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Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx

Review
Recent advances in the management of oral and
maxillofacial trauma
Rory C. O’Connor a,∗ , Kaveh Shakib b , Peter A. Brennan c
a Specialist Registrar in Oral and Maxillofacial Surgery, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Derby Road, Nottingham,
NG7 2UH
b Consultant Oral and Maxillofacial Surgeon, The Ridgeway, Enfield, Middlesex, EN2 8JL
c Consultant Oral and Maxillofacial Surgeon, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY

Accepted 20 August 2015

Abstract

This review summarises recently published papers on maxillofacial trauma in 2 widely read journals: the British Journal of Oral and Max-
illofacial Surgery (BJOMS) and the International Journal of Oral and Maxillofacial Surgery (IJOMS). Since a large proportion of the injuries
seen in oral and maxillofacial surgery (OMFS) departments are fractures of the facial skeleton, we primarily focus on their assessment and
treatment, but also cover problems that affect the temporomandibular joint (TMJ) (including ankylosis), military injuries, polytrauma, and the
use of perioperative drugs. Between 2012 and 2013, 121 articles were published in the 2 journals. Most of the research concerned mandibular
fractures, particularly those involving the condyle, but epidemiological studies and midfacial fractures were also well represented. Even though
the incidence of facial injury is high, it is difficult to collect data particularly when long-term evaluation is required, as rates of compliance
and attendance at follow up tend to be low. The number of large-scale studies was therefore small. A concerted effort to collaborate nationally
and across specialties to undertake larger studies will help to improve outcomes.
© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Facial trauma; Review; Fracture; Mandible; Condyle; Ankylosis

Introduction of facial injuries, and future areas that require development,

The assessment and management of patients with facial
injuries is a core part of the workload of the Oral and Max-
illofacial surgeon. The treatment of many injuries has now
been standardised, but techniques and technology evolve,
and in some areas, such as the treatment of condylar frac-
tures, there is conflicting evidence, and in others there is no
evidence at all. To gain an insight into the current contro-
versies about treatment, new approaches to the management
∗
Corresponding author. Tel.: +0115 969 1169; fax: +0115 9627939.
E-mail addresses: roaroconnor@gmail.com (R.C. O’Connor),
k.shakib@shakib.org (K. Shakib), peter.brennan@porthosp.nhs.uk
(P.A. Brennan).
we have summarised articles pertinent to OMFS trauma
published between 2012 and 2014 in 2 of the leading jour-
nals with the highest impact factors in the field, the British
Journal of Oral and Maxillofacial Surgery (BJOMS) and
the International Journal of Oral and Maxillofacial Surgery
(IJOMS). The review is designed to be an educational
resource, not an all-encompassing review to answer a specific
question.
Between the 2 journals, 121 articles relating to trauma
were published (Tables 1 and 2). The low number of prospec-
tive and randomised controlled trials has been highlighted
previously,1 and this trend seems to be continuing. Mandibu-
lar trauma is a popular topic but other regions, including the
frontal bone and temporomandibular joint (TMJ), are less

http://dx.doi.org/10.1016/j.bjoms.2015.08.261
0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
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Table 1
Articles on facial trauma published in the British Journal of Oral and Maxillofacial Surgery in 2012-2013 according to anatomical region.
Review Meta-analysis/ RCT Prospective Retrospective Case report/ technical note Letter Total
Mandible - 1 9 7 9 - 26
Midface 1 1 - 4 8 - 14
Frontal - - - 1 2 - 3
TMJ 1 - 1 1 2 1 6
Pan facial 1 - 5 4 - 2 12
Other 3 - 2 2 - - 7
Total 6 2 17 19 21 3 68

Table 2
Articles on facial trauma published in the International Journal of Oral and Maxillofacial Surgery in 2012-2013 according to anatomical region.
Review Meta-analysis/ RCT Prospective Retrospective Case report/ technical note Letter Total
Mandible - 1 8 9 4 4 26
Midface - - 3 6 1 4 14
Frontal - - 1 - 1 - 2
TMJ - - - 1 - - 1
Pan facial - - - 4 1 - 5
Other 1 - 1 - - 3 5
Total 1 1 13 20 7 11 53

Table 3
General key points.
Young men have the highest risk of facial injury because of interpersonal violence and sport. Alcohol and drug abuse are implicated in 15%-40%, and
47% of injuries, respectively
Children from the lowest socioeconomic group are 1.89 times more likely to sustain a facial injury than those from the highest group
Falls are the most common cause of facial injury in people over 60 and cause a large proportion of the total number of facial injuries
No more than 24 hours of postoperative antibiotics are necessary after repair of orbital and mandibular fractures as longer courses do not reduce
infection rates further
Perioperative steroids reduce postoperative nausea, vomiting, and swelling, and do not seem to impair healing through immunosuppression
Emergency access to theatre is inadequate for patients with facial injuries and 30% of cases are delayed because others are more urgent
The incidence of serious complications in patients with facial injuries who are operated on out-of-hours is over 3 times that of those operated on
in-hours

Table 4
Key points: mandibular fractures.
Cortical bone in the parasymphyseal region may be less than 4 mm thick, so the stabilisation of fractures with screws longer than 4 mm may injure the
apicies of the teeth
It is not necessary to remove a wisdom tooth that complicates a fractured mandibular angle as postoperative infection rates are the same (11%)
whether it is removed or not
For fractures of the angle, the incidence of plates being removed secondary to infection is higher if the plate was placed on the external oblique ridge
than on the buccal aspect of the mandible (OR 5.05)
Stress tests suggest that osteosynthesis of a fractured mandibular condyle should be done with 2 plates, as one is not sufficiently stable
Animal and histological studies have shown that resorbable poly D,L-lactide plates and pins are suitable tools in the fixation of condylar fractures, but
further evaluation in humans is required

Table 5
Key points: midfacial and orbital fractures.
Children with fractures of the orbital floor are at risk of muscular incarceration because of the trapdoor effect of the bone at the fracture site; this
requires prompt surgical release within 24-48 hours to prevent permanent visual disturbance
Fractures of the orbital wall may be treated conservatively if the defect is small (less than 3cm2 ), with little enophthalmos (less than 2 mm) and if there
is no entrapment of periorbital tissue
Cannulation of the lacrimal duct with a silicone catheter can protect the lacrimal appartus during repair of naso-orbitoethmoidal fractures

Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
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Table 6
Key points: nasal and frontal fractures.
An intraoperative anterior ethmoidal nerve block with infiltration of the dorsum of the nose provides good postoperative analgesia in patients
undergoing reduction of nasal fractures
Cranialisation or obliteration of the frontal sinus may be required if there is evidence on computed tomography of a fracture of the sinus floor or
medial wall of the anterior table, or an outflow obstruction, as they suggest blockage of the nasofrontal duct
Fractures of the anterior table of the frontal sinus may be accessed and repaired endoscopically by suitably trained surgeons with the incisions hidden
behind the hairline

Table 7
Key points: temporomandibular joint (TMJ).
Trauma is the most common cause of ankylosis of the TMJ particularly if sustained under the age of 5
Ossification of a haemarthrosis, intra-articular damage to the disc, aberrant lateral pterygoid pull, and periarticular soft tissue injury, have been
implicated in the development of ankylosis
For soft tissue injuries, magnetic resonance imaging (MRI) is the imaging of choice as it shows displacement of the disc and damage to the articular
surface not evident on plain radiographs or computed tomography
Treatment for ankylosis is not standardised. Simple excision (with or without arthroplasty), condylectomy with resurfacing of the joint with a
costochondral graft, and osteotomies have been described but none are free from recurrence

well represented. Most publications included are full-length
articles. Short communications and letters were included only
if they added to the knowledge. Tables 3 to 7 highlight key
points of management for each anatomical region.
Epidemiology of facial trauma
A total of 325 patients with facial injuries attended accident
and emergency (A&E) departments in the west of Ireland over
one week (5.2% of attendances), and the annual incidence
was 1619/100 000.2,3 Men were injured more than women
(68% compared with 32%), and half of all patients were aged
between 15 and 45. The commonest causes were falls (39%)
and sporting activities (29%). Fractures accounted for 25%
of presentations, and 65% of those affected were male. The
commonest sites were the nose (50%), mandible (25%), and
zygoma (12%).
In a Dutch trauma centre over a 6-year period, 394 patients
with facial fractures required an operation.4 The male:female
ratio was 3:1 with a peak incidence in young men (35% of
fractures). Forty-two percent were caused by car crashes.
Interpersonal violence and sports caused more injuries in men
than in women (ratios of 9.5:1 and 8.2:1, respectively), and
mandibular and zygomatic fractures accounted for more than
80% of the total. In another trauma centre the characteristics
of patients with facial injuries sustained in the workplace
were similar to those of the general population with young,
male, manual workers most commonly affected.5
Rashid et al analysed 1261 patients with 1994 mandibular
fractures in London over 5 years.6 The male:female ratio was
6.6:1 with peak incidences in the third decade for both sexes,
and a smaller peak in women over 70. Most of the fractures in
men were caused by interpersonal violence (77%) and falls
(18%), but in women falls were the most common cause. The
incidence of fractures associated with road traffic accidents
(4%) was low, which reflects the improvements in car safety.
Alcohol was implicated in 15%-40% of facial injuries,3,4,7
and in Scotland the incidence of facial injuries in children that
are related to alcohol has not improved in a decade.8 O’Meara
et al found that patients with facial fractures were more likely
to need an operation if they had consumed alcohol within the
preceding 8 hours, or were victims of interpersonal violence,
with relative risks of 1.61 and 3.10, respectively.9
McAllister et al found that 44/93 (47%) of those admit-
ted for facial injuries had evidence of illegal drugs in their
urine.7 Cannabinoids and benzodiazepines were most often
detected. Both alcohol and drugs were found in 17% of cases,
although 32/44 patients whose toxicology results were pos-
itive denied substance abuse. Reluctance to admit to using
drugs has implications for general anaesthesia and analgesia.
Patients with facial injuries often have other injuries on
the head and limbs (19%-30% and 22%-25% of associ-
ated injuries, respectively), which can prolong their stays in
hospital.3,4 In a review of the management of traumatic brain
injuries, Tsang and Whitfield reported that 24% of patients
with craniofacial fractures also had fractures in the base of
the skull, which were complicated by the leakage of cere-
brospinal fluid in 20%.10 Leaks can be treated conservatively,
but antibiotics are not recommended.
A total of 45 388 children (0.5% of the population) with
facial injuries required admission in Scotland over 10 years,
giving an incidence of 4.7/1000.8 Injuries occurred more
often in boys (6.21/1000) than in girls (3.20/1000), while
children younger than 2 years and those aged 15-17 were
most likely to be affected. Poor coordination in young chil-
dren when learning to walk predisposes them to falls, and
in older children, risk-taking behaviour and use of alcohol
increase the chance of injury. In another series, 91/325 (28%)
of presentations to A&E were children under the age of 14.2
As children from the lowest socioeconomic group are 1.89
times more likely to be injured than those in the highest,8
public health programmes designed to reduce the number of
facial injuries should be aimed at this group.

Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
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In a prospective, observational study that compared facial
injuries in those under and over the age of 60, Velayutham
et al found that falls were the most common cause in the
older group (40/470, 9%), and the site most commonly
fractured was the zygoma, which could often be managed
conservatively.11 However, 17/34 patients who fell were tak-
ing 5 or more drugs, which suggests an association between
polypharmacy and falls. As falls were also found to be the
leading cause of facial injury in patients over 60 in 2 other
series,2,6 those at risk should be enrolled in prevention pro-
grammes.
Mandibular fractures
Symphyseal and parasymphyseal fractures
For parasymphyseal fractures, osteosynthesis plates should
be placed below the apices of the teeth but above the mental
foramen. De Souza Fernandes et al assessed the thickness of
cortical bone, and the interapical distance of canine, first, and
second premolar teeth in cadavers.12 Roots were present at
the level at which the plate was fixed but a 2 mm diameter
screw could be used as there was more than 3 mm between
them. The buccal cortex was less than 3 mm wide, thinner
than that reported to be necessary for stabilisation. Al-Jandan
et al found that the buccal bony depth was 3.1 - 3.7 mm in
the canine and premolar region, and the predicted risk of
damaging the apex of the tooth during insertion of a screw
4 mm long was 30%, 18%, and 38% for canine, first, and
second premolars, respectively.13 More studies are required
to find out whether the minimum thickness of bone needed
to stabilise a parasymphyseal fracture could be reduced.
Mandibular fractures in children can be managed using
custom-made acrylic or acrylic and steel-wire splints,14,15
which are made using impressions taken under general anaes-
thesia and secured with circum-mandibular wires. However,
the technique is not suitable for fractures of the angle.
Fractures of the mandibular angle
Buried or partially erupted third molars may weaken the angle
because they reduce the area of bone, but in 190 patients no
association was found between the degree of eruption and
fracture.16 The presence of the tooth alone caused weak-
ness and predisposed the bone to fracture. Three-dimensional
finite element reconstruction of human mandibles has been
used to find out whether the presence of third molars weakens
the angle.17 The technique converts geometrically complex
structures into simple shapes that are more easily examined
to approximate structural behaviour.18
When a third molar is present, stress is concentrated at
the angle of the mandible, but is transferred to the condyle
if absent, leading to fractures here instead.16,17 The removal
of teeth in the fracture line has long been debated, and in a
meta-analysis of 1542 fractures of the angle in which teeth
Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
complicated the fracture site, postoperative infection rates
were 11% whether the tooth had been removed (84/788) or
not (84/754).19
Titanium miniplates are usually used to fix fractures of
the angle, but malleable plates are also available, which are
half the volume and more pliable. In a biomechanical study
on sheep, fractures of the angle were stabilised using mini-
plates or malleable plates on the external oblique ridge.20 The
malleable plates, which fractured above 90 newtons (less than
occlusal biting force) and showed more vertical displacement
than miniplates when loaded at lower forces, were considered
unsuitable. An alternative to fixation of the external oblique
ridge is plating of the buccal aspect of the mandible below the
ridge. A randomised prospective trial found that more ridge
plates (28/137, 20%) than buccal plates (6/124, 5%) had to be
removed because of infection (odds ratio 5.05).21 Smoking,
preoperative displacement of bony fragments by more than
5 mm, and postoperative malocclusion, were also associated
with infection.
Favourable and unfavourable patterns of angle fractures
have been described in which the pull of the masticatory
muscles either reduces or distracts the fracture. Pektas et al
compared osteosynthesis of the 2 patterns using titanium
miniplates placed buccally in sheep.22 There was no dif-
ference between the groups in the distance the fracture was
displaced under loading, and maximal breakage forces were
similar, which suggested that the fracture pattern should not
affect the operative technique.
Chen et al compared the use of resorbable poly-L-lactide
screws (reinforced with polyglycolic acid fibres) with tita-
nium and non-reinforced resorbable screws to fix sagittal
split fractures in pigs.23 Shear and torsional strength were
greater in the reinforced poly-L-lactide screws than the non-
reinforced screws, and there was no difference in breakage
force for each screw. In vivo testing is now required.
Condylar fractures
For condylar fractures, consensus has moved towards open
reduction and internal fixation (ORIF) with transoral or trans-
buccal access. Yang and Patil described a retromandibular
transparotid approach,24 but despite meticulous dissection
of the facial nerve during parotid transit, 8/42 patients
experienced transient weakness, and 3/42, a salivary fis-
tula. Narayanan et al used a transmasseteric anterior parotid
approach instead,25 and functional occlusion was achieved
in all patients with no facial weakness. By passing anterior
to the parotid, a window is created by the divergence of the
buccal and zygomatic branches of the facial nerve.25,26 Pau
et al used a transtragal incision, which combined preauricu-
lar and aural incisions to detach the tragal cartilage, to allow
deeper exposure of the fracture site.27 Although the carti-
lage was separated it did not become infected or necrotic.
The cartilage of the external auditory canal may also be
detached to expose fractures using the retroauricular trans-
meatal approach, which hides the scar behind the ear.28
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Endoscopic stabilisation of condylar fractures has been
tested in minipigs.29 Operating times for a novice improved
from 183 minutes to around 50 minutes after 10 procedures
had been completed, equalling that of an experienced sur-
geon.
Fixation of condylar fractures has been evaluated using
photoelastic stress analysis on mandibular resin models to
show areas of tension and compression by the diffraction of
light passing through the material.30 Fractures fixed using a
single miniplate were not sufficiently stable, but stability was
comparable to controls when 2 miniplates or one miniplate
and a microplate were used. Finite element analysis of human
mandibles also showed that 2 miniplates were better than
one.18 Distraction of the fragments using one miniplate, 2
non-parallel, and 2 parallel plates, was 115 ␮m, 46 ␮m, and
30 ␮m, respectively. The mean stress in the plates and screws
was 2.5 - 3.0 times greater when one miniplate (rather than
2) was used. Interestingly, 2 parallel miniplates led to less
bony distraction and stress than the non-parallel arrangement.
When the fragments of a subcondylar fracture overlap, Gahir
et al suggested inserting a screw in the mandibular angle
around which a wire can be hooked to provide traction along
the axis of the ramus.31
Anatomical reduction is necessary when treating intracap-
sular condylar fractures, as loss of articular cartilage has been
shown to distort growth and reduce the height of the ramus in
animals.32 Computer-aided design (CAD) using reformatted
computed tomography (CT) can simulate the reduction of a
fracture and guide the length and placement of screws.33–35
Schneider et al used resorbable poly D,L-lactide plates
secured with resorbable ultrasound-activated pins, and pins
alone, to treat condylar neck and intracapsular fractures in
sheep, respectively.36,37 Performance was comparable to tita-
nium screws, and macroscopic and histological evaluation
found little inflammatory infiltrate at the pin sites, normal
bony healing, and complete resorption at 12 months.
Resorbable screws were used to fix intracapsular condy-
lar fractures in 19 patients.35 Normal occlusion and mouth
opening were restored in 18 of them, and there were no long-
term complications. A resorbable mesh of the same material
secured with ultrasound-activated resorbable pins was used
to treat 5 patients with fractures of the condylar neck.38
Singh et al reported 12 patients whose condylar fractures
were fixed with one resorbable plate.39 In 6 the result was
satisfactory, but in the other 6 the plate failed intraoperatively
and had to be replaced or reinforced by a titanium plate, or
the patient put into intermaxillary fixation (IMF). Also, 7
screws broke. Since one titanium plate is not sufficient, one
resorbable plate will be unstable too.
The condyle is the most common part of the mandible
to fracture bilaterally,6 and complications are more severe.
Forouzanfar et al evaluated outcomes in patients with bilat-
eral condylar fractures who were treated conservatively with
IMF for 6 weeks.40 Overall, 9/71 (13%) developed a maloc-
clusion and none had pain in the TMJ, but only 41/71 (58%)
had long-term follow up. IMF seems to be appropriate in these
Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
5
cases even if a malocclusion develops, as it does not always
result in functional deficit or pain. However, 30 patients,
including 4 treated with osteotomy or orthodontics for a
malocclusion, were lost to follow up. The dentures of a 61-
year-old man with bilateral condylar fractures were secured
to his maxilla and mandible so they could act as splints during
healing.41
Midfacial and orbital fractures
Orbital fractures account for 45%-56% of all facial fractures
in children.42 The orbital roof is more likely to fracture than
the floor in children younger than 7 because of the protuber-
ance of the frontal bone, but muscle entrapment in a fracture
of the orbital floor necessitates urgent decompression. This
is because the trapdoor-type pattern predominates in patients
under 16 because of bony plasticity, which allows the floor
to hinge rather than break.43 Once the trapdoor springs back,
periorbital tissue becomes incarcerated in the fracture site and
causes diplopia and restricted eye movement. The oculovagal
reflex, which causes nausea and vomiting from traction on the
extraocular muscle or pressure on the globe, suggests entrap-
ment. The trapped tissue becomes ischaemic, and warrants
repair within 24-48 hours.42,43 Diplopia and restricted eye
movement are less common in blowout fractures as the bone
breaks completely, so it is suggested that they are repaired
within 3 days.43
Kunz et al assessed functional outcome in mild to moder-
ate fractures of the orbital wall to find out whether indications
to operate could be based on the site, size, and pattern of
fracture.44 Only enophthalmos correlated with the size of the
defect, whereas diplopia resolved in all patients, which made
it a less reliable indicator. Fractures of the orbital wall can
be treated conservatively when the defect is less than 3 cm2 ,
and when enophthalmos is less than 2 mm and no soft tissue
or muscle is trapped.
Hundepool et al found that endoscopically-controlled
reduction of fractures of the orbital floor improved enoph-
thalmos and diplopia when compared with controls because
it allowed visualisation of the entire defect.45 Even when
the orbit is reduced completely, diplopia can persist because
of adhesions from tethered scar tissue. Insertion of allo-
geneic amniotic membrane is a potential solution as it is not
adhesive.46
Custom-made polyetheretherketone implants, constructed
in 2 parts to enable each component to be inserted
along a different path, have been tested for reconstruction
of orbitozygomatic fractures.47 Reduction of comminuted
orbitozygomatic and nasofrontal fractures is easier with
screw-wire traction.48,49 A stainless steel wire, which is
twisted to form a tight coil with a loop at the end, is hooped
over a screw in the fragment of bone to enable it to be reposi-
tioned. Depressed fractures of the zygomatic arch can also be
reduced with wires inserted percutaneously if looped around
the arch.50 Circumzygomatic wires were used to suspend a
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loose maxillary obturator in a patient with a contralateral Le
Fort I fracture to permit feeding during healing.51
Iwai et al investigated whether intubation of the lacrimal
system with a silicone tube during ORIF of displaced naso-
orbitoethmoidal fractures prevented ductal blockage and
epiphora.52 Cannulation was successful in 13 patients and
none had epiphora, but care must be taken during cannulation
to prevent damage to the ductal system.
Nasal and frontal fractures
Yilmaz et al evaluated closed reduction of nasal fractures
in 24 children.53 At 6 months 15/24 were satisfied with the
result. Nine were not, and of them, 8 would consider an
operation to improve cosmesis. More patients were satisfied
when the reduction was done within 5 days of injury (12/16)
than after (3/8), but satisfaction was not clearly defined. An
anterior ethmoidal nerve block with percutaneous infiltration
of the dorsal nose given during reduction of nasal fractures
provides excellent pain relief and reduces the need for post-
operative analgesia.54
In fractures of the frontal sinus, 3 findings on CT suggest
obstruction of the nasofrontal duct: fractures of the sinus floor
or medial wall of the anterior table, and obstruction of the
outflow.55 If all 3 are present, there is a serious risk of injury
to the outflow tract with a positive predictive value of 81%, so
cranialisation or obliteration of the sinus is required. When
CT shows no evidence of obstruction the nasofrontal duct
may be intact, which permits preservation and reconstruction
of the frontal sinus.
Fractures of the anterior table can be accessed endoscop-
ically with incisions above the hairline.56 Rao et al plated a
fracture above the supraorbital rim through an incision in the
upper eyelid crease.57 They inserted screws using a 90◦ drill
and screwdriver, and smoothed the defect in the contour with
calcium phosphate cement.
Temporomandibular joint
Trauma was the most common cause of ankylosis, partic-
ularly if sustained before the age of 5 years.58 Patients
with sagittal condylar fractures and those from developing
countries were more likely to develop ankylosis because of
malnutrition, poor access to healthcare, the cost of treatment
and untreated infections.58,59
Ossification of a haemarthrosis, or damage to the intra-
articular disc have been proposed as causes of ankylosis.59
In sheep Liu et al found that bony overgrowth occurs in the
condylar head following a sagittal fracture.60 The degree
of overgrowth was reduced if the attachment of the lateral
pterygoid was cut, suggesting that the pull of the muscle con-
tributes to the remodelling of bone post fracture, which can
result in overgrowth and subsequent ankylosis.
Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
Damage to the soft tissue around the joint without frac-
ture can also lead to ankylosis, osteoarthritis, and internal
derangement of the disc.61 In 8 patients, magnetic resonance
imaging (MRI) showed displacement of the disc and destruc-
tion of the articular surface not evident on CT or radiograph.
If caught early, symptoms can be treated with arthroscopic
lysis and lavage before the joint degenerates. Yu et al used
MRI to show soft tissue injuries to the TMJ in 18 patients with
19 intracapsular condylar fractures.62 It confirmed displace-
ment of the disc (n = 15), tears in the capsule (n = 9), and tears
in the retrodiscal tissue (n = 16). All 19 had joint effusions,
16 of which were haemarthroses. Their findings suggest that
MRI is the best imaging technique for these injuries.
Operations for ankylosis are reserved for patients with
chronic pain and restricted mouth opening. Some surgeons
excise the ankylotic mass while others do an arthroplasty or
osteotomy.59 He et al did a high condylectomy and resurfaced
the joint with a costochondral graft, but also repositioned a
displaced disc.61 However, there is always a risk of recur-
rence. Kanatas et al used a 2-stage procedure in which the
ankylotic mass was removed and the joint reconstructed later
with a prosthesis.63 Persistent dislocation has been treated
with condylotomy to separate the dislocated condyle from
the mandible.64
Military injuries and polytrauma
Breeze et al proposed a framework for the development of
military neck protection after an increase in the number of
cervical injuries in the British forces.65 From 2006-2010,
explosions caused 79% of neck injuries, of which 41% were
fatal. Deaths resulted from serious injuries to the vessels or
spinal cord, so any neck injury model should incorporate
these structures. This should be coupled with a system that
maps surface wounds and records those caused by projectiles.
Analysis of fragments removed after injury enables better
understanding of their behaviour, but it is difficult to iden-
tify every piece, and removal is not always possible. CT can
locate and characterise fragments left in place to increase
sample sizes for modelling,66 and computer programs can
then simulate how structures in the neck respond to projec-
tiles, which can inform the design of a prototype. The British
OSPREY neck collar is not worn widely so development has
begun to interweave ballistic material into the collars of body
armour shirts.65
Panfacial injuries cannot be categorised in the same way
as isolated fractures, particularly when they traverse differ-
ent anatomical regions. Ahmad et al proposed a classification
based on existing scoring techniques.67 The “ZS” maxillo-
facial trauma scoring system, which combined and modified
4 existing systems, correlates well with current methods and
has good interobserver and intraobserver reliability (0.98 and
0.99, respectively), but requires refinement to incorporate soft
tissue injuries.
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Perioperative antibiotic and steroid prophylaxis
Antibiotic prophylaxis in facial trauma is haphazard as pro-
tocols vary between hospitals and depend on the preference
of the surgeon. Two randomised, double-blind, placebo-
controlled, single centre studies provided a foundation for
standardisation. In the first, which assessed antibiotic regi-
mens in patients who required repair of orbital fractures,68
amoxicillin with clavulanic acid was given intravenously
from admission to 24 hours postoperatively. The experimen-
tal group had 4 further days of the drug and the control a
placebo. There was no difference in infection rates between
the groups. The second study involved patients who had
ORIF for mandibular fractures.69 The antibiotic protocol was
identical to the first study but patients were also prescribed
chlorhexidine mouthwash. There was no difference in infec-
tion rates between patients who had one day as opposed to
5 days of antibiotics. The infection rate was higher (8/32)
when teeth were in the fracture line, than when they were
not (4/27), but this has not been confirmed elsewhere.21 Both
studies lacked statistical power, many eligible patients were
excluded, and the duration of preoperative antibiotics varied,
but as wide-ranging definitions of infection were employed,
infection rates were accurate.
A prospective multicentre audit evaluated infection rates
in patients who had fixation of mandibular fractures.70 In
the first cycle, antibiotics were given for 3-5 days postopera-
tively, and the infection rate was 10% (15/145). In the second,
antibiotic regimens were standardised to finish 24 hours post-
operatively, and 9% (14/157) had infections. Repairs of
orbital and mandibular fractures are clean-contaminated pro-
cedures so there is a risk of infection without antibiotics, but
evidence suggests that only 2 postoperative doses should be
given.
Perioperative glucocorticoids reduce nausea, pain, and
swelling, but also suppress immunity, which may impair
healing. In a randomised single-blind trial of patients who
required ORIF for fractured mandibles, healing was impaired
no more in those who were given dexamethasone periop-
eratively (7/20) than in controls (6/21).71 Interestingly, all
patients were given antibiotics for between 7 and 10 days
postoperatively. Age over 25 was associated with impaired
healing but smoking, delayed treatment, and duration of oper-
ation, were not.
Sports injuries
Farrington et al found evidence that supported the wear-
ing of protective headgear in different types of sporting
activities.72 The wearing of mouthguards in boxing and hel-
mets in cycling, are compulsory, but the use of protective
equipment in football and rugby is not. Mouthguards that
are 6 mm thick dissipate forces 4 times greater than those
2 mm thick, and the depth and density of the lining material
rather than the shell governs how well a helmet will perform.
Please cite this article in press as: O’Connor RC, et al. Recent advances in the management of oral and maxillofacial trauma. Br J Oral
Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.08.261
7
Although 90% of eye injuries are preventable, the uptake of
protective eyewear is poor even in high-risk sports.
Thermoplastic splints manufactured using 3-dimensional
scans of the face allow a quicker return to contact sport for
players with a facial fracture, as the images can be manip-
ulated to add areas of relief around the fracture before the
manufacture of a physical model.73
Service provision for facial trauma
Sherman and Kouchard developed a proforma for the assess-
ment of patients with facial injuries to improve both the
quality of the documentation and communication with
colleagues.74 Data collected from the proformas can be used
to guide service provision.
Access to emergency theatres in OMFS is poor because
injuries are not life-threatening. In a prospective UK audit,
operations in 67/222 of patients (30%) were delayed,75
mostly because other cases were more urgent. Bertram
et al found that more serious complications occurred
when patients were operated on out-of-hours (7/53, 13%)
than when operations were done in-hours (3/81, 4%),
although there was no difference in the incidence of minor
complications.76 Dedicated trauma lists would solve these
problems.
Conclusion
Although the incidence of facial trauma is high, the num-
ber of large-scale trials is disappointing. Randomisation is
often impossible, and most studies included less than 100
patients. The management of condylar fractures has devel-
oped, and resorbable osteosynthesis is a future avenue for
research. Collaboration in larger-scale trials would improve
outcomes, not just between departments, but nationally and
across different specialties.
Conflict of Interest
We have no conflicts of interest.
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