Clin Plastic Surg 31 (2004) 499 – 518
Pediatric craniofacial fractures: long-term consequences
Davinder J. Singh, MDa,b, Scott P. Bartlett, MDa,b,*
a
Division of Plastic Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, 10 Penn Tower,
Philadelphia, PA 19104, USA
b
The Children’s Hospital of Philadelphia, Wood Building, 1st Floor, 34th Street and Civic Center Blvd.,
Philadelphia, PA 19104, USA
Compared with adult facial fractures, fractures of
the pediatric craniofacial skeleton are uncommon.
However, they are frequently more difficult to manage because of the anatomical differences and
the evolving potential for growth and development
[1 – 6]. The overall treatment goal of structural restoration is similar in adults and children, but the
longevity of this restoration in children remains
largely unknown owing to a paucity of literature
documenting long-term follow-up, particularly in
upper and midfacial fractures [7 – 9]. The potential
growth disturbances and need for secondary surgery
associated with early condylar injury have been well
documented, but the growth and developmental problems resulting from upper and midfacial fractures are
elusive [10 – 16]. This article discusses the growth
and development of the pediatric craniofacial skeleton. It also reviews the literature on pediatric craniofacial fractures with particular emphasis on the effects
of craniofacial trauma on the evolving pediatric
craniofacial skeleton. The authors present their
long-term data from a retrospective review of pediatric craniofacial fractures treated operatively at the
Children’s Hospital of Philadelphia.
Epidemiology
The overall incidence of craniofacial trauma is
higher in children than in adults; however, the inci* Corresponding author. Division of Plastic Surgery,
University of Pennsylvania Health System, 3400 Spruce
Street, 10 Penn Tower, Philadelphia, PA 19104.
E-mail address: scott.bartlett@uphs.upenn.edu
(S.P. Bartlett).
dence of pediatric maxillofacial fractures is lower,
accounting for only 8% of all pediatric facial injuries
[17]. The lower incidence of pediatric maxillofacial
fractures is due to several factors, including a protected environment, a low ratio of facial mass to
cranium, and the greater elasticity of immature bone.
The incidence and distribution of facial fractures vary
with age. Retrospective reviews of maxillofacial
trauma involving both adults and children report that
approximately 1% of the fractures occur in patients
younger than 5 years of age, and that 1.5% to 23%
occur in those who are younger than 16 years of age
[1,2,4 – 6,18 – 20]. The wide range in incidence is due
to changes in diagnostic radiographic studies with the
advent of CT and to underreporting of two of the
more common pediatric facial fractures, nasal and
dentoalveolar, which are frequently treated nonsurgically and excluded from studies [2,4]. Pediatric facial
fractures are almost twice as common in boys as in
girls [6].
The incidence and distribution of fractures vary
considerably with age as the facial skeleton becomes
more prominent and increasingly mineralized. After
the age of 2 to 3, the facial bones lose much of their
elasticity [21]. With age, fractures shift from the
upper to the lower aspect of the face, with frontal
and orbital fractures having a higher incidence in the
0 to 5-year-old age group and midface and mandibular fractures having a higher incidence in the 6 to
16-year-old age group [17,22,23]. Looking at all age
groups, we see that nasal and mandibular fractures are
the most common, followed by orbital, midface, and
cranial vault in that order [5,17 – 19,22,23]. Kaban
[18], in his initial review, reported a 45% incidence of
nasal fractures and a 32% incidence of mandibular
fractures, whereas McCoy reported a higher inci-
0094-1298/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cps.2004.03.012
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D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
dence of mandibular fractures at 41% and a lower
of nasal at 23%. In a subsequent review, Kaban
reported five midface fractures (LeFort [LF] III level)
in a review of 184 fractures over 10 years [19,20].
McCoy et al [5] reported a 16.3% incidence for
orbital or malar complex fractures, a 5.8% incidence
for maxillary fractures, and a 4.7% incidence for
zygomatic fractures.
Causes of pediatric fractures include motor vehicle accidents (MVA), falls, and sports [6,24 – 27].
MVAs account for the more severe midface fractures,
with all-terrain vehicles (ATVs) and motorized
bikes becoming a more frequent source of injury
in the adolescent age group. Of all facial injuries
resulting from ATV accidents, 37% included facial
fractures [28]. Concomitant injury is high in pediatric patients with craniofacial fractures and
ranges between 10.4% to 88% [5,6,18,22,23,28,29].
These associated injuries include facial wounds, concussions, cerebrospinal fluid rhinorrhea, extremity
fractures, ocular injury, closed chest injury, and
abdominal injury.
sutures, and apposition-resorption. The face is affected
by growth spurts differing in direction, location, and
time. Facial dimensions at the age of 3 months are
equivalent to 40% of those of the adult, those at the
age of 2 years to 70%, and those at the age of 5 years
to 80%. The speed of growth decreases from 5 years
of age until the arrival of puberty. This period is
associated with an acceleration of growth of a hormonal origin and is followed by rapid retardation to
stop at the age of 17 years [31]. The two more
vulnerable periods during which injury or disturbance
may result in facial asymmetry are the transition
between deciduous and adult dentition, and puberty
with its spurt of mandibular growth [30].
While brain growth is the primary initiator of
cranial growth, the growth of the central face is
dependent on the ‘‘median-sagittal sector,’’ which is
comprised of the chondrocranial spheno-ethmoidonasal portion and the vomeropremaxillary and
pterygo-palatomaxillary portions (Fig. 1). The sphenoethmoidonasal portion terminates in the nasal septum
and the lateral cartilaginous expansions and plays no
role in the shape or position of the premaxilla. The
vomeropremaxillary portion propels the premaxilla
Growth and development
To understand pediatric fracture patterns, means
of management, and potential long-term sequelae of
craniofacial fractures, one must study the growth and
development of the craniofacial skeleton. The craniofacial skeleton grows differentially according to location, with different regions reaching adult
dimensions at different times. A discrepancy between
the growth of the cranium and the face creates a ratio
of 8:1 at birth, which becomes 4:1 at around 5 years
and 2:1 in the adult. At birth, the neurocranium has
achieved only 25% of its growth potential, and it
continues to expand rapidly to complete 75% by
2 years. By 10 years, the neurocranial growth is
95% complete, whereas the facial growth is only
65% complete [22,30,31].
Cranial growth is an example of continuous development in short periods of time and is activated in
large part by the brain and partially by means of the
sutures. The brain doubles its volume in the first
6 months and triples it at the end of the first year, thus
acting as a ‘‘functional matrix’’ in determining the
extent of cranial bone growth. Postnatal bone growth
results in narrowing of the sutures and closure of the
fontanelles. Growth continues rapidly until the age
of 3, waning thereafter into adulthood [30].
The face demonstrates discontinuous growth until
the completion of adolescence. It is multifactorial,
with successive mechanisms such as synchondroses,
Pt
mes
P
CH
Fig. 1. Median sagittal sector. (Modified from Stricker M,
Raphael B, Van der Meulen J, Mazzola R. Craniofacial
development and growth. In: Sticker M, Van der Meulen
R, Raphael B, Mazzola R, editors. Craniofacial malformations. New York: Churchill Livingstone; 1990. p. 82;
with permission.)
D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
forward. The pterygo-palatomaxillary portion controls the position of the middle face by supporting
the palatine bone, which serves as a transition with
the maxillary bone [30].
Upper facial growth is secondary to cerebral and
ocular growth, which primarily expands the orbit.
Orbital growth is complete by age 6 to 8 years.
Frontal sinus aeration becomes evident at age 4 to
5 years and finishes after puberty. Midfacial growth
varies according to stages of dental development.
Transverse maxillary growth is near completion by
age 2 years. The palatal and midline maxillary sutural growth are usually finished between ages
8 and 12 years. The pneumatization of the maxillary
antra correlates with dental eruption. The maxillary
sinuses approach the nasal floor by approximately
12 years of age, when most of the permanent teeth
have erupted, but do not reach full size until after
puberty [30,31].
The lower facial growth occurs in different stages
as well. The mandibular symphysis undergoes complete fusion by age 2 years, at which point the
deciduous teeth are erupting. The condyle contributes
primarily to vertical growth, which is activated by
muscular activity. Most of the mandible’s surfaces
undergo bone remodeling, which typically occurs
with puberty and takes place via apposition and
resorption [7,12,22].
Mechanisms of growth involve both the cartilage
and the periosteum. The cartilage constitutes a primary active area of growth because it is stimulated
by intrinsic dynamic forces. The condylar cartilage is
Table 1
Distribution of operatively treated pediatric craniofacial
fractures at the Children’s Hospital of Philadelphia from
1986 to 2002
Nasal
Dentoalveolar
Condyle
Condyle and mandible
Mandible
Maxilla
Orbitozygomatic
Isolated orbital
Frontal bone/Sinus
Frontal/SOR/Roof
Frontal/SOR/Roof/NOE
Frontal/SOR/Roof/NOE/Sinus
NOE
NOE and maxillary
Panfacial
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Fig. 2. Age distribution of facial fractures treated at the
Children’s Hospital of Philadelphia.
an exception to this in that it is a site of secondary
passive growth dependent on forces acting on it,
specifically the pterygoid muscles. The periosteal
system is also an area of passive secondary growth
and is composed of three structures: the sutures,
intermediary periosteum, and expanding joints. The
periosteum is influenced by muscular insertions,
which are responsible for apposition and resorption
according to Enlow’s theory [30,31] of 1968.
Synchondroses are areas of growth cartilage that
separate the zones of ossification in the cartilage of
the base and are vulnerable to insults and trauma
[32,33]. Controversy exists as to how much the
cartilaginous septum contributes to growth [8,9,12,
33,34]. Moss et al [33] believed that this cartilaginous
component has no intrinsic growth and only acts
passively by transmission of pressure. Powell et al
33
4
4
2
25
0
19
8
3
8
2
7
7
1
5
Abbreviations: NOE, naso-orbito-ethmoidal; SOR, superior
orbital rim.
Fig. 3. Six-year-old girl with bilateral condylar fractures.
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Fig. 4. (A,B) Postoperative occlusion in Class I relations.
[35] reviewed their pediatric patients (average age
13.8 years) who underwent maxillary removal and
reinsertion for anterior cranial base tumors and found
no major complications with regard to growth during
a mean 14-month follow-up. However, other authors
[36] have demonstrated intrinsic growth disturbances
by division of the upper portion of the cartilaginous
septum. In animal studies, surgical manipulation of
the septal cartilage and vomer resulted in significant
growth disturbances [37 – 39].
In addition to its intrinsic growth capacity, the
facial skeleton is responsive to growth activators.
Cellular proliferation, cerebral expansion, and function are the key activators of craniofacial growth [30].
The facial skeleton has cavities that expand and
contribute to growth. The growth of the pneumatic
cavities as well as the orbits and buccal cavity all
result in facial expansion in three dimensions. The
deposition of bone on one site and resorption on the
opposite site—as demonstrated by Enlow, particularly
in the maxilla and mandible—is the primary growth
mechanism [12,22,31,40].
An understanding of the growth centers and
development of the craniofacial skeleton enables
one to comprehend the pediatric facial fracture patterns and the challenges of their management, as well
as their long-term sequelae.
Pediatric facial fracture patterns
Fractures shift from the upper to the lower
aspect of the face with increasing age, primarily
because of the later growth and development of the
Fig. 5. (A,B) At 4 months post-injury, mild Class II occlusion and good jaw opening.
D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
maxilla and mandible and the decreasing elasticity of
the bone. The decreasing elasticity results from
increasing mineralization, which occurs exponentially
after the age of 2 to 3 years. Children often sustain
incomplete ‘‘greenstick’’ fractures, or less comminuted
fractures than adults when receiving equivalent traumatic force [21,41,42]. In contrast to adults, the
LeFort facial fracture patterns are rare in the pediatric
population before significant development of maxillary sinuses. If they do occur, they are typically in
combination with other fractures and are often unilateral [21,42].
In 1990, Moore and David [42] described the
typical oblique fracture patterns seen in high velocity
accidents in children. The fracture runs obliquely
across the frontal bone with radiation into the cranial
base and extension across the orbit and maxilla.
503
There is infrequent extension to the mandible. The
reason for the fracture’s oblique nature in the pediatric population is the lack of the structural pillars or
buttresses that determine adult fracture patterns.
These facial buttresses are not fully developed because of mixed dentition with unerupted teeth, less
paranasal sinus pneumatization, and a higher ratio of
cancellous bone.
Management
Concerning management, there is still controversy
on the issue of the closed versus the open approach
and the long-term sequelae of potential disturbance
of growth with the latter [3,29]. Contradictory evidence exists regarding subperiosteal undermining and
Fig. 6. (A – C) At 1.5 years post-injury, minimal mandibular hypoplasia and development of Class II malocclusion.
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D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
growth restriction, with some authors having demonstrated growth retardation following wide dissection
and devascularization in the growing skeleton [43].
Conversely, broad undermining of the fronto-orbital
region, as in the treatment of unicoronal synostosis, is
not observed to place any significant restriction on
growth [44].
Because the growing child has the capacity for
remodeling of the bone post-injury, particularly of the
condyle and mandible, a more conservative approach
is frequently taken, in contrast to the concept of
accurate anatomic reduction in adults [11,16]. In
general, if a reasonable anatomic position can be
obtained by means of the closed approach or a limited
exposure, it is preferred. Any consequent minor
occlusal disturbances are acceptable and can be
treated with orthodontics at a later age. When deciding upon an open versus closed approach and a
method of fixation in pediatric craniofacial fractures,
one must consider the severity of the fracture and the
age at the time of injury [21].
Pediatric craniofacial fractures pose many challenges, ranging from timing to technique to the
potential growth sequelae. Because of the rapid bone
healing in pediatric patients, fractures should ideally
be treated within 3 to 4 days, in contrast to the
Fig. 7. At 3 years post-injury, progression of mandibular hypoplasia (A,B), with CT scan demonstrating flattening of both
condylar heads and glenoid fossae (C,D).
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505
Fig. 8. A 6-year-old girl who sustained frontal bone, cranial base, and naso-orbitoethmoidal fractures (A,B), as demonstrated on
her CT scans (C,D). (E) Intraoperative photograph showing degree of centrofacial injury. (From Bentz ML. Pediatric plastic
surgery. Stamford (CT): McGraw Hill; 1997. p. 483; with permission.)
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2-week window in adults. The high incidence of
concomitant injury occasionally delays treatment
and results in significant difficulty in reducing fractures [21].
The various stages of mixed dentition pose limitations on methods of fixation and raise concern
about damage to permanent teeth. Greenstick or
minimally displaced fractures can be treated conservatively with closed reduction and no fixation. If
fixation is needed, wires and microplates should be
used [15,22]. Microplates provide stable but not
rigid fixation and avoid the potential growth restric-
tion. Studies involving this potential remain controversial, with some demonstrating growth disturbances
secondary to the rigid fixation [38,45 – 47]. Another
concern is the migration or translocation of these
plates as the pediatric skeleton expands via apposition and resorption [48]. Rigid fixation serves a clear
purpose in the severe, complex pediatric craniofacial
fractures, but consideration should be given to interval removal, depending on the age of the child
and the location and size of the plates [3]. In recent years, the use of the resorbable plating systems
in the growing craniofacial skeleton has become
Fig. 9. (A – C) Postoperative CT and photos showing good restoration of frontal bone and upper facial contour. (B,C From Bentz
ML. Pediatric plastic surgery. Stamford (CT): McGraw Hill; 1997. p. 483; with permission.)
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507
Autogenous bone grafts are more predictable, but
should be used judiciously in the growing craniofacial skeleton. Onlay grafts with rigid fixation for
contour may result in a secondary growth disturbance; however, if they are placed in a precise soft
tissue pocket, such as the nasal dorsum, and with
minimal fixation, they serve to restore contour in the
severely fractured midface [3].
In deciding upon surgical technique and in advising the patient and family, thought must be given to
the long-term effects of the trauma and treatment on
the growth and development of the pediatric craniofacial skeleton.
Long-term consequences
Fig. 10. Nine-month follow-up illustrating good upper and
midfacial projection on lateral profile.
more popular, with the goal of preventing growth
restriction and obviating the need for removal of
titanium hardware secondary to palpability or infection [49 – 51].
Another question in management concerns the
use of bone grafts and alloplastic materials, both of
which are used frequently in the adult population. In
the pediatric patient, the long-term results of alloplastic materials for reconstruction are unpredictable.
Despite timely and appropriate treatment of pediatric fractures, growth and developmental disturbances may result because of damage to active
growth centers. There have been case reports of late
craniofacial deformities secondary to trauma during
the growth years and numerous studies documenting
the sequelae of mandibular trauma [10 – 16]. However, there has been no longitudinal study of patients
treated in infancy and childhood and followed into
adolescence by the same surgeon.
Growth disturbances have been associated with
nasal trauma by means of premature ossification of
the septovomerine suture [52]. The role of the septum
in facial growth has been documented by several
Fig. 11. (A,B) Two years post-injury, the patient has developed a mild saddle nose deformity and frontal bone irregularity.
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Fig. 12. (A,B) Three years post-injury, photographs demonstrate the progression of her growth disturbance.
authors [8,53 – 55]. Zygomatic fractures are said to
pose little concern for growth disturbance [18,19,
23,29]. Fronto-orbital injury occurs with a frequency
of 3% to 35% in the pediatric population. It is
more common in the younger age group, where the
cranium and upper face are more prominent in
comparison with the mid- and lower face. Before
age 7 years, because of the presence of only rudimentary sinuses, internal orbital injury occurs almost
exclusively at the orbital roof with linear extension to
the frontal bone. After age 7, internal orbital injury of
the roof, floor, and medial and lateral walls occurs
along with frontal sinus fractures. At this point, the
growth is complete and concern for growth disturbance is minimal [6,29,41,42].
Naso-orbital-ethmoidal injuries are relatively infrequent, but are the most technically challenging to
treat in children [56,57]. Anatomic reduction and
Fig. 13. (A,B) Five years post-injury, photographs illustrate the severity of the saddle nose deformity and the marked irregularity
of the central frontal bone. The patient underwent secondary frontal bone contouring and augmentation rhinoplasty with cranial
bone graft.
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509
Fig. 14. Seven-year-old boy who sustained a LeFort II and mandibular fractures (A), as seen on his CT scans (B,C).
fixation are mandatory in an attempt to prevent
growth disturbances. Growth in this area is dictated
by development, and sutural growth at the frontoethmoidal, frontolacrimal, frontomaxillary, ethmoidomaxillary, nasomaxillary, and septovomerine sutures
is dictated by expansion of the cranium to compensate
for the brain. Premature ossification or obliteration of
these sutures may result in midfacial hypoplasia in
the vertical and anterior – posterior direction [6,22].
The maxilla is the least frequently injured pediatric facial bone [58 – 62]. Anatomic reduction is necessary to ensure proper growth and development,
with attention directed to the nasofrontal and fronto-
maxillary sutures and the septum. The septovomerine
suture has been associated with midfacial growth
disturbances after trauma [9,63].
Osterhout et al [63] published case reports of three
adolescent patients who needed LeFort III midface
advancement. They had a history of midface trauma
in childhood but had not been treated at that time by
the authors. Osterhout hypothesized that the growth
disturbance was secondary to ossification of sutures
and damage to cartilaginous growth sites.
In 1995, Iizuka et al [23] reviewed 54 pediatric
patients with 70 midface fractures and a mean age of
10.3 years. They reported 5% secondary surgery for
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Fig. 15. (A,B) Three months postoperatively, after reduction of fractures into Class I occlusion, the patient exhibits good
midface projection.
Fig. 16. (A – D) At 1.5 years post-injury, the patient has developed midface hypoplasia and a Class III malocclusion.
D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
511
Fig. 17. At 2.5 years post-injury, the patient has progression of the growth disturbance (A), as shown in flattening of his midface
on profile (B), and in his occlusal relations (C,D).
insufficient reduction and no issues with growth
disturbance, but conducted only a 14.2-month average follow-up.
Because of this lack of long-term follow-up of
patients by the primary surgeon, little is known about
the outcomes of pediatric facial trauma and intervention. The authors performed a retrospective review of
all patients who underwent surgical treatment for
craniofacial fractures at the Children’s Hospital of
Philadelphia between 1986 and 2003. Charts were
reviewed for causes, distribution of fractures, age at
time of injury, operative management, and outcome.
The investigation revealed 125 patients treated operatively. The mean age at time of injury was 10.9 years,
with a range from 8 months to 17 years. The mean
follow-up was 5 years, with a range from 5 months to
12 years. The most common fractures were nasal and
mandibular, followed by upper facial fractures and
then the combined oblique craniofacial fractures. The
distribution of fractures can be seen in Table 1, and
the distribution of patients into different age groups
can be seen in Fig. 2. The incidence of fractures
rose sharply from ages 3 to 6 years and reached a
peak in adolescence.
In assessing long-term effects, the nasal and
dentoalveolar fractures were excluded because of lack
of adequate follow-up. Of the remaining 88 craniofacial fractures, most were mandibular fractures,
which were underreported because many were treated
conservatively with soft diet and observation. In
reviewing these patients for growth and developmental anomalies, the authors found that 10 patients
(11.4%) were identified as having undergone or
requiring secondary surgery. Two of the ten patients
had condylar injury in childhood, one unilateral and
the other bilateral. Eight patients required secondary
surgery following significant midface trauma with
resultant growth and developmental disturbances.
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Fig. 18. At 4 years post-injury, the patient has gone from a convexity of his mid- and lower face to a concavity secondary to
disruption of normal midfacial growth (A,B). Flattening of the midface can be appreciated on submental view (C). Worsening of
his Class III malocclusion is seen (D).
Fig. 19. An 8-year-old girl presented with rhinorrhea secondary to the frontal bone, cranial base, and naso-orbitoethmoidal region
fractures (A) as seen in her CT (B). (From Bentz ML. Pediatric plastic surgery. Stamford (CT): McGraw Hill; 1997. p. 477 – 8;
with permission.)
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513
Fig. 20. (A,B) One year post-ORIF and bilateral cranialization of frontal sinuses, she had no symptoms and had good
facial symmetry.
A total of 20 patients were identified as having
been treated for midface fractures, either in isolation
or in combination with upper and lower face fractures. A fracture common to all these patients was the
naso-orbitoethmoid fracture. Eight of twenty patients
(40%) required or will require secondary surgery.
Mean age at time of injury for these eight patients
was 9.3 years, compared with 10.8 years for the
12 patients who sustained midface trauma but no
growth disturbance. One patient had a developmental
anomaly, a frontal mucocele, after repair of a nasoorbitoethmoidal and frontal sinus fracture with open
reduction and internal fixation (ORIF) and bilateral
frontal sinus cranialization at age 8 years. Six patients
required cranial bone graft to the nasal dorsum and
canthal repositioning, despite immediate cranial bone
graft to the nasal dorsum and anatomic reduction of
the naso-orbito-ethmoidal (NOE) fractures and canthi
at the time of primary surgery. One of these six also
required frontal bone contouring. One patient is
being followed until growth is complete and has
demonstrated a progressive midface hypoplasia with
Class III malocclusion, despite having undergone
ORIF with Class I occlusion postoperatively.
Case reports
Below are case reports illustrating the severity of
the primary injury, the treatment, and the long-term
follow-up, as well as documenting growth and developmental disturbances.
Case 1 (Figs. 3 – 7)
T.G., aged 6 years, presented with bilateral condylar fractures, a neck fracture on the right, and an
intracapsular fracture on the left after a fall. She
underwent closed reduction and a brief period of
maxillo-mandibular fixation (MMF). Her 1- and
4-month follow-up occlusal photos illustrate Class I
occlusion and good jaw opening. Her 1.5-year follow-up shows very minimal mandibular hypoplasia,
which is more evident on her 3-year follow-up at age 9.
Her CT scan at this time demonstrated flattening of
both glenoid fossae and greater flattening of the right
condylar head. She is currently being followed on a
yearly basis for mandibular growth.
Case 2 (Figs. 8 – 13)
A.R. sustained severe centrofacial trauma at the
age of 6 years when she was riding an ATV and was
struck in the face by a piece of farm machinery. She
suffered fractures of the frontal bone, cranial base,
and naso-orbitoethmoidal region. Axial CT scans
demonstrate the degree of bony displacement. Intraoperative photographs illustrate the injury. She
underwent acute cranial bone graft to the orbital roof,
right orbital floor, and nasal dorsum, in addition to
bilateral medial canthopexies and a galeal frontalis
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Fig. 21. Six years post-injury, she presented with complaint of headaches and orbital asymmetry (A,B). CT scans demonstrated a
frontal sinus mucocele on the right (C,D).
flap to the cranial base. Her 1- and 9-month follow-up
photos show good facial proportions and projection
on lateral profile. In her 2- and 3-year follow-up
photos, the development and progression of a
saddle deformity of the nasal dorsum are seen,
along with a contour irregularity of frontal bone.
On her 5-year follow-up, there is lack of growth
and projection of the nose and more grooving of
the frontal bone. She underwent secondary contouring with bone substitute and rhinoplasty with cranial
bone grafting to the nasal dorsum.
Case 3 (Figs. 14 – 18)
K.M. was involved in an MVA at the age of
7 years and sustained an LFII fracture and mandibular
body and parasymphaseal fractures. He underwent
ORIF of the LFII fracture with cranial bone graft to
the orbital floors and IMF via suspension wires
for treatment of his mandibular fractures and was
restored to a Class I occlusion. His 3-month postoperative photographs show stability of the reduction with good mid- and lower facial projection. His
1.5-year follow-up revealed lack of maxillary growth
and a Class III malocclusion. His 2.5- and 4-year
follow-ups showed a progressive maxillary hypoplasia with flattening of the malar region and a Class III
malocclusion, with an approximately 10-mm negative overjet. He awaits completion of facial growth
and will need either a LeFort I or III to correct his
midface deficiency.
Case 4 (Figs. 19 – 23)
D.D., aged 8 years, sustained a frontal sinus and
naso-orbitoethmoidal fracture and presented with
D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
515
Fig. 22. (A – C) She underwent direct excision, obliteration, and reconstruction of the orbital roof with cranial bone grafts.
significant rhinorrhea. She underwent a transcranial
open reduction and internal fixation with bilateral
frontal sinus cranialization. She also had bone graft
reconstruction of her cranial base and nasal dorsum.
Her 1-year postoperative photographs show good
facial symmetry and nasal projection. Six years postinjury, she presented with orbital asymmetry and
complaint of headaches. Her photographs illustrate
the decreased height of her right palpebral fissure
and prominence of her right supraorbital bar. CT
Fig. 23. (A,B) One year post-secondary surgery, she had no complaints and good orbital symmetry.
516
D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
scans revealed a right frontal sinus mucocele, and she
underwent obliteration of the right frontal sinus and
reconstruction of the orbital roof with cranial bone
grafts. Her 3-month and 1-year follow-up photographs
show restoration and maintenance of orbital symmetry
and no further problems with mucocele formation.
Discussion
Based on the information at hand, it seems that
operatively treated facial fractures in children have a
favorable outcome for growth and development in
most patients. In particular, isolated injuries to the
orbit, zygoma, forehead, and mandibular corpus,
exclusive of the condyle, are associated with normal
subsequent growth and development. Two contrasting groups remain in which growth outcomes may be
less than optimal: those with a direct injury, often
limited to the condyle, and those with complex
centrofacial injury. Despite the differences in the
complexity and severity of the injury causing the
subsequent growth disturbance in these two regions,
this altered growth pattern is most likely related to
disruption of a growth center in both cases.
The condylar cartilage is the only clinical example
of secondary cartilage that contains very young
prechondroblasts. These cells have not undergone
differentiation and are extremely sensitive to mechanical pressures; hence the growth at this site is dependent primarily on the cartilages’ activators or muscles
[30]. The condyle, a relatively small part of the facial
mass, is intricately attached to adjacent muscle, most
notably the medial and lateral pterygoids. The thin,
localized functional matrix of the condyle, if not
righted by closed or open reduction, may disallow
normal growth and redirect it according to displaced
forces, potentially altering mandibular growth.
Similarly situated but in a much larger functional
matrix is the central face. Contributors to the matrix
include the brain above, the orbits adjacent, and the
aerated sinuses of the maxilla. Tessier dubbed the intersection of these multiple functional structures the
‘‘crossroads of the face.’’ The septum may have a
specific growth focus that is disrupted by severe
trauma, but in order for more significant growth
disturbance to occur, as in the patient in Case Report
3, more members of this functional matrix need to be
injured or altered. Anatomic repair may go only so far
in rectifying this disjunction, explaining the enigma
of why some injuries heal and allow growth without
incident, while in others an altered state persists.
To a degree, secondary growth disruptions are
related to the force of injury, but, as we have seen
in the examples above, the disruption of the functional matrix may occur irrespective of the force.
Also relevant may be the timing of the injury. It is
likely that each growth center or functional matrix
complex goes through a more vulnerable period in its
growth wherein an injury will cause more secondary
sequelae than it would if it occurred at a different
point in time. Investigation focused on the effects of
treatment, such as subperiosteal undermining, rigid
fixation, and bone grafting, is needed to clarify the
role of each of these on growth and development.
Although we have focused primarily on facial
bone growth following injury and repair, mention
should also be made of other structures—for instance,
in Case Report 4, a frontal sinus mucocele that
developed 6 years after complete cranialization of
the sinus. Despite appropriate primary management
of frontal sinus fractures, a late frontal sinus mucocele may develop [64,65]. This example implies,
though it does not prove, the notion that ‘‘development of the sinus must go on’’ despite the anatomic
limitation imposed by cranialization. Biological determinism, the programming of specific growth processes adapted to survival, seems to have a role here.
Another example is that of injured tooth buds that
despite damage from injury and treatment continue to
erupt, often in disadvantaged positions. Yet another is
the injured nasal septal cartilage and its supporting
upper and lower lateral cartilages, which may develop
curvature over time after injury in childhood, a
process most of us have heard about from our patients
and witnessed as well.
It is difficult to predict with precision which
pediatric patients will have secondary growth and
developmental disturbances after craniofacial fractures. Many factors play a role in determining this,
and more research in the field of developmental
biology is needed to answer questions about the
effects of trauma, both incidental and surgical, on
the functional matrix of the craniofacial skeleton.
Summary
The majority of pediatric facial fractures are
associated with favorable long-term outcome, with
only 11.4% requiring secondary surgery. The vast
majority of the patients requiring secondary surgery
sustained severe centrofacial bony and cartilaginous
injury, which may be associated with secondary
growth and developmental disturbances. It is crucial
that pediatric patients be informed of the potential for
growth and developmental disturbances at the time of
D.J. Singh, S.P. Bartlett / Clin Plastic Surg 31 (2004) 499–518
the primary injury and that they be followed on a
yearly basis until growth is complete.
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