Residency · Residency · Oral Maxillofacial Surgery

Pediatric Facial Fractures

Overview

Facial fractures in children are less common than in adults due to the elasticity of pediatric bone and the protected position of the face relative to the cranium. Incidence increases with age, being rare under age 5 and more common in adolescents. Management must account for developing dentition, unerupted tooth buds, active growth centers, and sinus development. Conservative treatment is preferred when possible to avoid growth disturbance, and the growth and remodeling potential is significant in younger children.

Anatomic Considerations

Pediatric vs. Adult Craniofacial Skeleton

The cranium-to-face ratio is 8:1 at birth and decreases to 2.5:1 in adults. Young children therefore sustain more cranial than facial injuries, and the prominent forehead and retruded face protect the midface and mandible. Pediatric bone is more elastic with thinner cortices and higher cancellous content, making greenstick fractures more common and resulting in less displacement for a given force. Paranasal sinuses are poorly developed before age 7-8: the maxillary sinus is small at birth and fully develops by age 15-18, while the frontal sinus begins developing at age 2-4 and reaches adult size by age 15-20. The absence of pneumatization provides structural reinforcement but also leaves less room for fracture displacement. Unerupted tooth buds fill the mandibular body and maxilla, limiting the space for plate and screw placement and creating risk of damage to developing teeth during ORIF. The mandibular condyle is the primary growth center of the mandible, and condylar fractures in children risk growth disturbance -- unilateral condylar injury may cause facial asymmetry and mandibular deviation, while bilateral condylar injury may cause micrognathia, bird-face deformity, and ankylosis.

Fracture Healing

Healing is faster in children, with callus formation beginning within days. Early treatment is important because delayed repair (beyond 7-10 days) can be complicated by rapid healing. The remodeling capacity is excellent in younger children.

<image>Comparison illustration of a pediatric skull (age 4) and an adult skull showing the differences in cranium-to-face ratio, sinus development (small maxillary sinuses, absent frontal sinuses in the child), unerupted tooth buds occupying the mandible and maxilla, and the prominent cranial vault relative to the facial skeleton</image>

Epidemiology

Boys are affected more than girls at a ratio of 2:1. Causes vary by age: infants and toddlers are injured by falls and non-accidental trauma (NAT, which requires a high index of suspicion); school-age children are injured by falls, sports, and bicycle accidents; and adolescents are injured by MVC, sports, and interpersonal violence. The most common fracture site is the mandible, with the condyle being the most frequent subsite. Midface fractures are less common in young children but increase with age as sinuses develop. Orbital fractures, especially the trapdoor type, are increasingly recognized.

Non-Accidental Trauma (Child Abuse)

A high index of suspicion must be maintained for facial fractures in children under 3 years. Red flags include a fracture inconsistent with the reported mechanism, multiple fractures in various stages of healing, delayed presentation, associated injuries (long bone fractures, rib fractures, intracranial hemorrhage), and multiple ED visits. There is a mandatory reporting obligation for suspected child abuse. A full skeletal survey and ophthalmologic examination are recommended.

Fracture Management by Site

Mandible Fractures (Most Common)

General Principles

Conservative management is preferred in young children. Rapid healing allows shorter immobilization periods. Rigid fixation near tooth buds and the condylar growth center should be avoided.

Condylar Fractures

Condylar fractures are the most common mandibular fracture site in children, and conservative treatment is the standard. This involves brief MMF (7-10 days) or no MMF at all with immediate gentle mobilization, guiding elastics to correct the occlusion, a soft diet for 3-4 weeks, and physiotherapy with jaw exercises to maintain range of motion. The rationale for the conservative approach is the excellent remodeling potential (younger children remodel better), the risk that ORIF poses to the growth center, and the fact that functional remodeling of the condyle produces adequate joint function in most cases. ORIF is rarely indicated, considered only for complete dislocation into the middle cranial fossa or extracapsular displacement preventing function. Long-term monitoring with serial clinical and radiographic assessment for 2-5 years is essential, as there is risk of facial asymmetry, ankylosis, and growth restriction. Outcomes are worse with intracapsular fractures in very young children.

Symphysis/Body Fractures

Greenstick fractures are managed with observation and a soft diet. Displaced fractures are treated with closed reduction and MMF using acrylic splints and circummandibular wires when teeth are insufficient for arch bars. MMF duration is 2-3 weeks, which is faster healing than in adults. ORIF is used if closed reduction fails, employing resorbable plates and screws to avoid hardware near tooth buds. Monocortical screws are placed at the inferior border below the tooth buds.

Angle/Ramus Fractures

These are usually nondisplaced or minimally displaced (protected by musculature). Nondisplaced fractures are managed with a soft diet and observation. Displaced fractures require MMF for 2-3 weeks.

Midface Fractures

Le Fort Fractures

Le Fort fractures are rare in children under 12 years because sinuses are not yet developed. They increase in frequency with age as sinus pneumatization progresses and are managed similarly to adults when they occur. Le Fort I is the most common pediatric midface fracture pattern.

ZMC Fractures

ZMC fractures are less common in young children. They are managed conservatively if nondisplaced and with ORIF if displaced with functional or aesthetic deformity.

Orbital Fractures

Trapdoor Fracture (White-Eyed Blowout)

The trapdoor fracture is unique to the pediatric population. Elastic pediatric bone fractures and springs back, trapping orbital tissue (inferior rectus muscle or surrounding connective tissue). Clinical presentation includes minimal periorbital ecchymosis or edema (the "white eye"), severe restriction of upgaze, nausea, vomiting, and bradycardia (oculocardiac reflex), and pain with attempted eye movement. CT findings are often subtle, and the "missing muscle" sign or soft tissue tethered at the fracture edge should be sought. This requires urgent surgical repair within 24-48 hours, as delayed repair leads to ischemic necrosis of entrapped muscle causing permanent diplopia. Resorbable implants are preferred for children.

Frontal/Frontal Sinus Fractures

These are rare in young children because the sinus is not developed. Frontal bone fractures are cranial injuries managed by neurosurgery. Frontal sinus fractures in older adolescents are managed as in adults.

Dentoalveolar Fractures

Dentoalveolar fractures are common in children. Preservation of developing tooth buds is the priority. Avulsed or luxated teeth are splinted, and alveolar fractures are reduced and splinted for 4 weeks. Follow-up monitors pulp vitality and root development.

<image>CT images demonstrating common pediatric facial fracture patterns: a mandibular condylar fracture showing the displaced condylar head in a 7-year-old, a trapdoor orbital floor fracture with entrapped inferior rectus muscle in a 10-year-old (the "missing muscle" sign), and an alveolar fracture involving the developing permanent dentition in a 9-year-old</image>

Fixation Considerations in Children

Resorbable Plates and Screws

Resorbable fixation is preferred over titanium for pediatric ORIF. Materials include poly-L-lactic acid (PLLA), polyglycolic acid (PGA), and copolymers. Advantages include avoiding permanent hardware in a growing skeleton (titanium plates may restrict growth, migrate, or become palpable), no need for secondary removal, and no interference with future imaging. Disadvantages include lower mechanical strength (though adequate for pediatric forces), longer screw insertion time (may require tapping and heating), and rare inflammatory reaction during resorption. Resorption time is 12-24 months depending on material.

Titanium Plates

Titanium plates are used when greater rigidity is needed. Removal after healing (4-6 months) should be considered if plates are at or near growth centers. There is risk of translocation (migration of screws or plates as bone grows around them).

MMF Techniques in Children

Arch bars are difficult in mixed dentition, as primary teeth may not provide adequate retention. Circummandibular wires with acrylic splints are used for deciduous or mixed dentition. IMF screws are not recommended near tooth buds. Bonded orthodontic brackets can be used for elastic traction. Duration is shorter than in adults (2-3 weeks for body fractures, 7-10 days for the condyle).

Growth Disturbance

Risk Factors

Risk factors include younger age at injury, condylar fracture (especially intracapsular), bilateral injuries, severe displacement, and infection complicating the fracture.

Sequelae

Mandibular asymmetry with chin deviation to the affected side results from unilateral condylar growth disturbance. Micrognathia and retrognathia result from bilateral condylar growth disturbance. TMJ ankylosis is the most devastating complication and requires aggressive surgical management. Dental development abnormalities result from damage to tooth buds during injury or surgery. Open bite occurs from condylar shortening.

Monitoring and Management

Serial clinical examination and radiographs for 2-5 years post-injury are essential. Orthodontic intervention is provided as needed during growth. Distraction osteogenesis addresses significant mandibular growth restriction. Orthognathic surgery at skeletal maturity corrects residual deformity.

Clinical Pearls

Conservative management is the mantra in pediatric facial fractures because the remodeling potential of children is remarkable. Condylar fractures in children should almost always be treated conservatively, as ORIF of the pediatric condyle risks damage to the growth center and has not been shown to improve outcomes over closed treatment. The white-eyed blowout fracture is a pediatric emergency -- the minimal external signs belie the severity of the entrapment, and surgical repair within 24-48 hours prevents permanent muscle damage. Non-accidental trauma should always be suspected in unexplained facial fractures in young children, with findings documented and social services involved. Resorbable fixation should be used when ORIF is necessary because titanium hardware in a growing skeleton can cause complications. MMF in children is technically challenging, and creative solutions (splints, bonded brackets) may be needed when teeth are inadequate for arch bars. Long-term follow-up is essential because growth disturbances may not become apparent for years after the initial injury. Families must be educated about the importance of monitoring -- parents need to understand that fracture healing does not mean the case is closed, and growth must be tracked.

<image>Serial panoramic radiographs of a child who sustained a right condylar fracture at age 6, showing the initial fracture, condylar remodeling at 1 year, and the development of mild mandibular asymmetry with chin deviation to the right at age 12, illustrating the importance of long-term follow-up for growth disturbance</image>

References

• Koltai PJ, et al. The natural history of midface fractures in children. Ann Plast Surg. 1995.
• Smartt JM Jr, et al. Patterns of facial fractures in children. Plast Reconstr Surg. 2005.
• Zimmermann CE, et al. Pediatric facial fractures: recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg. 2005.
• Goth S, et al. Management of pediatric mandible fractures. J Craniofac Surg. 2012.
• Imahara SD, et al. Patterns and outcomes of pediatric facial fractures in the United States. J Pediatr Surg. 2008.
• Eppley BL. Use of resorbable fixation in pediatric craniofacial surgery. J Craniofac Surg. 2003.

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