Among the various craniofacial growth sites includes the mandibular condyles, which plays a dominant role in determining mandibular length, position, and symmetry. It functions as both a growth center and an adaptive site capable of remodeling in response to functional demands. A large portion of mandible growth is attributed to ossification at the condyle, which occurs by enchondral apposition and intramembranous surface remodeling. Both mechanisms contribute to the vertical growth and anterior disposition to the mandible relative to the cranial base. In addition to this, most of the ramus height is determined by condylar cartilage proliferation, which is strongly modulated by functional matrices such as masticatory muscle activity, tongue posture, and orofacial soft-tissue development. ^, As such, the condyles grow posterior-superiorly, which translates to the protrusive movement of the mandible in tandem with the maxilla. ^,

Among pediatric facial injuries, fractures involving the mandibular condyle pose the greatest risk for growth disturbance. Despite its susceptibility to injury, the condylar region in children possesses remarkable remodeling capacity due to its high vascularity and decreased bone mineralization. Conversely, severe or intracapsular fractures can permanently damage the growth cartilage, resulting in mandibular asymmetry, restricted movement, or temporomandibular joint ankylosis. ^,,,, Such growth disturbances often manifest progressively over years, underscoring the need for long-term follow-up throughout craniofacial development. Early physical therapy and monitoring of mandibular growth can reduce the long-term outcome of fracture sequelae.

Nonoperative management

Most minimally displaced or nondisplaced mandibular fractures in children respond well to conservative functional therapy, which includes soft diet, analgesia, avoidance of further physical trauma, jaw rest, and early mobilization/physiotherapy to avoid ankylosis and to allow condylar remodeling. Functional appliances, or intermaxillary fixation (IMF) with arch bars, miniscrews, or Risdon cables, is a viable option that can be used for short periods to re-establish occlusion and help guide the patient’s bite during the healing process ( Fig. 1 ). Long-term studies report good remodeling and acceptable functional outcomes with nonoperative care for many condylar fractures.

Risdon cables placed in patient with bilateral subcondylar fractures to stabilize occlusion.

Coordinated protrusive translation of the maxilla maintains harmonious functional relationships with both the mandible and cranial base, ensuring stable occlusion and balanced facial proportions. Although the maxilla itself develops by intramembranous ossification, midfacial growth is secondarily influenced by the cartilaginous nasal septum and nasal capsule, which act as central growth drivers that displace the nasomaxillary complex anteriorly and inferiorly. ^, Signs and symptoms of nasal fractures must be identified including radiographic indication, difficulty breathing via nose, crepitus, or significant nasal deviation ( Fig. 2 ). Septal hematoma must be identified, recognized, and drained promptly to prevent septal necrosis and subsequent nasal growth disturbances. Closed reduction is typically performed under appropriate anesthesia, with timing influenced by the child’s age and swelling. Postoperative monitoring for septal and nasal growth disturbance is required.

Major nasal septum deviation resulting from nasal fracture.

Maxillary movement occurs through a combination of passive displacement from cranial base elongation and active sutural growth, with passive displacement dominating in early childhood and sutural activity continuing throughout the mixed dentition period. Functional matrices such as nasal respiration, masticatory forces, and orofacial muscle activity provide the environmental stimuli that regulate both sutural growth and surface remodeling of the maxilla. ^, Trauma involving the midface during active growth—particularly across the maxillary sutures or nasal septum—can, therefore, disrupt these coordinated displacement and remodeling processes. Such disruption may result in weakened nasal slope, vertical deficiency, asymmetry, or secondary occlusal discrepancies that become more apparent with continued growth. ^,

Understanding the stage of dentition and the development of the alveolar processes in a pediatric patient with facial trauma is essential, as these factors influence both the fracture pattern and the appropriate treatment modality. ^, When fracture reduction or fixation is required, the clinician must balance the need for stable bone healing with preservation of normal tooth eruption and alveolar growth.

As vertical dental eruption progresses, corresponding appositional growth occurs within the alveolar bone, promoting downward and outward facial development. ^, This growth also proceeds transversely through remodeling along the alveolar ridges. In the maxilla, eruption of posterior teeth is accommodated by appositional growth at the maxillary tuberosities, while remodeling of the mandibular ramus generates space for eruption of the posterior mandibular dentition.

In the primary dentition, blunt force is frequently transmitted through the root to surrounding alveolar bone and the developing tooth bud, resulting in luxation injuries rather than crown fractures. In contrast, permanent teeth—anchored in denser alveolar bone—are more susceptible to enamel or crown-root fractures upon impact. It is also important to evaluate potential injury to the underlying permanent tooth germ following trauma to a primary tooth, as this may lead to enamel hypoplasia or altered eruption patterns in the successor tooth. Additionally, segmental fractures of the alveolar process injuries can compromise the stability of adjacent teeth and associated soft tissue lacerations or mobility of the alveolar segment.

The maxillofacial buttresses are thickened areas of bone which aid in distributing mastication and trauma forces across the facial skeleton. They are classically divided into vertical and horizontal classifications.

The vertical buttresses provide support and transition forces from the teeth’s occlusion and maxilla up to the cranial base. They are appointed in 4 major locations: nasomaxillary, zygomaticomaxillary, pterygomaxillary, and mandibular ramus. Fractures of the maxilla and zygoma in younger children are less common but may disrupt midfacial sutures and growth centers. Management favors conservative measures for nondisplaced fractures; ORIF is considered for displaced fractures that compromise occlusion, ocular function, or facial contour. Plate placement across sutures may alter midface growth and should be avoided; when fixation is required, minimal hardware and avoidance of suture crossing are advisable. Additionally, the use of resorbable fixation plates and screws are considered as well as the early removal of nonbioresorbable plates following healing of the fractures.

The horizontal buttresses provide support for maintaining facial width, projection, and overall transverse stability. They are appointed in 4 major locations: frontal bar, infraorbital rims, maxillary alveolus and hard palate, and the mandibular body. Understanding these buttresses is critical in planning fixation, as stabilization along these lines ensures both functional and esthetic outcomes while respecting growth centers.

When growth disturbance manifests with functional impairment or significant asymmetry, staged multidisciplinary reconstructive strategies can be discussed as long-term or late treatment options for reconstruction, asymmetric/deficit correction or functional restoration.

Different surgical interventions include deficit corrections, hard tissue repair or relief of functional limitations. Orthodontic–orthognathic approaches after or toward the end of skeletal maturity to correct occlusion and asymmetry are an option to correct malocclusion and asymmetry ( Fig. 3 A, B). Distraction osteogenesis is an additional long-term option for the correction of maxillary or mandibular hypoplasia in growing patients with notable asymmetry or disturbed growth. Additionally, temporomandibular joint surgery, such as arthroplasty or total joint reconstruction, is an option for ankylosis or severe condylar deficiencies in patients with pain or significant functional limitation.

( A ) Mandible in a retrognathic position following a motor vehicle collision, resulting in bilateral subcondylar and angle fractures. ( B ) Occlusion restored following orthognathic surgery.

Management of trauma to the maxillofacial region requires not only anatomic reduction but also restoration of occlusion, symmetry, and facial expression. To achieve these goals, injuries must first be classified systematically to guide the diagnosis. Treatment strategies vary depending on the location, displacement, complexity, and associated systemic injuries.

Facial fractures are classified based on anatomic site and pattern:

Midface —Le Fort I to III, Zygomaticomaxillary complex fractures, orbital floor (“blowout”) fractures, nasal bone and naso-orbito-ethmoidal fractures.

Mandible—Symphysis/parasymphysis, body, angle, ramus, condyle/subcondyle.

Dentoalveolar injuries —Isolated alveolar fractures, dental intrusions, extrusions, avulsions, and root fractures are often managed in conjunction with restorative and endodontic interventions. The extent of the dentoalveolar injury should be determined prior to treatment with both clinical and radiographic examination.

Management is primarily guided by the classic tenets of trauma surgery— airway, breathing, and circulation (ABC) —followed by definitive treatment:

Primary survey —ABC; prioritize life-threatening and limb-threatening injuries. Pediatric airway anatomy demands attention; facial swelling and/or bleeding may compromise the airway faster than adults.

Secondary survey —Detailed craniofacial examination including assessment for soft tissue lacerations, sensory deficits, dental injuries, malocclusion, trismus, facial asymmetry and ocular involvement. Document occlusion and mouth-opening before any intubation or sedation if possible. Photographic documentation and dental occlusal records are extremely helpful for later comparisons.

Imaging —Computed tomography (CT); (with pediatric dose protocols) is preferred for suspected midface or mandibular fractures to delineate displacement, condylar involvement, and intracranial injury. Cone-beam CT (CBCT) is valuable for dental and dentoalveolar trauma when soft-tissue and intracranial injury are not suspected. For the case of dentoalveolar trauma without access to hospital or advanced imaging, the use of periapical radiographs and panoramic imaging can also be used but is less than ideal for thorough radiographic assessment.