Geoffrey 3 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery-Craniofacial, Head and Neck Surgery-Pediatric Plastic Surgery. 3-Elsevier (2018)

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SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
as a reference is that it allows the clinician to determine if one
or both jaws contribute to a noted deformity. For example,
a patient’s class III malocclusion (underbite) could develop
from several different etiologies: a retrognathic maxilla and
a normal mandible as is common in cleft patients, a normal
maxilla and a prognathic mandible, a retrognathic mandible
and a more severely retrognathic maxilla, or a prognathic
maxilla and a more severely prognathic mandible. All of these
conditions yield a class III malocclusion, yet each requires a
different treatment approach. The surgeon can delineate the
true etiology of the deformity by the fact that the maxilla and
mandible can be independently related to a stable reference,
the cranial base. Next, cephalometric tracings are performed.
Cephalometric tracings give the surgeon an idea of how
skeletal movements will affect one another as well as the
soft-tissue profile. They also allow the surgeon to determine
the distances the bones will be moved to achieve the goals of
a specific procedure. Different tracing methods using acetate
paper are used for isolated maxillary, isolated mandibular, or
two-jaw surgeries. Much of the traditional hand cephalomet-
ric tracing, however, has given way to computer-aided cepha-
lometric analysis, which allows the surgeon to position the
maxilla and mandible electronically on the cephalogram
while recording the soft-tissue changes and measuring the
degree of repositioning.
Complete dental records, including mounted dental casts,
are needed to execute preoperative model surgery and fabri-
cate surgical splints. Casts allow the surgeon to evaluate the
The term “dental compensation” is used to describe the ten-
dency of teeth to tilt in a direction that minimizes dental
malocclusion. For example, in a patient with an overbite
(Angle class II malocclusion), lingual retroclination of the
upper incisors and labial proclination of the lower incisors
minimize the malocclusion. The opposite occurs in a patient
who has dental compensation for an underbite (Angle class
III malocclusion). Thus, dental compensation, which is often
the result of orthodontic treatment, will mask the true degree
of skeletal discrepancy. Precise analysis of the dental compen-
sation is done on the lateral cephalometric radiographs.
If the patient desires surgical correction of the deformity,
presurgical orthodontics will upright and decompensate the
occlusion, thereby reversing the compensation that has
occurred. This has the effect of exaggerating the malocclusion,
but it also allows the surgeon to maximize skeletal move-
ments. If the patient is ambivalent or not interested in surgery,
mild cases of malocclusion may potentially be treated by
further dental compensation, which may camouflage the
deformity and restore proper overjet and overbite. The impor-
tance of a commitment to surgery prior to orthodontics lies in
the fact that dental movements for decompensation and
compensation are in opposite directions, so this decision
needs to be made prior to orthodontic therapy.5
Patient selection
Identifying the proper patient for orthognathic surgery is a
key step to ensuring satisfaction and successful outcomes.
This includes amassing considerable data beyond a simple
history and physical exam and should be coordinated with
other members of the cleft/craniofacial team.
Cephalometric and dental evaluation
A cephalometric analysis and comparison to normative values
can help the surgeon plan the degree of skeletal movement
needed to achieve both an optimal occlusion and an optimal
aesthetic result. A lateral cephalometric radiograph is per-
formed under reproducible conditions so that serial images
can be compared. This film is usually taken at the orthodon-
tist’s office using a cephalostat, an apparatus specifically
designed for this purpose, and a head frame to maintain
consistent head position. It is important to be certain the
surgeon and orthodontist can visualize both the bony and
soft-tissue features in order to facilitate tracing every land-
mark. Once the normal structures are traced, several planes
and angles are determined (Fig. 28.2).
The sella–nasion–subspinale (SNA) and sella–nasion–
supramentale (SNB) are the two most important angles in
determining the positions of the maxilla and mandible rela-
tive to each other as well as the cranial base. These angles are
determined by drawing lines from sella to nasion to “A point”
or “B point”, respectively. By forming an angle with the sella
and nasion, this position is referenced to the cranial base. “A
point” provides information about the anteroposterior posi-
tion of the maxilla. If the SNA angle is excessive, the maxilla
exhibits an abnormal anterior position relative to the cranium.
If SNA is less than normal, the maxilla is posteriorly posi-
tioned relative to the cranial base. The same principle applies
to the mandible: “B point” is used to relate the mandibular
position to the cranial base. The importance of the cranial base
Fig. 28.2  The cephalometric radiograph is used to identify skeletal landmarks
used in determining the lines and angles that reflect facial development. These
measurements aid in determining the extent to which each jaw contributes to the
dentofacial deformity. S, sella turcica, the midpoint of the sella turcica; N, nasion,
the anterior point of the intersection between the nasal and frontal bones; A pt, “A
point”, the innermost point in the depth of the concavity of the maxillary alveolar
process; B pt, “B point”, the innermost point on the contour of the mandible
between the incisor tooth and the bony chin; Ba, basale, the most inferior point of
the skull base; Pg, pogonion, the most anterior point on the contour of the chin;
Go, gonion, the most inferior and posterior point at the angle formed by the ramus
and body of the mandible; Po, porion, the uppermost lateral point on the roof of the
external auditory meatus; Or, orbitale, the lowest point on the inferior margin of the
orbit; PNS, posterior nasal spine, the most posterior point on the maxilla; ANS,
anterior nasal spine, the most anterior point on the maxilla; Gn, gnathion, the center
of the inferior contour of the chin; Me, menton, the most inferior point on the
mandibular symphysis; MP, mandibular plane, the line connecting the Go and the
Gn; OP, occlusal plane.
MP
Go
Me
Gn
Pg
B pt.
OP
A pt.
ANS
PNS
Or
Ptm
Ar
Ba
Po
S

663
Patient selection
measured on the model block to determine the new three-
dimensional position of the maxillary cast. The occlusal
portion of the maxillary cast is removed from its base using a
saw. As much plaster is removed from the cast as is necessary
to accommodate the new position of the maxilla. Once the
model block verifies the maxilla is in its new position, the cast
is secured with sticky wax or plaster to the mounting ring.
Now it can be placed on the articulator. At this point, the
surgeon has a mounting of the postoperative maxilla related
to the preoperative mandible. An acrylic splint is made at this
point. This splint is called the intermediate splint and is used
in the operating room to index the new position of the maxilla
to the preoperative position of the mandible. A second mount-
ing with the casts in the occlusion desired by the orthodontist
is used to make a final splint that represents the new position
of the mandible to the repositioned maxilla. This is fabricated
in a manner similar to the splint for isolated mandibular
surgery. If the occlusion is good, intercuspal position can be
used to position the mandible without the splint.
3D CT modeling
There are several computer-assisted design (CAD) programs
that are now commercially available that can assist the surgeon
with some or all of the preoperative patient preparation. A
computed tomography (CT) scan of the facial skeleton, as well
as updated dental casts, are obtained preoperatively. Although
conventional helical CT scans with fine cuts through the face
are ideal, cone beam CT scans offer a comparable image
quality with considerably less cost and radiation exposure
(50 µSv compared to 2000 µSv). The program then joins the CT
and the dental cast to render a complete three-dimensional
model of the facial skeleton. A cephalometric analysis can
then be performed as well as simulated movements of the
jaws and chin in any dimension. Once the surgeon verifies the
osteotomy movements, CAD/CAM (computer-aided manu-
facturing) technology is used to fabricate surgical splints for
the patient. If necessary, 3D models of the patient can be made
showing the exact proposed movement (Fig. 28.3). Some
systems can actually “wrap” a 2D digital image around the
soft-tissue envelope of the 3D CT image, thus replicating a 3D
image of the patient’s face in color.
In these authors’ experience, 3D CT modeling has demon-
strated improved accuracy in diagnosis and treatment. The
elimination of traditional model surgery saves the surgeon
time in patient preparation. Finally, the 3D aspect of this
treatment-planning approach enhances the surgeon’s ability
to predict how osteotomies may affect soft tissue of the face.
These advantages facilitate the ability of the plastic surgeon
to provide optimal care for these patients.
Developing a treatment plan
Once the data are obtained, the surgeon can determine which
abnormalities the patient exhibits and the extent to which
these features deviate from the norm. The treatment plan is
the application of these data to provide the best aesthetic
result while establishing a class I occlusion. The goal is not to
“treat the numbers” in an attempt to normalize every patient.
The appearance of the soft-tissue envelope surrounding the
facial skeleton is the most crucial factor in determining the
aesthetic success of orthognathic procedures, and the jaws
occlusion both before and after articulation into proper posi-
tions. Analysis of new occlusion gives the clinician an idea of
how intensive the presurgical orthodontic treatment plan will
be. Casts also allow the clinician to distinguish between
absolute and relative transverse maxillary deficiency. Abso-
lute transverse maxillary deficiency presents as a posterior
crossbite with the jaws in class I relationship. A relative maxil-
lary transverse deficiency is commonly seen in a patient with
a class III malocclusion. A posterior crossbite is observed in
this type of patient, raising suspicions of inadequate maxillary
width. However, as the maxilla is advanced or the mandible
retruded, the crossbite is eliminated. Articulation of the casts
into a class I occlusion allows the surgeon to distinguish easily
between relative and absolute maxillary constriction.
Model surgery
Using the cephalometric tracings as a guide, the next step is
to reproduce the maxillary and/or mandibular movements on
articulated dental models. This allows for the fabrication of
occlusal splints to be used intraoperatively to guide jaw
repositioning in preparation for osteosynthesis. Model surgery
begins by obtaining accurate casts of the patient’s occlusion.
If the surgeon does not have a dental laboratory, the ortho-
dontist will obtain the casts. The success of the technical
portion of orthognathic surgery correlates directly with the
accuracy of the model surgery and splint fabrication.
Isolated mandibular surgery
It should be noted that if isolated mandibular surgery is being
performed, the casts can be hand-articulated into the desired
occlusion. The Galetti articulator is a useful tool that allows
securing of casts with a screw mount. A universal joint allows
the casts to be set in the desired relationship. Surgical splints
can then be made from the articulator. If the maximum inter-
cuspal position is the desired postoperative occlusion, a splint
may be unnecessary. The surgeon can osteotomize the man-
dible and secure it into its new position using the maximum
intercuspal position as a guide to the new position. The
surgeon should always verify the desired postoperative occlu-
sion with the orthodontist prior to surgery.
Isolated maxillary and two-jaw surgery
A “face bow” is a device used to relate the maxillary model
accurately to the cranium on an articulator. If a maxillary
osteotomy is being performed, one set of models should be
mounted on an articulator using the face bow. Two other sets
of models are used in treatment planning. Next, an Erickson
model block is used to measure the current position of the
maxillary central incisors, cuspids, and the mesiobuccal cusp
of the first molar. The face bow-mounted maxillary cast is
placed on the model block. The maxillary model is then
measured to the tenth of a millimeter vertically, anteroposte-
riorly, and end-on. By having numerical records in three
dimensions, the surgeon can reproduce the maxillary cast’s
exact location, as well as determine a new location. Reference
lines are circumferentially inscribed every 5 mm around the
maxillary cast mounting. The distances the maxilla will move
in an anteroposterior, lateral, and vertical direction have been
determined from the previous cephalometric exam. These
numbers are added or subtracted from the current values

664
SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
of the jaws that will optimize the soft-tissue features of the
face. By reducing the emphasis on “normal” values and
increasing the awareness of soft-tissue effects of skeletal
movements, it is realized that skeletal disproportion often
leads to a more favorable result.6
Treatment/surgical technique
General principles and pertinent anatomy
Several principles have broad application to jaw surgery.
Blood loss can be substantial in maxillofacial surgery and
even small volumes can have significant clinical implications
in the pediatric population. Standard techniques of head eleva-
tion, hypotensive anesthesia, blood donation, and the preop-
erative administration of erythropoietin are useful adjuncts to
reduce blood loss, especially in the younger population.
Before incisions are made, an antimicrobial rinse is helpful to
minimize the intraoral bacterial count. A topical steroid is
applied to the lips to reduce pain and swelling associated with
should be positioned so they provide optimal soft-tissue
support.
Historically, skeletal movements that expanded the soft
tissue of the face were less stable, so posterior and superior
movements were preferred. Although these movements were
more stable, they resulted in contraction of the facial skeleton
with the associated soft-tissue features of premature aging.
Since the introduction of rigid fixation systems, osteotomies
that result in skeletal expansion have been achieved with
a great degree of predictability. An attempt is made to
develop a treatment plan that will expand or maintain the
preoperative volume of the face. If a superior or posterior
(contraction) movement of one of the jaws is planned, an
attempt should be made to neutralize the skeletal contrac-
tion with an advancement or inferior movement of the other
jaw or the chin. It is important to avoid a net contraction of
the facial skeleton as this may result in a prematurely aged
appearance.
A class I occlusion can be achieved with the jaws in a
variety of positions. The goal in treatment planning is to use
the data from the patient’s examination to predict the location
Fig. 28.3  Three-dimensional computed tomography
reconstruction of patient with class III malocclusion
and anterior open bite. (A) Lateral preoperative view.
(B) Front preoperative view. (C) Three-dimensional
representation of computer-designed intermediate
splint which is fashioned for intraoperative use.
(D) Lateral view after Le Fort I osteotomy has been
simulated with intermediate splint in place. (E) Lateral
postoperative view after Le Fort I and bilateral sagittal
split osteotomies have been simulated with correction
of class III malocclusion and anterior open bite.
(F) Close-up view of predicted postoperative
occlusion.
A
B
C
D
E
F

665
Treatment/surgical technique
The important mandibular structures that may be injured
with the mandibular osteotomy are the mental nerve, the
inferior alveolar nerve, and the tooth apices. The third branch
of the trigeminal nerve enters the mandibular foramen to
become the inferior alveolar nerve. It runs below the tooth
roots and exits at the level of the first and second premolars
through the mental foramen. The region where it is most
medial to the outer cortex is located near the external oblique
ridge. This is where the vertical portion of the sagittal split
osteotomy is made because it affords the largest margin of
error.
Le Fort I osteotomy
The first step in any facial osteotomy is satisfactorily securing
the nasal endotracheal tube; our preference is a nasal Ring–
Adair–Elwin (RAE) endotracheal tube. The vertical position
of the maxilla is recorded by measuring the distance between
the medial canthus and the orthodontic arch wire. These verti-
cal measurements are absolutely critical. The maxillary vesti-
bule is injected with epinephrine prior to patient preparation.
An incision is made with needle tip electrocautery 5 mm
above the mucogingival junction from first molar to first
molar. A periosteal elevator is then used to expose the maxilla
around the piriform rim and infraorbital nerve. Obwegeser
toe-in retractors are held by the assistant at the head of the
operating table. As the dissection extends laterally, it is impor-
tant to remain subperiosteal to avoid exposure of the buccal
fat pad. A Woodson elevator is used to initiate reflection of
the nasal mucosa, and a periosteal elevator is used to complete
the dissection of the nasal floor and lateral nasal wall. A
double-balled osteotome is used to release the septum from
the maxilla and a uniballed osteotome is used to release the
lateral nasal wall. The surgeon can insert a finger on the
posterior palate to help feel when the cut is complete. A
periosteal elevator is used to protect the nasal mucosa, and
then a reciprocating saw is used to make a transverse oste-
otomy from the piriform aperture laterally until the cut
descends just posteriorly to the last maxillary molar and
drops through the maxillary tuberosity. The cut should be
made at least 5 mm above the tooth apices. This distance is
determined from preoperative Panorex radiographs. If cuts
are complete, the maxilla is downfractured with manual pres-
sure, or with Rowe disimpaction forceps which fit into the
piriform aperture and on the palate to provide increased
leverage for the downfracture. Pressure should be applied in
a slow, steady, controlled fashion, not in a series of quick
movements. If the maxilla is not mobilized with relative ease,
the cuts are likely not complete and should be re-evaluated.
Scoring the posterior maxillary wall with a 10 mm osteotome
may be necessary to aid in downfracture and to prevent an
uncontrolled fracture superiorly toward the cranial base.
Once the downfracture is complete, a bone hook can be used
by the assistant to hold the maxilla down while any remaining
bony interferences are removed. The descending palatine
arteries will be seen near the posteromedial maxillary sinus.
These can be clipped prophylactically without compromising
the blood supply to the maxilla (Fig. 28.4). Any rents in the
nasal mucosa are repaired at this stage with chromic suture.
The splint is then used to place the maxilla in its proper
position in occlusion with the mandible. Mandibulomaxillary
fixation (MMF) is then applied with 26-gauge wires around
prolonged retraction. Intravenous steroids may also be useful
to reduce postoperative edema.
The occlusion desired may not be the same as maximum
intercuspal position. The splint is useful in maintaining the
occlusion in the desired location when it does not correspond
to maximal intercuspal position. It is easy for the orthodontist
to close a posterior open bite, but very difficult to close an
anterior open bite with orthodontic treatment. At the end of
the case it is important to have the anterior teeth and the
canines in a class I relationship without an open bite.
Guiding elastics are useful postoperatively to control the
bite. Class II elastics are placed in a vector to correct a class II
relationship (maxillary lug is anterior to the mandibular lug).
Class III elastics are applied to correct a class III discrepancy.
With rigid fixation, the elastics will not correct malpositioned
jaws; they serve only to help the patient adapt to the new
occlusion. Minor malocclusions can be corrected with postop-
erative orthodontic treatment.
Certain skeletal movements are inherently more stable than
others. Stable movements include mandibular advancement
and superior positioning of the maxilla. Movements with
intermediate stability include maxillary impaction combined
with mandibular advancement, maxillary advancement com-
bined with mandibular setback, and correction of mandibular
asymmetry. The unstable movements include posterior posi-
tioning of the mandible and inferior positioning of the maxilla.
The least stable movement is transverse expansion of the
maxilla. Long-term relapse with rigid fixation has not been
demonstrated to be clearly superior to non-rigid fixation in
single-jaw surgery. However, in two-jaw surgery, rigid fixa-
tion results in less relapse. The judgment of the surgeon will
dictate the extent to which the facial skeleton can be expanded
without resulting in unacceptable relapse.
The maxilla is associated with the descending palatine
artery, the infraorbital nerve, the tooth roots, and the internal
maxillary artery. The internal maxillary artery runs about
25 mm from the pterygomaxillary junction, and the descend-
ing palatal artery descends into the posteromedial maxillary
sinus. The infraorbital nerve exits the infraorbital foramen
below the infraorbital rim along the mid pupillary line. The
maxillary tooth roots extend within the maxilla in a superior
direction. The canine has the longest root and is usually visible
through the maxillary cortical bone.
The patient who presents with a cleft lip and/or palatal
anomaly will have several anatomic differences when com-
pared to an unaffected patient. The maxilla is typically defi-
cient in both the anteroposterior and vertical dimensions.
Because midface retrusion can be significant, it frequently
appears that the mandible is prognathic, but it is rare that the
mandible demonstrates a true prognathia. It is a relative
prognathia secondary to the maxillary deficiency. Finally,
because of lesser-segment collapse, the dental midline is often
deviated toward the cleft side.
Despite
having
alveolar
bone
grafting
performed,
many cleft patients have deficient or missing bone in the
region of the alveolus. Persistent palatal fistulas may be
present as well. The lateral incisor is frequently missing in
these patients and closure of this space must be taken into
consideration at the time of treatment planning. If a large
fistula is present in the alveolus, modifications of the Le
Fort I procedure can be performed to facilitate a tension-free
alveolar closure.

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CHAPTER 28 • Cleft and craniofacial orthognathic surgery
nasal spine. Separation is verified by activating the device.
The maxilla is widened until the gingiva blanches and then
is relaxed several turns to avoid ischemia. The SARPE offers
the best stability for maxillary expansion in the young adult
and older patient. Transverse deficiencies of the mandible
can be corrected with a similar technique, that of distraction
osteogenesis (DO).
Bilateral sagittal split osteotomy (BSSO)
The endotracheal tube placement and epinephrine injection
are carried out in a similar fashion to the Le Fort I osteotomy.
The mucosal incision is made with electrocautery about
10 mm from the lateral aspect of the molars and extends from
the mid-ramus to the region of the second molar. If insufficient
tissue is left on the dental side of the incision, closure is more
difficult. A periosteal elevator is used to expose the lateral
mandible and the anterior coronoid process in a subperiosteal
plane. As the coronoid process is exposed, placement of a
notched coronoid retractor may facilitate the dissection. A
curved Kocher forcep with a chain can be clamped to the
coronoid process and the chain secured to the drapes. To
optimize blood supply, subperiosteal dissection is limited to
those areas required to complete the osteotomy. A J-stripper
is used to release the inferior border of the mandible from
the attachments of the pterygomasseteric sling. The eternal
oblique ridge and inferior border of the mandible should be
exposed. The medial aspect of the ramus is also dissected
subperiosteally. The mandibular nerve should be identified.
A Seldin elevator is inserted medial to the ramus to protect
the nerve. A Lindemann side-cutting burr is used to make a
cut on the medial ramus that is parallel to the occlusal plane
and extends about two-thirds of the distance to the posterior
ramus.
The osteotomy proceeds from medial to lateral until the
burr is in the cancellous portion of the ramus. Mandibular
body retractors are then placed and a fissure burr, or a recip-
rocating saw is used to make an osteotomy from the
the surgical lugs. The amount the maxilla will be impacted or
elongated was determined in the treatment plan. This distance
is added or subtracted from the medial canthal–incisor dis-
tance to determine the new vertical position of the maxilla.
Four 2-mm plates, usually L-shaped, can be used to secure the
maxilla. The MMF is released and occlusion verified prior to
closure. If the alar base is wide, an alar cinch can be performed
to normalize the width. Lip shortening may also result from
closure. A V–Y closure at the central incisor can help alleviate
this effect.
In patients who require increased cheek projection, a high
Le Fort I osteotomy can be performed. This differs in that the
transverse osteotomy is made as high as the infraorbital nerve
will allow. If further cheek projection is necessary, bone grafts
can be added. In the case of inferior or anterior positioning,
gaps between the segments greater than 3 mm should be
grafted with autogenous bone, cadaveric bone, or block
hydroxyapatite. Finally, if simultaneous expansion of the
maxilla is necessary, the maxilla can be split into two or more
pieces to allow concurrent expansion.
Surgically assisted rapid palatal expansion
Correction of transverse maxillary constriction is common in
patients with repaired cleft palates or those with craniofacial
syndromes such as Apert or Cruzon syndrome. Such palatal
constriction can be addressed in adolescence with non-surgical
orthodontic appliances. As the sutures begin to close during
late adolescence, relapse rates increase. A multiple-piece Le
Fort I osteotomy can be performed to provide simultaneous
maxillary expansion, but the degree of relapse is high. In
the young adult, the preferred procedure is the surgically
assisted rapid palatal expansion (SARPE) procedure. The
orthodontist places a palatal expander prior to the proce-
dure. A Le Fort I osteotomy is performed to mobilize the
maxilla completely from the upper face. A small osteotome
is used to make a thin cut between the roots of the central
incisors, and a midline split is completed to the posterior
Fig. 28.4  Blood supply to maxilla before (left) and after (right) Le Fort I osteotomy and downfracture. After the nasopalatine and descending palatine arteries are transected,
perfusion of the maxillary segment occurs via the lesser palatine artery.
Nasopalatine artery
Greater palatine artery
Ascending palatine artery
Facial artery
External carotid artery
Ascending pharyngeal artery
Maxillary artery
Lesser palatine artery
Descending palatine artery
Le Fort downfracture

667
Treatment/surgical technique
mid-ramus down along the external oblique ridge, gently
curving to the inferior border of the mandible. The cuts are
verified with an osteotome, and then large osteotomes are
inserted and rotated to separate the segments gently. The
tooth-baring segment is referred to as the distal segment, and
the condylar portion as the proximal segment.
The inferior alveolar nerve should be identified and found
in the distal segment. If part of the nerve is located within the
proximal segment, it should be gently released with a small
curette. After both osteotomies are complete, the distal
segment is placed into occlusion and secured by tightening
26-gauge wire loops around the surgical lugs. If a surgical
splint is necessary to establish a required occlusion, it is placed
between the teeth before MMF wiring. The proximal segments
are then gently rotated to ensure they are seated within the
glenoid fossa. When each condyle is comfortably seated
within the fossa, it is rotated to align the inferior borders of
the two segments and secured into position with a clamp.
Three lag screws are placed at the superior border of the
overlapping segments on each side of the mandible. To ensure
that the transbuccal trocar will be placed properly, a hemostat
is placed at the proposed screw location and pointed toward
the cheek. A small stab incision is made in the skin, and the
trocar is placed through the tissue bluntly until the tip enters
the oral incision. The trocar is then exchanged for a drill
guide, and the 2.0-mm and 1.5-mm drills are used in the lag
sequence to make three holes through the overlapping portion
of the proximal and distal segments. The screw lengths are
measured and the screws inserted. Alternatively, the Dal Pont
modification to the BSSO carries the buccal osteotomy anteri-
orly to the level of the first mandibular molar creating a longer
proximal segment which can be fixated without a transbuccal
screw. Instead, 2.0-mm plates with monocortical screws are
used to fixate the segments after the occlusal splint is placed.
The MMF is released, and the mandible is gently opened and
closed to verify the occlusion. If a malocclusion is noted, the
most likely etiology is that one or both condyles were not
seated properly during application of fixation. The fixation
should be removed and replaced until the correct occlusion is
established. The wounds are irrigated and closed with inter-
rupted 4-0 chromic sutures.
Intraoral vertical ramus osteotomy
A second technique for correcting mandibular prognathism
or asymmetry is the intraoral vertical ramus osteotomy. The
incision is the same as described above. A subperiosteal dis-
section is performed from the lateral ramus, and a LeVasseur
Merrill retractor is used to hold this tissue laterally. An oscil-
lating saw is then used to make a vertical cut from the sigmoid
notch to the inferior border of the mandible. The osteotomy
must be made posterior to the mandibular foramen on the
medial side. The antilingula is a useful landmark, and is
found as an elevation on the lateral mandible, indicating the
approximate location of the mandibular foramen. After both
sides of the mandible are complete, the distal segment is
moved into occlusion, making sure that the proximal seg-
ments remain lateral to the distal segments posteriorly.
Because rigid fixation is difficult to apply, a single wire, or no
fixation at all, is used, and the patient remains in MMF for 6
weeks. This osteotomy can be done from an external approach,
but this incision results in a scar on the neck.
Two-jaw surgery
Moving the maxilla and the mandible in one procedure
requires osteotomizing both jaws and precisely securing them
into position as determined by the treatment plan. If proper
treatment planning, model surgery, and splint fabrication are
performed, each jaw should be able to be placed into its
desired position with precision. In a maxilla-first approach,
the mandibular bony cuts are started first but terminated
prior to osteotomy completion. The maxillary osteotomy is
made, and the maxilla is placed into its new position using
the intermediate splint. The splint is used to wire the teeth
into MMF, allowing for indexing the new position of the
maxilla to the preoperative (uncorrected) position of the
mandible. With the condyles gently seated, the maxilloman-
dibular complex is rotated so that the maxillary incisal edge
is at the correct vertical height. The maxilla is plated into
position, the MMF is released, and the intermediate splint
removed. Next the mandibular osteotomies are completed,
and the distal segment of the mandible is placed into the
desired occlusion using the final splint. If the teeth are in good
occlusion without the splint, the final splint may not be neces-
sary to establish the desired occlusal relationship. Wire loops
secure the occlusal relationship, and the rigid fixation is
completed as previously described.
Genioplasty
Including a genioplasty in the treatment plan can be a power-
ful adjunct to mandibular movements, either by offsetting
soft-tissue collapse secondary to posterior mandibular repo-
sitioning or by augmenting anterior mandibular movement.
When performed asymmetrically, a genioplasty may also
correct for minor mandibular asymmetries.
After adequate local anesthetic infiltration, the mucosa
is incised from canine to canine with needle tip electrocau-
tery, 5 mm below the mucogingival junction. The mentalis
is transected, being sure to leave enough muscle cuff to
allow for reapproximation during closure. Failure to do so
can result in a ptotic soft-tissue envelope, or “witch’s chin”
deformity. Next, the dissection is carried out in a subperi-
osteal fashion identifying and protecting the mental nerves
bilaterally. Using a reciprocating saw, the mandibular midline
is gently marked to aid in centric fixation. The transverse
osteotomy is made approximately 3 mm below the mental
foramina in order to protect the intraosseous course of the
mental nerves and the canine tooth roots. The trajectory
of the osteotomy can be varied depending on the type of
correction required. The mobilized segment is then fixed
into the desired position with plates and screws, using the
midline mark as a guide. The mentalis is then repaired and the
mucosa closed.
Cleft surgery
Orthognathic surgery in cleft lip/palate patients is done simi-
larly to non-cleft patients with the exception of several
important modifications that are necessary to maintain blood
supply and assist in fistula closure.
In a unilateral cleft lip patient, the standard maxillary inci-
sion can be made with little jeopardy to the premaxillary
blood supply (Fig. 28.5). Each side of the cleft has an incision
made similar to that of the alveolar bone graft incision. This

668
SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
mucosa. Since the vomer will be split, the majority of blood
flow to the premaxilla must course from the premaxillary
buccal mucosa. A circumvestibular incision that violates this
mucosa will severely jeopardize the blood supply of the pre-
maxillary segment (Fig. 28.6). To minimize the risk of compli-
cations, the incision is stopped just lateral to the alveolar cleft
on each side. One minimizes reflection of the mucosa from the
premaxilla in order to preserve the blood supply. The oste-
otomy of the premaxillary segment is made from a posterior
approach just anterior to the incisive foramen. This allows
mobilization of the segment without violation of the buccal
mucosa. Similar to the unilateral cleft maxilla, residual fistulae
and inadequate alveolar bone may be present. If either is
allows for a two-layer closure of the palatal and nasal mucosa.
If supplemental bone grafting needs to be done at this time,
harvested bone can be placed into the alveolar gap after fixa-
tion has been applied. If a wide fistula is present, the surgeon
can compress the maxillary segments to reduce the size of the
alveolar space. This ensures the soft-tissue closure is under
minimal tension and the chance of fistula closure is optimized.
The canine may now be adjacent to the central incisor, but the
restorative dentist can fabricate a prosthetic crown for the
canine to make it look like a lateral incisor.
In the bilateral cleft patient, care must be taken not to make
the vestibular incision across the premaxilla. The premaxillary
blood supply originates from the vomer and the buccal
Fig. 28.5  (A) For patients with a unilateral cleft lip, the incision is made similar to a
standard Le Fort I osteotomy, except an alveolar dissection is used if supplemental
bone grafting or fistula closure is necessary. (B) The Le Fort osteotomy allows
compression of the maxillary segments if necessary to close a pre-existing fistula.
(C) Fistula repairs are easier after compression of the segments and exposure of nasal
and palatal tissue.
A
B
C

669
Treatment/surgical technique
Once the incision is made, the mucosa is reflected in a
subperiosteal plane to expose the piriform aperture, the
zygomatic buttress, and the posterolateral maxilla. A recipro-
cating saw is used to make a high Le Fort I osteotomy in most
cases. A high Le Fort I osteotomy is cut horizontally in a
lateral direct line from the piriform aperture to the zygomatic
buttress. One takes this line as high as possible while staying
identified, it can be corrected by a two-layer mucosal closure
and bone grafting into the alveolar defect. If large gaps are
present that may jeopardize fistula closure, the segments can
be compressed at the alveolar gaps to reduce tension of the
repair. Postoperative orthodontics and prosthetic restorations
of the teeth can correct almost any postoperative dental aes-
thetic irregularities.
A
B
Fig. 28.6  (A) For patients with a bilateral cleft, care is taken to avoid incisions across
the premaxilla. (B) The premaxillary osteotomy is completed from a posterior
approach. (C) Fistula repairs or supplemental bone grafting can be done at this time.
(D) Compression of the maxillary segments can be performed if wide fistulas are
present.
C
D

670
SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
class II malocclusion, which is almost always caused by
mandibular retrognathia and is almost always best treated by
mandibular advancement (Fig. 28.7). The mandible is small,
and forward positioning is an expansile movement that
enhances facial form. If the maxilla is also slightly deficient or
in an abnormal position, one may consider a bimaxillary
advancement to enhance further facial soft-tissue definition,
at least 5 mm below the inferior orbital foramen. A vertical
cut is now made from the lateral edge of the horizontal cut
and taken to an area about 5 mm above the tooth root apices.
The lateral nasal walls are cut with a uniball osteotome and
mallet. The vomer and septum can be reached through the
lateral maxillary osteotomies so the mucosa remains pre-
served. The pterygomaxillary junction can be separated with
a 10-mm curved osteotome, or the maxillary tuberosity can be
cut posterior to the last molar in the arch. The latter choice
makes downfracture easier and results in fewer complica-
tions. Downfracture is now completed with either digital
pressure or application of the Rowe disimpaction forceps. If
a wide alveolar fistula is present, the greater and lesser seg-
ments can be compressed at the alveolus. The occlusion that
would result from segment compression would be evaluated
on the dental casts during preoperative model surgery. Any
deficiency of alveolar bone can be corrected with supplemen-
tal bone grafts after application of fixation, and fistulas can be
corrected as well.
The surgical splint is then placed to orient the new position
of the maxilla to the mandible. Wire loops (26-gauge) are used
to place the patient in maxillomandibular fixation. It is
extremely important to make sure the condyles are seated as
the maxillomandibular complex is rotated to its new vertical
dimension. Generally, cleft patients have vertical maxillary
deficiency in addition to the sagittal deficiency. This requires
the maxilla to be positioned inferiorly to its new position. If
vertical lengthening greater than 5 mm is required, bone
grafts are placed between the osteotomy segments to reduce
relapse. Rigid fixation is now used to secure the maxilla into
its new position. If any instability remains across the maxil-
lary segments, a small plate can be placed across the segments
to reduce mobility and maintain the bone graft. Because the
osteotomized cleft maxilla results in a multisegment maxilla,
the surgical splints are wired in place for 6–8 weeks in order
to allow for bone healing.
Distraction osteogenesis
Distraction osteogenesis (DO) is a useful technique to gain
large advancements reliably with relatively low rates of
relapse. This technique takes advantage of osteoinductive
properties of tension and stress across the osteotomy to
expand the mandibular or maxillary segment rapidly while
allowing the soft tissue to relax over time. Without the need
for anatomic reduction or rigid fixation at the time of surgery,
DO is often technically easier and faster than traditional
orthognathic surgery. Moreover, various methods of distrac-
tion allow for precise control in several different vectors to
position the osteotomized segment accurately in space with
relation to the cranial base and other dentofacial landmarks.
Basic approaches to commonly
encountered problems
The following paragraphs outline basic treatment approaches
to commonly encountered dentofacial deformities commonly
seen in orthognathic patients.
Skeletal class II malocclusion
Conditions such as Treacher Collins syndrome, Stickler syn-
drome, and Pierre Robin sequence are often associated with
Fig. 28.7  Mandibular sagittal split osteotomies demonstrating mandibular
advancement and mandibular setback.

671
Outcomes, prognosis, and complications
especially in more mature patients. If the malocclusion is
minimal and there is little pre-existing dental compensation,
one may choose to have the orthodontist intentionally com-
pensate the dentition to correct the occlusion and avoid
surgery. In contrast, if the malocclusion appears minimal but
there is dental compensation, the skeletal discrepancy will be
more significant after the orthodontist decompensates the
dentition, and the patient may be a good surgical candidate
(Fig. 28.8).
Skeletal class III malocclusion
A class III malocclusion may be treated by advancing the
maxilla, posteriorly positioning the mandible, or by combin-
ing these procedures. It is important to consider the contribu-
tions of the mandible and the chin separately as each may
require different treatments to achieve aesthetic goals. If some
posterior positioning of the mandible is necessary, one may
advance the maxilla to counteract the skeletal contraction
produced from posteriorly positioning the mandible. Addi-
tionally, the patient may benefit from an advancement genio-
plasty, counteracting any skeletal contraction occurring from
a mandibular setback. As in the class II patient, a minor
malocclusion with minimal dental compensation may be cor-
rected with orthodontic treatment alone. In contrast, a minor
malocclusion with dental compensation may become a sig-
nificant malocclusion after dental decompensation, and the
patient will be a good surgical candidate. In cleft patients with
class III malocclusion, where the maxilla may be scarred from
prior interventions, combined Le Fort I advancement and
BSSO setback may be necessary even for relatively small
degrees of negative overjet (unless maxillary DO is enter-
tained) (Fig. 28.9).
Maxillary constriction
Patients can present with a maxilla that is narrow in a trans-
verse dimension. Maxillary constriction may occur as an iso-
lated finding or as one of multiple abnormalities. Up to about
15 years of age, the orthodontist can usually expand the
maxilla non-surgically with a palatal expander. If orthopedic
expansion cannot be done, a SARPE can be performed. If the
maxilla requires movement in other dimensions, a two-piece
(or multipiece) Le Fort I osteotomy can be performed to place
the maxilla in its new position while simultaneously achiev-
ing transverse expansion (Fig. 28.10).
Apertognathia
An anterior open bite is caused by a premature contact of the
posterior molars and is commonly seen in patients with
syndromic craniosynostoses such as Apert or Crouzon syn-
dromes. The recommended treatment is a posterior impaction
of the maxilla. By reducing the vertical height of the posterior
maxilla, the mandible can come into occlusion with the
remaining mandibular teeth. Posterior maxillary impaction
does not necessarily result in incisor impaction; the posterior
maxilla is simply rotated clockwise and upward using the
incisal tip as the axis of rotation. Therefore, incisor show
should not be affected. If a change in incisor show is also
desired, the posterior impaction is performed, and then the
whole maxilla can be inferiorly positioned or impacted to its
new position (Fig. 28.11).
Vertical maxillary excess
Vertical maxillary excess is typically associated with lip
incompetence, mentalis strain, and an excessive degree of
gingival show (long-face syndrome). The treatment approach
is to impact the maxilla to achieve the proper incisor show
with the lips in repose. Impaction, however, may result in
skeletal contraction, so the surgeon must consider anterior
repositioning of the jaws to neutralize the associated adverse
soft-tissue effects. As the maxilla is impacted, the mandible
rotates counterclockwise (with respect to a rightward-facing
patient) to maintain occlusion. This rotation results in anterior
positioning of the chin and is called mandibular autorotation.
The opposite occurs if the maxilla is moved in an inferior
direction. In this case, the chin point rotates in a clockwise
direction, resulting in posterior positioning of the chin point.
It is important to note these effects on the cephalometric
tracing during treatment planning because a genioplasty may
be required to re-establish proper chin position.
Short lower face
A short lower face is marked by insufficient incisor show
and/or a short distance between subnasale and pogonion.
Treatment is aimed at establishing a proper degree of incisor
show. The facial skeleton should be expanded to the degree
that provides optimal soft-tissue aesthetics. As the maxilla is
inferiorly positioned, resulting clockwise mandibular rotation
leads to a posterior positioning of the chin. The surgeon needs
to assess the new chin position preoperatively on the cepha-
lometric prediction tracing to determine if an advancement
genioplasty will be necessary to counter the effects of man-
dibular clockwise rotation.
Postoperative care
Postoperative care of patients undergoing orthognathic
surgery is paramount to a successful surgical outcome and a
satisfied patient and family. Close adherence to an oral hygiene
regimen, including regular tooth brushing and chlorhexidine
mouth rinses, will minimize the risk of postoperative infec-
tion, as will a short course of antibiotics targeted toward
common mouth flora. Additionally, steps taken to reduce
swelling, including ice, head elevation, and anti-inflammatory
medication such as Solu-Medrol, will greatly improve patient
comfort. A soft diet for at least the first 3 weeks postopera-
tively will help reduce the risk of malunion or hardware
failure. As well, guiding elastics are usually employed for the
first 2–3 weeks.
Outcomes, prognosis,
and complications
Accurate assessment of orthognathic surgical outcomes is
essential to maintaining safe practices, maximizing patient
satisfaction, and effectively evaluating an ever-changing field.
Indeed, this importance is echoed in the ways investigators
have analyzed postoperative results. These range from mea-
surement tools such as three-dimensional CT scanning and
volumetric analyses (used to evaluate postoperative changes
in bony and soft tissues immediately and over time) to

672
SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
Fig. 28.8  (A–H) 17-year-old female with Treacher
Collins syndrome. Pre- and postoperative views after
Le Fort I osteotomy with leveling and counterclockwise
rotation, asymmetric BSSO advancement, and
advancement genioplasty.
A
B
C
D
E
F
G
H

673
Treatment/surgical technique
Fig. 28.9  (A–H) 19-year-old patient with unilateral cleft lip
and palate. Pre- and postoperative views after Le Fort I
osteotomy and BSSO setback.
A
B
C
D
E
F
G
H

674
SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
questionnaires assessing patient-reported satisfaction scales
and quality of life. While there is currently no universally
accepted tool to demonstrate patient outcomes after orthog-
nathic surgery accurately and reliably, with reasoned and
reasonable expectations on the part of the patient, family, and
surgeon alike, orthognathic surgery can result in high levels
of satisfaction from both a functional and aesthetic level.
Of particular importance to the cleft and craniofacial popu-
lation is the effect of orthognathic surgery on speech. It is
generally accepted that the etiology of velopharyngeal insuf-
ficiency (VPI) in the cleft patient is due to the malalignment
or shortening of the palatal musculature, as well as growth,
development, and/or surgical sequelae that can lead to
abnormal structural relationships. Given the intricate attach-
ment of the muscular apparatus of the velum to the maxilla,
it follows that movement of the maxilla can change the pre-
operative velopharyngeal function.
Janulewicz et al. performed a retrospective study of the
change in velopharyngeal function of 54 cleft lip and palate
patients who underwent maxillary advancement with or
without a mandibular setback procedure over a 21-year
period.7 As summarized in Table 28.1, their study shows a
decline in competent velopharyngeal function (from 42% to
18%), an increase in both borderline incompetence (from 9%
to 22%), and complete VPI (from 13% to 20%). The authors
also noted that the quality of speech declined, as evidenced
by the increase in overall objective speech score from 2.46 to
4.24 (the higher the score, the worse the speech). In contrast,
the authors noted that articulation defects improved, although
the improvement did not achieve statistical significance.
Preoperatively 84% (46 patients) had at least one articulation
defect as compared to 73% (40 patients) postoperatively.
Other published studies have shown similar results or no
change in VPI function following jaw surgery. In their study,
Fig. 28.10  (A–E) Le Fort I osteotomies demonstrating maxillary lengthening, impaction, advancement, setback, and multipiece Le Fort.
B
A
D
C
E
Table 28.1  Comparison of preoperative and postoperative
speech variables
Total number of
patients: 54
Preoperative
evaluation
% (n)
Postoperative
evaluation
% (n)
VP function: competent
42% (23)
18% (10)
VP function: borderline
competent
36% (20)
40% (22)
VP function: borderline
incompetent
9% (5)
22% (12)
VP function: complete VPI
13% (7)
20% (11)
Normal nasality
40% (22)
40% (22)
Mild hypernasality
18% (10)
29% (16)
Moderate hypernasality
4% (2)
15% (8)
Severe hypernasality
4% (2)
2% (1)
Hyponasality
33% (18)
15% (8)
Reduced sibilant IOAPs
26% (14)
35% (19)
Reduced fricative IOAPs
16% (9)
26% (14)
Reduced plosive IOAPs
6% (3)
22% (12)
Anterior dentition errors
64% (35)
47% (26)
Mean speech score
2.46
4.24
IOAP, intraoral air pressure; VP, velopharyngeal; VPI, velopharyngeal
incompetence.
(Reproduced from Janulewicz J, Costello BJ, Buckley MJ, et al. The effects of Le
Fort I osteotomies on velopharyngeal and speech functions in cleft patients. J
Oral Maxillofac Surg. 2004;62:308–314.)

675
Outcomes, prognosis, and complications
assessment can predict postoperative speech and velopharyn-
geal function.
In summary, it appears that, while a positive effect on
articulation might be achieved by orthognathic surgery, it
might be at the expense of velopharyngeal function. Further
prospective, controlled studies would be helpful in elucidat-
ing the relationships between maxillary advancement and
speech.
Posnick and Tompson9 performed a retrospective study
evaluating relapse in cleft patients who had undergone
Phillips et al.8 showed that the extent of anteroposterior move-
ment of the maxilla is unrelated to velopharyngeal deteriora-
tion and is not a useful predictor. In their study of 26 cleft
patients (16 unilateral complete and 9 bilateral complete cleft
lips and palates), Phillips et al. demonstrated that all patients
with perceived hypernasal speech preoperatively had hyper-
nasality after advancement. Furthermore, 9 of 12 patients who
had preoperative nasopharyngoscopy showing borderline or
inadequate VP closure developed postoperative VPI. Based
on these results, Phillips et al. conclude that preoperative
Fig. 28.11  (A) Anterior open bite. (B) The Le Fort osteotomy allows posterior impaction of the
maxilla and clockwise rotation. (C) Counterclockwise mandibular autorotation closes the anterior open
bite.
A
B
C

676
SECTION I
CHAPTER 28 • Cleft and craniofacial orthognathic surgery
authors recommend a 2-mm overcorrection in inferior
positioning of the maxilla.
3. Rotation, clockwise or counterclockwise: The authors
report that most of their surgical rotation was lost and
relapse was seen in both clockwise and
counterclockwise rotations. They suggest overcorrection
to mitigate the effects of relapse.
4. Type of cleft: Orthognathic surgery in a bilateral cleft
patient was more likely to result in relapse, according to
their study. They attribute the increase in likelihood of
relapse to increased scarring of palatal tissues and
multiple missing teeth.
5. Previous alveolar bone grafting: Although studies have
reported the value of alveolar bone grafting in
establishing stability of advancement and minimizing
relapse, the study by Hirano and Suzuki10 found no
association between alveolar bone graft and the rate of
relapse in unilateral cleft lip and palate patients.
6. Number of missing teeth: The study by Hirano and
Suzuki10 also found no correlation between the number
of missing teeth and relapse although the authors stress
that multiple missing teeth can compromise the stability
of the occlusion.
7. Type of orthognathic surgery: There was no difference
in the relapse rate between patients undergoing
maxillary surgery alone and those who underwent
two-jaw surgery.
While both relapse and worsening VPI can occur with the
movements performed in orthognathic surgery, they are a
result of primary deficiencies in the soft tissue due to prior
scar formation as well as the underlying deformity and thus
are under only limited surgeon control. There are several
complications, however, on which the surgeon can have a
direct effect.
Improper positioning of the jaws is noted by malocclusion
or an obvious unaesthetic result. Special care must be taken
to ensure proper condyle positioning during fixation of the
mandibular osteotomy. If malocclusion results from improper
condyle position during fixation, it must be removed and
reapplied. The same is true for improper indexing of the
splint. For this reason, it is wise to verify splint fit prior to
surgery. Meticulous treatment planning prior to surgery
minimizes splint-related problems.
Measures to reduce the chance of an unfavorable mandibu-
lar split should always be employed. Removal of mandibular
third molars 6 months prior to the osteotomy allows time for
sockets to heal, decreasing the chance of a bad split. If the
segments do not appear to be easily separating, the surgeon
should verify that the osteotomies are complete. Excessive
force that could increase the chance of an uncontrolled man-
dibular split should be avoided. If an unfavorable split occurs,
the segments can be plated to re-establish normal anatomy,
and the proximal and distal segments can then be secured into
the desired position with rigid fixation.
Bleeding may occur from any area, but most commonly
from the descending palatine artery in the maxilla. This can
be stopped with packing or by placing a hemoclip on the
artery. Bone wax is useful for bleeding bony edges.
Nerve damage is rare, but can occur. The nerves associated
with these procedures are the infraorbital, inferior alveolar,
and mental nerve. If a transaction is witnessed, coaptation
Table 28.2  Patients with unilateral cleft lip and palate
undergoing Le Fort I osteotomy with miniplate fixation: mean
horizontal/vertical displacement and relapse
Time after
surgery
Effective horizontal
mean advancement
(mm)
Effective vertical
mean change (mm)
1 week
6.9 ± 2.6
2.1 ± 2.4
6–8 weeks
6.3 ± 2.6
1.9 ± 2.1
1 year
5.3 ± 2.7
1.7 ± 2.0
(Reproduced from Posnick JC, et al. Cleft-orthognathic surgery: the unilateral
cleft lip and palate deformity. In: Craniofacial and Maxillofacial Surgery in
Children and Young Adults, Vol. 2, Chapter 34. Philadelphia: WB Saunders;
2001.)
orthognathic surgery between 1987 and 1990. They found that
there was no significant difference in outcome between
patients who had maxillary surgery alone and those who had
operations on both jaws. Furthermore, the outcome did not
vary significantly with the type of autogenous bone graft used
or the segmentalization of the osteotomy. All 35 patients
included in the study underwent a modified Le Fort I maxil-
lary osteotomy with varied degrees of horizontal advance-
ment, transverse arch widening, and vertical change. Eleven
of the 35 patients also required mandibular surgery, consisting
of sagittal split osteotomies. In 13 of 35 patients a pharyngo-
plasty was in place at the time of maxillary Le Fort I osteotomy.
The results of the study are summarized in Table 28.2.
The mean horizontal advancement achieved for the group
was 6.9 mm; 5.3 mm was maintained 1 year later (mean
relapse 1.6 mm). In 11 of the 35 patients the relapse was less
than 1.0 mm. For the 13 patients who had a pharyngoplasty
at the time of the Le Fort I osteotomy, the mean horizontal
advancement was 8.2 mm immediately after the operation
and 6.5 mm 1 year later. Stability of the vertical displacement
was also evaluated. No maxillary vertical change was neces-
sary in 12 of 35 patients. The mean vertical displacement of
the maxilla in patients who underwent vertical displacement
was 2.1 mm; 1.7 mm was maintained 1 year later. The authors
concluded that neither horizontal nor vertical relapse was
related to the extent of movement. The overjet from the
cephalometric radiographs at the 1-year postoperative inter-
val was maintained in all patients, whereas a positive overbite
was maintained in only 30 of 35 patients (85%).
Other investigators have found a correlation between
relapse and the degree of advancement. To identify factors
associated with relapse after orthognathic surgery in the cleft
lip/palate patient, Hirano and Suzuki10 performed a retro-
spective study on 58 cleft patients who underwent orthogna-
thic surgery over a 10-year period. From their study, they
identified the following factors related to relapse:
1. Horizontal advancement: In their series the mean
horizontal relapse was 24.1% of the mean advancement.
There was significant correlation between extent relapse
and advancement. The authors report that complete
surgical mobilization of the maxilla is important in
preventing relapse.
2. Vertical displacement (inferior positioning): In their
study the mean inferior vertical elongation was 3.0 mm
with a relapse of 2.1 mm. Based on their study, the

677
Secondary procedures
2. Obwegeser H. Surgery of the maxilla for the correction of
prognathism. SSO Schweiz Monatsschr Zahnheilkd. 1965;75:365–374.
3. Enlow EH. Craniofacial growth and development: normal and
deviant patterns. In: Posnick JC, ed. Craniofacial and Maxillofacial
Surgery in Children and Young Adults. Philadelphia: W B Saunders;
2000:22–35. In this comprehensive chapter, the author provides a detailed
account of the development of the craniofacial skeleton, under both normal
conditions and in disease states. It highlights the temporal relationship
between growth of the cranial skeleton and the facial skeleton as well as
the differences among genders and in specific conditions of craniofacial
abnormalities.
4. Mao JJ, Wang X, Kopher RA. Biomechanics of craniofacial sutures:
orthopedic implications. Angle Orthod. 2003;73:128–135.
5. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations
in orthognathic surgery. Int J Adult Orthodon Orthognath Surg.
1995;10:97.
6. Selber JC, Rosen HM. Aesthetics of facial skeletal surgery. Clin Plast
Surg. 2007;34:437–445. This article highlights the changing paradigm in
orthognathic treatment planning from one based on pure cephalometric
analysis to one encompassing an evaluation of the aesthetic facial
soft-tissue proportions.
7. Janulewicz J, Costello BJ, Buckley MJ, et al. The effects of Le Fort I
osteotomies on velopharyngeal and speech functions in cleft
patients. J Oral Maxillofac Surg. 2004;62:308–314.
8. Phillips JH, Klaiman P, Delorey R, et al. Predictors of
velopharyngeal insufficiency in cleft palate orthognathic surgery.
Plast Reconstr Surg. 2005;115:681–686. This article is a retrospective
examination of 26 patients who underwent orthognathic advancement.
Assessments of speech and velopharyngeal function before and after
orthognathic surgery and the role of nasopharyngoscopy are detailed.
9. Posnick JC, Tompson B. Cleft-orthognathic surgery: complications
and long-term results. Plast Reconstr Surg. 1995;96:255–266. This
article is a retrospective evaluation of 116 patients with cleft palate who
underwent orthognathic surgery to correct malocclusion. The authors
report a mean follow-up of 40 months and describe common complications
and outcomes.
10. Hirano A, Suzuki H. Factors related to relapse after Le Fort I
maxillary advancement osteotomy in patients with cleft lip and
palate. Cleft Palate Craniofac J. 2001;38:1–10. This article is a
retrospective study of 58 patients (42 unilateral cleft and 16 bilateral cleft)
who underwent orthognathic surgery to correct maxillary hypoplasia. The
authors report a mean follow-up period of 2.5 years. Based on
cephalometric and statistical analyses, the authors elucidate factors related
to relapse after Le Fort I maxillary advancement.
11. Baker S, Goldstein JA, Seiboth L, Weinzweig J. Posttraumatic
maxillomandibular reconstruction: a treatment algorithm for the
partially edentulous patient. J Craniofac Surg. 2010;21:217–221.
with 7-0 nylon suture is recommended. The patient should be
informed that there is approximately a 70% chance of some
paresthesia immediately after surgery, but permanent changes
are seen in only 25% of patients.
The incidence of nonunion or malunion is rare after surgery.
If a malunion occurs, the jaw may need to be osteotomized
again to move it into proper position. A nonunion requires
secondary bone grafting to establish osseous continuity.
Secondary procedures
The need for secondary procedures in orthognathic surgery is
uncommon, especially when careful patient selection and
preoperative evaluation are employed. However, orthogna-
thic surgery rarely can completely resolve a significant
preoperative dentofacial deformity. Indeed, maxillary and
mandibular movements, in addition to altering occlusal
relationships and skeletal proportions, may highlight features
previously de-emphasized by malocclusion. In such cases,
procedures such as rhinoplasty, fat grafting, or malar augmen-
tation may help restore facial harmony.
It is important to realize that underlying issues related to
the primary cleft or craniofacial disorder may not be fully
addressed with orthognathic surgery. For example, patients
with repaired clefts who undergo orthognathic surgery to
address a class III malocclusion may still need surgeries to
complete their dental rehabilitation. Bone grafting and ves-
tibuloplasty may be as necessary after orthognathic surgery
as before.11 Likewise, in the setting of persistent edentulous
spaces, osseointegrated implants which are resistant to ortho-
pedic movements should be utilized only after jaw surgery
and postoperative orthodontics have determined final tooth
positions.
References
1. DeLuke DM, Marchand A, Robles EC, et al. Facial growth and the
need for orthognathic surgery after cleft palate repair: literature
review and report of 28 cases. J Oral Maxillofac Surg. 1997;55:694–
697, discussion 7–8.

SECTION II • Craniofacial
29 
Pediatric facial fractures
Edward H. Davidson and Joseph E. Losee
SYNOPSIS
■ Traumas that would likely produce fractures in adults often do not in
children due to intrinsic anatomical factors.
■ In addition to the unique anatomy of the pediatric patient, future growth
and development must be accounted for when addressing these injuries.
■ In deciding between operative and non-operative management of
pediatric facial fractures, the practitioner is essentially weighing the
risk of growth disturbance against the benefit of precise reduction and
rigid fixation.
■ When indicated, employing less invasive approaches to operative
management should be practiced.
Access the Historical Perspective section online at

Introduction
Facial fractures are relatively uncommon in children. Traumas
that would likely produce fractures in adults often do not in
children due to intrinsic anatomical factors such as larger fat
pads, decreased pneumatization of sinuses, increased skeletal
flexibility secondary to more malleable bone stock, and com-
pliant sutures. Parental supervision also prevents many
would-be fractures.1 The same structural characteristics of the
pediatric craniofacial skeleton that thwart fracture are respon-
sible for the unique injury patterns that are observed when
bony injury does occur. Pediatric facial fracture evaluation
begins with the conventional trauma evaluation and proceeds
through clinical and radiographic assessment, culminating in
conservative or operative management. In addition to the
unique anatomy of the pediatric patient, future growth and
development must be accounted for when addressing these
injuries. A non-operative approach is advised whenever
feasible, and long-term follow-up is mandatory to ensure
adequate outcomes and inform future practice. The objective
of this chapter is to provide the reader with an understanding
of the anatomical and growth-related factors that make pedi-
atric craniofacial fracture repair a unique entity and to offer a
discussion of specific treatment modalities in this context.
General principles
Epidemiology
Amongst the numerous authors that have catalogued and
analyzed their experience with pediatric facial fractures there
is consensus that these account for less than 15% of all facial
fractures. Frequency increases with age, prevalence is greater
in males (2–3 : 1), and severity of injury also worsens with
advancing age and male gender. Motor vehicle collision
(MVC), assault, and falls are the most common cause of facial
fracture.2–7 Reportedly, pediatric facial fractures are more
prevalent in spring and summer months, present in greater
numbers between midnight and noon, and most commonly
occur on Sundays and least commonly on Thursdays.4
The most common facial fracture in all pediatric age groups
is the orbital fracture. However, there is some contention in
determining the relative incidence of fracture patterns with
many studies having significant selection biases: subjects
enrolled or excluded according to admission status (inpatient
versus outpatient), necessity of operative management, and
treating specialty. To better characterize the full spectrum of
pediatric facial fractures, the authors described injury pat-
terns, associated injuries, and outcomes in a large consecutive
group of all pediatric patients with facial fractures evaluated
in a major children’s hospital emergency department from
fracture regardless of operative requirements, necessity for
hospital admission, or treating service. In this cohort, patients
were subdivided into three age groups: 0 to 5, 6 to 11, and 12
to 18 years.8 Although this stratification was based primarily
on dental maturity, additional characteristics are reflected by
this division. Children from 0 to 5 years of age are in primary

678.e1
Historical perspective
Historical perspective
Advances in facial fracture prevention include progress in
automotive technology, personal protective equipment in
sports, and the introduction of speed limits and alcohol, cel-
lular phone, and text messaging legislation. Improved imaging
modalities have facilitated the recognition of distinct cranio-
facial injury patterns in children; a relatively contiguous facial
skeleton, uninterrupted by large sinuses, is clearly appreci-
ated on 2D and 3D computerized tomography (CT). Manage-
ment strategies are incorporating biomaterials increasingly
compatible with craniofacial growth and development. A
growing appreciation of the pediatric craniofacial skeleton’s
resilience and the utility of late orthodontics is making prac-
titioners more comfortable with conservative strategies. A
better understanding of the implications of fracture manage-
ment on craniofacial growth and development is developing
as more long-term follow-up data is generated. Future direc-
tions will likely include the adoption of computer-aided
design and computer-aided manufacturing (CAD-CAM) of
3D printed bone substitutes and fixation devices, as well as
tissue engineering solutions.

679
General principles
Score (GCS) show a strong correlation with intracranial hem-
orrhage and cervical spine fracture. Evaluation for such
injuries is recommended in those with facial fractures and an
abnormal GCS.17 In the authors’ series, excluding soft-tissue
injuries, brain trauma was the injury most commonly associ-
ated with facial fractures across all age groups. A total of 55%
of patients with facial fractures had associated injuries: 81%
of these were considered “serious” and included cardiovas-
cular, cervical spine, or intra-abdominal trauma. Some 47%
had neurological injuries (60% of these were concussions),
and 3% had ophthalmologic injuries, including blindness. In
all, 1.4% died as a result of their injuries.8 Mechanism of injury
contributes to this; there were significantly more associated
neurologic injuries in children who sustained a craniofacial
fracture due to a non-violent mechanism – specifically, a
greater number of subarachnoid bleeds, subdural bleeds,
concussions, and comas. Patients in the non-violent group
were also more likely to have an injury to a vital organ system;
they experienced a greater number of respiratory, abdominal,
and musculoskeletal injuries.16 Nearly one third of pediatric
patients with facial fractures in the authors’ retrospective
series were diagnosed with a concomitant concussion. These
data suggest that a higher index of suspicion for concussion
should be maintained for patients with skull fractures and
potentially orbital and maxillary fractures. Given the possibil-
ity of a worse outcome with delayed concussion diagnosis,
patients with facial fractures may benefit from more active
early concussion screening.18
Though soft-tissue injury is presumed to be commonplace
with pediatric facial fractures, characterization of injury pat-
terns, influence on management, and any subsequent effect
on facial development have not been well investigated.19
Although uncommon, facial fractures associated with dog
bites (1.4% of dog bites) are a significant source of soft-tissue
morbidity, often requiring complex surgical repair in over
80% of cases.20
Growth, development, and fracture patterns
Craniofacial development is the culmination of a complex and
incompletely understood interaction between intracellular
processes, intercellular signaling, and environmental influ-
ences. Cranial-to-facial ratio decreases with maturity from 8 : 1
dentition and are more likely to be involved in supervised
activity; they also have the highest cranial-to-facial ratio.
From 6 to 11 years of age, children are in mixed dentition,
enter school, and begin to participate in sports. Patients from
12 to 18 years of age are in permanent dentition, are more
independent, and participate in potentially more at-risk
activities. Half (48%) of fractures were sustained by patients
12–18 years of age; 6–11-year-olds accounted for 32% of frac-
tures; and children under 5 years of age contributed 20% of
fractures.8 Similar patterns have been observed by other
authors.1–4,9 Although orbital fracture was the most common
fracture type for all age groups combined (29.8% of all frac-
tures), fracture type did vary by age at injury. Maxillary,
zygomaticomaxillary complex, and nasal fractures were more
common in older patients; oblique craniofacial fractures (skull
fractures occurring in combination with a facial fracture) were
more common in younger patients. Of mandible fractures in
the authors’ series (n = 179), condylar head and subcondylar
fractures were most common (48%).10 Anatomical distribution
varies with age; condylar fracture incidence decreases, while
body and angle fractures increase.11 Nasal fractures are likely
often underreported, with many treated in an outpatient
setting or going untreated.12 Midface fractures are uncommon
(10.4% of facial fractures in the authors’ series), likely second-
ary to the protection of the midface by the prominent forehead
and mandible in children, in addition to the robust anatomy
of this region.8 Zygomaticomaxillary complex (ZMC) fractures
are the most common of the rare midface fractures.1
The cause of injury also varied by age: violence, assault,
and MVC were the most common causes of injury in
12–18-year-olds, while activities of daily living caused the
most fractures in 0–5-year-olds.8 Fifty percent of injuries in
abused children involve the head or neck, and facial fractures
are seen in 2.3% of abused children.13 Craniofacial injury is the
second most common sport-related injury and is involved in
up to 20% of all pediatric sport-related injuries in the United
States with 10.6% of craniofacial injuries being sports-related.14
In the context of MVC, unrestrained children were signifi-
cantly more likely to sustain facial fractures: 65–70% of chil-
dren involved in all-terrain vehicle or bicycle accidents were
not wearing helmets.3 In the authors’ series, there was a
69% : 31% male-to-female ratio. A total of 62.6% of patients
were admitted to hospital, and 18.6% to an intensive care unit,
data consistent with other reports.8 The literature regarding
operative fixation of pediatric facial fractures is quite diverse,
varying from 25 to 78%. Nonetheless, older children require
surgery more frequently than younger children.15
The authors have also examined the epidemiologic data of
pediatric craniofacial fractures secondary to violence, compar-
ing these data to craniofacial fractures sustained from all other
causes. Patients with violence-related fractures were more
likely to be older, male, and non-white and live in a socioeco-
nomically depressed area. A greater number of patients with
violence-related injuries sustained nasal and mandible angle
fractures, whereas more patients with non-violence-related
injuries sustained skull and orbital fractures.16
Associated injuries
Facial fractures are high-energy injuries, and as such are
heavily associated with other injuries (up to 88% in some
reports).13 Facial fractures and a depressed Glasgow Coma
A
Fig. 29.1  (A) Frontal view and (B) side view of the growing craniofacial skeleton.
Note the decreasing cranial-to-facial ratio and increasing facial prominence.
(Reproduced from Mathes S, Hentz V. Plastic Surgery, 2nd edn. Philadelphia, PA:
Elsevier; 2006.)
B

680
SECTION II
CHAPTER 29 • Pediatric facial fractures
leptomeningeal cyst or “hernia”. Another consequence of the
underdeveloped frontal sinus is an increased incidence of
isolated orbital roof “blow-in” fractures.29 Blindness also
occurs with increased frequency due to the direct transmis-
sion of force to the orbit.29 Trapdoor fractures are more
common secondary to greater bony elasticity.30 Children tend
to have fractures without enophthalmos or vertical orbital
dystopia (VOD), likely secondary to more robust supporting
structures existing in this population. Enophthalmos and
VOD require composite injury to bone, ligaments, and peri-
osteum allowing for an increase in intraorbital volume
(Fig. 29.5).
Isolated midface fractures are rare in children as this region
is shielded by the prominent forehead and mandible.31 Palatal
splits are more common secondary to incomplete ossifica-
tion of the hard palate. These injuries represent significant
potential for growth disturbances secondary to the presence
of growth centers in the maxilla and nasal capsule and
because the midface is retruded relative to the cranium at this
age.32,33 Incomplete zygomaticofrontal (ZF) suture union leads
to fracture dislocations characterized by inferior displace-
ment of the zygoma and orbital floor, further contributing
to oblique fracture patterns.26 Oblique fracture patterns are
also encouraged by the underdevelopment of the midface
skeleton and major buttress systems. Until 10 years of age,
the underdeveloped maxillary sinus transmits force to the
at birth to 2 : 1 in adulthood (Figs. 29.1 & 29.2).21 The cranium
grows secondary to the brain, which triples in size during the
first year of life.21–24 This is a continuous process that is 25%
complete at birth, 75% complete at 2 years, and 95% complete
by 10 years. Facial growth is sporadic: it is 40% complete at 3
months, 70% at 4 years, 80% by 5 years, pauses until puberty,
and resumes until 17 years of age.21 The upper face grows
secondary to brain and ocular development; midfacial growth
follows the development of the nasal capsule and dentition.
Orbital growth is complete by 6–8 years, and nasal growth is
largely complete by 12–14 years. The majority of nasal growth
occurs in two distinct postnatal growth spurts, ages 2–5 years
and again during puberty. Additional growth after is usually
complete by age 16 to 18 in girls and 18 to 20 in boys, although
further growth of the nasal septum may occur up to the age
of 25 years.25 The palate and maxilla achieve two-thirds adult
size by 6 years.26 At birth, the mandible is formed by two
bones joined by cartilage at the symphysis, ossifying within
the first year of life. The majority of permanent teeth erupt by
12 years of age. The gonial angle becomes increasingly acute,
the ramus and body enlarge, and the distance between the
dentition and the inferior mandibular border increases. Corti-
cal bone replaces tooth buds as the primary component of
mandibular volume. The inferior alveolar nerve is displaced
superiorly to rest midway from the superior and inferior
mandibular borders. The mental foramen migrates to rest
ultimately beneath the first or second permanent premolar.27
The decreased bone mineral content of the infant skull
yields increased tolerance to force without fracture; fractures
that do occur are more likely to be incomplete, greenstick
fractures. In addition to mineralization, sinus pneumatization
and dental eruption are responsible for the evolving craniofa-
cial load-bearing capacity and subsequent fracture patterns
(Figs. 29.3 & 29.4). The maxillary sinus is aerated at 12 years
of age; the frontal sinus is not aerated until adulthood. Oblique
craniofacial fractures precede the Le Fort patterns seen in
adulthood as an incompletely pneumatized frontal sinus
transmits energy directly from the site of impact to the supra-
orbital foramen and then to the orbit and zygoma. In one large
study, Le Fort fractures were only seen in patients greater than
10 years of age.9 Forehead fractures in children may develop
into growing skull fractures (documented in 0.6–2% of pedi-
atric skull fractures).28 These lesions develop secondary to
brain pulsations transmitting through occult dural disrup-
tions and driving a growing bony diastasis resulting in a
Fig. 29.2  Schematic of growing face, in profile. Note decreased protection of face
afforded by cranium and increasing prominence (and exposure to injury) of
mandible.
5 1/2
4
k
w

1/2 wk
10 wk
tlu
d
A
11 yr
k
w
3
1
k
w
8
Newborn
Fig. 29.3  Pneumatization of the sinuses. Fracture patterns evolve with sinus
development.
3 months
1 year
4 years
8 years
12 years
0–4 years
4–12 years
12+ years

681
Diagnosis and presentation
decreased blood volume and ability to mask significant losses
with normotension prior to rapid decompensation.34,35 Hypo-
thermia is also more likely to be problematic given a child’s
increased surface area-to-volume ratio.34 A systematic physical
exam is performed. Eyelid hematoma, hearing loss, hemo-
tympanum, and cranial nerve (CN) palsy may herald skull
base fractures. Exophthalmos and inferior globe displacement
may represent a supraorbital or roof fracture. Ptosis may be
present secondary to levator paralysis. Orbital trauma will
likely be accompanied by periorbital ecchymosis and subcon-
junctival hematoma. Extraocular muscle restriction may cause
diplopia (Figs. 29.11 & 29.12). Forced duction is required to
rule out muscle entrapment in obtunded patients. Superior
orbital fissure syndrome (internal and external ophthalmople-
gia (CN II, IV, VI paralysis), proptosis, and CN V paresthesia)
and orbital apex syndrome (superior orbital fissure syndrome
with blindness secondary to CN II involvement) must be
emergently addressed (Fig. 29.13). Gaze limitations – even if
other clinical signs and symptoms are minimal and radio-
graphic studies are equivocal – may represent entrapment in
an entity termed the “white-eyed blowout fracture”.36 In naso-
orbito-ethmoid fractures, a bowstring test (palpation of the
bony medial canthal attachment on lateral distraction of the
lower eyelid) will assess the integrity of the medial canthal
tendon. Intraorbital distance is assessed to exclude traumatic
telecanthus.
Maxillary mobility and malocclusion may represent
midface fractures. ZMC fractures may be accompanied by
upper buccal sulcus hematoma, epistaxis secondary to a
fractured maxillary sinus, a preauricular depression, cheek
flattening, or lateral canthal dystopia. Impingement of a
depressed zygomatic arch on the coronoid process may yield
trismus. Medial displacement of the lateral wall with subse-
quent decrease in orbital volume may yield exophthalmos
(Fig. 29.14). Nasal deviation, compressibility of the nasal
dorsum, and septal hematoma must be appreciated on exam.
Nasal airway obstruction may represent septal hematoma.
Signs and symptoms consistent with mandible fracture
include malocclusion, drooling, trismus, decreased maximal
alveolus, resulting in alveolar fractures instead of Le Fort I
fractures. In the immature skeleton, Le Fort IIs are replaced by
unilateral naso-orbito-ethmoid (NOE) fractures. Le Fort IIIs
are replaced by multifragment oblique craniofacial fractures
(Figs. 29.6–29.8).9
The less mineralized, more compliant pediatric mandible
is more resistant to comminuted fractures. Condylar head and
subcondylar fractures are seen more frequently in children
due to incomplete ossification and a relatively weak condylar
neck (Figs. 29.9 & 29.10). While certain regions of the mandible
are classically highlighted as growth centers (e.g., condyles
and lingual tuberosity), condylectomy and differential masti-
catory strain studies point to a more diffuse, dynamic process
by which morphological change proceeds via coordinated
bone deposition and resorption.27 Heightened awareness of
potential growth disturbance and temporomandibular joint
(TMJ) ankylosis is, however, justified in the setting of condylar
fractures given an incomplete understanding of these injuries’
implications.
Diagnosis and presentation
The importance of a consistent approach to evaluating the
patient with craniofacial trauma cannot be overemphasized.
The first step in treating acute craniofacial injuries is ensuring
that the primary and secondary surveys have been completely
addressed. The craniofacial surgeon’s most direct interaction
with this process will likely be in assuring a secure airway
in cases where anatomy has been severely distorted. Given
the documented incidence of associated injuries, particularly
neurological, and the usual inability to cooperate with a thor-
ough physical exam, it is the author’s opinion that pediatric
patients with facial fractures benefit from routine CT scans of
the skull, face, and mandible. Periocular injuries benefit from
the formal evaluation by the ophthalmology service.
Infants are obligate nasal breathers, and their nasal airway
is relatively narrow and thus easily obstructed.34 Meticulous
hemostasis must be achieved given a child’s relatively
A
B
C
Fig. 29.4  (A–C) Development of the maxillary sinuses. The maxillary sinus plays an important role in determining how traumatic force will be transmitted through the
midface.

682
SECTION II
CHAPTER 29 • Pediatric facial fractures
and non-operative management of pediatric facial fractures,
the practitioner is essentially weighing the risk of growth
disturbance against the benefit of precise reduction and rigid
fixation. In the immature craniofacial skeleton with minimally
displaced fractures, a conservative approach is logical. For the
older child approaching skeletal maturity with significantly
displaced fractures, treatment is similarly straightforward
with open reduction and internal fixation (ORIF). However,
these two scenarios represent “tails of the bell-shaped curve”
with “black and white” decision-making. Most practitioners
are faced with a very large “gray area” in between, represent-
ing the vast majority of pediatric facial fractures – specifically,
the conundrum of “what to do” with the minimally displaced
fracture in the immature craniofacial skeleton.
The younger the patient, the higher the threshold for opera-
tive intervention. If operative intervention is pursued, while
it is critical to visualize fracture lines adequately, periosteal
stripping should be minimized as, in accordance with Moss
and Salentijn’s “functional matrix” principle, stripping may
adversely affect growth and development.37 Growth distur-
bances are felt by some to be minimized by using absorbable
plating systems in skeletally immature patients. A 10-year
retrospective review of 44 patients demonstrated resorbable
plates and screws can be an effective fixation method for facial
fractures in children in the primary and mixed dentition
periods. Whether used for plate fixation of fractures of
the tooth-bearing region of the mandible, a bone-anchored
method of mandibulomaxillary fixation (MMF), or in the very
low load-bearing upper and midface regions, they provide
adequate stability for the rapid bone healing of youth. The
blunt tips of the screws and their eventual resorption theoreti-
cally offer decreased risk to developing teeth and nerve
structures or ongoing facial growth and eliminate long-term
foreign body retention. No delayed foreign-body reactions or
inflammation has been seen with the resorbable polymers
used in this patient series.38
For mandible fractures, the authors have championed the
safe and efficacious use of arch bars in patients during primary
and mixed dentition as a challenge to conventional teaching.
A cohort of 23 pediatric patients with mandible fractures were
successfully treated with the aid of arch bars. There were no
periodontal defects, tooth avulsions, or disturbances to per-
manent dentition noted with regard to arch bar use.39
While some surgeons favor delaying intervention of facial
fractures until swelling resolves, others note the pediatric
craniofacial skeleton’s enhanced healing: loose fragments
may adhere within 3–4 days of injury.26 Converse advocated
prompt repair in the 1960s.40 The authors maintain that if the
decision is made to operate, this should be done early so long
as the degree of swelling is not prohibitive.
Outcomes, prognosis,
and complications
Outcomes and complications in pediatric facial fractures are
understudied. A broad range of complication rates in the lit-
erature (2.6–21.6%) implies vague documentation of these
injuries.9,41,42 Photographic, radiographic, and functional docu-
mentation over time is essential in developing literature to
inform our ongoing treatment of these potentially life-altering
incisive opening, discomfort on mandibular excursion against
symphyseal pressure, and dental step-off. The TMJ can be
evaluated by palpating the external auditory canal while
ranging the jaw. Certain patterns of malocclusion are associ-
ated with specific fractures. Anterior open bite often results
from bilateral condylar/subcondylar fractures secondary to
loss of posterior mandibular height and premature molar
contact. Unilateral posterior condylar/subcondylar fracture
may result in contralateral open bite. Mandible fractures must
trigger suspicion for cervical spine fractures given the proxim-
ity and high-energy nature of these injuries.
Treatment
Certain principles may be applied to the management of all
pediatric craniofacial fractures. In deciding between operative
Fig. 29.5  Sagittal section of the orbit. (A) Orbital floor fracture with preserved
orbital volume secondary to intact periorbita. (B) In contrast, the herniation of
orbital contents secondary to disrupted periorbita in association with a floor
fracture. It is the injury depicted in (B) that is required for enophthalmos or vertical
orbital dystopia.
A
B
Orbital fat
Orbital floor
Periorbita
Periorbita
Septofibrous connections
Septofibrous
connections

683
Outcomes, prognosis, and complications
subsequent growth effects.47,48 Complete resection of the
septum, as in hypertelorism correction, is well documented to
have devastating effects on the growth and development of
the midface.49 Severe bony and cartilaginous central facial
injury has been suggested to result in growth and develop-
mental anomalies in up to 40% of patients.21 However, this
does not represent an undisputed consensus in the literature.
Schliephake et al. examined 12 patients who had suffered
midface fractures during their childhood, and no correlation
was found between the age, the severity of injuries, surgical
treatment, and resulting deformities.50
The contribution of hardware to growth retardation is not
clear. Laurenzo et al. examined the effects of soft-tissue
manipulation, rigid microplate fixation, and multiple osteoto-
mies on the growing midface in rabbits. Disturbances in cra-
niofacial growth were produced by rigid plate fixation as well
as de novo by trauma, independent of fixation.51 Other groups,
however, have demonstrated regional bone growth compen-
sation that may overcome local growth restriction in response
to craniomaxillofacial bone planting in infant rabbits, such
that there is no long-term impairment.52,53 Berryhill et al.
injuries. Meaningful outcomes analysis in this field is depen-
dent on improved standardization of data collection.43 To this
end, the authors have introduced a classification system to
facilitate the clear characterization and discussion of adverse
outcomes in these injuries.44 Type 1 adverse outcomes are
intrinsic to the fracture itself (i.e., blindness following orbital
fracture, tooth loss following mandibular fracture). Type 2
adverse outcomes are directly secondary to surgical manage-
ment (i.e., ectropion following subciliary incision, enophthal-
mos following orbital fracture repair). Type 3 adverse
outcomes are those subsequent to the fracture itself, its treat-
ment, and/or the subsequent altered growth and develop-
ment – such as the development of a class II malocclusion
many years following mandibular fracture (Table 29.1). Spe-
cifically, whether the subsequent mandibular hypoplasia and
class II malocclusion were the result of the mandibular frac-
ture, its treatment with ORIF, or an inherent growth issue that
would have resulted in such a malocclusion despite sustain-
ing a fracture.
Infection, nonunion, and malunion are rare in comparison
to adults; secondary to increased osteogenesis; less frequent
indications for open reduction; and a lower frequency of
severely displaced fractures in children.15 Metallic cranial
hardware may pose a direct hazard to growing children as
it may translocate intracranially secondary to ectocranial
bone deposition and endocranial bone resorption (Figs. 29.15
& 29.16).
Growth outcomes
Growth disturbance secondary to facial trauma is an incom-
pletely understood phenomenon. Furthermore, establishing
whether it is the initial trauma, the subsequent management,
or contributions from both affecting facial growth remains
equally uncertain. Mustoe et al. concluded that closed reduc-
tion of nasal fractures is not deleterious for growth.45 Invasive
rhinoplasty is similarly benign according to Ortiz-Monasterio
and Olmedo.46 Other authors express significant concern for
Fig. 29.6  These are the classic Le Fort fracture patterns described in adult craniofacial fractures: (A) Le Fort I; (B) Le Fort II; (C) Le Fort III. Children exhibit distinct fracture
patterns, as described in the text and demonstrated in Figs. 29.7 and 29.8.
A
B
C
Table 29.1  Authors’ classification system for adverse outcomes
in pediatric facial fractures
Classification
Definition
Example
Type 1
Intrinsic to
fracture
Loss of permanent tooth with
mandible fracture
Type 2
Secondary to
intervention
Marginal mandibular nerve
injury during open
reduction, internal fixation
of mandibular fracture
Type 3
Subsequent to
growth and
development
Asymmetric mandibular
growth after condylar
fracture

684
SECTION II
CHAPTER 29 • Pediatric facial fractures
Secondary procedures
Imola et al. provide a useful overview of secondary pro-
cedures that may be required in managing craniofacial
fractures.55 Soft-tissue deformity and the evolution of a
scarred soft-tissue envelope are the single greatest barriers to
optimal outcomes. Poorly reduced fractures may require oste-
otomy and repeat ORIF. Traumatic telecanthus may require
reported 6 of 96 children with facial fractures undergoing
ORIF to have experienced delayed or restricted growth. As
they state, however, it is impossible to separate the develop-
mental effects of fixation from other intrinsic and extrinsic
factors.54 At an average of 3 years after treatment, the authors’
cohort of mandible fractures did not demonstrate growth
disturbances.10 In severe midface trauma, however, the authors
have described clinically significant impairment in growth in
up to 86% of cases.19
Fig. 29.7  Schematic examples of the oblique craniofacial fracture patterns encountered in children.
3
2
1
4
6
5
9
8
7
10
2
1
1
1
5
1
4
1
3
1
16
8
1
7
1
1
2
0
2
9
1
22
4
2
3
2

685
Cranial base and skull fractures
transnasal fixation; if the medial canthus must be reinserted,
it is essential to ensure sufficiently superior and posterior
positioning. Dorsal nasal deficiency may exacerbate the
appearance of telecanthus, and this may also be surgically
addressed. Mandibular growth disturbances may necessitate
advancement genioplasty or distraction. Secondary correc-
tion of enophthalmos requires anterior globe repositioning,
reduction of the orbital contents, and/or osteotomy and
repositioning of skeletal components. VOD may require four-
wall osteotomies for optimal results.55 Diplopia may occur
secondary to extraocular muscle dysfunction and/or globe
malposition; the inferior rectus and superior oblique are the
muscles most commonly involved. Growing skull fractures
require dural repair and cranioplasty. Hardware removal may
be indicated to minimize growth disturbances, to avoid risks
associated with transcranial migration, or if the hardware is
causing discomfort or aesthetic concern. Initial conservative
approaches to nasal trauma is often practiced to mitigate
iatrogenic impact on growth, albeit in the knowledge that
definitive septorhinoplasty will likely be required to restore
form at skeletal maturity.
Cranial base and skull fractures
Diagnosis and presentation
In children, between 10% and 30% of head injuries result in
skull fracture. It is important to remember that for the growing
child prior to development of a frontal sinus, forehead trauma
could result in skull and cranial base fractures. Patients must
be evaluated for evidence of fracture displacement, cerebro-
spinal fluid (CSF) leak, intracranial hematoma, deformed
facial contour, frontal-lobe contusion with mass effect, and
growing skull fracture. These may be indications for operative
management.
Fig. 29.8  Computed tomography (CT) scans in the axial plane demonstrate an oblique fracture at the level of the cranium (left) and cranial base (center). Right, the CT
scan represents a sagittal reconstruction of the same patient, with the course of the oblique fracture outlined in red.
Fig. 29.9  Anatomical vocabulary pertaining to the mandibular condyle. The
condylar head is green (except its articular surface, which is blue), the condylar
neck is yellow, and the subcondylar region is orange. Vague terminology in
reference to these structures often causes confusion in the clinic and in the
literature.

686
SECTION II
CHAPTER 29 • Pediatric facial fractures
for fracture elevation, frontal sinus repair, open fracture
debridement, or cosmetic repair; 7.5% required intervention
for treatment of a traumatic brain injury including hematoma
evacuation, external ventricular drain (EVD) placement, or
decompressive craniectomy.57
Goals of cranial base and skull fracture repair include
protection of the neurocapsule, dural reconstruction and
control of CSF leaks, prevention of infection, and aesthetic
restoration of craniofacial contour. A functioning sinus capable
of adequate drainage through growth and development must
be achieved. A coronal incision allows for craniotomy and
ORIF (Figs. 29.17–29.19). After exposing fractures with sub-
periosteal dissection, fracture fragments must be removed to
inspect the underlying dura. Epidural hematomas are evacu-
ated, and dural lacerations are repaired by the pediatric
neurosurgical team. The bone fragments are then replaced
and fixated. Caution must be exercised in manipulating
frontal–temporal orbital fractures given the proximity to the
Treatment
Pediatric skull fractures remain distinct from their adult
counterpart with a greater capacity to heal and remodel such
that the majority of pediatric skull fractures can be managed
conservatively.56,57 The authors performed a retrospective
review of 897 pediatric patients with a skull fracture. Of these
patients, 86% were treated non-operatively. The remaining
patients were grouped according to the indication for their
surgical intervention; 6.5% underwent repair of the fracture
Fig. 29.10  (A) Axial computed tomography scan demonstrating condylar head fractures. (B) Coronal view of a condylar neck fracture. (C) Serial coronal views of a
subcondylar fracture. (Reproduced from Mathes S, Hentz V. Plastic Surgery, 2nd edn. Philadelphia, PA: Elsevier; 2006.)
A
B
C
Fig. 29.11  Coronal computed tomography scan demonstrating an orbital floor
fracture with an entrapped inferior rectus muscle on the patient’s left side.
Fig. 29.12  Patient with an entrapped left inferior rectus. He is being instructed to
“look up”, but is unable to do so with his left eye due to the entrapped inferior
rectus.
Fig. 29.13  Superior orbital fissure (SOF) syndrome may well result from the injury
demonstrated in this axial computed tomography scan, in which a left frontal–
temporal–orbital fracture has collapsed the SOF. (Reproduced from Mathes S,
Hentz V. Plastic Surgery, 2nd edn. Philadelphia, PA: Elsevier; 2006.)

687
Cranial base and skull fractures
spontaneously regenerate large calvarial defects, yet in whom
split calvarial grafts are unreliable due to an underdeveloped
diploic space.60,61 This is controversial, however, as several
authors have described split calvarial grafts in young children,
even those less than 1 year of age.62–64 It is the authors’ belief
that despite the technical ability to split calvarial bone, the
concern lies in the quality of the bone product obtained for
reconstruction. Significant donor site morbidity (infection,
pain, hemorrhage, and nerve injury) in up to 8% of patients,
as well as low tissue yield, limits the usefulness of autogenous
middle meningeal artery. For patients mature enough to have
a frontal sinus, Rodriguez et al. present a useful algorithm of
approach.58 If the nasofrontal duct is obstructed, obliteration
or cranialization is indicated (see Fig. 29.18). Advantages of
cranialization over obliteration include wide exposure of the
injured area and single-stage elimination of the sinus as a
potential focus of infection. If the duct is traumatized but still
patent, nondisplaced anterior and posterior table fractures
can be carefully followed. Severely displaced anterior table
fractures can be reconstructed. If the frontal sinus is preserved,
serial CTs must be followed to ensure proper sinus develop-
ment and adequate drainage, and the nasofrontal ducts may
be stented via an endonasal approach. The presence of a CSF
leak directs management decisions regarding frontal sinus
fractures.59 Leaks are observed for 4–7 days of bed rest, pos-
sibly with lumbar drain, and cranialization is performed if the
leak persists. If the leak stops and the nasofrontal duct is
unobstructed, the sinus may be preserved. In the case of an
autocorrected leak with an obstructed duct, anterior table
ORIF is accompanied by “partial obliteration” (use of fracture
fragments to obliterate only the nasofrontal duct and the base
of the frontal sinus) following complete removal of sinus
mucosa. For the patient with a minimal to moderate isolated
anterior table fracture with cosmetic concerns only, the authors
have reported on a single 11-year-old patient with a depressed
frontal sinus fracture who was a candidate for surgical repair.
The patient chose no treatment, and at 1-year follow-up the
fracture was entirely remodeled – presumably secondary to
ongoing development and the complete pneumatization of
the immature frontal sinus.56
For the immature patient, cranial bone loss is a difficult
problem, especially in children too old (over 2 years) to
Fig. 29.14  Coronal computed tomography scan demonstrating a right frontal–
temporal–orbital fracture. The lateral orbital wall is compressed medially,
decreasing orbital volume and resulting in exophthalmos. (Reproduced from Mathes
S, Hentz V. Plastic Surgery, 2nd edn. Philadelphia, PA: Elsevier; 2006.)
Fig. 29.15  (A, B) The skull increases in thickness with craniofacial development
in a relationship reported by Pensler and McCarthy. (Redrawn from Pensler J,
McCarthy JG. The calvarial donor site: an anatomic study in cadavers. Plast
Reconstr Surg. 1985;75:648.)
0
2
4
6
8
10
12
50
0
100
150
200
Age (months)
Skull thickness (mm)
250
300
A
B
Fig. 29.16  Endocranial surface of a calvarial bone flap demonstrating transcranial
migration of metallic hardware in a pediatric patient. (Reproduced from Guyuron B,
Erikkson E, Persing J, et al. Plastic Surgery: Indications and Practice. Philadelphia,
PA: Elsevier; 2008.)

688
SECTION II
CHAPTER 29 • Pediatric facial fractures
appearing cranial base fractures. Growing skull fractures
complicate 0.03–1% of skull fractures and usually occur in
patients younger than 3 years of age.72,73 Missed growing skull
fractures may lead to gliosis, lateral ventricular dilation,
cerebral herniation, pulsatile exophthalmos, and VOD.28
In the authors’ series, of those patients undergoing surgical
intervention for cranial and skull base fractures, 42% experi-
enced complications, of which 24% were surgery related and
76% were related to the initial trauma. These included wound
infection, painful hardware, and CSF leaks.
Orbital fractures
Diagnosis and presentation
The clinical diagnosis of pediatric orbital fractures may be
complicated by the difficulty of achieving a complete exami-
nation in an uncooperative patient. When there is any suspi-
cion of fracture or neurological injury, CT scanning should
bone grafts.65 Bone substitutes are limited by a lack of biocom-
patibility and susceptibility to infection.66 In patients with
favorable wound conditions, the authors favor a bilaminate
construct composed of intra- and extracranially placed biore-
sorbable mesh with interposed demineralized bone matrix
mixed with bone dust and chips.67 The authors are cautiously
optimistic that a potential future role may exist for protein
therapy in pediatric craniofacial reconstruction.68,69 The role of
prophylactic antibiotics in pediatric skull fractures remains
unclear.
Outcomes, prognosis, and complications
These injuries may be complicated by CSF leak, meningitis,
sinusitis, mucoceles, mucopyoceles, or brain abscesses. CSF
leaks usually resolve spontaneously within 1 week; if the leak
persists, a 5–7-day lumbar drain trial should precede opera-
tive intervention.70,71 A cranial base fracture with an occult
dural disruption may lead to a “growing skull fracture” sec-
ondary to cerebral pulsations enlarging even innocent-
Fig. 29.17  (A) Frontal bone fracture after a motor vehicle collision. The bone fragments are mapped out as shown in (B) before they are reconstructed with absorbable
plates, as in (C). (D) The 6-month follow-up result. (Reproduced from Guyuron B, Erikkson E, Persing J, et al. Plastic surgery: indications and practice. Philadelphia, PA:
Elsevier; 2008.)
A
B
C
D
Fig. 29.18  Fracture of frontal bone.
Fig. 29.19  The fracture shown in Fig. 29.18 has been reconstructed according to
the method depicted in Fig. 29.17.

689
Orbital fractures
faster than the soft tissues can recoil, and the bony edges of
the fracture incarcerate the trapped soft tissue, strangulating
it. As well, for those children who do have phenotypically
“adult-like” orbital fractures resulting in bony displacement
and defect, resulting enophthalmos and VOD are less likely
to occur, possibly due to more elastic and robust orbital
periosteum and supporting ligaments (Fig. 29.20).76
Treatment
In the absence of entrapment or acute globe malposition
(enophthalmos and/or VOD), orbital fractures in children
are otherwise treated non-operatively; the predictors of late
enophthalmos described for adults may be less relevant in
children due to the hypothesized resistance of ligaments
and periosteum to tearing, thereby preventing expansion of
intraorbital volume and possibly guiding subsequent bone
healing.76–81 Stronger supporting structures may render open
reduction, internal fixation (ORIF) less necessary in these
fractures. The authors analyzed operative necessity in the
context of a three-group orbital fracture classification system
(n = 81): type 1, pure orbital fractures (limited to the orbit
without extension to adjacent bones); type 2, craniofacial
fractures (oblique fractures extending from the skull into the
orbital roof and face); type 3, orbital fractures contributing to
described patterns (impure blowout, ZMC, NOE) (Table
29.2).76 Type 1 fractures were non-operative (88%) unless there
was evidence of acute enophthalmos, VOD, or muscle entrap-
ment on forced duction. Type 2 fractures were managed
conservatively and tracked with serial scans until an ab-
solute operative indication was encountered (17% were ulti-
mately operative). Type 3 fractures were more likely (72%) to
require operative intervention because of the functional dis-
ability secondary to enophthalmos and/or VOD. Overall, 23
(28.3%) orbits were managed operatively.76 Success with this
conservative strategy is evidenced by a low rate of adverse
outcomes.
The goals of orbital fracture treatment include the restora-
tion of globe position and the correction of diplopia. If
ORIF is necessary, some authors have opined that the
Fig. 29.20  Galeal flaps pedicled at the level of the brow have been raised to line
the reconstructed anterior cranial base. A maneuver such as this is required to
ensure that a barrier is in place to protect the intracranial contents from “the outside
world”. (Reproduced from Guyuron B, Erikkson E, Persing J, et al. Plastic Surgery:
Indications and Practice. Philadelphia, PA: Elsevier; 2008.)
Table 29.2  The authors’ orbital fracture classification system
Type 1
Pure orbital fractures
1a
Floor fractures
1b
Medial wall fractures
1c
Roof fractures
1d
Lateral wall fractures
1e
Combined floor and medial wall fractures
Type 2
Craniofacial fractures
2a
Growing skull fractures
Type 3
Orbital fractures associated with common
fracture patterns
3a
Fractures of the floor and inferior orbital rim
3b
Zygomaticomaxillary fractures
3c
Naso-orbito-ethmoid fractures
3d
Other fracture patterns
ensue. In 1965, Soll and Poley published a paper on 4 young
patients with a history of orbital trauma with minimal evi-
dence of injury on imaging. During surgery, they noted orbital
tissues trapped within linear or wedge-shaped floor fractures.
This report was the first to demonstrate that the internal
orbital fractures in children are different than those in adults.
Whereas adults have comminution, pediatric orbital fractures,
with children’s more flexible bones, tend to sustain linear
and/or trapdoor fractures.74 In 1998, Jordan and colleagues
coined the term white-eyed blowout fracture. They are white-
eyed because there is no subconjunctival ecchymosis.36 The
eye looks uninjured; however, the patient will have severe
restriction of gaze secondary to entrapped tissue in a fracture
line that may be so small that there is no CT evidence of a
fracture, but the involved rectus muscle is not within the orbit,
instead being found within the sinus; so-called “missing
muscle syndrome”.75 This is often associated with the oculo-
cardiac reflex (bradycardia, nausea and syncope) and is an
absolute indication for urgent surgical intervention. The
mechanism by which these injuries occurs is an increase in
intraorbital pressure from the traumatizing force, which
creates a linear or trapdoor fracture of the bony floor or wall.
As the fracture opens, the periorbital soft tissues are pushed
through the open space. Because the bones in children are
elastic, the bone snaps back into position very quickly, much

690
SECTION II
CHAPTER 29 • Pediatric facial fractures
be no vertical asymmetry (hyperglobus) of the reconstructed
globe, because this will not change as the edema resolves.
Care must be taken to resuspend midface soft tissues when
closing the incisions.
Outcomes, prognosis, and complications
As with adults, potential complications include retrobulbar
hematoma, orbital cellulitis, lid malposition, persistent
enophthalmos and persistent diplopia.84 Retrobulbar hema-
toma is an uncommon but potentially vision-threatening
complication that presents with worsening pain, proptosis,
internal ophthalmoplegia, impairment, or loss of the pupil-
lary reflex. Management necessitates orbital decompression
with urgent lateral canthotomy and cantholysis as well as
adjunctive pharmacologic treatment with mannitol, acetazol-
amide, corticosteroids, and timolol. Orbital cellulitis is also
rare but may be more common if there is evidence of concomi-
tant paranasal sinusitis at time of fracture or operative repair.
Periorbital pain, erythema, and edema warrants treatment
with intravenous antibiotics and surgical drainage of any
abscess. If left untreated, it can lead to blindness, cavernous
sinus thrombosis, meningitis, or cerebral abscess. There is no
evidence that routine antibiotic prophylaxis affects risk. Lid
retraction/ectropion and entropion are a risk of any incision
in the lid with a higher risk of ectropion seen with subciliary
incisions. This may be temporary and respond to lid massage
and closure exercises if mild. If persistent, repair is not easily
remedied and may involve canthopexy, mucosal grafts, and
skin grafts. Some orbital fractures will result in diplopia due
to initial edema or trauma to the orbital contents, similarly
seen in the early postoperative period. Persistent postopera-
tive diplopia, despite adequate surgical correction, may
necessitate strabismus surgery. Enophthalmos can be mea-
sured objectively by exophthalmometry or subjectively by
noting posterior displacement of the globe on worm’s-eye
view, asymmetry of the upper eyelid creases, and asymmetry
in the distance between ciliary margin and superior and
inferior limbus.76 Enophthalmos can sometimes be corrected
by orbital floor or wall bone grafting, but may require osteoto-
mies and bony relocation and possibly lateral or medial
canthal adjustment.
In the authors’ series, 10.7% of isolated orbital fractures
suffered adverse outcomes: type 1: 3.6%; type 2: 3.6%; and
type 3: 3.6%. Three patients with isolated orbital fractures had
enophthalmos, all less than the clinically significant threshold
of 2 mm. Persistent diplopia did not occur in the authors’
series but was reported to be as high as 36% in a study by
Cope et al.76,85
Nasal and naso-orbito-ethmoid
fractures
Diagnosis and presentation
Children’s noses are structurally different from the adult nose.
The pattern of injury follows this underlying anatomy. In very
young children, nasal fractures are uncommon because of
the underdeveloped nasal bones. Instead, the projecting soft
tissues of the anterior nose are composed of compliant carti-
lages. These easily bend during facial trauma. Blunt force is
transconjunctival approach to the orbit is preferred secondary
to good cosmesis and a lower risk of ectropion. If lateral
exposure is necessary, a subciliary or mid-lid incision with
lateral “crow’s foot” extension avoids the lateral cantholysis
that may be necessary with a transconjunctival incision and
affords generous exposure extending to the lateral–superior
orbital rim/orbit. If medial exposure is necessary, a transcar-
uncular approach is performed, often obviating the need for
a coronal incision. A gingival buccal sulcus incision can be
added if necessary. Herniated tissues are reduced from the
fracture, the fracture is cleared of debris, and stable founda-
tions for fixation and grafting are identified (in the pediatric
population, this being autologous bone and/or resorbable
mesh).
In adults, because of the thinness of the bony orbital walls,
the bone usually shatters when injured, so one cannot simply
reduce the bones of the orbit. The bones are missing or non-
usable. Sheets of bone or another biomaterial are required to
replace the bony walls to restore the pretrauma anatomy. With
linear or trapdoor fractures in the pediatric patient, however,
once the soft tissues have been carefully removed from the
fracture, the defect may not require reconstruction. If the
defect has been made larger or a residual defect exists, recon-
structing it with whatever biomaterial the surgeon chooses
may be necessary.82 Particularly for the pediatric population,
there are advocates for resorbable implants. Typically, this
involves the use of a material made of a polymer of polylactic
and polyglycolic acid. These implants all resorb over one or
more years. Theoretically, the implant leaves a sheet of fibrous
tissue, allowing support of the globe that is sufficient once the
implant has resorbed, and published studies have not shown
problems with enophthalmos once the implant is gone.81
Alternatively, split calvarial grafts can be used (Fig. 29.21).
Some surgeons suggest that over time these can remodel to
recapitulate normal anatomy and growth. In the case of repair
of orbital floor fractures, irrespective of the implant used,
placement along the orbital floor behind the vertical axis of
the globe to recreate the convexity or upward bulge of the
maxillary sinus is important to maintain the anterior position
of the globe.82,83 The implant should be secured to prevent
mobility and/or extrusion. In the operating room, immedi-
ately after reconstruction, the surgeon should evaluate globe
position; and a slightly overcorrected, proptotic appearance
to the eye is the hallmark of an anatomic reconstruction,
owing to edema induced by surgery. However, there should
Fig. 29.21  Coronal computed tomography scan demonstrating orbital
reconstruction with split calvarial grafts (the image on the right is a magnified view
of the area outlined in red in the image on the left).

691
Nasal and naso-orbito-ethmoid fractures
closed reduction may be inadequate secondary to insufficient
release of tension on the septum, cartilages, and bony pyramid.
However, aggressive open treatment in children has signifi-
cant potential to affect facial growth adversely. Therefore a
closed reduction is usually offered to children with definitive
open management delayed until skeletal maturity. Uncompli-
cated injuries to the nasal septum (i.e., septal cartilage disloca-
tions from the maxillary crest) can also be managed in a closed
fashion.
Pediatric patients, given their ability to heal more quickly,
need reduction sooner, typically 3–7 days after injury.87–90
Several authors have, however, demonstrated no significant
differences in outcomes of airway obstruction and cosmesis
between pediatric nasal fractures treated early and those with
relatively delayed treatment.91,92
Septorhinoplasty following trauma in pediatric patients
should arguably be reserved for severely displaced fractures,
nasal obstruction resulting in sleep apnea, chronic mouth
breathing (causing malocclusion), and chronic refractory
sinus disease. Specific to the pediatric patient undergoing
nasal surgery is the discussion that the expected benefits of
an early intervention have to outweigh the possibility of iat-
rogenic inhibition of nasal growth. It should also be made
clear that the short-term postsurgical improvements may
diminish with future nasal growth and that revision surgery
is a possibility. Intuitively, surgery should be less aggressive
in younger children.25 Another important caveat for pediatric
patients is that a septoplasty can be safely performed as long
as the surgeon avoids the growth center at the nasal spine of
the maxilla.87
Pediatric NOE fractures are treated as in adults, and inter-
canthal distance must be restored to age-specific norms (Table
29.3) by reduction of the medial orbital rims. If necessary, the
medial canthal tendons are reattached with transnasal wires
passing superior and posterior to the posterior lacrimal crest
(type 2 and 3 NOE fractures of the classification of Markowitz
et al.).93 A cantilever bone graft is employed to restore the
nasal dorsal height. Complicated NOE fractures are exposed
by coronal, inferior orbital rim, and gingival buccal sulcus
incisions. As with pediatric septorhinoplasty, because of
ongoing growth, children with NOE fractures may have a
higher likelihood of requiring additional secondary surgery.86
A high index of suspicion for intracranial injury must be
maintained for fractures extending to the anterior skull base.
Outcomes, prognosis, and complications
Nasal fractures may result in an appearance deformity or
functional airway obstruction. Nasal deviation may result
dissipated across the maxilla and its buttresses. Subsequently,
this results in widespread generalized edema. However,
septal cartilage dislocation can result in acute airway obstruc-
tion and cause long-term growth disturbances. Children
younger than 2 years tend to have flexible bones, making
greenstick fractures more common. After the age of 2 to 3
years, increased bone mineralization makes greenstick frac-
tures less common.86,87
Patients should be evaluated for subjective nasal airway
obstruction and assessed for nasal deviation, compressibility
of the nasal dorsum, lacerations, crepitus, edema, tenderness,
depression, and deviation, or widening of the nasal base.
Adequate internal examination requires a nasal speculum.
Attention should be directed to an evaluation of the septum
to rule out associated hematoma, fracture, or obstruction.
NOE fractures are characterized by posterior and lateral
displacement of the nasal bones and medial orbital rims, with
fractures of the medial orbital walls and ethmoids. A free
medial orbital rim segment containing the insertion of the
medial canthus (the “central fragment”) (Fig. 29.22) results in
traumatic telecanthus. Even if not immediately apparent,
telecanthus may develop 7–10 days after trauma. Other typical
deformities suggesting NOE fracture include a shortened
nose with upturned tip and saddle nose deformity with
blunted dorsal nasal projection. The lack of a well-developed
frontal sinus in young children decreases this region’s ability
to absorb blunt force and act as a “crumple zone”, resulting
in force being directed into the supraorbital bar, basilar skull,
and intracranially. Hence, heightened suspicion of intracranial
injury is mandatory in a child with NOE fractures.86,87
Treatment
Septal hematomas warrant immediate intervention with an
incision through the mucoperiosteum. If bilateral septal inci-
sions are made, overlap must be avoided as septal perforation
may result. Dead space may be eliminated with septal quilt-
ing sutures or internal splints to compress the mucoperichon-
drium to the septal cartilage.
Non-displaced or minimally displaced nasal fractures may
be externally splinted. In the case of a displaced fracture,
Fig. 29.22  Coronal computed tomography scan demonstrating bilateral naso-
orbito-ethmoid fractures with their requisite “central fragments”.
Table 29.3  Age-specific norms for interorbital distance (IOD)
Age
Normal interorbital distance
Newborn
10–15 mm
2-year-old
20 mm
12-year-old
25 mm
Adult
35 mm
Radiographically: IOD = dacryon to dacryon. Clinically: IOD = Medial intercanthal
distance (MICD) – (4–6 mm).

692
SECTION II
CHAPTER 29 • Pediatric facial fractures
periorbital ecchymosis, edema, oral mucosa and conjunctival
hemorrhage, and flattening, widening, and elongation of
the middle third of the face. Assessment of facial contour,
including dental arches, palate, nasal bridge, forehead, zygo-
maticofrontal, and zygomaticomaxillary sutures, may reveal
tenderness, malocclusion or mobility suggestive of fracture.
Confirmation with CT imaging is the gold standard especially
given that Greenstick fractures arise in higher frequency in
children and are otherwise of increased difficulty to detect.95,96
Treatment
Treatment of pediatric midface fractures again is similar to in
the adult and must aim to achieve satisfactory reduction and
sufficiently stable fixation to permit bone healing whilst
avoiding disturbance to future growth.
Non-operative management is indicated for minimally
displaced and greenstick midface fractures, especially in
younger children. Conservative management in such cases is
characterized by soft diet and regular re-examination until
fracture healing.
Displaced and unstable fractures require either closed
reduction and splinting with mandibulomaxillary fixation
(MMF) or ORIF. The requirements for both the rigidity and
length of fixation are less than those of adults. Incompletely
developed dentition can render arch bars difficult to apply,
often requiring creative strategies such as circum-mandibular
wiring and piriform suspension wiring (Figs. 29.23 & 29.24).
Arch bars, despite conventional teaching, can, however, be
safely employed during primary and mixed dentition.39
Depending upon the patient’s age, shorter courses of MMF
are acceptable; some authors advocate fixation for 1 week or
less,1 followed by dental elastics in the very young.
When ORIF is necessary, the operator must avoid injuring
developing tooth buds when plating the facial buttresses.
Furthermore, resorbable plating systems are gaining increas-
ing popularity for their perceived decreased risk of resul-
tant growth disturbances compared with their permanent
from cartilaginous warping or incomplete reduction. An
untreated septal hematoma may yield septal thickening or
perforation, and ultimate saddle-nose deformity. Excessive
callous formation and bony overgrowth may lead to a dorsal
hump. As previously stated, these may require secondary
septorhinoplasty. As such, long-term follow-up with postop-
erative examination and photographic documentation is
essential. There are few long-term follow-ups to address pos-
sible growth disturbances after pediatric NOE fractures.
One review included 20 patients who sustained midface
fractures with an NOE component. Eight (40%) of these
patients required further surgery for various deformities; of
these, 6 required additional bone grafting to the nasal dorsum
and canthal repositioning, 1 required further frontal bone
recontouring, and 1 had midface hypoplasia.21 One study
reports a 5% rate of late lacrimal obstruction after ORIF of
NOE fractures. This is managed with dacrocystorhinostomy.94
In the authors’ series, 21.7% of nasal fractures exhibited
adverse outcomes (type 1: 8.7% and type 3: 17.4%) consisting
of persistent nasal deformity or airway obstruction.8 Second-
ary corrective surgery should be delayed until after skeletal
maturity unless clinically significant nasal airway obstruction
is present.
Maxillary, zygomaticomaxillary
complex and midface fractures
Diagnosis and presentation
Clinical symptoms and signs of these midfacial fractures are
similar to adults; however, because of the aforementioned
small paranasal sinuses and unerupted tooth buds in children,
midface fractures of the classical Le Fort patterns are unusual.
Examination of the patient may reveal palatal, vestibular, and
Fig. 29.23  Creative mandibulomaxillary fixation strategies are often required in
children.
Fig. 29.24  Drop piriform wires being placed for mandibulomaxillary fixation in a
pediatric patient. (Reproduced from Guyuron B, Erikkson E, Persing J, et al. Plastic
Surgery: Indications and Practice. Philadelphia, PA: Elsevier; 2008.)

693
Mandible fractures
of a surgical airway may be necessary. Cervical spine and
head injury must also always be considered and be evaluated
for with clinical examination and CT imaging as appropriate.
Lacerations, ecchymosis, and edema may herald underly-
ing fractures locations. Classically, a submental laceration is
suggestive of a superiorly orientated midline force and pos-
sible injury to the condyles. Paresthesias in the distribution of
the inferior alveolar nerve can result from body fractures.
Lingual and buccal paresthesias can also occur in displaced
fractures. The patient should be asked about how his or her
bite feels and about pain, particularly. Drooling and trismus
may be seen in association with mandible fractures. Bimanual
examination of the mandible can reveal bony step-offs. Palpa-
tion of the temporomandibular joints at the external auditory
canal during jaw movement may disclose a displaced condy-
lar head or crepitation. External auditory canal bleeding and
ecchymosis can also occur. Thorough intraoral exam must
also be performed to assess occlusion and any dental injury.
Panorex was historically considered to be the imaging modal-
ity of choice, although this has now largely been superseded
by CT imaging. The most fundamental aspect of diagnosis
and the need for intervention is determination of any subjec-
tive malocclusion.97
Treatment
Goals in the management of mandible fractures include the
preservation or restoration of normal occlusion and the
achievement of bony union while minimizing potential
growth disturbance and injury to developing tooth follicles.
For the immature skeleton, the exfoliation of primary teeth
and subsequent ability to remodel the jaws, as well as the
possibility of future orthodonture, favors the acceptance of
minor occlusal discrepancies, rather than aggressive treat-
ment (i.e., ORIF) to restore “perfect” occlusion, in the child
with mixed dentition.
Nondisplaced fractures
Nondisplaced or minimally displaced mandibular fractures
with normal occlusion in young children may be treated
with jaw rest and immobilization with a “jaw bra” and/or
cervical collar and liquid diet with regular re-examination
until healed.11 Minor malocclusions after fracture healing can
be managed with orthodontics. Dentoalveolar fractures can
often be managed conservatively with occlusive splinting,
arch bars, or bonded wires in combination with soft diet, good
oral hygiene, and mandible rest. Many pediatric patients are
in mixed dentition; aside from wear facets, preinjury dental
records are the surgeon’s only ally in establishing preopera-
tive occlusion. Occlusive splints can be fabricated based on
these materials. If necessary, MMF may require creativity in
children (see Figs. 29.23 & 29.24) but can be safely practiced.39
Condylar fractures
Assuming preserved occlusion, the operative indications for
condylar fractures are more controversial. The pediatric con-
dyles are regarded as growth centers, sensitive to disruptions
of blood supply and morphology with resultant susceptibility
to ankylosis and altered mandibular development.98 Intracap-
sular injuries should be managed conservatively to minimize
growth disturbance and TMJ ankylosis; the pediatric mandible
counterparts. Otherwise, strategies of ORIF of midface
fractures replicate those practiced in adults. Operative goals
in ZMC fracture management, therefore, include resolution of
orbital injury (VOD, enophthalmos), correction of malocclu-
sion, and the restoration of appearance (malar flattening). The
zygoma is aesthetically responsible for the malar eminence,
and an inferiorly displaced zygoma may displace the lateral
canthus via its attachment to Whitnall’s tubercle. Access to the
ZF suture may be gained through a subciliary incision, a sub-
conjunctival approach with lateral cantholysis, or the lateral
portion of an upper lid blepharoplasty incision. Additional
exposure is obtained with an upper buccal sulcus incision.
Some authors have reported that medially impacted large
fragment fractures may be addressed through an upper gingi-
val buccal sulcus incision alone with exposure of the anterior
face of the zygoma, fracture reduction, and confirmation of
orbital floor continuity with endoscopy via the maxillary
sinus.31 It is generally accepted that adequate reduction at
the lateral wall of the orbit or the greater wing of the sphenoid
is essential to proper reconstruction; reduction must also be
achieved at the lateral orbital rim/ZF suture, inferior orbital
rim, and the zygomaticomaxillary (ZM) buttress. Fixation is
then performed sequentially at the ZF suture, the inferior
orbital rim, and the ZM buttress. The operator must ensure
that orbital volume and morphology are not altered by the
initial injury or the reduction, and floor reconstruction may
be required in the procedure.34
Outcomes, prognosis, and complications
Maxillary fractures may result in nasolacrimal obstruction or
malocclusion. Adverse outcomes following ZMC fracture
repair include persistent infraorbital nerve (V2) hypothesia,
enophthalmos, VOD, facial widening, malar flattening,
canthal deformity, and ectropion secondary to lower lid
approaches. Zygomatic–coronoid ankylosis may occur after
severe zygomatic fracture.31 Pediatric patients undergoing
MMF may be particularly vulnerable to malnutrition which
is best avoided by thorough nutritional counseling, proper
education, and resource availability.
The authors have followed a cohort of children suffering
from midface fractures over time in a long-term growth and
development study. Severe pediatric midface trauma (i.e.
involving orbital fractures and at least half the midface but-
tresses) was found to often result in compromised bone
growth and permanent facial deformity. Surgical intervention
to restore projection and realignment is a necessity in these
massive injuries, which are rare. The relative contribution of
injury pattern and severity, as well as operative management,
on growth and development remains unclear.19
Mandible fractures
Diagnosis and presentation
Children with mandibular trauma are at risk for airway
compromise. Airway obstruction must first be addressed
with repositioning, suctioning, or finger sweep (to remove
any blood, loose teeth or foreign bodies, etc). Maneuvers such
as jaw thrust, anterior traction, or a tongue stitch may also be
adopted. Ultimately, endotracheal intubation or establishment

694
SECTION II
CHAPTER 29 • Pediatric facial fractures
older children since the condyles are less likely to regenerate
in children greater than 7 years of age and may require even-
tual osteotomy and cartilage grafting for TMJ function and
normalization of occlusion.99,100 In the case of bilateral neck
fractures in the older patient, ORIF of one side is reasonable,
with a short course of intermaxillary fixation. Other indica-
tions for open management include a foreign body in the TMJ,
failure to normalize occlusion with closed management, and a
condyle displaced into the middle cranial fossa. Every effort
should be made to avoid open management for intracapsular
fractures, high condylar neck fractures, coronoid fractures,
and any fracture in which there are no barriers to motion and
baseline occlusion is preserved.11,101 Condylar head fractures
themselves are treated with a short course of rest followed
by physical therapy (such as gum chewing). A condylar head
fracture in the presence of another mandible fracture is an
indication for ORIF of the other fracture to allow for early TMJ
motion. Of the 96 consecutive patients in the authors’ series,
53% underwent operative management.10 For combined
condylar and parasymphyseal fractures, the most common
bilateral mandible fracture combination, rigid fixation of the
parasymphyseal fracture whilst allowing range of motion
at the TMJ, can be achieved with customized IMF hooks
(Fig. 29.25).
Displaced fractures
For displaced fractures with malocclusion requiring open
treatment, existing lacerations and an intraoral approach
should be utilized whenever possible. Given the immature
mandible’s ability to remodel under masticatory forces, as
well as its amenability to orthodontic manipulation, it is wise
to accept imperfect reduction and occlusion in order to pre-
serve developing tooth follicles. Interosseous wiring of the
mandibular border and a dental bridle wire and/or a short
course of MMF may be adequate to maintain reduction (Fig.
29.26). If internal bony fixation is necessary in young patients,
has the potential to undergo restitutional remodeling (condy-
lar head regeneration). Unilateral condylar neck fractures are
often adequately managed with closed reduction, arch bars,
and contralateral elastics. Bilateral condylar neck fractures
with a loss of posterior height and resultant anterior open bite
may require a more aggressive approach. In younger children,
these fractures can be managed with closed reduction and
external fixation (MMF for 2–3 weeks). Some argue for a more
aggressive approach to dislocated condylar neck fractures in
A
B
Fig. 29.25  Custom IMF hooks allow for range of motion at the TMJ with rigid
fixation of parasymphyseal fracture in combined condylar and parasymphyseal
fractures.
C
Fig. 29.26  Circumdental suture functions as a bridle wire in combination with an
inferiorly placed monocortical adsorbable plate for a symphyseal fracture in a child.
(Reproduced from Guyuron B, Erikkson E, Persing J, et al. Plastic Surgery:
Indications and Practice. Philadelphia, PA: Elsevier; 2008.)

695
Conclusions
was of functional significance. Type 1 outcomes were seen
in 20% of operative patients and in 0% of conservatively
managed patients (P = 0.05), type 2 outcomes were seen in
13.3% of operative patients and in no conservatively managed
patients (P = 0.115), and type 3 outcomes were seen in 66.7%
of operative patients and in 45% of conservatively managed
patients (P = 0.402).10 In another reported series, patients were
at most risk for growth disturbances and facial asymmetry if
they sustained mandibular fractures between 4 and 7 years
of age and least likely to have growth sequelae if they were
injured prior to 4 years of age (children greater than 11 years
of age experienced an intermediate rate of growth distur-
bance) (Fig. 29.27). The authors of this series explain this age
distribution by positing that children in the youngest group
have better condylar blood flow, allowing for regeneration
and avoidance of growth disturbances; moreover, they note
that the majority of mandibular growth spurts occur at either
end of their 4–7-year-old age group.103
Conclusions
The craniofacial skeleton undergoes a dramatic structural and
topographical metamorphosis as it matures from the infant to
the adult state. The neonatal skull is profoundly different
from its adult counterpart and therefore responds to traumatic
forces with unique injury patterns. Specific functional and
aesthetic criteria must be met in reconstructing the various
regions of the pediatric craniofacial skeleton. These objectives
must be achieved with strategies that properly balance respect
for future growth. Craniofacial development, along with the
resilience of the pediatric skull and supporting structures,
often facilitates a less invasive approach to managing these
complex injuries. Key principles of facial fracture manage-
ment, unique to the pediatric population, include recognizing
the potential for growing skull fractures, determining inter-
vention for orbital fractures upon clinical rather than radio-
logic findings, and accepting mild malocclusion in pediatric
mandibular fractures.
monocortical screws should be utilized and hardware should
be placed at the inferior mandibular border to avoid injury
to developing tooth buds. Alternatively, resorbable plating
systems can be used.102
Outcomes, prognosis, and complications
Mandible fractures may be complicated by growth disturbances
or functional impairment such as malocclusion, trismus, or
TMJ ankylosis. Marginal mandibular nerve injury may result
from surgery. In the authors’ series of 215 mandible fractures
in 120 patients, each child undergoing surgery had a 63%
chance of an adverse outcome as compared to 17% in children
receiving conservative therapy. However, none of the adverse
outcomes recorded (i.e., limited TMJ opening, persistent pain)
Fig. 29.27  Cephalogram of a patient 2 years after a left mandibular body fracture.
The left mandibular ramus, angle, and body demonstrate decreased growth relative
to the contralateral side.
4. Ferreira PC, et al. Pediatric facial fractures: a review of 2071
fractures. Ann Plast Surg. 2016;77:54–60. This large series describes
nearly 1500 pediatric facial fracture patients over a 20-year period.
Fracture patterns, demographics, and associated injuries were  
assessed.
10. Smith DM, et al. 215 mandible fractures in 120 children:
demographics, treatment, outcomes, and early growth data. Plast
Reconstr Surg. 2013;131:1348–1358. A 10-year study outlining
management principles for pediatric mandible fractures.
11. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: ii.
management of traumatic injury or fracture. Plast Reconstr Surg.
2005;116:28e–41e.
19. Davidson EH, et al. Severe pediatric midface trauma: a prospective
study of growth and development. J Craniofac Surg. 2015;26:1523–
1528. This prospective cephalometric study highlights the effect on growth
and resultant facial deformity from severe pediatric midface trauma and
the need for new methods of management.
27. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: I. A
primer on growth and development. Plast Reconstr Surg.
2005;116:14e–23e.
28. Havlik RJ, Sutton LN, Bartlett SP. Growing skull fractures and their
craniofacial equivalents. J Craniofac Surg. 1995;6:103–110, discussion
111–112.
44. Losee J, Chao M. Complications in pediatric facial fractures.
Craniomaxillofac Trauma Reconstr. 2009;2:103–112.
58. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-year
experience treating frontal sinus fractures: a novel algorithm based
on anatomical fracture pattern and failure of conventional
techniques. Plast Reconstr Surg. 2008;122:1850–1866. An extensive
clinical experience is distilled into a practical, clearly presented algorithm
for the clinical management of frontal sinus fractures
76. Losee J, Afifi A, Jiang S, et al. Pediatric orbital fractures:
classification, management, and early follow-up. Plast Reconstr Surg.
2008;122:886–897.
93. Markowitz BL, Manson PL, Sargent L, et al. Management of the
medial canthal tendon in nasoethmoid orbital fractures: the
importance of the central fragment in classification and treatment.
Plast Reconstr Surg. 1991;87:843–853. This landmark paper introduces a
clinically relevant classification scheme for management of nasoethmoid
orbital fractures.
Access the complete reference list online at

695.e1
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Plast Reconstr Surg. 1991;87:843–853. This landmark paper introduces
a clinically relevant classification scheme for management of nasoethmoid
orbital fractures.
94. Furnas DW. Emergency diagnosis of the injured orbit. In: Tessier P,
Callahan A, Mustarde JC, et al., eds. Symposium on Plastic Surgery
in the Orbital Region. Vol. 12. St. Louis: CV Mosby; 1976.
95. Morales JL, Skowronski PP, Thaller SR. Management of pediatric
maxillary fractures. J Craniofac Surg. 2010;21:1226–1233.
96. Yu J, Dinsmore R, Mar P, Bhatt K. Pediatric maxillary fractures. J
Craniofac Surg. 2011;22:1247–1250.
97. Wolfswinkel EM, Weathers WM, Wirthlin JO, et al. Management of
pediatric mandible fractures. Otolaryngol Clin North Am.
2013;46:791–806.

695.e3
References
98. Blackwood HJ. Vascularization of the condylar cartilage of the
human mandible. J Anat. 1965;99:550–563.
99. Lehman JA, Sadawi ND. Fractures of the mandible in children. J
Trauma. 1976;16:773.
100. Ziccardi VB, Ochs MW, Braun TW, et al. Management of
condylar fractures in children: review of the literature
and case presentations. Compend Contin Educ Dent. 1995;16:
874.
101. Chrcanovic BR. Open versus closed reduction: mandibular
condylar fractures in children. Oral Maxillofac Surg. 2012;16:
245–255.
102. Goth S, Sawatari Y, Peleg M. Management of pediatric mandible
fractures. J Craniofac Surg. 2012;23:47–56.
103. Demianczuk AN, Verchere C, Phillips JH. The effect on facial
growth of pediatric mandibular fractures. J Craniofac Surg.
1999;10:323–328.

SECTION II • Craniofacial
30 
Orbital hypertelorism
Eric Arnaud, Giovanna Paternoster, and Syril James
SYNOPSIS
■ Hypertelorism is not a disease in itself; it is just a symptom which
may belong to various conditions.
■ It is mainly present in facial clefts but may accompany
faciocraniosynostosis, where craniosynostosis has to be corrected
independently before 1 year of age.
■ Surgical treatment of hypertelorism can be undertaken after age 4 and
preferably before age 8 (at completion of cerebral growth and before
frontal sinus growth).
■ The technique of correction depends upon the degree of interorbital
distance and on the occlusion.
■ According to the degree of interorbital distance, the technique is based
on a two-, three-, or four-wall mobilization, through a subcranial or a
transcranial approach.
■ If the occlusion is normal, the osteotomy is a box-shift type; if the
occlusion is angulated, a facial bipartition osteotomy and medialization
of the two hemifaces are performed.
■ Rhinoplasty is best performed at the end of growth: it represents one
of the most important morphological improvements of the whole
therapeutic sequence.
■ Minor additive procedures contribute to the completion of the result:
epicanthus correction, medial and lateral canthopexy, and fat grafting
in the temporal region.
■ Intellectual development in patients with facial clefts is usually good.
Introduction
Craniofacial malformations are disorders that affect both the
cranium and the face. In faciocraniosynostoses, the facial
maldevelopment is associated with craniosynostosis (prema-
ture fusion of one or several sutures). In facial clefts, the major
anomaly affects the face and is occasionally associated with a
cranial problem. Hypertelorism is not a disease in itself;
rather, it is a symptom or associated finding which accompa-
nies some craniofacial conditions. Hypertelorism is defined
by the abnormal increase in the interorbital distance (between
the bony orbits). The abnormality may be symmetrical or
asymmetrical.
In embryonic development, the development of the face
occurs early, between the fourth and eighth weeks of gesta-
tion. When one observes that the midportion of the face
develops immediately anterior to the forebrain, it is obvious
that there is a close relationship between the face and the
brain. Lateral to this midline prominence, paired elements
appear: the nasal placodes and the maxillary processes. These
structures merge in the midline whilst the frontonasal promi-
nence is displaced in a cephalic direction. This prominence
narrows to form the bridge and root of the nose. The develop-
ing eyes present as optic vesicles “outpouching” from the
brain and are initially positioned far laterally. The optic
vesicles move closer together as the frontonasal prominence
narrows. Simultaneously, the tip of the nose is derived from
the paired medial elements, as the paired maxillary and
mandibular processes fuse to form the lower part of the face.
Clefts of the midline craniofacial structure occur when this
delicate sequence of events is disrupted.
Access the Historical Perspective section online at

Basic science and disease process
If the frontonasal prominence remains in its embryonic posi-
tion, the optic placodes cannot migrate toward the midline,
and this results in orbital hypertelorism, often associated with
various anomalies of the forehead and nose. It had been
said that “the face predicts the brain”, and the importance of
the centrofacial anomaly appears to parallel the forebrain
defect.1 Conversely, interrupted development of the medial
prominence may lead to an absence of midline structures
with excessive narrowing, such as cyclopia or ethmocephaly.

696.e1
Historical perspective
Historical perspective
Hypertelorism is not dangerous in itself; and, until the surgi-
cal breakthroughs of Tessier in the late 1960s, one would
observe untreated adult patients, mainly with facial clefts, in
whom hypertelorism was the main visible feature. Those
patients with hypertelorism usually had normal mental
development and little complaint besides a desire for aesthetic
improvement. The intracranial approach has been the main
advance in the treatment making it effective to correct the
deformity. There is little doubt that the creativity of Tessier
and the boldness of his neurosurgeon colleague Gérard Guyot,
both working at Hôpital Foch in the suburbs of Paris, made
this a reality. When Tessier asked Guyot if it was conceivable
to medialize the orbits through an intracranial approach,
Guyot answered with the now famous “Why not?” and, from
that starting point, they made it possible. The first patient
with hypertelorism was treated in a staged surgical strategy,
with the initial procedure closing the superior extent of the
nasal fossa with a dermal skin graft and sacrifice of the olfac-
tory nerve. Six months later in a secondary procedure, medi-
alization of the orbits was performed (1967).

697
Basic science and disease process
Fig. 30.1  (A–C) Tessier classification.
30
1
23
4
5
6
7
7
8
9
10
11
12
13
14
Northern hemisphere
Southern hemisphere
Cranial clefts
Facial clefts
0
A
14 13 12
11
10
9
8
7
6
5
4
1
1
0
2 3
1
2
3
0
B
1
0
2
3
C
Hypertelorism alone is a mild degree of this sequence at the
orbital level.
The associated maxillary anomalies seen with hyper-
telorism consist mainly of insufficient anterior growth in the
upper maxilla, resulting in maxillary retrusion. Since the face
is physiologically underdeveloped in infancy, facial anomalies
may be more apparent later in childhood when facial growth
is completed.
There is little known of the genetics of craniofacial malfor-
mations, likely due to the limited number of cases. As major
facial clefts are rare, most of our knowledge of the pathogen-
esis of these malformations is based on studies of the forma-
tion of cleft lip and palate. Nevertheless, the role of heredity
is obvious in the more frequent clefts of the lip, palate, and
the lateral aspects of the orbit.
Radiation, infection, and maternal metabolic imbalances,
which can be involved in cleft lip, have not been reported to
be responsible for craniofacial malformations. Drugs and
chemicals such as tretinoin, thalidomide, corticosteroids, and
even aspirin are known to be responsible for malformations;
and, while facial development occurs early in pregnancy,2
mothers may ingest various drugs while unaware of being
pregnant. Causal environmental and hereditary factors prob-
ably play varying epigenetic roles in the formation of particu-
lar malformations.
Various systems of classification have been proposed for
craniofacial clefts; two of them are of special value when
assessing craniofacial anomalies. These are the “median facial
clefts” and the Tessier classification, an orbitocentric cleft
classification.
Diagnosis of hypertelorism and patient
presentation in facial clefts
Median facial clefts
Median facial clefts can be divided into two categories: those
presenting with a deficiency of tissue and missing parts and
those without lack of tissue but presenting with a widening
malformation.
Midline tissue deficiency malformations are almost always
linked with a forebrain deficiency. The term “arrhinencephaly”
has been used, but holoprosencephaly, a name proposed by
De Myer et al.,1 better reflects the lack of median tissues. On
the basis of this brain–facial linkage, and including some
concepts of Cohen and associates, the holoprosencephalic
malformations present with hypotelorism, as opposed to
hypertelorism.3
In contrast with the previous group, near-normal to excess
tissue midline disorders do not have a high correlation
between the facial anomalies and the underlying brain. The
deformities can range from a notch in the upper lip and a
widened nose to the most severe form of midline cleft. The
term “frontonasal dysplasia”, suggested by Sedano et al. for
this group of anomalies,4 is used widely, especially amongst
geneticists. Frontonasal dysplasia and holoprosencephaly are
therefore at opposite ends in this system of classification of
midline anomalies.
This classification does not take into account all the asym-
metrical and paramedian anomalies. For easier definition and
treatment implications, the authors use the Tessier classifica-
tion, which is based on surgical experience.
Tessier classification of facial clefts
In the Tessier classification,5 the orbit is the reference land-
mark, common to both the cranium and the face. The clefts,
numbered from 0 to 14, rotate around the orbit and follow
constant lines through the skeleton and soft tissues (Fig. 30.1).
Clefts can be mostly cranial if they run upward from the
eyelid (7–14) or mostly facial if they run downward from the
palpebral fissure (0–6). They are craniofacial if the upper and
lower pathways are connected.
The following combinations can be clinically observed: 0
and 14, 1 and 13, 2 and 12, 3 and 11, and 4 and 10. This concept
of additive facial and cranial clefts equaling 14 is helpful when
examining the patient and often allows identification of
malformation along its entire length, above and below the
orbit. The severity of the cleft is highly variable and can range
from a slight soft-tissue indentation to a complete open cleft.
The soft-tissue and skeletal clefts are, on the whole, superim-
posable. However, a detailed description of the soft-tissue
defect, in relation to the skeletal cleft, is more reliable, because
the skeletal landmarks are more consistent. The Tessier

698
SECTION II
CHAPTER 30 • Orbital hypertelorism
classification defines the 0–14 cleft as a midline widening,
present in frontonasal dysplasia.
Unilateral and bilateral forms of clefting are found in
various combinations, mainly asymmetrical when bilateral.
Three-dimensional computed tomography has greatly facili-
tated diagnosis, whilst magnetic resonance imaging explores
the brain, looking for an associated malformation. Stereolitho-
graphic models, constructed from computed tomography
images, are also available and may be useful for diagnosis and
surgical planning as these malformations are uncommon and
rarely identical.
Some isolated facial clefts, such as those affecting the lateral
aspect of the face in Treacher–Collins syndrome (bilateral 6,
7, and 8 clefts), do not present any surgical interest for the
neurosurgeon. The central and paramedial clefts affecting the
face and cranium are of neurosurgical interest, as the cranium
is the means of access for surgical correction.
Diagnosis of hypertelorism and patient
presentation in faciocraniosynostosis
Hypertelorism is not the main feature of faciocraniosynosto-
sis, and is variable in its presentation.6 When mild, it is fre-
quently left untreated; however, when more noticeable, it can
be addressed through a separate surgical step. Depending on
the dental occlusion, and particularly the horizontal position
of the upper maxillary arch, the treatment of hypertelorism
will vary between an orbital shift and a facial bipartition.
The timing of treatment is variable according to the pathol-
ogy; however, in the authors’ experience, skull expansion for
craniosynostosis treatment should precede hypertelorism
correction.7,8
Crouzon’s syndrome
Described by Crouzon in 1912,9 this syndrome involves
only the face and cranium and is not associated with other
anomalies elsewhere on the limbs or trunk. The fundamental
dysmorphology is an underdeveloped midface presenting
with exorbitism secondary to insufficient depth of the orbits,
hypoplasia of the malar bones, and a class III malocclusion.
Hypertelorism may be present but is usually mild. The
nose is short. Brachycephaly is usually present; however,
scaphocephaly, plagiocephaly, or even a cloverleaf skull may
be present. With an extended classification, the association
of facial retrusion and craniosynostosis might be named
as a related Crouzon’s anomaly. Commonly, the diagnosis of
Crouzon’s syndrome is difficult to make during the first year
of life, even if brachycephaly is obvious. It is often difficult to
know whether the midface will be affected, even on radiologi-
cal examination. Midface retrusion and exorbitism appear
later in life. In some cases, however, the diagnosis is evident
at birth.
Severe maxillary retrusion may produce airway obstruc-
tion with mandatory mouth breathing. There is a great vari-
ability of expression, and both severe and mild forms can be
observed in the same family.
The strategy of treatment of faciocraniosynostosis is either
two-staged10–12 (fronto-orbital first, then facial advancement
later) or a frontofacial monobloc advancement,13–15 preferably
with distraction.16 Whenever present, the hypertelorism might
be corrected around 4–5 years of age, usually with an orbital
shift (Fig. 30.2), because in Crouzon’s disease, the maxillary
arch is normal (at least in the horizontal dimension).
Pfeiffer’s syndrome
Described by Pfeiffer in 1964, this syndromic entity is an
association of faciocraniosynostosis and anomalies of the
hands and feet. The brachycephaly induced by bicoronal
synostosis is often asymmetrical and is associated with
midface retrusion secondary to maxillary hypoplasia. Hyper-
telorism is often present in this syndrome. The thumbs and
great toes are broad with a varus deviation and may be associ-
ated with soft-tissue syndactylies, the latter being difficult to
Fig. 30.2  Box-shift mobilization of orbits. (A) Before mobilization of the orbits.
(B) After mobilization of the orbits.
A
B

699
Treatment/surgical technique
bipartition is the operation of choice because it widens
the maxilla and improves the angle of the upper
dentition. On the other hand, if the maxillary arch and
occlusion are normal, it is preferable to avoid an
interpterygomaxillary disjunction.
■ The axis of the orbits: if the axis is normal, a horizontal
mobilization is satisfactory; if the orbits are laterally and
downwardly oblique, bipartition is required.
■ The nasal fossae: if they are narrow, bipartition and
medialization of the upper face improve the airways by
enlarging the lower part of the face.
■ Extent of the hypertelorism: bipartition is the operation of
choice in the most severe cases, whereas orbital shift is
indicated for more limited displacements.
■ The bipartition procedure can also be used to get
access to a lesion of the cranial base. Some midline
clefts are associated with an encephalocele of the
ethmoidosphenoidal area. After midline splitting, easy
access to the encephalocele can be obtained.
Treatment/surgical technique
Surgical principles in facial clefts
Tessier’s breakthrough collaboration between plastic and
neurological surgery allowed him to conceptually minimize
the surgical border existing between the face and the skull and
dramatically enhance the surgical treatment of upper facial
clefts.20 Tessier demonstrated that the frontocranial route was
a good approach to access the nose and orbits and that fron-
tocranial problems can be treated simultaneously with facial
problems. The fear of contamination from the facial cavities
was so great among neurosurgeons in 1967 that, for their first
case, Tessier and his neurosurgical colleague, Guyot, placed a
dermal skin graft on the dura of the anterior cranial fossa after
it had been elevated, voluntarily sacrificing both the olfactory
nerves. A few months later, they performed the combined
craniofacial approach. By 1970, a one-stage procedure to
address the orbits from superior and inferior approaches was
considered safe, and the olfactory nerves could be preserved.21
Preliminary disinfection of the nasal cavities, dissection of the
mucosal domes and their immediate repair if opened, preser-
vation or perfect repair of dura, changing of instruments if
passing through the facial cavities, and perioperative antibi-
otic therapy were preventive measures that helped to avoid
infection, osteitis, and meningitis.
There are two ways to mobilize the orbits when correcting
orbital hypertelorism. The treatment planning varies accord-
ing to the severity of the hypertelorism, the maxillary struc-
ture, and the age of the patient. An orbital shift can simply be
performed in cases of normal or subnormal dental occlusion.
In cases of restricted transverse maxillary structures, mobili-
zation of both hemifaces (necessitating a facial bipartition) can
be performed to correct the hypertelorism and the arched
palate at the same time.
The classic approach described by Tessier et al. in 196720
consisted, after removal of the enlarged medial portion, of an
en bloc mobilization of the orbits medially, the lower horizontal
cuts being situated below the infraorbital rim, through the
malar bone and the maxilla. In Tessier’s protocol, especially
diagnose early in life. Some severe forms exist, with marked
perinatal frontofacial retrusion resulting in visual and respira-
tory problems. This condition is sometimes associated with a
cloverleaf skull.
The strategy of treatment is similar to that for Crouzon’s, but
Pfeiffer’s syndrome is often more severe than Crouzon’s, with
a higher tendency to relapse after surgical advancement.
Apert’s syndrome (acrocephalosyndactyly)
First described by Apert in 1906,17 this syndrome is easy to
recognize because of the associated syndactylies of the hands
and feet. The severity of syndactyly is scored according to
Cohen and Kreiborg.18 Type 1 is syndactyly of the central three
digits, type 2 is syndactyly of digits 2–5, and type 3 is syndac-
tyly of all five digits.
The craniofacial involvement is always marked at birth, in
contrast with that in Crouzon’s, with brachycephaly (some-
times asymmetrical) associated with facial retrusion. Both
coronal sutures are fused, although some rare cases present
with unilateral coronal synostosis or without any synostoses
(4 cases without synostoses in our series). The hypertelorism
and the anterior open bite add to the distinction from Crou-
zon’s disease. In fact, the maxillary alveolar arch is higher than
the posterior part of the palate. Another main difference with
Crouzon’s is the frequent sagittal dehiscence of the sutural
system with the forehead frequently remaining wide open
during the first year of life; this contributes to the abnormally
wide forehead and face in this syndrome. Associated abnor-
malities of the central nervous system are more frequent than
in other syndromic craniosynostoses. The exception is Chiari-
like malformations, which are common in Crouzon’s but, due
to premature fusions of the lambdoid sutures, are uncommon
in Apert’s.19 Because of these patients’ divergent frontal plane,
bipartition procedures are more adapted to correct Apert’s-
associated hypertelorism. Nevertheless, skull expansion
(either anterior or posterior) is performed first, usually before
1 year of age to address the craniosynostotic skull.
Craniofrontonasal dysplasia
In the group of craniofacial dysplasias (see discussion of
median facial clefts with frontonasal dysplasia, below), some
cases present with a bicoronal craniosynostosis, including a
subgroup called craniofrontonasal dysplasia. There is a
brachycephaly, often marked, associated with the facial
anomalies of frontonasal dysplasia, which include hyper-
telorism, broad nasal bridge, and bifid nose; soft-tissue syn-
dactyly may also be present.
Craniofrontonasal dysplasia is far more common in females
than in males, consistent with its X-linked inheritance. In the
authors’ series, 36% of cases were familial, and 91% of patients
were females.
Patient selection
Orbital shift or bipartition?
The choice between orbital shift and bipartition is mainly
linked to a series of factors:
■ The maxillary arch: if the maxillary arch is narrow and
inverted with the incisors being higher than the molars,

700
SECTION II
CHAPTER 30 • Orbital hypertelorism
reconstructions. Sometimes both orbits have to be moved in
different directions.26,27
The age at operation is important. If there is a cranial cleft,
it is better to wait for the median frontal defect to ossify before
surgery is scheduled. The neurosurgical approach is by means
of a frontal bone flap. Its lower part depends on the variable
elevation of the orbital rim, often including elevation of one
side and transverse displacement on the opposite side.
Soft-tissue anomalies, such as skin excess, may be treated
initially by sagittal resection or can be postponed as this tissue
may contract over time. Another reason to delay midline skin
resection is that dorsal nasal bone grafting, which is almost
mandatory to achieve adequate nasal correction, requires
some degree of skin excess.
In minor cases, a limited procedure with one- to three-wall
mobilization may suffice.
Infrafrontal correction of hypertelorism
In the least significant hypertelorisms (less than 35 mm inter-
orbital distance), a single medial wall mobilization can be
undertaken. This procedure can be performed through a
limited subciliary incision, but the authors prefer a coronal
approach unless medial skin excess makes a nasal incision
mandatory. The thin bone of the medial wall of the orbit can
be easily in-fractured (Fig. 30.5).
In selected cases presenting with mild symmetrical hyper-
telorism (35–40 mm), large frontal sinuses, and a high pituitary
sella, the supraorbital rim and roof of the orbits can be left in
place with mobilization of the other three walls.20,28–31 However,
this method is less effective for the correction of the orbital
distance than the box-shift osteotomy. This subcranial
approach can be used in a horizontal shift or a bipartition
whenever the cribriform plate is high enough. Raveh and
Vuillemin32 used this inferior intracranial approach, cutting
the orbital roof and the ethmoidal cells from below, without
a frontal craniectomy. They claimed to have good control of
in adult patients, a supraorbital bar is kept in place in order
to ensure stability of the mobilized orbits.22
Bipartition, proposed by van der Meulen23,24 and developed
by Tessier,25,26 represents a mobilization of the two hemifaces
(Fig. 30.3). Instead of cutting below the orbits, the surgeon
makes the osteotomies through the zygomatic arch, the ptery-
gomaxillary junction, and medially through the palate. The
medial resection must have a “V” shape because there will be
an element of rotation, along with a narrowing on the midline.
The rotation allows for widening of the maxillary arch and
the nasal fossae and also for changing the axis of the orbits,
which have a lateral slant.
Surgical techniques in facial clefts
Principles
The two main aims of surgery for this condition are to bring
the orbits closer together and to create a nose of normal appear-
ance. The basic anatomical anomaly is an increase in both the
interorbital distance and the nasal bones whilst the glabellar
region is much wider than normal. The enlarged portion of the
midline structures is removed, and, after mobilization of the
orbits, the nasal skeleton is adjusted with the help of a bone
graft if more dorsal projection is needed (Fig. 30.4).
This combined approach allows the surgeon to move the
orbits and repair bony anomalies of the fronto-orbitonasal
complex. Orbital displacement is key to the treatment of major
craniofacial clefts. The orbit can be moved on a horizontal,
vertical, anterior, or posterior axis to correct all anomalies.
Reconstruction of a missing orbital roof or part of the fore-
head, canthopexies, and correction of soft-tissue problems can
be performed simultaneously.
Not all hypertelorisms are symmetrical, and asymmetrical
cases are more complex to correct. The cranial base is also
asymmetrical, and so the different distortions must be care-
fully evaluated by computed tomography three-dimensional
Fig. 30.3  Medialization of the two hemifaces after bipartition. (A) Before medialization. (B) After medialization.
A
B

701
Treatment/surgical technique
retrograde approach. A trephine hole can be created from
above to improve access for the interorbital resection, allow-
ing the nasal bones to be lifted and affording control of the
superior medial wall segments. Should a dural tear occur, a
frontal flap can be elevated for intracranial repair. The rest of
the osteotomies are performed as in the intracranial approach.
The mobilization must be carefully performed because the
the dura and a shorter recovery period due to less aggressive
surgery.
The periorbital regions are widely dissected through a
coronal approach and subciliary incisions. The osteotomies
are performed posteriorly enough to keep a wide bony plat-
form that will push the globe medially. Medially, the nasal
mucosa is dissected from under the nasal bones through a
Fig. 30.4  Box-shift osteotomy for midline cleft. (A) Before osteotomy: note both lateral spurs, avoiding the need for supraorbital bar. (B) After medial shift. (C) Age 5
years, before treatment. (D) Age 6 years, after operation. (E) Age 21 years.
A
B
C
D
E
Fig. 30.5  Three-wall medialization osteotomy (horizontal shift). (A) Before treatment at age 7 years. (B) After operation. (C) At age 21 years.
A
B
C

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SECTION II
CHAPTER 30 • Orbital hypertelorism
supraorbital rim to be preserved is about 1 cm in height; the
preserved frontal bridge also measures 1 cm, and the lower
limit of the frontal craniotomy must be at least 2 cm above the
orbits. Many craniofacial surgeons, including the authors, do
not preserve this horizontal band; the lower limit of the cra-
niectomy with this approach is 1 cm above the orbits. This
approach facilitates access to the anterior cranial fossa. An
anteroposterior landmark and a stable point of fixation are
fundamental. For these reasons, the authors preserve a low
lateral spur of frontal bone, with the frontal craniotomy flap
taking an upward angle at about the middle of the orbits (see
Fig. 30.2).
The frontal flap must be elevated with care as anomalies
are frequently encountered (e.g., a very deep groove for the
longitudinal sinus or a thick, or even bifid, crista galli). After
the frontal flap has been elevated, careful dissection of the
dura from the orbital roofs and from the edge of the greater
wing of the sphenoid bone and the adjacent part of the tem-
poral fossa is performed. The central region around the crib-
riform plate is the most challenging portion of the dissection.
If the cribriform plate is normal or only moderately altered,
the resection necessary to decrease the distance between the
orbits is performed in the ethmoidal cells on either side of the
cribriform plate. Sometimes, the cribriform plate is highly
abnormal with the olfactory grooves widely separated and
running close to the medial walls of the orbits. In these cases,
sacrifice of the olfactory nerves is unavoidable during a large
medial resection.
Meticulous repair of the dura is mandatory after resection
of the olfactory nerves. A periosteal patch is often useful to
reinforce the closure. The central resection is performed by the
craniofacial surgeon who has previously dissected the nasal
three-wall bony orbit is fragile. Stabilization is performed
medially with stainless-steel wires. Repositioning of the nasal
bones and control of the canthi are performed last before
closure.
Box-shift osteotomies (symmetrical
orbital hypertelorism)
When the interorbital distance is greater than 40 mm (Fig.
30.6), the neurosurgical approach is critical because it allows
access to the orbital roof and the central ethmoidosphenoidal
area. Only in rare circumstances, and in older patients, is it
possible to move the lower three-quarters of the orbits and
remove the excess width of the central nose below the cribri-
form plate while leaving the roof of the orbits intact. This
extracranial approach is only possible if the cribriform plate
is very high and the deformity is minimal.
Like most craniofacial teams, the authors prefer to use the
frontal approach to have a clear view of the anterior cranial
fossa; this also facilitates dura repair if necessary. In hyper-
telorism, anomalies of the midline often exist and good
exposure is essential for dural control. Of note, duplication of
the crista galli apophysis is not uncommon.
Frontal craniectomy
Frontal craniectomy allows access to the orbital roofs and
medial structures. The design of the frontal craniectomy must
be carefully planned by the craniofacial surgeon. The lower
limit is of importance. Some surgeons, following Tessier’s
technique, prefer to keep a bridge of bone intact at the lower
part of the forehead between the frontal flap and the mobilized
orbits to maintain stability. If this is to be performed, the
Fig. 30.6  Box-shift osteotomy for midline cleft. (A) Before osteotomy: note maximum width of bony resection. (B) After medial shift. (C) Front view at age 4 years before
treatment. (D) Front view at age 25 years. (E) Lateral view at age 4 years before treatment. (F) Lateral view at age 25 years.
A
B
C
D
E
F

703
Treatment/surgical technique
midline. If the osteotomy is too anterior, there will be a step
effect, limiting the displacement of the ocular globes.
A secondary rhinoplasty will most likely be necessary to
achieve an optimized aesthetic result.
Bipartition with intracranial approach (large
symmetrical hypertelorism with arched palate)
This technique varies slightly from the box-shift, but many
surgical steps are identical. Differences are as follows (see Fig.
30.3):
■ V-shape resection of bone at the nose
■ absence of osteotomy in the maxilla at the lower limit of
the orbit
■ osteotomy at the pterygomaxillary junction
■ the medialization part of the upper face creates an
opening at the palatal level (Fig. 30.7).
Asymmetrical cases
Asymmetrical cases are more difficult to correct than sym-
metrical ones. Sometimes each orbit must be moved in differ-
ent directions whilst on other occasions only one of the orbits
is involved in the planned displacement. The cranial base is
also asymmetrical; the various distortions must be carefully
evaluated by computed tomography with three-dimensional
reconstructions. Paramedian clefts create a situation in which
the affected orbit is displaced laterally and inferiorly to a
variable degree. A defect in the frontal bone is often associ-
ated. The orbit may be reduced in size (anophthalmia or
microphthalmia). Various anomalies of the maxillary and
nasal portion of the face may also be associated.
After the anomaly has been evaluated and classified
according to the Tessier system (see previous discussion), a
plan of treatment is devised. The correction must be planned
from top to bottom; that is, the frontal and orbital regions
must be reconstructed first. In most cases, a bilateral asym-
metrical correction is required. The neurosurgical approach
is by means of a frontal bone flap, its lower limit being care-
fully planned because of the variable reconstructions of the
mucosal domes by proceeding cephalad from below the nasal
bones. The paranasal osteotomies are performed vertically at
a slightly divergent angle. The transverse posterior osteotomy
is then performed. It is usually made in front of the crista galli
if the olfactory nerves are intact. In the most severe cases, this
osteotomy is performed posteriorly, removing most of the
ethmoid bone. The medial resection is lifted en bloc, and the
nasal mucosal domes are exposed. If they are not intact,
immediate suturing of the nasal mucosa is performed.
Osteotomies of the orbit
Next, the osteotomies are performed through the orbital roof,
lateral orbital wall, and posteromedial wall. The lower oste-
otomies vary according to whether orbital shift or bipartition
is being performed. The orbits are then brought together and
contact is established in the midline. All the interposing ele-
ments, such as an enlarged superior nasal septum or residual
posterior ethmoidal cells, must be removed. The dura must
be carefully protected during these maneuvers. After the
orbits are rigidly fixated in the midline by wires or miniplates,
the neurosurgical portion of the procedure is almost complete.
Dural integrity and hemostasis are ensured in the anterior and
temporal cranial fossae, and the frontal bone flap is secured
back in place.
Bone grafts from the cranial vault are needed to close the
gaps in the orbital walls and often to build up the nasal
dorsum. Sometimes, in adolescents and adults, it is possible
to split the frontal bone flap and use the posterior aspect for
bone grafts. More often, it is necessary to take bone grafts
from the cranial vault. Specifically, a thick, straight 5-cm
segment is necessary for nasal reconstruction. It is convenient
to take these bony pieces posterior to the frontal flap. In the
authors’ practice, bone dust from the burr holes and small
residual bony fragments are mixed with fibrin glue and used
to occlude the vault defects after the graft removal.
The optic nerve is not straight; it has laxity that allows it to
follow the displacement of the eyeball. Even a significant
displacement is well tolerated by the optic nerves. To permit
a good medial displacement of the eyeball, it is essential that
the medial wall of the orbit is also displaced towards the
Fig. 30.7  Hypertelorism correction by
bipartition for a frontocranial dysplasia.
(A) Before treatment at age 4.5 years.
(B) After treatment (observe temporal
hollowness, to be corrected secondarily).
A
B

704
SECTION II
CHAPTER 30 • Orbital hypertelorism
orbital shift and the facial bipartition depends on a series of
factors:
■ The maxillary arch: if the maxillary arch and occlusion
are normal, it seems preferable to avoid an
interpterygomaxillary disjunction, and box-shift
osteotomies are sufficient; this is the case in Crouzon’s
and Apert’s. Conversely, if the maxillary arch is narrow
and inverted, the incisors being higher than the molars,
bipartition is the operation of choice because it widens
the maxilla and improves the angle of the upper
dentition.
■ The axis of the orbits: if the axis is normal, a horizontal
mobilization is satisfactory. If they are laterally and
downwardly oblique, bipartition corrects these anomalies.
■ The nasal fossae: if they are narrow, bipartition improves
the airways, especially if a narrowing in the upper part of
the face is associated with a widening of the maxillary
arch.
These three criteria are all present in Apert’s, and therefore
bipartition is the procedure of choice for these patients. The
bipartition can be performed with a facial Le Fort III advance-
ment as a combined second step, sometimes by means of
osteodistraction. In cases of a Le Fort III osteotomy combined
with bipartition and distraction, we would use the combina-
tion of internal and external distraction devices (Fig. 30.8).
Face
Le Fort classically described three types of maxillary disjunc-
tion depending on the transversal level of the facial fractures.
Since the surgical facial advancements approximately repro-
duce these fracture lines on the face, Tessier gave the names
of Le Fort I, II, and III to the facial osteotomies. Although
Gillies was the first to perform a facial advancement in the
late 1940s,33 Tessier10 really developed the Le Fort III type of
advancement, his lines of osteotomies being deeper than
those of Gillies, located behind the lacrimal apparatus. The
facial advancement is usually of the Le Fort III type.
Patients who have previously undergone forehead
advancement normally have facial retrusion to a variable
degree. As a rule, we prefer to delay the facial advancement
until there is permanent dentition and a stable occlusive
relationship can be achieved. When the deformity is moder-
ate, there is no difficulty in convincing the patient and the
supraorbital rim, often including elevation on one side. Trans-
verse movement only is performed on the affected side. In the
paramedian clefts, the ethmoidal region is asymmetrical and
dural elevation should be performed with care. After the
orbits are properly positioned, the frontal bone flap is adjusted
and wired into place.
Sometimes only one orbit is displaced, usually inferiorly,
with one globe inferior to the other; this condition is defined
as orbital dystopia. In these situations, displacement of the
entire orbit en bloc is the solution. Partial maneuvers such as
elevation of the roof and placement of bone grafts on the floor
usually produce disappointing results. This en bloc displace-
ment of the orbit requires a frontal flap to gain access to the
roof. This frontal flap can be unilateral and corresponds to the
width of the orbital osteotomy. The frontal segment removed
to permit elevation of the supraorbital rim is utilized as a bone
graft placed below the orbit to maintain the elevation and fill
the resultant bony gap.
In some cases of asymmetrical clefting, an asymmetrical
bipartition has been used.
Timing and indications for surgery in
faciocraniosynostosis
Without early treatment, intracranial hypertension can lead to
optic atrophy and visual loss in craniosynostosis. This is
observed mainly in Crouzon’s syndrome and in oxycephalies.
In the series of Hôpital Necker Enfants-Malades, papilledema
was observed in 35% and optic atrophy in 10% of Crouzon’s
cases. In the other syndromes, papilledema was observed in
only 4–5% and no optic atrophy was observed.19 Because of
these risks, and as previously mentioned, strategic manage-
ment of faciocraniosynostosis usually demands at least a
two-stage procedure7,8,11,12 followed by later refinements. The
skull is operated upon first and the face secondarily. Apert’s
syndrome is definitely the most difficult to treat and might
require the largest number of additional procedures.
Orbits
In Necker’s experience, the surgical treatment of the associ-
ated hypertelorism is delayed until after the frontal advance-
ment and after 4 years of age.7,8 This strategy provides a thick
enough skull bone to perform stable fixation after mobiliza-
tion of the osteotomized segments. The choice between the
Fig. 30.8  Box-shift osteotomy for midline cleft. (A) Before osteotomy: front view at age 4 years. (B) Before osteotomy: lateral view at age 4 years. (C) Front view at age 23
years after augmentation rhinoplasty (observe good quality of midline nasal scar for skin excess). (D) Lateral view at age 23 years after augmentation rhinoplasty (nasal
revision to be performed for hump removal).
A
B
C
D

705
Postoperative care
family to wait. In patients with more severe deformity, the
social and psychological pressure is high, as well as the
demands of the family and often the child. In most severe
cases, difficulties in chewing and breathing as well as signifi-
cant inferior exorbitism are also present. In these situations,
after a warning that another operation (usually a Le Fort I)
will be necessary after permanent dentition is in place, we
perform a facial advancement.
In Apert’s, the advancement will be combined with a facial
bipartition, as mentioned earlier. This procedure is performed
before final dentition has erupted; therefore no attempt to
correct the open bite is made.
Surgical technique of hypertelorism
correction in faciocraniosynostosis
Because faciocraniosynostoses are essentially characterized
by backward displacement of the forehead and midface, both
having to be moved forward, this condition can be treated by
advancing the forehead and the face either separately or
simultaneously, possibly in combination with the correction
of the hypertelorbitism. The classical management includes
an initial anterior skull remodeling and, later, a facial advance-
ment as a second step, as detailed previously. In cases where
early frontofacial advancement is performed, the hyper-
telorism is corrected secondarily.7,8
Hypertelorism correction by bipartition
in combination with Le Fort III osteotomy
(Figs. 30.9 and 30.10)
The combination of hypertelorism and maxillary anomalies
makes the facial bipartition the logical operation in treating
Apert’s syndrome. This may be combined with a distraction
if indicated.
Coronal approach
The scalp is incised after subcutaneous infiltration with epi-
nephrine solution; the incision follows the scar of the previous
skull expansion if present. Exposure of the calvarial vault in
the subgaleal or supraperiosteal plane might be complicated
by scar tissue and bony dehiscence. Complete dissection of
the periorbita is conducted in the subperiosteal plane. Expo-
sure of the root of the nose, as well as the lateral walls of the
orbits and the zygomatic arches, is performed after undermin-
ing both temporalis muscles.
Subcranial osteotomies
The lower three-quarters of the orbits, the nose, the malar
bones, and the upper maxilla are to be mobilized. Bony cuts
are performed with a reciprocating saw in a bilateral manner.
The lateral cut of the orbit is usually started at the frontozy-
gomatic junction, then continued on to the floor of the orbit
to reach the sphenomaxillary fissure. Care must be taken
to avoid cutting through the lower orbital rim with an
anteriorly based osteotomy so as not to fracture the inferior
orbital wall in a shallow, distorted orbit. The zygomatic arch
is easily transected. The root of the nose is horizontally
sectioned while a 3-mm cranial buttress is maintained. A
medial V-shaped resection is then performed; the osteotomy
is extended downward to the medial wall of each orbit, taking
care to be posterior enough to avoid disruption of the medial
canthus. Finally, a bilateral pterygomaxillary disjunction is
made from above through the pterygoid fossa, with a finger
inside the mouth to control the position of the chisel.
An epinephrine solution is also infiltrated under the palatal
mucosa. A medial bony cut might be necessary through a
small mucosal opening behind the incisors. This will allow for
rotation of the two hemipalates. At this point the two hemi-
faces are free enough to be mobilized independently. A
combined movement of upper medialization and inferior
lateralization allows the rotation of both hemifaces to correct
the hypertelorism and the down-slanting of the eyelids.
Osteosynthesis and grafts
Osteosynthesis with metallic wires or miniplates is necessary
in the orbital region at the lateral junction of the orbital wall
and at the zygomatic arch in order to maintain the advance-
ment. Bone grafts, usually taken from the outer table of the
parietal calvaria, are mandatory at the root of the nose and in
the upper part of the lateral orbital walls. The grafts at the
frontozygomatic junction are triangular, whereas two quad-
rangular grafts, like two parts of the roof of a house, are
required at the root of the nose. Bone grafts might be useful
to fill the gaps at the lateral orbital walls to prevent enoph-
thalmos if a significant advancement is performed at the Le
Fort III level.
An archbar is anchored on the teeth with metallic wires to
maintain stability at the maxillary level.
Closure of the scalp is conducted in the usual manner after
the temporal muscles have been transposed anteriorly to fill
the temporal defect created by the medialization of the lateral
walls of the orbits.
If distractors are used for a combined advancement, a few
technique modifications would be employed:
■ The nose and lateral aspects of the frontozygomatic
regions would be grafted but not rigidly fixated.
■ In case of external distraction, the pulling wires would
preferably be at the pyriform apertures (Fig. 30.9).
■ In case of internal distracters, a transfacial pin would be
useful for fixation of both hemifaces (Fig. 30.10). Internal
distracters may be left as consolidators for a longer
period of time (3–4 months).
Postoperative care
Like all major transcranial craniofacial procedures, postopera-
tive care depends on the procedure itself and its implications
for systemic homeostasis. Close monitoring is best achieved
in a specialized pediatric intensive care unit for at least the
first 24 hours. It is not uncommon in our experience that the
degree of postoperative airway edema may dictate a pro-
longed intubation extending up to 3 or 4 days. After such a
delay, it is likely that the acute phase of the initial swelling,
sometimes impressive after 48 hours at the eyelid level but
also in the airway, has nearly, if not completely, resolved. A
conservative approach to the airway may avoid unwanted
reintubation after an early extubation. This is a significant risk
after bilateral hemifacial medialization, even if this procedure
enlarges the airway at the base of the nose.