C r a n i o f a c i a l Grow t h an d

Development
A Primer for the Facial Trauma Surgeon
Raquel Capote, DMD, MSD, MPHa,b,*, Kathryn Preston, DDS, MSc,d,
Hitesh Kapadia, DDS, PhDe,f,g

KEYWORDS
 Craniofacial  Maxillofacial  Craniomaxillofacial  Facial  Pediatric  Growth and development
 Trauma  Fractures

KEY POINTS
 The craniofacial complex follows a cephalocaudal gradient of development. The skeleton grows
differentially with different regions reaching adult dimensions at different times.
 Trauma to growth centers and growth sites during childhood can disrupt normal development. In-
traoperative soft tissue damage, periosteal stripping, scar formation, and rigid fixation may also
affect facial growth.
 The cranial vault after age 5 years and the orbit after age 7 years are generally of adult size and
definitive reconstruction may be achieved. The maxilla, mandible, and nose do not achieve their
adult dimensions until the adolescent pubertal growth spurt.
 Surgical treatment before skeletal maturity is less predictable and may require reoperation following
skeletal maturation.
 It is critical to educate the patient/family on the potential for growth disturbances with long-term
follow-up recommended until growth is completed.

INTRODUCTION brain and teeth contribute to the development of

structures and creation of spaces supporting multi-
The craniofacial complex comprises the neurocra- ple functions.
nium, face, and oral apparatus, representing a The process of craniofacial growth is controlled
morphologic and multifunctional region funda- by genetics, influenced by environmental factors.3
mental to being human. Structures develop through Trauma can lead to dysmorphology as a result of
a dynamic process that begins in utero and reply the disruptive injury, secondary to the treatment,
upon complex temporally and spatially coordinated and/or subsequent growth and development.4
tissue interactions.1 Craniofacial growth is charac- The pediatric craniofacial complex exhibits
terized by cephalocaudal and allometric patterns.2 distinct anatomic and physiologic differences
Growth of tissues such as bone, cartilage, and mus- compared to adults. It is important to identify not
cle as well as highly specialized organs such as the only the most appropriate intervention but the
oralmaxsurgery.theclinics.com

a
Department of Oral and Maxillofacial Surgery, Vanderbilt University Medical Center, Nashville, TN, USA;
b
Cleft and Craniofacial Program, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA;
c
Center for Cleft and Craniofacial Care, Phoenix Children’s Hospital, Phoenix, AZ, USA; d Department of Or-
thodontics, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ, USA; e Craniofacial Cen-
ter, Seattle Children’s Hospital, Seattle, WA, USA; f Division of Plastic Surgery, Department of Surgery,
University of Washington, Seattle, WA, USA; g Department of Orthodontics, School of Dentistry, University
of Washington, Seattle, WA, USA
* Corresponding author. Department of Oral and Maxillofacial Surgery, Vanderbilt University Medical Center,
T-4323A Medical Center North, 1161 21st Avenue South Nashville, TN 37232-2596.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am - (2023) -–-

https://doi.org/10.1016/j.coms.2023.04.007
1042-3699/23/Ó 2023 Elsevier Inc. All rights reserved.
2 Capote et al

optimal time to surgically intervene for best Concept 3: Mechanisms of Bone Growth: Drift
outcome while minimizing detrimental impacts on and Displacement
subsequent growth. An understanding of craniofa-
There are 2 main mechanisms by which bone
cial growth and development is critical to the man-
growth occurs: (1) drift (surface remodeling)
agement of pediatric facial trauma.
through bone formation on one side and resorption
on the other that produce a change in the size and
CORE CONCEPTS OF NORMAL GROWTH AND shape of the bone and result in a change in loca-
DEVELOPMENT tion in the direction of external bony deposition;
Concept 1: Growth Pattern (2) displacement (translation) is the movement of
Craniofacial growth is expressed as a patterned the whole bone as a unit to a new location caused
series of changes in size, shape, and location.5 by the growth of adjacent structures. The overall
At birth, the head is large in relation to the rest of direction of growth is the cumulative effect of
the body and the cranium is disproportionately displacement and drift19 (Fig. 3).
large relative to the face, following a cephalocau-
dal growth gradient and reflecting the dominance Concept 4: Growth Centers versus Growth
of brain development.1 The newborn skull is given Sites
over to the neurocranium. The eyes, outgrowths of
the forebrain, are relatively large. The midface and Fundamental to the understanding of craniofacial
lower third of the face are diminutive and take a growth is an appreciation of growth centers and
more retruded position (Fig. 1). With growth and growth sites.20,21 Areas of the growing skeleton
development, the face “catches up” to cranial that are primarily under the control of heredity
development, increasing susceptibility to midface are referred to as growth centers. Growth centers
and mandibular trauma. exhibit intrinsic, independent growth potential and
active tissue separating force. Examples are syn-
chondroses uniting endochondral bones in the
Concept 2: Differential Development and
cranial base and the nasal septal cartilage.
Maturation
In contrast, a growth site is an area of skeletal
The complexity and diversity of the skull arises growth that occurs secondarily and grows in
because the constituent bones enlarge differen- compensatory fashion due to growth in a proxi-
tially.1 Facial growth occurs in 3 planes with the mate location. Growth sites exhibit passive
transverse dimension completed first, followed filling-in and/or remodeling in response to extrinsic
by completion of horizontal growth, and finally by forces or functional demands imposed by adja-
vertical facial growth that continues into adult- cent structures. This concept falls closely in line
hood.6–9 The facial region demonstrates variation with the functional matrix theory. The brain, eye,
in growth rates during development (Table 110–18 and tooth may be considered the functional matrix
and Fig. 2). In particular, the mandible exhibits of the cranial vault, orbits, and alveolus, respec-
rapid growth around puberty. Surgical treatment tively. The sutures connecting intramembranous
performed before skeletal maturity is less predict- bones found in the cranial vault and face and the
able and may require reoperation following skel- periosteum are growth sites. It has been previously
etal maturation.14 believed that the mandibular condyle is a primary

Fig. 1. Comparison between neonate and adult skull.

 Craniofacial Growth and Development 3

Table 1
Average percentage growth completion of various craniofacial structures

Average % of Growth Average % of Growth

Completed by Age 1 Completed by Age 5 Average Age at Maturity in Years
Cranial vault 84–88 93–96 Males: 14–15
Female: 13–14
Orbits 77–86 87–93 Males/females: 7 variable
Zygoma 72–74 83–86 Males: 15
Female: 13
Maxilla 75–80 85 Males: 16
Female: 14
Mandible 60–70 74–85 Males: 18–20
Female: 14–16
Data from Refs10–18.

growth center although now the condyle is not displacement of the face. The maxilla articulates
credited as the sole determinate of mandibular with the anterior cranial base and the mandible ar-
growth potential. It is considered a growth site ticulates with the temporal bone. Growth at the SES
that is necessary for mandibular development displaces the facial skeleton forward relative to the
and is influenced by intrinsic and extrinsic braincase. As the SES grows and elongates the
factors.22 anterior cranial base, the cranial vault expands
and the ethmoid, zygomatic and palatine bones
NEUROCRANIUM elongate, thereby increasing the size of the orbits
and midface. As the SOS grows and elongates
The neurocranium is the part of the skull that en- the middle cranial fossa, it displaces the glenoid
closes the brain and includes the cranial base fossa in the temporal bone posteriorly and inferi-
and cranial vault. orly24,25 while moving the face forward away from
the vertebral column. This deepens the naso-
Cranial Base
pharynx, creating more space for airway, muscles
The cranial base forms the inferior aspect of the of mastication and room for growth of the
cranium and provides a platform from which the ascending ramus of the mandible.
face grows.1 At birth, the cranial base is short and The greatest rate of increase in cranial base
the spheno-ethmoidal synchondrosis (SES) and length and decrease in cranial base angulation oc-
the spheno-occipital synchondrosis (SOS) are pat- curs during the first 2 to 3 postnatal years.26 The
ent (Fig. 4). Bidirectional growth occurs interstitially anterior cranial base is closer to its adult size
at the cartilaginous joints located between 2 bones than the posterior cranial base throughout post-
of endochondral origin23 (Fig. 5). The SES and SOS natal growth. The SES fuses at about 7 years of
are growth centers and are major contributors to age whereas the SOS continues to grow through
anteroposterior growth of the cranial base and adolescence. The SOS is the last synchondroses

Fig. 2. Growth of the cranial vault, maxilla, and mandible from infancy to skeletal maturity. The cranial vault rea-
ches maturity well before the midface and is followed by the mandible.
4 Capote et al

Fig. 3. Mechanisms of bone growth: drift and displacement. (A) Drift (surface remodeling). (B) Drift and displace-
ment can occur in the same direction or in opposite directions as illustrated. (From Enlow D, Hans M. Essentials of
facial growth. W. B. Saunders; 1996. (Figure 3B).)

of the cranial base to fuse with closure time occur- doubling in volume in the first 6 months and again
ring in girls at approximately 13 to 15 years of age by the second birthday.28 The sutures normally
and in boys around 15 to 17 years of age.27 Once remain patent and actively growing to keep pace
growth in the synchondroses ceases, the cartilage as the brain expands. By age 5 years, the cranium
is replaced by bone to form synostoses. is 90% of adult size.15 After age 7 years, bony
apposition on the outer surface of the frontal
bone and development of the frontal sinus drifts
Cranial Vault
the frontal bone and root of nose anteriorly.23
The calvaria or cranial vault, together with the cra- The frontal sinuses that are absent at birth begin
nial base, encase and protect the brain. Like the to develop at age 2 years, are radiographically
cranial base, the most rapid postnatal expansion detectable around age 6 to 7 years, and reach their
of the calvaria is during the first 2 years after full size after puberty.29
birth.23 However, unlike the cranial base, cranial At birth, bones of the vault are thin, malleable,
sutures connecting the intramembranous bones and unilaminar. As displacement of the individual
of the calvaria are growth sites.20 flat bones of the cranial vault takes place, compen-
The cranial vault is composed of paired frontal satory bone growth occurs at the sutures and by
and parietal bones, the squamous parts of the surface remodeling of the outer and inner cortex
temporal bone, and interparietal part of occipital of the skull. An intervening diploë layer of spongy
bone that are separated by unossified sutures of cancellous bone appears around age 4 years. By
fibrous connective tissues (Fig. 6). The cranial adulthood, the calvarial bones are thicker, rigid,
vault enlarges primarily as a result of compensa- and trilaminar. The calvaria bones remain sepa-
tory growth at the sutural bone fronts stimulated rated by thin, periosteum-lined sutures for many
by expansile growth of the neural elements. years, eventually fusing in adult life.30
Growth proceeds rapidly during the first
24 months after birth, secondary to the brain FACE
The face incorporates different anatomic and func-
tional spaces and is composed of numerous indi-
vidual bones, several of which are paired and
most developing intramembranously. The anat-
omy of the face is divided into 3 main regions: up-
per, middle (midface), and lower (mandible).

Upper Face
The upper face contains the forehead, eyes, and
temporal region. The orbit is composed of bones
from the cranium (frontal, sphenoid, ethmoid,
lacrimal) and nasomaxillary complex (maxillary,
Fig. 4. Synchondroses. zygomatic, and palatine bones). The sutures
 Craniofacial Growth and Development 5

Fig. 5. Schematic drawing of a mid-

sagittal view of the cranial base showing
the spheno-occipital synchondrosis. Dia-
grammatic representation of the spheno-
occipital synchondrosis. The spheno-
ethmoidal synchondrosis, not shown, and
the spheno-occipital synchondrosis exhibit
a “bidirectional” pattern of growth. In
other words, both bones at the joint in-
crease in size as growth proceeds. (From
Enlow D, Hans M. Essentials of facial
growth. W. B. Saunders; 1996.)

between the bones of the eye are growth sites by the nasal septum.23 The nasal septum consists
and, in a similar fashion to the cranial sutures of the perpendicular plate of the ethmoid bone,
and other facial sutures, are important sites of septal cartilage, and vomer.33 The nasal septum
compensatory growth. cartilage is continuous with the perpendicular
The orbits expand primarily in response to the plate of the ethmoid bone in the anterior cranial
rapidly developing eyeballs. This is greatest be- fossa at its caudal end and is firmly attached to
tween birth and 2 years of age and contributes to the anterior nasal spine of the premaxilla through
anterior and lateral displacement of the midface. the septospinal ligament. The nasal septum carti-
The orbits complete approximately half of post- lage is a growth center affecting vertical and
natal growth by age 2 years.18,31 Adult dimensions sagittal growth of the nose and maxilla.33–35 The
are nearly attained by 7 years of age,18 after which majority of nasal growth occurs in 2 growth spurts,
the rate slows considerably until maturity.32 There between 2 to 5 years of age and again at pu-
is inferior and lateral expansion in this region sec- berty.35,36 Growth is usually completed by age
ondary to changes in the anterior cranial fossa and 16 to 18 years in girls and 18 to 20 years in boys,
maxilla associated with midface displacement. although additional growth of the nasal septum
The intercanthal width reaches full maturation at may continue thereafter.
age 8 years in females and 11 years in males and The maxilla moves downward and forward rela-
the biocular width at 13 years in females and tive to the cranial base, accompanied by the orbits
15 years in males.11 Bony apposition on the orbital and nasal cavity, with each of these structures
floor offsets the anteroinferior displacement of the increasing in volume as they grow.1 The zygomatic
whole maxilla and contributes to midface height.23 arches also grow laterally and are relocated in a
posterior direction within the face. The
Midface/Nasomaxillary Complex zygomatic-arch length is 83% of adult length at
5 years of age. By 5 years of age, the bizygomatic
The midface is connected to the neurocranium by width is 86% and the midfacial width is 89% of
a circummaxillary suture system and the midline adult width.15 The zygomatic bones provide mid-
face width, cheek definition, and shape/definition
to the lateral and inferior orbital borders.
The maxilla grows by (1) bony apposition at the
circummaxillary and intermaxillary sutures
compensatory to midfacial displacement and (2)
surface remodeling (drift). Growth at the cranial
base and nasal septum results in downward and
forward displacement of the nasomaxillary com-
plex followed by bony apposition at the circum-
maxillary and intermaxillary sutures13,23 (Fig. 7).
The facial aspect of the premaxillary–maxillary su-
ture is partially ossified at birth, whereas the
palatal region tends to close by age 6 years,
although variability of complete suture obliteration
with age has been reported.37–39 An increase in
Fig. 6. Diagram of the calvarial sutural complex.
maxillary width is achieved predominantly through
Notice that peripheral sutures coalesce as they course growth of the midpalatal suture, with a smaller
inferiorly and medially, ending in the spheno-occipital contribution from external remodeling. The midpa-
synchondrosis. latal maxillary suture has been reported to close
6 Capote et al

Fig. 7. Maxillary growth. The whole maxillary region is displaced downward and forward away from the cranium.
This then triggers new bone growth at the various sutural contact surfaces between the nasomaxillary complex
and the cranial floor. (From Enlow D, Hans M. Essentials of facial growth. W. B. Saunders; 1996.)

between 15 and 19 years of age.40 Sagittal growth Although all aspects of the mandible increase sub-
of the maxilla continues until about 14 years of age stantially in size, the paramount posterior-superior
in females and 16 years of age in males.19 growth vector of the mandible is achieved through
A complex pattern of bone resorption and depo- the combined processes of endochondral ossifi-
sition occurs over the surface of the maxilla as it is cation at the condyle and surface remodeling at
displaced downward and forward within the face. the ascending ramus.13
Bone is deposited in the maxillary tuberosity re- The cartilage of the mandibular condyle pro-
gion, contributing to an increase in length of the vides movable articulation, endochondral bone
entire maxilla and creation of additional space for growth, and regional adaptive growth. Its respon-
the developing dentition. Concomitantly, almost siveness to mechanical, functional, and hormonal
the entire anterior surface of the maxilla is an stimuli set it apart from primary cartilaginous
area of resorption. Growth and development of growth centers.21,23 Therefore, the secondary
the maxilla parallels growth and pneumatization cartilage of the condyle is more consistent with
of the maxillary sinus.41 Midfacial height increases the concept of an adaptive, compensatory growth
due to the combined effects of inferior cortical drift site.42
and inferior displacement. The inferior translation The mandible increases in size by a combination
of the maxilla is associated with bone resorption of 3 growth processes: endochondral bone growth
at the nasal floor (increasing the nasal cavity) and at the condyle; surface remodeling throughout,
bony deposition along the hard palate.6 The height particularly on the posterior ramus; and dental
of the midface is further increased by continued
development of the dentition and alveolar bone.
Vertical facial growth is the last dimension to be
completed and continues into adulthood.

Mandible
The lower third of the face is composed of a single
bone in the adult, the mandible. The mandible
functions as a lever and a link for muscles involved
in mastication, speech, and other oral functions. At
birth, the right and left hemimandibles have not yet
fused, the chin is rudimentary and retrusive, the
gonial angle is obtuse, the ramus is short, both in
absolute terms and in proportion to the corpus,
and there is no appreciable alveolar bone. The
Fig. 8. Mandibular growth: biologically correct super-
developing primary teeth are discernible in their
imposition of the mandible registered on the inner ta-
crypts on radiographs.
ble on the mandibular symphysis. The condyle and
The mandible articulates at each glenoid fossa ramus elongate in a posterior and superior direction
of the temporal bone in the middle cranial fossa.13 while the body of the mandible lengthens. There is lit-
As the whole mandible is displaced downward and tle growth of the chin in the development of the
forward relative to the cranial base, the condyle mandible. (Adapted from Enlow D, Hans M. Essentials
and ramus grow upward and backward (Fig. 8). of facial growth. W. B. Saunders; 1996.)
 Craniofacial Growth and Development 7

eruption with development of alveolar bone.13,43 maintaining alveolar bone depends on the pres-
Significant postnatal development is attributed to ence of teeth. Prior to the eruption of the decidu-
differential formation and modeling of bone along ous teeth, there is no appreciable alveolar bone.
nearly the entire surface of the mandible, particu- As the teeth erupt into functional occlusion, the
larly along its superior and posterior aspects. The alveolus proliferates in response to migration of
increase in ramus height and anteroposterior the periodontal ligament. When a tooth is
depth is achieved through resorption on the ante- extracted, the alveolus at that site resorbs. If a
rior surface of the ramus and greater deposition tooth is surgically transposed or moved orthodon-
along the posterior surface of the ramus. At the tically into that site in the arch, alveolar bone will
same time, the corpus increases in length, proliferate. In sum, the tooth is the functional ma-
providing the necessary space for development trix of the alveolus. Ankylosis arrests both dental
and eruption of the mandibular dentition. Associ- eruption and alveolar bone formation in the
ated with these changes in the absolute and rela- affected area. Likewise, when a tooth is congeni-
tive sizes of the mandible are decreases in the tally absent, the alveolar bone in that segment of
gonial angle between the ramus and corpus.23 the dental arch does not form (unless an adjacent
The mandibular width increases by bony apposi- tooth migrates into that space).
tion along the buccal outer surface of the corpus Appositional bone growth of the alveolar pro-
and ramus and, to a lesser extent, resorption of cess occurs rapidly during the first 2 to 3 years
bone occurs along the lingual, inner surfaces. to accommodate the deciduous teeth.45 Dental
Expansion of the mandible in the posterior direc- arch width and perimeter change dramatically,
tion via bone deposition along the posterior border especially during the transitions to the early mixed
of the ramus results in a longer and wider and permanent dentitions.46 The teeth continue to
mandible. migrate and erupt throughout childhood and
At 7 years of age, bigonial width in males is 85% adolescence, even after they have attained func-
of adult width and in females 88% of adult width.44 tional occlusion.23 Teeth normally continue to
Growth in length and height of the mandible con- erupt and form alveolar bone in synchrony with
tinues through the period of puberty. Height of the vertical growth. The posteruptive movements of
mandibular corpus depends in large part on growth teeth are directly related to the spaces created
of the alveolar bone. The mandible typically reaches by growth displacements and movements of other
adult size between 14 and 16 years in females and teeth. The dentoalveolar compensation mecha-
between 18 and 20 years in males.16,17,19 nism attempts to maintain a normal interarch
occlusal relationship in the presence of variation
ORAL APPARATUS in skeletal pattern.47 Unlike teeth, dental implants
are not capable of compensatory eruption or other
The oral apparatus is composed of the dentition physiologic movements.48
and the supporting structures within the maxilla
and mandible. It is greatly influenced by the soft
tissues such as the tongue and muscles of
CLINICAL IMPLICATIONS
mastication.23
Anatomic and Physiologic Differences in the
Pediatric Skeleton
Teeth Many age-related trends in pediatric facial trauma
are explained by growth and development of the
The deciduous and permanent teeth are special-
craniofacial skeleton. Soft-tissue injuries such as
ized organs of epithelial-mesenchymal origin. Nor-
soft tissue avulsion, lacerations, and contusions49
mally, a complete set of primary teeth (20) have
are more common than fractures in children, espe-
erupted by 2.5 to 3 years of age. The mixed denti-
cially in younger children where the bones have a
tion stage is heralded by eruption of the first perma-
greater tendency to bend rather than break. Addi-
nent molars around 6 to 7 years of age. During the
tionally, the facial nerve is in a more superficial po-
mixed dentition, both primary and permanent teeth
sition in the infant and young child, leading to
are present. The mixed dentition stage is complete
greater chance of nerve damage in lateral facial
following the exfoliation of the last primary tooth. All
soft-tissue injuries.50
permanent teeth except third molars (28 total in
A significant force of impact must be endured for
number) erupt by 12 to 13 years of age.
the elastic pediatric craniofacial bones to fracture.51
The pediatric facial skeleton has increased cancel-
Alveolar Bone
lous bone stock, larger buccal fat pads, decreased
Alveolar bone anchors the teeth and absorbs pneumatization of sinuses, buttressing unerupted
the stresses of mastication. Developing and teeth, and compliant sutures. These anatomic
8 Capote et al

features allow the facial skeleton to absorb energy Classical Le Fort midface fractures are rare in
without fracturing and when fracture does occur, young children due to the presence of prominent
it more likely results in a greenstick or nondisplaced buccal fat pads, immature sinus development,
fracture49,51,52 (Table 2). and buffering unerupted tooth buds.52,60 Maxillary
The changing anatomy and physiology of a child sinus expansion coincides with dental eruption
affects facial fractures considerably. The ratio of during the mixed dentition, ages 6 to 12 years,
cranium-to-facial skeleton, development of the and achieves full dimensions by puberty.53 After
paranasal sinuses, and stage of dentition all influ- age 6 years, maxillary fractures occur more
ence the incidence and fracture patterns frequently but the elasticity of the bone and mixed
observed. In addition, compared to adults, chil- dentition may limit displacement. At age 12 years,
dren exhibit greater osteogenic potential, faster which coincides with the permanent dentition and
healing rate, and capacity for significant dental further expansion of the maxillary sinus, Le Fort
compensation.53 midface type fractures become more common.61
Similarly, zygomaticomaxillary complex fractures
parallel the pneumatization of the maxillary sinus.
Fracture Patterns and Locations
Midface fractures typically result from high en-
There is a higher incidence of cranial injuries in ergy impacts such as motor vehicle collisions
young children (less than 5 years of age) due to and when present in young children, they are rarely
the large cranium-to-face ratio. In young children, isolated. There is a high incidence of associated
a prominent forehead “protects” the later maturing neurocranial injuries because the force required
lower face from trauma. The forehead during this to cause the maxillary fracture is sufficient to be
period, therefore, is more exposed and prone to transmitted to the cranial cavity.62
injury. Because of the lack of pneumatization of Likewise, nasal orbital ethmoid fractures (NOE)
the frontal sinus before age 7 years, orbital roof typically require high impact forces to the central
fractures are more likely to occur.54 In childhood, nasal region. NOE fractures are rare compared to
orbital roof injuries are considered fractures of isolated nasal fractures,63,64 which require less
the skull base. As such, intracranial injuries are force to produce.65 Nasal fractures are one of
frequently coincident.51,54,55 Meanwhile, fractures the most common pediatric facial fractures. As
of the orbital floor are relatively rare in children the nasal framework is more cartilaginous than
younger than 5 years. After age 7 years, there is bony, fractures of the cartilaginous septum are
an increased incidence in orbital floor fractures often found in children, whereas fractures of the
that coincides with growth of the maxilla and bony nasal pyramid do not occur as frequently.
maxillary sinus pneumatization.56–58 Children with Septal cartilage in children tends to buckle during
orbital floor fractures are prone to entrapment59 trauma, making septal hematoma formation a
due to the elasticity of the pediatric orbital bone more common finding than in adults.36,66 Expan-
and potential for greenstick fracture. sion of the hematoma separates the cartilage
Whereas cranio-orbital injuries are seen more in from the mucoperichondrium, obstructing blood
the very young, midface and lower face injuries flow to the nasal cartilage and causing pressure
occur more frequently in the older and adolescent induced avascular necrosis of the nasal cartilage
child. As the child grows, the forward and down- if left untreated.
ward projection of the face increases the inci- The mandibular condyle is also a common site
dence of midface and mandibular fractures. of fracture. Children younger than 5 years of age

Table 2
Summary overview of differences within the pediatric population

Infant/Child Young Adolescent Older Adolescent

Greenstick fracture Fracture pattern variable Fracture pattern may be adult-
like
Small or absent sinuses Developing sinuses Mature sinuses
Developing tooth buds and Late mixed dentition/ Permanent dentition
challenging interdental permanent dentition
fixation
Bony healing occurs quickly High energy trauma more
frequent
 Craniofacial Growth and Development 9

are more likely to sustain intracapsular fractures of the orbit until skeletal maturity.72,73 The cranium
and condylar neck fractures.67 With increasing and orbits are about 90% of adult size by age 5 to
age, there is a shift toward subcondylar fractures 7 years. To avoid or minimize growth impedance,
and in adolescence angle and body fractures are when possible, reconstructions are performed
more common.36,67,68 when growth is nearly complete.

Growth Disturbance and Other Sequela

Nasomaxillary Complex Fractures
Trauma to growth centers (synchondroses, nasal
Nasoseptal and midface trauma in children can
septal cartilage), interruption of growth sites (su-
result in progressive deformity of the nose and
tures, periosteal absorption-resorption pro-
midface with both functional and esthetic conse-
cesses), damage to the mandibular condyle, and
quences.36,74 It has been suggested that the
scar formation can disrupt normal facial growth
younger the child at the time of nasal septum
and development. In addition, intraoperative soft
destruction, the greater the long-term effects on
tissue damage, periosteal stripping, and rigid fixa-
midfacial growth.74 Thus, “in the pediatric popula-
tion may affect the growing skeleton and devel-
tion, aggressive open septorhinoplasties are typi-
oping dentition.16,69 Interdental fixation is
cally avoided until skeletal maturity, and early
challenging in the mixed dentition.53 Metal fixation
closed reductions are recommended.”67 Nonethe-
systems carry real risk of injury to unerupted per-
less, long-term follow-up studies of pediatric nasal
manent tooth follicles and theoretical complica-
fractures treated with closed reduction have re-
tions such as growth restriction (i.e., plate across
ported that over half the patients have deformity
suture lines). Bioresorbable plates and screws
of the external nose including bony and cartilage
have been proposed as an alternative.60 When in-
deviations, saddling, dorsum widening, and
ternal bony fixation is necessary in younger pa-
hump.65,75,76 Grymer and colleagues75 pointed
tients, monocortical screws should be used and
out that 70% of the patients with nasal deformities
the hardware placed to avoid developing tooth
at the time of their study had reported satisfactory
buds.52
results following the initial treatment by closed
Generally, 3 main areas of growth may be
reduction indicating that improvements dimin-
affected: the orbital region, the nasomaxillary
ished with future nasal growth. Secondary correc-
complex, and the condyle.70 Dysmorphology
tions may still be needed at skeletal maturity.67
may result from the initial trauma, the intervention,
Severe midface fractures, both treated and un-
or a combination of both, during the growth years.
treated, have been shown to produce very high
Whether a growing child is initially managed non-
incidence of subsequent deformities.67,77–79
operatively or operatively, the patient and family
These include maxillary hypoplasia, facial asym-
should be made aware of the potential for aberrant
metry, nasal airway obstruction, and malocclu-
growth resulting in asymmetries and occlusal dis-
sion.77–82 Complications are most pronounced in
crepancies which may not become evident until
patients who sustained multiple facial fractures
adolescence.53 Long-term follow-up is essential.
likely because of both injury burden and extensive
surgery required for reconstruction.
Orbital Fractures
Orbital roof fractures can be associated with dural
Mandibular Condylar Fractures
disruption.67 A very rare, delayed complication is a
growing skull fracture that occurs secondary to a Condylar fractures can result in retrognathia, facial
tear in the dura mater that coexists with the frac- asymmetry, mandibular midline deviation to the
ture, allowing intracranial content to herniate affected side, malocclusion, tooth loss or injury,
through it and widening of the skull defect. temporomandibular joint dysfunction and/or
Following surgical correction, some children degeneration, limited mouth opening, and bony
require a second operation to restore the axis of ankylosis.4,67,83–88 An opposing maxillary occlusal
the orbit or correct orbital asymmetry.67,71 cant may also be observed.89 Several studies have
Fractures of the orbital region in very young chil- reported less growth disturbances in young chil-
dren may also result in periorbital tissue atrophy dren less than 5 years of age due to high vascu-
and subsequent orbital volume loss. Because the larity and regenerative capacity.90–92 Demianczuk
development of the bony orbit is driven by the and colleagues93 showed the greatest risk for sig-
volumetric expansion of its intraorbital contents, nificant growth disturbances was in the 4 to 7 year
namely the eyeball, in children with traumatic or old and 8 to 11 year old groups, observing respec-
disease-related loss of an eye, an implanted tively that 24% and 16% of these children required
expander device may be used to sustain growth corrective orthognathic surgery.
10 Capote et al

Patients with condylar fractures, whether unilat- 8. Bjork A. Facial growth in man, studied with the aid of
eral or bilateral, may exhibit loss of posterior ramus metallic implants. Acta Odontol Scand 1955;13(1):
height secondary to telescoping of the condylar 9–34.
fragment(s). Because children demonstrate 9. Fields HW. Craniofacial growth from infancy through
remarkable bony remodeling, condylar fractures adulthood. Background and clinical implications.
are frequently treated with closed reduction with Pediatr Clin North Am. Oct 1991;38(5):1053–88.
a short period of maxillomandibular fixation as 10. Farkas LG, Posnick JC, Hreczko TM. Anthropo-
needed.83,87,91 Zhu and colleagues94 reported metric growth study of the head. Cleft Palate Cranio-
that in children aged 6 years and older, the fac J 1992;29(4):303–8.
condylar process remodeled incompletely. How- 11. Farkas LG, Posnick JC, Hreczko TM, et al. Growth
ever, the remodeling of the glenoid fossa and in- patterns in the orbital region: a morphometric study.
crease in ramus height compensated for the Cleft Palate Craniofac J 1992;29(4):315–8.
hypotrophy of the condylar process on the frac- 12. Farkas LG, Posnick JC, Hreczko TM. Growth pat-
tured side. As children age, the ability to remodel terns of the face: a morphometric study. Cleft Palate
and spontaneously heal is reduced. Mild maloc- Craniofac J 1992;29(4):308–15.
clusions from minimally displaced fractures have 13. Enlow D, Hans M. Essentials of facial growth. Phila-
the potential to resolve spontaneously with erup- delphia, PA: W. B. Saunders; 1996.
tion of permanent dentition and through bony 14. Costello BJ, Rivera RD, Shand J, et al. Growth and
remodeling that occurs with growth and func- development considerations for craniomaxillofacial
tion.67,69 Patients who sustain multiple fractures surgery. Oral Maxillofac Surg Clin North Am 2012;
of the mandible are significantly more likely to 24(3):377–96.
have an adverse outcome that those with isolated 15. Waitzman AA, Posnick JC, Armstrong DC, et al. Cranio-
mandibular fractures.86 The mandible is one of the facial skeletal measurements based on computed to-
last bones to reach skeletal maturity and as such is mography: Part II. Normal values and growth trends.
vulnerable to growth and functional perturbations Cleft Palate Craniofac J 1992;29(2):118–28.
after injury to the condyles. 16. Wheeler J, Phillips J. Pediatric facial fractures and
potential long-term growth disturbances. Cranio-
maxillofac Trauma Reconstr 2011;4(1):43–52.
CONFLICTS OF INTEREST 17. Bhatia SN, Leighton BC. A manual of facial growth: a
computer analysis of longitudinal cephalometric
The authors do not have any conflict of interests,
growth data. Oxford: Oxford University Press; 1993.
financial or otherwise.
18. Berger AJ, Kahn D. Growth and development of the
orbit. Oral Maxillofac Surg Clin North Am 2012;24(4):
545–55.
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