PediatricCraniomaxil lofacial

Trauma Robert M. Kellman, MDa, Sherard A. Tatum, MDb,*

KEYWORDS

� Pediatric � Surgery � Maxillofacial � Craniofacial � Craniomaxillofacial � Trauma � Management� Injury

KEY POINTS

� As children grow and develop, their craniomaxillofacial (CMF) structure changes dramatically.

� This change informs the location, pattern, and nature of CMF injury.

� Dental development stage significantly impacts management of fractures involving occlusion.

� Many pediatric fractures are amenable to conservative, nonoperative, or minimally invasivemanagement.

� Growth effects from the injury as well as the management must be considered and monitored longterm.

INTRODUCTIONEtiologies

Although trauma is a leading cause of death in pe-diatric age groups, pediatric craniomaxillofacial(CMF) trauma accounts for only about 15% of allCMF trauma, and that number includes teenagers.Younger children probably only account for about5% of CMF trauma, and maxillofacial injuries inthis age group are frequently associated with skullfractures and concomitant neurologic injuries.1

Unique to the infant are facial fractures causedby traumatic delivery. In the newborn, this facialtrauma can be owing to forceps being used tobring the baby down through the birth canal. Thiscan result in neonatal injury, including fracturesof the skull and facial skeleton, as well as softtissue trauma, such as injury to the facial nerve.These injuries are less common today than pre-viously owing to the increased use of Cesareansection when a difficult delivery is anticipated.

No disclosures or conflicts.a Department of Otolaryngology, Upstate Medical UniStreet, Syracuse, NY 13210, USA; b Departments of OtolaState University of New York, 750 E Adams Street, Syracu* Corresponding author.E-mail address: tatums@upstate.edu

Facial Plast Surg Clin N Am 22 (2014) 559–572http://dx.doi.org/10.1016/j.fsc.2014.07.0091064-7406/14/$ – see front matter � 2014 Elsevier Inc. All

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In the edentulous and deciduous dentition stage,skull fractures are muchmore common thanmaxil-lofacial fractures because the cranium is moreprominent than the face. Falls are the most com-mon cause, but abuse/neglect must remain acause for which providers are vigilant, particularlywith repeated injuries or sketchy histories.2,3 Inthe nonambulatory child, being dropped or rollingoff a bed or sofa are likely mechanisms of injuryoften leading to lateral as well as frontal skull andskull base injuries.4 Small children also sufferinjuries owing tomotor vehicle accidents. The earlyambulating child is more likely to fall forward, strik-ing the chin and forehead on the ground. The mostcommon soft tissue injuries are owing to dog bitesthat can be associated with fractures. However,primarily soft tissue injuries are beyond the scopeof this article.

As the child grows, sports, motor vehicle, andbicycle accidents and fighting become more com-mon causes. As children approach their teens,

versity, State University of New York, 750 E Adamsryngology and Pediatrics, Upstate Medical University,se, NY 13210, USA

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they are more likely to be involved in trauma asso-ciated with more adult behavior. Teenagers aremore likely to engage in risk-taking adventuresand substance abuse that might lead to anincreased risk of traumatic injury.5 Falls fromheights and vehicular trauma become more fre-quent during the teen years.6 Like adults, commoncauses include recreational accidents, particularlywith off-road vehicles like all-terrain vehicles andbicycles. Other sports-related injuries are morecommon, and interpersonal and industrial trau-matic events increase in frequency.5,7 Becausethe management of post puberty teenage traumais similar to adult trauma, the rest of this article fo-cuses primarily on prepubescent and pubescentpatients.

Comparative and Developmental Anatomy

The pediatric age group includes everyone frombirth to maturity, which is typically considered tooccur around the age of 16 years, although someconsider it to continue to age 18. During thistime, the pediatric facial skeleton goes throughprogressive development and major changes.Some of these include8:

� Change in the size ratio of the cranium to theface;

� Change in the ratio of facial soft tissue tobone, dental eruption / shedding / erup-tion; and

� Pneumatization of the sinuses.

The softness of the infant bone results in moreincomplete (greenstick) fractures in infancy, whichchanges as the child grows and the solidity of the

Fig. 1. Cranial to facial ratio comparison in a neonate,Medical Center, New York, NY; with permission.)

bone increases. The growth centers are morecellular and therefore even softer and more sus-ceptible to injury.9

Skull–Face Ratio

At birth, the cranium is much larger relative to thefacial skeleton than it is at maturity. In the smallchild, the relative proportion of the craniofacialskeleton represented by the face, particularly thelower face, is still much less. As the child grows,the lower face lengthens and widens, developingto represent a greater proportion of the overallcraniofacial skeleton. Similarly, the mid face,although larger than the mandible in early child-hood, still represents a much smaller area relativeto the skull.9 As the child develops into adulthood,the relative growth of the face exceeds that of theskull, and the relative size of the facial skeletonincreases (Fig. 1). Thus, in infancy, cranial injuriesare far more common in proportion to those of thefacial skeleton, and as children grow and mature,nasal, mid facial, and mandibular fractures be-come more common.10 As the facial skeletoncomes to represent a larger proportion of thecraniofacial skeleton, it becomes more exposedto potential injuries. Therefore, mandible fracturesare less frequent, owing to the small area of themandible relative to the face and skull in the infant.However, the small ambulating child is likely to tripand fall forward, striking the chin and fracturing themandible even if it is still relatively small. The nosealso becomes more prominent with maturation,and the small, diminutive noses of infancy are typi-cally displaced by the larger, adult nasal anatomy.In adulthood, the nose is the most frequentlyfractured facial bone, followed by the mandible.

toddler, and adult. (Courtesy of Columbia University

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Small Sinuses

The paranasal sinuses are small in infancy, andthe frontal sinuses in fact do not even begin todevelop until the preteen years. The paranasalsinuses develop throughout childhood.11 Thenewborn has small ethmoid sinuses and poorlyaerated sphenoid sinuses, as well as typicallysmall maxillary sinuses. The frontal sinuses gener-ally do not even begin to form until 9 to 12 yearsof age. By the teenage years, the maxillary,ethmoid, and sphenoid sinuses tend to be welldeveloped, with the frontals reaching full growtharound age 16 to 18 years (Fig. 2). Sinus develop-ment corresponds with the enlarging size of themaxillofacial skeleton. As the face develops, itoccupies a greater percentage of the head re-lative to the cranial vault. This is believed to con-tribute to the greater relative incidence of facialfractures compared with skull fractures as matu-rity is reached.

Brain and Ocular Injuries

The facial skeleton is smaller, making the cranialvault more exposed to injury. The sinuses aretheorized to provide protection to the cranium,brain and eyes, among other structures, func-tioning as a “crumple zone” that can lead to facialfractures that might absorb energy upon impactand thereby minimize the damage to more vitalstructures. The less collapsible facial skeletonmay lead to an increased number of cranial andneurologic injuries in infancy and early childhood.

Fig. 2. Development of paranasal sinuses, birth toadult. (Courtesy of Dr Russell Faust, Franklin, MI.)

Tooth Buds

As children grow and develop, their facial struc-tures grow and develop. This includes the teeth,which start out as germinal centers within thebones of the maxilla and mandible and occupymost of the bone in the lower maxilla and anteriormandible in early childhood (Fig. 3). Aswedevelop,these form teeth that gradually erupt through thealveolar bone and through the gingiva. There areultimately 20 deciduous teeth that generally eruptbetween ages 1 and 6 years, and these are thenpushed out by the developing permanent dentitionbetween the ages of 6 and 14 years. The final 4posterior molars develop later and become theso-called wisdom teeth. There are ultimately 32teeth in the full adult dentition. These are numbered1 to 32, counting from the maxillary right posteriormolar to the left, 1 to 16, then continuing aroundfrom the mandibular left posterior as number 17to the right posterior molar, which is number 32.The deciduous teeth are designated in the sameorder with letters, A–J in the maxilla and K–T inthe mandible.

The presence of deciduous and mixed dentitioncreates unique difficulties for the CMF surgeon,because the conical deciduous teeth do not holdwires and arch bars well. Also, as their roots resorbthey are easily extracted with wires. The presenceof the unerupted permanent dentition in the bonemakes it difficult to properly position plates forrepair of fractures. Once the permanent teethhave fully erupted, they provide excellent fixationpoints for wires that can be used to attach archbars for stabilization of the occlusal relationships.

As noted, tooth buds are present in the bone ofthe maxillae and the mandible, making them proneto injury when facial fractures occur. If a tooth budis injured, it is less likely to develop into a fullyformed normal tooth, and eruption may be lesslikely. Tooth buds can be injured by trauma, partic-ularly fractures, and they can be injured by thesurgeon during the repair.

Softer Bone

The developing bone is less calcified and there-fore less hard than fully mature calcified bone.The interosseous sutures are also softer andmore flexible. This flexibility makes completethrough and through fractures less likely, alsocontributing to the lower frequency of fracturesneeding repair in the pediatric age group. Theseincomplete fractures, known as ‘greenstick’ frac-tures are more often seen in children. This term‘greenstick’ refers to the greater resilience seenin living (green) branches of a tree, comparedwith the easy-to-break, dried out dead branches.

Fig. 3. Skulls with outer cortex removed showing deciduous and permanent dentition in early childhood. (Cour-tesy of McLoughlin Dental Care, Milwaukie, OR; with permission.)

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Greenstick fractures are generally incomplete likebending of the bone, so that little or no reductionof the fracture might be needed. One cortex isfractured, and the fragments are held togetherby the second cortex of the bone. However,growth centers like the condylar region are rela-tively hypercellular and therefore softer, leadingto greater susceptibility to burst-type fractures.Such fractures are rarely seen in adults.

More Soft Tissue

Children have more soft tissue both subcutane-ously and in localized fat pads (baby fat) coveringthe maxillofacial skeleton than normal adults,which results in a greater likelihood of soft tissueinjury.12 As might be expected, owing to greaterpadding of the skeleton, this leads to fewer frac-tures. (Of course, the softer bone is less likely tobreak, adding to this effect.) However, severesoft tissue injuries are still common, and the facialnerve is in a more superficial anatomic position inthe infant and young child.

Fracture Patterns

As in adults, any part of the pediatric CMF skeletoncan be fractured, but certain fractures are morecommon. The difference in fracture patterns seenin children relative to adults is owing to a combina-tion of the noted factors, namely, the mechanismsof injury, the softness and compliance of the bone,the presence of tooth buds, the smaller size of theparanasal sinuses, the relatively small size of theface compared with the skull, and the greateramount of facial soft tissue. Because of these

differences between adult and pediatric anatomyand the differences in likely mechanisms of injury(low-energy short falls vs high-energy sports andmotor vehicle injuries), the fracture mechanismsand patterns are different as well. All of these fac-tors affect the exposure of the facial skeletal bonesto trauma as well as their response to impact.Skull fractures are more common than facial

fractures, but orbital roof and other skull base frac-tures without calvarial fractures are also morelikely. Upper facial fractures are typically associ-ated with cranial vault fractures and are, therefore,often associated with more serious intracranialinjuries.Midface fractures are uncommon until the mixed

dentition stage, becoming more common in pu-berty; when they do occur before mixed dentition,they do not typically follow Le Fort fracture pat-terns because of tooth buds and underdevelopedsinuses. Orbital floor fractures become more com-mon as the maxillary sinus pneumatizes.Nasal fractures are probably the most common

facial fracture in children, but many are probablymissed owing to decreased nasal prominence inthe child or not studied owing to noncentralizedand/or minimal management.The mandible is the next most commonly frac-

tured facial bone with symphyseal and condylarfractures leading.4,5 The frequency of forward fall-ing, the softness of the condylar growth center,and underdevelopment of the menton are likelycontributors. Dental and dentoalveolar fracturesstart to become more common as the teeth erupt.Children who are victims of high-energy injuriescan suffer pan facial fractures, as can adults.

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FACIAL ANATOMYCranium

Cranial vault (skull) fractures are more commonthan maxillofacial bone fractures in infants andyoung children. The cranium is initially almosttwice the area of the facial skeleton and the facialskeletal size does not usually begin to catch upin growth until about age 5 or 6 years, afterwhich facial growth progresses significantly rela-tive to the cranium to ultimately occupy abouttwo thirds of the craniofacial skeletal area. Thus,cranial bone fractures are far more likely in infantsand young children, as are intracranial injuries.The frontal bones occupy the region of the fore-head, superior to the orbits. The temporal boneshouse the ears and their associated structures,as well as the facial nerves. The sphenoid bonescontribute significantly to the anterior skull baseand internal orbits, in particular housing the opticcanals through which the important optic nervespass.

Orbits

Like in adults, the orbits are complex structures,housing the globe, along with its surroundingmusculature, vasculature, and nerves. Nine bonescontribute to the orbital structure. Cranial nervesIII, IV, V1, and VI pass through the superior orbitalfissure, and the optic nerve passes through theneighboring optic canal, along with its vessels.The anterior and posterior ethmoid arteries comeoff the ophthalmic artery in the orbit and passmedially into the ethmoid sinuses just below theskull base. The medial and inferior orbital wallsare very thin, allowing for globe trauma to be trans-mitted through them into the sinuses, which seemsto be protective of the globe when it is directlytraumatized.

Maxilla

The paired maxillae occupy the areas below theorbits, thereby encompassing the middle verticalone third of the face lateral to the nose. Essen-tially, the nose and maxillae occupy the area be-tween the frontoorbital area and the mandible. Asthe maxillae lengthen and the maxillary sinusesenlarge, the face elongates and develops itsadult length. The young maxilla contains a smallmaxillary sinus, and the bone inferiorly is filledwith the germinal centers that will eventuallyform the maxillary dentition. As the infant ma-tures, the deciduous dentition descends into theoral cavity, and as the adult teeth form anddescend, they push the deciduous teeth outand ultimately replace them. The roof of the sinus

forms the floor of the orbit. The medial wall formsthe lateral wall of the nose, and the floor contrib-utes to the roof of the oral cavity. The infraorbitalnerve (V2) exits the orbit through the floor (theroof of the sinus) and exits the maxilla anteriorlythrough the infraorbital foramen, after which it in-nervates the skin of the cheek, upper lip, andlateral nose.

Mandible

The mandible is an arch-shaped bone hingedbilaterally from the skull base by the temporoman-dibular joints, which sit in the glenoid fossae justinferomedial to the zygomatic roots of the tempo-ral bones. It is the only moving bone of the maxil-lofacial skeleton, and it is critically important formastication. The process of mastication involvesboth up-and-down and side-to-side movementsthat allow the teeth to grind food. The masticatorymuscle slings stabilize the mandible and help tosplint fragments after a fracture. Posteriorly, thevertical rami contribute to the vertical height ofthe face and serve to create the hinge that con-nects the mandibular bodies that house the denti-tion to the condylar heads, which articulate withthe glenoid fossae. The inferior alveolar nervesenter the medial (lingual) sides of the mandibularrami at the lingula and then travel anteriorly withinthe mid portion of the mandibular bodies to exitthrough the mental foramina to innervate the skinof the lower lips and chin. Along the way, thenerves supply the mandibular dentition, includingthe anterior dentition via a continuing branch.The curved central anterior portion of the mandibleis called the symphysis. The presence of thenerves and tooth roots as well as the germinal cen-ters for developing teeth (tooth buds) add to thedifficulty of repairing mandibular fractures. Obvi-ously, any appliances placed into bone (ie, screws)have to be judiciously positioned to avoid theseimportant structures.

Occlusion

The main goal of repair of maxillofacial fracturesthat involve either the maxilla or mandible orboth is to reestablish normal or preinjury occlu-sion. Note that what is normal or preinjury occlu-sion might be abnormal occlusion in an individualpatient, rather than the textbook normal occlusion.There is a normal relationship between the upperand lower teeth that is defined as normal occlu-sion. The maxillary dentition is supposed tooverride the mandibular dentition, so that themaxillary incisors extend forward of the mandib-ular dentition, called overjet, and the maxillarybicuspids and molars have buccal cusps that

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extend buccally (laterally) over the mandibularbuccal (lateral) cusps. The maxillary canines alsoextend buccally (laterally) over the mandibular ca-nines. The maxillary incisors also extend verticallyover the mandibular incisors, and the distance ofthe vertical overlap is called overbite.If the maxillary and mandibular incisors meet

end to end it is underjet (usually called negativeoverjet), which is even worse if the maxillary in-cisors come down behind the mandibular incisorsas an anterior cross-bite. The correct anterior–pos-terior relationship of the molars is defined bythe relationship between the mesiobuccal cusp(anterior–lateral cusp) of the maxillary andmandib-ular first molars. If the mandibular first molarmesiobuccal cusp sits within the same groove ofthe maxillary first molar, it is defined as Angle’sclass I occlusion. If the maxilla sits anterior (mandi-ble is posterior or distal), then it is class II, and if themaxilla sits posterior (mandible is anterior creatinga prognathic appearance), then it is Angle’s classIII. If the maxillary teeth are more lingual (medial),then it is a cross-bite, which can be either unilateralor bilateral.This discussion refers to occlusion for adult

permanent dentition. The deciduous teeth havesimilar relationships, but a class II–like occlusionreferred to as a flush terminal plane is more normalbecause of the relatively small mandibular arch inthis age child (Fig. 4). In transitional or mixed denti-tion, assessment of the occlusion is difficult. Thegeneral alignment of the dental arches is a start.There should be appropriate relationships amongthe teeth present. Sometimes the anatomic align-ment of the fracture lines is the best guide, withthe understanding that minor occlusal abnormal-ities in this phase are common anyway and willoften self-correct with natural dentofacialdevelopment.

FRACTURESFrontoorbital Maxillary Fractures

Nasal/nasoorbital ethmoid/medial blowoutCentral facial fractures are uncommon in smallchildren, but they do occur. They are usually theresult of major traumas, such as those seenin sporting vehicle accidents (all-terrain and otheroff-road vehicles) and when a child is unrestrainedand in a motor vehicle accident. They may alsooccur in pedestrian or bike interactions withmotor vehicles. The likelihood of these fracturesincreases as the face grows and the central facebecomes anatomically larger and more exposed.The nasal fracture occurs with milder trauma andinvolves only the nasal bones. Most childhoodnasal fractures are minimally displaced and often

do not require any treatment. However, if thenose is deformed, an attempt at closed reductionis reasonable. Open reduction, that is, rhinoplasty,is usually reserved for bony maturity, unless theairway is so severely compromised that it affectsairway function significantly (Fig. 5).Nasoorbital ethmoid (also called nasoethmoid

complex) fractures occur when the nasal root ishit hard enough to force it posteriorly. It telescopesbetween the orbits, collapsing the ethmoids. Thebones holding the medial canthal ligaments arereleased, allowing the lids to move laterally andcreating the appearance of hypertelorism, calledtelecanthus or pseudohypertelorism. Damage tothe ethmoids includes the medial orbital walls.13

Note that when the anterior skull base isinvolved in fractures, the subcranial approachcan be used, just as it is in adults. This approachincludes removal of the nasal root for access tothe ethmoids and removal of the inferior frontalbones for access to the anterior skull base fordirect repair of dural defects.

Inferior blowout/zygomaticomaxillary fractureThe inferior wall of the orbit “blows out” when thereis direct trauma to the globe (and sometimes tothe inferior orbital rim as well). The orbital floorgives way and “blows out” into the maxillary sinus,allowing the globe to decompress into the sinusrather than rupture. If the inferior rectus is entrap-ped, there is inability to look up, typically creatingdiplopia. In the so-called white-eye blowout frac-ture, the inferior rectus entrapment leads to amarked vagal response, including nausea andvomiting, and often marked discomfort. This isconsidered an urgent case, and urgent release ofthe entrapment is indicated.13

The zygomaticomaxillary complex fracturerefers to the dislocation or separation of the malareminence from the temporal bone, frontal bone,and the maxilla on a given side of the face. Theattachment of the zygoma (which includes themalar eminence) to the temporal bone is viathe zygomatic arch, the anterior portion of whichis the zygoma and the posterior portion of whichis the temporal bone, the frontal bone along thelateral orbital rim and the maxilla inferomediallyup to and including the inferior orbital rim. In addi-tion, there is an attachment to the sphenoid wing inthe lateral wall of the orbit. Because of the broadattachment to the maxilla, which is usually themost shattered portion of this fracture, it is gener-ally called a zygomaticomaxillary fracture.

LeFort I, II, and III fracturesLe Fort fractures are named after Rene LeFort,who first described these patterns in cadavers.

Fig. 4. Various deciduous occlusal relationships and their respective adult occlusal relationships. (From Proffit WR,Fields HW, Sarver DM. Contemporary orthodontics. New York: Elsevier; 1993. p. 81–4; with permission.)

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All 3 types refer to a separation of the bonesbearing the maxillary dentition from the bonessuperior to them. Designations I, II, and III referto the level at which this separation takes place.A horizontal fracture across both maxillae thatcompletely separates the entire maxillary alveolifrom the remaining maxillae above, mobilizes thealveolar arches and dentition along with the palate,and is called a Le Fort I fracture. Of course, it hasto transect the maxillary sinuses and the nasalseptum, as well as fracture the pterygoid plates,something common to all Le Fort–level fractures.

The Le Fort II or pyramidal fracture typically breaksthrough the maxillae laterally, but then traversesthe infraorbital rims and floors as well as the medialorbits, completing the separation at or near thenasal root, and also including the nasal septumand pterygoid plates. The Le Fort III fracture, orclassical “craniofacial separation” crosses thezygomatic arches and lateral orbital walls andfloors, as well as the medial orbits and nasal roots,again including the nasal septum and pterygoidplates. Typically, few fractures precisely mimicthese patterns, and most are a combination of

Fig. 5. Baby with broken nose.

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multiple levels of fracture. As noted, owing to thesmall size of the facial skeleton in infants andyoung children, these fractures are uncommon inthe younger age groups. When they do occur,there is usually a high-energy trauma involved,such as with motor vehicle crashes, and they areassociated with multiple associated injuries(Fig. 6).

Fig. 6. Le Fort fracture. (A) Preoperative, (B) and (C) Preo

Manbibular Fractures

Condylar and subcondylar fracturesFractures of the condylar head are fortunately un-common in older children and teenagers, becausethey tend to disrupt the temporomandibular jointand lead to various degrees of malfunction. Ingeneral, most surgeons do not surgically violate

perative imaging, (D) Intraoperative.

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the joint for repair of these fractures, althoughthere is controversy regarding this management,particularly in Europe. Fractures below the jointare generally referred to as subcondylar fractures,so long as the anterior extent of the fracture fallswithin the sigmoid notch and the posterior extentis behind the angle of the mandible. If the fracturecrosses below the coronoid, it is considered aramus fracture, and if it extends anterior to theangle, it is considered a vertical ramus fracture.

Most surgeons advocate conservative (non-open) repair of subcondylar fractures in children,although again, this course of action is con-troversial as well.14 In younger children, probablyyounger than 14 years, and certainly youngerthan 12 years, there is a greater propensity forremodeling of the joint and subcondylar area, sothat even unreduced fractures, so long as theocclusion is reduced, typically heal with whatseems to be normal or near-normal anatomy after1 to 2 years.

Coronoid fracturesThe coronoid fracture occurs when the coronoidprocess is separated from the remainder of theramus of the mandible. It is a horizontal fractureof the ramus above and anterior to the sigmoidnotch. It may sometimes be associated with asubcondylar fracture, making it a complete frac-ture across the ramus area but above the sigmoidnotch. Coronoid fractures are uncommon, andmost often they do not require repair. If thepatient is having extreme discomfort or significantdysfunction, some people advocate repair.

Ramus fracturesFractures of the ramus of themandiblemay be hor-izontal, vertical, or a combination thereof, includingvarious patterns of diagonal fractures. As noted, ifthe fracture occurs between the posterior ramusand the sigmoid notch, it is a subcondylar fracture.Depending on the degree of discomfort and dys-function caused, many of these can be managedconservatively, particularly in children.

Angle fracturesAngle fractures of the mandible occur behind themandibular dentition and typically extend posteri-orly toward the actual angle of the mandible.Because they are behind the dentition, they arenot well stabilized by conservative measures,that is, fixing the occlusion. Fortunately, as noted,fractures in children are often incomplete (green-stick fractures), in which case the lack of instabilitymay allow for conservative treatment to be effec-tive. However, when there is instability, moredefinitive (open) treatment is usually indicated.

Mandibular body fracturesFractures of the mandibular body and symphysisoccur along areas of dental occlusion. This makesthe precise realignment critically important owingto the importance of dental occlusion for thepatient. However, the presence of the tooth rootsand tooth buds canmake rigid fixation very difficultand risky, so that all options must be considered.Sometimes, when possible, dental splints can becrafted and used to stabilize the occlusion andthereby the bone fragments, which leads to heal-ing with proper occlusion.

Symphysis and parasymphysis fracturesThe symphysis is an extension of both mandibularbodies, and like the bodies, it contains dentition.However, it is less stable owing to its curvature,so that the forces that occur across fractures inthis area are directed in multiple directions, andtherefore more fixation is generally required to sta-bilize this area adequately. Again, dental splintsoften can stabilize the occlusion effectively andlead to satisfactory healing.

Dentoalveolar fracturesDentoalveolar fractures occur when a traumadirectly involves the dentition and the alveolarbone holding the teeth. These are typically treatedby gentle closed reduction and stabilization withadjacent teeth, and this is often done by dentallytrained professionals. All efforts are made tomaintain teeth, even deciduous teeth, becausethey serve an important role as “spacers,” pre-venting migration of remaining teeth. Alveolarfractures can often be stabilized by cementingsolid wires to the teeth, which stabilizes boththe teeth to each other and the bones that holdthem.15,16

PHYSICAL EXAMINATION

The injured child is likely to be anxious and resis-tant to vigorous palpation of their injured headand face. Much can be gleaned from pupillaryand extraocular movement, patterns of ecchy-mosis and edema, scalp, face, and oral lacerationsand occlusion. Findings such as altered con-sciousness, globe injury, hyphema, septal hema-toma, and dental avulsion should be ruled outbecause of the urgent nature of their management.Gentle palpation for deformities and stop-offs canbe attempted, but should be done patiently andwith awareness of the impact on the child. Morecomplete physical examination can be done ifthe child is sedated for a procedure or imaging.This is also a good time for an ophthalmologicevaluation, if warranted.

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IMAGING AND DIAGNOSIS

There is a greater concern for the long-term effectsof radiation on the growing child than the adult.This has led to more attention being paid to theamount of radiation being delivered to pediatricpatients being imaged particularly in those caseswhere repeat imaging is required. That beingsaid, the standard of care for imaging of mostsignificant pediatric CMF trauma is computedtomography. Children’s and other hospitals’ radi-ology departments have begun to minimize radia-tion dosage in their imaging protocols, using rapidsequence spiral and other techniques. The brain isgenerally imaged as well as the CMF skeletonbecause of the chance of associated neurologicinjury. Depending on the age and anxiety of thechild sedation is frequently required for qualityscans. Multiplanar and 3-dimensional image re-formatting is often helpful in complicated cases.17

SURGICAL APPROACHES TO THE CMFSKELETONTiming

Although certain injuries such as uncontrolledhemorrhage, large dural tears, globe injuries,and extraocular muscle entrapment require emer-gent management, most facial skeletal fracturescan be repaired nonemergently. However, therobust inflammatory response and relatively rapidbone healing of the pediatric patient must beconsidered. A fracture that can easily be reducedat 1 week might be quite difficult to reduce at2 weeks. This also applies to immobilization. Amaxillomandibular fixation period as brief as3 days might be adequate to stabilize a (sub)condylar fracture and prevent temporomandibularjoint ankylosis with early function.

Airway Management

Depending on the severity of the injury, an airwaymight have already been established in the fieldor emergency department. Also depending oninjury severity, consideration should be given toconversion to tracheostomy when prolonged intu-bation is anticipated. When the airway is to be es-tablished in the operating room, there are severaloptions. Standard orotracheal intubation isadequate if the patient does not have to be putinto occlusion as part of the trauma management.If there is adequate space, a retromolar positioningof the orotracheal tube allows the jaws to bebrought into occlusion. A temporary surgical air-way alternative to tracheostomy that has beensuggested by some is the submental airway. Na-sotracheal intubation has been feared in maxillary,

ethmoid, and skull base fractures owing to thepossibility of the tube passing through fracturedbone into the brain, so-called intracranial intuba-tion. Although this possibility should be respected,it is very unlikely in all but the most severe trauma,if appropriate technique is employed. The firstpoint is to direct the tube parallel to the palate,not the nasal dorsum. Lifting the nasal tip helpswith this. Second, a finger in the nasopharynxcan intercept the tube tip and guide it throughthe turn in the nasopharynx. Orienting the angleof the tube tip open superiorly facilitates this pas-sage of the tube through the nasopharynx andinferiorly toward the larynx. The tube should bewell secured with tissue adhesive and tape toreduce the chance of intraoperative extubation.

Coronal Approach

The coronal approach is the workhorse for accessto the upper facial skeleton, including the frontalregion, the superior and upper lateral orbits, andthe zygomatic arches (see Fig. 6). It is also thebest access for reaching the nasal root region,particularly for repair of nasoorbital ethmoid frac-tures and fractures that extend into the anteriorskull base.The incision is generally carried from over 1 ear

across the scalp to the other. It can be extendedeither into the preauricular crease if needed, orsome surgeons prefer to extend it inferiorly justbehind the auricle, although some find this locationmore difficult when inferior exposure is needed.The incision may be straight or curvilinear (“sinewave” or “W-plasty”), to make the scar less visiblewhen the hair grows.The incision can be carried down to the perios-

teum, which can be elevated secondarily in casea pericranial flap is needed, or it can be takendown to bone, and the pericranium is thus pre-served in the flap itself for later separation if needed.The incision then reaches the bone from temporalisto temporalis, and over the muscle the incision istaken down to the level of the deep temporal fascia,but not through it. In the temple area,when the fat isseen between the layers of the temporalis fascia,the surgeon has the option of hugging the fasciaor opening the outer layer and elevating over or un-der the temporal fat pad to minimize risk of injury tothe temporal branches of the facial nerve. Elevationcan then be carried forward at these levels to theorbital rims, where great care is used to preservethe supraorbital nerves. Access to the nasal rootand medial orbits as well as the upper lateral orbitsand zygomatic arches is then possible.Note that the coronal approach provides broad

access to the inferior frontal bones and nasal

Fig. 7. Various positions for skeletal suspensionwiring. (From Bluestone CD, Rosenfeld RM. Surgicalatlas of pediatric otolaryngology. Hamilton (Ontario):BC Decker Inc; 2002; with permission.)

Fig. 8. Application of a Risdon cable for deciduousmaxillomandibular fixation.

Pediatric Craniomaxillofacial Trauma 569

root and if needed the ethmoid areas for perfor-mance of the above-noted subcranial approach,when repair of the anterior skull base is indicated.

Periorbital Approach

Access to the frontozygomatic suture and lateralorbit can be achieved via an upper lid lateralblepharoplasty incision or via the coronal incision,as described. The inferior orbit is generally ac-cessed via a lower lid incision of some type.Today, most surgeons utilize transconjunctivalapproaches, either preseptal or postseptal. Sub-ciliary and infraorbital incision are sometimesused, but are less popular today. The medial orbitcan be accessed via a transcaruncular incision.

Intraoral Approach

Intraoral exposure of maxillary and mandibularfractures is performed through the mucosa justabove and just below the gingiva, usually about5 mm from the gingival margin. The oral vestibularincisions are then taken down to the bone, and thebone is exposed by elevating deep to the perios-teum. Care is taken not to injure the infraorbitalnerve when exposing the maxillary bone. Similarly,care is taken to avoid injury to the mental nerveswhen exposing the mandible.

Transcervical Approach

As in adults, the mandible can be exposed usingexternal incisions. The submandibular, Risdon,retromandibular, and submental incisions pro-vided good exposure when needed. Such inci-sions are carefully placed in the relaxed skintension lines to minimize visibility of future scars.Care should also be taken to preserve the mandib-ular branches of the facial nerves.

REDUCTION OF THE OCCLUSION/MAXILLOMANDIBULAR FIXATION

As in adult maxillofacial fractures, the most impor-tant aspect of reduction of maxillary and mandib-ular fractures is to assure that the occlusion isreestablished. This can be more difficult in youngchildren, particularly those with mixed dentition.When available, dental splints may prove helpfulin stabilizing the occlusion.15 Splints are fixed tothe maxilla by placing wires from the splint to themaxillary and/or zygomatic bones. Fixing a splintto the mandible generally requires the placementof 2 or 3 circummandibular wires. When 2 separatesplints are used, arch bars or hooks in the splintswill allow fixation of the occlusion (ie, maxilloman-dibular fixation) by wiring the splints together afterthey are fixed to the bones (Fig. 7).

When arch bars are used, great care has to beused not to extract teeth with the wires that securethem to the teeth. Duringmixed dentition, the rootsof exposed teeth are resorbing, which makes themvulnerable to avulsion. Also, in children in decidu-ous and mixed dentition, it is very difficult to applya stable arch bar owing to the short height of thecrowns. An alternative is a Risdon cable, which isbasically a narrower arch bar constructed fromstrands of wire that are fixed to the most posteriordentition (Fig. 8). The original Risdon cable was

Kellman & Tatum570

placed using 2 wires that were tied to the mostposterior (distal) molars and brought anteriorlyalong the teeth and tied together in the midline.Today, it is more typical to start at 1 end, fix thewire to the molar, then attach the twisted wire toeach tooth with a circumdental wire (like an archbar) until it reaches the other end, where it is fixedto the contralateral last molar tooth. The twists ofthe circumdental wires that fix the cable to eachtooth are then used to attach rubber bands forstabilizing the occlusion.

MINIMALLY INVASIVE AND NONOPERATIVEMANAGEMENT

When the bones are stable, particularly when frac-tures are incomplete, nonoperative managementmay be possible and desirable because it is asso-ciated with fewer complications.18,19 As long asthe patient is able to open and close with approx-imately normal occlusion, a mechanical soft dietduring the healing period may be adequate.Closed reduction of some fractures that are in-completely mobile is another option.Minimally invasive often refers to the use of

endoscopically assisted techniques. These havebeen used successfully for management of orbitalfloor fractures, medial orbital fractures, and sub-condylar fractures of the mandible. Orbital floorfractures may be approached through the maxil-lary sinus, but great care must be exercised,because small fragments of bone may be inadver-tently advanced into the orbit. Medial orbital frac-tures may be repaired using endoscopes via thenose; however, in view of the small size of thenasal cavity and ethmoids in small children, thishas the potential of being challenging technically.Finally, subcondylar fractures of the mandible areparticularly amenable to endoscopically assistedapproaches. However, the need to do so shouldbe uncommon in the prepubescent child and likelylimited to cases in which conservative measuresfail to produce normal occlusion.

FIXATIONWires

Many modern surgeons forget or never knew thatinterosseous wire fixation was the mainstay ofbone fixation before the introduction of platesand screws for rigid fixation of fractures. It shouldbe emphasized that, although rigid fixation is stillrecommended, even in the pediatric age group,wire fixation is a reasonable alternative to stabilizemobile fragments, particularly when assisted bythe stabilization of the occlusion with arch bars,wires, or splints to limit bone motion. The main

advantage of interosseous wire fixation is thatonly small drill holes are required for wire place-ment, thereby making it easier to avoid tooth rootsand developing tooth buds.

Plates/Removal

Rigid fixation plates are used in the pediatric pop-ulation as they are in the adult population, but thelocations for placement are more limited owing tothe smaller bones and the presence of the toothbuds in both the mandible and maxillae.20

Frontal fractures can be repaired using verysmall plates and screws, but it must be kept inmind that in infants and small children growthmay lead to the plates migrating inward, and there-fore absorbable plates should be considered. Forzygomaticomaxillary and Le Fort fractures, smalltitanium plates are contoured to the shape of thebones and fixed in place with titanium screws. Inthe inferior maxillae, great care should be takento avoid unerupted dentition and tooth roots. Simi-larly, in the mandible, plates often need to beplaced in the biomechanically unfavorable inferiorportion of the bone, owing to the presence of thetooth buds. However, this disadvantage is some-times offset by the overall short stature of theimmature bones.Whenusingnonabsorbable titaniumplates, plate

removal is commonly recommended in the pediat-ric population, although this remains controversial.Themain reason for advocating removal in the pastwas the concern about interference with later bonegrowth, particularly in the prepubescent child.However, this hasnot been seen in clinical practice.Nonetheless, what has been seen has been bonegrowth over the titanium plates, thereby incorpo-rating theplates into thedevelopingbone. Althoughthis does not preclude later removal, it certainlydoes make it more difficult and requires drilling anamount of bone from over the plate, which cansometimes represent a substantial amount ofbone loss. For these reasons, many surgeons re-move titanium plates and screws from the growingfacial bones, particularly the cranium and man-dible, 6 months to 1 year after repair.

Absorbable Plates and Screws

As an alternative to titanium plates and screws,biodegradable plates and screws have beendeveloped for use primarily in the pediatric popu-lation (although they can be used in adults).20

These implants are generally made of various(co)polymers of polylactic and polyglycolic acids,although polydioxanone has been used also. Themain problems associated with their use includestructural weakness compared with titanium,

Pediatric Craniomaxillofacial Trauma 571

necessitating use of larger implants to accomplishsimilar fixation, as well as the fact that the greaterthe stress on the implants, the faster they degradeby hydrolysis. Thus, they seem to offer somewhatless strength for less time when the need forstrength might actually be greater. Fortunately,these issues have not seemed to represent a prob-lem in clinical use. Obviously, the use of absorb-able hardware obviates the need for reoperationto remove the implants.

COMPLICATIONSInfection and Malunion

Early complications, such as infection and mal-union, are similar to those seen in adults, althoughless common because of faster bone healing andthe potential for compensatory changes withgrowth, development, and eruption of adult denti-tion. The likelihood of tooth root injury is greaterowing to the lack of space in the bone, and therisk of injury to developing tooth buds is unique tothe pediatric population. Unfortunately, tooth rootinjuries canoccur easily from injudiciousplacementof bone screws. Long-term complications such asgrowth disturbance are unique to this popula-tion.1,21 The overall complication rate increaseswith the number and severity of fractures.18

Malocclusion

Malocclusion is always a risk when treating maxil-lary and mandibular fractures, and great care mustbe taken to ensure that the occlusion is reduced asclosely as possible to the premorbid relationship.In addition, any malposition of the facial skeletalbones during repair can result in facial deformities.Imprecise or inadequate reattachment of themedial canthal ligaments can result in persistentand unsightly telecanthus.

Nerve Injury

Nerve injuries are typically a result of the present-ing injuries; however, they may also occur as aresult of exposure, repair, and particularly screwplacement. Great care should be taken to avoidinjuring cranial nerve branches during accessand repair of maxillofacial fractures. However, forfacial nerve injuries, early intervention is recom-mended, if the possibility of nerve trunk or branchtransection is suspected.

Ocular Injury

Ocular injuries are more likely to be owing to theinitial trauma; great care must be exercised whenoperating in and around the orbit to avoid creatingany injuries to the globe and/or cornea. In addition,

great care is used to minimize the likelihood ofmuscle entrapment during repair of orbital frac-tures. Performing forced duction testing bothbefore and after any intraorbital intervention is rec-ommended. Unfortunately, diplopia may persisteven when there is no persistent entrapment afterinjury to an extraocular muscle, which is believedto be owing to either direct muscle injury orpossibly injury to the nerve that supplies the mus-cle. These are dealt with by ophthalmologists whospecialize in the management of problems of theextraocular muscles.

Soft Tissue Injury

Soft tissue injuries and surgical incisions can leadto scarring and contracture that lead to deformitieseven when the underlying bones are perfectlypositioned. Great care must be exercised to avoidtrauma to the orbital septum when accessing theorbit, because lid malpositions (ectropion andentropion) can be challenging to repair. Some au-thors recommend the use of a Frost stitch tostretch the lower lid after surgical access hasbeen performed. Postoperative massage of thelower lid often helps to relax scars in this areaand resolve developing malpositions nonsurgi-cally, particularly if the intervention is begun beforethe problem becomes severe. In young children,scars have a remarkable propensity to improveon their own, so scar revision surgery is usually de-layed at least 1 year in most cases to allow naturean opportunity to resolve the problem (of course,dramatic situations might provide exceptions tothis recommendation).

Nasal Septal Hematoma

Nasal septal hematomas may complicate nasaltrauma. It is important to look for and identifythese, because early intervention will minimizethe risk of later septal problems that may requirechallenging reconstructions.

LONG-TERM FOLLOW-UP

Long-term follow-up is typically recommended inchildren until they have reached skeletal maturity,because growth may be affected by trauma tothe developing facial skeleton.22 Problems thatare not obvious immediately after the injury maybecome more of an issue later on, and secondarysurgery may be needed to address such issues.18

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