Maxillary Fractures in Children Treatment & Management

Updated: Apr 06, 2020
  • Author: Abbas A Younes, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Surgical Therapy

Pediatric fractures generally heal rapidly. If fractures are displaced and a stable reduction cannot be achieved, perform a surgical reduction with rigid fixation. Plating systems provide the most common method of rigid fixation. The trend in pediatric facial fractures is toward resorbable plating systems. [11] The surgical approach uses the same incisions that are used with adult patients. Nearly the entire face can be exposed with an appropriate combination of coronal, transconjunctival, subciliary, upper and lower gingivobuccal, and Risdon incisions. [12]

Nasal fractures

Isolated nasal fractures are common. These fractures are underrepresented in series because they are often treated in an office or outpatient setting. The nasal cartilage is soft and compliant in the child. This may predispose the child to septal fractures. Children are prone to open-book fractures as well. Initially, the presence of a septal hematoma should be excluded. Bleeding between the internal lining of the perichondrium and septum may occur. Drain septal hematomas to prevent dorsum collapse due to pressure necrosis or superinfection. In the early period, edema often obscures evidence of displacement. Once the edema has subsided (usually 3-4 d after trauma), the child should return to the clinic for examination. If a cosmetic deformity exists, closed reduction under anesthesia usually is successful. If the injury is more than a week old, open reduction is often required.

Orbital fractures

In Posnick's 1993 series, the orbital floor was involved in 32% of orbital fractures, the medial wall was involved in 19%, and the roof was involved in 18%. [5] Most patients (33 of 41) with orbital fractures were aged 6 years and older. In Koltai's 1995 series, incidence of roof fractures was 35%, floor was 25%, mixed was 35%, and medial was 5%. [13] The etiology of orbital fractures in children includes motor vehicle collisions at 42%, sports at 32.5%, and falls at 17.5%. Koltai determined that the age at which the probability of orbital floor fractures exceeds the probability of orbital roof fractures is 7 years. The overall change in facial geometry affects where the orbit is likely to be struck and affects the dissipation of force. [14]

Orbital roof fractures occur in younger children and more frequently have associated neurocranial injuries; however, they are less likely to require operative intervention. The lack of pneumatization of the frontal sinus correlates with the orbital roof fracture in younger children. The postulated reason for this phenomenon is the lack of cushioning effect of the sinus and transmission of force sustained on the frontal prominence directly to the orbital roof.

The need for fracture fixation depends on the presence of gross displacement of fracture segments and on decreased extraocular muscle movement with positive forced duction testing or alteration of orbital volume. A spicule of roof bone may impinge on the extraocular muscles and may decrease orbital volume, leading to exophthalmos. Patients who have sustained orbital roof fractures should be seen by neurosurgery and ophthalmology consultants. A high rate of intracranial injuries is associated with these fractures. Large orbital roof fractures may cause exophthalmos, vertical dystopia, and orbital encephaloceles.

Incidence of orbital floor fractures parallels development of the maxillary sinus. Symptoms of floor fractures include periorbital ecchymosis, lid edema, subconjunctival hemorrhage, diplopia, pain, and step-offs. Infraorbital anesthesia almost always exists. Upward gaze restriction may be secondary to entrapment or soft tissue edema. Initial edema can be misleading. Enophthalmos may become apparent with resolution of edema. Floor fractures are best evaluated with coronal CT scanning, but they can be visualized adequately with well-performed coronal reformations of high-quality axial CT scans.

If fractures are severe or clinical or CT scan evidence of entrapment exists, early surgical exploration and repair are indicated. Otherwise, patients may be observed for a week for development of enophthalmos or step-offs, both of which may become more apparent with resolution of edema.

Frontal sinus/frontobasilar fractures

Frontal sinus and frontobasilar fractures are managed as are similar fractures in adults. The frontal sinus is not well developed until ages 5-8 years, and without the sinus to provide a cushion, fractures tend to extend superiorly up the skull or across the orbital roof. If displaced, perform operative reduction through a coronal incision and fixate the anterior wall to maintain the forehead and brow contour. In children, however, the posterior sinus wall is more frequently involved and cerebrospinal fluid (CSF) leaks are more common. If the floor of the sinus is also involved, injury to the frontonasal duct is likely; remove the sinus mucosa, plug the frontonasal duct, and obliterate the sinus. If the posterior wall is involved, consult a neurosurgeon. If displacement of the posterior table by more than the thickness of the table exists, obliterate the frontal sinus with debridement of the mucous membranes and occlusion of the nasofrontal duct.

Midface fractures

Midface fractures are relatively rare in children and are rarer still in the younger age groups. These fractures account for less than 1% of Rowe's 1968 series of 1500 cases. [3] In a series of 54 midface fractures in patients younger than 16 years, only 11% were in patients younger than 6 years. Lack of development of paranasal sinuses and the presence of unerupted maxillary dentition decrease incidence of these fracture types in children younger than 6 years. Additionally, the younger child's maxilla is soft, spongy, and elastic and is sheltered by a thick adipose layer. These fractures are most commonly caused by high-velocity injuries; therefore, associated injuries are frequent. Half of patients have associated injuries, mostly to the head and face. A quarter of pediatric patients with midface fractures have injuries outside the head and face region.

Motor vehicle collisions are the most frequent etiology overall, and falls are the leading cause in children younger than 6 years. The pattern of maxillary injuries includes dentoalveolar (34.3%), zygoma (30%), and Le Fort fractures (20%). Children may have a sagittal split of the palate. In Rowe's 1968 series, only 4% of pediatric fractures were Le Fort-type fractures. [3] In Iizuka's 1995 series, Le Fort fractures only occurred in children older than 5 years. [15] In children younger than 5 years, dentoalveolar fractures are more common. In fact, in patients younger than 6 years, only dentoalveolar fractures occurred. In addition to their anatomic variance, these younger patients frequently sustain falls that generally are low-velocity injuries.

Le Fort fractures in children are classified as in adults. Le Fort I describes a fracture separating the palate and alveolus from the rest of the maxilla. The fracture line extends through the floor of the nose, maxillary sinus, and pterygoid plates. These fractures are associated with older patients, in whom the maxillary sinus is more developed and the permanent teeth are erupted. A Le Fort II or pyramidal fracture separates the midface from the skull. The fracture extends across the maxilla, the medial and lateral orbital walls, and the nasofrontal sutures, thus creating a free-floating pyramidal segment.

A Le Fort III fracture or craniofacial dysjunction involves a complete separation of the face from the cranium. The fracture line includes the zygomatic arch, frontozygomatic suture, lateral and medial orbital walls, nasofrontal suture, septum, and pterygoid plates. Massive edema and periorbital ecchymosis are common in patients with these fractures. Undertake treatment to establish occlusion, normal facial proportions, and symmetry.

If these fractures are displaced, rigidly fixate the bony segments. As with the mandible, take care to avoid damaging teeth developing in the maxilla. Operative strategy involves establishing occlusion, fixating the mandible, and reestablishing the horizontal and vertical buttresses of the face. Fractures may be approached through the same incisions used in adult patients: gingivolabial sulcus, bicoronal, transconjunctival, or subciliary incisions. As with other pediatric facial fractures, perform treatment within a week of injury.

Naso-orbito-ethmoid fractures

Naso-orbito-ethmoid (NOE) fractures are uncommon in children. The region is not prominent or well developed in the young child. These fractures range from simple fractures to severely comminuted fractures involving the orbits, maxilla, and frontal bone. Symptoms include a depressed and flattened nasal root, telecanthus, subconjunctival hemorrhage, and mobility of the medial canthal tendon on bimanual palpation. Additional clinical features include rounding of the medial canthus, horizontal shortening of the palpebral fissure, and an intercanthic distance greater than the palpebral fissure width.

Note that children have a relatively wide intercanthic distance, especially children younger than 10 years. Also, more soft tissue is draped across the nasal bridge, making the area difficult to assess.

The operative approach is through a coronal incision. The surgical goal is to reposition the canthal-bearing segment to stable bone in the frontonasal and medial maxillary buttresses and to establish a normal intercanthic distance, normal nasal form, and bony and soft tissue support for the eye. Do not set the intercanthic distance too wide.

Zygomaticomaxillary complex fractures

ZMC fractures become more common with increasing age, as the zygoma becomes more prominent. The frontozygomatic ligament is weak in children, and force applied to this area may cause unilateral craniofacial detachment. Therefore, these fractures more commonly involve the lateral wall and orbital floor. Symptoms of these fractures include depressed contour, bony step-off, subconjunctival hemorrhage, periorbital hematoma, depressed lateral canthus, abnormal mandibular movement due to restriction of the underlying coronoid process, and epistaxis from bleeding into the maxillary sinus.

Because these fractures often are greenstick, open reduction and internal fixation (ORIF) frequently is unnecessary. Nondisplaced fractures can be managed conservatively. A Gillies approach can be used for simple reduction. Rigid fixation is indicated for fractures that are more displaced or unstable. [16] These fractures must be reduced at 3 sites: frontozygomatic, infraorbital rim, and zygomaticomaxillary buttress. If orbital symptoms (eg, enophthalmos, diplopia) are present or if evidence of a floor defect is found on imaging studies, the question of floor involvement and prolapse of orbital contents should be raised and the orbital floor explored. In children, calvarial bone grafts are generally used to re-create the floor.

Eppley (2005) showed that the use of resorbable plates and screws for fixation of pediatric facial fractures enables realignment and stable positioning of rapidly healing fracture segments without any future metal retention. He treated 15 patients (age range: 4-11 y) with isolated frontal, supraorbital, intraorbital, or orbitozygomatic fractures by ORIF with 1.5-mm resorbable plates, mesh, and screws. No long-term implant-related complications were seen.

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Complications

The major concern in treating pediatric facial fractures is the effect on long-term growth and development. Concerns over growth disturbance secondary to soft tissue disruption with dissection must be balanced with poor result and growth disturbance from leaving a grossly displaced fracture untreated. In general, if a fracture is stable or out of alignment, it should be fixated using as little dissection as possible.

The clinical effects of treatment on facial growth are unknown. Animal studies on the effect of fracture and fracture fixation on craniofacial growth have yielded conflicting results. In 1991, Lin demonstrated a regional growth restriction in animal craniofacial skeletal growth with plate and screw fixation and with wire fixation over an osteotomy. [17] Plating across a suture alone did not affect growth, nor did wide undermining and periosteal elevation.

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Outcome and Prognosis

In general, the outcome from timely surgical intervention is excellent in the pediatric population. [2, 18] In McCoy's 1966 series of 64 children, only a single documented case of growth disturbance was found. [4] This case involved a patient with a delayed treatment of a nasoethmoidal fracture.

Both leaving untreated fractures in a nonanatomic position (eg, displaced) and overtreating fractures with excess periosteal elevation, soft tissue disturbance, and plating may result in growth disturbance. The consensus appears to indicate fixation of malpositioned fragments using the smallest amount of surgery possible. Minimize dissection. Use the fewest number and smallest-size plates. Additionally, consider possible interval removal of hardware (if not using resorbable systems).

The introduction of resorbable plates may alleviate some concern over long-term effects of fixation. Resorbable plates undergo a 2-step degradation. The first step is hydrolysis, which breaks the long chains into shorter ones. This step markedly reduces the strength of the substance. The second step is phagocytosis of the shorter chains by macrophages. This step decreases the mass of the substance. Most current resorbable plates are made of a combination of polyglycolic acid, which is subject to rapid hydrolysis and poly L-lactic acid, which is more slowly resorbed. Lactosorb is a trade name for a combination plate that resorbs in 9-15 months.

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Future and Controversies

As discussed, the introduction of resorbable plates may alleviate some concern over long-term effects of fixation. Also, these plates may decrease the foreign body risk as well as the possible need for future removal. The use of a combination type plate in pediatric craniofacial surgery (including both developmental abnormalities and trauma) has been reported. In limited series, no instability or relapse of fracture site has been reported. Unfortunately, little long-term follow-up information currently is available. Some technical aspects remain to be improved; however, these plates appear adequate for stabilization of bone segments during the healing process; long-term follow-up of effects on growth remains to be seen.

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