Pediatric Facial Fractures

  • Uncommon, <1% under 6 and 5% under 12
  • preponderance of mandibular fractures (86% vs 14% maxillary fractures; or 40% of all facial fractures), particularly of the condyle
  • Nasal fractures relatively common compared to midface fractures
  • High Le Fort fractures are very rare in the pediatric population - Blows severe enough to disrupt the cartilaginous suture lines frequently result in dural tears, extensive brain damage, and death.

Differences in Anatomy

  1. Smaller face in infants - in newborns the bony volume of the face withrespect to the cranium is 1:8, in adults it is 1:2
  2. cranial sutures in young children are not fused, and the growing bone is immature and pliable
  3. children between 6 and 12 years of age have mixed temporary and permanent dentition
  4. midface of children is foreshortened, with abbreviated midfacial buttresses and minuscule sinuses that progressively increase in size until the permanent teeth erupt

Differences in Physiology

  1. airways more difficult to maintain
  2. prone to gastric distention, vomiting, aspiration, and concurrent intracranial injurywith CNS damage.
  3. smaller blood volume

Differences in Presentation

  1. With lack of pneumatisation of frontal sinus fracture (thus lack of dispersion of impact), direct blow will lead to isolated orbital roof fracture
  2. Entrapment with orbital floor fractures is more common due to trapdoor effect

Differences in Approaches

  1. Use of permanent plates and screws not advised due to migration with bone growth
    Resorbable plates are increasingly being used and shown to be as rigid as titanium with multipoint fixation
  2. Some clinicians prefer to use wire, splints, andother nonrigid systems in the repair of facial fractures in children because of the risk of damage to the tooth buds.
  3. MMF is accomplished with a combination of acrylic splints and piriform aperture or circummandibular wires.

Guidelines

  • use CT scans routinely even when the injuries appear trivial
  • consider observation for minimally displaced fractures
  • be conservative and attempt the least invasive surgical procedure first
  • use microplates whenever possible, resorbable preferred
  • avoid alloplasts and use bone grafts sparingly
  • always respect dental alveoli
  • follow patients serially using photographs and cephalometric technique

Pediatric Mandibular Injuries

  • 20-50% of all childhood facial fractures
  • MVA, falls, altercations and sporting injury

Fracture pattern

  • In early childhood the mandible is weakened by numerous unerupted and developing permanent teeth, which limit the amount of bone and create regions susceptible to fracture
  • Pediatric fractures are more likely to incomplete and minimally displaced because ofthe relative lack of thick cortical bone and elasticity of the tissues, which allows the bones to bend rather than break.
  • Because of the presence of tooth buds and developing crypts, fractures are often long and irregular in character, with the fracture generally running inferiorly and anteriorly.
  • Condylar neck constitutes the weakest region of the entire mandible and is therefore the most susceptible to fracture.
  • Becauseof the well protected position of the condylar process, however, injuries are often the result of indirect forces, where the forces of impact are transmitted along the mandible from distant sites such as the angle, body or symphysis to the condylar neck.
  • incidence of condylar fractures is initially high and decreases with age.
  • Conversely, fractures of the body and angle are initially infrequent, but increase with age.
  • Intracapsular trauma or contusion injuries to the soft tissues of the temporomandibular joints are often found in situations where there are associated dental injuries with a clenched mouth – often associated with TMJ crush injury
  • Extracapsular fractures or fractures of the condylar neck and subcondylar regions often occur when the mouth is open at the time of injury so thatsome of the impacting force is transmitted along the mandible to its weakest link, that is, the condylar neck and subcondylar areas. Dental injuries are uncommon in these type of fractures.
  • In children <2, the articular surface is extremely vascular, and bleeds into the TMJ is relatively more common, potentially causing heamarthrosis. The short stocky nature of thecondylar neck makes it relatively resistant to fracture
  • After age 12, the capacity to remodel is significantly reduced although bone formation remains brisk

Differences

  • essential considerations are growth and dentition
  • given the high incidence of greenstick fractures and capacity for remodeling, many fractures are treated conservatively

Non surgical

  • Conservative management has many advantages, including a decreased immobilization time, decreased muscular atrophy, better oral hygiene, and a decreased risk of ankylosis.
  • Indications: condylar fractures and nondisplaced or greenstick fractures of the body and ramus in which normal occlusion is present following injury.
  • condylar fractures may have an increased risk ofgrowth disturbances, no particular surgical therapy has been demonstrated to be more or less efficacious in preventing these problems.
  • Treatment includes - soft diet, rigorous physiotherapy, avoidance of rigorous physical contact, and symptomatic pain control.

Closed Reduction

  • With respect to closed reduction, stabilization ismost frequently achieved with
  1. intermaxillary fixation with drop wires
  2. advantages: avoids dentition, low morbidity
  3. may be used for uni/bicondylar fractures
  4. requires presence of stable dentition
  5. Drop wires should never be placed around the zygomatic arch, as the wires will likely cut through the soft bone
  6. may not be efficacious in the treatment of fractures posterior to the dentition, such as fractures of the angle.
  1. occlusal splints with circummandibular wires

  1. arch bars or interdental wires
  2. frequentlyproblematic if age<11, as it is difficult to maintain wires around the bases of the deciduous dentition due to absence of a distinct cingulum and the fact that these teeth are prone to extrusion whenintermaxillary fixation
  3. arch bars can only safely be used inpatients older than 11 whose permanent dentitionhas been able to form adequate roots.

  • Adverse Long effects of conservative management
  1. malocclusion
  2. Asymmetry, growth disturbance
  3. condylar fractures in growing patients rarely lead to serious long-term mandibular growth disturbances
  4. Ankylosis (0.4%)
  5. Importance of early mobilization
  6. Never immobilize for >2 weeks
  7. TMJ dysfunction

Open reduction

  • Indicated for fractures low in the condylar neck with significant displacement or malocclusion, especially in children more than 9 years of age.
  • Advantages: decreased immobilization time, quicker resumption of a soft diet, and a quicker return to normal dental hygiene habits.
  • In patients less than 9 years of age, plates should be placed only on the mandible’s inferior border using monocortical screws. Drill holes always should be placed at the most inferior position and directed posteromedially, not superiorly.
  • Transosseous wiring and bicortical screws reserved for children >11 years old.