PEDIATRIC OTOLARYNGOLOGY 0031-3955/96 $0.00 + .

20

MANAGEMENT OF FACIAL
TRAUMA IN CHILDREN
Peter J. Koltai, MD, FACS, FAAP, and Dimitry Rabkin, MD

The leading cause of death among children is trauma. Each year, 100,000
children are permanently disabled, and 15,000 die at a cost of $15 billion dollars
ann~ally.’~ A manifestation of this epidemic is that occasionally children sustain
severe injury of their face, requiring appropriate therapy. The management
principles in the treatment of facial trauma are the same for all age groups;
however, the techniques required for reconstruction for children must be modi-
fied to accommodate their developing anatomy, rapid healing, immature psy-
chology, and their potential for deformity as a consequence of altered facial
growth.
In the past 20 years, the use of rigid fixation via well-concealed incisions
has become routinely used for adult facial trauma patients; however, the applica-
bility of these surgical techniques for children is contr~versial.~,
7, 8, 14, 21 There
is evidence that periosteal stripping may alter the growth of bone, and questions
persist about the effects of implanted plates and screws on the growing face.
The paradox in the treatment for these severe injuries is that the techniques
necessary to accomplish a complete reconstruction may adversely affect the
growth and development of the face. It is not entirely possible to resolve this
dilemma; however, a rational approach to treatment can be formulated. This
article highlights the contemporary management of facial trauma in children.

EPIDEMIOLOGY

Pediatric maxillofacial injuries account for approximately 5% of all facial

fractures, although the incidence has been reported as low as 1.5% and as high
as 15Y0.4,6, 15, 2o Children younger than age 5 years have a significantly lower
risk ranging from 1% to 1.5%. At the authors’ institution, children accounted for

~~ ~ ~~ ~ ~~ ~~

From the Section of Pediatric Otolaryngology, Albany Medical College, Albany (PJK); and
Lenox Hill Hospital, New York (DR), New York

PEDIATRIC CLINICS OF NORTH AMERICA

-
VOLUME 43 NUMBER 6 * DECEMBER 1996 1253
1254 KOLTAI & RABKtN

9% of all facial injuries.I2 With increasing age, there is an increase in the

incidence of facial fractures; however, it is not until late adolescence, with the
maturation of the face and the adoption of a more active lifestyle, that the
distribution and frequency of maxillofacial trauma evolves into the patterns seen
among adults. The authors have not observed a higher incidence among older
children but have found that adolescents are more likely to have severe injuries
that require surgical intervention. The literature varies with regard to the sex
distribution of facial fracture^.^, 6, 12, 18, 25 Most studies suggest an overall
male preponderance, especially accentuated among adolescents. In the authors’
experience, pediatric facial fractures have been remarkably consistent across
genders, which may reflect the high frequency of motor vehicle passenger
accidents, a mechanism of injury that tends to be gender neutral.
Nasal fractures are by far the most common facial bone injuries in children.
Precise statistics on their frequency are difficult to determine, because nasal
fractures are readily treated in an office setting, whereas more severe injuries
are managed in hospital^.^
The most common facial fractures in children requiring hospitalization are
mandibular fractures. The incidence varies between 20% and 30% when nasal
fractures are included, and between 30% and 50% when nasal fractures are
excluded?,9, 27 The condyle is the most vulnerable part of the child’s mandible,
accounting for 40% to 70% of mandibular fractures. With maturation, the fre-
quency of symphyseal, body, and ramus fractures increases. Dentoalveolar frac-
tures, such as nasal fractures, often are treated in an office setting; hence it is
difficult to get their true frequency, and it is likely that the incidence is under-
reported in large hospital-based series.
Midfacial fractures are generally rare in children, and their incidence varies
widely in the literature?,6, 12, 15, 20, 25 Orbital fractures are seen in 20% to 25% of
pediatric fractures, zygomaticomalar complex (ZMC) fractures are seen in 10%
to 15%, and LeFort maxillary fractures are seen in 5% to 10%. The sporadic
distribution of midfacial injuries, especially among preadolescent children, high-
lights their uniqueness and emphasizes how limited any one surgeon’s experi-
ence may be with these complex injuries.
Associated injuries are a common feature of childhood maxillofacial
trauma.4,6, 12, 15, 18, *O, 25 Neurologic and orthopedic injuries were seen in 30% of
children with facial fractures in the authors’ institution,’z which has reinforced
the importance of a complete initial assessment of a child with facial trauma
and highlights the dilemma with regard to the timing of the reconstruction
because of the rapid healing of bony injuries in children.

ETIOLOGY

To understand the cause of pediatric facial fractures, two separate issues

need to be addressed: (1) the traumatic event that results in injury to a child’s
face and (2) the unique anatomic features of the pediatric facial skeleton that
predispose it to a pattern of injuries observed.
Childhood play is the most common cause of these injuries, when all forms
are considered; however, since the famous case report from LangI3in 1889 about
a 13-year-old boy ”who was struck on the right eyebrow as he was running in
the street, by the shaft of a cart drive at a trot,” it has been recognized that road
traffic accidents are the cause of most serious childhood maxillofacial injuries
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1255

and have an incidence of approximately 50% in most published series, half of

which are passenger injuries and half are pedestrian injuries4,6, 12, 15, 20, 25 Facial
fractures resulting from child abuse have been reported, all of which highlight
the significance of considering such a cause, especially among children fewer
than 5 years of age, because most child battering occurs in this age group.Z2, 26
A child's face has protective anatomic characteristics that reduce the likeli-
hood of facial fractures, including their soft and elastic bone, which is shielded
by a thick layer of fat and muscle and unweakened by the development of the
paranasal sinuses. Immature bone has greater elasticity that is caused by thin
cortical plates and a greater proportion of cancellous bone. This elasticity also
explains the higher incidence of greenstick fractures in children. Finally, the
presence of unerupted teeth in the mandible and maxilla render these structures
more resistant to fracture?

FACIAL GROWTH

An appreciation of facial development is helpful in understanding the

differences between pediatric and adult facial fractures. Eighty percent of cranial
growth occurs during the first years of life. Although facial growth is also rapid
during this period, it is only after 2 years of age that the face begins to grow
faster than the skull. The orbit and the brain near the completion of growth by
7 years of age; however, lower facial growth continues into the early 20s. In a
newborn infant, the cranial volume in proportion to facial volume is 8:1, whereas
in the adult this ratio is 21. When an accident occurs, the higher craniofacial
ratio in children results in a greater proportion of cases in which the force of
injury is absorbed by the forehead, which probably accounts for the higher
incidence of pediatric skull fractures compared with severe midfacial fractures.
This fact is highlighted by the authors' recent study of 40 children with orbital
fractures." Orbital roof fractures were significantly more likely to occur among
young children, were associated with higher incidence of neurocranial injury,
and rarely required surgical reconstruction. Lower orbital fractures occurred
generally after the age of 7 years, were not associated with cranial injuries, and
frequently required surgical reconstruction. The age distribution of roof frac-
tures, a type of skull fracture, is indicative of the greater craniofacial ratio of
young children, the vulnerability of the large cranium to trauma, and the lack
of pneumatization of the frontal sinus. On the other hand, the age distribution
of lower orbital fractures, a type of facial fracture, reflects the growth and
development of the face, which unfolds from beneath the overhanging cranium
and becomes more vulnerable to trauma with maturation.
The process of facial growth and remodeling gives a child's face its age-
specific features. Alteration of the proportional growth secondary to the injury
may result in later deformities; however, facial malformations are not an inevita-
ble consequence of trauma. Multiple studies have sought to define the effect of
fractures on subsequent facial growth. Injuries to certain vulnerable sites, such
as the nasal septum, head of the condyle, and the multiple suture sites of the
midface, adversely affect future facial growth. Functional factors also seem to
have a role in post-traumatic development. The mandible, which is constantly
in motion and requires a continuous dynamic adaptation of bone and muscle,
seems less vulnerable to traumatic deformity compared with the midface.
1256 KOLTAI & RABKIN

RIGID FIXATION

Rigid fixation is a technique that has been developed in the past 20 years
for the management of facial trauma. It involves the use of implanted metal
plates secured by screws to restore the craniofacial skeleton to its preinjured,
three-dimensional form. Wide exposure is generally necessary for the application
of rigid fixation, and a variety of exposure techniques have developed to accom-
plish this purpose. Rigid fixation in young children is controversial, because
there is concern that it may impair facial growth. Many studies have been
performed on infant animals showing that plate fixation across midfacial and
cranial suture lines may result in growth retardation across the plated sutures
and in the bones adjacent to the sutures12;however, it is difficult to draw
definitive conclusions from these studies about the use of plate-and-screw fixa-
tion. Most of these investigations have been performed on very young animals
that have rapid facial development compared with humans. The use of rigid
fixation in very young children, who are in the most rapid phase of craniofacial
growth, generally is reserved for the repair of congenital craniofacial anomalies
and not trauma, because plates used on the cranium in very young children
may occasionally result in intracranial displacement. This observation has
brought into question the safety of metal implants in children and suggested
consideration for plate removal; however, a closer analysis suggests that the use
of plates on rapidly growing bone is similar to the use of wire to support the
trunk of a sapling tree: although the wire remains stationary, the tissues of the
tree grow around the wire, incorporating it into the fabric of the tree. Similarly,
rapidly growing bone in the infant’s cranium flows around the plate during the
process of growth, surrounding it and incorporating it within the framework of
the bone. This process has not been observed in older children and is consistent
with the understanding of craniofacial growth. The authors have removed plates
from a child who was 7 years of age, after a full year of implantation, and did
not find the plates incorporated into the bone either in the mandible or in
the midface.
It is difficult to make definitive statements about the use of plate-and-screw
fixation following trauma in younger children, except that it should be per-
formed with caution and reserved for fractures that cause the original features
to be difficult to restore by other means. The alternative of no correction is
unacceptable, because the soft tissues shrink and contract to mirror the abnormal
skeletal infrastructure, and interfragmentary wiring does not yield a stable three-
dimensional reconstruction in complex cases.
The current state of knowledge and clinical needs in difficult pediatric facial
fractures require recognition of both the risks and the benefits of rigid fixation.
It is hoped that in the future, plates will be available that are absorbable and
will make these concerns invalid. The questions about the potential growth
restrictions from the implants and consideration for removal are valid but must
be weighed against the additional injury to the facial soft tissues required by
their removal.

EMERGENCYMANAGEMENT

It is important to follow the basic principles of trauma management in the

initial assessment of children with facial fractures. A primary survey is made of
the child’s airway, breathing, and circulation. A variety of airway interventions
are available, depending on the type of injury. In general, when the only injury
 MANAGEMENT OF FACIAL T R A W IN CHILDREN 1257

is to the face, carefully posturing the child is usually adequate. The oral cavity
should be suctioned of blood and secretions and gently cleaned of teeth and
bony fragments. Occasionally, when mandible fractures result in retrodisplace-
ment of the oral structures, a midline traction suture in the tongue may be
helpful in maintaining the patency of the airway.
Orotracheal intubation is necessary when there is concomitant cranial
trauma, severe bleeding associated with midfacial fractures, or oropharyngeal
obstruction and posterior retrusion of the mandible. Orotracheal intubation must
be accomplished after radiographic evaluation of the cervical spine. Consider-
ation of performing the intubation in the operating room with rigid instrumenta-
tion should be considered when concurrent oropharyngeal or laryngeal injuries
are present. Cricothyrotomies and crash tracheotomies in the emergency depart-
ment generally are avoided in favor of orotracheal intubation. Tracheotomies are
necessary only when severe panfacial injuries are present but can be routinely
performed when major facial fractures are associated with intracranial, thoracic,
or abdominal injuries. Tracheotomies should be performed in the operating
room.
Hypovolemic shock can result from blood loss from the highly vascular
broken face of a child. Hypovolemic shock is a double threat because much of
the blood can be lost into the airway. Volume expansion with crystalloid solution
via large bore intravenous lines is necessary. Transfusion with type-specific red
blood cells and other blood products, such as plasma and platelets, may be
appropriate when severe hemorrhage is present.
The secondary survey of the head and neck proceeds in an orderly fashion,
starting with the assessment of the neurologic status of the child, which includes
evaluation of the neck and cervical spine, inspection of the eyes, otoscopy,
rhinoscopy, and finally examination of the face and oral cavity. Important parts
of this examination are assessments of function of the fifth nerve and the motor
function of the seventh nerve. Ophthalmologic evaluation is important to rule
out intraocular trauma and should include ophthalmoscopy and a test for range
of motion, diplopia, and pupillary reflexes. Otoscopy is important because
anterior canal wall injuries are indicative of condylar fractures, and blood behind
the drum suggests temporal bone fracture. Anterior rhinoscopy is helpful for
the evaluation of septal injuries, including septal hematoma, and occasionally
for identifying cerebral spinal fluid rhinorrhea.
Examination of the facial skeleton should begin with inspection followed
by manual palpation. A variety of signs suggest facial fractures, including
facial asymmetry with edema, ecchymosis, periorbital swelling, trismus, and
malocclusion. One usually begins with a bimanual examination of the face,
starting over the zygomatic arches and proceeding systematically down toward
the mandible. Asymmetry, tenderness, and crepitation are all indications of
underlying fractures. The malar bones, orbital rims, and nasal bones are gently
palpated. The stability of the maxilla is assessed by placing a hand on the
cranium and using the other hand to rock the premaxilla while observing for
movement in the middle third of the face. Intraorally, the palate is examined for
lacerations and possible fracture; attention is paid to the gingival labial sulcus
for irregularities and ecchymosis, which are signs of injury to the anterior
buttresses of the face. The manual examination of the mandible starts with
palpation of the temporal mandibular joints, using the finger in the external
auditory canal. The skin covering the ramus, angle, and body of the mandible
are palpated, and intraoral and extraoral bimanual manipulation of the body
and symphysis finishes the evaluation.
1258 KOLTAI & RABKIN

RADIOLOGIC EXAMINATION

Pediatric facial fractures used to be difficult to document radiographically;

however, the advent of computed tomography (CT) has revolutionized their
imaging.’,* An axial CT scan is indicated for orbital and maxillary fractures and
is particularly helpful in assessing the volume of the orbits and the changes
in facial width. Coronal projections add important information in complex
nasoethmoid fractures and orbital fractures, documenting the changes in the
orbit floor and the orbital roof (Figs. 1 and 2). Unfortunately, coronal projections
may be difficult to obtain in an uncooperative or injured child. Every effort
should be made to obtain both projections for major injuries, because the com-
bined scans accurately define the injured anatomy in anticipation of the surgical
correction. Three-dimensional CT reconstructions also have proven to be a
valuable adjunct to two-dimensional CT scanning for preoperative assessment
and surgical planning of facial fractures.’O
CT scans can be helpful for mandible fractures; however, the most useful
diagnostic radiograph is the panoramic view (Panorex), which displays the total
anatomy of the mandible, including the condyles and the upper and lower teeth
(Fig. 3). Unfortunately, a Panorex requires that the child be seated in a steady
upright position, which is not always possible when the patient is severely
injured or very young. Hence, alternate views may be required for documenta-
tion of their fractures. The Towne’s view, which is an anterior/posterior
projection, is specific for the condyles (Fig. 4). The lateral oblique projections are
particularly useful for the angle, and intraoral projections can be helpful for
dentoalveolar fractures (Fig. 5).
The imaging of nasal fractures remains controversial because of the inaccu-
racy of standard nasal radiographs in isolated nasal which is especially
true in children whose nasal bones are not fully fused, making radiographic
interpretation difficult. Nevertheless, it has been the authors’ experience that
children being referred from the emergency department for clinical examination

Figure 1. Axial CT scan of 13-year-oldpatient with nasoethmoid fracture.

 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1259

Figure 2. Coronal CT scan of same child as in Figure 1.

routinely have been radiographed. There may be legal or psychological benefits

from obtaining such radiographs; however, they are rarely clinically useful.
Significant nasal fractures in children that result in flattening of the nasal dorsum
warrant proper imaging with axial and coronal CT scans to rule out occult
nasoethmoid injuries.

SURGICAL EXPOSURE
Most facial fractures in children, such as zygomatic arch fractures or nasal
fractures, may be routinely treated by conservative, traditional, closed tech-

Figure 3. Panorex view of 10-year-old patient with left parasymphyseal and right ramus
fracture.
1260 KOLTAI & RABKIN

Figure 4. Towne’s view of 6-year-old patient with bilateral subcondylar fracture.

niques or limited open techniques; however, for severe injuries that require
extensive rigid fixation, the development of camouflaged extended incisions for
complete exposure has been a major advance.z1The entire facial skeleton can be
accessed and reconstructed using one or more of five incisions. The arch of the

Figure 5. Lateral oblique view of 15-year-old patient with right body fracture.
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1261

mandible can be exposed through a lower gingivolabial sulcus incision, although

comminuted mandible, angle, and ramus fractures are probably best exposed
through an external approach (Fig. 6). The upper third of the face, including the
zygomatic arches; lateral, superior, and medial orbital rims; and nasoethmoid
region, can be exposed through a coronal incision (Fig. 7). The inferior orbital
rim and orbital floor can be exposed by a subciliary or transconjunctival incision
(Figs. 8 and 9). The maxilla, particularly the important anterior buttresses, can
be exposed by an upper gingivolabial sulcus incision (Fig. 10).

NASAL FRACTURES

Children’s noses differ significantly from those of adults. The soft, compliant
cartilages that constitute the projecting tissues of the anterior nose easily bend
during blunt trauma. Therefore, the impacting force is dissipated across the
maxilla and its buttresses, resulting in a broad area of edema, with loss of
anatomic specificity. Rarely, the external cartilages may be dislocated from the
bony framework; however, the septum, which is more rigid, is more likely to
be fractured.
Several types of septal trauma include detachment of the septal perichon-
drium from the cartilage as it is deformed during injury. The bleeding from the
internal lining of the perichondrium into the space in between it and the septum

Figure 6. A, Gingivolabial sulcus incision for intraoral approach to parasymphyseal fractures

of the mandible. 6,lntraoral exposure of fracture. C, Wire osteosynthesis of fracture.
1262 KOLTAI & RABKIN

Figure 7. A, Bicoronal incision begins at the root of the helix on one side and extends over
the cranium to the opposite side. B, The incision goes through the periosteum above the
temporal line and deep to the temporalis fascia below the temporal line to protect the
frontalis branch of the facial nerve. C, The dissection is carried forward to the lateral orbital
rim and inferiorly to the zygomatic arch in a subfascial plane.
///usfrationcontinued on opposite page

results in a septal hematoma. The septum also may be torn from its bony
attachments, resulting in nasal obstruction and long-term growth disturbances.
Stellate and vertical injuries involving the anterior septum result in immediate
nasal obstruction and may cause delayed growth disturbances of the twisting
variety. In very young children, the nasal bones are rarely fractured because of
their minimal projection. A high index of suspicion should be maintained with
pediatric nasal fractures in the presence of occult orbital and nasoethmoid
injuries. As children approach adolescence, their nasal fracture patterns begin to
approach those of adults.
The care of children with nasal fractures involves the initial evaluation and
definitive management. In the authors’ experience, the initial examination of a
child with a nasal fracture may be very limited by midfacial swelling. A child
with soft tissue swelling only and no fracture is difficult to discern from the
child who has a modestly displaced bony injury. Several days are required for
the swelling to go down before the true extent of the deformity can be appreci-
ated. On the other hand, immediate intranasal examination is important to
examine the presence of septal injury, particularly septal hematoma. Unilateral
nasal obstruction is the hallmark of septal hematoma and can be observed on
anterior rhinoscopy as an obvious purple bulge on one side of the nose. The
bulge is compressible with a cotton tip applicator and does not shrink with
topical vasoconstriction. A septal hematoma is not a benign injury, and the
consequence of an untreated hematoma is a thick, fibrotic, and obstructive
septum. If the hematoma becomes infected, the resulting loss of cartilage causes
a saddle nose deformity. These injuries should be treated immediately with
evacuation, which, in a child, typically requires general anesthesia.
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1263

Figure 7 (Continued).

If anesthesia is required for the immediate treatment of the septum, the rest
of the nose can be assessed and treated at the same time; however, in most
cases, children are asked to return 3 to 4 days after injury, when a more accurate
examination is possible. If a bony or septa1 fracture is present resulting in a
cosmetic deformity or a fixed nasal obstruction, then definitive surgical manage-
ment is undertaken. Closed reduction of the bony fracture can be performed
with intranasal instrumentation and bimanual external manipulation. If signifi-
cant dislocations are present or if the injury is more than 2 weeks old, then open
reduction may be necessary.
1264 KOLTAI & R A B K N

Figure 8. The subciliary incision is made below the lashes. At the orbital rim, the periosteum
is incised and the floor is exposed.

Newborn Nasal Trauma

An occasional problem in newborn infants is an asymmetric tip deformity

(Fig. 11).These infants typically have a flattened nasal tip off to one side, with
the septum tilted in the same direction. The bony dorsum, on the other hand, is
invariably straight. There is some controversy as to whether this type of defor-
mity is caused by birth trauma or by prolonged intrauterine positional pressure.
Some surgeons advocate immediate surgical reduction of these deformities by
straightening and relocating the septumw;however, in the authors' experience,
these deformities generally straighten themselves over time without any late
sequelae, and the authors try to reassure the parents that the nose will straighten
in time. Although it is hypothetically possible for such a displacement to cause
neonatal airway obstruction, this has not been the authors' experience, even
with the most severe deformities.

MANDIBLE FRACTURE

The age-specific growth of the mandible and developing dentition differenti-

ate the care of pediatric mandible fractures from those of adults. Adequate
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1265

immobilization is difficult before 2 years of age because of incomplete eruption

of the deciduous teeth; however, later growth and remodeling frequently com-
pensate for a less-than-ideal postinjury alignment. The primary teeth, which
have firm roots between 2 and 5 years of age, can be used for splints and arch
bars. Deciduous roots are resorbed between 6 and 12 years of age; hence
arch bars may need extra support from circummandibular wiring and piriform
aperture suspension. Permanent teeth are safe anchors for fixation after 13 years
of age.

Condylar Fractures

The three anatomic types of condylar fractures include intracapsular crush

fractures of the condylar head and high condylar fractures through the neck
above the sigmoid notch. The third type, which is the most common, is low
subcondylar fracture and is often an incomplete "greenstick" fracture.
Clinical and experimental observation support a conservative closed ap-
proach to the management of most pediatric condylar fractures. Although some
investigators advocate open surgical treatment, for many children the primary
decision in management is not whether to open the fracture but whether the
child needs immobilization with intermaxillary fixation. Children with unilateral
condylar fractures often present with normal occlusion and normal mandibular
movement. For these injuries, only a soft diet and movement exercises are
necessary, which also can apply to bilateral subcondylar fractures in which
normal function is present. However, if an open bite deformity with retrusion
of the mandible and movement limitation are present, then a brief period of
immobilization, lasting 2 to 3 weeks, followed by the use of guiding elastics
results in normal function.

Arch Fractures

For symphyseal and parasymphyseal fractures in children, treatment modal-

ities can range from observation to open reduction with rigid fixation. The risk
of injury to unerupted tooth buds and the remodeling potential from subsequent
growth generally dictates a conservative strategy. Anterior arch fractures with
normal to moderate displacement can often be realigned with careful manual
manipulation with the child under anesthesia and immobilized with interdental
wiring, arch bars, or cap splints. In very young children, an acrylic splint held
in place by a circummandibular wire is most useful.
Even in younger children, some complex injuries require bone-to-bone
reapproximation. To better reduce severe misalignments, open reduction with
internal fixation of the fragments may be required, which can be accomplished
with either interfragmentary wiring or monocortical miniplate fixation in
conjunction with intermaxillary fixation. Both techniques require care in drill
hole placement to prevent injury to the developing tooth buds. In children with
permanent dentition, adult techniques are applicable.

Body and Angle Fractures

Body and angle fractures in children are often incomplete. These patients
tend to have normal occlusion and movement. Frequently, only soft diet and
1266 KOLTAI & RABKIN

&LTAl/qz

Figure 9. A and 6,Exposure of the lower fornix for transconjunctival approach to the orbital
rim. C and 0,Severance of the inferior limb of the lateral canthal tendon with additional
exposure of the lower fornix. E and F,Incision of the conjunctiva below the tarsus with scis-
sors.
Illustration continued on opposite page

analgesics are required. With displacement, treatment depends on the degree of

distraction and the dentition. Intermaxillary fixation is usually adequate, but
open reduction and internal fixation may be necessary.

Dentoalveolar Fractures

In children with primary teeth, dentoalveolar fractures are not a serious

dental emergency as in adults; however, when a secondary tooth is avulsed,
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1267

KaTsr I 92

Figure 9 (Continued). G and H, Incision and elevation of the rim periosteum. I, Exposure
of the orbital floor. J, Closure of the conjunctival incision, and reattachment of the lateral
canthal tendon to its cut stump inside the orbital rim.

survival of the tooth depends on reimplantation within an hour of the injury.

Identification of a child’s tooth as being primary or secondary may be difficult,
especially between the period of mixed dentition; thus, reimplantation should
always be attempted. The most common sites of injury are the incisors and
canines as a result of their prominence. Fractures may involve the tooth or the
surrounding cortex. Acute treatment requires cleansing of the avulsed tooth
with saline and replacing it in the socket. If the child is uncooperative, then the
tooth can be kept in saline-soaked gauze or a bowl of milk until the child can
be seen by a dentist for reimplantation and stabilization. Large avulsed frag-
ments of teeth and alveolar bone require anatomic reduction and prolonged
intermaxillary fixation. Dental consultation is important for complete manage-
ment.

ORBITAL AND NASOETHMOID FRACTURES

The orbit and nasoethmoid region are prominent components of the face of
children, and injuries to this area can have serious cosmetic and functional
consequences. The extent of these injuries is related to the magnitude of the
impacting force and vary from minor fractures, such as blow-outs of the orbital
floor, to complex fractures involving the rim, multiple walls, and apex, with
1268 KOLTAI & RABKIN

Figure 10. A, Maxillary gingivobuccal sulcus incision for exposure of the mid-face. 5, Facial
degloving for exposure of anterior and lateral maxillary fractures. C,Miniplate reconstruction
of maxillary buttresses.

alteration of orbital volume, ocular mobility, and visual acuity. Management

depends on the extent of the injury, ranging from observation to surgical inter-
vention requiring craniofacial exposure, rigid fixation, and bone grafting. Appro-
priate management requires accurate diagnosis of both the functional and struc-
tural changes by physical examination and CT scanning. Ophthalmologic
evaluation is essential, with the first priority being assessment of visual equity.
Periorbital edema, ecchymosis, and subconjunctival edema often obscure the
position of the globe. Nevertheless, the eye must be inspected for exophthalmos,
enophthalmos, and vertical dystopia. Measurement of intraocular pressure is
obtained. Motility is assessed by both voluntary range of motion and by forced
duction testing with the child under general anesthesia. The integrity of the
infraorbital and supraorbital nerves is tested. The intercanthal distance is as-
sessed for hypertelorism. The medial canthal ligaments are identified, and the
rims are palpated for discontinuities.
Classified by its pattern of fractures, the orbit has three anatomic regions.
The hard circumferential bone of the orbital rim can be divided into three
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1269

Figure 11. Asymmetric tip deformity in a newborn infant.

subunits. The supraorbital rim is a portion of the frontal bone. The inferolateral
rim is part of the malar bone. The medial rim to which the medial canthal
ligaments are attached is part of the nasoethmoid complex. The middle compo-
nent of the orbit consists of the thin plates of the bone forming the medial and
lateral walls and the floor and the roof. The orbital apex forms the posterior
component in the orbit and contains the optic foramen and orbital fissures
through which come the neural and vascular structures inherent to the functions
of the eye.

Zygomaticomalar Complex Fractures

Zygomaticomalar complex fractures (ZMC)parallel the pneumatization of

the maxillary sinus and are uncommon before the age of 5 years. This type of
fracture can be classified by the patterns seen on CT scans, which generally
correlate with the energy of the impacting force. Low-impact injuries may lead
to greenstick fractures of the malar segment, whereas high-impact injuries lead
to various degrees of disruptions and comminutions of the infraorbital rim,
anterior maxillary buttresses, and orbital walls.
Surgical correction of Z M C fractures is indicated when bony displacement
is present. Surgical correction involves adequate exposure of the fractured but-
tresses, a process called tviungulution because it involves visualization of the
three key sites: (1) the frontozygomatic suture, (2) the infraorbital rim, and (3)
the anterior buttresses (Fig. 12).Two-point fixation at the frontozygomatic suture
and infraorbital rim is generally adequate; however, with fragmented fractures,
reconstruction of the anterior buttress may be necessary. Prolapse of the orbital
content into the maxillary sinuses can be supported by a variety of materials,
depending on the extent of the destruction of the orbital floor.

Supraorbital Rim Fractures

The supraorbital rim is relatively resistant to fractures in children, because

it is not weakened by the expansion of the frontal sinus. When the impacting
1270 KOLTAI & RABKIN

Figure 12. The process of triangulation involves visualization of the fracture sites of the
three buttresses involved in these injuries: the frontozygomatic suture, the infraorbital rim,
and the zygomaticomaxillarybuttress.

force is high, the fracture can extend to the frontal bones and into the orbital
roof. Therefore, repair of supraorbital rim fractures is a concomitant part of the
neurosurgical repair. Older children who have fractured the frontal sinus must
be evaluated and treated as adults.

Nasoethmoid Fractures

Nasoethmoid fractures vary from minimal to severely comminuted com-

pound injuries with extension into the orbits, maxilla, and frontal bone. These
injuries are typically classified by the severity of the fracture; however, they are
defined by dislocation at the nasofrontal suture, nasal bones, medial orbital rim,
and infraorbital rim. A nasoethmoid fracture is four-sided and yields a bony
core referred to as the centvul fragment. The difficulty of the reconstruction
depends on the comminution and dislocation of the central fragment. Severe
nasoethmoid fractures require aggressive surgical management because of the
difficulty of the correction of secondary deformities. These injuries are typically
approached coronally. Adequate exposure is the key to complete reconstruction,
particularly of the medial canthal ligaments, because failure to recognize their
disruption results in a post-traumatic telecanthus, which is an unsightly de-
formity.

Orbital Roof Fractures

Pediatric orbital roof fractures in young children traditionally have been

considered a rare injury; however, they are probably more common than pre-
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1271

viously suspected because of the availability of direct coronal CT eva1uation.l6

A history of a blow to the brow in conjunction with late periorbital ecchymosis
may be an important clue in differentiating these from other orbital fractures. A
complete ophthalmologic and neurologic evaluation is necessary, because these
injuries have a high rate of associated intracranial injuries. Repair of roof frac-
tures is not consistently required; however, large fractures may cause exophthal-
mos, vertical dystopia, and orbital encephaloceles and must be considered for
reconstruction within 7 to 10 days of injury.

Orbital Wall Fractures

Pure medial and lateral wall fractures are rare. Medial injuries are usually
part of the nasoethmoid complex fracture. Isolated lamina papyracea fractures
usually are caused by blunt trauma to the nose, rim, or eye. Orbital emphysema
commonly is seen on CT scans. Injuries with fixed enophthalmos and entrap-
ment may require repair. Lateral wall fractures are usually seen with LeFort
injuries and ZMC fractures and are repaired as part of the overall reconstruction.
Isolated lateral wall fractures rarely need reconstruction.

Orbital Floor Fractures

These injuries parallel maxillary sinus development and hence are not
usually seen before the age of 5 years. Nevertheless, they are the most common
isolated type of orbital fracture among older children. Floor fractures depend on
the force of injury and may result in increased orbital volume and enophthalmos
because of loss of globe support from destruction of the floor. Periorbital ecchy-
mosis, lid edema, subconjunctival hemorrhage, and diplopia are the typical
presenting signs and symptoms. Infraorbital nerve hypoesthesia is nearly univer-
sal but is rarely permanent. Floor defects are best demonstrated with coronal
CT scanning, whereas axial cuts help to demonstrate orbital volume changes.
The treatment of isolated blowout fractures is controversial and varies from
observation to early exploration and repair. The authors’ approach is to observe
these children for 7 to 10 days. If persistent enophthalmos, extraocular muscle
restriction, or pain on movement of the eye is present, then exploration is
performed. Severe injuries, as well as those with CT finding of muscle entrap-
ment, are routinely explored.

MAXILLARY FRACTURES

The LeFort classification is used to describe maxillary fractures in children

and adults. LeFort I fractures separate the palate from the maxilla; LeFort I1
fractures separate the central midface from the cranium; and LeFort 111 fractures
separate the entire face from the cranium. This anatomic classification rarely
suffices to describe the true clinicai extent of these injuries, and the authors
found that a functional classification based on the energy of the impacting force
is useful for predicting the difficulty of the reconstruction. Type I injuries are
minimally displaced; type I1 fractures are moderately displaced with some
comminution; and Type 111 fractures are severely displaced with multiple com-
minution of the major buttresses, resulting in a highly unstable injury that
requires three-dimensional reconstruction and bone grafting.12
1272 KOLTAI & RABKTN

Maxillary fractures are rare in children and clinically present with severe
facial edema, periorbital ecchymosis, and malocclusion. There is a high incidence
of associated neurocranial injuries, because the force required to cause the
maxillary fracture is sufficient to be transmitted to the cranial cavity. Diagnosis
depends on good physical examination and appropriate radiologic assessment.
Axial and coronal CT scanning is indispensable for properly assessing the
severity and degree of bony displacement and in developing a surgical plan.
Coordination of care with the pediatric intensivist, ophthalmologist, neurologist,
neurosurgeon, and anesthesiologist is required to provide contemporary care
for the multiply injured child. Although early operative intervention is generally
ideal in the management of these fractures, medical contraindications may exist.
Significant fracture displacement should be reduced within 10 days, because
rapid interfragmentary healing makes late correction difficult.
The goals of therapy are the re-establishment of facial symmetry, occlusion,
and normal three-dimensional proportions. Injuries with minimal or no displace-
ment do not require correction; however, if alteration of form or function is
present, then surgical intervention is necessary. The sequencing of severe maxil-
lary fractures, especially panfacial fractures in which the mandible is broken, is
an important component of the reconstructive effort. Classically, reconstruction
begins with the re-establishment of the occlusion followed by the repair of the
mandible if it is broken, which then forms a solid base on which the upper face
is reconstructed (Fig. 13). Different strategies with respect to the sequencing of
maxillary fractures have evolved. Traditionally, midfacial reconstruction begins
with the realignment of the external frame of the face, followed by working
inward toward the central core. This approach emphasizes the control of the
facial width and projection, which is the function of the zygomatic arch (Fig.
14). Other craniofacial techniques emphasize the use of the anterior cranial base
as a template for reconstruction of the midface. This type of sequencing begins
with restoration of the occlusion, followed by reconstruction of the frontal bone
to which the relations of the nasoethmoid regions, orbit, and outer facial frame
are re-established (Fig. 15). Reconstruction is then completed by connection of
the midface to the occlusal unit at the LeFort I level. The authors’ approach to
pediatric injuries is based on the recognition that the face is composed of
component units connected by their associated buttresses and that the most
prominent and most challenging aesthetic unit is the nasoethmoid area (Color
Fig. 4; see Color Plate). If mandible fractures are present, then the repair is
started by establishing occlusion and mandibular reconstruction. The central
core is then reconstructed, followed by positioning of the orbits and the outer
facial frame to the central core.

SUMMARY

In today’s fast-paced society, many children sustain severe maxillofacial

injuries that require surgical reconstruction. The factor that differentiates the
treatment of pediatric facial fractures from those of adults is facial growth.
Anticipation of mandibular growth facilitates repair because most injuries can
be treated with intermaxillary fixation. Midfacial injuries, on the other hand,
may be more sensitive to alterations of facial growth, and complex cases require
more sophisticated correction. The techniques of three-dimensional reconstruc-
tion of complex facial fractures has been facilitated greatly by the use of a rigid
plating system, wide craniofacial exposure, and bone grafting. These techniques
have sound theoretic and practical applications in severe pediatric facial trauma.
 MANAGEMENT OF FACIAL TRAUMA IN CHILDREN 1273

Figure 13. Bottom-up approach. Traditional sequencing begins with reconstruction of the
occlusion and the mandible, which then serves as a template for the upper face.

Figure 14. Outside-in approach. The outer facial frame is reconstructed with emphasis on
the zygomatic arches to narrow and project the face.

Figure 15. Inside-out approach. Reconstruction begins with the central core of the face
utilizing the anterior skull base as the template.
1274 KOLTAI & RABKIN

ACKNOWLEDGMENT
The authors greatly appreciate the efforts of Loretta Lynne Crowe in the preparation
of the manuscript.

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Address reprint requests to

Peter J. Koltai, MD, FACS, FAAP
Albany Medical College
Division of Otolaryngology A-41
47 New Scotland Avenue
Albany, NY 12208