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displaced fractures. D: The infraorbital rims, zygomatic bodies, and maxilla are palpated and
examined from the top of the head to determine depressions and fracture displacement. E: The
nasal bone and maxilla are examined for stability and possible fracture displacement. F: The
nose is examined intranasally to determine the placement of the nasal septum and the possible
displacement of nasal bones or disruption of nasal mucosa. G: The occlusion is observed to
determine any disturbances of normal teeth relations. H: The mandible is palpated and then
retracted to determine sites of discomfort and possible mandibular fractures.

Neurologic examination of the face should include evaluation of both sensory
and motor functions. All three branches of the trigeminal nerve should be
evaluated for sensation. Anesthesia of the cheek suggests injury to the infraorbital
nerve, whereas anesthesia of the lower teeth and lower lip suggests inferior
alveolar nerve involvement. The facial nerve should be evaluated by asking the
patient to wrinkle the forehead, close and open the eyes fully, smile, show his or
her teeth, and close the mouth tightly.

Determination of Appropriate Imaging Modality
The use of radiography in the evaluation and management of children with facial
trauma should be considered if there is a concern for fracture based on history and
physical examination. The complexity of bony and soft tissue facial structures can
make the interpretation of plain radiographs difficult. In addition, plain
radiographs are often inadequate to determine whether a patient requires
operative intervention.
Computed tomography (CT) has mainly replaced plain radiographs in the
definitive assessment of bony facial injuries because it has a greater ability to
detect fractures and associated displacement as well as visualize soft tissue
structures. Axial views demonstrate fractures of the anterior and posterior walls
of the frontal sinus, medial and lateral orbital walls, posterior wall of the
maxillary sinus, zygomatic arches, and mandible. Coronal views demonstrate
fractures of the ethmoid, sphenoid, and paranasal sinuses; orbital floors and
infraorbital rims; the nasoethmoid region; and mandibular condyles and

symphyses. Coronal imaging requires hyperextension of the neck and thus
requires prior exclusion of a cervical spine injury. Three-dimensional CT imaging
can help guide operative repair.
Despite their limitations, there are specific plain radiograph views that may be
of utility for the evaluation of facial fractures in children. The Waters view
(occipitomental) is used to visualize the midface region: the orbital rims and floor
of the orbit, nasal bones, zygoma, and maxilla. This view may be particularly
useful in patients suspected of having a blowout fracture of the orbit, as well as
for detecting fluid in the maxillary sinus. The Caldwell view supplements the
Waters view for the evaluation of the upper two-thirds of the face, including