Vol. 90 No.

2 August 2000

ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY

REVIEW ARTICLE

Maxillofacial injuries in the pediatric patient

Richard H. Haug, DDS,a and John Foss, DDS,b Lexington, Ky, and Cleveland, Ohio
UNIVERSITY OF KENTUCKY AND METROHEALTH MEDICAL CENTER

Approximately 22 million children are injured in the United States annually. Children are uniquely susceptible to
craniofacial trauma because of their greater cranial-mass-to-body ratio. The pediatric population sustains 1% to 14.7% of all
facial fractures. The majority of these injuries are encountered by boys (53.7% - 80%) who are involved in motor vehicle acci-
dents (up to 80.2%). The incidence of other systemic injury concomitant to facial trauma is significant (10.4% - 88%). The
management of the pediatric patient with maxillofacial injury should take into consideration the differences in anatomy and
physiology between children and adults, the presence of concomitant injury, the particular stage in growth and development
(anatomic, physiologic, and psychologic), and the specific injuries and anatomic sites that the injuries affect. This comprehen-
sive review, based on the last 25 years of the world’s English-speaking surgical literature, presents current thoughts on the
anatomic and physiologic differences between adults and children, a synopsis of childhood growth and development, and an
overview of state-of-the-art management of the pediatric patient who has sustained maxillofacial injury. (Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2000;90:126-34)

Millions of children are injured in the United States
annually, and many of them sustain facial trauma.
Because of the differences between adults and children
in anatomic, physiologic, and psychologic develop-
ment, not only do the consequences of trauma differ,
but the management techniques should be modified to
address the child’s particular stage of anatomic, physi-
ologic, or psychologic development.1-3 Despite the
high incidence of pediatric injury in the United States,
the current maxillofacial surgical literature is sparse,
with reports focusing only on very specific areas of
interest. The purpose of this article is to provide a
comprehensive review of the English medical literature
regarding maxillofacial injuries in the pediatric patient
to assist the clinician in the management of this unique
and highly specialized area of traumatology.
Inconsistencies appear throughout the current litera-
ture regarding the terms pediatric and child and their
corresponding ages. Although the pediatrician may treat
aDivision Director and Professor of Oral and Maxillofacial Surgery,
University of Kentucky College of Dentistry.
bResident in Oral and Maxillofacial Surgery, MetroHealth Medical
Center, Cleveland, Ohio.
Received for publication Oct 29, 1999; returned for revision Jan 20,
2000; accepted for publication Apr 11, 2000.
Copyright © 2000 by Mosby, Inc.
1079-2104/2000/$12.00 + 0 7/12/107974
doi:10.1067/moe.2000.107974
patients up to the age of 21, the common definition of
pediatrics is “that branch of medicine that addresses the
child and its development and care, and the diseases of
children and their treatment.”4,5 The pediatric patient
may be categorized according to various stages of
growth and development. The infant includes the
newborn to 1 year of life.4,5 Preschool is that childhood
period between 2 and 6 years of age, whereas the child
is defined as 11 to 13 years and younger.4,5 School-age
is that period between 6 and 10 to 12 years.4,5 Puberty
is the period during which secondary sex characteristics
develop, and adolescence is roughly 11 to 19 years of
age.4,5 For the sake of this review, the term pediatric
will refer to patients 19 years of age or younger, and
children from birth to 13 years of age.
THE EPIDEMIOLOGY OF PEDIATRIC
MAXILLOFACIAL INJURY
Approximately 22 million children are injured in the
United States annually. This represents 1 of every 3 indi-
viduals in this age group.1-3 Injuries surpass all other
major diseases of children in frequency and conse-
quence.1-3 A review of current literature has shown great
statistical variation regarding pediatric maxillofacial
injury. Estimates regarding the incidence of pediatric
facial fractures range between 1% and 14.7% for victims
under the age of 16 (Table I), and 0.87% to 1% for those
less than 5.6-22 These are most frequently boys (53.7%-

126
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Haug and Foss 127
Volume 90, Number 2

Table I. Characteristics of pediatric patients with facial fractures

References
Incidence among all facial fracture patients <16 y of age 1%-14.7% 6-22
<5 y of age 0.87%-1%
Sex distribution Boys 53.7%-80% 10,14,15,19,20,23-39
Anatomic distribution Mandible 15%-86.7% 8,14,15,18,19,24,28-33,37,42-44,46
Midface (maxilla, zygoma, nose) 8%-54%

Upper face (orbit, frontal bone) 12%-45%

Concomitant injury Overall incidence 10.4%-88% 10,18,20,24,25,27-30,35,41,43,44

Neurocranium 26%-82%
Thoracic 4%-27%
Abdominal 2%-18%
Orthopedic 3%-32%

80%).10,14,15,19,20,23-39 The cause is most often a motor Table II. Etiology of pediatric facial fractures
vehicle accident (5%-80.2%), violence (3.7%-61.1%), MVA 5%-80.2%
falls (7.8%-48%), a bicycle (7.4%-48%), play (10%- Violence 3.7%-61.1%
42%), and others (Table II).10-16,20-29,31,33,34,36,40-45 Falls 7.8%-48%
Although motor vehicle accidents (with the child as Bicycle 7.4%-48%
an occupant, pedestrian, or cyclist) are responsible Play 10%-42%
Sports 1.2%-33%
for the highest incidence of fatalities, drownings, house Pedestrian 10%-25%
fires, and homicides rank next.1-3 Anatomically, the Other 4.5%-23%
most frequently encountered pediatric facial fracture Object 1%-23%
is the mandible (15%-86.7%), followed by the mid- Crush 10%
face (8%-54%) and the upper face (12%- Birth 0.1%-4%
45%).8,14,15,18,19,24,29,33,37,38,42-44,46 Of concern in the From references 10-16,20-29,31,33,34,40-45.
pediatric population is the high frequency of concomitant
injury (10.4%-88%).10,18,20,24,25,27-30,35,41,43,44 This
predilection is most likely because of the anatomic differ- anxiety, regression, depression, or aggression.
ences between children and adults. However, by age 8, self-generated coping strategies
may have developed.47 Finally, at adolescence, the
GROWTH AND DEVELOPMENT trauma victim’s sense of autonomy may appear chal-
Psychological development lenged. Authority, rules, and limits may be questioned,
The greatest concern when treating the pediatric resulting in various forms of noncompliance.47
patient is the effect of the injury or treatment on growth
and development. This is both anatomically and Facial growth
psychologically important and may have various By the end of the first year of life, the 2 mandibular
effects on management for the different stages of halves have joined in the midline, with complete
psychological development as delineated in the intro- symphysis fusion from the inferior border to the alve-
duction. During infancy, hospitalization, trauma, and olus by age 2. At this time, the chin prominence
surgery will disrupt established patterns of feeding and develops, and the deciduous teeth erupt. The condyle
sleeping. Thus, behavioral disturbances and nutrition contributes to the vertical growth of the mandible. The
are a concern during this developmental phase.47 sixth year marks the mixed dentition phase. Growth of
Throughout the preschool phase, separation anxiety the mandible occurs by deposition posterior and
and fear of the loss of mother act as stressors, possibly resorption anterior to the ramus. The adult dentition is
leading to regressive behavior. Additionally, the present by ages 12 to 13.18,44,48,49
perception of cause and effect of hospitalization, At age 2, most of the transverse maxillary growth is
trauma, and surgery may make the child feel complete (followed by vertical and then anterior-
punished.47 During the school-age phase, hospitaliza- posterior). Palatal, premaxillary, and midline maxillary
tion, trauma, and surgery are potential insults to the sutural growth is complete with suture obliteration by
child’s emerging abilities. Interventions may evoke ages 8 to 12. During the sixth year, the mixed dentition
128 Haug and Foss ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 2000

Table III. Pediatric normal values

Distance
Blood Caloric of
Respir- pressure require- midtrachea
Pulse ations range, Urinary ment Maintenance Endotracheal to teeth/ Blood
(beats/ (per systolic, output (cal/kg/ fluids tube size gingiva Average volume
min) min) diastolic (cm3/h) 24 h) (cm3/day) (mm) (cm) wt (kg) (cm3)
Neonate (0-28 d) 80-180 60-90, 20-60 2.5 110-130 For children Uncuffed 2.5-3.5 8-10 >2.5 0.46 ×
<1 mo, 250 hemacrit
× 63
Infant (1st y) 75-160 30-60 87-105, 53-66 4-10 100-130 250-110 Uncuffed 3.0-4.5 9-11 4.10 300-800
Pre-school (2-6 y) 60-110 22-40 95-105, 53-66 12-20 75-90 1100-1500 Uncuffed 4.5-5.5 12-15 12-20 900-1600
School age (6-11 y) 60-110 18-30 97-112, 57-71 20-23 60-75 1560-1660 Cuffed/uncuffed 5.5-6.5 15-17 20-33 1600-2640
Adolescent (11-19 y) 50-90 12-16 112-128, 66-80 35-70 30-60 1800-2500 Cuffed 7.0-8.0 18-20 35-70 2625-5600
From references 1-3,4,7,46,47.

phase, the antra are present and well developed. After
puberty and eruption of all teeth, the maxillary sinuses
reach their full size.18,25,10,44,48-51
By age 2, most of the cranial sutures are obliterated.
At this time the orbits are 85% to 90% complete. From
the sixth to the eighth year, orbital growth becomes
complete and the ethmoid sinuses grow rapidly.
Between the seventh and eighth year, the frontal
sutures are closed and the frontal sinuses are well
developed. After puberty, the frontal sinuses reach full
size, the ethmoid sinuses undergo a growth spurt, and
the sphenoid sinuses begin their main phase of devel-
opment.18,25,43,47,48
ANATOMIC DIFFERENCES BETWEEN
CHILDREN AND ADULTS, AND THEIR
CONSEQUENCES IN TRAUMA
In general, children tend to have a smaller body mass
than adults, which during a traumatic episode, results
in a greater force per unit of body area. The child’s
incompletely calcified skeleton is close to the internal
organs with less fat and more elastic connective tissue.
These factors result in multiple internal organ injuries,
often without external signs. Children have a higher
surface-area-to-body volume ratio, which makes them
prone to the quick development of hypothermia and
can complicate hypotensive management by pooling
blood in the peripheral vasculature rather than
supplying the viscerum. Children also have a higher
metabolic rate and cardiac output which, when coupled
with higher oxygen demand, result in a low reserve
during resuscitation.
The child’s airway is of a smaller caliber, with rela-
tively large and flaccid oral and pharyngeal soft tissues,
a cephalad larynx, a shorter trachea, and a shorter,
narrower epiglottis (Table III).1-3,52-54 This results in
increased airway resistance, easy obstruction, difficult
intubation, and easy self-extubation. The child’s ribs and
sternum are extremely compliant, resulting in a
decreased reserve when respiratory efforts are dimin-
ished. The diaphragm aids in breathing and abdominal
distention, or increased intrathoracic pressure dimin-
ishes ventilation. Therefore, with low pediatric lung
compliance, ventilation becomes inefficient during
respiratory distress.1-3,44
When considering pediatric circulation during trauma
evaluation and resuscitation, the surgeon must
remember that children have a higher cardiac output and
increased oxygen demand, resulting in a low oxygen
reserve. The pediatric stroke volume is smaller than that
of an adult, and as a result, cardiac output is rate-deter-
mined (Table III). Thus bradycardia leads to hypoxia
and hypercapnea, both ominous signs. Even minor
injuries could result in blood loss that is physiologically
meaningful. The child’s blood pressure is maintained
through physiologic compensation such as vasoconstric-
tion, tachycardia, and myocardial contractility, which
may mask other signs of volume reduction. With this
physiologic compensation, symptoms of volume deple-
tion may not occur until it is too late to recover.1-3,44
Pediatric abdominal injury requires immediate
surgical involvement. The skeleton is not completely
calcified or mature, and skeletal injury may result in
growth disturbance, a higher proportion of greenstick
fractures, and blood loss that is proportionally greater
than in the adult.1-3,44
There are differences between the pediatric and adult
head and spine that should be considered during
trauma. Children are susceptible to secondary brain
injury because of differences in cerebral physiology and
oxygen demand. The cranial-mass-to-body-mass ratio
is high, which results in higher-energy impacts to the
cranium. The child has a lower total body blood
volume; thus scalp lacerations and subgaleal or
epidermal bleeds could result in hypotension. With
mobile cranial suture lines and open fontanelles,
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 2
expanding mass lesions may be hidden until rapid
decompensation occurs. Vomiting after trauma is
common for children and is not necessarily indicative of
increased intracranial pressure. The characteristics of
the pediatric cervical spine include flexible interspinous
ligaments, incomplete articulations, flat facet joints, and
anteriorly wedged vertebral bodies with a greater
cranial mass. The result is increased susceptibility to
spinal cord injury without radiographic abnormality.1-3
THE BATTERED OR ABUSED CHILD
Of significance to the clinician who treats pediatric
maxillofacial injuries is the battered or abused child.
The challenges in the management of this form of
trauma extend beyond mere physical injury and include
psychological management and medico-legal consider-
ations. Fifty percent of the physical injury in the
battered or abused child is to the head and neck.
Profiles of battered children are typically of newborn
or preschool boys, whereas sexually abused children
are typically 11-year-old girls. Three hundred thousand
incidents of sexual abuse occur annually in the United
States, with parents or caretakers as the perpetrators in
90% of cases.55-58
Multiple physical injuries to the head and neck char-
acterize the abused child. Teeth are frequently missing,
broken, or nonvital, yet there is typically no attempt at
restoration or repair by the parent. The gingiva, palate,
and tongue may show evidence of burns, hematoma
from forced fellatio, or sexually transmitted disease.
The lips may be ecchymotic or burned (particularly
from cigarettes). The facial bones may impart evidence
of multiple fractures, hematomas, or healed malunions.
The ears may show ecchymosis, lacerations, perforated
tympanic membranes, or a cauliflower external appear-
ance. Laryngeal fractures from choking and rope burns
to the neck from hanging are indicative of abusive
injury. Facial skin of the child victim might show bite
marks, imprints of objects (eg, belt buckles), abrasions,
scars, ecchymosis, burns (thermal or chemical), or
alopecia.40,55-58 In addition to these head and neck
findings, other physical findings should be evaluated.
These include retinal hemorrhage, multiple subdural
hematomas (especially without skull fracture),
ruptured viscera, old scars, healed long-bone fractures,
and evidence of genital or perianal trauma. The practi-
tioner should suspect battery or abuse if any of the
following are found: a discrepancy between the history
and degree of injury, a prolonged period between
injury and care, inappropriate parental responses or
noncompliance, a history of repeated trauma and visits
to different emergency departments, apparent differ-
ences regarding the history of the event between
parents, or any combination of these.55-58
Haug and Foss 129
GENERAL CONSIDERATIONS FOR THE
PEDIATRIC MAXILLOFACIAL TRAUMA VICTIM
As with all trauma victims, initial assessment and
resuscitation should follow the “ABCs” of advanced
trauma life support, with a focus on the unique differ-
ences in pediatric anatomy and physiology (Table
III).1-3,52-54 The high incidence of multisystem injuries
concomitant with maxillofacial injuries should be the
initial management focus. The diagnosis of facial frac-
tures is based on a clinical examination and is
confirmed with imaging. Because of the incompletely
calcified areas of the developing skeleton, the presence
of a developing dentition, and the importance of the
cartilaginous and soft tissue structures, plane or
panoramic radiographs are not always effective.
Computed tomography is the image of choice in
assessing the pediatric facial skeleton, especially for
mid-facial and upper-facial injury and for intracapsular
(comminuted or medial pole) fractures of the devel-
oping condyle.
FIXATION CONSIDERATIONS
When formulating a plan of treatment for pediatric
patients with facial trauma, a number of elements must
be considered. These include the age of the patient (to
maximize growth and development), the anatomic site
(to optimize form and function), the complexity of the
injury (displacement, comminution, and the number of
sites), the time elapsed since injury (ideal to treat
within 4 days), concomitant injury (fitness for anes-
thesia and duration of surgery), and the surgical
approach (closed versus open). The fixation preference
will be dictated by the age, anatomic site, complexity,
and approach.
Monomandibular fixation
Monomandibular fixation, by means of an arch bar,
acrylic splint (or stent), or thermoplastic material, may be
the only acceptable alternative in situations such as the
edentulous newborn with a mandibular body or sym-
physis fracture. This technique is particularly helpful for
greenstick or minimally displaced fractures when the
patient is partially edentulous (ages 5-12). These patients
generally require circummandibular wires or some form
of skeletal suspension. Maxillomandibular fixation is
usually maintained for 3 to 4 weeks. This fixation has the
disadvantage of limiting anatomic reduction and
restricting full function.16,30,38,51,59
Maxillomandibular fixation
By age 2, 10 teeth exist in each arch, and maxillo-
mandibular fixation may be achieved. Yet the lower
height of contour of the primary dentition may require
acrylic support, circummandibular wiring, or skeletal
130 Haug and Foss
Table IV. Anatomic distribution of mandibular injury
Condyle 14.5%-60%
Alveolus 8.1%-50.6%
Body 5.6%-44%
Symphysis 1.8%-40.4%
Parasymphysis 23.9%-33.7%
Angle 3%-27%
Ramus 0.75%-10%
Coronoid 0%-19%
From references 10,13,15,16,23,29,34,39,42,46.
suspension. Thinner wire (28 or 30 gauge) is suggested
for ligating the arch bar to the dentition. Before age 2
and after age 6, missing or resorbed teeth limit this
technique. Maxillomandibular fixation with closed
reduction may not permit anatomic reduction.
Although nutrition and airway are concerns, child
tolerance and subsequent compliance are the major
drawbacks of this technique.15,16,18,20,21,27-30,33,46,60
Internal fixation
Internal fixation implies some form of open approach
with subsequent subperiosteal dissection. This invasion
has the potential to interrupt or limit the osteogenic
potential of the periosteum, to create scars that may
further restrict growth, or both.6,7,58 Proponents of this
technique use experience with the surgical correction of
pediatric craniofacial deformity as an example of
successful treatment without adverse effects.
Unfortunately, the craniofacial surgical patient popula-
tion is already deformed or altered in growth, and no
control population for subperiosteal dissection on normal
children exists. A number of advantages are apparent
when using this technique. Absolute anatomic reduction
can be achieved, nutrition is improved by permitting a
rapid return to a normal diet, the airway is less of a
concern during extubation or reintubation than with
maxillomandibular fixation, and tolerance and compli-
ance are less important issues.6,7,18,20,21,27-30,43,44,59,61-65
Although resorbable technology for fixation now
exists, it has been our experience that significant soft
tissue inflammation occurs (especially around the orbit),
which later results in immobile (leathery) soft tissues. As
techniques and materials improve, this mode of fixation
may approach ideal.6,7,18,20,21,27,30,43,44,59,61-65 Semirigid
fixation with small (1.0-1.3 mm outer diameter) titanium
plating systems currently offer the best fixation alterna-
tive. However, their effects on growth and the potential
for migration to occur as the bones remodel are currently
unknown. When a fixation modality is required, it is the
author’s experience that a small titanium plating system
should be placed through limited incisions that
adequately expose the fracture. The hardware may then
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 2000
Table V. Anatomic distribution of midfacial injury
Alveolus 5%-65%
Nose 1%-45%
Zygoma 7%-41%
Maxilla 1.2%-20%
Le Fort I (0.5%-26%)
II (0.9%-20%)
III (1.9%-16%)
From references 11,13-15,20-24,27-31,33,37,39,42-44.
be removed 2 to 3 months after placement. Care must be
taken in patients with a developing dentition to avoid
damage to the tooth buds during screw place-
ment.6,7,18,20,21,27-30,43,44,61-65
No fixation
Many authors have suggested that for nondisplaced or
greenstick fractures in the pediatric population, observa-
tion alone is adequate. Close periodic follow-up every 2
to 3 days for 2 to 4 weeks, with vigilant observation and
“hands on” examination, is required. The younger the
patient population, the more appropriate this postinjury
observation becomes. Diet should be limited to liquids
or puree. Close parental supervision and elimination of
any contact sports or significant physical activity are
also imperative.6,7,15,20,21,24,29,30,34,43,46,59,62,66
DENTAL AND DENTOALVEOLAR INJURY
Dental and dentoalveolar injury is frequently over-
looked in surveys that review pediatric maxillofacial
injury. This has occurred because some authors consider
this area inconsequential compared with other forms of
injury, and accurate data regarding incidence or
frequency are only represented by hospital admissions.
Offices, emergency departments, or other sites for ambu-
latory management have not had their records scrutinized
for these forms of injury like hospital records have been.
Those reviews that do include dental or dentoalveolar
injury show a significant incidence in the pediatric popu-
lation. Mandibular alveolar injury has been reported to
range between 8.1% and 50.6% of pediatric facial
injuries and the maxillary alveolus from 5% to 65%
(Tables IV and V).8,17,20-24,27-31,34,37,39,42-44,46,51,67,68
These forms of injury can be classified as tooth fractures,
luxation, avulsion, or alveolar process fractures. For
these forms of injury to occur, teeth must be present.
Thus, these injuries are rare in the newborn and are most
prevalent in the 8-year to 9-year age group, with maxil-
lary central incisors being the most frequently affected.
Permanent teeth with crown fractures excluding pulpal
involvement generally require a temporary restoration
until definitive repair can be provided by a restorative
dentist. Those injuries that affect the pulp may be treated
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 2
with pulp capping, pulpotomy, or apexification proce-
dures. Fractured deciduous teeth that cannot be restored
should be extracted. Intruded primary teeth should be
allowed to re-erupt. Luxated teeth should be repositioned
and stabilized for 2 to 4 weeks. Wire, acrylic, and arch
bars offer satisfactory methods of stabilization. Avulsed
primary teeth should not be replaced, whereas avulsed
adult teeth should be reimplanted within 2 hours (prefer-
ably 30 minutes) and stabilized for 4 weeks. Alveolar
fractures should be anatomically reduced and stabilized
for 4 weeks. Depending on the stage of development,
dentoalveolar injury may lead to a host of dental growth
disturbances ranging from dilaceration to ankylosis with
an altered eruption sequence.8,9,12,13,15,17,20,21,37,38,46,51,67,68
MANDIBULAR CONDYLE
Although mandibular fractures have been reported to
occur with a greater incidence (15%-86.7%) than other
pediatric facial fractures, it is the condyle that is the most
frequently injured region of the mandible (14.5%-60%)
(Tables I and IV). This type of injury, especially in the
pediatric age group, is amenable to less aggressive
therapy. Open reduction should be considered when the
occlusion cannot be reestablished because of the position
of the fractured condylar segment, when the segment is
displaced into the middle cranial fossa, or when a foreign
body is present. If a decision is made for an open
approach, then semirigid fixation may be considered.
Observation should be considered for intracapsular frac-
tures (whether comminuted or medial pole). Along with
close follow-up and vigilant evaluation of the occlusion,
aggressive physical therapy is indicated to limit the
chance for development of a fibrous union or bony anky-
losis. Greenstick and minimally displaced condylar frac-
tures are amenable to observation and soft diet. If
displaced, a short course (1-2 weeks) of maxillo-
mandibular fixation or traction with elastics and a soft
diet are effective. Lindhal16 and a number of other
authors have shown that in the developing patient, this
form of therapy results in no meaningful alterations in
growth or function.7,16,17,18,21,27,28,30,37-39,44,52,59-61,66,69-73
MANDIBULAR ANGLE, BODY, RAMUS, OR
SYMPHYSIS INJURY
Injuries to the mandible other than the condyle or alve-
olus have been reported to occur with varying degrees of
frequency (Table IV). Therapy for these forms of injury
adhere to the principles discussed previously in the
section entitled Fixation Considerations. Generally,
observation and soft diet are preferred in the patient
under 2 years of age and in those with greenstick or mini-
mally displaced fractures. Young children (those without
a complete dentition) may be effectively treated with
monomandibular fixation for body and symphysis
Haug and Foss 131
injuries. Maxillomandibular fixation for a period of 4
weeks is effective for body, ramus, angle, or symphysis
injuries. If semirigid therapy is considered, it should be
removed within 2 to 3 months to minimize restrictions to
growth and development. Treatment should be initiated
within 4 to 7 days after injury.4,12-15,18,23,24,26,34,36,37,74-76
MAXILLARY INJURY
The maxilla is the least frequently injured pediatric
facial bone (1.2%-20%) (Table V).11,13-15,20,24,27-
31,33,37,39,42-44 Absolute anatomic reduction is necessary
under these circumstances to ensure proper growth and
development with attention directed to the nasofrontal
and frontomaxillary sutures, as well as to the septum. The
septovomerine suture has been associated with midfacial
growth disturbances subsequent to trauma.40,77,78
Maxillary injury is virtually nonexistent in those under
age 2, and its frequency increases with age as the antra
become more fully pneumatized. Closed reduction with
maxillomandibular fixation for 2 to 3 weeks is effective
to reestablish the occlusion in minimally displaced frac-
tures. If an open reduction with semirigid internal fixa-
tion is chosen, the approach should be made through a
circumvestibular incision. Care should be taken to avoid
damage to the developing dentition by crew inser-
tion. Treatment should be initiated within 2 to 4
days.7,17,18,20,21,28,30,40,43,44,46,50,51,61,64,77,78
ZYGOMA INJURIES
Zygomatic fractures occur with relative frequency in
the pediatric facial fracture population (7%-41%)
(Table V). Treatment of this form of injury is generally
straightforward. Only observation is required for
greenstick or minimally displaced fractures, whereas
displaced fractures require an open approach. Intraoral
and Giles approaches are effective for displaced arch
fractures, and transconjunctival incisions with lateral
canthotomy extensions are effective for most other
zygomatic injuries. Little concern has been expressed
in the literature regarding growth disturbances subse-
quent to zygomatic fractures.17,18,20,21,28,30,43,44,59,61,64
NASAL INJURY
With the exception of alveolar injuries (5%-65%),
those to the nose are the most frequently encountered
midfacial injury in children (1%-45%) (Table V).
When evaluating nasal injury, attention must be paid to
the nasal bones and to the cartilaginous structures as
well. Nasal fractures are frequently masked in children
by edema. If edema obscures initial diagnosis, refrac-
ture or osteotomy of the healing malunion and defini-
tive treatment by intranasal packing and external
splinting should be initiated after identification.
Although the closed approach is the most beneficial
132 Haug and Foss
Table VI. Anatomic distribution of upper facial injury
Naso-orbital-ethmodial 1%-8%
Orbital 10%-13%
Roof (18%-35%)
Floor (25%-58%)
Medial (5%-28%)
Frontal-orbital 2.9%-35%
From references 8,19-21,24,27,30,38,39,42-44,83.
modality, strict attention to anatomic reduction of the
nasal bones, lateral nasal cartilages, and osseous and
cartilaginous septum is mandatory. A displaced but
incomplete fracture should be mobilized and treated as
a complete fracture. Growth disturbances have been
associated with nasal trauma and failure to adequately
treat injuries that extend to the nasoethmoid sutures
and those that cause premature ossification of the
septovomerine suture.40,59,60 Although the compliant
nature of the pediatric nose makes it less susceptible to
fracture, it is vulnerable to such soft tissue injuries as
cartilaginous detachment and septal hematoma.40,59,60
Direct trauma can cause detachment of the upper
lateral cartilages from the nasal bones. Direct reap-
proximation and suturing through an open approach or
support by intranasal packing are acceptable methods
of treatment. When displaced, the compliant pediatric
nose might flex and can shear periosteum or interrupt
blood vessels, resulting in a septal hematoma. These
hematomas must be incised and drained to prevent
septal necrosis and subsequent growth distur-
bances.14,17,20,21,27,28,43,44,50,51,59,61,77,78
NASO-ORBITAL-ETHMOIDAL INJURY
Naso-orbital-ethmoidal injuries are among the most
technically difficult injuries to treat in children and
perhaps the most potentially deforming in the growing
patient. They occur with relative infrequency (1%-8%)
(Table VI).8,19-21,24,25,27,30,39,42-44,79 In the highly
unusual situation that a fracture occurs in this region
and is nondisplaced, observation is acceptable. Yet if
any suspicion exists regarding displacement, an open
approach and anatomic reduction are required. Growth
in this area is dictated by development, and sutural
growth is dictated by expansion of the cranium to
compensate for the brain at the frontoethmoidal, fron-
tolacrimal, frontomaxillary, ethmoidomaxillary, naso-
maxillary, and septovomarine sutures. Precise and
anatomic reduction are required. Premature ossifica-
tion or obliteration of these sutures may result in
midfacial hypoplasia in the vertical and anterior/poste-
rior direction. Consideration may be given to the use of
resorbable plates and screws when treating this form of
injury to minimize the need for a second bitemporal
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 2000
incision and flap reflection to remove hardware and
eliminate hardware migration. Migration of titanium
plates and screws into the cranium from remodeling in
the growing patient has been reported. If traumatic
telacanthus occurs, precise anatomic repositioning and
attention to careful handling of the soft tissues are
imperative because canthopexy is frequently associated
with an unnatural appearance in children.21,28 If in
doubt about the precise location for reattachment, the
canthal ligament should be reattached in a more supe-
rior and posterior position. Treatment should ideally be
initiated within 4 days of injury.17,18,21,28,43,44,78,79
ORBITAL AND FRONTAL BONE INJURY
Fronto-orbital injury has been reported to occur with a
frequency ranging between 2.9% and 35% in the pedi-
atric facial fracture population (Table VI). Isolated orbital
injury occurs with a frequency between 10% and 13%.
The floor is affected 25% to 58% of the time, the roof
18% to 35%, and the medial wall 5% to 28%. Although
these numbers reflect relative frequency for the total
pediatric population, the various forms of injury are age-
specific. Before age 7, because of the presence of only
small or rudimentary sinuses, internal orbital injury
occurs almost exclusively at the orbital roof with linear
extension to the frontal bone. After age 7, internal orbital
injury of the roof, medial and lateral walls, and floor
occur along with frontal sinus fractures. Nondisplaced or
minimally displaced orbital roof fractures that occur in
children without impairment of extraocular movement
may be observed. Because the orbital roof is the floor of
the anterior cranial fossae and because linear fractures
frequently extend into the frontal bone, neurosurgical
consultation should be obtained. If the bones are
displaced, extraocular muscle movements are inhibited,
or intracranial injury mandates treatment, an open
approach by means of a bitemporal flap is indicated. As
in the case of naso-orbital-ethmoidal fractures, the use
of resorbable fixation is suggested to eliminate the need
for a second surgical procedure to remove hardware
and to prevent its migration or restriction of
growth.9,17,18,20,27,28,30,41,43-45,59,61,63,79,80
After age 7, when most internal orbital injuries occur,
the growth is complete and open reduction will provide
anatomic reconstruction without concern for growth
disturbance. A transconjunctival incision and lateral
canthotomy extension provide adequate access to the
floor and lateral wall at this age. A superior blepharo-
plasty incision may be required to approach the medial
wall or roof. Titanium microscrews and plates should
have no effect on growth at this time. Although allo-
plasts for internal orbital reconstruction have been
discouraged by some authors, after growth is complete,
only allergy or intolerance contraindicates their use. If a
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 2
concern exists that orbital growth is not complete, then
resorbable mesh, film, or sheets are acceptable internal
orbital reconstruction media. Treatment of orbital and
frontal injury should be instituted within 5 to 7 days for
best results.9,17,18,20,21,27,28,30,41,42,44,45,59,61,63,79,80
SOFT TISSUE INJURIES
Pediatric soft tissue injuries are frequently over-
looked when discussing pediatric trauma. Yet they
occur in association with facial fractures 29% to 56%
of the time. Management principles are much the same
as for adults except that treatment should be initiated
within hours because healing occurs sooner. Although
immature collagen in the child’s soft tissues provides
very cosmetic results the vast majority of the time,
hypertrophic scars and keloids may form in this patient
population. Specialized structures, such as the facial
nerve and salivary ducts, may require microvascular
repair. If a nasolacrimal duct laceration has occurred, a
dacryocystorhinostomy stent should remain for 2 to 3
weeks (4 months for an adult).
Although isolated abrasions, lacerations, and contu-
sions may occur with motor vehicle accidents, falls,
and sports, the most extensive and devastating pediatric
soft tissue injuries occur from animal (especially dog)
bites. Consideration for antimicrobial skin prepara-
tions, rabies prophylaxis, tetanus prophylaxis, and
antibiotic therapy must be given when treating animal
bites. Psychosocial counseling may be required for
patients and families sustaining these forms of injury
not only because of trauma, but also because of the
deforming nature of the soft tissue injury in the
child.8,17,28,35,36,44,51,59,81-83
REFERENCES
1. Chameides L, Hazinski MF, editors. Pediatric advanced life
support. Dallas: American Heart Association; 1997. p. 8-1–8-9.
2. Cummins RO, editor. Advanced cardiac life support. Dallas:
American Heart Association; 1997. p. 1-60–1-68.
3. Ramenofsky ML, editor: Advanced trauma life support.
Chicago: American College of Surgeons; 1994. p. 261-82.
4. Anderson DM, editor. Dorland’s illustrated medical dictionary.
28th ed. Philadelphia: WB Saunders; 1994. p. 31, 311, 506, 720,
721, 836, 1314, 1385, 1448, 1494, 1614.
5. Spraycar M, editor. Physician’s desk reference medical dictionary.
1st ed. Baltimore: Williams and Wilkins; 1995. p. 1182.
6. Bierne OR, Myall RWT. Rigid internal fixation. Oral Maxillofac
Surg Clin North Am 1194;6:153-67.
7. Kaban LB. Diagnosis and treatment of fractures of the facial bones
in children, 1943-1993. J Oral Maxillofac Surg 1993;51:722-9.
8. Rowe NL. Fractures of the facial skeleton in children. J Oral
Surg 1968;26:505-15.
9. Kim DB, Sacapano M, Hardesty RA. Facial fractures in chil-
dren. West J Med 1997;167:100.
10. Chidzonga MM. Facial fractures in children. Cent Afr J Med
1987;33:274-7.
11. Porter SR. Facial fractures in children. Br Dent J 1987;163:144.
12. Carroll MJ, Hill CM, Mason DA. Facial fractures in children. Br
Dent J 1987;163:289.
Haug and Foss 133
13. Carroll M J, Hill MC, Mason DA. Facial fractures in children.
Br Dent J 1987;163:23-6.
14. Gussack GS, Lutterman A, Powell RW, Rodgers K, Ramenofsky
ML. Pediatric maxillofacial trauma: unique features in diagnosis
and treatment. Laryngoscope 1987;97:925-36.
15. Adekey EO. Pediatric fractures of the facial skeleton: a survey
of 85 cases from Kaduna, Nigeria. J Oral Surg 1980;38:355-8.
16. Lindahl L. Condylar fractures of the mandible. I. Classification
and relation to age, occlusion, and concomitant injuries of teeth
and teeth-supporting structures, and fractures of the mandibular
body. Int J Oral Surg 1977;6:12-21.
17. James D. Maxillofacial injuries in children. In: Row NL, editor.
William maxillofacial injuries. New York: Churchill Livingston;
1985. p. 538-58.
18. Koltai PJ, Rabkin D. Management of facial trauma in children.
Pediatr Clin North Am 1996;43:1253-75.
19. Sherick DG, Buchman SR, Patel PP. Pediatric facial fractures:
analysis of differences in subspecialty care. Plast Reconst Surg
1998;102:28-31.
20. Iizuka T, Thoren H, Annino DJ Jr, Hallikainen D, Lindqvist C.
Midfacial fractures in pediatric patients. Arch Otol Head Neck
Surg 1995;121:1366-71.
21. Parker MG, Lehman JA. Management of facial fractures in chil-
dren. Persp Plast Surg 1989;3:1-13.
22. Amaratunga NA. Mandibular fractures in children—a study of
clinical aspects, treatment needs, and complications. J Oral
Maxillofac Surg 1988;46:637-40.
23. Zachariades N, Papavassiliou D, Koumoura K. Fractures of the
facial skeleton in children. Craniomaxillofac Surg 1990;18:151-3.
24. McGraw BL, Cole RR. Pediatric maxillofacial trauma: age related
variations in injury. Arch Otol Head Neck Surg 1990;116:41-5.
25. Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital fractures in
children. Arch Otol Head Neck Surg 1995;121:1375-9.
26. Thoren H, Iizuka T, Hallikainen D, Nurminen M, Lindqvist C.
An epidemiological study of patterns of condylar fractures in
children. Br J Oral Maxillofac Surg 1997;35:306-11.
27. Thaller SK, Huang V. Midfacial fractures inthe pediatric popu-
lation. Ann Plast Surg 1992;29:348-52.
28. Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving
patterns of treatment. J Oral Maxillofac Surg 1993;51:836-44.
29. Fortunato MA, Fielding AF, Gurensey LH. Facial bone fractures
in children. Oral Surg Oral Med Oral Pathol 1982;53:225-30.
30. Kaban LB, Mullikan JB, Murray JE. Facial fractures in children:
an analysis of 122 fractures in 109 patients. Plast Reconst Surg
1977;59:15-20.
31. Stylogianni L, Arsenopoulos A, Patrikiou A. Fractures of the facial
skeleton in children. Br J Oral Maxillofac Surg 1991;29:9-11.
32. Tanaka N, Uchide N, Suzuki K, Tashiro T, Tomitsuka K,
Kimijima Y, et al. Maxillofacial fractures in children. J
Craniomaxillofac Surg 1993;21:289-93.
33. Güven O. Fractures of the maxillofacial region in children. J
Craniomaxillofac Surg 1992;20:244-7.
34. Thoren H, Iizuka T, Hallikainen D, Lindqvist C. Different patterns
of mandibular fractures in children: An analysis of 220 fractures
in 157 patients. J Craniomaxillofac Surg 1992;20:292-3.
35. Demas PN, Braun TW. Pediatric facial injuries associated with
all-terrain vehicles. Oral Maxillofac Surg 1992;50:1280-3.
36. Koumakis SE, Rafie J, Ghorayeb B, Stiernberg CM. Pediatric
gunshot wounds to the head and neck. Otolaryngol Head Neck
Surg 1996;114:756-60.
37. Hill CM, Croshen RF, Mason DA. Dental and facial injuries
following sport accidems: a study of 130 patients. Br J Oral
Maxi llofac Surg 1985;23:268-74.
38. McGraw-Wall B. Facial fractures in children. Facial Plast Surg
1990;7:198-205.
39. Ramba J. Fractures of facial bones in children. Int J Oral Surg
1985;14:472-8.
40. Precious DS, Deliaire J, Hoffman CD. The effects of nasomax-
illary injury on future growth. Oral Surg Oral Med Oral Pathol
1983;66:525-30.
41. Messinger A, Radkowski MA, Greenwald MJ, Pensler JM.
134 Haug and Foss
Orbital roof fractures in the pediatric population. Plast Reconst
Surg 1989;84:213-6.
42. Anderson PJ. Fractures of the facial skeleton in children. Injury
1995;26:47-50.
43. Kaban LB. Facial trauma I. Midface fractures. In: Kaban LB,
editor. Pediatric oral and maxillofacial surgery. Philadelphia:
WB Saunders; 1990. p. 209-32.
44. Posnick JC. Diagnosis and management of pediatric craniomax-
illofacial fractures. In: Peterson LP, Indresano AT, Marciani RD,
et al, editors. Principles of oral and maxillofacial surgery.
Philadelphia: WB Saunders; 1992. p. 623-40.
45. Moore MH, David DJ, Cooter RD. Oblique facial fractures in
children. J Craniofac Surg 1990;1:4-7.
46. Kaban LB. Facial trauma II: dentoalveolar injury and
mandibular fractures. In: Kahan LB, Anderson DM, editors.
Pediatric oral and maxillofacial surgery. Philadelphia: WB
Saunders; 1990. p. 233-60.
47. Campis LK, Pillemer FS, DeMaso DR. Psychological consider-
ations in the pediatric patient. In: Kaban LB, editor. Pediatric
oral and maxillofacial surgery. Philadelphia: WB Saunders;
1990. p. 22-5.
48. Williams PL, Warwick R, editors. Grays anatomy. 36th ed.
Philadelphia: WB Saunders; 1980. p. 293-350, 141-53, 1149-50.
49. Enlow DH. Handbood of facial growth. Philadelphia; WB
Saunders. 1982.
50. Rock WP, Brain DJ. The effects of nasal trauma during child-
hood upon growth of the nose and midface. Br J Orthod
1983;10:38-41.
51. Maniglia AJ, Kline SN. Maxillofacial trauma in the pediatric age
group. Otol Clin North Am 1983;16:717-30.
52. Rowe MI, Marchildon MB. General principles. In: Dudrick SJ,
Bave AE, Eiserman B, et al, editors. Manual of preoperative and
postoperative care. Philadelphia: WB Saunders; 1983. p. 281-306.
53. Wynn RL, Meiller TF, Crossley HL, editors. Drug information
handbook for dentistry. Abbreviations and measurements. 2nd
ed. Hudson (OH): Lexicomp; 1997. p. 993.
54. Norman ME, editor. Dehydration. In: Schwartz MW, editor.
Clinical handbook of pediatrics. Philadelphia: Williams and
Wilkins; 1995. p. 219.
55. Ambrose JB. Orofacial signs of child abuse and neglect: a dental
perspective. Pediatrician 1989;16:188-92.
56. Needleman HL. Orofacial trauma in child abuse: types, preva-
lence, management, and the dental professional involvement.
Pediatr Dent 1986;8:71-9.
57. Warlock P, Stower M, Barbor P. Patterns of fractures in acci-
dental and non-accidental injury in children: a comparative
study. Br Med J 1986;293:100-2.
58. Welbury RK, Murphy JM. The dental practitioner’s role in
protecting children from abuse: the orofacial signs of abuse. Br
Dent J 1998;184:61-5.
59. Blakey GH, Ruiz RL, Turvey TA. Management of facial frac-
tures in the growing patient. In: Fonseca RI, Walker RV, Betts
NJ, et al, editors. Oral and maxillofacial trauma. 2nd ed.
Philadelphia: WB Saunders; 1997. p. 1003-43.
60. Sahm G, Witt E. Long-term results after childhood condylar frac-
tures: a computer tomographic study. Eur J Orthod 1989; 11:154-
60.
61. Posnick JC. Management of facial fractures in children and
adolescents. Ann Plast Surg 1994;33:442-7.
62. Bartlett SP, DeLozier JB. Controversies in the management of
pediatric facial fractures. Clin Plast Surg 1992;19:245-58.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
August 2000
63. Denny AD, Rosenberg MW, Larson DL. Immediate reconstruc-
tion of complex cranio-orbital fractures in children. J Craniofac
Surg 1993;4:8-20.
64. Posnick JC. Craniomaxillofacial fractures in children. Oral
Maxillofac Surg Clin North Am 1994;6:169-85.
65. Posnick JC, editor. The role of plate and screw fixation in the
treatment of pediatic facial fractures. In: Yaramchuk MJ, Gruss
JS, Manson PN, editors. Rigid fixation of the craniomaxillofacial
skeleton. Boston: Butterworth Heinemann; 1992. p. 396-419.
66. Leake D, Poykos J, Habal MB, Murray JE. Long term follow-up
of fractures of the mandibular condyle in children. Plast Reconst
Surg 1971;47:127-31.
67. Andreason JO, editor. Traumatic injuries of the teeth. 2nd ed.
Philadelphia: WB Saunders; 1981.
68. Braham RL, Roberts MW, Morris ME. Management of dental
trauma in children and adolescent. J Trauma 1977;17:857-65.
69. Rowe NL. Fractures of the jaws in children. J Oral Surg
1969;27:497-507.
70. Feifel H, Albert-Deumlich J, Rideiger D. Long-term follow-up
of subcondylar fractures in children by electronic computer
assisted recording of condylar movements. J Oral Maxillofac
Surg 1992;21:70-6.
71. Lindahl L, Hollender L. Condylar fractures of the mandible. II.
A radiographic study of remodeling process in the temporo-
mandibular joint. Int J Oral Surg 1977;6:153-65.
72. Lindahl L. Condylar fractures of the mandible. III. Positional
changes of the chin. Int J Oral Surg 1977;6:166-72.
73. Lindahl L. Condylar fractures of the mandible. IV. Function of
the masticatory system. Int J Oral Surg 1977;6:195-203.
74. Semb G, Shaw WC, editors. Facial growth in orofacial cleft
disorders. In: Turvey T, Vig KWL, Fonseca RJ, editors. Facial
clefts and craniosynostosis: principle and management.
Philadelphia: WB Saunders; 1996. p. 28-9.
75. Kawamoto T, Osaka N, Goto H, Aono H, Yamamoto Y. Stress
distribution in child’s skull under static loading. Bull Josai Dent
J 1986;15:189-96.
76. Hazelrigg CO, Jones YE. Conservative management of a fracture
mandible in a ten-month-old child. J Oral Med 1985;40:112-4.
77. Bachmayer DI, Orthod D. Maxillary hypoplasia secondary to
midfacial trauma in childhood: discussion. Plast Reconst Surg
1987:80:498-9.
78. Ousterhout DK, Vargervik K. Maxillary hypoplasia secondary to
midfacial trauma in childhood. Plast Reconst Surg 1987;80:491-7.
79. Posnick JC. Pediatric orbital fractures. Oral Maxillofac Surg
Clin North Am 1993;5:495-506.
80. Gruss JS. Orbital roof fractures in the pediatric population. Plast
Reconst Surg 1989;84:217-8.
81. Morgan JP, Haug RH, Murphy MT. Management of facial dog
bite injury. J Oral Maxillofac Surg 1995;53:435-41.
82. Haug RH, Morgan JP, editors. Management of human and
animal bites of the maxillofacial region. In: Fonseca PO, Walker
RV, Betts NJ, et al, editors. Oral and maxillofacial trauma. 2nd
ed. Philadelphia: WB Saunders; 1997. p. 875-96.
83. Brogan TV, Bratton SL, Dowd MD, Hegenbarth AM. Severe dog
bites in children. Pediatrics 1995;96:947-54.
Reprint requests:
Richard H. Haug, DDS
Division of Oral and Maxillofacial Surgery
College of Dentistry, D-508
Lexington, KY 40536-0297