Facial Fractures in Children Fractures of the facial skeleton are notably infrequent in the pediatric age group, particularly among children who are younger than 5 years of age. In Rowe'sl analysis of 1500facial fractures, less than 5% of patients were under 12 years of age, and fewer than 1% were children 6 years or less. Several large reviews of facial trauma have concurred with these low figures, with the incidence of facial fractures in children ranging from 1 to 6% in most study series.24 Despite the lower incidence of these injuries compared with that of the adult population, the impact of pediatric facial fractures can be more serious because the facial structures are still undergoing significant developmental changes and growth. Facial trauma in children may result in injury to the facial growth centers, leading to subsequent developmental abnormalities in the injured area. Facial hypoplasia and asymmetry, as well as impairment of normal function, can be the ultimate outcome of these injuries. Children are generally subjected to a more protected environment than adults and are therefore less likely to be exposed to potential traumatic injuries of the magnitude to result in facial fractures. Infants and young children are protected by laws requiring car seat restraints. The small size and weight of a child results in less inertia when a child is thrown forward in a motor vehicle accident, which serves to reduce the force of impact on the face in comparison to an adult. Children younger than school age are not involved in team sports and are less likely to be involved in altercations with their peers. Although certainly this reduced exposure to potential causes of facial trauma is a factor in the lower incidence of facial fractures in the pediatric population, anatomic differences between the pedi-
atric facial skeleton and that of the adult may contribute to the lower incidence. Two of the most important anatomic factors in the reduced frequency of facial fractures in children are the larger craniofacial ratio in the pediatric facial skeleton and the lack of pneumatization of the paranasal sinuses. The pediatric cranium is proportionately much greater in size than the facial skeleton. The face is relatively underdeveloped, and the surface area of the face is comparatively small to that of the cranium. In the infant, the maxillary antra and zygoma are poorly developed and the mandible is small and unobtrusive. In contrast, the frontal cranium is quite prominent5 (Fig. 1). The cranium and forehead effectively shield the smaller lower and middle thirds of the face from injury. The relative lack of pneumatization of the paranasal sinuses in children less than 10years of age adds to the stability of the midface. With pneumatization of the paranasal sinuses and the growth and development of the permanent dentition, there is vertical and anterior growth of the maxilla and mandible. This facial growth results in a decrease in the craniofacial ratio from 8:l in infancy to 2.5:l in adulthood.6 Correlated to the maturational growth patterns of the pediatric facial skeleton, the frequency of facial fractures increases with increasing age during childhood. In particular, the proportionateIy increased growth of the middle and lower facial thirds that occurs with maxillofacial development places these entities in a more prominent position and allows them to become more susceptible to traumatic injury. In our recent study, supraorbitalrim and frontal skull fractures were found to be the most common facial fractures of childern aged 0 to 6 years old, whereas mandible fractures were found to be the
Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center Houston, Houston, Texas Reprint requests: Dr. McGraw-Wall, Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center Houston, 6431 Fannin, Suite 6132, Houston, TX 77030 Copyright 01991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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Becky L. McGraw-Wall, M.D.
FACIAL FRACTURES IN CHILDREN-McGraw-Wall
normal anatomic positions following injury. In addition, the cortex of the pediatric skeleton is very thin in comparison to that of the adult, with a greater proportion of spongy cancellous bone, so that the pediatric facial bones are more elastic and resilient to injury, For these reasons, a higher frequency of greenstick fracture injuries occur, without a disruption through both cortices and often without significant displacement of the fracture fragments. Children also have more prominent buccal fat pads that tend to cushion the impact of the offending trauma and lessen the force transmitted to the underlying bony architecture.6
ETIOLOGY O F PEDIATRIC FACIAL TRAUMA
The majority of pediatric maxillofacial trauma is secondary to motor vehicle accidents. Legislation requiring special car seat restraints for infants and toddlers and seat belts for children and adult pasmost common fractures in children older than 6 sengers should help reduce this incidence, dependyears5 (Fig. 2). Fractures involving the inferior orbit, ing on public compliance. Automobile-pedestrian zygoma, and maxilla were almost exclusively found accidents are another frequent etiology of facial in children older than 10 years. This tendency to- trauma, especially in toddlers and preschool age ward upper face fractures in younger children and children. In Houston, where there has been little lower face fractures in older children correlates with public sentiment supporting gun control laws, we have found accidental gunshot wounds to the face to patterns of facial maturation. be the next most frequent cause for pediatric maxilloThe presence of multiple developing tooth buds of facial trauma.5 Other important causes include falls, both the deciduous and permanent dentition within automobile-bicycle injuries, sports-related injuries, the maxilla and mandible increase the elasticity and altercations, equestrian-related accidents, and child stability of the pediatric facial skeleton. The multiple abuse. Physicians should always be attuned to the dental follicles within the mandible and maxilla help possibility of abuse, especially when the extent of to maintain the fractured bone fragments in their injury exceeds that which is expected by the history of the injury as reported by the parent. There is a reported male preponderance for facial fractures, which is less pronounced in children younger than 6 years, but increases with age into adulthood.5
INITIAL EVALUATION A N D MANAGEMENT Diagnosis of facial fractures is more challenging in pediatric patients. The thick buccal fat pads, along with the associated edema and ecchymosis following injury obscure palpation of the facial skeleton. The frequency of greenstick and minimally displaced fractures makes clinical evaluation even more challenging. In addition, the presence of mixed denMandible Frontal Orbit Le Fort tition and missing or partially erupted teeth make Fracture Site Figure 2. The incidence of pediatric mandible fractures evaluation of occlusal abnormalities more difficult. and Le Fort type injuries increased with increasing age, in The injured child is apprehensive and often uncomconjunction with the increasing prominence of the lower fortable or in pain, and as a result may not be cooperand middle facial thirds, whereas the incidence of frontal and orbital fractures decreased with increasingage.5 Group I ative with the examiningphysician. Sedation may be required to complete an evaluation of the extent of = 0-6 years; group 2 = 7-11 years; and group 3 = 12-16 years. injury. A common method of sedation involves ad-
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Figure 1. Comparison of the premature infant facial skeleton with that of the adult facial skeleton. Note the relative underdevelopment of the mid and lower face, and the prominence of the forehead and cranium of the neonatal skull.
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Figure 3. Zonarc of the mandible.
ning of the brain, or in patients with cervical fractures who cannot be repositioned for plain films of the face. CT scans are particularly useful in the diagnosis and evaluation of frontal skull and sinus fractures, and for fractures involving the orbit and midfacial fractures (Fig. 4).
ASSOCIATED INJURIES
Associated injuries occur more frequently in children with maxillofacial trauma, especially multiple associated injuries.7 Skull fractures and intracranial injuries are particularly more common in children. This may be related to the elasticity and stability of the pediatric facial skeleton. A greater amount of force is required to achieve a fracture of the pediatric facial skeleton and that force is readily transmitted to the adjacent cranium. In our recent study associated fractures occurred in 88% of children aged 0 to 16 years with facial fractures, and 61% had multiple associated injuries. These were predominantly head injuries and skull fractures, especially in children aged 0 to 6 years, correlating to the larger craniofacial ratio and frontal prominence of this younger age group.5 Neurosurgical consultation should always be considered when dealing with pediatric maxillofacial trauma. Orthopedic injuries also frequently occur in association with pediatric facial fractures. Concomitant cervical fractures have not been found to occur with greater frequency in the pediatric population.7.8 However, the possibility of cervical spine injuries should not be ignored in a child sustaining traumatic injuries severe enough to cause facial fractures.
SPECIAL CONSIDERATIONS
Management of pediatric facial fractures is generally similar to that of adults; however, there are several special considerations in the management of pediatric facial fractures. The periosteum of the pediatric patient has a greater osteogenic potential, and the metabolic rate is higher, so that fracture healing occurs at a faster rate. Fracture union routinely occurs within 3 weeks; therefore a shorter period of intermaxillaryfixation is required. Longer periods of fixation can result in secondary problems in children, in particular, ankylosis of the temporomandibular joint. Frequently 10 days to 2 weeks is an adequate period of time of intermaxillaryfixation for some mandible fractures. Because of this faster rate of union, the time frame for reduction of facial fractures in children is somewhat more limited. A delay in treatment may result in callous formation and healing of the unreduced fracture fragments, so that
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ministering a "pedi cocktail," a combination of narcotic and tranquilizing agents given intramuscularly: meperidine hydrochloride, 2 mglkg; chlorpromazine, 1 mglkg; and promethazine hydrochloride, 1mgkg. One must be certain to evaluate the patient fully for an associated head injury prior to administering any central nervous system depressant. In addition, the diagnosis and management of other more serious life-threatening injuries, such as airway problems, bleeding, shock, or cervical spine injuries, should take precedence. Airway insufficiency should be managed with placement of an endotracheal tube, instead of a tracheostomy whenever possible. Tracheostomies in children are frequently associated with complications and are best avoided unless absolutely necessary. A low-placed tracheostomy has the potential for problems related to the relatively superior position of the innominate vein in young children. As well, the incidence of tracheal stenosis, tracheomalacia, and decannulation accidents is much higher in children. Because of the difficulties in clinical diagnosis just delineated, radiographic evaluation plays an important role in pediatric facial trauma. However, the radiographic diagnosis of pediatric facial fractures is also more difficult. The underdevelopment and poor pneumatization of the paranasal sinuses result in less radiographic contrast for evaluating the facial skeleton using plain films of the face. Moreover, the presence of multiple tooth buds and mixed dentition can obscure visualization of the fracture line. The multiple positions necessary for adequate evaluation by plain films are time consuming and require a level of patient cooperation with which young patients may be unable to comply. Panoramic radiographs (Zonarcs) of the mandible and midface often help to better delineate these hidden fracture lines, as well as help to evaluate the status of the dentition involved in the fracture (Fig. 3). Computerized tomography (CT) scans of the facial bones are helpful in children, especially for those patients with associated head injuries requiring simultaneous CT scan-
Figure 4. A: CT scan of a 3-year-old child showing marked displacement of the posterior lateral orbital wall (arrowhead)in conjunction with a zygomatic fracture (small arrow).B: lntraoperative photograph of the same child showing extensive comminution of the zygorna, as well as soft tissue avulsion.
subsequent attempts at reduction to reestablish the proper occlusal relationships are inhibited. Ideally reduction should be carried out within 5 to 7 days of the injury for optimal results. A conservative treatment approach has been the standard of care for facial fractures in children in order to avoid injury to the multiple growth centers and developing dental follicles. The use of miniplates and screws is seldom indicated because of the greater likelihood of injury to the multiple developing tooth buds, and because of the concern for inhibition of bone growth. Intermaxillary fixation and judicious interosseous wiring when needed to stabilize further the fracture are the mainstays of surgical treatment for pediatric facial fractures. Care must be taken to place the interosseous wires low along the mandibular border to avoid injury to the developing dentition. Wires should not be placed in the tooth-bearing bone of the maxilla. Such infringement will cause loss of the affected teeth and may result in osteomyelitis of the mandible or maxilla. The pediatric facial skeleton can undergo a significant amount of remodeling following traumatic injury under the forces of mastication. Meticulous reduction of fracture fragments is usually unnecessary because of this remodeling potential. As well, mild occlusal irregularities resulting from fractures may
resolve with alveolar growth at the time of eruption of the permanent teeth.9 Fractures involving toothbearing bone may result in delayed or noneruption of the teeth adjacent to the fractures, and the parents should be advised of this at the time of injury. Facial fractures with minimal or no displacement in patients with satisfactory and repeatable occlusion can frequently be treated expectantly on a soft, mechanical diet without surgical intervention. Intermaxillary fixation can be challenging in children, particularly in the 9- to 12-year age group. The mixed dentition present in this age group makes application of standard interdental wiring for arch bars and intermaxillary fixation unstable and often results in less than satisfactory immobilization. This can be attributed to the exfoliation of the deciduous teeth with their dental roots in varying stages of absorption, missing teeth, the spreading of the interdental contact points, and the different stages of eruption of the permanent teeth present (Table 1). Moreover, the shape of the deciduous teeth is not as optimal for placing interdental wiring for securing arch bars or intermaxillary fixation. Whereas the crown of a permanent tooth is constricted at its lower cervical third, which allows for easier and more secure placement of interdental wires, the crown of a deciduous tooth is widest at its lower cervical third
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FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Tooth
Deciduous Exfoliation
Permanent Eruption
Central incisors Lateral incisors Cuspids Bicuspids First molars Second molars Third molars
6-8 years 7-8 years 9-1 2 years Not present 10-1 1 years 10-1 1 years Not present
6-8 years 7-9 years 9-12 years 10-1 2 years 6-7 years 11-1 3 years 17-21 years
and tapers toward its incisal or occlusal surface (Fig. 5). This makes stabilization of an arch bar or intermaxillary fixation somewhat tenuous when relying on interdental wiring alone. Nonetheless, it is possible to use interdental wiring for application of arch bars and intermaxillary fixation in children between the ages of 4 and 8 years by carefully placing the wires below the contact ponits of the deciduous canines and molars. In general, the use of interdental wiring alone in children between the ages of 9 and 12 may be unreliable. The addition of circum-mandibular wires can help secure the mandibular arch bar in position. As well, passing suspension wires from the maxillary arch bar through the piriform process and through the malar-maxillary buttress can help stabilize the maxillary arch bar and maintain the intermaxillary fixation in the proper occlusal relationship (Fig. 6). The zygomatic arches are thinner and not as strong as those of the adult and should not be used for suspension wires. When interdental wiring is not possible due to the mixed dentition, an acrylic dental splint can be fabriDeciduous Dentition
-Cervical 3rd -Middle 3rd lnc~sal3rd
Permanent Dentition
Figure 6. Stabilization of maxillary arch bar by wires passed from the arch bar through the piriform rims and the anterior nasal spine.
cated for immobilizationor intermaxillaryfixation. A plaster study model taken from an impression of the patient's teeth is broken along the fracture lines of the mandible and maxilla, so that the segments can be aligned into the appropriate occlusal relationships. The acrylic splint is then made using the plaster model, usually incorporating wire hooks or arch bar segments into the splint for use in intermaxillary fixation. The splint can be fixed to the jaws using circum-mandibular wiring and suspension wires from the piriforms and malar buttresses, as described before.
Middle 3rd lnclsal 3rd
NASAL FRACTURES
B---
Pediatric nasal fractures are often unrecognized and unreported by both the patient and parent, as
' -Ciiwral3rd
U h 4 - 3lnc~sal r d 3rd
---~ e ~ c a 1 3 1 d
--- Mlddle 3rd ---lncisal 3rd
Figure 5. The conical shape of the deciduous dental crown compared with that of the permanent dental crown. Note that the deciduous crown is widest at the junction of the lower cervical third and the middle third, whereas the permanent crown is widest at the iunction of the middle third and the incisal or occlusal third.
well as ture nasal the primary skeletonexamining is primarily physician. cartilage, Theand immathe nasal bones are not fused, so that radiographs of the nose are usually not helpful in assisting with the diagnosis of nasal fracture, The cartilage tends to bend and displace rather than fracture, makes reduction more difficult because it does not "snap" into place as the nasal bones of adults usually do. separation of the perichondrium from the cartilage
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Table 1. Tooth Exfoliation/Eru~tionSchedule
can cause a septal hematoma, which if not recognized may result in a septal abscess. Either may cause necrosis due to pressure or infection of the underlying cartilage and ultimately a saddle nose deformity if not incised and drained in a timely manner. Surgical intervention is indicated when a nasal fracture is significantly displaced causing a cosmetic deformity or nasal airway obstruction. Closed reduction (often requiring general anesthesia) is the procedure of choice, using digital pressure or a blunt-ended elevator. However, conservative septorhinoplasty may be indicated when this technique is unsuccessful in attaining adequate reduction of the displaced skeletal elements. It is important to resect the least amount of septal cartilage necessary to avoid potential injury to nasal growth centers and subsequent iatrogenic deformity or airway obstruction. Care must be taken to leave the mucoperichondrial flaps intact and place 1-2 septal mattress sutures to prevent hematoma formation. Osteotomies using a 2 mm ostoeotome may be required when closed reduction is inadequate to restore normal alignment of the nasal dorsum.10 Cosmetic rhinoplasty, especially nasal tip surgery should be delayed until after puberty.
fractures, as well as Le Fort fractures, are uncommon in children less than 10 years of age because of the small size of the midface, the lack of pneumatization of the maxillary sinuses, and the high tooth-to-bone ratio of the maxilla. With increasing age and facial maturation, these fractures increase in frequency. Management is similar to that of adult patients, involving open reduction for treatment of displaced fractures and interosseous wiring for unstable fractures. CT scanning is useful in determining the location of fracture sites in the complex midfacial structures and the extent of displacement of the fracture fragments (Fig. 7). Precise anatomic reduction of nasoethmoid fractures is important to prevent subsequent problems with hypertelorism, traumatic telecanthus, or lacrimal dysfunction. Depressed orbital floor fractures should be treated within 5 to 7 days of injury because of the fast healing rate, to reduce the incidence of post-traumatic enophthalmos, and sooner if evidence of entrapment exists to avoid problems with persistent diplopia (Fig. 8). For severely comminuted fractures of the zygoma and orbital rim, the use of microplating techniques may be necessary; however, they are not routinely recommended in pediatric facial fractures and are contraindicated in fractures involving tooth-bearing bone.
FRACTURES OF THE UPPER FACIAL THIRD
MANDIBLE FRACTURES
Injuries to the upper facial third are more common in children younger than 6 years of age, due to the prominence of the upper face in this age group. Frequently fractures to the frontal skull, supraorbital rim, and orbital roof occur as isolated facial injuries in this young population, and decrease in frequency as the lower and midfacial skeleton develops and grows with maturity.5 Fortunately the frontal sinus is poorly pneumatized until the age of 6 years, so that fractures of the frontal bone and supraorbitalrim are usually of the greenstick variety and seldom require treatment. Children with displaced fractures need to be treated with open reduction using a bicoronal approach or an overlying soft tissue wound if present. In particular, children with inferiorly displaced fractures that involve the orbital roof are at risk for later development of an orbital encephalocoele and should be surgically reduced in the early post-traumatic period.11 Older children with fractures of a pneumatized frontal sinus are managed similar to adult patients.
Fractures of the mandible are rare in young children but tend to increase in frequency as the mandible grows to occupy a more prominent position in the facial architecture. Unilateral fractures of the mandibular body are reported to be the most common mandibular fractures in children less than 6 years old;l2 however, fractures involving the condyle have been reported to have a 66% incidence in children less than 10 years 01d.13 Nondisplaced fractures of the mandibular body can often be treated with observation and a soft diet, since the multiple crypts of the developing dentition tend to help hold the adjacent fragments into position, like pieces of a puzzle. Closed reduction and intermaxillary fixation may be necessary for displaced fractures, but, again, a shorter period of intermaxillary fixation is required, usually less than 3 weeks. Application of arch bars and utilization of interarch elastics is helpful in children, particularly in body-condyle combination fractures, because it allows for mobilization while maintaining the appropriate occlusal relationship. In patients with mixed dentition, use of an acrylic or occlusal-type splint may be necessary (Fig. 9). Displaced fractures proximal to the erupted dentition MIDFACIAL FRACTURES will require interosseous wiring to stabilize the fracFractures of the midfacial structures, including ture, using the most inferior edge of the mandible to zygomatic, nasoethmoid, orbital rim, and blowout avoid injury to the developing tooth buds. Ortho-
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FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Figure 7. A: Subtle findings on plain films of a 7-year-old child with a minimally displaced zygomaticmaxillary complex fracture, and a unilateral Le Fort I fracture with a split palate. B: CT scan showing the greenstick fracture through the zygoma. C : CT scan showing the displaced fracture through the maxillary alveolus.
Figure 8. A: Preoperative photograph of an 11-year-oldchild, who was observed for 2 months by the referring physician following blunt trauma to the left eye. Note the restriction of movement on upward gaze. B: Coronal CT scan of the orbit showing the entrapment of orbital fat.
dontic consultation is recommended for patients pediatric facial skeleton. Occlusion abnormalities, with displaced fractures through tooth-bearing bone. delayed or incomplete eruption of the permanent Fractures of the condyle in children can result in dentition, and ankylosis of the temporomandibular significant growth abnormalities or functional dis- joint are the most frequent complications of pediatric turbances. Minimally or nondisplaced unilateral facial fractures. Early diagnosis and management of fractures of the condyle that have no pain or devia- facial injuries will minimize the incidence and severtion on opening can be managed without immobiliza- ity of these sequelae. tion. Otherwise, a 7- to 10-dayperiod of immobilization is recommended. Bilateral condyle fractures should be managed with a 2-week period of interREFERENCES maxillary fixation to reestablish vertical ramus height and avoid open bite deformities. Close postopera1. Rowe NL: Fractures of the facial skeleton in children. J Oral tive follow-up is important in children with condylar Surg 26:505-515, 1968 fractures. Midline opening exercises and interarch 2. Morgan BD, Madan DK, Bergerot JPC: Fractures of the middle third of the face-a review of 300 cases. Br J Plast Surg training elastics are required in patients who de25:147-151, 1972 velop malocclusion or deviation on opening. Open 3. Panagopoulos AP: Management of fractures of the jaws in children. J Int Coll Surg 28:806-815, 1957 reduction of condylar fractures in children may result in functional or growth abnormalities of the 4. McCoy FJ, Chandler RA, Crow MI: Facial fractures in children. Plast Reconstr Surg 37:209-215, 1966 temporomandibular joint and is therefore reserved 5. McGraw BL, Cole RR: Pediatric maxillofacial trauma: Agerelated variations in injury. Arch Otolaryngol Head Neck for severely displaced fractures in which proper ocSurg 116:41-45, 1990 clusion cannot be attained with closed reduction 6. Maniglia AJ, Kline SN: Maxillofacial trauma in the pediatric techniques. age group. Otolaryngol Clin North Am 16:717-730, 1983
SUMMARY The goal of management of pediatric facial fractures is preservation of function and facial symmetry. A conservative approach is essential to avoid additional injury from iatrogenic trauma. Fortunately, complications arising from pediatric facial fractures are few, despite the potential for injury to multiple growth centers. Nonunion and malunion of pediatric facial fractures are uncommon due to the rapid healing rate and remodeling potential of the
7. Gussack GS, Luterman A, Rodgers K, et al: Pediatric maxillofacial trauma: Unique features in diagnosis and treatment. Laryngoscope 97:925-930, 1987 8. Morgan WC: Pediatric mandibular fractures. Oral Surg 40: 320-326, 1975 9. James D: Maxillofacial injuries in children. In Rowe NL, Williams JL (eds): Maxillofacial Injuries. Edinburgh: Churchill Livingstone; 1985, pp 538-558. 10. Stucker FJ, Bryarly RC, Shockley WW: Management of nasal trauma in children. Arch Otolaryngol 110:190-192, 1984 11. Messinger A, Radkowski MA, Greenwald MJ, Pensler JM: Orbital roof fractures in the pediatric population. Plast Reconstr Surg 84213-218, 1989 12. MacLennan WD: Fractures of the mandible in children under the age of six years. Br J Plast Surg 9:125-128, 1956 13. Lehman JA, Saddawi ND: Fractures of the mandible in children. J Trauma 16:773-777, 1976
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FACIAL FRACTURES IN CHILDREN-McGraw-Wall
atric facial skeleton and that of the adult may contribute to the lower incidence. Two of the most important anatomic factors in the reduced frequency of facial fractures in children are the larger craniofacial ratio in the pediatric facial skeleton and the lack of pneumatization of the paranasal sinuses. The pediatric cranium is proportionately much greater in size than the facial skeleton. The face is relatively underdeveloped, and the surface area of the face is comparatively small to that of the cranium. In the infant, the maxillary antra and zygoma are poorly developed and the mandible is small and unobtrusive. In contrast, the frontal cranium is quite prominent5 (Fig. 1). The cranium and forehead effectively shield the smaller lower and middle thirds of the face from injury. The relative lack of pneumatization of the paranasal sinuses in children less than 10years of age adds to the stability of the midface. With pneumatization of the paranasal sinuses and the growth and development of the permanent dentition, there is vertical and anterior growth of the maxilla and mandible. This facial growth results in a decrease in the craniofacial ratio from 8:l in infancy to 2.5:l in adulthood.6 Correlated to the maturational growth patterns of the pediatric facial skeleton, the frequency of facial fractures increases with increasing age during childhood. In particular, the proportionateIy increased growth of the middle and lower facial thirds that occurs with maxillofacial development places these entities in a more prominent position and allows them to become more susceptible to traumatic injury. In our recent study, supraorbitalrim and frontal skull fractures were found to be the most common facial fractures of childern aged 0 to 6 years old, whereas mandible fractures were found to be the
Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center Houston, Houston, Texas Reprint requests: Dr. McGraw-Wall, Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center Houston, 6431 Fannin, Suite 6132, Houston, TX 77030 Copyright 01991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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Becky L. McGraw-Wall, M.D.
FACIAL FRACTURES IN CHILDREN-McGraw-Wall
normal anatomic positions following injury. In addition, the cortex of the pediatric skeleton is very thin in comparison to that of the adult, with a greater proportion of spongy cancellous bone, so that the pediatric facial bones are more elastic and resilient to injury, For these reasons, a higher frequency of greenstick fracture injuries occur, without a disruption through both cortices and often without significant displacement of the fracture fragments. Children also have more prominent buccal fat pads that tend to cushion the impact of the offending trauma and lessen the force transmitted to the underlying bony architecture.6
ETIOLOGY O F PEDIATRIC FACIAL TRAUMA
The majority of pediatric maxillofacial trauma is secondary to motor vehicle accidents. Legislation requiring special car seat restraints for infants and toddlers and seat belts for children and adult pasmost common fractures in children older than 6 sengers should help reduce this incidence, dependyears5 (Fig. 2). Fractures involving the inferior orbit, ing on public compliance. Automobile-pedestrian zygoma, and maxilla were almost exclusively found accidents are another frequent etiology of facial in children older than 10 years. This tendency to- trauma, especially in toddlers and preschool age ward upper face fractures in younger children and children. In Houston, where there has been little lower face fractures in older children correlates with public sentiment supporting gun control laws, we have found accidental gunshot wounds to the face to patterns of facial maturation. be the next most frequent cause for pediatric maxilloThe presence of multiple developing tooth buds of facial trauma.5 Other important causes include falls, both the deciduous and permanent dentition within automobile-bicycle injuries, sports-related injuries, the maxilla and mandible increase the elasticity and altercations, equestrian-related accidents, and child stability of the pediatric facial skeleton. The multiple abuse. Physicians should always be attuned to the dental follicles within the mandible and maxilla help possibility of abuse, especially when the extent of to maintain the fractured bone fragments in their injury exceeds that which is expected by the history of the injury as reported by the parent. There is a reported male preponderance for facial fractures, which is less pronounced in children younger than 6 years, but increases with age into adulthood.5
INITIAL EVALUATION A N D MANAGEMENT Diagnosis of facial fractures is more challenging in pediatric patients. The thick buccal fat pads, along with the associated edema and ecchymosis following injury obscure palpation of the facial skeleton. The frequency of greenstick and minimally displaced fractures makes clinical evaluation even more challenging. In addition, the presence of mixed denMandible Frontal Orbit Le Fort tition and missing or partially erupted teeth make Fracture Site Figure 2. The incidence of pediatric mandible fractures evaluation of occlusal abnormalities more difficult. and Le Fort type injuries increased with increasing age, in The injured child is apprehensive and often uncomconjunction with the increasing prominence of the lower fortable or in pain, and as a result may not be cooperand middle facial thirds, whereas the incidence of frontal and orbital fractures decreased with increasingage.5 Group I ative with the examiningphysician. Sedation may be required to complete an evaluation of the extent of = 0-6 years; group 2 = 7-11 years; and group 3 = 12-16 years. injury. A common method of sedation involves ad-
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Figure 1. Comparison of the premature infant facial skeleton with that of the adult facial skeleton. Note the relative underdevelopment of the mid and lower face, and the prominence of the forehead and cranium of the neonatal skull.
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Figure 3. Zonarc of the mandible.
ning of the brain, or in patients with cervical fractures who cannot be repositioned for plain films of the face. CT scans are particularly useful in the diagnosis and evaluation of frontal skull and sinus fractures, and for fractures involving the orbit and midfacial fractures (Fig. 4).
ASSOCIATED INJURIES
Associated injuries occur more frequently in children with maxillofacial trauma, especially multiple associated injuries.7 Skull fractures and intracranial injuries are particularly more common in children. This may be related to the elasticity and stability of the pediatric facial skeleton. A greater amount of force is required to achieve a fracture of the pediatric facial skeleton and that force is readily transmitted to the adjacent cranium. In our recent study associated fractures occurred in 88% of children aged 0 to 16 years with facial fractures, and 61% had multiple associated injuries. These were predominantly head injuries and skull fractures, especially in children aged 0 to 6 years, correlating to the larger craniofacial ratio and frontal prominence of this younger age group.5 Neurosurgical consultation should always be considered when dealing with pediatric maxillofacial trauma. Orthopedic injuries also frequently occur in association with pediatric facial fractures. Concomitant cervical fractures have not been found to occur with greater frequency in the pediatric population.7.8 However, the possibility of cervical spine injuries should not be ignored in a child sustaining traumatic injuries severe enough to cause facial fractures.
SPECIAL CONSIDERATIONS
Management of pediatric facial fractures is generally similar to that of adults; however, there are several special considerations in the management of pediatric facial fractures. The periosteum of the pediatric patient has a greater osteogenic potential, and the metabolic rate is higher, so that fracture healing occurs at a faster rate. Fracture union routinely occurs within 3 weeks; therefore a shorter period of intermaxillaryfixation is required. Longer periods of fixation can result in secondary problems in children, in particular, ankylosis of the temporomandibular joint. Frequently 10 days to 2 weeks is an adequate period of time of intermaxillaryfixation for some mandible fractures. Because of this faster rate of union, the time frame for reduction of facial fractures in children is somewhat more limited. A delay in treatment may result in callous formation and healing of the unreduced fracture fragments, so that
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ministering a "pedi cocktail," a combination of narcotic and tranquilizing agents given intramuscularly: meperidine hydrochloride, 2 mglkg; chlorpromazine, 1 mglkg; and promethazine hydrochloride, 1mgkg. One must be certain to evaluate the patient fully for an associated head injury prior to administering any central nervous system depressant. In addition, the diagnosis and management of other more serious life-threatening injuries, such as airway problems, bleeding, shock, or cervical spine injuries, should take precedence. Airway insufficiency should be managed with placement of an endotracheal tube, instead of a tracheostomy whenever possible. Tracheostomies in children are frequently associated with complications and are best avoided unless absolutely necessary. A low-placed tracheostomy has the potential for problems related to the relatively superior position of the innominate vein in young children. As well, the incidence of tracheal stenosis, tracheomalacia, and decannulation accidents is much higher in children. Because of the difficulties in clinical diagnosis just delineated, radiographic evaluation plays an important role in pediatric facial trauma. However, the radiographic diagnosis of pediatric facial fractures is also more difficult. The underdevelopment and poor pneumatization of the paranasal sinuses result in less radiographic contrast for evaluating the facial skeleton using plain films of the face. Moreover, the presence of multiple tooth buds and mixed dentition can obscure visualization of the fracture line. The multiple positions necessary for adequate evaluation by plain films are time consuming and require a level of patient cooperation with which young patients may be unable to comply. Panoramic radiographs (Zonarcs) of the mandible and midface often help to better delineate these hidden fracture lines, as well as help to evaluate the status of the dentition involved in the fracture (Fig. 3). Computerized tomography (CT) scans of the facial bones are helpful in children, especially for those patients with associated head injuries requiring simultaneous CT scan-
Figure 4. A: CT scan of a 3-year-old child showing marked displacement of the posterior lateral orbital wall (arrowhead)in conjunction with a zygomatic fracture (small arrow).B: lntraoperative photograph of the same child showing extensive comminution of the zygorna, as well as soft tissue avulsion.
subsequent attempts at reduction to reestablish the proper occlusal relationships are inhibited. Ideally reduction should be carried out within 5 to 7 days of the injury for optimal results. A conservative treatment approach has been the standard of care for facial fractures in children in order to avoid injury to the multiple growth centers and developing dental follicles. The use of miniplates and screws is seldom indicated because of the greater likelihood of injury to the multiple developing tooth buds, and because of the concern for inhibition of bone growth. Intermaxillary fixation and judicious interosseous wiring when needed to stabilize further the fracture are the mainstays of surgical treatment for pediatric facial fractures. Care must be taken to place the interosseous wires low along the mandibular border to avoid injury to the developing dentition. Wires should not be placed in the tooth-bearing bone of the maxilla. Such infringement will cause loss of the affected teeth and may result in osteomyelitis of the mandible or maxilla. The pediatric facial skeleton can undergo a significant amount of remodeling following traumatic injury under the forces of mastication. Meticulous reduction of fracture fragments is usually unnecessary because of this remodeling potential. As well, mild occlusal irregularities resulting from fractures may
resolve with alveolar growth at the time of eruption of the permanent teeth.9 Fractures involving toothbearing bone may result in delayed or noneruption of the teeth adjacent to the fractures, and the parents should be advised of this at the time of injury. Facial fractures with minimal or no displacement in patients with satisfactory and repeatable occlusion can frequently be treated expectantly on a soft, mechanical diet without surgical intervention. Intermaxillary fixation can be challenging in children, particularly in the 9- to 12-year age group. The mixed dentition present in this age group makes application of standard interdental wiring for arch bars and intermaxillary fixation unstable and often results in less than satisfactory immobilization. This can be attributed to the exfoliation of the deciduous teeth with their dental roots in varying stages of absorption, missing teeth, the spreading of the interdental contact points, and the different stages of eruption of the permanent teeth present (Table 1). Moreover, the shape of the deciduous teeth is not as optimal for placing interdental wiring for securing arch bars or intermaxillary fixation. Whereas the crown of a permanent tooth is constricted at its lower cervical third, which allows for easier and more secure placement of interdental wires, the crown of a deciduous tooth is widest at its lower cervical third
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FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Tooth
Deciduous Exfoliation
Permanent Eruption
Central incisors Lateral incisors Cuspids Bicuspids First molars Second molars Third molars
6-8 years 7-8 years 9-1 2 years Not present 10-1 1 years 10-1 1 years Not present
6-8 years 7-9 years 9-12 years 10-1 2 years 6-7 years 11-1 3 years 17-21 years
and tapers toward its incisal or occlusal surface (Fig. 5). This makes stabilization of an arch bar or intermaxillary fixation somewhat tenuous when relying on interdental wiring alone. Nonetheless, it is possible to use interdental wiring for application of arch bars and intermaxillary fixation in children between the ages of 4 and 8 years by carefully placing the wires below the contact ponits of the deciduous canines and molars. In general, the use of interdental wiring alone in children between the ages of 9 and 12 may be unreliable. The addition of circum-mandibular wires can help secure the mandibular arch bar in position. As well, passing suspension wires from the maxillary arch bar through the piriform process and through the malar-maxillary buttress can help stabilize the maxillary arch bar and maintain the intermaxillary fixation in the proper occlusal relationship (Fig. 6). The zygomatic arches are thinner and not as strong as those of the adult and should not be used for suspension wires. When interdental wiring is not possible due to the mixed dentition, an acrylic dental splint can be fabriDeciduous Dentition
-Cervical 3rd -Middle 3rd lnc~sal3rd
Permanent Dentition
Figure 6. Stabilization of maxillary arch bar by wires passed from the arch bar through the piriform rims and the anterior nasal spine.
cated for immobilizationor intermaxillaryfixation. A plaster study model taken from an impression of the patient's teeth is broken along the fracture lines of the mandible and maxilla, so that the segments can be aligned into the appropriate occlusal relationships. The acrylic splint is then made using the plaster model, usually incorporating wire hooks or arch bar segments into the splint for use in intermaxillary fixation. The splint can be fixed to the jaws using circum-mandibular wiring and suspension wires from the piriforms and malar buttresses, as described before.
Middle 3rd lnclsal 3rd
NASAL FRACTURES
B---
Pediatric nasal fractures are often unrecognized and unreported by both the patient and parent, as
' -Ciiwral3rd
U h 4 - 3lnc~sal r d 3rd
---~ e ~ c a 1 3 1 d
--- Mlddle 3rd ---lncisal 3rd
Figure 5. The conical shape of the deciduous dental crown compared with that of the permanent dental crown. Note that the deciduous crown is widest at the junction of the lower cervical third and the middle third, whereas the permanent crown is widest at the iunction of the middle third and the incisal or occlusal third.
well as ture nasal the primary skeletonexamining is primarily physician. cartilage, Theand immathe nasal bones are not fused, so that radiographs of the nose are usually not helpful in assisting with the diagnosis of nasal fracture, The cartilage tends to bend and displace rather than fracture, makes reduction more difficult because it does not "snap" into place as the nasal bones of adults usually do. separation of the perichondrium from the cartilage
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Table 1. Tooth Exfoliation/Eru~tionSchedule
can cause a septal hematoma, which if not recognized may result in a septal abscess. Either may cause necrosis due to pressure or infection of the underlying cartilage and ultimately a saddle nose deformity if not incised and drained in a timely manner. Surgical intervention is indicated when a nasal fracture is significantly displaced causing a cosmetic deformity or nasal airway obstruction. Closed reduction (often requiring general anesthesia) is the procedure of choice, using digital pressure or a blunt-ended elevator. However, conservative septorhinoplasty may be indicated when this technique is unsuccessful in attaining adequate reduction of the displaced skeletal elements. It is important to resect the least amount of septal cartilage necessary to avoid potential injury to nasal growth centers and subsequent iatrogenic deformity or airway obstruction. Care must be taken to leave the mucoperichondrial flaps intact and place 1-2 septal mattress sutures to prevent hematoma formation. Osteotomies using a 2 mm ostoeotome may be required when closed reduction is inadequate to restore normal alignment of the nasal dorsum.10 Cosmetic rhinoplasty, especially nasal tip surgery should be delayed until after puberty.
fractures, as well as Le Fort fractures, are uncommon in children less than 10 years of age because of the small size of the midface, the lack of pneumatization of the maxillary sinuses, and the high tooth-to-bone ratio of the maxilla. With increasing age and facial maturation, these fractures increase in frequency. Management is similar to that of adult patients, involving open reduction for treatment of displaced fractures and interosseous wiring for unstable fractures. CT scanning is useful in determining the location of fracture sites in the complex midfacial structures and the extent of displacement of the fracture fragments (Fig. 7). Precise anatomic reduction of nasoethmoid fractures is important to prevent subsequent problems with hypertelorism, traumatic telecanthus, or lacrimal dysfunction. Depressed orbital floor fractures should be treated within 5 to 7 days of injury because of the fast healing rate, to reduce the incidence of post-traumatic enophthalmos, and sooner if evidence of entrapment exists to avoid problems with persistent diplopia (Fig. 8). For severely comminuted fractures of the zygoma and orbital rim, the use of microplating techniques may be necessary; however, they are not routinely recommended in pediatric facial fractures and are contraindicated in fractures involving tooth-bearing bone.
FRACTURES OF THE UPPER FACIAL THIRD
MANDIBLE FRACTURES
Injuries to the upper facial third are more common in children younger than 6 years of age, due to the prominence of the upper face in this age group. Frequently fractures to the frontal skull, supraorbital rim, and orbital roof occur as isolated facial injuries in this young population, and decrease in frequency as the lower and midfacial skeleton develops and grows with maturity.5 Fortunately the frontal sinus is poorly pneumatized until the age of 6 years, so that fractures of the frontal bone and supraorbitalrim are usually of the greenstick variety and seldom require treatment. Children with displaced fractures need to be treated with open reduction using a bicoronal approach or an overlying soft tissue wound if present. In particular, children with inferiorly displaced fractures that involve the orbital roof are at risk for later development of an orbital encephalocoele and should be surgically reduced in the early post-traumatic period.11 Older children with fractures of a pneumatized frontal sinus are managed similar to adult patients.
Fractures of the mandible are rare in young children but tend to increase in frequency as the mandible grows to occupy a more prominent position in the facial architecture. Unilateral fractures of the mandibular body are reported to be the most common mandibular fractures in children less than 6 years old;l2 however, fractures involving the condyle have been reported to have a 66% incidence in children less than 10 years 01d.13 Nondisplaced fractures of the mandibular body can often be treated with observation and a soft diet, since the multiple crypts of the developing dentition tend to help hold the adjacent fragments into position, like pieces of a puzzle. Closed reduction and intermaxillary fixation may be necessary for displaced fractures, but, again, a shorter period of intermaxillary fixation is required, usually less than 3 weeks. Application of arch bars and utilization of interarch elastics is helpful in children, particularly in body-condyle combination fractures, because it allows for mobilization while maintaining the appropriate occlusal relationship. In patients with mixed dentition, use of an acrylic or occlusal-type splint may be necessary (Fig. 9). Displaced fractures proximal to the erupted dentition MIDFACIAL FRACTURES will require interosseous wiring to stabilize the fracFractures of the midfacial structures, including ture, using the most inferior edge of the mandible to zygomatic, nasoethmoid, orbital rim, and blowout avoid injury to the developing tooth buds. Ortho-
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FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Figure 7. A: Subtle findings on plain films of a 7-year-old child with a minimally displaced zygomaticmaxillary complex fracture, and a unilateral Le Fort I fracture with a split palate. B: CT scan showing the greenstick fracture through the zygoma. C : CT scan showing the displaced fracture through the maxillary alveolus.
Figure 8. A: Preoperative photograph of an 11-year-oldchild, who was observed for 2 months by the referring physician following blunt trauma to the left eye. Note the restriction of movement on upward gaze. B: Coronal CT scan of the orbit showing the entrapment of orbital fat.
dontic consultation is recommended for patients pediatric facial skeleton. Occlusion abnormalities, with displaced fractures through tooth-bearing bone. delayed or incomplete eruption of the permanent Fractures of the condyle in children can result in dentition, and ankylosis of the temporomandibular significant growth abnormalities or functional dis- joint are the most frequent complications of pediatric turbances. Minimally or nondisplaced unilateral facial fractures. Early diagnosis and management of fractures of the condyle that have no pain or devia- facial injuries will minimize the incidence and severtion on opening can be managed without immobiliza- ity of these sequelae. tion. Otherwise, a 7- to 10-dayperiod of immobilization is recommended. Bilateral condyle fractures should be managed with a 2-week period of interREFERENCES maxillary fixation to reestablish vertical ramus height and avoid open bite deformities. Close postopera1. Rowe NL: Fractures of the facial skeleton in children. J Oral tive follow-up is important in children with condylar Surg 26:505-515, 1968 fractures. Midline opening exercises and interarch 2. Morgan BD, Madan DK, Bergerot JPC: Fractures of the middle third of the face-a review of 300 cases. Br J Plast Surg training elastics are required in patients who de25:147-151, 1972 velop malocclusion or deviation on opening. Open 3. Panagopoulos AP: Management of fractures of the jaws in children. J Int Coll Surg 28:806-815, 1957 reduction of condylar fractures in children may result in functional or growth abnormalities of the 4. McCoy FJ, Chandler RA, Crow MI: Facial fractures in children. Plast Reconstr Surg 37:209-215, 1966 temporomandibular joint and is therefore reserved 5. McGraw BL, Cole RR: Pediatric maxillofacial trauma: Agerelated variations in injury. Arch Otolaryngol Head Neck for severely displaced fractures in which proper ocSurg 116:41-45, 1990 clusion cannot be attained with closed reduction 6. Maniglia AJ, Kline SN: Maxillofacial trauma in the pediatric techniques. age group. Otolaryngol Clin North Am 16:717-730, 1983
SUMMARY The goal of management of pediatric facial fractures is preservation of function and facial symmetry. A conservative approach is essential to avoid additional injury from iatrogenic trauma. Fortunately, complications arising from pediatric facial fractures are few, despite the potential for injury to multiple growth centers. Nonunion and malunion of pediatric facial fractures are uncommon due to the rapid healing rate and remodeling potential of the
7. Gussack GS, Luterman A, Rodgers K, et al: Pediatric maxillofacial trauma: Unique features in diagnosis and treatment. Laryngoscope 97:925-930, 1987 8. Morgan WC: Pediatric mandibular fractures. Oral Surg 40: 320-326, 1975 9. James D: Maxillofacial injuries in children. In Rowe NL, Williams JL (eds): Maxillofacial Injuries. Edinburgh: Churchill Livingstone; 1985, pp 538-558. 10. Stucker FJ, Bryarly RC, Shockley WW: Management of nasal trauma in children. Arch Otolaryngol 110:190-192, 1984 11. Messinger A, Radkowski MA, Greenwald MJ, Pensler JM: Orbital roof fractures in the pediatric population. Plast Reconstr Surg 84213-218, 1989 12. MacLennan WD: Fractures of the mandible in children under the age of six years. Br J Plast Surg 9:125-128, 1956 13. Lehman JA, Saddawi ND: Fractures of the mandible in children. J Trauma 16:773-777, 1976
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