Crecieminto Facial

Facial Skeletal Tr auma in the G ro w i n g P a t i e n t
Christopher Morris, DDS, MDa, George M. Kushner, DMD, MDb, Paul S. Tiwana, DDS, MD, MSc,*
KEYWORDS
 Pediatric  Skeletal facial trauma  Rehabilitative physiotherapy  Craniofacial trauma

KEY POINTS
 Appreciate the anatomy and physiology unique to pediatric patients.  Understand the potential implications of surgical insult onfuture growth and development.  Emphasize the importance of early rehabilitative physiotherapy on future growth and function.

INTRODUCTION
The management of maxillofacial trauma has changed over time. These changes are caused by the evolving complexity of injuries secondary to higher-impact mechanisms and advances in imaging, instrumentation, and fixation. The greatest influence on surgicalmanagement of pediatric craniomaxillofacial disease likely came from the contribution of Dr Paul Tessier1 in his principles of cranio-orbital surgery first introduced in 1967.1 Others have additionally provided the many operative principles of maxillofacial trauma used today, such as the sequencing of panfacial injuries, autogenous bone grafting, and the important role of rigid fixation inre-establishing facial height, width, and projection.1–3 These principles have provided the fundamental underpinnings of modern facial fracture treatment. More recently, these principles that work so well in adult patients have been applied in the management of pediatric maxillofacial trauma. Posnick and Kaban4–7 have more clearly described the epidemiology and further clarified the advantages of rigidinternal fixation for these injuries.1,4–7 The current understanding of complex facial injuries has primarily been through the observation of adult patients. However, one must recognize

that the treatment of pediatric patients requires additional considerations and that the application of adult-type treatment can be inappropriate in many circumstances. There is still a place for conservatism in thetreatment of craniomaxillofacial injuries in children. The maxillofacial trauma surgeon will best serve pediatric patients with a combination of ageappropriate sensitivity and a fundamental understanding of the complex issues surrounding the growth of the craniofacial skeleton and the potential for traumatic and surgical injury to negatively alter it.

GENERAL CONSIDERATIONS Craniofacial Growthand Development
The role of the human face is significant, both functionally and esthetically. This role is secondary to the highly evolved and specialized functions of the face in vision, breathing, mastication, speech, smell, and hearing, among others. Indeed, it is the culmination of an extremely complex process of growth and development that provides the functional and aesthetic framework ofthe human face. Interruption of this process, such as insult from maxillofacial injury, may produce deleterious

Division of Oral & Maxillofacial Surgery, UT Southwestern Medical Center, Dallas, TX, USA; b Department of Surgical & Hospital Dentistry, The University of Louisville, Louisville, KY, USA; c Pediatric Oral & Maxillofacial Surgery, Children’s Medical Center, UT Southwestern MedicalCenter, Dallas, TX, USA * Corresponding author. E-mail address: paul.tiwana@utsouthwestern.edu Oral Maxillofacial Surg Clin N Am 24 (2012) 351–364 doi:10.1016/j.coms.2012.05.005 1042-3699/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.

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alterations of the facial framework resulting in aesthetic and functional deficits.For the surgeon who treats pediatric facial fractures, an understanding of this process becomes crucial in developing and exercising sound surgical judgment.8–10 The cranial vault at birth is comprised of flat plates of intramembranous bone separated by connective tissue. The interposing areas or sutures allow for the deformation of the head through the pelvis during delivery and then to...