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Pe diatric F acial Tr aum a

Tom W. Andrew, MBChB, MSca, Roshan Morbia, MDb, H. Peter Lorenz, MDa,b,*

 Pediatric  Child  Fracture  Facial  Bone  Injury  Surgery

 The incidence of head trauma is higher in the pediatric population; however, facial fractures are less
prevalent than in the adult population.
 Anatomic and behavioral factors contribute to the increasing incidence of facial fracture with age.
 The decision between operative and nonoperative management is the compromise between pedi-
atric facial growth, and precise reduction and rigid fixation.
 When maxillomandibular fixation is needed, a technique should be adopted that does not damage
developing dental tooth buds, such as circummaxillomandibular wiring.

Trauma is the predominant cause of morbidity Facial fractures carry a significant morbidity
within the pediatric population. Pediatric trauma despite only accounting for 4.6% of pediatric
results in 12,000 deaths annually in the United trauma.2 Considerable force is required to cause
States.1 The incidence of facial trauma in the pedi- a fracture in the pediatric facial skeleton; thus,
atric population is higher than in the adult popula- 55.6% of pediatric facial fracture cases have se-
tion. However, the incidence of facial fracture is vere concomitant injuries.3 Pediatric patients
lower as a result of reduced mineralization of the with facial fractures spend twice as long in the
facial skeleton, large fat pads, decreased pneuma- hospital and 3 times as long in the intensive care
tization of sinuses, and compliant sutures. These unit (ICU) compared with those without facial
anatomic factors allow the facial skeleton to fracture.2
absorb energy without fracturing, and when frac- The most common mechanisms of pediatric
ture does occur, it is more likely incomplete, result- facial fracture are road traffic incidents (55.1%),
ing in greenstick injury. assaults (14.5%), and falls (8.6%).2 The cause of
In addition to the unique anatomy of the pediat- facial fracture in children correlates with age. Falls
ric patient, future growth and development must are most common among infants and toddlers;
be accounted for when addressing injuries. A road traffic accidents are usually seen in school
nonoperative approach is advised whenever children, and interpersonal violence (IPV) is most
possible, and long-term follow-up is mandatory often seen in older teenagers. Age also correlates
to ensure adequate aesthetic and functional out- with the incidence of pediatric facial fracture
comes. The objective of this article is to provide (Table 1).3 The frequency and severity of injury in-
the reader with an understanding of the unique el- crease with age, and the prevalence is greater in
ements of facial fracture management in the pedi- boys (2–3:1). The incidence of pediatric facial frac-
atric population. ture is lowest in 5 year olds (5.6%), and the highest

Disclosure Statement: Drs Andrew and Lorenz have received funding from Hagey Laboratory for Pediatric
Regenerative Medicine.
Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic Surgery, Department of Surgery,
School of Medicine, Stanford University, 257 Campus Drive, Stanford, CA 94305, USA; b Division of Plastic Sur-
gery, Department of Surgery, School of Medicine, Stanford University, 770 Welch Road, Suite 400, Stanford, CA
94305, USA
* Corresponding author. Hagey Laboratory for Pediatric Regenerative Medicine, 257 Campus Drive, Stanford,
CA 94305.
E-mail address:

Clin Plastic Surg - (2018) -–-
0094-1298/18/Ó 2018 Elsevier Inc. All rights reserved.
2 Andrew et al

Table 1
be strictly followed. The assessment consists of
Correlation of age with incidence of pediatric the primary survey, resuscitation, secondary sur-
facial fracture vey, diagnostic evaluation, and definitive manage-
ment.13 The airway is precarious in children and
0–5 y 6–11 y 12–18 y should be secured at all times. Despite the severity
Age Group old old old of facial trauma, the child should always be
Most common Falls Motor IPV assessed in the structured airway, breathing, cir-
mechanism (43.6%) vehicle (25.3%) culation, survey approach.
crash The pediatric population presents exceptional
(24.9%) considerations for initial management. Their rela-
Operative 28.2% 36.0% 39.4% tive size and surface area to volume ratio puts chil-
intervention dren at risk for multisystem injury, with potential
ICU admission 28.8% 20.6% 12.9% rapid decompensation due to hypovolemia and
hypothermia. A small shoulder roll should be
Data from Grunwaldt L, Smith DM, Zuckerbraun NS, et al.
Pediatric facial fractures: demographics, injury patterns,
placed to compensate for the occipital promi-
and associated injuries in 772 consecutive patients. Plast nence in infants and toddlers. Children are at
Reconstr Surg 2011;128(6):1263–71. higher risk of spinal cord injury without radiological
findings due to their relatively large head and a
greater cartilaginous component of the vertebral
among teenagers, with 55.9% occurring between column, so additional care should be taken in sup-
15 and 17 years old.2,4 porting the cervical spine even after radiological
Nonaccidental injuries, although rare, are impor- clearance.
tant to consider in every pediatric facial trauma Nonaccidental injury (NAI) should be suspected
assessment. Nonaccidental injuries result in head if inconsistencies in the history of presentation,
or neck injuries in 50% of cases.5 Facial fractures prolonged duration between injury and care,
caused by IPV are more likely to occur in older, noncompliance, or multiple presentations are pre-
male, non-white, and lower socioeconomic pa- sent. NAI is associated with higher injury severity
tients.6 IPV often results in nasal and mandible scores, higher ICU readmission rates, and
angle fracture, whereas non–interpersonal increased mortality.14 The head and neck region
violence–related injuries more likely result in skull accounts for more than two-thirds of injuries
and orbital fracture. Craniofacial injuries occur in from abuse.5 Communication of concerns for NAI
20% of all pediatric sport-related injuries in the to the child protection team is essential.
United States.7 Road traffic accidents are the The head and neck examination should be
most common cause of pediatric facial fracture methodical, fastidious, and consistent. In some in-
among children, accounting for 50% of cases. Un- stances, the age of the patient limits compliance,
restrained children are significantly more likely to and sedation or general anesthesia may be neces-
sustain facial injury. However, the incidence of sary to complete a comprehensive assessment.
facial fracture has significantly reduced since the Examination of all abrasions, lacerations, and con-
introduction of seatbelt legislation.8 tusions should be performed, removing any ob-
Anatomic site of facial fracture varies according structions, including bandages and secretions.
to age in the pediatric population. Nasal fractures Lacerations should be explored for tissue loss,
are often underreported, most of which do not un- viability, and depth, while evaluating the recon-
dergo surgical management.9 Anatomic distribu- structive options and the possibility of using these
tion of mandible fractures varies with age: wounds as surgical access for fracture repair. As
condylar head and subcondylar fractures are much as feasible, facial motor and sensory nerve
most common (48%); however, the incidence of function should be documented before surgical
condylar fracture decreases with age, whereas wound or fracture treatment intervention.
body and angle fracture incidence increases.10,11 Inspection of the craniofacial skeleton should
Surgical treatment rates for pediatric facial frac- involve the identification of particular signs that
ture vary greatly, from 25% to 78%.3 However, are characteristic for associated facial fractures,
older children more often require surgery than such as hypertelorism, Battle sign, malocclusion,
younger children.12 trismus, entrapment, raccoon eyes, facial numb-
ness, and otorrhea and/or rhinorrhea. These signs
PREOPERATIVE ASSESSMENT suggest an underlying craniofacial fracture and
necessitate radiographic imaging. Palpation of
When managing a child with facial trauma, the the cranium and facial skeleton should be per-
Advanced Trauma Life Support protocol should formed in a methodical superior to inferior fashion,
Pediatric Facial Trauma 3

with emphasis on frontal bones, zygomatic arches, structures or facial growth. Foreign-body reaction
orbital rims, oral cavity, and mandibular stability. is rare with the resorbable polymers used for facial
Otoscopy, rhinoscopy, and ophthalmoscopy are fracture management.17 Some surgeons have pro-
essential to exclude subtle facial injuries. Eye ex- posed delayed operative intervention of facial frac-
amination can be challenging in the pediatric tures until edema settles. However, because of the
trauma population. Pupillary reactivity, ocular enhanced healing of the pediatric skeleton, mal-
mobility, globe position, and vision should be union may be initialized within 3 to 4 days of injury.
assessed. Formal assessment by the ophthal- If the decision is made to operate, the procedure
mology team is recommended for all periorbital should be performed as soon as localized edema
fractures and any situation with suspected visual is no longer prohibitive.
Digital photography plays a vital role in docu- SKULL AND FOREHEAD FRACTURES
mentation and can assist in counseling families
regarding aesthetic challenges as well a support- There is an increased risk of pediatric skull and
ing multidisciplinary surgical planning. Radiolog- forehead trauma due to a high cranium to face ra-
ical images should be limited in the pediatric tio. Given the lack of protection from pneumatizd
population, and low-dose scanning protocols frontal sinus in younger children, the incidence of
should be followed.15 The ability to visualize facial intracranial injury with frontal bone fracture has
fractures may be limited by anatomic and behav- been reported to be as high as 35% to 64%.18,19
ioral limitations. Bony deformity may be obscured Cerebrospinal fluid (CSF) leak is also common,
by tooth buds, lack of ossification, the predisposi- occurring in 18% to 36% of frontal bone
tion for greenstick-type fractures, and extensive fractures.20
soft tissue injury. Computed tomography (CT) When suspecting a frontal bone fracture, the pa-
has become the mainstay of diagnostic evaluation tient must be evaluated for fracture displacement,
for pediatric facial fracture.12 CT allows for CSF leak, intracranial hematoma, deformed facial
detailed assessment and identification of sus- contour, and frontal-lobe contusion. All dressings
pected injuries. CT scans also provide a format should be removed to allow full visualization, and
for surgical planning and 3-dimensional lacerations should be washed to examine. The
reconstructions. skull should be thoroughly palpated for any bony
or soft tissue defect. Brow examination should
include palpation of bony step-offs and
UNIQUE FEATURES OF PEDIATRIC FACIAL paresthesia, and brow or lid ptosis should be
FRACTURE documented.
In deciding between operative and nonoperative Before pneumatization of the frontal sinus, frac-
management of pediatric facial fractures, the tures of the frontal bone or supraorbital ridges are
craniofacial surgeon must weigh the risk of growth considered to be anterior cranial base fractures.
disturbance with the benefit of precise reduction
Operative Approach
and stable fixation. In the immature craniofacial
skeleton with minimal displacement, a conserva- The goals of skull and forehead fracture repair
tive approach is often preferable. In contrast, a include protection of the neurocapsule, dural
child close to skeletal maturity with significant reconstruction, control of CSF leaks, prevention
bone displacement should be managed with of posttraumatic infection, and aesthetic restora-
open reduction and internal fixation. In accor- tion of craniofacial contours.
dance with the “functional matrix” principle of Most pediatric frontal fractures that are mini-
Moss and Salentijn,16 periosteal stripping should mally or non-displaced can be treated conserva-
be minimalized when fixating the fracture, because tively with adequate follow-up. When frontal
the periosteum serves as the main contributor to fractures are significantly displaced, a surgical
new bone formation. Hence, extensive periosteal approach via a coronal incision in combination
stripping is more likely to result in adverse skeletal with a frontal craniotomy is needed. A combined
development. plastic and neurosurgical approach is often neces-
To avoid growth disturbance, resorbable plating sary for these complicated procedures. After
systems have been proposed in skeletally imma- exposing the fracture, the dura must be inspected.
ture patients. Resorbable plating provides tempo- Epidural hematomas are evacuated, and dural lac-
rary stabilization of bony fracture without the need erations are repaired. When a CSF leak is present
for a second surgery for plate removal. The blunt with minimal bone displacement, it can be
tips of the screws and future resorption offer observed and managed with 4 to 7 days of bed
decreased risk to developing teeth and nerve rest, possibly with a lumbar drain. Cranialization
4 Andrew et al

Fig. 1. (A) Coronal and (B) sagittal CT images demonstrating left orbital floor “trapdoor” fracture with entrap-
ment of orbital soft tissue contents in a 14-year-old male patient.

is performed if the leak persists. In younger chil- 7 years, after which age a decrease in the neuro-
dren, only resorbable plating systems should be cranium to viscerocranium ratio occurs, and the
used because metallic hardware can transmigrate development of the frontal sinus “crumple zone”
endocranially due to calvarial bone growth. begins. The relatively large neurocranium in young
When the frontal sinus is present, the goal of children increases the susceptibility of neurologic
surgical repair is to achieve adequate drainage injury due to orbital fracture. In contrast, older pa-
throughout growth and development. If the poste- tients are more likely to sustain midface and
rior wall or inferior drainage system has been ophthalmic injury. Routine ophthalmologic consul-
severely damaged, then the frontal sinus should tation should be obtained in any patient with peri-
be cranialized. To ensure complete separation of orbital trauma. Inspection for subconjunctival
the nose from the intracranial cavity, the floor of hemorrhage and extraocular muscle movement
the sinus should be lined by vascularized tissue, range, including diplopia, should be performed.
such as a pericranial flap or galeal-frontalis flap. Superior orbital fissure syndrome, which com-
Preservation of the frontal sinus requires long- prises internal and external ophthalmoplegia,
term follow-up with serial CT scans to ensure proptosis, and CN VI paresthesia, should be
adequate drainage. Nasofrontal duct stents can treated as an emergency. If superior orbital fissure
be placed if there are concerns with drainage. syndrome occurs in combination with blindness, it
Endoscopic sinus surgery can be done to open is described as orbital apex syndrome.
duct/drainage. The orbital floor “trapdoor” fracture occurs most
commonly in children. “Trapdoor” fracture occurs
ORBITAL FRACTURE when the transient opening in the orbital floor en-
traps the orbital contents, including the inferior
Orbital fractures occur as a result of 2 mechanisms. rectus muscle (Fig. 1). The signs of entrapment
First, the “hydraulic” theory suggests that direct include nausea, vomiting, and oculocardiac reflex.
pressure and compression force of the globe Inferior orbital entrapment is a clinical diagnosis
directly fracture the thin bone of the orbital wall, in and cannot be excluded by imaging studies alone.
particular, the inferior and medial walls resulting in Forced duction testing is a useful way of distin-
orbital blowout.21 Second, the “bone conduction” guishing diplopia of entrapment from pseudoen-
theory describes the distribution of energy trapment from nerve injury due to localized
absorbed at the orbital rim resulting in buckling of swelling. Forced duction testing in children is often
the floor with fracture at the weakest point.22 performed under general anesthesia. The conjunc-
Pediatric orbital fractures are clinically distinct tiva is grasped with forceps close to the limbus
from adult orbital fractures. Fractures of the supra- and is moved away from the side of suspected
orbital rim are often classified as skull base frac- entrapment. Medial wall fractures carry a signifi-
tures because they include the frontal bones cant but reduced risk of entrapment involving the
before sinus pneumatization. The incidence of medial rectus muscle. Caution should be taken
orbital roof fractures is highest before the age of when considering a possible white-eyed blowout
Pediatric Facial Trauma 5

Fig. 2. Bicoronal approach to a bilateral displaced NOE fracture in a 13-year-old patient. (A) Displaced NOE frac-
tures. (B). Reduced and plated NOE fractures and transnasal medial canthoplasty wires.

fracture. In these patients, the eye appears unin- herniated soft tissue, the stable bony ledges of
jured without subconjunctival hemorrhage; how- the fracture are spanned with plates or bone grafts;
ever, the child will have severe restriction of gaze many craniofacial surgeons use autologous mate-
secondary to soft tissue entrapment in the trap- rial, such as split calvarial bone fragments, iliac
door fracture. The soft tissue herniation may not crest, or rib grafts, for orbital reconstruction of the
be readily visible on CT. The bony fracture line is growing facial skeleton. Absorbable plates and
usually difficult to image on CT. Entrapment in mesh are used for fixation as needed.
the white-eyed blowout fracture is often associ- Possible complications include retrobulbar he-
ated with the oculocardiac reflex (bradycardia, matoma, orbital cellulitis, lid malposition, enoph-
nausea, and syncope), which is an absolute indi- thalmos, and persistent diplopia. Retrobulbar
cation for urgent surgical intervention. hematoma is sight threatening and presents with
pain, proptosis, and internal ophthalmoplegia
Operative Technique and should be managed with urgent lateral can-
tholysis for orbital decompression.
In the absence of entrapment or acute globe
malposition, management is often conservative. NASAL AND NASOETHMOIDAL FRACTURE
The goals of orbital fracture treatment include the
restoration of globe position with correction of Nasal fractures are common among children. The
diplopia and release of entrapment. If open reduc- presence of soft cartilage and incompletely ossi-
tion internal fixation (ORIF) is necessary, some fied nasal bone means that pediatric nasal frac-
investigators have suggested that the transcon- tures are often missed. The younger child has a
junctival approach is preferred for good cosmesis reduced risk of nasal bone fracture due to
and a lower risk of ectropion.23 If lateral exposure decreased rostral projection, shorter dorsum,
is necessary, a subciliary or midlid incision with larger cartilaginous portion, and increased bony
lateral “crow’s foot” extension avoids the lateral compliance. The incidence peaks in adolescence
cantholysis that may be necessary with a transcon- because of anatomy and behavioral factors.4
junctival incision and affords generous exposure Naso-orbital ethmoidal (NOE) fractures are rare
extending to the lateral-superior orbital rim/orbit. in the pediatric population and occur as a result
If medial exposure is necessary, a transcaruncular of high-energy trauma. Unlike in adults, patterns
approach is performed, often obviating a coronal of fracture are different due to proportional differ-
incision. A gingival buccal sulcus incision can be ence in midface to neurocranium and the lack of
added if necessary. Herniated tissues are reduced pneumatization of the frontal sinus. Pediatric
from the sinus; the fracture is cleared of debris, and NOE fractures are characterized by posterior and
stable edges for fixation and grafting are identified. lateral displacement of nasal bones and medial
After adequate exposure and relocation of orbital wall, including the ethmoid (Fig. 2). The
6 Andrew et al

medial canthus inserts at the medial orbital wall, present with malar flattening, enophthalmos, and
resulting in potential traumatic telecanthus; this lateral canthal dystopia (Fig. 3). CT is the gold-
may not be apparent until 7 to 10 days after injury standard imaging modality for midface fracture
when edema has subsided. confirmation because soft tissue swelling can
Physical examination must include endonasal often obscure midface deformity.
examination to rule out septal hematoma. Septal The treatment goals of surgery in pediatric mid-
hematoma requires immediate intervention with face fractures are to achieve accurate reduction
mucoperiosteal incision. Caution should be taken and sufficiently stable fixation to permit bone heal-
to avoid overlapping bilateral incisions resulting ing while avoiding disturbance to future growth.
in potential septal perforation. Suture quilting and Minimally displaced and greenstick midface frac-
postoperative intranasal splints should be used tures are often managed nonoperatively, espe-
to compress the mucoperichondrium to obliterate cially in younger children. Displaced or unstable
any dead space. Non-displaced nasal fracture maxillary fractures require either closed reduction
may be managed with external splint. The septum with mandibulomaxillary fixation or ORIF. Rigidity
is an important center for midface growth. and length of fixation are less than in adults.
Because of the potential risks of restricted facial When performing ORIF, care must be taken to
growth, definitive open management of displaced avoid injury to the developing tooth buds when
nasal fractures is often delayed until skeletal matu- plating fractures.
rity. However, displaced nasal bone fractures still The operative goals in ZMC fracture surgery are
require closed reduction, which is best performed correction of malocclusion and restoration of ma-
under general anesthesia. Ash forceps are used to lar prominence. Access to the zygomaticofrontal
relocate the septum, and a Goldman elevator is (ZF) suture may be achieved through a brow inci-
used to reduce nasal bones, as is done in adults. sion or upper lid blepharoplasty incision. Gener-
Because of the rapid healing ability of children, ally, 3-point fixation is required at the ZF suture,
closed reduction should be performed 3 to inferior orbital rim, and zygomaticomaxillary
7 days after injury. Pediatric open septorhinoplasty buttress. Maxillary fractures may result in nasola-
is typically reserved for severely displaced frac- crimal obstruction or malocclusion. Pediatric pa-
tures, sleep apnea, and chronic refractory sinus tients with maxillomandibular fixation (MMF) are
disease. at risk of malnutrition.
Pediatric NOE fractures with telecanthus should
have the intercanthal distance restored to age- MANDIBLE
specific standards; this is often performed by
reduction of the medial orbital rims. Medial canthal Children with mandible fractures are at risk of
tendons are reattached with transnasal wires airway compromise. The airway must be secured
passing superiorly and posteriorly to the posterior during initial management; at times, endotracheal
lacrimal crest. As in nasal fractures, the likelihood intubation or a surgical airway may be necessary
of additional secondary surgery in adolescence is to achieve this. CT imaging of the head and neck
high due to factors related to facial skeletal are also necessary to exclude concomitant in-
growth. juries. Furthermore, the panorex has largely
Nasal fracture may result in several deformities. been superseded by CT imaging on the
Nasal fractures in children may affect facial skel- mandible.
eton growth, resulting in nasal hypoplasia. Nasal Intraoral lacerations, ecchymosis, and edema
deviation may occur as a result of cartilaginous may suggest an underlying mandibular fracture.
warping or incomplete reduction. If untreated, a Paresthesia of the inferior alveolar nerve can occur
septal hematoma may result in septal thickening in displaced fractures. A thorough intraoral exam-
or perforation, ultimately developing into a ination must be performed, and subjective maloc-
saddle-nose deformity. clusion may be noted. Drooling and trismus may
also be noted. Bimanual examination of the
MIDFACE/ZYGOMATICOMAXILLARY mandible may demonstrate bony step-offs. The
FRACTURES external auditory canal may show bleeding and
ecchymosis. Palpation of the TMJ at the external
Classical Le Fort midface fractures are rare in chil- auditory canal during jaw movement may demon-
dren due to an undeveloped buttress system, strate crepitation or a displaced condylar head.
small paranasal sinuses, and unerupted tooth Trismus causing maloccluusion with no or minimal
buds. Examination may reveal a mobile midface, bony displacement can be seen in children. CT im-
palpable bony step-offs, and malocclusion. Zygo- aging is critical to determine if significant displace-
maticomaxillary complex (ZMC) fractures often ment is present.
Pediatric Facial Trauma 7

Fig. 3. A 13-year-old male patient with bilateral NOE, left ZMC, left orbital floor, palate, and left Le Fort I frac-
tures. (A) Coronal CT and (B) 3-dimensional reconstruction images. (C) Left zygomatic body with orbital floor
blowout fracture intraoperatively. Existing laceration used for fracture exposure. (D) Fixation of zygomatic
bone and split calvarial bone grafts to orbital floor.

The treatment goals are to achieve restoration of developing dental tooth buds such as circummax-
normal occlusion and to achieve bony union illomandibular wiring. In addition, the primary
without interrupting potential facial growth devel- dentition does not hold interproximal space wires
opment. In the developing jaw, future orthodontic for arch bars well. During mixed dentition, MMF
correction allows for minor occlusal discrepancies plating systems are not advised due to developing
rather than aggressive corrective operative treat- tooth buds (Fig. 4). Correlation with CT images
ment. If possible, the patient’s dentist and ortho- and displacement is mandatory. Fractures can
dontist should be contacted to obtain any be managed with a liquid diet and frequent exam-
preinjury dental records. ination, with surgery reserved for situations in
A minimally displaced mandibular fracture may which occlusion is not improving.
be managed with jaw rest and immobilization Mandibular condyles are growth centers that are
with a jaw compression wrap or cervical collar as sensitive to disruptions in blood supply and prone
well as a liquid diet. Dentoalveolar fractures can to ankyloses with fracture trauma and/or sur-
often be managed with occlusive splinting, arch gery.25 Intracapsular fractures, high condylar
bars, and/or bonded wires. Minor malocclusion neck fractures, and coronoid fractures should be
should be managed orthodontically after bony managed conservatively to minimize these com-
healing is finished. Applying MMF in children dur- plications. Early range-of-motion exercises should
ing primary and mixed dentition phases may be be started at 3 to 5 days after injury with physio-
challenging but can be safely practiced.24 When therapy. Unilateral condylar neck fractures and
MMF is needed during these phases, a technique bilateral condylar neck fractures are often
should be adopted that does not damage managed conservatively with a liquid diet.
8 Andrew et al

Fig. 4. Preexisting orthodontic appliances can be used to establish MMF. (A) Preoperative photograph. (B) Post-
operative photograph with patient in wire loop MMF. (C) Long-term outcome.

However, in older patients, ORIF of one side is become appropriate. Long-term growth patterns
reasonable to avoid potential temporomandibular of children after facial fracture remain unpredict-
joint (TMJ) dysfunction and also to restore occlu- able, emphasizing the need for long-term follow-
sion. Open management is also recommended up and further multicenter, controlled trials.
when a foreign body is in the TMJ or when
condylar displacement into the middle cranial REFERENCES
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