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Craniomaxillofacial Trauma

April 29, 2022 - read ≈ 24 min



Daniel P. Caruso, DDS, MD

Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA


Elaina Pullano, DMD

Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Harvard School of Dental Medicine, Boston, MA

Jeffrey T. Hajibandeh, DDS, MD

Instructor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA



Craniomaxillofacial trauma is a significant and complex issue to manage in wartime settings. Injuries of the facial skeleton are commonly sustained secondary to projectiles and munitions and may present with various hard and soft tissue defects that often require extensive secondary.1 Facial injuries should be immediately triaged and managed either acutely or secondarily depending upon the local craniofacial factors and the global injury burden of the patient.2 The patterns of facial injury sustained in a wartime setting differ from the civilian population with a higher propensity of mid- and upper facial injuries likely due to the combination of missile and blast injuries,3 however the morbidity and mortality from these injuries is similar.4 Additionally, many patients suffer a combination of bone and tissue loss that requires secondary management.5 The articles serves to review acute management strategies for craniomaxillofacial injuries in the wartime setting which follow the AO/ASIF principles of facial fracture management.

The principles of Advanced Trauma Life Support (ATLS) should be applied and followed in the emergency setting regardless of the injury burden. Facial injuries may be intimidating in appearance and pose a particular risk for airway compromise, especially in the unconscious patient.6 Hemorrhage may obstruct visualization and midface fractures can cause distortion of anatomy due to displacement into the oropharyngeal cavity.7 Securing the airway is a priority and injuries complicating this task must be quickly recognized in order to provide the most appropriate and efficient treatment.

Most maxillofacial injuries are not true emergencies and definitive management can usually be delayed until the patient’s overall condition has been optimized. However, definitive treatment should not be delayed longer than 2 weeks as fracture edge resorption, displaced fracture healing, and the soft tissue healing response all complicate surgery and compromise outcomes.6,7 Immediate intervention is only indicated in a select few situations including tracheostomy, hemorrhage control, visual loss due to optic nerve trauma, and extraocular muscle entrapment.8 Additionally, penetrating neck injuries may warrant immediately exploration and must be considered as part of the initial management.9

When available, computed tomography (CT) is the standard of care for diagnosis of facial fractures.8,10 Plain films can provide basic information regarding fracture site, displacement, and the presence of foreign bodies or retained projectiles. At least two different views are necessary to aid localization. Forces strong enough to cause facial fractures are associated with concomitant injuries including blunt cerebrovascular injuries (BCVI), traumatic brain injuries, and C-spine injuries, which may necessitate additional imaging (e.g., vascular studies).6,7

Life saving measures always take the highest precedence and should not be delayed when necessary. However, it is useful to understand the principles of reconstruction and consider the definitive surgery to minimize unnecessary interventions that may impact the patient’s final form. Correct early management and preservation of viable tissue leads to the best possible functional and esthetic outcomes for the patient.

Ballistic Injuries

Generally, high velocity weapons cause more destructive injuries due to the direct transfer of energy on impact leading to extensive tissue cavitation, avulsion, devitalization, and bony comminution.11 High energy wounds may take days to weeks to fully declare themselves due to sequential necrosis and are therefore unamenable to early intervention.6,12 Low velocity weapons tend to cause damage that is confined to the missile tract and thus may be appropriate for early management in certain cases.6

Physical examination is usually confounded in the early post injury period due to significant edema, which distorts the remaining tissues and masks the true tissue deficit.6 Complete assessment of the extent of hard and soft tissue damage is critical. Whenever possible, missing tissue should be identified and found, including avulsed teeth, which may have been aspirated or displaced into adjacent tissues posing a future infection risk.6

Ballistic wounds tend to be heavily contaminated with compromised vascularity leading to further necrosis, devitalization, and infections.12 Appropriate antibiotic coverage combined with serial washouts and debridement are the mainstay of treatment.6 Viable tissue should be conserved when possible, as lost tissue will increase the difficulty of reconstruction and may require pedicled or vascularized free tissue transfers.6,12 Aggressive handling of tissues with tenuous blood supplies and periosteal stripping should be avoided whenever possible. Unique challenges in reconstructing the maxillofacial region include reconstitution of the masticatory complex to support oral nutrition, achieving appropriate anterior-posterior projection and shape of the facial skeleton, maintaining lip competence and control of salivation.12

Injuries Requiring Emergent Intervention

Retrobulbar Hematoma and Emphysema

Hemorrhage within the confined orbital cavity can result in elevation of tissue pressures which may lead to decreased vascular perfusion and ischemia of the optic nerve or retina.8 Patients may present with painful proptosis, increased intraocular pressure, ecchymosis of the eyelid, chemosis, decreased visual field, decreased visual acuity, and/or an afferent pupillary defect.6,8 Blindness can become permanent one hour after onset if intraocular pressure is not released.6

Intervention involves immediate decompression by performing a lateral canthotomy and inferior cantholysis. This can be accomplished at the bedside under local anesthesia. A pointed scissor is inserted horizontally into the outer lid angle laterally so that the instrument contacts the underlying bone of the lateral orbital rim.8 Next, the lateral palpebral fissure is cut horizontally including the skin, the orbicularis oculi muscle, and the conjunctiva.8 Finally, the scissors are introduced through the incision vertically to cut the inferior canthal tendon releasing the lower lid from the lateral orbital wall.7,8 This allows for the globe to prolapse anteriorly and relieves the pressure within the orbit. Large dose systemic corticosteroids and osmotic agents are also apart of established protocols for treatment.8

Severe emphysema may also significantly increase intraorbital pressure.8 If visual function or orbital contents are endangered than decompression should also be considered as above. Whenever a fracture of the maxillary sinus is present, patients should be placed on sinus precautions as the acute change in pressure can lead to worsening emphysema.6,8

Extraocular Muscle Entrapment

Orbital fractures can occur in isolation or as part of a more complicated fracture pattern. Fracture of the orbit can lead to entrapment of an extraocular muscle between segments. The inferior rectus is most frequently involved due to its proximity to the orbital floor. Entrapment is more common in children due to the inherent elasticity of their bones.6

Physical examination would show limitation in eye movement dependent on the entrapped muscle with severe pain.6,8 A forced duction test can be performed if there is concern for entrapment. The conjunctiva of the inferior fornix is grasped and moved in all directions, assessing for any areas of resistance.7 An entrapped muscle can undergo avascular necrosis within 24 hours of injury.7 Therefore, the patient should be taken to the operating room immediately for release of the muscle and repair of the orbital floor defect if necessary.

Severe Hemorrhage

Massive facial hemorrhage is rare but can have fatal consequences if not managed in a timely manner.7 When hemorrhage compromises the airway, clinicians should be prepared to urgently establish a surgical airway.7 Treatment of hemorrhage depends on the source of the bleeding.7 Superficial wounds can usually be managed effectively with pressure and hemostatic agents. Bleeding emanating from deep vessels is much more difficult to localize and treat. Interventions include oronasal packing, early fracture reduction, and electrocautery.6–8 When the source of bleeding is not known or inaccessible, indirect pressure with packing should be attempted.7 Epistaxis can be treated with nasal packing or balloon tamponade using a 14 French Foley catheter inserted into the posterior nasal cavity.7

Hemorrhage that does not resolve with local measures may require interventional embolization.6–8 Assessment for the use of anticoagulant and anti-platelet medications is critical as treatment decisions will change and may involve reversal of medication effects. If the bleeding cannot be controlled and the patient becomes unstable, ligation of the external carotid artery can be performed. This is a relatively simple and low risk procedure that can be performed under local or general anesthesia.7

Nasal Septal Hematoma

Trauma to the nasal septum can result in a hematoma which compromises the blood supply to the cartilage due to increased pressure. If left untreated the cartilage may necrose causing a septal perforation and/or nasal dorsum depression.8 The main symptom of septal hematoma is severe nasal obstruction.8 The septum may appear swollen or boggy on examination. Treatment involves making a small incision into the mucoperichondrium and evacuating the blood. The nose can then be packed, or quilted sutures can be placed, to prevent further reaccumulation of blood.8

Mandibular Trauma

General Considerations

Mandibular fractures secondary to combat injuries tend to have more complex patterns of injury.3,13 Definitive management of mandibular injuries serves not only to reconstruct the form and function of the lower jaw, but it may decrease the need for tracheostomy in the combat setting.14 The primary goal of treating mandibular injuries is reestablishment of premorbid occlusion while maintaining preinjury function and mobility.6,10,15 The patient’s bite must be set and verified prior to fracture fixation as anatomic reduction does not always equate to the correct occlusal relationship. Ensuring the correct occlusion is accomplished via maxillomandibular fixation (MMF). MMF can be established using arch bars, ivy loops, interdental wires, or bone screws. A video demonstration of arch bar application can be found by clicking this link: https://surgeryreference.aofoundation.org/cmf/basic-technique/maxillomandibular-fixation-mmf#principles-general-considerations.10

Patients with mandible fractures should be placed on a “non-chew” diet (i.e. blenderized diet) which should be continued postoperatively for a period of 6 weeks. Prophylactic antibiotics should be given for all open fractures.6,10 Importantly, a fracture that extends through the tooth socket is considered an open fracture. Penicillin/amoxicillin is the most common choice for appropriate coverage and clindamycin can be used for patients with a penicillin allergy. In wounds that are grossly contaminated an antibiotic should be used that contains a beta lactamase inhibitor (e.g., amoxicillin-clavulanate).6

Management of mandible fractures includes observation, closed reduction, and open reduction internal fixation (ORIF). Observation is reserved for nondisplaced fractures in a highly compliant patient. General indications for closed reduction and ORIF are outlined in Table 1.6,10,15 These are guidelines and not strict rules; clinical judgement should be applied to each case.


The mandible is divided into distinct anatomic sites that will dictate the necessary treatment (Figure 1).10 Exam findings indicative of fracture include malocclusion, mobility of the tooth bearing segments with bimanual manipulation, preauricular pain, deviation of the mandible on opening, and neurosensory changes in the inferior alveolar nerve (IAN) distribution.6,10 Swelling, hematomas, lacerations, and loose teeth may be helpful in identifying the location of the fracture/s.        

Initial Management

Displaced fractures through the tooth bearing segments of the jaw may initially be temporized with the aid of a “bridle wire,” which serves to stabilize the fracture, prevent further soft tissue damage, aid in protecting the airway, tamponade medullary hemorrhage, and increase patient comfort while definitive treatment is delayed.6,10 This is accomplished using a 24- or 26-gauge wire and placing it circumferentially around the teeth adjacent to the fracture line. The wire is then tightened in a clockwise direction until stability is achieved. If the teeth adjacent to the fracture are loose, decayed, or avulsed, the nearest stable teeth can be used.

Closed Reduction

Closed reduction with MMF immobilizes the jaws and allows the fracture segments to heal in the appropriate position. It is relatively cost-effective, less invasive, and can be performed under local anesthesia. In addition to the fractures listed in Table 1, further indications for closed reduction include patients who cannot undergo general anesthesia, patients refusing operative management, and unavailability of plates and screws.6 Due to the inability to open the jaw, MMF is generally contraindicated in patients with increased aspiration risk, psychiatric disorders, seizure disorders, and alcohol use disorder.10

MMF is usually maintained for a period of 4 weeks. At this point the interarch wires are cut and elastic bands are placed bilaterally for an additional 2-4 weeks. This allows the patient to function while guiding their bite into the correct position. If the patient’s occlusion remains stable during this period of function, then all hardware can be removed at the 6–8-week mark. Intracapsular condylar fractures are unique and pose an exception to this rule. The period of MMF is shortened in order to prevent ankylosis and complications with functional limitations.6,10 Usually, a maximum of 2 weeks of MMF is sufficient followed by several weeks of guiding elastics.6

Another option for closed reduction is external pin fixation which also serves to hold fractures in their correct anatomic positions. Indications for an external fixator include severely comminuted fractures and heavily contaminated wounds.6 Ideally, two pins with a large distance between them are placed into the largest fracture segments to prevent rotation.6

Both MMF and external fixator placement do not require periosteal stripping at the fracture site and thus do not compromise bloody supply, introduce infection, or displace comminuted bone.6 Soft tissue and bony defects can be debrided while fixators or MMF are in place. The benefit of an external fixator is that a patient can open their jaw, which allows for better oral hygiene and nutrition as well as less trismus from fibrosis and scarring.6

Open Reduction Internal Fixation

This section will focus on key concepts and general principles for ORIF, as there is an extensive number of clinical scenarios and fracture combinations that warrant unique consideration, which is beyond the scope of this resource. There are several factors that must be taken into account when planning to perform ORIF: specific area that is fractured; number of fractures; muscular pull on the fractured segments; type and directionality of the fracture; approach needed to access the fracture including pertinent anatomy; and necessary hardware.

The basic principles of rigid fixation include reduction of bony segments, stable fixation with immobilization of fragments, maintaining blood supply, and early function.6,10 It is important to expose all fractures adequately prior to proceeding with reduction and fixation. Nearly all noncomminuted fractures of the symphysis, body, and angle can be approached through a transoral incision.15 Comminuted fractures of the ramus, gunshot wounds, condylar fractures, and atrophic fractures typically require transfacial approaches.15 Once all fractures are exposed, the next step is to place the patient into MMF to establish the occlusion.

There are a variety of hardware options and selection is generally dependent on fracture location and number of fractures. The concept of load-bearing means that the hardware must sustain the entirety of the forces at the fracture site.10 This is usually accomplished with a reconstruction plate and locking screws. Indications include poor bone quality, significant comminution, segmental defects, and atrophy.6 The concept of load-sharing allows for the use of smaller plates due to bony buttressing by the intact cortices on either side of the fracture, but this is not appropriate for comminuted fractures.10

Generally, plates should be placed as close to the inferior and/or posterior border as possible in order to avoid the IAN and tooth roots. This is also important when deciding to use monocortical or bicortical screws. Monocortical screws have less purchase and are therefore less stable, but are helpful in avoiding important structures.10 Teeth that have been avulsed or are extremely mobile should be removed, especially if they interfere with fracture reduction.6

Midface Fractures

General Considerations

Fractures of the midface present in a variety of combinations and patterns that are dependent upon the mechanism of injury. Unlike civilian trauma, there may be a higher propensity of midfacial injuries sustained in a combat situation.3 Generally, low velocity trauma leads to less severe midface injuries than high velocity trauma.6 The degree of complexity is dependent both on the morphology of the fracture and the degree of injury to the soft tissue envelope.8

The goals of treatment include restoring the facial buttresses and prominences, recontouring the bony orbit, and reestablishing occlusion.8 As with mandibular trauma, occlusion is the most important parameter for correcting facial contour and appropriately reducing fractures.6 However, unlike the mandible, the midface is not subject to major muscular forces. Therefore, fractures of the midface can best be managed with miniplate or microplate fixation due to the decreased necessity for plate strength and stability.6 Low profile plates are recommended in order to prevent implant prominence. The facial buttresses should be used to fixate fractures when able, as they provide the best stability.6,8 Common fractures patterns of the midface include nasal, orbital, naso-orbital-ethmoid (NOE), zygomaticomaxillary complex (ZMC), and Le Fort.

Midface fractures can be managed with observation, closed reduction, or ORIF. Fractures that are stable, simple, and closed can be managed conservatively if a patient is compliant with treatment.7 ORIF is indicated for multiple or comminuted fractures, panfacial fractures, defect fractures, and open fractures.7 A patient with polytrauma who is medically stable should undergo early fracture treatment as stability will help to prevent infection and need for secondary reconstructive surgery.7

Orbital Fractures

Fracture of the orbital walls can occur separately or in conjunction with ZMC, NOE, and Le Fort fractures. The initial clinical exam is usually obscured by periorbital edema and ecchymosis which may mask symptoms such as diplopia and enophthalmos.6 When there is no evidence of extraocular muscle entrapment, globe injury, or retrobulbar hematoma, definitive management is typically delayed until edema has resolved and an accurate clinical assessment can be made.

Minimally displaced orbital floor fractures or asymptomatic fractures may heal without intervention. Indications for surgical repair include diplopia that does not resolve within 2-3 weeks of injury, enophthalmos greater than 2 mm, clinically notable hypoglobus, or defects larger than 1 cm2.6 Ocular injuries such as hyphema, globe ruptures, and retinal tears are relative contraindications to surgery and should undergo ophthalmologic assessment prior to proceeding.7

The goal of surgery is to restore the preinjury orbital volume. Exposure of the orbital floor can occur via a subciliary, subtarsal, or infraorbital approach. An implant is typically placed over the defect in the orbital floor elevating the globe to its proper position. Once the implant is placed in the proper position, it may be fixated to the infraorbital rim using a screw or nonresorbable sutures.8 Patients should remain on sinus precautions both preoperatively and postoperatively.

Nasal Fractures

Nasal fractures may occur in an isolated manner or as part of Le Fort or NOE fractures. They involve the nasal bones and/or the associated cartilages and septum. Nasal fractures can cause significant bleeding and need to be addressed before performing diagnostic/definitive treatment.8 It is important to rule out a septal hematoma as reviewed above. Steps, humps, and crepitus on manual palpation are all signs of a fracture.

Nasal fractures are usually observed or treated with closed reduction.6 Rarely do isolated nasal bone fractures need to be reduced in an open manner. Reduction is indicated for severely displaced fractures causing nasal airway obstruction.8 Fractures are reduced with a combination of elevators and manual manipulation to realign the nasal bones and nasal septum. Splints may be placed over the dorsum or in the nares in order to help stabilize the reduced fracture.8 If splints are placed in the nose then antibiotics are required until removal.8

Naso-Orbital-Ethmoid Fractures

NOE fractures are classified into three types: (I) one large fragment with the medial canthal tendon attached (Figure 2); (II) comminution with the medial canthal tendon attached to a large fragment (Figure 3); and (III) comminution with detachment of the medial canthal tendon (Figure 4).8

Examination will usually reveal swelling at the medial canthal tendon and tenderness upon palpation of the area. The nose may be impacted at the nasofrontal suture due to the lack of support for the nasal septum and cartilages and there may be widening of the intercanthal distance.6,8 A bow string test should be performed by pulling the eyelid laterally while the medial canthal tendon area is palpated to detect movement of fracture segments.8

It is critical to rule out a cerebrospinal fluid (CSF) leak and damage to the lacrimal apparatus, as these injuries require specialized management.8 Indications for surgery include instability of the medial canthal tendon, loss of nasal projection and support, comminution of the medial orbital wall, interruption of lacrimal drainage, and concomitant fractures undergoing repair.7

Depending on the extent of the injury, a coronal incision is frequently used as it allows for exposure of the superior and medial orbital aspects as well as the nasal bones.8 A lower eyelid incision and intraoral vestibular incision may also be needed to assess the inferomedial orbit and nasomaxillary suture, respectively.6

There is much debate regarding the amount of fixation needed for NOE fractures. Type I fractures typically require three-point fixation and type II fractures usually require more extensive exposure due to comminution.6 These same principles apply for type III fractures, however a dorsal nasal cantilever type bone graft might be necessary to reestablish support.6 Type III fractures also require direct transnasal wiring of the medial canthal tendon to a position superior and posterior to its original insertion in order to prevent relapse, migration, and telecanthus.6

Zygomaticomaxillary Complex:

The zygomatic bone articulates with the sphenoid, maxillary, temporal, and frontal bones. ZMC fractures can be challenging as appropriate reduction at one suture line does not ensure correct reduction at the others. Patients may present with periorbital ecchymosis and edema, subconjunctival hemorrhage, flattening of the malar eminence or zygomatic arch, trismus, anesthesia in the cranial nerve (CN) V2 distribution, diplopia, and/or enophthalmos.6–8

ZMC fractures can be managed conservatively with a soft diet and observation. They are not emergencies and injuries to the globe, if present, should be managed first.7 The decision to operate should be based on signs, symptoms, and functional impairment. Functional considerations include decreased mouth opening from the fractured zygoma impinging on the coronoid process and persistent diplopia due to an increase in orbital volume.6,7 Other indications include malar projection asymmetry, enophthalmos, orbital dystopia, and zygomatic arch depression.7

Exposure of fractures may include a combination of the following approaches: maxillary vestibular, transconjunctival with/without lateral canthotomy, superior blepharoplasty, and hemicoronal. The fracture severity and involved articulations will dictate the needed exposure. If unsure based on the radiographic assessment, the surgeon can start with a maxillary vestibular incision and use additional approaches as necessary.

There is no consensus regarding how many points of fixation are needed. Generally, more comminution and instability will require more fixation.7 If the fracture is stable after being reduced then there may be no need for fixation. One approach is to plate the zygomaticomaxillary suture first and if the complex is not stable, additional plates can be used in the zygomaticofrontal and infraorbital rim regions.7 If the zygoma is comminuted or part of a panfacial trauma, plating the zygomaticofrontal suture first may be the most useful. The orbital floor should be treated after the ZMC has been reduced into the appropriate position. Perioperative antibiotics and steroids should be given and the patient should be placed on sinus precautions pre and postoperatively.

Le Fort Fractures

Le Fort fractures are classified into three different types reflecting an increase in injury severity, complexity of repair, and concomitant neurologic/ocular injuries.7 Le Fort injuries commonly occur in a variety of combinations and rarely do they follow the exact fracture pattern described. Failure to repair Le Fort fractures can result in midface retrusion, midface elongation, and anterior open bite.6,7 When the orbit is involved, unrepaired fractures can lead to enophthalmos, diplopia, and impaired lacrimal drainage. Surgical intervention as soon as the patient’s medical status allows is important as delayed treatment can lead to difficulty with mobilizing and reducing the osseous components due to impaction and soft tissue contracture.7,8

Le Fort I fractures occur at the level of the piriform aperture and involve the anterior and lateral walls of the maxillary sinus, lateral nasal walls, and the pterygoid plates (Figure 5).6 During examination, the maxilla should be grasped with a finger and thumb and pulled in all directions to assess for mobility. The patient may also have malocclusion and hypoesthesia in the area of the infraorbital nerve.

Le Fort II fractures are more evident upon examination. The fracture extends to include the nasofrontal suture and the infraorbital rims (Figure 6).6 Classic examination findings include bilateral periorbital ecchymosis/edema, epistaxis, infraorbital nerve hypoesthesia, and malocclusion with an anterior open bite. Pulling on the maxilla will cause the infraorbital rims and nasofrontal suture to move as one unit.

Le Fort III fractures are classified craniofacial dysjunction because the facial skeleton becomes detached from the cranial base (Figure 7).6–8 The fracture also extends to the nasofrontal suture, but involves the upper lateral orbital rims. A “dish face” deformity may result with mobility of the zygomaticomaxillary complex. CSF leakage, edema, periorbital ecchymosis, traumatic telecanthus, and epiphora may be present.

Nasotracheal intubation is necessary as occlusion will need to be assessed intraoperatively. If this is not possible than consideration should be given to submental intubation or even tracheostomy.6 It is important to achieve passive mobilization of the fractured segments before fixating.6 Le Fort I fractures can be exposed via maxillary vestibular incision. Le Fort II fractures may require exploration of the orbital floor, in which case a lower eyelid incision would be necessary. Le Fort III fractures require the broadest exposure which can be accomplished via a coronal incision combined with other approaches.


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