CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART TWO

J Oral Maxillofac Surg

63:385-391, 2005

Use of Resorbable Plates and Screws

in Pediatric Facial Fractures
Barry L. Eppley, MD, DMD*
Purpose: The use of resorbable plates and screws for fixation of pediatric facial fractures is both well

tolerated and effective. It enables realignment and stable positioning of rapidly healing fracture segments
while obviating any future issues secondary to long-term metal retention.
Patients and Methods: Forty-four pediatric facial fractures were treated over a 10-year period at our
institution using differing techniques of polymeric bone fixation. Twenty-nine mandible fractures in
patients under the age of 10 (age range, 6 months to 8 years) were treated. Displaced fractures of the
symphysis, parasymphysis, body, and ramus underwent open reduction and either 1.5-mm or 2.0-mm
plate and screw fixation in 14 patients. Subcondylar fractures were treated by a short period of
maxillomandibular fixation (3 weeks) achieved with suture ligation between resorbable screws placed at
the zygoma and symphysis or a circummandibular suture attached to a zygomatic screw. Fifteen patients
(age range, 4 to 11 years) with isolated frontal, supraorbital, intraorbital, or orbitozygomatic fractures
were treated by open reduction and internal fixation with 1.5-mm resorbable plates, mesh, and screws.
Results: No long-term implant-related complications were seen in any of the treated patients.
Conclusions: Resorbable polylactic and polyglycolic acid plates and screws can be an effective fixation
method for facial fractures in children in the primary and secondary dentition periods.
2005 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 63:385-391, 2005
The pediatric facial trauma patient provides several
different considerations that are not present in the
adult. First, the pediatric patient has the tremendous
advantage of an accelerated ability to heal in a very
short time with few complications, aided by the wellvascularized tissues of the face. Second, through the
assistance of growth and an inherent ability to adapt,
recovery of damaged orofacial tissues and function is
much better than in the adult. Despite these advantages, certain distinctions do exist in the pediatric
facial trauma patient that must be considered. This
includes an appreciation of the unique characteristics
and anatomy of the developing immature face, the
different facial injury patterns from certain trauma
risk exposures that occur in the pediatric patient, and
the potential growth implications from traumatized
facial structures that make long-term follow-up of

these patients important. These factors, combined

with the relatively limited experience of most clinicians with significant facial injuries in children due to
their low incidence, may make certain treatment decisions different than what one might do in the adult.
For the sake of this particular review, the term pediatric facial fractures will refer to fractures in those
children under the age of 10 with an incomplete
permanent dentition. Children older than 10 years of
age are essentially treated as adults, where the advantages of resorbable fixation over metal implants are in
many cases more obscure.

Resorbable Fixation Devices

Although a variety of resorbable bone fixation devices of differing polymer compositions are currently
available for craniomaxillofacial applications, this author has exclusively used co-polymer plates and
screws composed of 82% polylactic and 18% polyglycolic acid (PLLA-PGA, LactoSorb; Walter Lorenz Surgical, Jacksonville, FL). Their long history of uncomplicated use in cranial vault surgery, favorable
biomechanical properties, and a confirmed resorption
time of 1 year or less make them ideal for the pediatric
patient. The use of resorbable plates and screws involve 2 differences from similar-appearing metal de-

*Professor of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN.

Address correspondence and reprint requests to Dr Eppley:
Indiana University School of Medicine, 702 Barnhill Dr, 3540,
Indianapolis, IN 46202; e-mail: beppley@iupui.edu
2005 American Association of Oral and Maxillofacial Surgeons

0278-2391/05/6303-0032$30.00/0
doi:10.1016/j.joms.2004.11.011

385

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RESORBABLE PLATES/SCREWS IN PEDIATRIC FACIAL FRACTURES

FIGURE 1. Resorbable plate and screw fixation (1.5 mm) of bilateral mandible fractures in a 4-year-old girl. A, Reduction of left parasymphyseal
fracture. B, Reduction of right angle fracture with a superior border plate. C, Centric occlusion obtained by free hand technique.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial Fractures. J Oral Maxillofac Surg 2005.

vices. First, complex bending of the plates requires a

heat source to allow the polymer chains to bend and
not fracture. The mandible and forehead, however,
have relatively flat and gently curved surfaces, which
do not require enough bending to make this a concern. In the zygoma and orbit, more complex shaping
of the plates may be needed. The placement of resorbable screws requires pretapping the screw threads
before screw insertion, which is a 2-step process (ie,
drilling and tapping).

Mandible Fractures
Pediatric mandible fractures are uncommon and
have been treated by a wide variety of fixation methods. Incomplete or nondisplaced fractures as well as
fractures of the subcondylar region are treated by
traditional methods of a soft diet or closed reduction.
Displaced fractures are better served by open reduction and internal fixation (ORIF).

Rigid metal fixation of mandibular fractures in children, however, can be complicated by a mixed dentition that can occupy the entire vertical dimension of
the bone and places teeth and the inferior alveolar
nerve at risk during screw insertion. In addition, ongoing development of the mandible poses risk of
intrabony translocation of metal plates and screws,
risking potential growth and teeth disturbances and
difficulty with secondary removal if needed.
The goal of ORIF is a balance between stability of
the fracture site and the potential risks of operative
exposure of the bone. In children, this balance is
particularly precarious as the implantation time of the
metal devices is essentially for most of the patients
lifetime. For these reasons, the use of resorbable fixation implants in developing facial bones is particularly appealing.1 Given the location of mixed dentition throughout the bone and the course of the
inferior alveolar nerve, ORIF of the mandible in children uses smaller-gauge resorbable miniplates with

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BARRY L. EPPLEY

FIGURE 2. Resorbable plate and screw fixation (1.5 mm) of severely displaced left mandibular parasymphyseal fracture in a 5-year-old boy. A,
Magnitude of mandibular arch displacement. B, Intraoral exposure of fracture. C, Reduction and fixation of fracture with 1.5-mm plates and
monocortical screws. D, Postoperative panoramic radiograph showing fracture alignment and screw holes around developing tooth buds.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial Fractures. J Oral Maxillofac Surg 2005.

monocortical screws. As the pediatric mandible is

fairly malleable, fractures tend to be less displaced
and rarely comminuted. Because the dentition is often
mixed and more bone growth is expected, absolute
compression of the fracture edges together is not
necessary. These considerations, in conjunction with
the difficulty in applying arch bars in the mixed dentition, allows for the use of a free hand technique
during fracture repair.2 Fractures are usually exposed
through an intraoral approach unless an existing laceration allows for direct access to the bone through
the skin. Once the fracture site is prepared, the bone
edges are manually reduced while the dentition is
held together in centric occlusion by an assistant. A
1.5-mm resorbable plate with at least 2 screw holes
on each side of the fracture is held along the inferior
border of the mandible in tooth-bearing regions. A
short drill bit (1.1 mm in diameter, 5 mm in length)
is used to place bone holes through the desired screw
positions on the plate. The drill holes are through the
outer cortex only so as to avoid drilling into unerupted teeth. A hand-held tap (1.5 mm) is then used to
cut the screw threads. Resorbable screws (1.5 mm in

diameter, 4 or 5 mm in length) are inserted until flush

with the plate (Figs 1, 2). In most cases, 1.5-mm plates
usually provide adequate fixation.
The free hand technique for maintaining a centric
occlusion before plate fixation works fairly well for most
isolated pediatric mandibular fractures. However, alignment of the visible buccal cortex does not always guarantee a perfect occlusal result, particularly in mandibular injuries with obliquely oriented fractures. In these
fracture patterns, the lingual cortex may be misaligned
and a gap on this side of the mandible may persist.
Unlike fixation with more rigid metal plates, resorbable
plates cannot really be overbent and their physical properties merely allow them to lie passively against the
bone. Such lingual misalignment cannot be easily corrected by these less rigid resorbable plates. Because this
classic principle of mandibular fixation cannot be effectively used, it is therefore important to carefully check
occlusal interdigitation after resorbable plate placement.
When mandibular fracture alignment cannot be easily reduced or held properly in centric occlusion, an
alternative technique is to place temporary wire ligature reduction across the fracture site (Fig 3). In this

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RESORBABLE PLATES/SCREWS IN PEDIATRIC FACIAL FRACTURES

FIGURE 3. Inferior border reduction technique before plate application in right mandibular parasymphyseal fracture in an 8-year-old boy. A,
Fracture exposure through cervical skin incision. B, Fracture reduced by inferior border metal screws and wire ligature. C, Shows 2.0-mm plate and
screw fixation. D, Metal screw and wire ligatures removed before closure.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial Fractures. J Oral Maxillofac Surg 2005.

technique, which may require a transcutaneous approach, metal screws are placed along the inferior
border and a wire ligature is placed between them to
reduce the fracture. While the reduction is held in
this manner, a resorbable plate is then placed on the
buccal cortex along the inferior border. The wire
reduction devices are subsequently removed.
One significant advantage of resorbable screws in
the pediatric mandible is the avoidance of potential
odontogenic injury.3 As the drill hole and tapping of
the screw threads penetrate only the outer cortex,
injury to developing teeth is unlikely. Even if the
resorbable screw tip encroaches upon a tooth, its tip
is blunt and nonpenetrating. Subsequent resorption
of the screw removes any potential obstruction to
tooth eruption. As such, resorbable plates and screws
may be applied in even the youngest mandible, where
the entire bone is composed entirely of teeth and
nerve (Fig 4).
MAXILLOMANDIBULAR FIXATION

A significant percentage of pediatric mandible fractures involve the condyle and can usually be treated

with a short period of immobilization without surgical

opening of the fracture site. In children, the frequent
absence of teeth due to primary teeth exfoliation and
the poor retentive shape of deciduous teeth crowns
make the traditional use of arch bars and interdental
ligatures impossible to apply. Several methods have
been described for achieving mandibular immobilization in the child, including the use of acrylic splints
and combined circummandibular and transnasal wiring. Acrylic splints, although effective, usually require
intraoperative impressions and model fabrication,
which are somewhat impractical given the value of
intraoperative time and limited access to dental materials, expertise, and laboratory facilities. Transnasal
wiring, combined with circummandibular wires, are
also effective but risk injury to developing teeth along
the pyriform aperture, the quality of the bone in the
paranasal region or anterior nasal is thin, and wire
engagement is not always secure. In addition, wire
removal in children almost always requires some type
of anesthetic for its removal.
In children, the amount of tolerance for displacement of the condyle is much higher than in adults and

BARRY L. EPPLEY

FIGURE 4. Resorbable plate and screw fixation in mandibular symphysis fracture in 3-week-old male infant. A, Fracture exposure through
chin laceration. B, Shows 1.5-mm plate and screw fixation. C, Postoperative radiograph showing fracture alignment.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial
Fractures. J Oral Maxillofac Surg 2005.

the length of mandibular immobilization may be

shorter. Any surgical method that can reasonably hold
the mandible in occlusal contact for a short period
will work. Borrowing from a soft tissue anchoring

389
method in endoscopic forehead surgery,4 a variation
of a bone-anchored method as opposed to using the
dentition may be used. This is accomplished through
resorbable screws placed into the zygomatic body
and mandibular symphysis to which is attached a
large monofilament circummandibular suture. While
it must be placed intraoperatively, this method of
maxillomandibular fixation (MMF) is rapid and secure, does not damage the teeth, and can be removed
in the office in the older child.
Under general anesthesia, a small maxillary vestibular incision is made bilaterally and the inferior aspect
of the zygoma is exposed. A 2.0-mm resorbable soft
tissue anchoring screw, in which a hole through the
screw head had been placed during manufacture, is
placed into the inferior aspect of the zygoma after an
initial drill hole (1.5 mm) and 2.0-mm threads were
created with a tap. One resorbable screw into each
zygoma is all that is necessary (Fig 5A). An awl is then
used to pass a large (0 or 2-0) nonresorbable monofilament suture around each side of the mandible
through the small percutaneous stab created by the
awl in the submandibular region. On the lingual side
of the mandible, the suture can be passed either
through the interdental space or around the last tooth
in the arch so that both ends of the suture are in the
buccal space. One end of the suture is finally passed
through the screw in the zygoma and tied bilaterally
with the mandible in centric relation (Figs 5B, C). The
knot should be placed high in the maxillary vestibule
so that it does not excessively irritate the gingival or
buccal mucosa. An alternative technique that adds
more interocclusal stability is to also place resorbable
screws in the symphysis at the inferior border as well
as that of the zygoma. The monofilament suture is tied
between the 2 screws, thus avoiding the need for a
circummandibular suture (Fig 6). When postoperative
release is desired after several weeks, the sutures may
be easily cut and removed in the office. The resorbable screws are left behind in the bone, which will be
eventually cleared within the first postoperative year.
In most children over age 5, the release may be
performed in the office with no discomfort. In the
younger child, sedation or a mask anesthetic may be
needed due to their decreased level of cooperation.
This bone-anchored (zygomaticomandibular) form
of MMF is particularly useful in children where the
short roots and nontapering tooth forms limit their
acceptance of any form of ligation. While wires may
be stronger, the use of a large monofilament suture
appears to be adequate (particularly when applied
bilaterally) and may be more comfortable for the
patient. The use of this MMF method in teenagers and
adults has not been attempted and is suspect due
to the higher forces generated by the masticatory
muscles.

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RESORBABLE PLATES/SCREWS IN PEDIATRIC FACIAL FRACTURES

FIGURE 5. Application of maxillomandibular fixation

through a bone-anchored approach. A, Shows
2.0-mm resorbable screw in inferior aspect of zygoma. B, Large monofilament suture passed through
the screw head and passed around the mandible. C,
When placed bilaterally and tied down, the patient is
maintained in centric occlusion.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial Fractures. J Oral Maxillofac Surg
2005.

MIDFACE FRACTURES

Zygoma
Zygomatic bony injuries almost never occur in the
developing face until the combination of globe development and pneumatization of the maxillary sinus is complete. Once this occurs, around the age of 7, the zygomatic facial prominence becomes evident and more
likely to be traumatized and fractured. Due to the
greater pliability of the bone at these young ages, most
zygomatic fractures are incomplete with the frontozygomatic suture being the pivot point. As such, the zygoma
is most displaced along the posterior maxillary buttress
in most cases.
With this fracture pattern, intraoral reduction and
single-plate application is usually the only fixation
point needed. Realignment of the posterior maxillary
buttress restores anatomic reduction along the infraorbital rim and lateral orbital wall.

Orbit
Fractures of the bony orbit are relatively uncommon
in children but increase after age 7 due to the completed
growth of the globe. Once a child is old enough so that
pneumatization of the sinuses is complete, orbital fracture patterns resemble that of adults with floor blowouts
being the most common fracture defect. Orbital roof
fractures, which are rare in adults, may be seen in
association with anterior cranial base injury from direct
blunt trauma to the brow region.
Maxilla
Fractures of the maxilla (midface) are not likely to
occur unless there is a maxillary sinus that provides an
air space between the eyes and the teeth. When combined with the protective features of the juvenile face,
such as a poorly projecting flat face and a greater
amount of facial fat for padding, horizontal fractures in
this region (Le Fort I) have not been seen by this author.

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BARRY L. EPPLEY

Frontal/Brow
Unlike adults, the prominence of the forehead and
thinness of the bone in children makes fractures of the
frontal bone, supraorbital rim, and orbital roof possible
with direct impact-type injuries. With significant force,
intracranial injury (pneumocephalus, epidural and subdural hematomas, and cerebral contusion) are seen. Posterior displacement of the frontal and supraorbital rim or
inferior displacement of the orbital roof requires open
surgical reduction. Wide exposure through coronal incisional access combined with a frontal craniotomy is
often needed to dismantle the fracture sites, obliterate
the involved sinus, and reassemble the contour of the
brow and frontal bone. Fixation of the bone segments
with resorbable 1.5-mm devices is well suited to the low
load-bearing demands of this region (Fig 7).
Resorbable plates and screws can be an effective
fixation method for facial fractures in children in the
primary and mixed dentition periods. Whether used for

FIGURE 7. Resorbable plate fixation of supraorbital rim and frontal

craniotomy flap in severely impacted frontal injury. A, Impacted fracture. B, Fixation of repair.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial
Fractures. J Oral Maxillofac Surg 2005.

plate fixation of fractures of the tooth-bearing region of

the mandible, a bone-anchored method of MMF, or in
the very low load-bearing upper and midface regions,
they provide adequate stability for the rapid bone healing of youth. The blunt tips of the screws and their
eventual resorption offer essentially no risk to developing teeth and nerve structures or ongoing facial growth
and eliminates long-term foreign body retention. No
delayed foreign-body reactions or inflammation has
been seen with the resorbable polymers used in this
patient series.

References
FIGURE 6. Alternative to a circummandibular ligature for maxillomandibular fixation. A, Placement of additional screws in symphysis
through which the monofilament suture is passed from the zygomatic
screws. B, Tying down the suture between the 2 screw locations
bilaterally provides a very secure method of maxillomandibular
fixation.
Barry L. Eppley. Resorbable Plates/Screws in Pediatric Facial
Fractures. J Oral Maxillofac Surg 2005.

1. Mouzakes J, Koltai PJ: The biology of pediatric facial fractures.

Facial Plast Surg Clin North Am 6:487, 1998
2. Davison SP, Clifton MS, Davison N, et al: Pediatric mandible
fractures. A free hand technique. Arch Facial Plast Surg 3:185,
2001
3. Koltai PJ, Rabkin D, Hoehn J: Rigid fixation of facial fractures in
children. J Craniomaxillofac Trauma 1:32, 1995
4. Eppley BL, Coleman JC III, Sood R, et al: Resorbable screw
fixation technique for endoscopic brow and midfacial lifts. Plast
Reconstr Surg 102:241, 1998