Complicated Maxillofacial Fractures

Key points

  • To understand the variety of presentations of pediatric maxillofacial trauma.

  • To appreciate the effects of facial trauma on the growing facial skeleton.

  • To detail the differences in management of maxillofacial injuries in the growing child.

  • To understand the influence of age in the patterns of presentation of maxillofacial trauma in the elderly.

  • To review the considerations in the management of facial trauma in the geriatric population.



The occurrence of maxillofacial trauma in children is comparatively less when compared with maxillofacial trauma in adults. Of all pediatric emergency room visits, 12.3% are for craniofacial trauma. Based on the National Trauma Databank, the face is the fourth most commonly affected region in pediatric trauma cases, with the head being the most commonly affected. Although the pediatric population is vulnerable to craniofacial trauma owing to anatomic differences, of all maxillofacial trauma, only 1% to 15% involves patients under the age of 16 years. The majority of pediatric facial fractures are sustained in children 15 to 17 years of age. A large number of studies demonstrate a male predominance for pediatric maxillofacial fractures, with the male to female ratio also increasing with patient age within the pediatric category. The frequency of pediatric facial fractures increases with age, with the highest incidence of facial fractures occurring in those ages 12 to 18 years. This pattern is likely attributed to an increase in risk-taking behavior and a decrease in parental supervision. Fewer than 1% of maxillofacial fractures occur in children less than 5 years of age.

Statistics evaluating the most commonly fractured facial structures vary, and it is important to acknowledge that nasal bone and dentoalveolar fractures are likely underreported in the literature. Fracture patterns also vary based on the age of the pediatric patient. The site of facial fracture in pediatric patients tends to shift from the upper to the lower portion of the face as age advances, with mandible fractures being the most common fracture in teenagers, whereas orbital fractures are most commonly sustained in children ages 0 to 11 years. Overall, the most common fracture locations have been demonstrated to be the mandible (40.7%), orbit (33.5%), maxilla (11.7%), frontal (10.5%), and zygomatic arch (3.6%) ( Table 1 ).

Table 1
Most common fractures associated with pediatric maxillofacial trauma
Fracture Location Frequency (%)
Mandible 40.7
Orbit 33.5
Maxilla 11.7
Frontal 10.5
Zygomatic arch 3.6

The most common mechanism of injury varies based on geographic location, but can also be further evaluated based on the age groups of the pediatric patients, with those aged 0 to 5 years most likely sustaining facial fractures from activities of daily living; ages 6 to 11 years most often sustaining injuries caused by a motor vehicle collision, play, and bike riding; and those aged 12 to 18 years most commonly caused by violence followed by sports-related injuries ( Table 2 ). It has been found that overall in the pediatric population, motor vehicle collisions account for most common mechanism (30.7%), followed by sports (24.4%) and assault (13.7%; Table 3 ). It is also important to note that 46% of patients sustain concomitant injuries, most commonly cerebral trauma or injury of the extremities.

Table 2
Mechanism of injury in pediatric maxillofacial trauma based on age
Age (y) Mechanism of Injury
0–5 Activities of daily living
6–11 Motor vehicle collision, play, bicycle riding
12–18 Interpersonal violence, sports-related injuries

Table 3
Overall distribution of mechanism of injury in pediatric maxillofacial trauma
Mechanisms of Injury Frequency (%)
Motor vehicle collision 30.7
Sports-related injury 24.4
Assault 12.7

Although most cases of craniofacial trauma to the pediatric population are the result of unintentional injury, child abuse must be considered, because 2.3% of child abuse victims sustain facial fractures. Signs of child abuse include repeat injuries, multiple injury sites, delay in seeking treatment, inappropriate parental responses, and questionable circumstances of injury.

In addition to fractures sustained from trauma, it is important to note the impact of soft tissue injuries in the pediatric population. Two percent of all emergency room visits involve open wounds of the maxillofacial region in pediatric patients, with animal bites as a common mechanism. More than 400,000 children are treated annually in the emergency room for dog bite injuries, which occur most commonly to the cheeks, lips, nose, ears, and often result in complex, irregular wounds with avulsions.

Special considerations

When compared with adults, children have anatomic and developmental differences that affect patterns of injury and also influence management and outcomes. Pediatric patients have an increased cranial mass to body ratio, making them predisposed to craniofacial trauma. The increased cranium to face ratio of the pediatric patient, however, which is 8:1, compared with 2:1 in adults, decreases the risk of maxillofacial injury versus skull injury in the pediatric population. There are also protective features of the pediatric cranium when compared with the adult population ( Table 4 ). Of these factors, one benefit is a more flexible skeleton. Furthermore, the tooth to bone ratio is increased by the presence of tooth buds, which also contributes to the increased flexibility and stability. Facial projection is decreased secondary to the lack of pneumatization of the facial sinuses, which serves as another protective factor. Because of the many protective features that prevent facial fractures in the pediatric population, when a child does present with facial fractures, one must consider that a severe injury was likely sustained.

Table 4
Protective anatomic features of the pediatric patient
Protective Feature Impact on Outcome of Trauma
Increased cranium to face ratio More likely to sustain injury to skull than maxillofacial structures
Increased skeletal flexibility Decreased risk of complete fracture; more likely to sustain greenstick fracture
Increased tooth to bone ratio Increased stability and flexibility
Lack of pneumatization of sinuses Reduced facial projection

The development of craniofacial features contributes to common fracture patterns seen among the pediatric population. Displaced fractures are less common in children owing to the added cushioning from fat pads, greater compliance in structures, and increased bony flexibility. Development as children age further affects fracture patterns seen in this population. Owing to its relatively large size, the frontal bone is prone to fracture in pediatric patients. Patients under 7 years of age are more prone to orbital roof fractures, because the frontal sinuses have not undergone pneumatization by that age. Orbital fractures involving the walls and floor are more common in patients greater than 7 years of age. Trapdoor fractures, also referred to as white eye, blowout fractures, occur almost exclusively in children, and may or may not be associated with tissue entrapment. In addition to typical symptoms including restriction of extraocular muscle movement resulting in diplopia, entrapment may also present as nausea, vomiting, and bradycardia in children. As children age, the midface becomes larger and more protrusive, making it more likely to be involved in fractures. Le Fort fractures are uncommon in the pediatric population. Mandible fractures, particularly greenstick fractures, are overall more common in children than midface fractures. Condylar fractures are less common in children owing to the highly vascularized pediatric condyle and thick neck, making it more resistant to impact forces, and in children less than 6 years of age, condylar fractures are more often intracapsular than extracapsular in location. The likelihood of sustaining a fracture requiring operative fixation increases with patient age, which may be secondary to severity/mechanism of injury or owing to the loss of protective anatomic features with maturing age as discussed elsewhere in this article.

Special technical modifications

Fracture management is influenced by fracture location, complexity of injury, and associated injuries, as well as the patient’s age and time since injury. Owing to their anatomic and physiologic differences and concern for future growth, treatment modifications must be applied when managing pediatric facial fractures ( Table 5 ). Pediatric fractures require earlier intervention if needed, as well as potentially a shorter period of immobilization owing to the increased osteogenic potential and resultant rapid healing of pediatric patients. Ideally, facial fractures of a pediatric patient should be reduced and fixated within 4 days of injury. If immobilization is necessary, an average of 7 to 14 days, compared with 4 to 6 weeks for adults, is indicated, to avoid severe ankylosis of temporomandibular joints. Although open reduction and internal fixation (ORIF) remains the gold standard treatment for displaced fractures, the possibility of disturbing the periosteum and vascular supply as well as scar formation contributing to interference in growth must be considered. Surgical management, whether open or closed, should be reserved for displaced facial fractures. Nondisplaced fractures should be managed with observation and liquid or soft diet and analgesics. Keeping growth disturbances in mind, it is suggested that ORIF is useful in older children (>12 years of age), whereas a conservative approach in younger children (<12 years of age) should be considered. Pediatric patients often tolerate minor malocclusion better than adults owing to their potential for growth and remodeling, as well as having some capacity for spontaneous occlusal readjustment after injury and treatment as deciduous teeth are shed and permanent teeth erupt. Pediatric displaced subcondylar fractures should be managed with conservative therapy, including arch bars or a similar appliance with contralateral elastics and early rehabilitation and range of motion, because this region has the ability to remodel without surgical reduction.

Table 5
Treatment modifications for pediatric facial fractures
Treatment Modification Implication for Modification
Surgical intervention within 4 d when indicated Rapid healing secondary to increased osteogenic potential
When maxillomandibular fixation indicated only apply for 7–14 d Risk of ankylosis of temporomandibular joint
Reserve open or closed surgical management for displaced fractures Risk of scar tissue and growth disturbance
Manage nondisplaced fractures with liquid/soft diet and analgesics Avoid growth disturbance
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Jan 19, 2020 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Complicated Maxillofacial Fractures
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