The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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866
Whereas the first two issues can be managed with orthodon­
tic therapy followed by orthognathic surgery in adulthood,
joint ankylosis requires immediate surgery. Osteotomy with
the interposition of an alloplastic material such as silicone
is indicated in children. Interposition of autologous tissue
(temporalis fascia or fat), which is recommended in adults,
may induce ossification in children. Condylar resection and
joint replacement by a costochondral rib graft or a custom-
made joint prosthesis can also be considered in adults (Fig.
47.15c,d). Postoperative functional therapy is essential.
Conclusion
Functional and aesthetic rehabilitation are the main thera­
peutic goals in jaw fractures. In all high-velocity injury
fractures of the maxilla and the mandibular body, ORIF
with miniplates through an intraoral surgical approach is
the treatment of choice. Maintaining the occlusion by pre­
operative maxillomandibular fixation and meticulous soft
tissue closure after ORIF are essential.
by physiotherapy.7 Exceptions to the functional concept in­
clude heavily dislocated fractures with the condylar segment
displaced into the tympanic wall, the cranial fossa, the in­
fratemporal fossa, or the external auditory meatus. Bilateral
fractures combined with other jaw fractures and nonadjust­
able occlusion may also be relevant operative indications.10
Surgical approaches do not differ from those in adults.
Unfavorable Results and Solutions
After functional therapy, a high frequency of radiologic ab­
errations occur that are not associated with restrictions of
aesthetics, jaw function, or occlusion. Possible unfavorable
outcomes after pediatric fractures of the mandibular con­
dyle include the following:
•• Facial asymmetry after abnormal growth (mandibular
retroposition and long face) (Fig. 47.15a)
•• Malocclusion or open bite
•• Joint ankylosis (Fig. 47.15b)
Box 47.3
•• The frequency of anesthesia is not reduced
compared with open reduction and internal fixation
(ORIF):
○
○Application of an intermaxillary fixation
apparatus must be carried out under general
anesthesia.
○
○Removal of the apparatus should be performed at
least under sedation.
•• Fixation of a mandibular arch is complicated
by absent curvatures of deciduous teeth and by
incomplete dentition.
•• Wearing an intermaxillary fixation apparatus for 2
to 4 weeks is uncomfortable, hampers nutrition, is
associated with reduced dental hygiene, and results
in gingivitis and pain.
•• Although several authors favor ORIF with resorbable
plates, titanium plates are preferable because of
several disadvantages of resorbable plates:
○
○Larger dimension compared with titanium plates
○
○More complex fixation mechanism
○
○Tissue reaction during degradation
○
○Higher costs
•• ORIF with titanium plates is necessary under the
following special circumstances:
○
○To avoid screwing into permanent retained teeth
○
○With the use of 1.5-mm plates instead of 2-mm
miniplates, which are obligatory for adults
○
○When early removal of plates (after 2 months) is
anticipated
Arguments Against Closed Reduction
a
b
c
d
Fig. 47.15 Unfavorable results after conservative management of a bilateral mandibular condyle fracture in childhood. (a) Retroposition
of the mandible, long face syndrome, and reduced mouth opening. (b) Coronal computed tomography showing ankylosis of both tem­
poromandibular joints. (c) Harvesting of a rib graft for condylar process replacement. (d) Preauricular osteosynthesis of the rib graft after
condylar resection.

867
Chapter 47 Fractures of the Jaws
Pathologic jaw fractures are often associated with mul­
timorbid patients who have malignant tumors, a history of
malignant tumor treatment, or medication weakening the
jaw bones. Hence treatment must be modified in accordance
with the underlying disease. At a marginal age and general
condition, pain reduction and avoidance of infection must
be the therapeutic target; bony reunion and functional re­
habilitation are less important considerations.
To prevent complications in atrophic mandibular
fractures, an extraoral approach, the use of macroplates,
and slight denudation of the periosteum should be con­
sidered. Therapy of jaw fractures in children is marked
by respecting the growing structures. This includes the
use of 1.5-mm plates for ORIF and early plate removal.
Secondary teeth need to be protected, and the prominent
role of physiotherapy in condylar process fractures must
be kept in mind.
The handling of condylar process fractures of the mandi­
ble poses a major challenge. Fracture lines and bony disloca­
tion must be exactly identified by conventional radiography
or CT. Conservative treatment by maxillomandibular fixation
should be considered in condylar head fractures and commi­
nuted fractures when fractured bony segments are too small
to bring in osteosynthesis material. For all other cases an
algorithm is presented that describes appropriate intraoral
or extraoral surgical approaches in relation to the fractured
anatomic region of the condylar process. Consecutive mini­
plate osteosynthesis with two plates is therefore mandatory.
Heavily comminuted jaw bone fractures with loss of im­
portant bony segments might require techniques such as
three-dimensional surgery planning, harvest of autologous
bone from distant anatomic regions, or the use of microvas­
cular pedicled transplants. A gunshot wound not only causes
comminuted bony fractures, but also results in an additional
shortage of soft tissue; osteocutaneous FFFs or scapular flaps
can be used in these cases.
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2. Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-
based medicine: Mandible fractures. Plast Reconstr Surg
2014;134(6):1381–1390
3. Schwenzer N, Ehrenfeld M. Zahn-Mund-Kieferheilkunde.
4th ed. Stuttgart: Georg Thieme Verlag; 2011
4. Braasch DC, Abubaker AO. Management of mandibular
angle fracture. Oral Maxillofac Surg Clin North Am 2013;
25(4):591–600
5. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Man­
dibular osteosynthesis by miniature screwed plates via a
buccal approach. J Maxillofac Surg 1978;6(1):14–21
6. Goodday RH. Management of fractures of the mandibular
body and symphysis. Oral Maxillofac Surg Clin North Am
2013;25(4):601–616
7. Chrcanovic BR. Open versus closed reduction: mandibu­
lar condylar fractures in children. Oral Maxillofac Surg
2012;16(3):245–255
8. Gander T, Bredell M, Eliades T, Rücker M, Essig H. Splintless
orthognathic surgery: a novel technique using patient-spe­
cific implants (PSI). J Craniomaxillofac Surg 2015;43(3):
319–322
9. Champy M, Wilk A, Schnebelen JM. [Treatment of man­
dibular fractures by means of osteosynthesis without in­
termaxillary immobilization according to F.X. Michelet’s
technique]. Zahn Mund Kieferheilkd Zentralbl 1975;63(4):
339–341
10. Kisnisci R. Management of fractures of the condyle, con­
dylar neck, and coronoid process. Oral Maxillofac Surg
Clin North Am 2013;25(4):573–590
11. Spanio S, Baciliero U, Fornezza U, Pinna V, Toffanin A, Pad­
ula E. Intracranial dislocation of the mandibular condyle:
report of two cases and review of the literature. Br J Oral
Maxillofac Surg 2002;40(3):253–255
12. Spiessl B, Schroll K, Ningst H, eds. Facial bones. In: Special
teaching of fractures and luxations-a short compendium
in five volumes. Stuttgart: Georg Thieme Verlag; 1972
13. Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassifica­
tion of fractures of the condylar process of the mandible.
Br J Oral Maxillofac Surg 2005;43(1):72–73
14. Schön R, Gutwald R, Schramm A, Gellrich NC, Schmel­
zeisen R. Endoscopy-assisted open treatment of condy­
lar fractures of the mandible: extraoral vs intraoral ap­
proach. Int J Oral Maxillofac Surg 2002;31(3):237–243
15. Schön R, Schramm A, Gellrich NC, Schmelzeisen R. Fol­
low-up of condylar fractures of the mandible in 8 patients
at 18 months after transoral endoscopic-assisted open
treatment. J Oral Maxillofac Surg 2003;61(1):49–54
16. Arcuri F, Brucoli M, Baragiotta N, Benech R, Ferrero S,
Benech A. Analysis of complications following endoscopi­
cally assisted treatment of mandibular condylar fractures.
J Craniofac Surg 2012;23(3):e196–e198
17. Downie JJ, Devlin MF, Carton AT, Hislop WS. Prospec­
tive study of morbidity associated with open reduc­
tion and internal fixation of the fractured condyle by
the ­transparotid approach. Br J Oral Maxillofac Surg
2009;47(5):370–373
18. Parekh D, Glezerson G, Stewart M, Esser J, Lawson HH.
Post-traumatic parotid fistulae and sialoceles. A prospec­
tive study of conservative management in 51 cases. Ann
Surg 1989;209(1):105–111
19. Laskawi R, Winterhoff J, Köhler S, Kottwitz L, Matthias C.
Botulinum toxin treatment of salivary fistulas following
parotidectomy: follow-up results. Oral Maxillofac Surg
2013;17(4):281–285
20. Meyer C, Kahn JL, Boutemi P, Wilk A. Photoelastic analy­
sis of bone deformation in the region of the mandibu­
lar condyle during mastication. J Craniomaxillofac Surg
2002;30(3):160–169
21. Neff A, Mühlberger G, Karoglan M, et al. [Stability of os­
teosyntheses for condylar head fractures in the clinic and

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management of huge mandibular composite tissue de­
fects. J Craniomaxillofac Surg 2015;43(9):1769–1775
29. Thurmüller P, Kesting MR, Hölzle F, Retzgen H, Wolff KD.
Volume-rendered three-dimensional spiral computed to­
mographic angiography as a planning tool for microsurgi­
cal reconstruction in patients who have had operations or
radiotherapy for oropharyngeal cancer. Br J Oral Maxillo­
fac Surg 2007;45(7):543–547
30. Cawood JI, Howell RA. A classification of the edentulous
jaws. Int J Oral Maxillofac Surg 1988;17(4):232–236
31. Luhr HG, Reidick T, Merten HA. Results of treatment of
fractures of the atrophic edentulous mandible by com­
pression plating: a retrospective evaluation of 84 consec­
utive cases. J Oral Maxillofac Surg 1996;54(3):250–254,
discussion 254–255
32. Müller S, Bürgers R, Ehrenfeld M, Gosau M. Macroplate
fixation of fractures of the edentulous atrophic mandible:
immediate function and masticatory rehabilitation. Clin
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33. Eyrich GK, Grätz KW, Sailer HF. Surgical treatment of frac­
tures of the edentulous mandible. J Oral Maxillofac Surg
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34. Ellis E III, Price C. Treatment protocol for fractures of the
atrophic mandible. J Oral Maxillofac Surg 2008;66(3):
421–435
biomechanical simulation]. Mund Kiefer Gesichtschir 2004;
8(2):63–74
22. Parascandolo S, Spinzia A, Parascandolo S, Piombino P,
Califano L. Two load sharing plates fixation in mandibular
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fac Surg 2010;38(5):385–390
23. Asprino L, Consani S, de Moraes M. A comparative bio­
mechanical evaluation of mandibular condyle fracture
plating techniques. J Oral Maxillofac Surg 2006;64(3):
452-456
24. Meyer C, Kleinheinz J, Meyer C, eds. The TCP plating tech­
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Quintessenz; 2009:185–192
25. Pautke C, Bauer F, Otto S, et al. Fluorescence-guided bone
resection in bisphosphonate-related osteonecrosis of the
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Oral Maxillofac Surg 2011;69(1):84–91
26. Ariji Y, Izumi M, Gotoh M, et al. MRI features of mandibu­
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27. Kesting M. Oral Cancer Surgery: A Visual Guide. Stuttgart:
Georg Thieme Verlag; 2015
28. Weitz J, Kreutzer K, Bauer FJ, Wolff KD, Nobis CP, Kest­
ing MR. Sandwich flaps as a feasible solution for the
Discussion by David E. Morris
This discussion offers practical technical notes I have
found important when teaching residents. My ap­
proaches arise from my own experience and the envi­
ronment and system within which I work.
Maxillary Fractures
In treating maxillary fractures, the most common error
I see is failing to adequately mobilize the fractured max­
illary segment. Significant force is required to fracture
and displace the maxilla; the nature of the trauma is
often a motor vehicle collision with a vertically impact­
ing force. To reduce the fracture, the impacted maxil­
lary segment must be mobilized and pulled downward
to its preinjury position. If maxillomandibular fixation
(MMF) is established and the maxilla is fixated with­
out having disimpacted the fracture adequately, several
clinical pictures may result. One is that the midface is
vertically shortened, decreasing the patient’s dental
display and thereby creating an artificially aged ap­
pearance. Another is an anterior open bite; in this case,
while establishing the MMF the surgeon pulls the con­
dyles from their fossa, because the anterior maxilla has
not been mobilized and brought down to its preinjury
position.
It may take significant work to adequately mobilize
the maxilla. Rowe disimpaction forceps have great value
in this. Even without a true bony union, the impacted
maxilla may feel “stuck.” I expose the entire maxilla
subperiosteally, just as I would if I were doing a Le Fort
osteotomy, to include its anterior and lateral aspects.
The nasal floor and nasal sidewalls are exposed submu­
cosally. Osteotomes may be passed along the fracture
lines, including a curved osteotome for the pterygomax­
illary junction. At the same time, a Tessier bone hook is
hooked on the piriform rim and used to exert continu­
ous downward force. A channel retractor can be hooked
behind each of the lateral maxillary buttresses to help
in mobilization. Using such maneuvers, the fractured
segment must be mobilized, before fixation, to a degree
that allows the mandibular dental arch to be effortlessly
lifted into the maxillary arch into its preinjury occlusion.
Before closure the following should be verified:
1. The patient’s occlusion appears as it did before the
injury based on the dental wear pattern with the
patient in centric relationship (i.e., out of MMF and
without distracting the condyles from their fossa).
2. Adequate dental display is evident.
The latter may be difficult, because the pretrauma dis­
play is not known, but the surgeon should have some
idea based on patient age and how much impaction
was likely based on how the fragments vertically line

869
Chapter 47 Fractures of the Jaws
up. The former (verifying preinjury occlusion) is essen­
tial in the treatment of every jaw fracture, maxillary
and mandibular.
Mandibular Fractures
In the treatment of mandibular fractures, there are sev­
eral junctures at which key comments should be noted:
•• Initial treatment of the fracture
○
○Establishment of maxillomandibular fixation
○
○Fracture exposure
○
○Fixation
•• Late operation
○
○Late débridement
○
○Prosthodontics
Initial Treatment of the Fracture
Establishment of Maxillomandibular
Fixation
Placement of MMF is generally requisite for treatment
of a mandibular fracture. In certain cases (e.g., some
condylar fractures), a period of MMF may be the treat­
ment itself, although in most cases intraoperative MMF
is placed as a means to facilitate accurate internal fixa­
tion.
Any time I plan to rely on MMF beyond the intra­
operative period (e.g., condylar fractures to be treated
closed), I always use arch bars to establish MMF, for two
reasons:
1. Arch bars enable both an initial period of tight
MMF (with wire loops or tight elastics) and then a
subsequent period of guiding elastics. MMF screws
do not enable the use of guiding elastics.
2. If an MMF screw were to fall out, or the patient
prematurely breaks or cuts a wire, MMF is difficult
to reestablish without anesthesia and reoperation.
I believe that there is a tendency to overuse MMF screws
(both for achieving intraoperative MMF and as a means
for closed reduction). In contemplating their use, the
surgeon must analyze the fracture pattern and, for any
fracture beyond a simple, nondisplaced fracture, con­
sider whether a set of MMF screws will accurately hold
the reduction. Based on the fracture pattern, some­
times more than two sets may be required, at which
point the surgeon must weigh the issues of time saved
(over arch bars) and the risk to the dental roots.
Fracture Exposure
When using arch bars for MMF, I prefer to place the arch
bars before fracture exposure, because the field is less
bloody. Whereas the upper arch can be secured, I place
the lower arch bar loosely (using fewer circumdental
wires, and not tightening them). Once the mandibular
fractures are exposed and the bone edges have been
débrided, the segments are held in a reduced position
with the patient in MMF. At this point the circumdental
wires are tightened. Tightly securing the mandibular
arch bar at the outset of the case will “lock” the frac­
tured mandibular arch into a nonreduced configura­
tion.
In exposing fractures through or near the mental fo­
ramen, I try to minimize iatrogenic damage to the nerve
by avoiding its direct exposure. Two separate lower ves­
tibular incisions are made, and a 1-cm wide bridge of
mucosa is left untouched overlying the nerve. The buc­
cal surface of the mandible is exposed subperiosteally
down to its inferior border both proximal and distal to
the fracture. A No. 9 elevator is passed along the inferior
border to connect these two incisions, forming a tun­
nel. The bent plate is then passed through this tunnel
(Fig. 47D.1).
Fixation
I prefer to treat most mandibular fractures through an
intraoral approach. To do this, retractors must be ap­
propriately positioned to allow placement of screws at
right angles to the bone, either directly or with a trans­
buccal trocar. The surgeon must be careful to limit the
force of retraction so as not to displace the fracture seg­
ments. Despite MMF with arch bars and tight interarch
wires, the segments can be separated in retraction. A
plate placed while the segments have been distracted
through traction may result in an open bite on that side.
Occlusal splints are an important modality for fix­
ation of dentoalveolar fractures. The surgeon should
consider their use for fractures where control at the oc­
clusal level (in addition to fixation at the skeletal level) is
desirable. Textbooks often do not discuss in detail how
splints are fabricated. Although there are a number of
ways to fabricate splints, I find it useful to be able to
do so intraoperatively rather than just in the dental lab.
For this I use Triad TruTray (Dentsply), which is a soft,
pliable prosthodontic tray material that is light cured
(Fig. 47D.2).
Although most fractures are amenable to treatment
with internal fixation, the surgeon should remember
that external fixation remains a useful tool in certain
situations.1 I primarily use external fixation for ballis­
tic injuries with significant comminution and collateral
soft tissue damage. Here external fixation may offer
several advantages over internal fixation in the acute
setting. The surgeon avoids the further devasculariza­
tion through early exposure of already-compromised
bony segments. The soft tissue envelope surrounding
the fracture is maintained; once it contracts because

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
870

Fig. 47D.1 Intraoral approach to anterior mandibular body fractures. (a) Two separate incisions are made, leaving a 1-cm mucosal
bridge overlying the mental nerve to decrease the likelihood of avulsion. An elevator is passed along the inferior border, creating
a subperiosteal tunnel inferior to the nerve, through which the plate will be situated. The dotted lines designate sites of incisions,
leaving a mucosal cuff between them. This cuff should correspond with the position of the first and second premolars. (b) The red
arrows indicate that subperiosteal dissection is first carried down to the inferior border through each incision, then the dissections
are joined together along the inferior border, thus below the mental nerve.
1 cm mucosal bridge
First premolar
a
Mental nerve
First premolar
Incision
Subperiosteal
dissection
b
Fig. 47D.2 Intraoperative fabrication of an oral surgical splint. (a) Soft Triad TruTray custom tray material is rolled into a U-shape.
(b) It is pressed onto the mandibular dental arch in this patient with a mandible fracture with a dentoalveolar component. (c) The
splint is cured using a handheld light (3M Unitek). (d) On the back table, the edges have been smoothed with a burr and holes
drilled. The splint is secured using one of several techniques (to an arch bar, circumdental wires, or maxillomandibular fixation
screws).
d
c
b
a
of collapsed bony segments, it is very difficult to re-
expand. Finally, in certain situations, it may not be pos­
sible to reliably cover internal hardware with soft tis­
sue acutely.
When using an external fixation device, I prefer to
place biphasic pins (ideally two) into each of the major
segments, and then a methylmethacrylate bridge across
the external end of these pins. This technique is effec­
tive in that it is relatively lightweight, lacks the bulk of
devices with multiple joints, and is simple to place (Fig.
47D.3). I err on the side of placing the longest pins pos­
sible to allow clearance of the methylmethacrylate bar
from the skin; this is an issue because I am typically
placing these in patients with significant edema. Once
the pins are placed, the dental arches are placed into
MMF before the methylmethacrylate is placed across the

871
Chapter 47 Fractures of the Jaws
Fig. 47D.3 Placing a mandibular external fixation device. (a,b) A comminuted right mandibular body fracture from a gunshot
wound. (c) Two biphasic pins are placed into each of the major fracture segments. (d) The dental arches are brought into maxil­
lomandibular fixation in preinjury occlusion. (e) A methylmethacrylate bar is placed across the external threads of the pins. (f)
Hexagonal nuts are placed over the screw ends. (g) Computed tomography verifying pin placement. (h) The fracture is explored
at the time of device removal and treated as clinically indicated. In this case a reconstruction plate with bone graft was placed.
d
c
b
a
h
g
f
e

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
872
pins and allowed to cure. The MMF is released and ac­
ceptable occlusion is checked after the methylmethac­
rylate has cured. I often leave the lower arch bar in place
(however the patient is not left in MMF) to provide ad­
ditional support at the occlusal level during the period
of external fixation.
Although many texts mention external fixation as a
modality, few discuss the length of treatment and subse­
quent management. I leave the external fixation device
in place for approximately 6 weeks. At the time of device
removal, I explore the fracture site internally; the clini­
cal findings dictate any adjuvant procedures that may
be performed at that time: débridement of loose, nonvi­
able bone; internal fixation; internal fixation with bone
grafting; or no internal treatment. If with removal of the
external device there is movement around the fracture
site, the MMF is maintained during placement of inter­
nal fixation. If bone grafting is anticipated, an external
approach is used with exploration.
For most fractures I prefer an internal approach,
because transbuccal instrumentation can minimize
external scars. However, the surgeon must consider
the clinical scenario at hand and modify the approach
accordingly. An example of this is when bone graft is
anticipated for treating nonunions. In this case, to min­
imize potential oral contamination of the bone graft, I
prefer an external approach.
Late Operation
Late Débridement
In the acute treatment of comminuted fractures the
surgeon sometimes must determine whether to pre­
serve some of the fragments. For large fragments to be
preserved, I rigidly fixate them to the plate and maxi­
mize adjacent bony contact. To preserve smaller frag­
ments, the surgeon must realize the risk that they may
not incorporate and thus be willing to débride or re­
move such loose fragments later if indicated. If a patient
presents late after open reduction and internal fixation
(ORIF), with drainage from a skin opening and the sug­
gestion of a sinus tract, the surgeon should suspect a
loose bony fragment, loose hardware, or a foreign body.
This can be evaluated radiographically before surgical
débridement (Fig. 47D.4).
Fig. 47D.4 A retained foreign body after open treatment of a mandibular fracture. This patient had a left mandibular body frac­
ture caused by a gunshot injury. He initially underwent débridement with open reduction and internal fixation. (a,b) He presented
several months later with drainage from a pinpoint opening at the posterior end of his scar. (c) A sinus tracked to the medial as­
pect of the mandibular body. (d) A bullet fragment as well as a tied plastic bag of crack cocaine that had been lodged into the
bone were removed.
d
c
b
a

873
Chapter 47 Fractures of the Jaws
Prosthodontics
Although the initial goal in jaw fracture treatment might
be to anatomically reduce and fixate the fractured seg­
ments appropriately, optimal treatment should include
restoring the patient’s function to allow effective biting,
chewing, and eating. Teeth or dentoalveolar segments may
have been lost during the course of injury, or the surgeon
may have been unable to salvage bony segments.
I work closely with our multidisciplinary center’s
prosthodontist to provide the surgical support needed
for full oral rehabilitation. As later secondary proce­
dures I sometimes perform alveoloplasty, bone graft­
ing including ridge augmentation, vestibuloplasty, and
placement of intraoral osteointegrated implants. In the
latter case, our prosthodontist is in the operating room
to be sure that implants are placed in a way that best
facilitates a later implant-retained prosthesis. It is im­
portant to be able to either perform these procedures or
to be able to refer these patients to an associate who can.
Conclusion
The goals in treating jaw fractures are to restore prein­
jury occlusion, restore facial form (including maintain­
ing the expanded soft tissue envelope), and optimize
function. This starts with upholding basic surgical
principles during acute management: adequate expo­
sure and reduction, paying careful attention to MMF,
and adequate fixation. Techniques for external fixation
and intraoperative splint fabrication are important ad­
juncts to the surgeon’s armamentarium. The patient is
followed long term until preinjury function, or a state
as close to preinjury as possible, is achieved.
Reference
1. Manson P. Facial fractures. In Mathes S, ed. Plastic Sur­
gery. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2006

Bronze portrait from the statue of the Empress Julia Aquilia Severa found in
Sparta, Greece. 3rd century AD. (National Archaeological Museum, Athens,
Greece. © Hellenic Ministry of Culture and Sports/Archeological Receipts Fund.
Photo: Klaus Valtin von Eickstedt.)

875

Facial Fractures
Karl C. Bruckman, Rizal Lim, and Joe I. Garri
CHAPTER
48
Traumatic injuries to the craniofacial complex can be dev­
astating. Long-term sequelae lead to disfigurement and
dysfunction if not managed appropriately. Trauma to the
face can involve soft tissue, bone, salivary glands, or sen­
sory organs. Initial management of facial trauma follows
Advanced Trauma and Life Support guidelines. Once stabi­
lized, facial injuries are treated.
To optimize outcome, a systematic approach should be
undertaken:
1. Accurate diagnosis by physical examination and sup­
porting radiographic studies
2. Formulation of optimal surgical timing as well as meth­
odology of surgical repair
3. Proper execution of treatment plan, including:
•• Adequate surgical exposure while following basic
aesthetic principles
•• Anatomic reduction
•• Stable fixation
•• Optimal soft tissue management and resuspension
4. Early mobilization and proper rehabilitation
Despite best efforts, treatment results of facial trauma
may be suboptimal. Reduction may collapse over time be­
cause of cicatricial or muscular forces. Bony malunion or
nonunion may occur. There may be poor scar formation
or neurologic injury secondary to operative treatment.
Unfavorable outcomes should be approached in a similar
fashion to the initial injury. A methodical approach that be­
gins with a physical examination supported by radiologic
studies followed by goal-directed surgery leads to success.
H.K. Kawamoto (personal communication, 2016) reiterates,
“You have to know what the problem is before you can fix
it.” This chapter discusses the treatment for unfavorable re­
sults of upper and midface fractures.
Managing Unfavorable Results
and Complications in Facial
Fractures
Infection
Although rare in the facial area, infection is the first compli­
cation surgeons must watch for postoperatively. The time
course may be in the initial days after the operation, but
infection may not present until weeks or months later, in
the form of hardware infection and exposure.
If signs of infection are noted in the acute phase of heal­
ing, then simply releasing sutures or staples and gently re­
opening portions of the wound can be beneficial. This al­
lows egress of infected material and exposes the wound to
oxygen, inhibiting anaerobic bacterial growth. Many prac-
titioners choose to treat perioperatively with a 5- to 7-day
course of oral antibiotics that covers oral flora. For an in­
fection that is more physiologically severe or when clini­
cal evidence of an infection progressing beyond a localized
wound is present, hospital admission is indicated. Treatment
includes volume resuscitation, parenteral antibiotics, and
débridement of infected tissues.
Hardware infections present either in the early or late
stage as exposure or purulence around plates and screws.
Hardware exposure can often be treated conservatively until
bony healing is complete. If bony union is not achieved, the
hardware pockets are irrigated of frank purulence and dé­
brided conservatively. The wounds can then be reclosed over
a drain and a course of antibiotics given. After bony union is
achieved, the hardware can then be removed.
Osteomyelitis is uncommon in facial bones but can occur
after excessive periosteal stripping and contamination of a
fracture. Osteomyelitis presents with localized (rubor, calor,

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
876
Hypertrophic scarring appears at 3 to 4 weeks and can
potentially be inhibited by serial intralesional steroid injec­
tion.7,8 This intervention will act locally to inhibit scar tis­
sue formation. Immunomodulators such as 5-fluorouracil
have also been shown in some studies to be effective.8–10
Laser and phototherapy may decrease the prominent red­
ness of scars.11,12
If an unaesthetic scar persists beyond 6 to 8 weeks de­
spite optimal scar therapy, scar revision and excision may
be performed. This may be performed as a simple excision
or other forms of local tissue rearrangement. The timing for
revisions generally allows 3 to 6 months of healing to permit
full resolution of tissue inflammation. As is the case with any
elective procedure, it is important to medically optimize the
patient for wound healing. The patient should be nutrition­
ally optimized, tobacco free, and under adequate glycemic
control. Full scar excision removes chronic inflammation and
allows closure with noninflamed tissue. The wound should
be designed in a way to hide it within the resting tension
lines of the face, as well as to allow local tissue recruitment
and tension-free closure.
Malunion or Nonunion
Abnormal fracture healing results in delayed union, non­
union, or malunion. Delayed union is slow or delayed bone
healing. This occurs in cases with prolonged tissue inflam­
mation, infection, or insufficient bone stabilization. Insuf­
ficient stabilization may be caused by screw loosening,
dolor) or systemic (fever, myalgias) infection. Osteomyelitis
is diagnosed by a combination of bone biopsy and specific
radiographic findings.1,2 Management of osteomyelitis in­
cludes surgical débridement of affected bone, removal of
all internal hardware, maintaining bone orientation, and 6
weeks of intravenous antibiotics.3,4 The remaining bone seg­
ments’ orientation may be maintained by external fixation
devices or replacement of plates. If the surgeon chooses to
replace the internal plates, then load-bearing reconstruc­
tion plates are preferred with locking screws placed away
from the site of infection in well-vascularized, healthy bone.
Soft Tissue Injuries
Scar formation from traumatic soft tissue injuries affects
the result as much as bony reduction. Often, cicatricial
formation of the face leads to aesthetic and functional im­
pediments. Lacerations with crushed edges, avulsed hypo­
perfused superficial tissue, increased bacterial burden and
local inflammation, and tight wound closure all combine to
increase scar formation.
To optimize cutaneous wound healing, patients should
be advised to avoid sun exposure and perform scar massage
or topical treatments. Massage mechanically softens the scar
tissue and counteracts cicatricial thickening and contraction.
Silicone gel or sheets improve scar contour and thickness.5,6
These interventions can be started after the removal of su­
ture, provided the wound is healing well, typically after 10
to 14 days.
Summary Box
•• General
○
○Infection
○
○Soft tissue injuries
○
○Malunion or nonunion
•• Frontal sinus fractures
○
○Contour irregularity
○
○Meningeal tears and injury
○
○Mucocele/mucopyocele
•• Naso-orbitoethmoid fractures
○
○Telecanthus
○
○Epiphora or disruption of the lacrimal system
○
○Cerebrospinal fluid leakage
○
○Loss of nasal projection
○
○Epicanthal folds and soft tissue secondary
abnormality
•• Orbital fractures
○
○Ocular injury
○
○Diplopia
○
○Enophthalmos/hypoglobus
○
○Complications related to the use of alloplastic
materials
○
○Ectropion and lagophthalmos
•• Zygomaticomaxillary complex fractures
○
○Malar flattening
○
○Enophthalmos and lateral canthal dystopia
○
○Sensory nerve damage
○
○Masticatory dysfunction
•• Nasal bone fractures
○
○Airway obstruction
○
○Aesthetic deformity
○
○Septal complications
•• Le Fort fractures
○
○Malocclusion
○
○Nasal septal deviation
○
○Maxillary sinusitis
○
○Cerebrospinal fluid leakage
○
○Nerve damage
○
○Loss of facial projection
•• Panfacial fractures
Unfavorable Results and Complications in the Treatment of Facial Trauma

877
Chapter 48 Facial Fractures
and produces secretions that drain through nasofrontal
ducts traversing the inferomedial sinus floor and to the na­
sal middle meatus. The anterior wall forms brow and fore­
head contours, whereas the posterior wall forms the limit
of the anterior cranial fossa.
Fractures of the frontal sinuses have many patterns and
can include one or both sinuses; involve the anterior wall,
posterior wall, or both walls; and may or may not extend
to or cause obstruction of the frontal duct system. Initial
treatment involves three considerations that determine the
outcome. The anterior wall supports the aesthetic contours
of the brow and forehead. The posterior wall supports the
anterior cranial fossa and dura. Fractures injure the dura and
form a communication between the brain and nasal cavity.
The nasofrontal duct drains the sinus, and obstruction can
lead to trapping of secretions and infection. Management of
these fractures focus on restoring integrity of the anterior
walls but also on the creation of what has been conceptu­
ally referred to as a safe sinus.17,18 This concept refers to pre­
venting mucous trapping by removing mucosal elements of
the sinus when the nasofrontal ducts are compromised or
intracerebral infection is of concern.
The initial treatment of frontal sinus fractures starts
with prophylactic antibiotics. Antibiotic choice should
cover gram-negative, gram-positive, and anaerobic bacte­
ria, such as clindamycin. Anterior table fractures are reduced
and plated into anatomic position. Injury to the nasofrontal
duct is treated by sinus obliteration, removal of all muco­
sal elements, and closure of the nasofrontal duct. Displaced
fracture of the posterior wall is treated by (1) cranialization,
(2) removal of the posterior wall, (3) removal of all muco­
sal elements, and (4) repair of dural injuries. Reconstructive
failure of these four elements may create undesirable results.
Contour Irregularity
Contour irregularity of the forehead and glabella result
from loss of soft tissue, bone fragment resorption, or in­
accurate realignment of the bones. If this occurs, it may
be noticeable and become a stigmata of previous injury,
sometimes causing patient distress. Evaluation starts with
physical examination followed by CT. Scans can determine
whether the aesthetic abnormality is related to soft tissue
atrophy or underlying bony irregularity. Bony irregular­
ity in the form of overlapping step deformity or irregular
thickness can be burred or filed down. Options to improve
soft tissue contour defects include soft tissue grafts like
fascia, dermis, or fat. For large or bony defects, bone grafts
as well as alloplastic materials such as prefabricated poly­
ethylethylene or porous polyethylene may be used. Each of
the aforementioned materials has its proponents, depend­
ing on the size and type of contour. Autogenous options are
superior because of a decreased potential for infection or
granulomatous reactions. Overcorrection is indicated to ac­
count for the expected fat and bone graft resorption over
the first year and beyond (Fig. 48.1).
fractures of the bone adjacent to hardware, or plate frac­
ture. Delayed union becomes nonunion when bone fails to
ossify after adequate healing time.13 A nonossified fibrous
bridge often forms between bone ends and is mechanically
insufficient to support the fractured segments, resulting in
structural collapse against adjacent muscular or cicatricial
forces. Nonunion is more likely to occur in the mandible
than in the maxilla, where the forces supported are greater.
Malunion is nonanatomic postreduction alignment of prox­
imal and distal bone.14 Malunion follows poor reduction as
well as hardware loosening and failure. Malunion presents
with clinical findings of a step deformity at fracture seg­
ments, malocclusion, or an asymmetrical facial contour.
The evaluation of malunion or delayed nonunion starts
with a physical examination. It is appreciated by facial bone
mobility, step-off, and asymmetry. The physical examination
is followed by radiographic imaging. Computed tomography
(CT) provides a thorough evaluation for bony gaps and non­
viable bone. If vascularized bone flaps are necessary, CT an­
giography can confirm donor vascular anatomy of the flap. In
these cases, the patient should be fully evaluated for physi­
ologic tolerance for prolonged surgery.
The treatment for bony nonunion involves removing the
previously placed hardware and excising the fibrous bridge.
Bone, as free or vascularized graft, is then used to bridge the
segment, and the entire construct is supported by hardware.
The length of the bone gap is important because it determines
the treatment. Nonvascularized or allogenic cadaveric bone
grafts adequately reconstruct defects up to 6 cm, whereas vas­
cularized bone grafts, from the fibula or iliac crest, are ideal
for defects larger than 6 cm.15 For a defect smaller than 6 cm
in a nonirradiated patient, treatment options include cadav­
eric or nonvascularized autogenous bone graft. Adding a sub­
stance such as bone morphogenetic protein (BMP) to this site
may improve osteoinductive potential, through direct stimu­
lation of bone growth and induction of bone stem cells. These
nonvascularized corticocancellous grafts are secured to the
bone plate within this continuity defect.
Bony defects larger than 6 cm require reconstruction
with vascularized bone flaps. With these large bone gaps,
vascularized bone provides osteogenic potential for healing
and prevents the resorption seen in conventional bone grafts.
Possible donor sites include the fibula, iliac crest, scapula,
and radius, each with their own set of advantages and dis­
advantages. Flaps may be transferred as bone and soft tissue
composite free tissue to correct soft tissue deficits.
Frontal Sinus Fractures
The frontal sinus begins to develop at age 6 years. In adults,
the sinus is completely formed as air-filled spaces in the
forehead on either side of the midline. With an average to­
tal volume of 14 mL, the frontal sinuses are composed of an
anterior and posterior wall and can exist as two separate
spaces separated by a bony midline septum or a large com­
municating single cavity.16 Mucosa lines the bony cavity

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
878
Meningeal Tears and Injury
Meningeal tears and injury can result in persistent cerebro­
spinal fluid (CSF) leak and secondary CSF space infection.
This can either result from poor healing and sealing of the
dural closure or unidentified dural tears. Evaluation for a
chronic CSF leak is a clinical diagnosis but can be verified
by beta-transferrin levels of the fluid. The clinical presen­
tation is persistent clear nasal drainage. CT may be useful
to identify the location of the dural defect. Dural defects
are repaired by direct suture or using dural patches of free
fascial graft or alloplastic collagen sheets.19,20 A preferred
method is the use of vascularized pericranium or tempo­
ralis to cover suture lines (Fig. 48.2). When there is signifi­
cant dead space and continued CSF leak, pericranium and
temporalis flaps may be insufficient. These situations may
be best dealt with using free tissue transfer, which can fill
dead space, improve vascularity to the region, and stimu­
late sealing of the dura.21
Mucocele and Mucopyocele
Mucoceles of the frontal sinus result from sequestered se­
cretions caused by partial or complete nasofrontal duct
obstruction. They occur when there is an unrecognized
nasofrontal duct obstruction or because of retained sinus
mucosa after obliteration or cranialization and may occur
years after the initial injury.22,23 Infected mucoceles are
called mucopyoceles. Mucoceles expand from continued
mucous secretion and compress and distort surrounding
structures. Diagnosis is clinical, based on a history of fron­
tal sinus fracture, fevers, visual symptoms, and headaches.
CT defines the patient’s anatomy and structural distortion
caused by the mucocele (Fig. 48.3).
Early treatment of mucoceles involves ample drainage,
which can be performed endoscopically if identified before
significant anatomic distortion. If endoscopic drainage fails
or is not technically feasible, a craniotomy is required to
Fig. 48.1 (a,b) A young patient presented after posttraumatic frontal sinus and bone repair with significant frontal and cranial bone loss.
(c) Split calvarial bone was used to reconstruct the frontal bone, glabella, and forehead. (These images are provided courtesy of J.I. Garri.)
b
a
c
Fig. 48.3 After a frontal sinus fracture, this patient presented with a
left-sided mucopyocele that destroyed the orbital roof and rim. (This
image is provided courtesy of J.I. Garri.)
Fig. 48.2 A collagen alloplastic patch is used to seal the dura. (This
image is provided courtesy of J.I. Garri.)

879
Chapter 48 Facial Fractures
physical examination correlated with CT to better define
the bone and soft tissue relationship.
Scarring and fibrosis of the soft tissue around the medial
canthal tendon distorts its position, leading to degrees of
telecanthus. Alternatively, the previous medial canthal wir­
ing may erode the bone and allow the canthus to slip later­
ally. This situation is most easily addressed with tissue rear­
rangement using small, local flaps. Horizontal discrepancies
can be corrected with V-Y advancement, whereas vertical
discrepancies are addressed with z-plasty–style transposi­
tion flaps. These flaps should be full-thickness tissue down
to bone. The flap controlling the canthal angle is then rean­
chored to bone by a transnasal suture or wire to maintain
the new soft tissue position. The wiring traditionally is per­
formed by coronal incision, but a transcaruncular approach
is a less invasive. The wire is passed posterior and superior
with slight overcorrection. Alternatively, if bone erosion is
a concern, a small plate may serve as the fixation point for
the transnasal wire.
If the bones are malpositioned, then a bone-centric ap­
proach is required. This starts by removing previous hard­
ware and re-creating the NOE fracture via osteotomy and
correctly reducing the segments. If the medial canthal ten­
don (MCT) is not fixed to these segments, it may still require
transnasal canthopexy to achieve the anatomic position. Of
note, the technique is very difficult, and the best secondary
treatment of telecanthus is not defined. Skin thickness and
tissue draping of the canthal–sidewall junction can be wors­
ened by edema and is a stigmata of the injury. Transnasally
fixed bolster dressings on both canthal–sidewall junctions
help control the edema and maintain the soft tissue. These
should be left in place for 7 to 10 days.
Epiphora or Disruption of the Lacrimal
System
Lacrimal apparatus damage occurs either from the injury
or during the initial repair. The normal course of tears flows
from the upper and lower puncta, through the superior
and inferior canaliculi traversing the orbicularis, into the
remove all retained sinus mucosa. Through a coronal inci­
sion, a craniotomy allows access to the mucocele. The brain
is separated from the mucocele, and any inflammatory tis­
sues are removed. The posterior table segments are removed
and any remaining sinus surfaces are burred to remove all
mucosal rests. Distorted facial and cranial structures are re­
constructed with autologous bone graft (Fig. 48.4). The dead
space is then obliterated by a pericranial or temporalis flap.23
If these are too scarred for use or have been used already, or
the dead space is large, the surgeon must consider alternate
options such as free tissue to close off those spaces.
Naso-orbitoethmoid Fracture
Treatment Principles
The naso-orbitoethmoid (NOE) region is a complex focus
of bony articulations involving multiple facial buttresses.
Here the nasal bones and cartilages, maxillary frontal pro­
cesses, lacrimal bones, orbital plate, ethmoid air cells, crib­
riform plate, and frontal bone adjoin. NOE fractures affect
the shape and position of the nasal pyramid, root of nose,
and medial canthus. Accurate reduction prevents contour
and symmetry irregularity of the nasal sidewall. The grade
of injury determines the surgical maneuvers necessary to
correct the medial canthal deformities. This includes re­
duction or fixation of fractured segments and transnasal
wiring.
Telecanthus
Telecanthus is an increased distance between the medial
canthi.24 It is a soft tissue relationship and differs from hy­
pertelorism, which is increased interpupillary distance.25
The normal intercanthal distance equals the length of the
patient’s palpebral fissure, approximately 31 to 33 mm.26
This is a gender-specific and ethnically variable measure­
ment. Malpositioned medial canthi is a challenging prob­
lem to correct. Poor medial canthal position and appear­
ance can be caused by soft tissue secondary healing and
bone malposition. The evaluation should include a keen
Fig. 48.4 (a) After a frontal sinus fracture with mucopyocele formation, this patient’s anterior table had irregularity and openings into
the sinus. (b) Resection of necrotic bone exposed the sinus and allowed débridement of the mucopyocele and separation from the brain.
(c) Reconstruction is with split calvarial bone graft. (These images are provided courtesy of J.I. Garri.)
b
c
a

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
880
and loss of support for the nasal pyramid. This may lead to
upper and middle nasal vault deficiency, concavity of the
nasal dorsum, and loss of nasal length or tip projection.
Further secondary nasal reconstruction is discussed in the
Nasal Bone Fractures section.
Epicanthal Folds and Soft Tissue
Secondary Abnormality
With facial trauma, the bony support may be significantly
distorted, such as in NOE fractures, and overlying soft tissue
may heal in an unaesthetic manner. The surgeon should be
careful when closing the soft tissue envelope at the initial
repair, because wound dehiscence and widened scars may
complicate healing.
The medial orbit and canthus is an area of concern
when underlying skeletal contours are altered and soft tis­
sue swelling results. Prolonged tissue edema causes tissue
thickening and loss of fine soft tissue anatomy. This may re­
sult in epicanthal folds, blunting of the medial canthal an­
gle, or disruption of the canthal tendon repair. This is best
treated with prevention. A rigid bolster dressing is placed on
both nasal sidewalls and secured transnasally with suture.
A rigid dressing can be assembled using a halved aluminum
foam nasal splint or rolled petroleum gauze. Secondary revi­
sion can be quite complex and rarely will restore premorbid
aesthetics. The soft tissue is rearranged as outlined in the
Telecanthus section.
Orbital Fractures
Treatment Principles
Forces transmitted hydrostatically through the globe or
through adjacent bones fracture the orbital walls.30 They
are also associated with high-level midface fractures like
Le Fort II and III patterns. Although blow-in fractures oc­
cur, blowout fractures are more common and result in in­
creased orbital volume, restricted extraocular movement,
and visual disturbances. The globe is evaluated for injury
before repair to prevent exacerbation of injury and blind­
ness. At primary repair the goals of treatment are restora­
tion of correct orbital volume and reduction of orbital rim
step-offs. This is performed through transconjunctival,
subciliary, and subtarsal incisions. The orbital wall defects
are closed with either autogenous bone graft, resorbable
and nonresorbable synthetic plates, or titanium plates. Or­
bital floor reconstruction plates are positioned on the pos­
terior ledge of the fracture to accurately re-create volume.
Poor outcomes from orbital fractures include ocular injury,
diplopia, enophthalmos, eyelid malposition, and hardware
complications.
Ocular Injury
Ocular injury after orbital fractures is common, occurring
in approximately 60% of cases.31 The incidence increases as
lacrimal sac in the lacrimal fossa, and through the lacrimal
duct, exiting under the inferior nasal turbinate. Considering
that 90% of tear volume evaporates, injuries may never be
identified. Approximately 17% of nasolacrimal duct injuries
associated with NOE fractures require surgical correction.27
Evaluation starts with determining a history of excessive
tearing postoperatively. Traumatic telecanthus may be part
of the history, because it is associated with lacrimal duct ob­
struction.28 Postoperative eyelid malposition should also be
considered, because eyelid incisions are commonly used in
facial open reduction and internal fixation. Epiphora may be
expected in the initial postoperative period from edema of
the lacrimal apparatus, but persistence beyond the normal
healing time of 6 weeks necessitates testing. CT imaging can
help identify bony fractures involving or occluding the lac­
rimal duct. Jones (primary dye test) test confirms lacrimal
duct obstruction, with a sensitivity of 97% and specificity
near 100%.29 Jones test 1 is performed, in which fluorescein
is instilled at the medial canthus and subsequently drained
at the inferior turbinate onto a cotton applicator. A positive
test shows the duct is patent. If the test is negative, Jones test
2 is performed, which involves cannulation of the lacrimal
duct and injection of fluorescein under pressure. A positive
test means partial obstruction or stenosis of the lacrimal
apparatus exists.
Dacryocystorhinostomy is the operative repair of naso­
lacrimal dysfunction. This procedure is performed classically
through an external open technique or endoscopic transna­
sal approach. External dacryocystorhinostomy begins with
a well-placed incision within the medial orbital soft tissue,
medial to the MCT. Dissection is carried down to the peri­
osteum over the lacrimal crest. Periosteum is cleared from
bone anterior to the lacrimal fossa, and the lacrimal sac is
identified by passing a probe through the puncta. An oste­
otomy is made anterior to the lacrimal fossa to expose the
nasal mucosa with a high-speed bur. The nasal mucosa is
then elevated from bone and incised. A mirrored incision
is made into the lacrimal sac. Crawford tubes are passed
through superior and inferior canaliculi into the lacrimal
sac. The terminal ends of the Crawford tubes are then placed
through the osteotomy into the nasal cavity. The tubes are
trimmed to stay within the nasal vestibule and secured with
suture. An ostomy between nasal and lacrimal sac mucosa is
then created by suturing the open mucosal edges. The skin
incision is closed in layers, emphasizing aesthetics. Crawford
tubes remain in place for at least 3 weeks to up to 6 months
to maintain patency of the surgically created nasolacrimal
fistula.
Loss of Nasal Projection
A significant posttraumatic deformity caused by NOE frac­
tures is the loss of nasal projection. The contours of the nose
are supported by the nasal process of the frontal bone, the
nasal bones, the frontal process of the maxilla, the septum,
and upper and lower lateral cartilages. Significant trauma
to the NOE complex may result in depression of its subunits

881
Chapter 48 Facial Fractures
diplopia include intraocular pathology, extraocular muscle
dysfunction, and discrepancies in globe position from en­
ophthalmos or hypoglobus. CT will further define the ex­
traocular anatomy and areas needing orbital volume cor­
rection. The treatment for diplopia depends on the cause,
and subsequent correction of such typically ameliorates
the visual disturbance. If diplopia persists, corrective lenses
may be used to further improve symptoms.
Enophthalmos and Hypoglobus
Although both conditions can occur concomitantly, enoph­
thalmos is underprojection of the globe in the anteroposterior
plane, whereas hypoglobus is caudad globe displacement into
the space of the maxillary sinus. Both enophthalmos and hy­
poglobus cause extraocular muscle dysfunction by changing
the axis of muscular action.
Enophthalmos is quantified by two methods. A Hertel
exophthalmometer directly measures the corneal lateral
canthal distance. Immediately postinjury or postoperation,
this measurement will be normal or exophthalmic because
of periorbital swelling. Enophthalmos may not develop until
several weeks after the injury. CT may be used to calculate
orbital volume and approximate the difference from nor­
mal.35 Both of these conditions may cause periorbital asym­
metry, cosmetic concerns, and disruption of the visual axis
and can oftentimes be associated with diplopia. Postopera­
tive enophthalmos and hypoglobus result from improper
reconstruction of orbital volume, atrophy of traumatized
orbital fat, or resorption of autogenous bone graft materials
used in the repair.
Orbital volume requires correction to resolve globe posi­
tion problems. Causes include plate malposition projecting
into the maxillary sinus, or poor plate adaption creating an
oversized orbit. This reconstructive error must be revised by
adapting the plates to correctly rest on the posterior ledge of
the fracture, thus reducing orbital volume. The orbital vol­
ume can be fine-tuned with bone graft in addition to plates
(Fig. 48.5).
the number of other associated facial fractures increases.
Associated ocular injuries include hyphema, retinal injury
and hemorrhage, ocular hypertension, optic neuropathy,
and globe rupture.31 Delayed repair of the orbital fractures
is necessary to allow these injuries to stabilize. Any of these
preexisting injuries can progress to blindness if not man­
aged appropriately and with caution. Ocular injury may
also occur during the dissection of the orbital defects by
blunt force. The optic nerve enters the superomedial orbit
approximately 40 mm from the orbital rim. Iatrogenic com­
plications are rare and are best treated with prevention.
A rare complication after injury is sympathetic oph­
thalmia. This condition typically follows globe rupture.
The clinical presentation results from a coordinated feed­
back response loop between injured excitatory and the un­
injured sympathizing eyes. The injured eye presents with
decreased vision stimulating photophobia, visual accom­
modation paresis, and pain in the sympathizing eye. The
mainstay of treatment is enucleation within 2 weeks of in­
jury upon failed improvement of vision. Medical treatments
include high-dose steroids, immune modulators such as cy­
closporine and mycophenolate, or intraocular injection of
steroids.32
Diplopia
Diplopia results from the initial trauma or after surgical
intervention. It is important to document diplopia and
how it presents at rest or extremes of gaze. After orbital
surgery, continued diplopia occurs in 8 to 30% of patients.33
Diplopia incidence increases in older patients after delayed
orbital fracture repair.34 Immediate postoperative swelling
of extraocular muscles may contribute to diplopia; follow­
ing an interval for edema resolution, continued diplopia
requires further workup. A thorough history and physical
examination is performed, with ophthalmologic consulta­
tion, to diagnose the cause. Diplopia immediately after the
initial reconstruction may be caused by plate impingement
on extraocular muscles. Causes of persistent postoperative
Fig. 48.5 (a) After an orbital fracture this patient had post­
reduction orbital dystopia. (Image a is provided courtesy of
S.A. Wolfe.)
a
Continued

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
882
Ectropion and Lagophthalmos
Postoperative scarring after eyelid incisions for orbital ex­
posure may cause lid shortening with lagophthalmos and
lower-lid imbalance. This poses aesthetic as well as func­
tional problems. Dissection of the orbicularis oculi and
orbital septum causes the classically described cicatricial
shortening of the middle lamella. In practice, this results
in mechanical lid imbalance and eversion of the lash line,
or ectropion. Ectropion reportedly occurs more with sub­
ciliary incision, but it may also occur with subtarsal and
transconjunctival approaches.36,37 The incidence of ectro­
pion after transconjunctival approaches is reported as less
than 1%.37,38
Swelling leads to some expected lagophthalmos after
surgery. In early postoperative healing, tarsorrhaphy sutures
or lid taping helps limit swelling and counteract lagophthal­
mos. Persistent lagophthalmos is initially treated with lid
massage several times per day. Ectropion or lagophthalmos
persisting beyond 6 months requires surgical correction.
Preoperative evaluation of ectropion or lagophthalmos
requires careful physical examination. Lid position, move­
ment with upward and downward gaze, and visible scarring
are closely noted. Surgical correction involves incision of the
affected conjunctiva and orbital septum and an interposition
Complications Related to the Use of
Alloplastic Materials
Most surgeons use alloplastic materials to treat orbital frac­
tures because of the decreased operative time and ease of use.
Aside from poor plate adaptation or positioning, alloplastic
materials may create problems caused by the hardware. These
include palpability, infection, and fibrosis.
The orbital skin is thin, and as edema resolves, plates
may become more visible and palpable. Plate placement
away from the orbital rim and use of low-profile screws for
fixation help to prevent this. Plate repositioning, modifica­
tion, or partial removal may improve prominent hardware
concerns.
Alloplastic materials pose a long-term risk of erosion,
infection, and periorbital fibrosis. Use of bone or absorbable
hardware prevents this complication. Any implant may be­
come infected; however, those with more tissue ingrowth
are at decreased risk. Alternatively, excessive tissue inflam­
mation and ingrowth may lead to fibrosis of periorbital
structures. Extraocular muscle scarring to the plate leads to
restriction of ocular movement and diplopia. Secondary re­
constructive plate complications such as infection, exposure,
and fibrosis mandate removal of hardware and replacement
with autogenous bone.
Fig. 48.5, cont’d (b–d) An intracranial orbital box osteotomy allows cepha­
lad repositioning of the orbital rim to alter globe support. (e) Postoperative
orbital symmetry is achieved. (Image e is provided courtesy of S.A. Wolfe.)
e
Area of bone
to be removed
b
c
d

883
Chapter 48 Facial Fractures
planning is also an option, using CT to make surgical cutting
and plating guides. Malar flattening is treated with skeletal
and soft tissue repositioning and augmentation.
Skeletal repositioning is the appropriate treatment for
malar flattening resulting from poor reduction, specifically
the associated flat-wide morphology. Soft tissue or skeletal
augmentation will not correct posttraumatic flat-wide fa­
cies, only make the face dysmorphic. Prior incisions are used
to reexpose fractures. Prior hardware is removed and oste­
otomies are created to mobilize the fracture segments. They
are then restabilized with hardware according to standard
principles. If the problem is only malar projection without
problems of width, the options are skeletal augmentation
with bone graft, alloplastic cheek implants, or soft tissue
suspension or augmentation procedures. Fat grafting is be­
coming a simple solution that may be applied to soft tissue
and some skeletal causes of malar flatness. The caveat of fat
grafting is the likely need for multiple sessions, and over­
correction at each session, although skeletal problems are
generally best corrected with skeletal surgery.
Enophthalmos and Lateral Canthal
Dystopia
Zygoma and its contributions to the lateral orbital wall
and floor contribute to orbital volume. Whitnall’s tubercle
resides on the orbital surface of the frontal process of the
zygoma. Inaccurate reduction or failure to resuspend the
soft tissues may result in changes to the orbital volume, en­
ophthalmos, and lateral canthal malposition.
Lateral canthal dysmorphology progresses after lateral
canthal disruption from Whitnall’s tubercle or poor lateral
rim reduction and loss of support. On examination, the phy­
sician finds lateral canthal rounding, or vertical malposition.
After tendon avulsion from trauma or treatment, or mal­
positioned lateral orbital rim segments, loss of lateral can­
thal tension results in canthal rounding. Treatment for bony
causes of lateral canthal dysmorphia may be accomplished
with bone repositioning or recontouring; however, lateral
canthal procedures are effective and less invasive. Cantho­
pexy and lateral tarsal strip canthoplasty resuspend the
eyelids, reconstructing the palpebral cant and sharp can­
thal verge. Both techniques involve fixation to the lateral
orbital rim arcus marginalis. Alternatively, canthal fixation
to a drill hole on the lateral canthus provides more stability.
Evaluation and treatment of orbital volume discrepancy
and enophthalmos follow a similar set of principles, as dis­
cussed in the Orbital Fractures section of the chapter, includ­
ing orbital rim position as a contributor to orbital volume.
Physical examination makes the diagnosis of inaccurate vol­
ume reproduction, focusing on asymmetry and bony step-
off. CT improves understanding of anatomic relationships
and assists surgical planning. Correction of orbital volume
discrepancies from poor rim reconstruction requires osteo­
tomy of the errant bone segments and fixation in the correct
orientation. This may require bone grafting to augment the
rim support of the eye and change orbital volume (Fig. 48.6).
spacer graft. The repair classically uses a hard palate muco­
sal spacer; however, acellular dermal matrices have gained
popularity. The scarred tissue is excised and the spacer graft
of acellular dermal matrix or hard palate mucosal graft is
secured. If a palatal graft is used, it is oriented such that the
oral mucosa opposes the sclera.
Zygomaticomaxillary Complex
Fractures
Zygomatic fractures challenge even seasoned surgeons
with their unique quadripod anatomy and three-dimen­
sional articulations. The zygoma may be fractured at the
arch alone or at the articulations with the maxillary, tem­
poral, frontal, and sphenoid bones of the zygomaticomaxil­
lary complex (ZMC). This tetrapod orientation defines the
inferolateral orbital rim, wall and floor, and malar height
and projection. The zygoma position controls aesthetically
sensitive landmarks such as the cheek highlights and facial
width.
Initial repair of zygoma fractures is indicated for sig­
nificant displacement causing facial asymmetry, associated
orbital fractures, trismus, and infraorbital nerve pain. Prin­
ciples of orbital surgery apply, because the typical fracture
patterns involve the floor and lateral wall. Ophthalmologic
evaluation for globe trauma is indicated. In cases that are
treated nonoperatively, masseteric action can displace an
initially acceptable zygoma position caudally. The princi­
ples for repair are re-creation of malar projection, reducing
the step-offs of the interior and lateral orbital rims, decom­
pressing and preserving the infraorbital nerve, and treating
any concomitant orbital floor defect. Zygomaticosphenoid
reduction is the most important landmark for proper zy­
goma positioning. The reduced position is maintained with
appropriately chosen hardware. The soft tissues are then re­
suspended to counteract long-term facial ptosis before com­
pletion of the repair.
Malar Flattening
Malar flattening results from a combination of poor reduc­
tion of the zygoma or failure to resuspend the soft tissues.
An underprojecting zygomatic body forces the zygomatic
arch laterally to create a wider, flatter hemiface. An under­
projecting zygomatic body also affects the position of the
orbital rim and creates a negative orbital vector and asym­
metrical lower eyelid position. The orbitomalar and zygo­
matic ligaments maintain the innate position of the malar
fat pad over the body of zygoma. Failure to re-create this
suspension also results in malar hollowing and, over time,
premature ptosis on the operated side. Alternatively, inci­
dental or operative trauma may result in malar fat atrophy.
The diagnosis of the cause is made first with a physical
examination, followed by CT to define the skeletal relation­
ships of the zygoma. The soft tissue thickness may be com­
pared to the nonoperated side. Computer-assisted surgical

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884
Nasal Bone Fractures
Nasal bones are the most commonly broken bones of the fa­
cial skeleton. Their position dictates the height of the bony
vault of the nose and defines cephalad portions of the nasal
dorsum. The nose as a central feature of the face carries a
heavy weight in facial symmetry, aesthetics, and harmony.
Nasal fracture may also involve septal fracture, as well as
other more complex midface fractures. The index reduction
of nasal fractures focus on re-creating nasal dorsal symme­
try, disimpaction of nasal septal fractures, and maintaining
nasal airway patency. Unsatisfactory outcomes after closed
treatment of nasal fracture include airflow obstruction,
aesthetic deformity, and nasal septal complications result­
ing from septal hematoma. An unsatisfactory outcome may
be revised if identified within 3 weeks after intervention.
However, if more than 3 weeks lapse, allowing a full heal­
ing duration of 6 months and delayed revision surgery may
be advisable.
Airway Obstruction
Nasal airflow obstruction results from fractures of the
bony or cartilaginous septum or violation of the inter­
nal nasal valve from injury to the upper lateral carti­
lages. Evaluation for nasal airway obstruction includes a
Sensory Nerve Damage
The infraorbital nerve travels along the orbital floor, exiting
the anterior maxilla at the infraorbital foramen. Displaced
or comminuted ZMC fractures may lacerate or compress
the nerve. Trauma may also injure the zygomaticotempo­
ral and zygomaticofacial trigeminal branches that provide
sensation of the lateral face and temple. Transient anesthe­
sia or paresthesia after midface trauma is not unexpected.
Treating nerve injury starts with deficit mapping and
weekly monitoring. A 5-day steroid taper in the early post­
traumatic period decreases nerve edema and facilitates
recovery. Continued dysesthesia past 3 months prompts
surgical exploration with nerve decompression. Nerve de­
compression has been shown to improve sensory deficits in
traumatized nerves.39
Masticatory Dysfunction
The masseter attaches to the zygomatic arch, and the tem­
poralis traverses deep to the arch. Posttraumatic and post­
operative masticatory dysfunction develops from displace­
ment of the arch and impingement on the temporalis or
inflammation of the masseter. Maintaining range of motion
with physical therapy is important until the posttraumatic
inflammation resolves.
Fig. 48.6 (a) After zygomaticomaxillary complex reduction in the setting
of panfacial fracture, the patient has orbital dystopia. (b) Zygomatic and
orbital floor osteotomies allow lowering of the interior orbital rim. (c) The
bony defects are back grafted. (d) Postoperative results. (Images a and d
are provided courtesy of S.A. Wolfe.)
d
Area of bone
to be removed
b
c
a

885
Chapter 48 Facial Fractures
This is best approached through an open rhinoplasty ap­
proach. The affected upper lateral cartilage is separated from
the septum sharply on the affected side or sides. Spreader
(cartilage) grafts are sutured between the septum and upper
lateral cartilage, thereby increasing the internal nasal angle
and decreasing resistance.
Aesthetic Deformity
Residual nasal aesthetic deformities may result from in­
accurate reduction, relapse of nasal fracture, inadequate
splinting, recurrent trauma, or premorbid nasal asymmetry
and septal deviation. This is a subjective and aesthetically
sensitive entity with significant interobserver ­variation.
Symmetry and projection are important aspects to this
reconstruction. The aesthetic deformity is approached by
dividing the nose into classically described upper, middle,
and lower thirds.
Upper vault asymmetry results from depression of the
nasal bones and tilt of the bony pyramid (Fig. 48.7). Minor
deviations, resulting from mostly caudal deviation, may dis­
rupt dorsal aesthetic lines. In this scenario, the bony cap of
the nasal bones may be reduced by osteotome or rasp and
the dorsal lines reinforced with a dorsal onlay graft (Fig.
48.8). For more significant deviations in which the bony pyr­
amid is deviated, nasal sidewall osteotomies are performed
to create greenstick fractures, thus allowing for mobilization
to reestablish symmetry.
detailed nasal examination with a nasal speculum to eval­
uate for septal deviation or preexisting maxillary crests
that concomitantly reduce nasal cross-sectional area. Cot­
tle’s maneuver evaluates symptomatic internal nasal valve
insufficiency, and ­nasal manometry objectively measures
pressure flow variation, confirming diagnosis.40 Facial CT
delineates deviations of the nasal septum and aids surgi­
cal planning.
Isolated septal causes for airflow obstruction may be pri­
marily treated with a septoplasty. This may be approached
by an endonasal or open septorhinoplasty. Once the carti­
laginous and bony septum are identified, they are separated
at their articulation. The septum may bow in craniocaudal
or anteroposterior dimensions; the anatomy dictates the ap­
proach to straightening the septum. Craniocaudal bowing re­
quires separating the vomer from the palate and shortening
at the caudal free end of the septum. The surgeon must be
cautious near the skull base to avoid fracturing the cribri­
form plate. In a similar fashion, if an anteroposterior buckle
exists, the bony and cartilaginous septum may be serially
shortened. Alternatively, the central portions of cartilagi­
nous septum are removed, maintaining a 1-cm dorsal-caudal
L-strut. This eliminates the deviated segment while main­
taining nasal support. Alternatively, the entirety of the car­
tilaginous septum can be removed en bloc, straightened and
secured to a polydioxanone sheet, and replaced.41
Airway obstruction responsive to Cottle’s maneuver may
result from upper lateral cartilage fracture and weakness.
Fig. 48.7 (a) This patient experienced a trauma that
caused nasal pyramid collapse of the upper vault and a
ski-slope deformity. (b) After reduction and nasal bridge
reconstruction, she had a more natural nasofrontal angle.
(These images are provided courtesy of S.A. Wolfe.)
a
b
Fig. 48.8 (a) A nasal dorsal onlay graft is prepared from split cal­
varial graft. (b) This is then fixed to the nasal pyramid through a
coronal approach. (These images are provided courtesy of S.A.
Wolfe.)
b
a

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
886
Le Fort Fractures
Treatment Principles
Fractures causing midface-cranial disjunction are catego­
rized based on studies by Rene Le Fort.46 The classification
system defines three levels of fracture, each of which is
through the pterygoid plates and then extending to involve
various portions of the facial skeleton. Le Fort fractures may
occur at differing levels on each hemiface and may include
palatal fracture. The common element to all Le Fort frac­
tures is posttraumatic malocclusion. Suboptimal repair of
these fractures affects occlusion, facial height, and projec­
tion.
Treatment for repair of Le Fort fractures begins with
re-establishment of the premorbid dental occlusion. Den­
tal impressions and model surgery are performed to cre­
ate an acrylic surgical splint that will guide fracture seg­
ment realignment into a premorbid occlusion and maintain
maxillary alveolar segment reduction. Arch bars are used to
help secure the fracture segments to the splint and main­
tain occlusal reduction during midface stabilization. Splint
creation and model surgery is especially helpful in combina­
tion Le Fort mandible fractures. Le Fort I fractures primar­
ily require reestablishing occlusion; however, higher level
II and III fractures follow combined principles of NOE and
ZMC fracture treatment. After reduction and stabilization,
the operative splint is kept in place to maintain maxillary
width and, depending on the stability of repair, the patient is
kept in maxillomandibular fixation. The maxillomandibular
fixation and occlusal splinting is maintained for 4 to 6 weeks
(see Chapter 43).
Malocclusion
The nature of a Le Fort fracture makes the patient suscep­
tible to significant postoperative malocclusion. This is best
avoided by using dental impressions and models to recon­
struct the proper premorbid occlusion. In Le Fort fractures
involving the palate, occlusal splinting is maintained for
4 to 6 weeks. Postoperative malocclusion is evaluated by
physical examination and with dental impressions and
films. Management of malocclusion starts with orthodon­
tia. Orthodontic evaluation will determine if the malocclu­
sion can be corrected with braces. If not, then the dentition
can be optimized for orthognathic surgery.
Nasal Septal Deviation
The nasal septum rests caudally on the maxillary crest. Le
Fort fractures will violate the septum and may be persis­
tently deviated despite adequate reduction of the midface
and occlusion. Septal deviation may result in symptomatic
nasal airway obstruction. This is avoided by removing por­
tions of the maxillary crest during the initial repair. Diag­
nosing persistent septal deviation and airway obstruction
is difficult early postoperation, because it commonly results
from soft tissue swelling. If the nasal airway obstruction
Middle vault repair focuses on enhancing dorsal aes­
thetic lines and airway patency. The presence of internal
nasal valve collapse drives decision-making. Spreader grafts
maintain internal nasal valve patency and enhance dorsal
lines. Alternatively, dorsal onlay grafting may achieve a simi­
lar goal if the dorsal lines are asymmetrical and the internal
nasal valve is intact.
Lower third nasal tip aesthetic deformities require mod­
ification of the lower lateral cartilages. Domal suturing is
useful to correct asymmetry of the lower cartilages. Alter­
natively, cartilage grafting is useful to improve structural
support of the lower lateral cartilages in situations of trau­
matically attenuated cartilage. Alar rim retraction can be
treated with chondrocutaneous grafting.
Septal Complications
Untreated septal hematomas may result in avascular ne­
crosis of the septal cartilage because of separation of the
mucosa from the septal cartilage. Septal fracture and buck­
ling of the septum may result in shortened height of the
cartilaginous septum. The end result is loss of support, de­
creased nasal projection, or saddle nose deformity, termed
middle vault collapse.
Correction requires reconstruction of the nasal support
structures. The surgical approach requires an open rhino­
plasty or combined open rhinoplasty coronal approach to
allow full exposure and adequate fixation of reconstructed
support structures. Autogenous cartilage graft is harvested
from costal cartilage and fashioned into a two-piece dorsal
onlay with an extended columellar strut graft. The dorsal
component of the graft is configured as a multilayer sand­
wich sutured to the most cephalad end of the septal carti­
lage. The caudal end of the dorsal graft then interlocks with
the extended strut graft in a tongue-in-groove fashion. Al­
ternatively, rib cartilage graft can be shaped into a single-
piece L-strut.
Fractures of the nasal septum result in chronic devia­
tion that causes breathing difficulty. Septal injuries may
also cause chronic septal perforations, presenting as whis­
tling or crusting of the nose. This can result from a tear or
perforation secondary to trauma or nasal septal hematoma.
Posttraumatic septal deviations are treated by submucosal
resection or modification of deviated cartilages from the os­
teocartilaginous junction described in the Airway Obstruc­
tion section and in Chapter 25.
Chronic septal perforation is repaired with local mucosal
flaps. Local, bipedicled, mucoperichondrial flaps from the
septum, nasal floor, and turbinate are elevated and advanced
to cover the cartilaginous defect. Mechanical stability may
also be added by using temporal fascia to reinforce the car­
tilaginous defect, up to 25 mm.42 For larger defects with in­
adequate local mucosa, regional flaps are used. Pericranium
lined with skin graft is used to reconstruct near-total septal
defects.43 Other local tissue options include nasolabial or fa­
cial artery myomucosal flaps. Free tissue such as superficial
inferior epigastric artery perforator or free radial forearm
are also options.42–45

887
Chapter 48 Facial Fractures
are present, revision surgery involves osteotomy with sub­
sequent realignment of fracture segments or skeletal aug­
mentation with bone graft or alloplast facial projection and
contour. Secondarily, Le Fort fractures are mobilized with
Le Fort osteotomies, in which pterygomaxillary osteotomy
is used to separate the fracture segments from the skull
base. Of note, skeletal augmentation, though appealing, will
not compensate for a poor initial reduction and serves to
make the face more dysmorphic. The first choice in these
scenarios is revision reduction and fixation.
Panfacial Fracture
As the definition implies, panfacial fractures involve the
entire facial (and often cranial) skeleton. Patients who have
experienced an event traumatic enough to cause such frac­
tures must first be stabilized before operative repair. The
decision to place a temporary surgical airway either acutely
(in the event of respiratory compromise) or before recon­
struction should be considered under these circumstances.
Panfacial fractures involve all three levels of the fa­
cial skeleton. These patients experience high levels of en­
ergy, and life-support protocols must be followed to rule
out airway compromise and life-threatening cerebral, vis­
ceral, or cervical spine trauma before treating the facial
injuries.49 The initial evaluation must encompass all mo­
tor, sensory, and functional capacities of the craniofacial
unit. These include specific visual changes, anosmia, au­
ditory dysfunction, facial motor dysfunction, sensory loss,
airway compromise, and dental injury and malocclusion.
Surgical treatment requires a systematic approach that re-
establishes facial height, width, and projection. Most sur­
geons approach fixation from stable portions then move
to unstable areas. Poor results affect the shape of the face
and occlusion.
Unfavorable results in panfacial fractures originate from
poor reduction or suboptimal fixation of the separate frac­
ture segments. They share all the suboptimal outcomes as
each fracture pattern. The face is conceptually approached
as upper, middle, and lower thirds and the skeletal reposi­
tioning is planned accordingly. Evaluation and surgical plan­
ning comes from the physical examination, but CT can help
with the three-dimensional movements needed to restore
facial shape. In these situations, virtual surgical planning
may help, including cutting guides, three-dimensional skull
and facial models, and the ability to prebend plates. After
panfacial fractures, malocclusion may be best treated with
orthognathic surgery if the remainder of the facial appear­
ance is suboptimal.
Conclusion
Facial fracture care is a very rewarding yet challenging sur­
gical subspecialty that includes both aesthetic and func­
tional concerns. To reduce postoperative complications and
suboptimal outcomes, the surgeon must follow well-estab­
lished principles of diagnosis and treatment and combine
them with optimal execution and postoperative care.
persists beyond 3 weeks, it is not likely to resolve with more
time. The diagnosis of nasal airway obstruction is made
by physical examination. Typically a full 3 to 6 months of
healing is allowed before revisions are performed. Septal
deviation in Le Fort fractures are approached similarly to
isolated septal fracture deviation.
Maxillary Sinusitis
Maxillary sinusitis may occur as a long-term sequela of
Le Fort fracture and involves damage to the walls of the
maxillary sinus, disrupting and exposing the underlying
mucosa. The initial insult leads to bacterial soft tissue colo­
nization and inflammation. Mucosal inflammation or trau­
matic violation of the sinus outflow may result in chronic
mucous stasis. The diagnosis is made clinically; however,
CT may highlight the cause. The initial management is a
short course of antibiotics, such as amoxicillin and clavu­
lanate, for 7 to 10 days. Persistent symptoms such as pain,
discharge, or chronic congestion necessitate referral to
otolaryngology for possible endoscopic sinus drainage and
débridement. Once the fracture is healed, the removal of
infected hardware may improve symptoms of chronic si­
nusitis.
Cerebrospinal Fluid Leakage
With high-energy trauma to the midface, Le Fort frac­
tures may extend to the skull base. Skull base fractures
with dural injury result in CSF drainage. Most commonly
this involves fractures to the nasofrontal junction, where
they may extend along the anterior cranial fossa adjacent
to the cribriform plate. CSF drainage from facial fractures
are treated similarly; the management is described in the
Frontal Sinus Fractures section.
Nerve Damage
Le Fort midface fractures may result in injury to sensory
branches of the trigeminal V2 nerve. Other sensory nerves
that may be injured include the olfactory and optic nerves.
The incidence of olfactory dysfunction after Le Fort injury
is approximately 30%, whereas blindness occurs in 1%.47,48
Most neurologic injury results from contusion, shear, or
impingement. The goal of surgical management is pres­
ervation of nerves and avoidance of transection or further
injury. Most injuries result in degrees of neuropraxia that
are treated with initial steroid tapers to decrease nerve
inflammation. Secondary operations for neuropraxia are
rarely necessary, unless persistent neuralgia results from
continued nerve impingement or neuroma formation.
Loss of Facial Projection
Similar to ZMC fractures, decreased midface projection
may occur with all levels of Le Fort fractures. Accurate re­
duction, fixation, and soft tissue suspension are paramount
at the time of initial treatment. When delayed deformities

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
888
they occur. By gaining optimal experience and maintaining
sound principles even during correction of secondary nega­
tive sequelae, the surgeon can minimize the impact and im­
prove the outcome of unfavorable results.
To prevent or at least minimize complications, the sur­
geon must not only be aware of the best diagnostic and
treatment principles but also be cognizant of potential
pitfalls that could lead to negative outcomes. The surgeon
should then be able to treat these negative outcomes should
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Chapter 48 Facial Fractures
42. Virkkula P, Mäkitie AA, Vento SI. Surgical outcome and
complications of nasal septal perforation repair with tem­
poral fascia and periosteal grafts. Clin Med Insights Ear
Nose Throat 2015;8:7–11
43. Sertel S, Pasche P. Pericranial flap for inner lining in nasal
reconstruction. Ann Plast Surg 2016;77(4):425–432
44. Iida T, Yoshimatsu H, Tashiro K, et al. Reconstruction of a
full-thickness, complex nasal defect that includes the na­
sal septum using a free, thin superficial inferior epigastric
artery flap. Microsurgery 2016;36(1):66–69
45. Hernández Martinez VM, Garcia Benavides L, Totsuka
Sutto SE, Cardona Muñoz EG, Campos Bayardo TI, Pas­
coe Gonzalez S. Effectiveness of degradable and non-de­
gradable implants to close large septal perforations in an
experimental model. J Plast Surg Hand Surg 2016;50(4):
222–226
46. Patterson R. The Le Fort fractures: René Le Fort and his
work in anatomical pathology. Can J Surg 1991;34(2):
183–184
47. Renzi G, Carboni A, Gasparini G, Perugini M, Becelli R.
Taste and olfactory disturbances after upper and middle
third facial fractures: a preliminary study. Ann Plast Surg
2002;48(4):355–358
48. Rajkumar GC, Ashwin DP, Singh R, Prashanth R, Rudresh
KB. Ocular injuries associated with midface fractures: a
5 year survey. J Maxillofac Oral Surg 2015;14(4):925–929
49. Advanced Trauma and Life Support Manual. 9th ed.
Chicago: American College of Surgeons; 2012
34. Hoşal BM, Beatty RL. Diplopia and enophthalmos after
surgical repair of blowout fracture. Orbit 2002;21(1):27–
33
35. Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enophthal­
mos by computer-based volume measurement of orbital
fractures in a Korean population. Ophthal Plast Reconstr
Surg 2008;24(1):36–39
36. Raschke GF, Rieger UM, Bader RD, Schaefer O, Guentsch
A, Schultze-Mosgau S. Transconjunctival versus subciliary
approach for orbital fracture repair—an anthropometric
evaluation of 221 cases. Clin Oral Investig 2013;17(3):
933–942
37. Ridgway EB, Chen C, Lee BT. Acquired entropion associ­
ated with the transconjunctival incision for facial fracture
management. J Craniofac Surg 2009;20(5):1412–1415
38. Baumann A, Ewers R. Use of the preseptal transconjuncti­
val approach in orbit reconstruction surgery. J Oral Maxil­
lofac Surg 2001;59(3):287–291, discussion 291–292
39. Das AK, Bandopadhyay M, Chattopadhyay A, et al. Clini­
cal evaluation of neurosensory changes in the infraorbital
nerve following surgical management of zygomatico-
maxillary complex fractures. J Clin Diagn Res 2015;9(12):
ZC54–ZC58
40. Cottle MH, Loring RM, Fischer GG, Gaynon IE. The max­
illa-premaxilla approach to extensive nasal septum sur­
gery. AMA Arch Otolaryngol 1958;68(3):301–313
41. Boenisch M, Nolst Trenité GJ. Reconstruction of the nasal
septum using polydioxanone plate. Arch Facial Plast Surg
2010;12(1):4–10
Discussion by Jürgen Hoffmann
The main challenge with facial fractures is recogniz­
ing and managing complications, which in some cases
might be more demanding than surgery itself. This is
where clinical expertise is needed, especially when
cases cannot be assigned to an algorithm. Expertise
results from a discussion of favorable and, even more
important, unfavorable results and treatment concepts.
Avoiding and Managing
Complications in Facial Fractures
Infection
Infection may be associated with an increase in mor­
bidity and results in poorer functional and aesthetic
outcomes. However, whereas in earlier days routine
antibiotics were advocated, their use now needs to be
justified and restricted to defined indications. Antibi­
otics never should be used to tranquilize an unexpe­
rienced surgeon, but should instead be adapted to the
clinical situation. An algorithm should be used that
respects the clinical findings and allows for a patient-
specific treatment planning. However, there is limited
published evidence to rely on.1
For closed fractures, which are treated conserva­
tively, we do not use antibiotics at all.2 Patients with
typical fractures of the midface and the mandible, which
are corrected with an open approach, receive a prophy­
lactic antibiotic at the time of surgery.
Patients with a severe comminution or who present
late with open fractures, which might also be related
to a lack of patient compliance, are treated with 1 to 3
days of antibiotics. The same is true for patients with se­
vere lacerations of the soft tissues or known comorbidi­
ties (e.g., immunosuppression or diabetes).3 In addition,
swelling should be treated by local cooling, which may
also have an impact on pain.
When infection occurs, a thorough analysis is nec­
essary to identify the focus. An infected hematoma, an

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890
instable osteosynthesis, exposed alloplastic material, or
infected bone might be the reason.
Soft Tissue Injuries
Paul Manson4 once said, “A surgeon, in making an in­
cision, is stating that the aesthetic results of ‘no treat­
ment’ will be worse than the appearance of the inci­
sional scar.” On one hand, a correct reduction requires
an adequate exposure of the fragments; on the other
hand, minimal invasion in combination with surgical
approaches that respect the basics of plastic surgery
are a prerequisite for good aesthetic results. Thanks
to improved techniques of image data–based planning
and minimalized osteosynthesis, the morbidity of an
open reduction has decreased enormously in the last
decades.
This is mainly true for typical fractures of the facial
skeleton but may be challenging in the case of complex
soft tissue involvement, comminuted fractures, or poor
bone quality (because of osteoporosis, severe atrophy, or
irradiation or related to an antiresorptive medication).
In such cases the approach may need to be more exten­
sive, resulting in a poor aesthetic result and unpredict­
able wound healing.
Malunion and Nonunion
The major goal of fracture reduction is the correct re­
alignment of the fragments. If this is accomplished,
good occlusion and a restituted facial symmetry are
likely. However, this may be difficult in the presence of
bony defects caused by a severe comminution or a bal­
listic impact. The surgeon must be aware of key areas
that should be respected for an adequate reduction. In
the case of central midfacial and mandibular fractures,
the repositioning of the dental arch is essential; a cor­
rect dental occlusion should be obtainable with the use
of bars and splints.
Evaluation of a facial trauma typically involves the
use of computed tomography (CT), which allows the
surgeon to determine the dislocation of fragments us­
ing multiplanar projections. Many surgeons are adept
at manipulating digital images; in complex cases a sur­
face rendering of the bony structures can be helpful to
achieve a three-dimensional overview.
Computer-aided design and computer-aided mod­
eling (CAD/CAM) software that allows for virtual mir­
roring of an unaffected contralateral side by use of
navigation systems has dramatically improved surgical
strategies in reconstructive surgery of the craniomaxil­
lofacial skeleton, particularly with respect to the pre­
diction of suitable symmetrical bone repositioning. The
data can be acquired preoperatively or intraoperatively.
An intraoperative evaluation is possible using opti­
cal navigation, which allows for the control of a correct
alignment of bony structures. In addition, C-arms make
assessment of the three-dimensional orientation of bony
fragments possible5 (Fig. 48D.1).
Enophthalmos and Hypoglobus
Typical midfacial fractures are usually associated with
orbital fractures. Depending on the location of the frac­
ture, the patient’s age, and the impact on the affected
bone, variable patterns of bony defects can be seen (Fig.
48D.2). Whereas an isolated typical blowout fracture
results from a buckling of the infraorbital rim and a ret­
ropulsion of the orbital content, high impacts do result
in an extended comminution, not only of the orbital
floor but also of the medial orbital wall. In the long run,
orbital defects might lead to a bulbar dystopia, which
impairs the patient aesthetically and functionally.
The management of orbital fractures is controver­
sial, particularly the indications for surgery and the ideal
Fig. 48D.1 Intraoperative image data acquisition by use of a C-
arm shows proper alignment of titanium mesh to reconstruct
the orbital floor.
Fig. 48D.2 A typical fracture of the orbital floor in combination
with a zygomatic bone fracture.

891
Chapter 48 Facial Fractures
In cases of malunion or nonunion of the fragments as­
sociated with infection, a more rigid fixation is neces­
sary. In some cases revascularized soft and hard tissue
free flaps are required.12
Frontal Sinus Fracture
Fractures of the frontal base need to be assessed clini­
cally and radiologically. Involvement of the anterior
table of the frontal sinus typically leads to an irregu­
lar contour, which might be seen as soon as swelling
is gone, potentially up to 2 to 3 weeks after trauma.
More severe cases may be associated with a menin­
geal tear. In this case a cerebrospinal fluid leak must
first be excluded by use of a beta-trace protein immu­
noblot of rhinorrhea samples. Computed tomography
helps to assess whether the frontonasal duct might be
obstructed, which could lead to a mucocele even years
after the trauma (Fig. 48D.3). Extensive approaches
were used in the past for such cases, but a wait-and-see
policy is sometimes acceptable if patient compliance
instills confidence for long-term radiologic evaluation.
If a mucocele seems likely, an endoscopic approach is a
possible choice for treatment.13
Naso-orbitoethmoid Fracture
Naso-orbitoethmoid (NOE) fractures often present
in combination with frontobasal and central midfa­
cial fractures (Fig. 48D.4). The main problem with
NOE fractures is the aesthetic outcome resulting from
a tear of the medial ligaments, which leads to a tele­
canthus. This situation should be addressed with pri­
mary surgery, which should be planned according to
the individual findings. The medial canthal ligaments
may be stripped during the open reduction. This can
be prevented by marking the points of insertion of this
anatomic structure. An NOE fracture is repaired step­
wise, preferring a coronal approach to expose the bony
fragments thoroughly. If the medial orbital walls are
materials to be used. The orbital repair normally can be
planned in advance; there are only a few indications for
immediate treatment. Absolute indications for immedi­
ate repair would be trapdoor fractures in children with
early ischemic necrosis of the ocular muscles and retro­
bulbar hematomas with deterioration of visual acuity.6–8
The orbital defect can be classified by first consider­
ing the location and second the extension of the bony
lesion as seen on CT.9 A thorough clinical evaluation re­
garding bulbar motility and assessing the extent of dip­
lopia is obligatory. Bulbar dystopia often is mentioned
as an absolute indication for an operative approach
but rarely becomes significant in the first weeks after
trauma. The results of clinical and radiologic evaluation
should determine the choice of materials available for
orbital repair. Small defects tend to heal by formation
of fibrous tissue, whereas larger defects require more
or less rigid material to guarantee an adequate support
of the orbital contents by restoring the contour of the
bony orbit. When there are no fractures of the postero­
medial wall, a cantilevered reconstruction is recom­
mended, with titanium meshes, polyethylene implants
with preformed shapes, or patient-specific implants.10
The typical approaches to an isolated orbital floor frac­
ture are a preseptal or postseptal transconjunctival or a
subciliary approach.11
Complications with the Use of
Alloplastic Materials
Internal fixation of fractures typically is achieved by
plates and screws, which need to be chosen in relation
to the clinical needs. With the abundance of alloplastic
materials available, it can be difficult to choose a solu­
tion that provides adequate strength but does not lead
to late sequelae. This is less challenging for the midface,
but it is important when treating mandible fractures,
especially if the bone is poor quality. Loosened, broken,
and infected hardware typically should be removed
without replacement if fracture healing is completed.
Fig. 48D.3 A frontobasal fracture with involvement of the fron­
tonasal duct.
Fig. 48D.4 A naso-orbitoethmoid fracture (three-dimensional
reconstruction of computed tomography).

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892
destructed, a reconstruction of the posteromedial orbit
needs to be addressed to ensure a good projection of
the bulbs (the surgeon must be alert to this key area).
Conclusion
The last few years have seen an enormous evolution of
the techniques and materials available for the repair
of facial fractures, which makes treatment decisions
much more complex. Radiologic evaluation with CT
provides abundant information concerning fracture
and defect types and allows for patient-specific treat­
ment planning, thus reducing the associated morbidity
considerably. In addition, digital images can be used to
create medical models to be used for construction of
preshaped plates and implants, which may be placed
with the assistance of computer navigation techniques.
Plates and screws have vastly improved, but the
forces applied (e.g., by the masticatory functions) have
not changed. This natural state must be respected to
achieve a successful treatment.
References
1. Brooke SM, Goyal N, Michelotti BF, et al. A multidis­
ciplinary evaluation of prescribing practices for pro­
phylactic antibiotics in operative and nonoperative
facial fractures. J Craniofac Surg 2015;26(8):2299–
2303
2. Malekpour M, Bridgham K, Neuhaus N, et al. Utility of
Prophylactic Antibiotics in Nonoperative Facial Frac­
tures. J Craniofac Surg 2016;27(7):1677–1680
3. Raikundalia M, Svider PF, Hanba C, et al. Facial fracture
repair and diabetes mellitus: an examination of post­
operative complications. Laryngoscope 2017;127(4):
809–814
4. Manson PN, Ruas E, Iliff N, Yaremchuk M. Single eyelid
incision for exposure of the zygomatic bone and or­
bital reconstruction. Plast Reconstr Surg 1987;79(1):
120–126
5. Wilde F, Schramm A. Intraoperative imaging in or­
bital and midface reconstruction. Facial Plast Surg
2014;30(5):545–553
6. Dubois L, Steenen SA, Gooris PJ, Bos RR, Becking
AG. Controversies in orbital reconstruction-III. Bio­
materials for orbital reconstruction: a review with
clinical recommendations. Int J Oral Maxillofac Surg
2016;45(1):41–50
7. Dubois L, Steenen SA, Gooris PJ, Mourits MP, Becking
AG. Controversies in orbital reconstruction-II. Timing
of post-traumatic orbital reconstruction: a system­
atic review. Int J Oral Maxillofac Surg 2015;44(4):
433–440
8. Dubois L, Steenen SA, Gooris PJ, Mourits MP, Becking
AG. Controversies in orbital reconstruction-I. Defect-
driven orbital reconstruction: a systematic review.
Int J Oral Maxillofac Surg 2015;44(3):308–315
9. Jaquiéry C, Aeppli C, Cornelius P, Palmowsky A, Kunz
C, Hammer B. Reconstruction of orbital wall defects:
critical review of 72 patients. Int J Oral Maxillofac
Surg 2007;36(3):193–199
10. Zimmerer RM, Ellis E III, Aniceto GS, et al. A prospec­
tive multicenter study to compare the precision of
posttraumatic internal orbital reconstruction with
standard preformed and individualized orbital im­
plants. J Craniomaxillofac Surg 2016;44(9):1485–
1497
11. Christensen BJ, Zaid W. Inaugural survey on practice
patterns of orbital floor fractures for American oral
and maxillofacial surgeons. J Oral Maxillofac Surg
2016;74(1):105–122
12. Hernandez Rosa J, Villanueva NL, Sanati-Mehrizy P,
Factor SH, Taub PJ. Review of maxillofacial hardware
complications and indications for salvage. Cranio­
maxillofac Trauma Reconstr 2016;9(2):134–140
13. Sama A, McClelland L, Constable J. Frontal sinus mu­
cocoeles: new algorithm for surgical management.
Rhinology 2014;52(3):267–275

893

Pediatric Facial Fractures
Seth R. Thaller and David Gerth
CHAPTER
49
Pediatric facial fractures are relatively rare compared with
adult injuries. The proportions and mechanical properties of
the growing facial skeleton protect children from craniofacial
fractures, and the watchful eye of parents decreases occur­
rence in early life. Because of their infrequency, large long-
term clinical studies are not available to assess management
and evidence-based outcomes. Despite the lack of standard
treatment guidelines, outcomes are generally reported to be
acceptable, owing to the resiliency of the growing craniofa­
cial region. Nevertheless, those that do occur can be a clini­
cal challenge to correct. Comprehensive understanding of
the most significant complications will guide the surgeon in
appropriate management of these patients. This chapter re­
views the complications and untoward results of maxillofa­
cial injuries in children, their avoidance, and their treatment.
Facial Growth
The pediatric skull consists of a relatively large neurocranium
and a small viscerocranium. This ratio begins at 8:1 at birth
but diminishes to 2:1 by adulthood. Differential growth in­
creases the length and projection of facial structures com­
pared with the cranial vault during postnatal development.
Pediatric bone is soft and pliable. It develops adult quality as it
increases in cancellous bone content. These general changes
along with specific anatomic changes account for the unique
nature of pediatric facial fractures and their outcomes.
Paranasal Sinuses
The frontal sinus is absent at birth. Frontal bone pneumati­
zation begins at age 3 years and reaches the nasion by age 4
years. The frontal sinus is only pea-sized by age 7 years. Full
adult size and conformation is not reached until age 15 to
19 years.1 The maxillary sinus also starts as a bud at birth.
By age 7 years the maxillary sinus has extended laterally
to the midpupillary line. Growth continues as permanent
dentition erupts.
Nasal Bones and Septum
The pediatric nose possesses several unique traits com­
pared with an adult. The growing nose is less projected. The
nasal framework is more cartilaginous and the nasal bone
suture is open. Nasal growth is biphasic. The first growth
phase occurs between ages 2 and 5 years, and the second
occurs during puberty.2 Most nasal growth is completed by
age 16 years for young women. Growth may continue be­
yond age 18 years for young men.3
Mandible and Dentition
Most of the development of the mandible derives from
growth at the condyle and ramus.4 Tooth eruption and de­
velopment of the alveolar process also contributes to man­
dible maturation. The body and symphysis remain rela­
tively unchanged.
Deciduous tooth eruption begins at approximately 6
months. It is complete at 2 years. Exfoliation begins around
6 years through root resorption. Concurrently, eruption of
permanent dentition begins and continues through age 12
years. Incisors erupt around age 6 years, and canines around
age 9 years. Wisdom teeth usually erupt in early adulthood.5
During the transition through mixed dentition, there is rel­
atively low bone stock. Permanent tooth follicles occupy a
large portion of mandibular volume.
Epidemiology of Pediatric Facial
Fractures
Demographics
Between 6 and 15% of all facial fractures occur in pediatric
patients.6,7 The incidence is lowest for patients age 0 to 5
years (0–1% of all facial fractures) and increases thereaf­
ter.6,8–15 Sex distribution, male to female, is 1.7:3.1.8,9,16

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
894
and circulation A primary survey will prompt the surgeon
to secure the airway. Pediatric patients, especially younger
ones, require greater attention because of the size and po­
sition of the larynx. The secondary survey includes exami­
nation of the head and neck for cranial nerve and ocular
function, skeletal stability, and any sources of hemorrhage.
Appropriate imaging of the facial skeleton and cervical
spine, as prompted by physical examination, will assist in
determining the presence and extent of fractures. Once the
patient’s age, severity of injury, and presence of concurrent
injuries have been accounted for, specific treatment planning
for facial fractures can be initiated.
Associated Acute Sequelae
Skull Fracture and Intracranial Injury
Intracranial injury associated with facial bone fractures
occurs at a relatively high frequency in the pediatric age
group. Lack of paranasal sinus development in children
may contribute to forces being transmitted to the cranium
and its contents.28 As such, computed tomography (CT) is
indicated to evaluate the status of the cranium and under­
lying intracranial contents. Injuries requiring neurosurgi­
cal intervention may require craniotomy, craniectomy, or
repair of dural tears. If the frontal sinus is present and in­
volved, it must be managed accordingly.
Patients with facial fractures and associated cranial
or skull base injury are at risk for further complications.29
Structural deformity, olfactory nerve dysfunction, and surgi­
cal-site infection may occur. Ophthalmic complications, such
as ptosis, visual field disturbances including blindness, dip­
lopia, telecanthus, or enophthalmos are potential sequelae.
Persistent cerebrospinal fluid (CSF) leakage may result as
well. Prolonged neurological deficits and posttraumatic hy­
popituitarism are further sequelae that warrant extended
follow-up and observation.
Cerebrospinal Fluid Rhinorrhea
Fourteen percent of naso-orbital-ethmoidal (NOE) frac­
tures are associated with CSF rhinorrhea.14,25 Between
70 and 85% of traumatic CSF leaks resolve within 1 week.30,31
If CSF leak persists beyond 1 week, placement of a lumbar
drain usually satisfactorily decompresses the site of leak­
age. This allows for dural tear closure. If the lumbar drain
fails to resolve the CSF leak, neurosurgical repair of the
skull base defect should be performed. Unrecognized CSF
leak or fistula may progress to meningitis, encephalitis, or
even brain abscess.
Superior Orbital Fissure and Orbital Apex
Syndrome
Injury to the contents of the superior orbital fissure and
the optic canal is usually secondary to a skull base or or­
bital roof fracture. Prompt diagnosis by cranial nerve and
Etiology
The causes of pediatric fractures are diverse. Between 10 and
38% of fractures are caused by falls, and 27 to 34% by play ac­
cidents. Between 17 and 54% are by motor vehicle accidents,
1 to 21% are by sporting injuries, and 3 to 48% are caused
by assault.7–10,17–19 Though rare, there have been a few docu­
mented cases of facial fracture from traumatic birth.9,16,18,20
Fracture Types
Fracture distribution is unique compared with adult facial
fractures7–10,16–19,21–27 (Box 49.1).
Associated Injuries and Complications
Associated injuries are more common in pediatric maxil­
lofacial trauma than in adult cases. Depending on the case
series, 36 to 89% of patients experience other injuries con­
current with facial fractures6,7,9,16,19:
•• Soft tissue lacerations: 14 to 88%
•• Extremity injuries: 2 to 70%
•• Head trauma: 4 to 80%
•• Facial nerve palsy: 1%
•• Abdominal trauma: 1 to 18%
•• Cervical spine trauma: 1 to 2%
•• Globe trauma: 1 to 8%7,9,19,20,22
Overall complication rates range from 12 to 26%.9,18,22 De­
tails regarding specific complications are reviewed later in
this chapter.
Principles of Evaluation and
Management
As in any trauma case, surgeons must follow proper
protocol in the management of the airway, breathing,
Box 49.1
•• Nasal bones: 5–59%
•• Mandible: 17–87%
○
○Parasymphyseal: 27–32%
○
○Body: 9–45%
○
○Angle: 8–33%
○
○Condylar: 12–55%
○
○Ascending ramus: 1–3%
•• Dentoalveolar: 8–32%
•• Maxilla: 3–16%
•• Zygoma: 3–25%
•• Naso-orbital-ethmoid: 1–8%
•• Frontal bone: 1–5%
•• Orbital: 7–41%
Facial Fracture Distribution

895
Chapter 49 Pediatric Facial Fractures
Infection, Malunion, Nonunion, and
Osteomyelitis
Complications of bony healing are relatively rare in pediat­
ric facial fractures. They are usually associated with com­
minuted fractures.36 A growing facial skeleton heals faster
than that of an adult.37 Furthermore, few fractures are com­
minuted or significantly displaced, facilitating appropriate
reduction. Infection may occur and osteomyelitis can occur
at any fracture site. Overall incidence ranges from 8 to 9%.9
Four percent of cases are complicated by malunion.9 Early
definitive treatment and appropriate surgical technique
will minimize cases of infection. If hardware is present and
infection persists, eventual removal may be necessary.
Sequelae of Rigid Reduction
Research in cleft lip and palate repair has demonstrated
an association with wide subperiosteal undermining and
potential future adverse alterations in bony growth.38 Al­
though this study has not been extended to the repair of
maxillofacial fractures in the growing skeleton, minimizing
periosteal elevation in fracture repair is prudent for pre­
serving normal craniofacial growth patterns.
The role of rigid fixation in the development of a cranio­
facial growth disturbance remains controversial. In animal
studies, both wire and compression plate fixation of the cra­
niofacial skeleton have resulted in growth alterations.39–41
These studies involved disruption of the coronal suture
line as well. No animal models have investigated removal
of hardware or wiring and the subsequent growth patterns.
Furthermore, no studies exist that examine changes in the
growing mandible, the most common site undergoing open
reduction for trauma. Regardless, there are several case re­
ports detailing migration of retained fixation hardware dur­
ing growth.42–45 Some case series have reported intracranial
migration of hardware and association with injury to the
globe, seizure activity, meningitis, and damage to underly­
ing cortex.46,47
Because of the risk of growth disturbance and hardware
migration, some have advocated resorbable hardware. Re­
sorbable plates are typically manufactured as a blend of ma­
terials. Poly-L-lactic acid (PLLA) maintains its strength for up
to 6 months. It is less malleable than other resorbable ma­
terials. Polyglycolic acid, poly-DL-lactic acid, and polydiox­
anone are weaker but more malleable. Current resorbable
plates are typically composed of a blend of PLLA and one
of the other materials to achieve desirable physical char­
acteristics. All resorbable plates are mechanically weaker
than titanium fixation plates. To circumvent this, resorbable
plates are usually larger in profile. Manufacturers effectively
exchange strength and low profile for resorbability. Some
cases of device extrusion and sterile abscesses have been
reported.48
In their series of 1,884 pediatric craniofacial patients,
Eppley et al49 reported outcomes in patients treated with
resorbable poly-L-lactic-polyglycolic acid (PLLA-PGA)
ophthalmologic evaluation is vital to prevent a permanent
visual disturbance and blindness.
Cervical Spine Trauma
Because significant energy is required to cause a pediatric
facial fracture, there must be a high level of suspicion for
cervical spine injury. Examination during the secondary sur­
vey and appropriate CT studies may assist in the diagnosis.
When injury is suspected, the cervical spine must be immo­
bilized until definitive examination can be performed.
Soft Tissue Laceration
The overall incidence of soft tissue injury with pediatric
facial trauma is 14 to 42%.9,32 Severe injuries may result in
a soft tissue defect from avulsion. Between 1 and 56% of
cases have a significant soft tissue defect.9,33,34 Suboptimal
long-term outcomes in the appearance of these scars has
been reported at 6.5%.35 As in other laceration repairs, the
surgeon should monitor wounds for hypertrophic scars.
Revision techniques include steroid injection, laser therapy,
scar revision, and reorientation of scar via z-plasty or geo­
metric broken lines.
Unfavorable Results and
Complications in Postoperative
Facial Fracture Repair
Summary Box
Unfavorable Results and Complications in
Pediatric Facial Trauma Repair
•• Postoperative facial fracture repair
○
○Infection, malunion, nonunion, and
osteomyelitis
○
○Sequelae of rigid reduction
•• Upper third of the face
○
○Posttraumatic growing skull fracture
○
○Mucocele
•• Middle third of the face
○
○Telecanthus
○
○Complications of orbital floor fractures
•• Nasal and septal fractures
○
○Growth disturbance
○
○Residual deformity
○
○Septal hematoma
•• Dentoalveolar and mandible fractures
○
○Tooth loss and permanent tooth root injury
○
○Malocclusion
○
○Growth disturbance
○
○Temporomandibular joint ankyloses

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
896
mal craniotomy with removal of meningovascular cicatrix;
drainage of cystic structures; dural repair, which may re­
quire grafting; and reconstruction of the cranial vault. Ron­
geuring bone rather than performing a craniotomy will re­
sult in loss of bone stock. This makes healing difficult. Bone
grafting of the anterior skull base or orbital roof may be in­
dicated. Patients may require secondary procedures for per­
sistent orbital asymmetry.57
Mucocele
Mucoceles are the result of fractures involving the frontal
sinus associated with mucosal tear.69 Mucosa entrapped
in a fracture line may result in cyst formation. Growing
mucoceles produce several inflammatory cytokines, such
as prostaglandin and collagenase. These can erode sur­
rounding bone.70,71 Mucocele development occurs over
a span of years. They are only likely to present in adult­
hood.72 Furthermore, mucoceles originating from trauma
in childhood are rare, given that the frontal sinus is not
present before age 4 years and is not fully developed until
adulthood.1
Treatment of a mucocele remains controversial. Integ­
rity of the posterior table, dura, frontal recess, and any other
bony defects must be assessed. All diseased mucosa must be
removed. If the frontal recess is patent and functional, then
the frontal sinus may be left intact. Otherwise, obliteration
or cranialization with occlusion of the frontal recess is indi­
cated. Orbital roof or frontal bone defects should be recon­
structed as needed.
Unfavorable Results Involving the
Middle Third of the Face
Telecanthus
NOE fractures are the major cause of telecanthus in pedi­
atric facial trauma. Comminuted NOE fractures usually re­
quire transnasal fixation to properly reposition the medial
canthal tendon. A drill hole is placed posterior to the lacri­
mal fossa and linked to the fragment containing the medial
canthal tendon with a small-gauge wire.73 This technique
usually provides an anatomical reduction of the fracture.
Alternatively, permanent sutures anchored to a miniplate
can achieve the same result. Regardless of the technique
used, anatomical repositioning requires satisfactory supe­
rior and posterior positioning of the canthal remnant. Re­
sidual telecanthus may nevertheless result even after satis­
factory initial treatment. In Singh and Bartlett’s series74 of
20 pediatric patients with NOE fractures, 6 required further
canthal repositioning.
plates. There were five cases of resorbable device failure
requiring reoperation. Failure was the result of plate frac­
ture rather than screw pullout. Twelve patients suffered
from foreign body reaction presenting at 4 to 10 months
after surgery.
Imola et al48 published a case series of 57 patients
treated with resorbable plates, 11 of whom underwent fa­
cial fracture repair. Two of three mandibular fracture cases
experienced delayed union. One of those two patients re­
quired revision surgery via metal plate fixation because of
plate extrusion and surgical site infection. With continued
improvement in biomaterial technology, more recent case
series have reported few complications with resorbable
plates for mandible fractures.50–52 These included infection
requiring removal of hardware (1 of 22 patients).
Unfavorable Results Involving the
Upper Third of the Face
Posttraumatic Growing Skull Fracture
Although uncommon in adults, superior orbital fractures
are more common than floor fractures in children younger
than age 7 years.25 This is most likely related to the timing
of the development of the frontal and maxillary sinuses. As
such, supero-orbital fractures are more likely to be associ­
ated with a dural tear. They are at risk for progressive dias­
tasis of the fracture line. Although only 0.03 to 2.2% of all
pediatric skull fractures result in growing skull fractures,
90% occur in patients younger than 3 years. Fifty percent
occur in those younger than 1 year.53–57 Younger children
are susceptible because of their malleable cranial vault and
rapidly growing brain.53,58,59 The presence of a dural tear at
the time of injury seems to be necessary for the develop­
ment of a growing skull fracture.58,60–63 Typically, the scalp
is intact. A collection of CSF at the fracture site (cephalhy­
drocele) indicates the dural tear. Other presenting symp­
toms may include diplopia, proptosis with or without pul­
satility, eyelid edema, or orbital asymmetry. Patients may
present 2 to 18 months after injury.64
Without proper recognition and treatment, the skull
fracture will continue to expand with destruction of the
bony vault, porencephalic cyst, epilepsy, paresis, cerebral
scarring, brain atrophy, and cerebral herniation.63,65,66 A sig­
nificant mass effect on the orbit may result in optic nerve
compression.67
Prompt diagnosis and treatment of a dural tear associ­
ated with a fracture is vital to avoid a growing fracture. If
the injury has already progressed to a growing skull frac­
ture, surgical treatment with wide exposure using a coro­
nal incision is advocated. Dural edges are usually retracted
at the time of repair.66,68 Havlik et al66 recommend for­

897
Chapter 49 Pediatric Facial Fractures
Data regarding long-term outcomes and complica­
tions of surgical intervention in pediatric floor fractures are
lacking. Nevertheless, surgeons typically advocate surgical
approaches that allow for adequate exposure and proper im­
plant placement. A transconjunctival approach allows for a
“scarless” surgery but has limited exposure compared with
external approaches. Lateral canthotomy can improve expo­
sure, but the surgeon must repair the canthal ligament be­
fore case completion. “Middle lamella” syndrome, violation
and subsequent scarring of the orbital septum with resul­
tant lower lid malpositioning, has not been investigated in
detail in the pediatric literature. Measures should be taken
to avoid its occurrence. In the external approach or the pre­
septal subconjunctival approach, surgeons should incise the
orbital septum below the orbital rim to allow for appropriate
graft coverage and suture reapproximation. Nonresorbable
alloplastic implants are at risk for migration in the growing
orbit and should be avoided. They may impinge on orbital
structures and adversely affect movement. Infection is also
an increased risk. It is treated with implant removal. In the
case of supramid, the foreign body capsule should be mar­
supialized into the maxillary sinus, because spontaneous
hemorrhage has been reported.86
Persistent diplopia after orbital trauma may also result
from transient muscle ischemia with subsequent strength
imbalance. Injury to cranial nerves III, IV, or VI may also neg­
atively affect ocular motility. Any suspected impingement
should be evaluated and imaged as necessary. In cases of
muscular imbalance, prism glasses can be used for conserva­
tive management. More aggressive therapies include botuli­
num toxin injections into restricted extraocular muscles or
strabismus surgery to address muscle length.87
Either a pure orbital floor fracture or a zygomaticomax­
illary complex fracture involving the orbital floor will re­
sult in enophthalmos if the floor defect is not properly as­
sessed and corrected (Fig. 49.1). Most surgeons recommend
a period of observation to allow for resolution of periorbital
edema to ascertain true extent of enophthalmos. Losee et
al76 examined their series of patients with orbital fractures
and the outcomes with conservative management. Three of
ten pure orbital fractures managed conservatively had de­
tectable enophthalmos. These patients had higher energy
impact trauma, larger fracture widths, greater fracture area,
displacement, and soft tissue herniation. None of the pa­
tients with enophthalmos demonstrated any functional defi­
cit. Degree of enophthalmos for all three patients measured
no more than 1 mm. These findings suggest that conserva­
tive management of pediatric enophthalmos without further
complication of dystopia or entrapment may be considered.
This may be related to the elasticity of the orbital connective
tissue in a child and the ability of their periosteum to resist
tearing.26,76 However, some cases do require secondary sur­
gery. In their review of complex orbital fractures, Nowinski
Complications of Orbital Floor Fractures
Any fracture involving the orbital floor may cause entrap­
ment of orbital contents. Trimalar, Le Fort, and simple floor
fractures are all susceptible. Pure orbital wall fractures are
more common in children than adults because of their
incomplete pneumatization of the paranasal sinuses. As
stated previously, children older than 7 years are more
likely to experience floor fractures, whereas those younger
than 7 years are more susceptible to pure orbital roof frac­
tures. Furthermore, because most pediatric facial fractures
occur after the age of 5 years, most simple orbital fractures
in children involve the floor.75,76 Orbital floor fractures are
typically classified as “direct,” involving a direct impact to
the orbital rim with subsequent fracture of both the inferior
orbital rim and the orbital floor, or “indirect,” consisting of
a force impacting the orbital contents and causing them to
break through the weakest point of the orbital walls. In the
pneumatized maxilla, this is the orbital floor.
Because of the propensity of pediatric bone to green­
stick fracture, entrapment is significantly more common
in children.77 Patients with entrapment may present with
symptoms of oculocardiac reflex: bradycardia, nausea, and
syncope.78 Surgeons should nevertheless perform forced
duction testing at the time of injury to rule out entrapment
even if symptoms are absent. Children may present without
any associated findings. This has been termed “white-eyed”
blowout.79 Patients without entrapment can be observed for
enophthalmos and diplopia during the days after injury. En­
trapment can also occur during surgical repair of an orbital
floor fracture. Before closure during orbital floor reconstruc­
tion, the surgeon should repeat forced duction testing to rule
out entrapment of orbital contents.
Although inferior rectus entrapment with symptoms of
oculocardiac reflex is considered a surgical emergency, the
timing of orbital floor repair with asymptomatic entrapment
remains unsettled. Some authors advocate treatment within
1 or 2 days.77,79,80 Prolonged entrapment may predispose
the inferior rectus to ischemic contracture and necrosis.81
Fibrosis and adhesions of intraorbital contents may also
be a causative factor of ocular restriction.82 Furthermore,
some studies have shown that most cases have no muscle
within the entrapped contents.83,84 Regardless of the cause,
no definitive treatment protocol currently exists. Cases of
restricted movement with onset as early as 72 hours after
injury have been documented.78 Conversely, some evidence
suggests that immediate repair is not necessary. Egbert et
al85 reported a case series of 34 patients. They reported no
difference in mobility or diplopia for children treated within
1 month of fracture. However, patients receiving therapy
within 7 days had a more rapid improvement in symptoms
than those treated later. They recommended early treatment
for patients with severe symptoms of entrapment.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
898
bone fusion. Nasal bones separate at the midline, causing
central depression and lateral flaring and displacement over
the frontal process of the maxilla.
Verwoerd and Verwoerd-Verhoef2 described common
patterns of pediatric nasal septal fractures. Vertical fractures
involve fractures caudal to the insertion of the upper lateral
cartilages and extend to the anterior nasal spine. Left un­
treated, they will result in deviation of the caudal septum
and nasal tip. A “C-formed fracture” extends posteriorly and
superiorly from the central cartilaginous septum to the per­
pendicular plate. These fractures result in both bony and
cartilaginous septal deviation. Recognition of these fracture
patterns during physical examination will assist the surgeon
in performing the appropriate treatment and reduction ma­
neuvers in these patients. This requires both external and
internal nasal examination. External examination should fo­
cus on inspection of the deformity and palpation of crepi­
tus, mobility, and step-offs. Proper instrumentation is para­
mount to complete intranasal examination and will allow
the surgeon to evaluate the presence of a septal hematoma,
septal fracture or deviation, epistaxis, intranasal lacerations,
and patency of the internal nasal valve. Headlight illumina­
tion, suction, topical decongestants, and a nasal speculum
are all necessary for adequate exposure and examination.
et al88 documented 3 of 14 patients with persistent enoph­
thalmos or ocular dystopia requiring surgical revision.
Unfavorable Results Involving Nasal
and Septal Fractures
Accurate incidence of nasal fractures has been difficult to
ascertain. Many are managed in an outpatient setting. In­
patient statistical analysis may therefore omit many cases.
Regardless, most authors regard the nose as the most com­
mon site of pediatric facial fractures.8,9,16–19,21–23,89
Several nasal fracture classification schema exist. Mo­
ran90 specifically described patterns seen in children. Lat­
eral fractures are the most common. These involve ipsilat­
eral infracture and contralateral outfracture of the junction
of the ascending process of the maxilla and the nasal bone.
Linear fractures are nondisplaced and without comminu­
tion. Frontal fractures, like those in adults, are more likely
to cause greater trauma. Vector of force may transmit injury
posteriorly to the lacrimal and ethmoid bones, or posterior
telescoping of the nasal tip or pyriform aperture may occur.
“Open book” fracture is a type of frontal fracture particu­
lar to the pediatric population related to incomplete nasal
a
b
Fig. 49.1 A pediatric patient after an orbital blowout fracture. (a) Radiological findings of the floor blowout, with herniation of the orbital
contents into the maxillary sinus and a “greenstick” fracture of the floor. (b) The intraoperative view of the placement of an orbital floor
implant via a transconjunctival approach.

899
Chapter 49 Pediatric Facial Fractures
have reported deformities and growth disturbances that
have arisen years after surgical treatment.104–106 This is
most likely related to injury and repair occurring before the
adolescent growth spurt. Reestablishing the end-to-end re­
lationships of cartilage fragments should be the surgeon’s
goal to minimize future growth disturbance. If saddle nose
deformity does develop, secondary surgery is required to es­
tablish satisfactory dorsal height and length (see Fig. 49.2).
Residual Deformity
Pediatric bone has a tendency to “greenstick” fracture be­
cause of its soft, pliable nature. Reduction may need to be
supported with both an external splint and internal pack­
ing to maintain the anatomical position of the bone frag­
ments. Intranasal lacerations associated with infracture of
nasal bones should be closed to assist in reduction. Revi­
sion surgery with osteotomies may be required, especially
in cases of nasal airway obstruction secondary to bone frag­
ment malposition. Comminution of the nasal bones in NOE
fractures poses a greater challenge. Rigid fixation of these
small fragments is technically challenging. Internal splint­
ing may assist in reduction of small fragments.107 Growth
disturbance may result as well. Regardless, the exact pre­
morbid appearance may be difficult to achieve.108
Recontouring the nasal profile can be accomplished with
a variety of autogenous grafts. Typically rib cartilage or split
calvarium is used to reconstruct the nasal dorsum. If there
is no dorsal support, a cantilevered bone graft from split
calvarium or rib can be used. Nasal tip support can be re­
stored with a cartilaginous columellar strut, fashioned from
ear or rib cartilage. Septal cartilage should not be harvested
in these cases. Septum is both a growth center for the nose
and a source of dorsal support. Timing for such secondary
procedures is not defined. Because the nose continues to
grow until at least age 16 years depending on the sex of the
Growth Disturbance
Researchers have postulated two models of nasal growth
and development. According to Verwoerd and Verwoerd-
Verhoef’s model,2 two growth centers exist in the nose. The
sphenodorsal zone extends from the sphenoid to the nasal
dorsum and results in increased length and height of the
nasal dorsum. The keystone area, the junction of the upper
lateral cartilages and the nasal septum at the bony–carti­
laginous interface, is part of this growth zone. The sphe­
nospinal zone extends from the sphenoid to the anterior
nasal spine and results in increased projection of the nose
and maxilla. Injury to either growth center may result in
progressive deformity in the dimensions each growth cen­
ter controls. Another model describes a two-phase growth
of the premaxilla.91 In this model, the septo-premaxillary
ligament transmits an inferior and anterior force from the
growing nasal septum to the premaxilla until the maxillae
reach their definitive boundaries. A second phase of growth
then occurs, intrinsic to the orbital and posterior surfaces
of the maxillae. Saddle nose deformity of the nasal dorsum
(Fig. 49.2), widening of the nasal bridge, widening of the
nasal base, decreased nasal length, and decreased projec­
tion are all possible sequelae in patients even after satisfac­
tory surgical treatment of a nasal fracture.92,93
Because the nose continues to grow into late adoles­
cence or even adulthood for men, most surgeons recom­
mend a conservative approach to the management of nasal
fractures. Furthermore, the younger the patient at the time
of injury, the more likely long-term deformities will occur.
Although cases of nasal trauma at birth may resolve with no
intervention, some authors advocate immediate treatment
regardless of nasal airway patency.94,95 They propose that
the ease and safety of the maneuver weighed against the
risk of functional and developmental abnormality justifies
intervention. Otherwise, pediatric nasal fractures should be
treated within 3 to 5 days after injury. Bony healing is more
rapid than that of adults.96 Closed reduction under anes­
thesia permits proper examination, reduction, and splinting
of the fracture. Older children may tolerate treatment with
regional nerve blocks. In cases of severe nasal obstruction,
some surgeons recommend open septorhinoplasty.97–101
Care must be taken to avoid the aforementioned growth cen­
ters whenever possible. Resection of septal cartilage should
always be minimal, unless septal deflection is the major
contributor to airway obstruction. Bony and cartilaginous
septal continuity should be maintained. Resected cartilage
should be recontoured and replaced. Surgeons may opt to
use polydiaxone scaffolding to support the regrafted car­
tilage. Animal studies have demonstrated normal cartilage
growth after a cartilage defect has been bridged with poly-
diaxone.102 Spreader grafts should be avoided. They disrupt
the dorsoseptal growth center. Crushed cartilage can fill ar­
eas at risk for perforation. However, it lacks the mechanical
strength to support the growing nose.103
Unfortunately, replacement of cartilage does not guar­
antee normal nasal growth after repair. Several case series
Fig. 49.2 Saddle nose deformity. The dorsal height of the middle
third of the nose is decreased.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
900
after injury.110 Root resorption is the cause of reimplanta­
tion failure in 80 to 96% of cases.111
Tooth root injury is common in alveolar bone fractures,
especially with preexistent periodontal disease. Isolated tooth
root injury requires stabilization with a flexible splint for a
minimum of 4 weeks.112 Segmental dentoalveolar fractures
should be stabilized with intermaxillary fixation (IMF) or
splinting. During the period of mixed dentition, the primary
teeth are unreliable in supporting arch bars. IMF screws allow
four-point fixation with immobilizing wires. Permanent tooth
bud injury becomes a risk with screw placement, however.
Up to 4% of patients treated with IMF suffer from dental root
injury or tooth loss.113–116 IMF screws are also at risk for screw
loosening and possible aspiration of hardware.117
Circummandibular wiring with a splint is therefore pre­
ferred treatment for these patients, as it allows for immobi­
lization and maintenance of occlusal relationships without
any trauma to the dentition. During reduction of the alveo­
lar fragment, care must be taken to preserve as much peri­
osteum as possible. Necrosis of the fragment is otherwise a
likely outcome (Video 49.1).
Mandibular fracture lines commonly pass through the
crypts of unerupted canines and second molars, putting
them at risk for injury. Permanent tooth buds are at great­
est risk for injury before age 3 years, before completion of
crown calcification.118 Injury is also a risk if mandibular and
dentoalveolar fractures are treated with rigid fixation. Mini­
plates with monocortical screws should be used with nonre­
sorbable fixation. The risk of tooth root injury is decreased
compared with bicortical screws. Knowledge of the timing
of permanent tooth eruption is helpful. Imaging should be
accessible in the operating room119 (Fig. 49.4). Resorbable
screws are another surgical option. They have blunt, non­
penetrating tips and absorb rapidly. Therefore they do not
obstruct tooth eruption.120 However, they are not self-tap­
ping. Drilling holes will still put tooth buds at risk. Copi­
ous irrigation is mandatory to avoid thermal trauma to the
child, staged procedures may be required to achieve satis­
factory results.
Septal Hematoma
Septal cartilage in children is softer than adults, predis­
posing it to buckle-type injuries. This increases the risk of
developing septal hematoma.90 Prompt recognition of he­
matoma by physical examination is paramount to avoid­
ing avascular necrosis of the septum or abscess formation.
Intranasal examination demonstrates widening of the sep­
tum, usually at the caudal end (Fig. 49.3). The septum is er­
ythematous and ballotable. Incision and drainage followed
by either packing or splinting to prevent reaccumulation is
usually sufficient treatment.
If septal hematoma is unrecognized or treatment is de­
layed, abscess formation may result. Untreated drainage of
the abscess could progress to intracranial thrombophlebitis
secondary to retrograde infection via valveless veins drain­
ing the central midface—the “danger triangle.” Abscesses
should be opened, cultured, and treated with a drain to per­
mit egress of infected material. Once septal hematoma has
progressed to abscess, the risk of septal necrosis increases.
For this reason, some authors advocate drainage via an open
rhinoplasty approach with immediate reconstruction of the
septum with polydiaxone foil.109 If septal hematoma pro­
gresses to septal necrosis, the patient is at risk for eventual
development of a saddle nose deformity (see Fig. 49.2).
Unfavorable Results Involving
Dentoalveolar and Mandible Fractures
Tooth Loss and Permanent Tooth Root
Injury
Permanent tooth avulsion or luxation can result from man­
dibular fracture or from isolated dentoalveolar trauma.
Avulsed teeth should be reimplanted as soon as possible
Fig. 49.3 Septal hematoma with widening of the caudal septum on
anterior rhinoscopy. The patient was treated with needle drainage
and a nasal splint.
Fig. 49.4 Dental panoramic radiograph of a patient with mixed
dentition. Note the presence of permanent tooth buds within the
substance of the mandible. Permanent canines are closest to the
mandibular border. (From Kushner GM, Tiwana PS. Fractures of
the growing mandible. Atlas Oral Maxillofac Surg Clin North Am
2009;17[1]:81–91.)

901
Chapter 49 Pediatric Facial Fractures
or mixed dentition.129 Otherwise, surgeons must decide be­
tween screw- or bone-anchored fixation. With IMF screws,
the surgeon must take care to avoid the unerupted dentition.
Interosseous wiring can be passed through the maxilla and
around the piriform aperture. Suture lines should be avoided
when creating a drill hole for the wire to pass through, be­
cause they cannot reliably support wire position. McNichols
et al130 recommend passing the wire through a hole drilled
through the palate posterior to the incisors. If the patient
demonstrates malocclusion after 2 weeks of fixation, further
therapy is indicated. Guiding elastics with or without orth­
odontic appliances are usually effective in such cases.
In cases of significant displacement, comminution, or
multiple fractures, more aggressive treatment is necessary
to restore and maintain occlusal relationships and promote
union of fragments. This includes rigid fixation with metal
or resorbable plates or stabilization via an occlusal or lingual
splint secured with circummandibular wiring131 (Figs. 49.5
and 49.6). If open reduction and internal fixation (ORIF) is
used, occlusion must be checked at the end of the case by re­
leasing IMF. Lingual cortex splaying can easily go unnoticed
during plate fixation, because that surface is not directly vi­
sualized during reduction and fixation.
Regardless of the nature or extent of injury, the surgeon
must balance the requirements of adequate bony healing
with early mobilization in pediatric patients. Rapid growth
potential of the mandible allows for a greater margin of er­
ror. Malocclusion that may develop has a strong proclivity
for self-correction via growth of the mandible. Conversely,
prolonged immobilization will inhibit mandibular growth
and possibly introduce ankylosis, two far more difficult un­
toward sequelae to correct.
Growth Disturbance
The condyle is an important growth site for the mandi­
ble.132,133 Vascular impairment from condylar fracture or
bone and tooth root. Circummandibular wiring with a splint
is another surgical option for management of isolated dis­
placed symphyseal/parasymphyseal fractures.121 The splint
and wiring are kept in place for 2 to 3 weeks. Other alterna­
tives to screw and plate fixation include transnasal wiring,
arch bars, Ivy loops, and Risdon cables. Long-term follow-
up is required to observe for permanent tooth disturbances.
Approximately half of all traumatized tooth buds suffer
from some type of growth disturbance.36,122,123 Sequelae in­
clude pulp necrosis, enamel hypoplasia, and sequestration.124
If pulp necrosis is detected, an attempt is made to preserve the
tooth via a root canal.125 Sequestration is more common in the
maxilla.8 Surgeons should débride any fragments to prevent
delayed wound healing.8 Ultimately, injury of permanent tooth
buds can result in malocclusion because of maleruption of ad­
jacent teeth. Such cases are more likely to occur in the incisor
region, where midline drift of canines can negatively affect
occlusion. Injury to primary teeth can also affect permanent
teeth in several ways.126,127 Enamel hypoplasia, root deforma­
tion, sequestration of the tooth germ, odontome formation,
abnormal eruption, and impaction are all possible sequelae.
Malocclusion
Any fracture of the mandible or maxilla can result in mal­
occlusion. Although remodeling of the growing mandible
allows for satisfactory results with less than perfect frag­
ment reduction, malunion or nonunion can occur and may
result in failure to restore premorbid occlusal relationships.
Dentoalveolar injury resulting in tooth loss, tooth seques­
tration, ectopic tooth eruption, or other injury to perma­
nent teeth can also cause malocclusion. Posttraumatic
growth disturbances are another risk factor.
Most pediatric mandibular fractures result in simple
greenstick or nondisplaced fractures. These are generally
amenable to conservative management with a mechanical
soft diet. Displaced fractures may require closed reduction via
IMF to establish proper occlusion. Because of the nature of the
developing dentition, adequate anchorage of IMF can be prob­
lematic. Deciduous teeth cannot reliably support arch bars
and circumdental wiring, because they lack a well-developed
cingulum.128 Risdon cables offer a more malleable, lower pro­
file option to traditional arch bars for patients with deciduous
Fig. 49.5 Occlusal splint.
Fig. 49.6 Placement of circummandibular wire via an awl. The awl
guides the wire along the lingual cortex of the mandible. Once the
lingual end of the wire is secured, the awl is withdrawn and advanced
along the buccal surface of the mandible.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
902
Temporomandibular Joint Ankyloses
Temporomandibular joint (TMJ) ankylosis is one of the most
challenging complications of mandibular condyle fractures.
Untreated TMJ ankylosis leaves the patient with several un­
toward sequelae. These include facial deformity resulting
from growth disturbance and complications secondary to
trismus, such as difficulty with deglutition and poor oral
hygiene. Incidence of ankylosis is variable depending on
the case series. It ranges from 1 to 46% of patients with con­
dylar or subcondylar fractures.9,18,36 Intracapsular condylar
fractures in the growing mandible pose potential problems
that predispose the patient to ankylosis143 (Fig. 49.8). Chil­
dren younger than 3 years are at increased risk of ankylosis
because of the unique qualities of the condyle in that age
group. Condylar neck is covered in thin bone and is com­
posed of a vascular sponge.144
Therefore the possibility of crush injury is high when
the condyle is stressed along its long axis.145,146 This type
of fracture can result in hemarthrosis or bone fragments
in the intracapsular region and significantly increases the
risk of joint ankyloses.147 Patients placed in IMF for longer
than 3 weeks are also at greater risk for ankyloses.148 The
incidence is higher in patients with delayed presentation or
diagnosis. In Adekeye’s series,9 all of the patients with an­
kylosis presented more than 6 months after injury. Because
of the difficulty in surgical management and the severity of
crush injury will contribute to growth impairment. This will
in turn result in asymmetry of the lower face, ankylosis, and
possibly malocclusion. Risk is greater when injury occurs be­
fore age 3 years.134 Animal studies have confirmed the role
of the “functional matrix” in mandibular growth, suggesting
that preservation of function is more important to contin­
ued growth than the risk of trauma to the bone itself.135,136
Therefore temporomandibular joint ankylosis contributes
directly to growth disturbance by inhibiting the activity of
the functional matrix.33,137,138 Likewise, prevention of anky­
losis is usually the best prevention for the onset of growth
disturbances. In fact, several studies have reported cases of
complete resorption and reestablishment of the fractured
condyle after conservative management only.139,140 The re­
modeling capacity of the mandible appears to decrease as
the patient reaches maturity.141,142 Therefore some surgeons
choose to treat one side of bilateral condylar fractures with
ORIF in older patients (Fig. 49.7).
When growth disturbance is detected, the patient
should be promptly referred to an orthodontist for further
evaluation. If conservative measures fail to be effective, a
variety of treatments are available. Fat grafting and facial
implants can recontour visual asymmetries. However, these
do not address the basic underlying functional abnormali­
ties that may have arisen. Orthognathic surgery may be re­
quired to restore normal mandibular function and occlusal
relationships.
a
b
c
Fig. 49.7 (a) Coronal computed tomography of a patient with bilateral condylar fractures. (b) The right side underwent an open reduction.
(c) Postoperative mouth opening shows an acceptable maximal interincisal distance.

903
Chapter 49 Pediatric Facial Fractures
performed. The glenoid fossa is reestablished if needed with
a burr and relined. If the disc is preserved, this can be re­
positioned. Otherwise, a temporalis flap is rotated into the
fossa.153,154 The patient is then placed in maxillomandibu­
lar fixation (MMF) with an occlusal splint. A costochondral
graft is harvested and interposed between the glenoid fossa
and remaining ramus. Care must be taken to use no more
than 1 to 2 mm of cartilaginous cap. Otherwise, graft over­
growth may occur.151,155,156 The chondral surface of the graft
is placed to abut the glenoid fossa and temporalis flap. The
graft is then secured with miniplate fixation and the wound
is closed. Postoperatively, the patient is kept in MMF for a
maximum of 10 days. Splinting is used for 3 months and
gradually adjusted over that time to accommodate growth
of the maxillary teeth and any residual open bite. Alterna­
tively, distraction osteogenesis (DO) can be used to lengthen
the ramus to reach the glenoid fossa.157–159 No MMF is re­
quired with DO. Physiotherapy is initiated immediately af­
ter surgery.
Outcomes in the treatment of TMJ ankylosis in children
are variable. Favorable outcomes become less likely as du­
ration between onset of ankylosis and treatment increases.
As the patient ages, facial asymmetry worsens. Secondary
hypertrophy of the coronoid process enhances trismus.
Therefore rapid treatment is paramount to successful man­
agement. In his report of two pediatric TMJ ankylosis cases,
Kennett160 determined that recurrence of ankylosis was the
most common outcome of ankylosis surgery. Posnick and
Goldstein161 published their data regarding TMJ ankylosis
management in nine pediatric patients. Of those, four pa­
tients had ankylosis secondary to trauma. Only one patient
maintained the minimal passive maximal incisor opening
the sequelae, surgeons should take great care to prevent the
occurrence of ankylosis. Condylar fractures in the growing
mandible are treated with early mobilization, aspiration of
any hemorrhage, and intra-articular steroids.149 After 7 to
10 days, opening exercises with guiding elastics allow for
condylar remodeling.36,139,147
Management of TMJ ankylosis can be a significant re­
constructive challenge. Corrective surgical techniques are
extremely demanding. Additionally, growth over time must
be considered. High resolution CT with three-dimensional
reconstruction of the affected joint will allow proper plan­
ning. Several surgical techniques have been described. No
standard of management exists. Techniques usually include
condylectomy with joint replacement via graft, and coro­
noidectomy with temporalis stripping as needed. Kaban and
colleagues150,151 published their protocol for aggressive an­
kylosis excision. To facilitate postoperative physiotherapy,
complete passive opening while in the operating room is the
primary goal.151 Their protocol emphasizes complete exci­
sion of the ankylosis and attention to both ipsilateral and
contralateral coronoid processes. These elements had pre­
viously been identified as causes of surgical failure. First,
the TMJ is accessed via preauricular incision with temporal
extension. Soft tissues are dissected until the surgeon has
exposed the zygomatic arch, full width of the mandibular
ramus, sigmoid notch, and coronoid process.152 The entire
ankylosis mass is then excised, taking care to protect the
skull base. The surgeon must pay close attention to ensure
that the medial aspect of the TMJ is resected as well.
After ankylosis excision and ipsilateral coronoidectomy,
the maximal interincisal opening (MIO) is tested. If the MIO
is smaller than 35 mm, contralateral coronoidectomy is also
I
II
III
VI
V
IV
Fig. 49.8 Condylar fracture types, Spiessl and Schroll classification. I, Nondisplaced. II, Low neck fracture with displacement. III, High neck
fracture with displacement. IV, Low neck fracture with dislocation. V, High neck fracture with dislocation. VI, Head fracture.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
904
allows for bony remodeling, obviating the need for pre­
cise bony compression, as would be required in the adult
skeleton. Therefore most fractures of the growing facial
skeleton can be managed conservatively with early mobi­
lization of the temporomandibular joint. More aggressive
approaches that would be appropriate for adults increase
the risk of complications in children. Prolonged IMF can
lead to ankylosis. Heavy plates with bicortical screws may
cause injury to unerupted permanent teeth, and extended
periosteal elevation may disturb bone growth. Nasal
bone fractures should initially be treated conservatively
to preserve growth centers, with the understanding that
secondary surgery may be required. Long-term follow-up
of these patients is warranted to ensure that proper fa­
cial growth occurs. However, because of the patient de­
mographic, long-term controlled studies remain lacking.
Evidence-based conclusions in pediatric facial fractures
therefore remain a challenging goal.
of 30 mm at follow-up. Postoperative trismus was worse
for patients with bilateral ankylosis. Kaban et al151 have re­
ported satisfactory results using the protocol discussed pre­
viously. In 18 joints with a preoperative MIO of 16.5 mm,
1 year postoperative mean MIO was 37.5 mm.150 A more
recent series of 11 patients with mean preoperative MIO of
11.5 mm (range 1–23) showed postoperative MIO of greater
than 30 mm in 10 of 11 patients. Mean follow-up time was
24.8 months (range 4–74).
Conclusion
Overall, pediatric facial fractures are rare. Mandible frac­
tures are the most common injury in patients requiring
hospitalization. Pediatric facial fractures heal more rap­
idly than those of the adult skeleton. Early diagnosis and
treatment is paramount to achieving a favorable outcome.
Furthermore, the growth potential of the facial skeleton
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146. Rushton MA. Growth at the mandibular condyle in rela­
tion to some deformities. Br Dent J 1944;76:1
147. Lund
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109. Shandilya M, Den Herder C, Dennis SC, Nolst Trenité G.
Pediatric rhinoplasty in an academic setting. Facial Plast
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110. Wolfswinkel EM, Weathers WM, Wirthlin JO, Monson
LA, Hollier LH Jr, Khechoyan DY. Management of pedi­
atric mandible fractures. Otolaryngol Clin North Am
2013;46(5):791–806
111. Andreasen JO. Luxation of permanent teeth due to trau­
ma. A clinical and radiographic follow-up study of 189
injured teeth. Scand J Dent Res 1970;78(3):273–286
112. Casey RP, Bensadigh BM, Lake MT, Thaller SR. Dentoalve­
olar trauma in the pediatric population. J Craniofac Surg
2010;21(4):1305–1309
113. Coburn DG, Kennedy DW, Hodder SC. Complications
with intermaxillary fixation screws in the manage­
ment of fractured mandibles. Br J Oral Maxillofac Surg
2002;40(3):241–243
114. Roccia F, Tavolaccini A, Dell’Acqua A, Fasolis M. An audit
of mandibular fractures treated by intermaxillary fixa­
tion using intraoral cortical bone screws. J Craniomaxil­
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115. Ho KS, Tan WK, Loh HS. Case reports: the use of inter­
maxillary screws to achieve intermaxillary fixation in
the treatment of mandibular fractures. Ann Acad Med
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116. Coletti DP, Salama A, Caccamese JF Jr. Application of in­
termaxillary fixation screws in maxillofacial trauma. J
Oral Maxillofac Surg 2007;65(9):1746–1750
117. Fabbroni G, Aabed S, Mizen K, Starr DG. Transalveolar
screws and the incidence of dental damage: a prospec­
tive study. Int J Oral Maxillofac Surg 2004;33(5):442–
446
118. Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intru­
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119. Kushner GM, Tiwana PS. Fractures of the growing
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2009;17(1):81–91
120. Koltai PJ, Rabkin D, Hoehn J. Rigid fixation of fa­
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1995;1(2):32–42
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Maxillofac Surg 2014;18(1):65–68
122. Suei Y, Mallick PC, Nagasaki T, Taguchi A, Fujita M, Tani­
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123. Wilson S, Smith GA, Preisch J, Casamassimo PS. Epi­
demiology of dental trauma treated in an urban pe­
diatric emergency department. Pediatr Emerg Care
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124. Andreasen JO. Fractures of the alveolar process of the
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155. Perrott DH, Kaban LB. Temporomandibular joint ankylo­
sis in children. Oral Maxillofacial Clin North Am 1994;6:
196–203
156. Peltomäki T, Vähätalo K, Rönning O. The effect of a uni­
lateral costochondral graft on the growth of the marmo­
set mandible. J Oral Maxillofac Surg 2002;60(11):1307–
1314, discussion 1314–1315
157. Stucki-McCormick SU. Reconstruction of the mandibular
condyle using transport distraction osteogenesis. J Cra­
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158. Dean A, Alamillos F. Mandibular distraction in tem­
poromandibular joint ankylosis. Plast Reconstr Surg
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159. Hikiji H, Takato T, Matsumoto S, Mori Y. Experimental
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148. MacLennan WD. Consideration of 180 cases of typical
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153. Pogrel MA, Kaban LB. The role of a temporalis fascia and
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Surg 1993;51(5):530–533, discussion 534
Discussion by Arun K. Gosain
This discussion focuses on a few key areas that are es­
sential to the management of pediatric facial fractures.
First, the definition of pediatric facial fractures is
variable, and because of the nature of activities of chil­
dren and adolescents, most series discussing pediatric
facial fractures actually have more patients in their teen­
age years than children age 12 years and below.1–5 Chil­
dren are less likely to suffer from frontal sinus fractures
because of the lack of significant development of the
frontal sinus until after age 7 years. Similarly, children
are less likely to develop orbital blowout fractures be­
cause of the insignificant aeration of the maxillary si­
nuses until the development of permanent dentition.6
The following cases illustrate several sequelae:
1. Bilateral subcondylar fractures of the mandible
with medially displaced condyles
2. Displaced nasal fractures
3. Medial orbital wall fracture with muscle entrap­
ment
4. Frontal sinus fracture extending into the orbital
roof
Bilateral Subcondylar Fractures of the
Mandible with Medially Displaced
Condyles
A 10-year-old boy presented with bilateral subcondy­
lar fractures after being thrown from his bicycle af­
ter impact with a passing car. The patient presented
with an anterior open bite, and the computed tomog­
raphy (CT) scan demonstrated bilateral subcondylar
fractures with medial displacement (Fig. 49D.1). The
patient was treated with maxillomandibular fixation.
Because the patient was in mixed dentition, dentally
anchored arch bars would likely be unstable. Circum­
mandibular wires were used to secure the mandible,
and wires to the piriform aperture were used to se­
cure the maxilla. The circummandibular–to–piriform
aperture wires provided maxillomandibular fixation,
which was retained for 21/2 weeks. Upon removal of
the wires the anterior open bite had resolved, and the
patient was instructed on range-of-motion exercises
to the jaw. CT performed 3 weeks after the injury
showed the mandibular condyle to be significantly

909
Chapter 49 Pediatric Facial Fractures
more upright bilaterally, with no loss of posterior fa­
cial height (see Fig. 49D.1).
This case illustrates how the management of pe­
diatric mandible fractures differs from the manage­
ment of similar fractures in adults. First, the use of
maxillomandibular fixation was altered to avoid Eric
arch bars. The dental roots in mixed dentition are not
strong enough to support fixation techniques using
these arch bars. Therefore fixation is achieved by an­
choring the body of the mandible via circummandib­
ular wires to the maxilla via piriform aperture wires.
The duration of maxillomandibular fixation is also
shortened to 2.5 weeks in the pediatric age group to
avoid ankylosis. Of note is that the condyle assumes
an upright position very quickly in children once fa­
cial height is restored through maxillomandibular fixa­
tion, as demonstrated on the CT scan, which shows a
dramatic change in the position of the condyles within
3 weeks of the initial injury.
Displaced Nasal Fractures
A 9-year-old boy presented with displaced nasal frac­
tures after being hit in the face by a baseball. The bony
nasal pyramid was found to be displaced to the left on
physical examination, which was confirmed on plain
radiographs (Fig. 49D.2). Plain radiographs also dem­
onstrated that the cephalic portion of the nasal septum
was displaced to the left (see Fig. 49D.2). The patient
was taken to the operating room for a closed reduction
of the nasal fracture 3 days after the injury to allow the
edema to subside and to better appreciate the structure
of the underlying nasal bones. With the patient under
general anesthesia, the septum and nasal pyramid was
brought to midline using Asch forceps. This was fol­
lowed by outfracture of the right nasal bones to restore
symmetry to the nasal pyramid. An Aquaplast (Qfix)
splint was applied to protect the nose and remained in
place for 7 days. Three weeks after the injury, the nasal
a
b
Fig. 49D.1 Mandible fixation in a 10-year-old boy. (a) Bilateral subcondylar fractures demonstrating medial displacement of the
condyles. (b) The condyles are significantly more upright 3 weeks after the injury following a 21/2-week period of maxilloman­
dibular fixation.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
910
bones are straight with no evidence of prior displace­
ment and no perceived alteration in nasal air flow (see
Fig. 49D.2b,c).
This case illustrates management of one of the most
common pediatric facial fractures. Of note is that shift in
the nasal pyramid results in a shift of the nasal septum
and entire nasal dorsal complex. Therefore it is essen­
tial to centralize the septum along with the remainder
of the nasal pyramid to avoid relapse. Closed reduction
of nasal fractures is a key maneuver in the pediatric age
group to avoid an open rhinoplasty and the possible
nasal growth retardation that may result. Nasal bones
and septum are much more flexible in children than in
adults, and rarely have I had to follow up with a formal
rhinoplasty patient for further correction of nasal form
after closed reduction.
Medial Orbital Wall Fracture with
Muscle Entrapment
A 12-year-old boy sustained a kick to the face during a
martial arts class. He presented with slight restriction
of superolateral gaze of the left eye with associated se­
vere pain and diplopia. Mild bradycardia occurred with
extreme lateral gaze. CT demonstrated a medial orbital
wall fracture less than 1 cm in diameter with entrap­
ment of the medial rectus muscle (Fig. 49D.3). The
patient underwent an exploration of the medial wall
fracture through a transconjunctival incision in the
lower eyelid, with reduction of the medial rectus and
orbital contents and placement of a resorbable plate to
repair the medial orbital wall. He has had resolution of
diplopia and he has regained full range of extraocular
muscle function.
a
b
c
Fig. 49D.2 (a) Nasal bone fracture in a 10-year-old boy with displacement of the nasal pyramid. (b) Preoperatively. (c) Follow-up
3 weeks after closed reduction of the nasal fracture.

911
Chapter 49 Pediatric Facial Fractures
This case illustrates the concept that the orbital floor
and medial orbital wall in children is less prone to frank
blowout, in part because of greater flexibility of the bones
of the orbital walls. However, elasticity of the bones tends
to result in greenstick fractures of the orbital walls rather
than comminution and blowout, and the spring-back of
these bones is more likely to result in entrapment of the
extraocular muscles.7 Bradycardia often accompanies
these fractures, as illustrated in this child.8 Extraocular
muscle entrapment constitutes an urgent indication for
orbital exploration, because prolonged entrapment may
render the muscle ischemic, resulting in irreversible im­
pairment. Use of a resorbable plate to support the orbital
floor may be preferable to placement of a nonresorbable
alloplast in children, because the latter may become ob­
solete with facial growth.
a
b
Fig. 49D.3 Axial (a) and coronal (b) slices from a CT scan of the facial bones showing a medial orbital wall fracture with entrap­
ment of the medial rectus muscle.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
912
Frontal Sinus Fracture Extending into
the Orbital Roof
The patient is a 9-year-old girl who was involved in
a pedestrian versus motor vehicle accident. She suf­
fered loss of consciousness, accompanied by a com­
minuted fracture involving the anterior and posterior
tables of the frontal sinus, the entire left orbital roof
and superior orbital rim, and extending to the medial
aspect of the right orbital roof and superior orbital rim
(Fig. 49D.4a). The anterior and posterior tables of the
frontal sinus were displaced as a unit, with pea-sized
pneumatization of the sinus noted (Fig. 49D.4b). The
patient was taken to the operating room in conjunc­
tion with the neurosurgery service, where the frontal
sinus was cranialized and the superior orbital roof and
orbital rim were reconstructed bilaterally. Resorbable
plates were used to fix the anterior table of the fron­
tal sinus and comminuted fractures of the orbital roof
and superior orbital rim bilaterally (Fig. 49D.4c). The
patient recovered all cognitive functioning with no im­
pairment of vision. However, 9 months after the injury
the patient had residual ptosis of the left upper eyelid
(Fig. 49D.4d).
This case illustrates management of skull fractures
extending into the frontal sinus and orbital roof in chil­
dren. As indicated in the chapter, frontal bone pneuma­
tization begins at age 3 years and continues through age
15 to 19 years.9 At age 9 years, this patient demonstrates
early but incomplete pneumatization of the frontal sinus,
making the anterior and posterior walls of the frontal
sinus essentially one unit other than the pea-sized ­areas
of pneumatization. Therefore the anterior and poste­
rior tables of the frontal bone were displaced as a unit,
Fig. 49D.4(a,b) Computed tomography of a severely displaced frontal bone extending to comminuted fractures of the superior
orbital rim and orbital roof bilaterally in a 9-year-old girl. The frontal sinus is minimally aerated at this age (b). (c) Reduction and
fixation of the comminuted frontal bones, superior orbital rims, and left orbital roof using resorbable plates. (d) The patient had
persistent left upper eyelid ptosis 9 months after the injury.
a
b
c
d

913
Chapter 49 Pediatric Facial Fractures
unlike when these fractures occur in adults, when the
two tables are rarely displaced as one unit. Cranializa­
tion, if performed, is done in those sections of the fron­
tal bone in which adequate aeration of the frontal sinus
has occurred. The use of resorbable plates is important
in the pediatric cranium to minimize potential growth
disturbance and to avoid transcranial migration of the
plate that may occur with metallic plates. Ophthalmic
complications may accompany these injuries, and this
patient demonstrates residual ptosis even though vision
is not impaired. Correction of ptosis requires secondary
surgery, but because of the accompanying damage to the
muscles and nerves of the region, achieving symmetry of
the lids at rest and with dynamic closure of the eyelids
is extremely difficult.
Conclusion
With proper management, many of the unfavorable
sequelae discussed here can be avoided. However, be­
cause of considerations in facial growth and the de­
velopment of facial structures, such as aeration of the
sinuses and dental development, the presentation and
management of these injuries is significantly different
from that in adults. A facial trauma team cannot be se­
lective as to the age of the victims of facial trauma. In
addition, often both parents and children have injuries,
particularly after motor vehicle accidents. Therefore it
is imperative for surgeons who are caring for patients
with facial trauma to be well versed in the presentation
and management of pediatric facial trauma.
References
1. McCoy FJ, Chandler RA, Crow ML. Facial fractures in
children. Plast Reconstr Surg 1966;37(3):209–215
2. Gussack GS, Luterman A, Powell RW, Rodgers K, Ra­
menofsky ML. Pediatric maxillofacial trauma: unique
features in diagnosis and treatment. Laryngoscope
1987;97(8 Pt 1):925–930
3. Hall RK. Injuries of the face and jaws in children. Int J
Oral Surg 1972;1(2):65–75
4. Adekeye EO. Pediatric fractures of the facial skeleton:
a survey of 85 cases from Kaduna, Nigeria. J Oral Surg
1980;38(5):355–358
5. Sherick DG, Buchman SR, Patel PP. Pediatric facial frac­
tures: a demographic analysis outside an urban envi­
ronment. Ann Plast Surg 1997;38(6):578–584, discus­
sion 584–585
6. Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital frac­
tures in children. Arch Otolaryngol Head Neck Surg
1995;121(12):1375–1379
7. Grant JH III, Patrinely JR, Weiss AH, Kierney PC, Gruss
JS. Trapdoor fracture of the orbit in a pediatric popula­
tion. Plast Reconstr Surg 2002;109(2):482–489, discus­
sion 490–495
8. Sires BS, Stanley RB Jr, Levine LM. Oculocardiac reflex
caused by orbital floor trapdoor fracture: an indication
for urgent repair. Arch Ophthalmol 1998;116(7):955–
956
9. Arnaud E, Renier D, Marchac D. Development of the
frontal sinus and glabellar morphology after frontocra­
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niofac Surg 1994;5(2):81–92, discussion 93–94

914
CHAPTER
50
Complex Soft Tissue and Bony
Maxillofacial Reconstruction
Kurt Vinzenz and Christian Schaudy
Modern plastic surgery concepts are based on the para­
digm that plastic surgery must restore function as well as
anatomy in all cases, regardless of the indication for sur­
gery. In the case of facial plastic surgery, respecting the fa­
cial proportions is an elementary prerequisite for achieving
an aesthetic reconstruction.1
The facial skeleton is a lightweight, mechanically stable
structure that contains pneumatized cavities, houses organ
systems, and allows for the fixation of the facial soft tissue
envelope in a way that maintains musculoskeletal balance.
In the case of loss or aplasia of facial parts, facial disfigure­
ment increases in parallel with the extent of the maxillofa­
cial defect. In this situation, ignoring the functional anatomy
during the reconstruction effort invariably results in unsat­
isfactory outcomes.
Since the introduction of microsurgical flap transfer,
other methods of regenerative plastic surgery involving the
induction of bone and soft tissues in surgical protocols with
advanced block-grafting techniques, including prefabricated
composite grafts and distraction osteogenesis and histogen­
esis, have been introduced and can help avoid unfavorable
results in patients with severe maxillofacial defects.
The bone–muscle crosstalk, which is associated with the
regenerative plastic surgery methods mentioned earlier, has
beneficial clinical effects on the musculoskeletal balance of
the face and is useful for achieving a full rehabilitation.
Restorative plastic surgery requires the simultaneous re­
construction of maxillofacial aesthetics and function in all
cases, regardless of the indication for surgery, and relies on
the surgical concept of like-with-like reconstruction com­
bined with the skeletal rearrangement of the disfigured face.
By considering aesthetics and function as an inseparable
unit during the induction of functional tissues, the histori­
cal separation between plastic reconstructive and aesthetic
surgery has been broken.
Avoiding and Managing
Unfavorable Results in
Complex Soft Tissue and Bony
Maxillofacial Reconstruction
Summary Box
Complications in Maxillofacial Reconstruction
•• Absence of physiologic mucosal lining and gingiva
•• Facial deformity
•• Need for repeat bone grafts
•• Oral mobility loss
•• Implant loss
•• Excessive mucous secretion
•• Persistent peristalsis
•• Maceration
•• Hair growth
Evolution of Reconstructive
Maxillofacial Surgery to Avoid
Unfavorable Results
The face is involved in speaking, mastication, deglutition,
and effortless breathing, and these functions dictate the
main objective of any facial treatment: to restore physi­
ological function.
The reconstruction of the face, a pneumatized, light­
weight, mechanically stable structure to which the facial soft
tissue envelope is fixed to maintain musculoskeletal balance,
has proven to be a surgical challenge.