation of facial and
skull fractures [1]. They found that over 50% of these patients sustained
skull vault fractures and 8% had skull base fractures. In our study,
approximately 30% of those with facial fractures sustained a concomi­
tant skull base or skull vault fracture. Skull fractures can have serious
complications such as cerebrospinal fluid leak, meningitis, and associ­
ated intracranial injuries [18,24]. A study describing outcomes of basilar
skull fractures indicated that 15.9% had permanent neurologic deficits
[18]. The association between facial fractures and skull fractures is
important to recognize; these multi-level craniofacial traumas have
increased morbidity and require a multidisciplinary team. The type of
facial fracture or specific patterns may help predict the presence of a
concomitant skull fracture. Historically, nasal bone fracture has been
C.N. Cleveland et al. American Journal of Otolaryngology–Head and Neck Medicine and Surgery 42 (2021) 102874

Fig. 1. Incidence of facial fracture by age.

Table 2 Table 3
Demographic characteristics of patients with facial fractures. Summary of facial fractures among children admitted with facial fractures.
Variable N Percent P valuea Fracture type N (total N=5568)a %

Gender Vault of skull 618 11.1

Male 3795 68.2 <.001 Skull base 1366 24.5
Female 1768 31.8 Nasal 1518 27.3
Unknown <10 – Orbital floor 1081 19.4
Maxilla 1723 30.9
Race
Mandible 2056 36.9
White 2691 53.0 <.001
Unspecified facial fracture 55 1.0
Black 994 19.6
a
Hispanic 974 19.2 Total N refers to the number of patients with facial fractures per HCUP KID.
Asian/Pacific Islander 132 2.6
Native American 58 1.1
Other 232 4.6
Table 4
Unknown 489 –
Summary of frequencies of each mandibular fracture site.
Primary payer
Fracture type (ICD 10 code) N (N = 2056) %a
Private insurance 2503 45.1 <.001
Medicaid/Medicare 2477 44.6 Condyle (S02.61) 369 17.9
Self-pay 244 4.4 Subcondylar (S02.62) 264 12.9
No charge 13 0.2 Coronoid process (S02.63) 28 1.4
Other 315 5.7 Ramus (S02.64) 196 9.5
Unknown 18 – Angle (S02.65) 527 25.6
Symphysis (S02.66) 574 27.9
Median household income for patient’s zip code (US$)
Alveolar ridge (S02.67) 98 4.8
<$42,999 2477 44.6 <.001
$43,000–$53,999 1404 25.7 a
% of total mandible fractures.
$54,000–$70,999 1203 22.0
>$71,000 956 17.5
Unknown 102 – head dislocation [26]. Further investigation is needed to define the re­
lationships between facial fracture type and presence of skull fractures.
Region
Northeast 890 16.0 <.001
The most common facial fracture in the present study was the
Midwest 1205 21.6 mandible (36.9%). This is consistent with the existing literature which
South 2136 38.4 has found mandibular fractures to be the most common
West 1337 24.0 [6,10,14,23,27–30]. When analyzing the mandibular fracture subtypes,
Per HCUP guidelines, cell sizes with N<10 cannot be reported. symphysis fractures were the most common overall (27.9%), followed
a
Chi square test. by angle (25.6%), and condyle (17.9%). Imahara et al. analyzed the
National Trauma Data Bank and concluded that the most commonly
associated with fracture of the cribriform plate. In addition, Martello isolated mandibular fracture in children was localized to the symphysis
and Vasconez reported that orbital roof fractures are frequently associ­ (16.6%) [6]. This number did not include those who sustained multiple
ated with skull fractures (69%) [25]. In a rare case, there has been a mandibular fractures (15.5%). Similarly, Andrade et al. found that 50%
report of a middle cranial fossa fracture as a result of traumatic condylar of pediatric isolated mandibular fractures occurred in the parasymphysis

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C.N. Cleveland et al.
Fig. 2. Percent children with facial fractures by type of mandibular fracture.
or symphysis [11]. Ferreira et al. found that condylar or subcondylar
fractures were the most prevalent mandibular fracture in children at
37.7%; however, they included those who had multiple fractures in the
analysis [10]. The discrepancy is likely due to differences in reporting
data such as grouping of distinct fracture sites or lack of characterization
of fracture sites in those who sustain multiple mandibular fractures.
This is the largest study to describe an association between
mandibular fracture subtype and age. Iida and Matsuya found condylar
fractures to be more predominant in children less than 6 years of age
[27]. They also reported that children over 13 years of age most
commonly had angle fractures. In our cohort, condylar fractures were
the predominant subtype in children less than 5 years old. Teenagers,
especially those between the ages of 16 and 19 years, had a higher
prevalence of mandibular angle fractures. In adults, the angle is the most
common location in isolated mandibular fractures. These are particu­
larly prevalent in cases of interpersonal violence [31]. This is consistent
with the idea that this age group is more susceptible to adult behaviors
and consequently adult fracture patterns.
The preponderance of younger children who sustain condylar frac­
tures is clinically important. In children, the condyle is short and highly
vascular with a thin cortical plate which makes it vulnerable to fracture
[21]. The condylar region is critically important to the growth of the
mandible and is considered a primary growth center [32]. The proximity
of this region to the temporomandibular joint makes it a highly impor­
tant functional area as well. Children under the age of 3 are the most at
risk for growth disturbance and other adverse outcomes such as facial
asymmetry, malocclusion, trismus, and ankylosis as a result of these
fractures [21,32]. Due to the functional importance of the condyle in the
temporomandibular joint, prompt recognition of condylar injury and
treatment are critical to preserve function as well as maintain mandib­
ular ramus height in the pediatric patient.
Treatment of mandibular fractures varies by age and options include
observation, maxillomandibular fixation (MMF), or open reduction and
internal fixation (ORIF). In general, non-displaced fractures can be
managed conservatively with a modified diet and early range of motion
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 42 (2021) 102874
[33,34]. MMF may be required in some cases of minor malocclusion
[34]. Stage of dentition is one of the most important reasons for dif­
ferences in treatment modality. With regard to MMF, a child under the
age of 2 years is considered edentulous as their teeth do not provide
needed support for fixation. In these cases, an acrylic splint with circum-
mandibular wires can achieve fixation. Risdon cables and mini-arch bars
can be used when deciduous teeth erupt between 2 and 5 years old. Once
primary teeth develop children are able to tolerate arch-bar placement
[34]. ORIF is generally avoided in younger children due to presence of
tooth buds and ongoing bone growth. In older children, these concerns
lessen [33–35]. When necessary, ORIF can be done using absorbable
fixation systems. Recent studies have shown success with the use of
resorbable fixation plates and screws without significant implant related
complications [36–39]. These are not yet widely used and the use of
resorbable plates is FDA approved only for non-load bearing areas,
which does not include the mandible. These systems afford a temporary
rigid fixation for bone healing and avoid a need for future removal of the
plate [34]. Larger comparative studies in pediatric patients are needed
in order to determine the superior fixation type which yields successful
long term outcomes.
The HCUP KID database used for this study provides a robust sample
however, some limitations must be considered. As with any large
database, the information obtained is only as accurate as the diagnostic
coding. Potential coding errors could lead to over or underestimated
prevalence of fractures and mischaracterization of mandibular fracture
subtype. Although this database does include a large number of hospitals
in the United States, not all institutions are included in this data set. KID
surveys only inpatient hospital stays; the prevalence of fractures re­
ported does not include those that were treated as outpatients. There­
fore, this data set is not inclusive of all pediatric facial trauma in the
country.
5. Conclusion
In this group of admitted children, facial fractures increased in
C.N. Cleveland et al.
frequency with increasing age. The mandible was the most commonly
fractured facial bone, with an age-related pattern in fracture location.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Chelsea N. Cleveland: Formal analysis, Writing - Original Draft,
Writing - Review & Editing, Visualization
Andrew Kelly: Formal analysis, Writing - Original Draft, Writing -
Review & Editing, Visualization
Jason DeGiovanni: Formal analysis, Writing - Original Draft, Writing
- Review & Editing, Visualization
Adrian A. Ong: Formal analysis, Writing - Review & Editing,
Visualization
Michele M. Carr: Conceptualization, Formal analysis, Writing - Re­
view & Editing, Visualization
Acknowledgements
The Healthcare Cost and Utilization Project Kids’ Inpatient Database
and the hospitals participating in the HCUP KID are the source of the
data used herein; they have not verified and are not responsible for the
statistical validity of the data analysis or the conclusions derived by the
authors.
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