Pediatric Panfacial

F r a c t u res
Sameer Shakir, MDa,*, Russell E. Ettinger, MDb,c, Srinivas M. Susarla, DMD, MD, MPHb,c,
Craig B. Birgfeld, MDb,c

KEYWORDS
 Panfacial trauma  Pediatric facial fracture  Craniofacial growth

KEY POINTS
 Pediatric craniomaxillofacial trauma differs from that of adults in terms of management, epidemi-
ology, injury pattern, and long-term growth.
 Although pediatric panfacial fractures are rare, they are associated with polytrauma that risks se-
vere morbidity and mortality and requires high-acuity multidisciplinary care.
 The surgical management of pediatric panfacial fractures is generally more conservative not only
due to inherently augmented healing and remodeling capacity but also due to concern over future
growth impairment.
 Undertreatment of displaced fractures in the pediatric population, however, may lead to deformities
in adulthood that are exceedingly challenging to treat secondarily.

INTRODUCTION deleterious effects on future growth and develop-

ment. In the largest reported series of pediatric pan-
Although rare, pediatric panfacial injuries pose sig- facial injuries, Dalena and colleagues reported an
nificant bony and soft tissue reconstructive chal- operative rate of 46% with most patients managed
lenges owing to anatomic differences and the nonoperatively to preserve osteogenic and growth
potential for future growth and development. Man- potential.4 Nevertheless, surgical indications for
son and colleagues defined panfacial fractures as fracture fixation relate to the presence of displaced
those involving the upper (frontal bone), middle fractures. Undertreatment of displaced pediatric
(midface), and lower (occlusal unit) facial thirds fractures often results in exceedingly challenging
(Fig. 1A).1 Contemporaneous definitions have end-stage deformities encountered at skeletal
broadened to include fractures of the midface maturity. Limited soft tissue dissection, autogenous
and mandible because reconstruction follows the bone grafting, and fixation using titanium or resorb-
same principles as those for a true panfacial frac- able devices are used to minimize the appearance
ture (see Fig. 3A).2–4 In pediatric patients, facial of premature aging while yielding appropriate
trauma often involves the soft tissue or dentoal- anatomical reduction and stable fixation.
veolar structures.5 The presence of multilevel Unlike the adult population, operative sequencing
injury is frequently indicative of a high-energy of pediatric panfacial fractures may favor a top–down
trauma with potential life-threatening conse- rather than bottom–up approach due to routine con-
quences that must be appropriately prioritized ac- servative management of critical growth centers
cording to Advanced Trauma Life Support (ATLS) including the mandibular condyle.4,6,7 Similar to the
protocols. adult population, dissection and fixation should
oralmaxsurgery.theclinics.com

Management of pediatric facial fractures is more extend from stable to unstable regions to appropri-
conservative than that of adults to minimize ately reestablish facial width, height, and projection.

a
Division of Plastic Surgery, Children’s Wisconsin, Milwaukee, WI, USA; b Department of Surgery, Division of
Plastic Surgery, University of Washington, 4800 Sand Point Way NE, M/S OB.9.520, Seattle, WA 98150, USA;
c
Craniofacial Center, Seattle Children’s Hospital, 4800 Sand Point Way NE, M/S OB.9.520, Seattle, WA
98150, USA
* Corresponding author. Plastic Surgery, 9000 West Wisconsin Avenue, Suite 340, Milwaukee, WI 53202.
E-mail address: [email protected]

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

https://doi.org/10.1016/j.coms.2023.04.006
1042-3699/23/Ó 2023 Elsevier Inc. All rights reserved.
2 Shakir et al

Fig. 1. (A) Three bony subunits of the face. Frontal bone and cranium (blue), midface (green), and mandible
(pink). The midface consists of the maxilla, zygoma, nasal, lacrimal, ethmoid, and palatine bones. (B) Horizontal
buttresses (gold). Supraorbital bar, infraorbital rims and zygomatic arch, lower maxillary and palate, upper
mandibular, and lower mandibular buttresses. (C) Vertical buttresses (purple). Posterior vertical mandibular, pter-
ygomaxillary, maxillary-zygomatic-frontal, and the medial maxillary naso-frontal buttresses. (From Massenburg
BB, Lang MS. Management of Panfacial Trauma: Sequencing and Pitfalls. Semin Plast Surg. 2021;35(4):292-298.
Published 2021 Sep 23.)

Pediatric Facial Anatomy and Fracture occurs throughout puberty. Underlying brain and
Patterns ocular signaling determines maturation of the up-
per face and orbits, with orbital growth typically
The various regions of the craniofacial skeleton
complete by 6 to 8 years. Maxillary sinus pneuma-
achieve skeletal maturity at different times, which
tization correlates with dental development, as the
correlates with the variable patterns of facial frac-
sinus reaches the nasal floor around 12 years
tures seen in growing children. Upper, middle, and
when most of the permanent dentition has erup-
lower facial growth occurs in a cranial to caudal di-
ted. The septal midface drives nasomaxillary
rection from infancy to adolescence. The cranial-
growth while the condylar growth center dictates
to-facial ratio begins at 8:1 at birth with prominent
posterior height. Alveolar development during
frontal projection and decreases to 2:1 at maturity,
eruption of the permanent dentition drives vertical
which accounts for the comparatively increased
maxillary growth.5 The mandibular symphysis
incidence of cranial vault fractures and severe
fused around 2 years, which coincides with the
head injury observed in the pediatric population.8
eruption of the primary dentition. Muscle activation
By 2 years of age, the neurocranium has achieved
signals vertical mandibular growth at the condyles,
75% of its growth. By 10 years of age, the neuro-
with bony surface remodeling continuing into pu-
cranium has achieved 95% of its growth potential,
berty.13 Enlow’s theory of apposition and resorp-
although facial growth lags behind at 65%.9 Unlike
tion (ie, bony deposition on one side followed by
cranial growth, which demonstrates continuous
resorption on the other) helps to explain maxillary
development, facial growth demonstrates discon-
and mandibular growth.14 Furthermore, Moss’s
tinuous growth until adolescence.9 Specifically,
“functional matrix” theory highlights the impor-
facial growth at 3 months approximates 40% of
tance of the periosteum as a major contributor to
its adult growth potential, 70% at 2 years, and
bone formation.10 Applying this conceptual frame-
80% at 5 years. The completion of facial growth
work to management, subperiosteal exposure of
subsequently occurs during the pubertal growth
fractures in pediatric patients should be limited
spurt.9 Consequently, facial fractures occurring
only to the extent required to visualize the fracture
during the periods of mixed dentition and the pu-
and apply fixation.
bertal growth spurt may lead to facial asymmetry,
With increasing age, pediatric facial fracture pat-
particularly if displaced and untreated.
terns shift in frequency from a cranial to caudal di-
Craniofacial growth centers include cartilage/
rection. Anatomic factors associated with this
synchondroses and sutures/periosteum.10–12
change include further development of the midface
With sinus aeration beginning around 4 to 5 years
and mandible and increased bone mineralization,
(as early as 2 years), maturation of the frontal sinus
 Pediatric Panfacial Fractures 3

which decreases bony elasticity after age 2 to 3-fold increase in intensive care length of stay, 2-
3 years.9 The lack of well-developed facial but- fold increase in total length of stay, increased
tresses results from unerupted dentition, ventilator requirement, and higher mortality rate
decreased paranasal sinus pneumatization, and (4.0 vs 2.5%).8
increased cancellous bone.9 Unlike the character-
istic LeFort fracture patterns observed in adults, CLINICAL EVALUATION
pediatric facial fractures typically present in oblique
orientations due to these distinct anatomic differ- The increased incidence of severe concomitant
ences.15,16 These obliquely oriented fractures injuries to the head and chest that typically accom-
extend across the prominent frontal bone, radiate pany pediatric bony trauma necessitates age-
into the anterior cranial base, and extend across appropriate ATLS protocols that prioritize the
the orbit into the maxilla while typically sparing primary survey and resuscitation while deferring
the mandible.9,15 management of potentially “distracting” craniofacial
injuries to the secondary survey.5,23 As head and
neck trauma accounts for more than 66% of child
Epidemiology of Pediatric Facial Fractures
abuse, nonaccidental trauma should be suspected
Although a detailed epidemiologic overview will be if there are inconsistences in the history, prolonged
discussed in another article, a brief review is crit- duration between injury and presentation, noncom-
ical to understand the complexities posed by pliance, and/or multiple presentations.24,25
multilevel pediatric facial trauma. In a review of Airway management may be challenging in the
the National Trauma Database, Imahara and col- context of inherently flaccid pharyngeal and ante-
leagues identified 277,008 pediatric trauma pa- rior laryngeal structures that may be concomitantly
tients with 4.6% sustaining facial fractures.8 The injured leading to hypoxia.5 Associated commi-
proportion of patients with facial fractures nuted mandible fractures may lead to tongue
increased with increasing age, suffered from unre- base collapse owing to decreased support of the
strained blunt trauma (eg, motor vehicle collision genioglossus and geniohyoid muscles anteri-
[MVC]), and was more likely to be men and Cauca- orly.3,26 Established mechanisms for airway con-
sian.8 Nasal and maxillary fractures were most trol including oral intubation, nasal intubation,
common in infants, whereas mandible fractures submental intubation, and tracheostomy.27 Oral
were most common among teenagers. A quarter intubation may affect appropriate reduction and
of patients underwent operative fracture fixation fixation of the occlusal unit unless there is the
during their initial hospitalization, with increasing absence of occlusion or absent teeth to allow for
age predicting operative management—unsur- posterior placement. Nasal intubation limits
prisingly, only 11% of toddlers aged 2 to 4 years comprehensive management of nasal and naso-
underwent operative management.8 orbito-ethmoid (NOE) fractures and may be
As described above, key anatomical differences contraindicated in the setting of skull base injury.
help to explain the overall decreased incidence of Submental intubation, which is less morbid than
pediatric facial fractures when compared with a tracheostomy, allows for the management of
adults. Craniofacial disproportion, underdevelop- complex midface fractures and restoration of the
ment of the paranasal sinuses, added bimaxillary occlusal unit but may be contraindicated in
strength from unerupted dentition, relative micro- comminuted mandible fractures that require a
gnathia, well-developed fat pads, compliant su- transcervical approach.28 Tracheostomy may ulti-
tures, and a viscoelastic skeleton are protective mately be indicated to secure a stable airway away
mechanisms unique to the pediatric popula- from extensive craniomaxillofacial injury, however,
tion.8,9,17–22 The finding of displaced facial frac- carries its own complication profile.27
tures in the pediatric patient consequently Arterial bleeding may be present from wounds
suggests a high-energy mechanism and the possi- involving the scalp, tongue, and/or nose. Large
bility of severe concomitant injuries outside of the scalp wounds may be temporarily controlled with
craniofacial skeleton. Based on the Abbreviated staples or tacking sutures while the nasal pas-
Injury Scale, patients with facial fractures demon- sages may be packed with intranasal gauze or Fo-
strated a 2-fold increase in their Injury Severity ley catheters to tamponade anterior nasal
Scores, when compared with patients without bleeding. Posterior midface bleeding may require
facial fractures.8 The prevalence of brain injury, prompt interventional embolotherapy.29 Hypoten-
skull base fracture, cervical spine fracture, and sion and hypothermia are inherent risks for the pe-
blunt cerebrovascular injury were considerably diatric polytrauma patient in the setting of
higher among patients found to have facial frac- increased cardiopulmonary compensation despite
tures.8 Moreover, the facial fracture cohort had a significant blood loss and increased body surface
4 Shakir et al

Fig. 2. (A) Traditional panfacial presentation. A 5-year-old boy involved in an all terrain vehicle (ATV) rollover pre-
senting with panfacial fractures. Secondary survey is notable for a large transverse full-thickness forehead lacer-
ation with open, comminuted fractures of the frontal bone. (B) Preoperative CT imaging. Underlying fractures
include comminuted, displaced frontal bone fractures, severely displaced right LeFort 1/2/3 fractures, mild-to-
moderately displaced left LeFort 2 fracture, and severely displaced right mandibular body fracture with malocclu-
sion. (C) Immediate postoperative fracture fixation. Through a top–down, outside–in approach, he underwent
ORIF of his bifrontal bone fractures using a resorbable plating system followed by titanium fixation of the right
zygoma and the bilateral NOE segments. Following established of midface width and projection, he underwent
upper titanium fixation of his right maxilla along the zygomaticomaxillary “buttress” to restore midfacial height
through an upper sulcus intraoral approach. Finally, he underwent titanium fixation of the right mandibular
body using monocortical fixation along the inferior border through an extraoral approach to control for lingual
splay. The remaining nondisplaced and mildly displaced fractures were allowed to heal and remodel.

area:volume ratio.5 As previously discussed, the down approach, for example, helps to ensure
increased risk for intracranial, ocular, and cervical identification the full catalog of facial injuries.
spine injuries highlights the importance of prompt
neurosurgical and ophthalmologic evaluation to
preserve brain, vision, and hearing function. In in- Sequencing
fants and toddlers, the cervical spine should be Unlike the adult population where fracture fixation
carefully supported despite radiographic clear- may be delayed within 7 to 14 days of injury in the
ance given their increased cranial-to-facial ratios setting of prohibitive localized edema, malunion
and increased cartilaginous component of the may develop within 3 to 4 days of injury given
vertebral column.24 Periorbital fractures and in- the enhanced healing potential of pediatric pa-
juries with concern for visual loss should be tients.24 In the setting of panfacial injuries, recon-
promptly evaluated by ophthalmology. structive principles include (1) preservation of
Physical examination should include assess- brain, vision, and hearing function; (2) stabilization
ment of characteristic signs and patterns sugges- of open mandible fractures; (3) provisional skeletal
tive of underlying fractures such as hypertelorism, support until definitive reconstruction; (4) preser-
Battle sign, malocclusion, trismus, entrapment, vation of the soft tissues including neurovascular
periorbital ecchymoses, paresthesia, otorrhea, and ductal elements, cranial nerves, and lacrimal
and rhinorrhea (Fig. 2A).24 Computed tomography system; (5) systematic fracture fixation planning;
(CT) imaging serves as a critical diagnostic and (6) limited bone grafting in the setting of precise
surgical planning tool especially for maxillofacial sequential fracture reduction; and (7) soft tissue
fractures that may be greensticked or nondis- reconstruction.29 In general, panfacial injuries
placed (Fig. 2B). High-dose CT imaging risks the compromise the relationship between the occlusal
development of cataracts, whereas low-dose CT unit and skull base with a loss of customary struc-
imaging compromises visualization of the over- tures needed for anatomic alignment (Fig. 1B, C).2
lying soft tissues and intracranial structures.5 Plain Gruss and colleagues popularized the top–down/
film radiography may be of limited value in fracture outside–in approach, which begins with establish-
detection due to distinct pediatric anatomy ing facial width along the frontal bar and cranial
including developing tooth buds and nonpneuma- base articulation (Fig. 2A–C).33 This approach
tized sinuses, for example.30–32 In panfacial serves as the historical preference for plastic sur-
trauma, a systemic review of imaging in a top– geons owing to their comparative comfort with
 Pediatric Panfacial Fractures 5

establishing facial width and projection.34 Marko- impingement, and ocular findings (eg, exoph-
witz and Manson popularized the bottom–up/in- thalmos, mechanical gaze restriction, lid ptosis,
side–out approach, which focuses first on the ophthalmoplegia, and vision loss) warrant surgical
occlusal unit and has been championed by oral repair in the form of open reduction and fixation or
and maxillofacial surgeons.29,35–37 Often, patient removal and replacement with autologous bone
presentation will dictate one approach over the via a coronal approach and bifrontal crani-
other in the setting of significant comminution of otomy.5,43 An anteriorly based pericranial flap
the occlusal unit or cranial bone, for example. may be utilized to reinforce an underlying dural
Operative considerations include working from repair if there is any concern for CSF leak.
stable bone to unstable bone, adequate sequential
bony reduction of displaced fractures, avoiding
Zygoma and Orbit
unnecessary grafting of malreduced segments,
and careful autologous bone grafting of severely Once the fronto-orbital frame has been reestab-
comminuted or missing bone.3 Autologous bone lished, the zygomatic body and arches are
grafting may be obtained from the iliac crest, rib, reduced to narrow the facial width, correct orbital
or cranium.38 Incision patterns follow standard ap- dystopia, and restore appropriate malar projec-
proaches utilized in the adult population in addition tion. Displaced zygoma fractures may be
to utilization or extension of preexisting lacera- managed similarly to the adult population with
tions. Additional pediatric considerations include the caveat of avoiding fixation-related damage to
conservative treatment of greenstick-type frac- unerupted maxillary dentition. Consequently, fixa-
tures owing to a comparatively increased tion can be limited to the superior portions of the
periosteum-to-bone ratio, iatrogenic injury to zygomaticomaxillary complex in the setting of
growth centers from extensive periosteal strip- increased capacity for pediatric bony remodeling
ping, growth suture restriction from rigid fixation, (see Fig. 2C).5 Inadequate reduction of the facial
and evolving scar formation.5,39 width results in a commonly observed broad, flat
facial appearance in panfacial injuries.
Top–down/outside–in approach Orbital floor fractures in children occur following
Cranium and orbital roof Existing scalp lacera- pneumatization of the maxillary sinuses.39 Frac-
tions or a formal coronal incision may be used to tures with true extraocular muscle entrapment
access the fronto-orbital region. Goals of frontal warrant urgent treatment within 8 hours to prevent
bone management include correcting the cranial critical muscle ischemia, Volkmann’s type
contour especially along the supraorbital ridge, contracture, and subsequent motility issues,
adequate fracture reduction with relation to other which can portend a need for strabismus sur-
cranial bones, and management of cerebrospinal gery.44,45 Unlike the adult population, entrapment
fluid (CSF) leak. The pediatric cranium, which is of the periorbita results from increased elasticity
more elastic than the mature bicortical skull, can and greenstick-type fractures observed in pediat-
develop “ping pong” or nondisplaced linear frac- ric patients. The mechanism involves blunt ocular
tures that are challenging to identify and treat.5 trauma that transiently increases intraocular pres-
These fracture types, as well as growing skull frac- sure and temporarily displaces the orbital floor into
tures, are covered elsewhere in this volume. the maxillary sinus. The inferior periorbital tissues
Interestingly, children who sustain significant subsequently herniate into the maxillary sinus.
trauma to the frontal/glabellar region may develop Once the intraocular pressure normalizes, the dis-
hypoplasia of the frontal sinus—as seen in patients placed orbital floor returns to its anatomic align-
who undergo fronto-orbital reconstruction for cra- ment, leaving the periorbita/inferior rectus
niosynostosis in infancy.39,40 Although nondis- muscle trapped within the sinus.5,39 Orbital
placed fractures do not require operative fixation, entrapment remains a clinical diagnosis with ex-
displaced fractures or underlying injuries to the amination findings including extraocular move-
nasofrontal ducts require reduction and fixation. ment restriction, diplopia, increased scleral show
After the frontal sinus has pneumatized, operative of the contralateral eye during upward gaze (ie,
management mirrors the algorithmic approach uti- “white eye fracture”), and oculocardiac reflex
lized in the adult population.41 Before frontal sinus with vagally mediated symptoms including
aeration, direct cranial trauma may propagate nausea, vomiting, bradycardia, and hypotension.5
along the orbital roof toward the orbital apex, Reconstruction can be performed through a trans-
resulting in injury to the optic nerve, dura mater, conjunctival or transcutaneous incision as part of
and brain with associated hypoglobus, proptosis, panfacial fracture exposure. Following reduction
gaze restriction, and pulsatile exophthalmos.5,42 of the periorbital contents, autologous bone graft
Associated intracranial injury, bony fragment from the iliac crest, rib, or cranium (eg, split cranial
6 Shakir et al

bone graft or pericranial shave graft) may be used dissection and appreciating future dental compen-
for orbital floor reconstruction.5,45 Recently, sation in patients presenting with injuries during
resorbable alloplastic materials have demon- the period of mixed dentition.5 In severely dis-
strated equal efficacy when compared with autol- placed fractures requiring open reduction and in-
ogous grafts.46 ternal fixation, patients should be counseled on
future growth impairment in the form of nasomax-
Naso-Orbito-Ethmoid and Nasoseptum illary hypoplasia telecanthus, and/or vertical
growth deficiency.50
Once the upper, outer bony support (ie, frontozy-
Once the maxillary width is restored, a palatal
gomatic) has been established, the medial vertical
split may be fixated using hardware or a prefabri-
buttress can be restored. NOE fractures account
cated splint based on the preinjury arch width.
for less than 1% of pediatric facial fractures but
Interdental fixation remains a challenge in the pe-
present significant reconstructive challenges as a
diatric population and securing wires may need
significant portion of patients ultimately require
to pass around the zygomatic arch or piriform
revision to restore appropriate projection of the
through the palate using a passing trocar to avoid
nasal dorsum and correct secondary telecanthus.9
injury to primary or developing dentition.5 If there is
Similar to the adult population, NOE fractures are
significant maxillary comminution or easier access
classified and treated according to the same Mar-
to the mandible, maxillary reconstruction can be
kowitz system.5,8,47 Lopez and colleagues pro-
deferred until after mandible fixation. Alternatively,
posed nonoperative management of Type I
lower midface fractures may be allowed to heal
fractures, case-by-case operative management
with an understanding that expectant malocclu-
of Type II fractures depending on the presence
sion, tooth loss, and/or contour irregularities will
of permanent dentition, degree of displacement,
require subsequent orthognathic surgery, osteoin-
and presence of open fracture, and consistent
tegrated implants, and onlay grafting/alloplastic
operative management of Type III fractures with
reconstruction.39 Proponents of this approach
transnasal wiring, canthal barb resuspension, or
cite the cleft literature, which documents under-
suture canthopexy.5,48
growth of the maxilla in the setting of periosteal
The increased cartilaginous composition, bony
elevation of the hard palate.51
elasticity, and decreased dorsal projection of the
Assuming prior fixation of the midface with
pediatric nose results in relative protection of the
restoration of the maxillary width, the mandible
nasoseptal unit when compared with the adult
can then be placed into alignment. The presence
population.5 However, this increased deforming
of developing tooth buds and increased bony elas-
capacity results in increased septal distortion
ticity results in pediatric mandible fractures that
and increased risk of hematoma, which must be
are typically nondisplaced or mildly displaced.
promptly drained to prevent abscess and saddle-
Growth centers located along the condyles, poste-
nose deformity. When possible, nonoperative or
rior border of the ramus, and dentoalveolus favor
closed reduction of nasoseptal fractures should
conservative management of pediatric mandible
be performed due to the septum’s role as a critical
fractures, given their remarkable remodeling ca-
growth center. Nevertheless, severe injuries of the
pacity (Fig. 3D, E). Mild malocclusion may resolve
central midface result in the loss of nasoglabellar
spontaneously with eruption of the permanent
support that benefit from open reduction and/or
dentition and subsequent remodeling with growth.
reconstruction in the form of dorsal nasal canti-
Consequently, minimally-to-mildly displaced pedi-
lever bone grafting to restore adequate
atric mandible fractures may be reasonably
projection.3,49
managed with observation and a soft, nonchew
diet.5 With the top–down/outside–in approach,
Occlusal Unit
open fixation of a mandibular condylar fracture
Following central midface reconstruction, the can be avoided, which is especially important in
remaining panfacial injuries relate to the occlusal the growing mandible. Injury to the condyle,
unit (Fig. 3B, C). Unerupted maxillary dentition whether posttraumatic or iatrogenic, can lead to
and the lack of maxillary sinus pneumatization in growth arrest and temporomandibular joint bony
patients aged younger than 5 years provide rela- ankylosis, resulting in retrognathia, facial asymme-
tive protection against maxillary fractures. Similar try, malocclusion, and limited mouth opening.39
to adult reconstructive principles, the medial and Several studies have demonstrated reasonable re-
lateral maxillary buttresses should be restored sults concerning subsequent growth following
through reduction and/or judicious autologous conservative treatment.52,53 Stratifying by denti-
bone grafting if needed. Iatrogenic growth distur- tion, Lopez and colleagues suggested nonopera-
bances can be avoided by limiting subperiosteal tive management of condylar fractures in the
 Pediatric Panfacial Fractures 7

Fig. 3. (A) Contemporaneous panfacial presentation. A 6-year-old girl involved in an MVC presenting with signif-
icant injuries to the occlusal unit while sparing the frontobasilar region. Preoperative CT imaging is notable for
displaced bilateral LeFort 1/2/3 fractures and 4-piece mandible with severely displaced right body, minimally dis-
placed left parasymphysis, and displaced left subcondylar fractures. (B) Immediate postoperative fracture fixa-
tion. Through a top–down, outside–in approach, she underwent open reduction and internal fixation (ORIF)
of bilateral zygoma fractures from to restore facial width followed by bilateral orbital floor reconstruction using
titanium mesh implants to correct orbital dystopia and ORIF of bilateral NOE fractures with cantilever reconstruc-
tion of the nasal dorsum using split cranial bone graft to restore central midfacial projection. Next, she under-
went spanning ladder plate reconstruction of the maxilla from the zygomatic body to the nasomaxillary
buttresses to restore midfacial weight and set the midfacial height. Finally, she underwent ORIF of her right
mandibular body fracture using inferior border and tension band plates through an extraoral approach to con-
trol for lingual splay and ORIF of his left mandibular parasymphyseal fracture through an intraoral approach.
Given the inherent benefit of the top–down approach and general avoidance of the condylar growth center,
the displaced left subcondylar fracture was managed nonoperatively. Conventional titanium plate fixation sys-
tems were utilized. (C) Interval growth. CT imaging obtained at 12 years of age, nearly 6 years postoperatively
demonstrates interval facial growth with significant healing and remodeling. Note removal of the lower midfa-
cial fixation plates and mandibular tension bands at 8 years of age, approximately 2-year postoperatively. (D) Im-
mediate postoperative dentition. Note the placement of inferior border plates along the mandible with
monocortical fixation to avoid the developing dental follicles. Note the lack of consistent paranasal sinus aera-
tion with unerupted maxillary dentition. Note the position of the displaced left subcondylar fracture, which
was left to remodel. (E) Dental development into permanent dentition. At 12 years of age, nearly 6 years post-
operatively, panoramic radiograph demonstrates extensive bony remodeling along the mandibular fractures with
largely uninterrupted eruption of the permanent maxillary and mandibular dentition. Note some flattening of
the left condylar head and mild vertical discrepancy along the ramus condyle unit.
8 Shakir et al

deciduous period, case-by-case operative man- overcorrected to correct the interorbital distance
agement during the mixed period, and closed and to allow for the reduction of the ZMC fractures
versus open reduction and fixation during the per- to restore appropriate facial width. The reduction
manent phase.52 of the NOE and ZMC segments is assessed along
In comparing the use of resorbable plate fixation the temporal and (naso)frontal bones. Finally, the
to conventional titanium hardware, Chocron and midfacial height is set by reducing the occlusal
colleagues found no differences in complication unit to the fixated upper midface with or without
profiles.54 It is our preference to utilize temporary judicious autologous bone graft.
traditional rigid fixation along the mandibular infe-
rior border in a monocortical fashion to decrease Soft Tissue Management and Postoperative
injury to developing dentition (see Fig. 3D, E). Care
Hardware is typically removed 8 to 12 weeks
Despite limited subperiosteal dissection in the pe-
following fixation to prevent growth restriction
diatric population, inadequate soft tissue redrap-
and bony overgrowth.5 Interdental control remains
ing following degloving of the craniofacial
a challenge in the pediatric patient given a lack of
skeleton results in soft tissue ptosis and the
fully erupted dentition, developing tooth buds,
appearance of premature aging.56 Resuspension
and/or loose, conical primary dentition that com-
of the soft tissues around the lower eyelid, malar
plicates conventional circumdental wiring tech-
eminence, and pterygomasseteric sling prevents
niques. Similar to maxillary wiring techniques, a
the development of tear trough deformities and
lingual mandibular splint may be used to control
cicatricial scarring along orbital rim hardware, mid-
splay using circumandibular wires.5 If maxilloman-
face descent and nasolabial fold deepening, and
dibular fixation is needed, length of treatment
jowling, respectively.3,57 Temporal hollowing may
should be less than 10 days followed by guiding
be avoided by resuspension of the deep temporal
elastics with functional therapy for an additional
fascia and meticulous dissection along the tempo-
10 days to decrease the risk of bony ankylosis.5,55
ralis. Mentalis strain and chin ptosis can be
avoided by resuspension of the mentalis. Canthal
Bottom-Up/Inside–Out Approach dystopia should be addressed with fixation of the
lateral canthi in an overcorrected superior and
Unlike in the adult population where various oper-
posterior vector and fixation of the medial canthi
ative approaches remain equally efficacious, the
in an overcorrected posterior and superior vector.
bottom–up/inside–out approach popularized by
Additionally, disruption of the medial canthus re-
Markowitz and Manson may be more chal-
gion warrants the use of external nasal bolster
lenging.4,37 The approach begins with the occlusal
splints to compress and allow for readaptation of
unit and frequently requires open reduction and in-
the medial canthus soft tissues and NOE fractures,
ternal fixation of displaced condylar fractures to
respectively.2
restore lower posterior facial height and width,
Postoperative care largely follows adult fracture
which is generally avoided in the pediatric popula-
fixation protocols including a nonchew diet for 4 to
tion given the remodeling capacity of the condyle
6 weeks, sinus precautions for 2 weeks, head of
and its critical role as a growth center.36 Moreover,
bed elevation greater than 30 , chlorhexidine oral
the lack of erupted dentition may obviate the ability
rinses versus brushing in the setting of intraoral
to obtain preoperative dental impressions and
manipulation, and antibiotic ointment application
splints used to recreate the preinjury occlusion.
along cutaneous incisions/lacerations. Vision
In the absence of mandibular condyle fractures
checks and airway monitoring should be routinely
and appropriate restoration of lower facial height,
performed.3
a bottom–up/inside–out approach may be consid-
ered.4 Delena and colleagues reported the
Complications
bottom–up approach as the second most common
in their single institution retrospective review of pe- Beyond the site-specific complications that mirror
diatric panfacial fracture management.4 Interdental the adult population, the most significant long-
control of the occlusal unit is critical in this approach term consequence of pediatric fracture fixation
because the remainder of the craniofacial skeleton remains its effect on subsequent growth and
builds on this foundation.29 Mandibular splay from development. Rottgers and colleagues previously
symphyseal and/or parasymphyseal fractures proposed a classification scheme of adverse out-
must be carefully reduced along the lingual cortex. comes following pediatric facial fracture repair.58
Following reduction of the mandible and interdental Type 1 outcomes were defined as those related
control, the panfacial fracture articulates at the to the fracture itself, such as telecanthus following
LeFort 1 level.3,29,37 Next, the NOE segments are NOE fracture. Type 2 outcomes were defined as
 Pediatric Panfacial Fractures 9

outcomes related to management, such as hard- given the extensive remodeling capacity of
ware infection. Type 3 outcomes were defined as the pediatric patient. Consider operative
outcomes related to impaired growth and devel- management of displaced fractures to pre-
opment, such as midface hypoplasia. The authors vent the development of challenging end-
further substantiated the prevailing pediatric frac- stage deformities.
ture fixation theme in that nonoperative manage-  Regardless of the management strategy used,
ment is preferred to reduce the risk of Type 2 counsel patients on the unpredictable need
and 3 adverse outcomes.4,5,9,39,58 for secondary revision at skeletal maturity.
Growth disturbance following nasal trauma may
occur due to premature ossification of the septo-
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