Pediatric facial injuries can occur through various means like falls, motor vehicle accidents, abuse, and sports. Facial fractures are more common after age 5 while soft tissue injuries may require special care due to difficulties obtaining child cooperation and potential effects on growth. Examination involves inspection of injuries and palpation of bone surfaces to identify fractures, with radiologic imaging like CT used to further evaluate injuries. Treatment depends on the type of injury but may include cleaning wounds, repairing soft tissue lacerations, setting facial bones, and stabilizing dental injuries. Close monitoring is needed for developmental effects.

1. Pediatric Facial Injuries
By:Dr. Amit Kr. Choudhary

2. • Children are subject to injuries and trauma similar to adult types.
• Less common in children, particularly during the first 5 years of life.
• 95% of fractures occur after the age of 5 years
• The automobile is responsible for a large number of deaths and
severe injuries in childhood
• Higher percentage of associated injuries (73%) compared with
adults (58%).
• The leading cause
 falls (accounting for 36%),
 motor vehicle accidents (25%),
 pedestrians (12%),
 bicycles (10%),
 motorcycle injuries (1%), and
 other types of injuries (16%).

3. • Soft tissue injuries and fractures may require special
therapeutic techniques because of the
 Difficulties in obtaining the cooperation of young children.
 late effects on growth and facial development.
 Faulty or arrested development (growth) stemming from the injury.
 Developmental malformations seen in young adolescents and adults are
often secondary to early childhood injuries.
 Maldevelopment of growth may result from facial fractures despite
adequate treatment,

4. CLINICAL EXAMINATION
• The clinical examination consists of an orderly inspection,
palpation, and a functional examination.
• Areas in which lacerations or bruises are present are identified
as specific areas of concern.
• palpation of all bone surfaces should be performed by
beginning in the skull and forehead areas;
• Orbits and the nose are palpated to identify any evidence of
tenderness, irregularity, and "step" or "level“ discrepancies in
the surface bone structure.
• Crepitus may be present, particularly over a nasal or orbital
rim fracture.

5. Intraoral examination
• Loose teeth and intraoral lacerations or hematomas.
• Lateral pressure on the mandibular and maxillary
dental arches is necessary to determine instability or
pain in fractures involving the midline of the
mandible or maxilla.
• A common fracture is a "sagittal" fracture of the
palate and maxilla. The fracture may easily be
missed in the absence of a mucosal laceration if the
segments of the maxilla are not examined for lateral
instability as well as for anteroposterior movement.
• The presence of avulsed, loose, or missing teeth
should signal the possibility of a significant fracture
of the mandible or maxilla

6. • Double vision.
• Visual acuity and visual fields assessed.
• Mandibular motion or "bite" .

7. RADIOLOGIC EVALUATION
• X-ray - Bone structures are cancellous that fracture lines are
difficult to observe.
• Computed tomographic (CT) scanning- concomitant brain
injury can be evaluated

9. Occipitomental view

10. Panorex

11. EMERGENCY TREATMENT
• The control of hemorrhage,
• The provision of an adequate airway, and
• The prevention of aspiration
• In young children, the dimensions of the trachea and pharynx
are small, and they can easily be obstructed by blood clots,
mucus, fractured teeth, or foreign objects

12. PRENATAL, BIRTH, AND INFANT
INJURIES
• Birth injuries may result from prolonged labor with difficult passage
through the birth canal and delivery by obstetric forceps.
• Infant and child skulls are pliable because of the segmental arrangement,
flexibility, resilience, and relative softness of the bones.
There are two presentations,
[A] an appearance of a shallow groove and
[B] an elliptical or round depression posterior to the coronal suture.
• The shallow groove is common and has few sequelae.
• The depression, without surgical revision, results in death in more than
50% of patients secondary to increased intracranial pressure or
hemorrhage.
• This occurred from a depressed skull fracture with an epidural hematoma
or possibly from a sagittal sinus injury.

13. • Deviation of the septum or nose has been attributed to forced
deflection of the nose during birth.
• This may cause permanent facial scars or osseous deformities in the
region of the zygomatic arch and temporomandibular joint, which
may result in temporomandibular ankylosis with developmental
hypoplasia of the mandible.
• Facial nerve injury - The lack of development of the mastoid process
at birth and the subcutaneous position of the facial nerve
predispose to facial paralysis by pressure from delivery forceps.
• Injuries to the eye or its adnexa, such as damage to the extraocular
musculature, may be caused by intraorbital hemorrhage.
• Separation of the halves of the mandible at the symphysis
following placement of the surgeon's finger in the baby's mouth for
manipulation to deliver the baby.

14. • Sternocleidomastoid Injury
 Breech delivery with lateral
hyperextension.
 Tear of the muscle or fascia, resulting
in a hematoma and eventual cicatricial
torticollis deformity.
 contracture of the muscle may lead
to craniofacial asymmetry
(deformational frontal plagiocephaly).
• Steroid injections into the areas of the
contracture and muscle stretching have
been used for constructive therapy.

15. BATTERED CHILD SYNDROME
• Three children die each day of abuse or neglect.
• 51% of the fatalities are caused by physical abuse.
• An estimated 2000 children die annually in the United States .
• Children who are younger than 2 years are particularly at risk.
• Other risk factors for child abuse include prematurity, physical
disability, low birth weight, and low socioeconomic level.
• Males, twins, and stepchildren are particularly at risk.

16. • Physical indications of child abuse include
o bruises and welts,
o burns,
o lacerations and abrasions,
o skeletal injuries,
o head injuries, and
o internal injuries.
• Bruises and welts, when they are associated with
abuse, will often be seen on an infant, especially
around the facial area.
• Bruises may also be seen on the posterior side of
the body and trunk, hidden by clothing.
• Clustered bruises
• Bruises at various stages of healing with fresh ones
being noted in nearly contiguous areas.
• The abuse may result in contusions or lacerations of
the tongue, buccal mucosa, palate, gingiva, or
frenulum; fractured, displaced, or avulsed teeth;
facial bone fractures; or bruising or scarring at the
corners of the mouth.

17. • Bite marks - ecchymoses, abrasions, or
lacerations are found in an elliptical or
ovoid pattern, particularly if there is a
central area of ecchymoses.
• Burns
• Immersion-type burns are suggested when
hot liquid is placed around the arms or
legs, such as a "stocking-type burn" or a
"donut burn" in the area of the buttocks or
genitalia.
• Cigarette burns
• Rope burns, which indicate confinement
around the arms or legs.
• Other types of injuries, such as dry burns,
indicate that the child may have been
forced to sit on a hot surface or has had a
hot implement applied to the skin.

18. • Lacerations to the face, particularly the lip, eye, or
any other portion of the infant's face, such as tears in
the gum tissue, may be caused by force-feeding.
• Any laceration or abrasion to the external genitalia
• Skeletal injuries, such as those to the metaphyseal
region or corner fractures of long bones, a splintering
of the end of the bone that is caused by twisting and
pulling, are indicative of abuse.
• Epiphyseal separation at the center of the bone from
the rest of the shaft can also be caused by twisting
and pulling actions.
• Periosteal elevation and detachment of the periosteum
from the shaft of the bone are associated with
hemorrhage from the periosteal shaft.

19. SOFT TISSUE INJURIES
• Maxillofacial soft tissue trauma and injuries in the pediatric
population range from contusions and abrasions to massive
avulsive injuries.
• Contusions and ecchymosis usually require only symptomatic
treatment.
• Hematoma - drainage may have to be performed. In the
"currant jelly" stage, a hematoma can most easily be drained
by incision. After further liquefaction, aspiration may be
performed.
• Hematomas of the external ears - "cauliflower ear" deformity

20. Lacerations
o simple,
o beveled,
o torn,
o burst, or
o stellate type.
• Cleaning and débridement and the foreign body removal.
• Suturing should be in layers and must be meticulous.
• Soft tissue containing cartilage are being repaired, as in the ear or nose,
stabilizing stitches with absorbable material should be used to stabilize the
cartilage in its proper place, followed by a layered closure.
• Quilting sutures prevent reaccumulation of hematoma.
• Lacerations in special regions of the face require particular attention to
realignment of the anatomy (e.g., the vermilion border of the lips, eyelid
margin, and eyebrows).
• The eyebrow should never be shaved because regrowth may not occur.

21. • Soft tissue wounds in children heal rapidly.
• Children's fractures generally heal in half the time of fractures
in adults.
• Lacerations properly repaired at an early age will become less
conspicuous with the passage of time.
• Cheek and mandibular margin wounds tend to heal with
considerable hypertrophic scarring.
• Dense restrictive scars may interfere with bone growth,
particularly in the area of the chin and mandible

22. • Defects of the nose are adequately repaired in some patients with
composite auricular grafts,
• Larger defects of the nose need forehead flap reconstruction
• Intraoral lacerations are usually sutured precisely to prevent
contamination.
• Lacerations of the tongue are sutured in several layers to reduce the
chance of hematoma formation.
• Major salivary gland duct is lacerated, both ends must be located and a
suture anastomosis performed.
• If the parotid duct is lacerated, the distal end is usually first found by
placement of a probe or a catheter (22-gauge angiocatheter sleeve)
through the oral opening after the sphincter has been dilated with a
pediatric punctum dilator. The tube used for duct irrigation may also be
anchored at the duct orifice and used as a stent for the duct anastomosis.
• The stent is left in place for 2 weeks, if possible, and removed.
• A dependent or suction drain may be used.
• If a fistula develops, it may be treated by aspiration, pressure dressings,or
placement of a suction drain.

23. Facial nerve injury
• The nerve should be repaired
o primarily if the wound is clean and the laceration relatively
sharp.
o In more destructive injuries, nerve repair is usually performed
secondarily with nerve grafts.
• The traditional rule was that facial nerve injuries should be
repaired surgically if they occur posterior to a vertical line
drawn through the lateral canthus.
• Presently, injuries occurring anterior to this line should be
repaired if the branches can be located

24. • Soft tissue hematomas
o may result in disturbance of a growth center or fibrosis,
inhibiting facial growth.
o Pressure necrosis or thinning of the surrounding structures.
o If they occur over cartilage, hematomas can result in septal
necrosis, exporation, or distortion, as in a cauliflower ear or
nasal septum

26. FACIAL FRACTURES

27. Etiology
• In the infant, falls, toy injuries, and animal bites are common.
• Battered baby syndrome, in which lacerations (particularly in
the frenulum of the upper lip), facial or skull fractures, and
cervical spine and cerebral injuries can be observed.
• Falls from heights are frequent in infants.
• Vehicular trauma sustained in a motor vehicle or on a bicycle),
athletic injuries, sporting accidents, and injuries occurring
from airborne objects are often observed in children older than
5 years.
• Boys are subject to injury more than girls are in almost all age
groups after 5 years.

28. Symptoms
o swelling, pain, and numbness in a cranial nerve distribution
o Visual disturbance consists of diminished vision, double
vision, or inability to open the eyelid.
o Nasal or oral bleeding,
o tooth displacement, difficulty in eating,
o malocclusion,
o decreased excursion of the jaw,
o bruising, and ecchymosis point to a skeletal injury.
o Exophthalmos or enophthalmos may be present.
o A cerebrospinal fluid (CSF) leak may indicate involvement of
the cranial base.
o Subcutaneous emphysema is seen in the periorbital area when
air enters the tissues from fractures of the nose, orbit, or
sinuses.

29. Alveolar Fractures
• In the young child, teeth may be
dislodged from a segment of the
alveolar bone subjected to labial,
buccal, or lingual displacement .
• The fragments of bone can
frequently be molded into
alignment, and the teeth survive if
they are adequately supported for
several months by an arch bar or
orthodontic support.
• If treatment is begun within an
hour and root canal therapy is
instituted, a tooth can be
replanted with success
• Bone fragments should not be
dissected from the attached soft
tissue if possible. These loose
bone fragments, if covered with
soft tissue, often survive as grafts

30. Fracture crowns
• Fractured crowns of teeth
without exposure of the pulp
should be protected by dental
methods.
• If the crown of the tooth is
fractured and dental pulp
exposed,the prognosis may be
good if the tooth is capped or a
partial pulpectomy is performed.
• Fracture of the root near the
base of the crown usually
requires extraction.
• Damage to the permanent tooth
buds may result in deformed
tooth structures, false eruption,
or irregular arrangement of the
erupting teeth in the dental arch

31. Dental injuries
[A]deciduous teeth
[B]permanent dentition.
 Injuries to deciduous dentition may occur between the ages of
1 and 2½ years when children are learning to walk.
 most common injury is one of displacement of the upper
incisors. This may result in an intrusion of the tooth into the
premaxilla, a loosening or partial dislocation.

32. • Intruded teeth frequently re-erupt in the subsequent weeks and
may reach full eruption in 4 to 6 months.
• In a child younger than 2½ years with incomplete root
formation, intruded teeth may retain normal vitality after re-
eruption.
• In children older than 2½ or 3 years, calcific degeneration and
necrosis of pulp are common sequelae to the re-eruption of
intruded teeth after root formation is mature.

34. • Subluxation of permanent teeth with the associated alveolar
bone is treated by repositioning and splinting according to
conventional methods.
• The teeth frequently become nonvital and require root canal
therapy and root canal filling at a later date, particularly when
the root formation is complete at the time of injury.
• If complete avulsion of the permanent tooth occurs when the
root is immature and the apex widely open, the tooth should be
reimplanted and stabilized in the socket within a few minutes
of injury

35. Mandibular Fractures
• When fractures occur, as in the body of the mandible, there is
often a considerable degree of displacement, fracture lines tend
to be long and oblique, extending downward and forward from
the upper border of the mandible.
• In adult the direction of the fracture line is usually downward
and backward.

36. • Before the eruption of the permanent or secondary dentition, the
developing follicles occupy most of the body of the mandible.
• If interosseous fixation is to be employed,the wires must be placed near the
lower border of the mandible.
• The teeth cannot be employed for fixation .
• These fractures are best treated by open reduction with small rigid fixation
devices, such as the 1.3, 1.5, or 2.0 systems.
•
• Unicortical screws and proper plate placement are required.

37. • Alternatively, an impression of the mandible can be taken
under light anesthesia and an acrylic splint fabricated. After
realignment of the fragments, the splint is placed over the
mandibular arch, lined with softened dental compound for
conformity adjustment, and maintained in position by screws
or circummandibular wires.

38. • Intermaxillary fixation is obtained by the assistance of skeletal
wires to support and stabilize arch bars.
• These are anchored to screws placed to avoid tooth buds.
Transalveolar wiring above the apices of the teeth can be used
in the older child after the eruption of the secondary dentition.
• After 10 years of age, the dentition may be adequate for
standard intermaxillary dental fixation.

40. • The loose and displaced bone fragments become adherent to
one another within 3 or 4 days after injury.

41. Condylar Fractures
• The condylar articulation with the base of
the skull is a complex ginglymoarthrodial
joint that permits rotation and forward
motion of the condyle onto the anterior lip
of the glenoid fossa as the jaw opens .
• The joint surfaces are lined with cartilage ,
and a disk of fibrocartilage is suspended
between the joint surfaces.
• Condylar fractures and "crush" injuries
may result in growth deformity in the
mandible, but it is more likely with a
condylar fracture.
• In older children, the condylar areas thin
with growth and represent a weak point
considered more susceptible to greenstick
or complete fracture

42. • The articular disk may also be
bruised, torn, or dislocated,
impairing joint motion.
• Hematoma may occur within
the joint, resulting in fibrosis
and ankylosis.

43. • Fractures of the condylar neck may be complete or incomplete
(greenstick) and may be characterized by the degree of
angulation between fragments (more angulation equals more
deviation of the distal mandible and more ramus shortening)
and the degree of override or overlapping of the fragments .
• Greenstick fractures heal quickly, whereas dislocated fractures
without bone contact or with override heal slowly with
potential malocclusion.
• The condyle may also be dislocated from the fossa, and it is
usually found medial to the joint in the pterygoid fossa.

44. RESTITUTIONAL REMODELING
• The condyle area in young individuals is capable of
restitutional remodeling. It is not uncommon for individuals to
generate a new condylar head after a complete dislocation
• young (<5 years) should frequently be managed with closed
reduction and an initial period of intermaxillary fixation
followed by guided elastic traction,
• whereas the older child with significant severe derangement
should be considered for open reduction.

45. • During the first 3 years of postnatal life, the condyle is short
and thick and thus less susceptible to fracture; however, it is
more vulnerable to a crushing injury because of its vascular
trabecular structure.
• The crushing results in intraarticular and periarticular
hemorrhage and scattered osteogenesis, and progressive
ossification may result in temporomandibular ankylosis.
• Early or immediate motion is thought to minimize the
ankylosis complication

46. • Before the age of 5 years, the condylar neck is less developed,
and the bone tissues are soft and more susceptible to the crush
type of injury.
• After the age of 5 years, the condyle will, in all probability,
fracture at the neck.
• The crush type of injury may also be associated with condylar
cartilage damage.
• Mandibular hypoplasia may result when the cartilage is
injured.
• The degree of deformity seems to be inversely proportional to
the age at which the injury is sustained. The younger the
patient at the time of injury, the more severe is the deformity

47. • Condylar fractures are divided into two groups,
 Intracapsular
 Extracapsular.
Extracapsular fractures may be further subdivided into
 condylar neck
 subcondylar fractures.
The condylar neck fractures may be further subdivided into
 dislocated
 nondislocated .

48. • Intracapsular fractures management - "conservative" treatment
consisted of early motion and pain medication.
• Nondislocated neck fractures were treated by a soft diet and
pain medication or a short period of intermaxillary fixation (2
to 4 weeks).
• Lehman used a preauricular approach and recommended
drilling a screw into the condylar head to allow it to be levered
back into the fossa.
• A major problem resulting from treatment of dislocated
condyle fractures by closed reduction is early dysfunction with
an inability to consistently achieve centric occlusion, which
may also lead to late arthritic changes.

49. Zygomatic and Orbital Fractures
• Zygomatic fractures are rare in younger children and most
commonly occur in the older child.
• Considerable force is required to fracture the resilient zygoma
of the young child, and the fracture usually takes the form of a
fracture-dislocation.
• Lack of complete union at the zygomaticofrontal suture also
explains the infrequency of this type of fracture.
• Treatment is similar to that of adult zygomatic fractures and
includes three anterior incisions for most fractures to explore
the zygomaticofrontal suture, infraorbital rim, and maxillary
alveolar process for alignment and fixation

50. • The radiographic evaluation of a zygomatic fracture formerly
consisted of Waters and Caldwell views to assess the
displacement .
• The Waters view defines the infraorbital rim and lateral wall
of the maxillary sinus; the orbital floor is also visualized.
• The Caldwell view assesses displacement at the
zygomaticofrontal suture.
• Posterior displacement of the malar eminence and depression
of the zygomatic arch are assessed through submentovertex
skull films or axial CT scans.

51. Thank you