Controversies in the management of pediatric facial fractures

The treatment of pediatric maxillofacial fractures demands consideration of different factors than those in the adult and, therefore, a different therapeutic approach. We currently believe that certain principles in the management of these injuries can be outlined, recognizing that they may require modification as additional experience accumulates. These management principles are as follows: 1. Maintain a high index of suspicion for maxillofacial injury in the pediatric patient, especially when multiple trauma exists. 2. In addition to careful physical examination, utilize CT scanning on a routine basis, even for apparently trivial injuries. 3. Give consideration to observation only for minimally displaced fractures. 4. Respect the functional matrix and employ the least invasive surgical approach that will access the fracture and allow stable reduction. 5. Employ methods of fixation that adequately stabilize the facial skeleton without rigidly immobilizing long segments. 6. If rigid internal stabilization is necessary, in the form of conventional plate and screw fixation, give consideration to interval removal. 7. Microplates appear to provide enough stability so that their use can be advocated whenever possible. 8. Avoid the use of alloplastic materials, especially in the very young patient. 9. Use bone grafts sparingly, except in instances in which inlay reconstruction is necessary and onlay reconstruction is required to maintain soft-tissue support. 10. Be aware of the pediatric dentition and avoid iatrogenic injury to evolving teeth and tooth buds. Perhaps the most important principle of all is to document injuries and their method of treatment and to follow patients serially. This will allow further definition of fracture patterns and the effects of injury and its treatment on growth, thereby giving the surgeon a better understanding and ability to develop more concise treatment philosophies for the future.