Int. J. Oral Maxillofac. Surg.

2011; 40: 3337

doi:10.1016/j.ijom.2010.08.006, available online at http://www.sciencedirect.com

Clinical Paper
Trauma

Complications related to
midfacial fractures: operative
versus non-surgical treatment

F. R. Kloss1, R. G. Stigler1,
A. Brandstatter2, T. Tuli1,
M. Rasse1, K. Laimer1,
O. L. Hachl1, R. Gassner1
1
Dept. of Cranio-Maxillofacial and Oral
Surgery, Innsbruck Medical University,
Anichstr. 35, 6020 Innsbruck, Austria;
2
Division of Genetic Epidemiology, Innsbruck
Medical University, Schoepfstrasse 41,
A-6020 Innsbruck, Austria

F. R. Kloss, R. G. Stigler, A. Brandstatter, T. Tuli, M. Rasse, K. Laimer, O. L. Hachl,

R. Gassner: Complications related to midfacial fractures: operative versus nonsurgical treatment. Int. J. Oral Maxillofac. Surg. 2011; 40: 3337. # 2010
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
Abstract. The treatment of midfacial fractures depends on the dislocation of the
fracture and patient-related limitations. Surgical treatment risks iatrogenic
complications. In 740 patients with midfacial fractures, the age, sex, fracture type,
concomitant injuries, cause of accident and the decision to use operative or nonsurgical treatment were recorded. Follow-up was performed 6 and 12 months after
the injury. In 41% the fractures were isolated; they were multiple in 59%. Initially,
hypaesthesia of the infraorbital nerve was present in 10% of the single and 16% of
the multiple fracture patients. Surgical treatment was performed in 57% of the
single and in 75% of the multiple fracture patients. Women underwent surgical
treatment considerably less frequently than men. After 6 and 12 months,
significantly more complications were present in the surgically treated cohort.
Nerve disturbances and meteorosensitivity were most prominent. These results,
together with previous findings, indicate that there is a need for prospective clinical
investigations that fulfil the criteria of evidence-based medicine to generate
guidelines for decision making in trauma surgery. In the meantime, the decision to
use surgical treatment for midfacial fractures has to be made carefully.

Introduction

Patients with midfacial fractures often

present to maxillofacial emergency
departments following sport accidents,
traffic accidents or violence.8 Owing to
the heterogeneous presentation of midfacial injuries and the concomitant injuries, deciding on treatment may be
difficult and possible complications
and their relative risk play a crucial role
in the decision. The decision making
process is complicated by the frequent
presence of multiple fractures and
0901-5027/01033 + 05 $36.00/0

concomitant injuries, and iatrogenic

complications.
The initial diagnostic management is
well established and standardized2,10. A
precise clinical and radiological examination includes the orbit, eye ball and soft
tissues, and neighbouring structures8,11,12.
Concomitant injuries are common and
include haematomas, ocular injuries, and
nerve disturbances. The incidence of
infraorbital nerve (ION) paraesthesias is
common1,7,13. The underlying pathophysiology is heterogeneous; the nerve can be
injured because it lies within the fracture

Keywords: midfacial fracture; surgical treatment; non-surgical treatment; concomitant

injury; complication.
Accepted for publication 3 August 2010
Available online 25 September 2010

or it can be affected by haemorrhage or

oedema. The influence of surgical procedures on the nerves regenerative capacity
is also controversial. Another complication of midfacial fractures is meteorosensitivity (pain or discomfort caused by
certain weather conditions), which is often
mentioned by patients as a reason for
decreased quality of life after osteosynthetically treated midfacial fractures.
These complications can also be provoked iatrogenically or can be reduced
by the choice of treatment. Although
many studies have investigated the

# 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

34

Kloss et al.
Table 1. Aetiology of injury mechanisms.

complications related to different surgical

treatments or types of fractures, little
attention has been paid to complications
related to non-surgical treatment.
The aim of this study is to investigate
and evaluate complications related to midfacial trauma and to the non-surgical or
surgical treatment used to treat it.

Injury mechanism
Sports accident
Traffic accident
Violence
Accident at work
Accident at home
Accident at playground
Suicidal attempt
Miscellaneous
Unknown

Materials and methods

The authors carried out a retrospective

review of the records 844 patients with
midfacial injuries introduced to their
department between January 2001 and
December 2003. These patients were treated either non-surgically or surgically.
Surgical treatment is defined as active
closed or open reduction with osteosynthesis; non-surgical treatment includes any
other treatment option. The criteria for
surgical treatment were displacement
and/or impairment of functionality.
Initially the following parameters were
recorded: age, sex, number of fractures,
concomitant injuries, the cause of the
accident, and the decision to use operative
or non-surgical treatment. Follow-up
examinations were performed 6 and 12
months after the injury. Any adverse event
or complication was documented.
As well as the descriptive statistics, the
following parameters: treatment decision,
neurosensory changes, meteorosensitivity,
pain and disturbing scars, were used for
inferential statistics. Crosstabs were used
to display the number of cases in each
category defined by two or more grouping
variables. x2 measures were applied to test
the hypothesis that the row and column
variables in a crosstabs were independent.
Fishers exact test was used if sample sizes
were small. The relative risk and the associated 95% confidence interval were calculated as measure of association between
the presence or absence of a factor and the
occurrence of an event. All statistical
analyses were performed with SPSS
16.0 (SPSS Inc., Chicago, IL, USA). Statistical graphs were drawn with Microsoft
Excel.

Percentage (%)
33.1
14.6
10.0
7.8
7.5
5.8
0.7
5.0
15.5

Initial clinical presentation

The patients were classified as having single fractures (n = 305; 41%) or multiple
fractures (n = 435; 59%) (Fig. 1a) and
showed a gender distribution of 205
(27%) female and 535 (73%) male patients
(Fig. 1b) with a mean age of 40.9 years.
Additional soft tissue injuries were present in 92%. 30% showed two soft tissue
lesions and 36% at least three soft tissue
injuries, defined as periorbital haematoma
(n = 385; 52%), laceration (n = 382;
52%), bruise (n = 287; 39%), midfacial
haematoma (n = 152; 21%) or excoriations (n = 149; 21%). Hypaesthesia of
the second branch of the trigeminal nerve
was diagnosed in 98 patients (13%); only 1
patient had anaesthesia (Fig. 2). Dental

[(Fig._1)TD$IG]

injuries were found in 19% (n = 141).

The dominant lesion was an avulsion
(n = 84; 11%), followed by lateral luxations (n = 71; 10%), dental fractures with
non-exposed pulp (n = 63; 9%) and
exposed pulp (n = 25; 3%).
Involvement of the eyes was recorded in
36% (n = 266) of the casualties. Hyposphagmas (subconjunctival haemorrhages) (n = 138; 19%) and contusion of
the bulb (n = 128; 17%) were the most
frequently observed injuries (Fig. 2).
Diplopia and motility dysfunction were
recorded initially in 12% of the single
fracture and in 15% of the multiple fracture patients (Fig. 2). Only 3 patients
presented with rupture of the eye bulb.
Treatment

Sixty-two percent (n = 456) of patients

underwent surgical treatment, 38% (284
patients) followed a non-surgical regimen.
Differences were observed between the
treatment decision made in single and multiple fractured patients. Fifty-seven percent
(131 patients) of the single fracture patients
underwent surgical procedures compared
with 75% (325 patients) of the multiple
fracture patients who underwent open
reduction and osteosynthesis (Fig. 3a).

Fig. 1. (a) Distribution of isolated or single fractures and complex or multiple fractures. (b)
Almost three-quarters of the patients with midfacial fractures were male.

[(Fig._2)TD$IG]

Results

Between January 2001 and December

2003, the data from 844 patients with
midfacial injuries were recorded in a database. 740 patients (88%) presented had
fractures in the midface and were included
in this investigation. The main causes of
these fractures and the concomitant injuries were sports accidents (33%) followed
by road accidents (15%), violence (10%)
and accidents at work (8%) (Table 1).

Fig. 2. Distribution of the most common concomitant injuries, documented initially after the
trauma. There is a statistically significant difference in the prevalence of ION disturbances and
contusio bulbi between single and multiple fracture patients.

[(Fig._3)TD$IG]

Complications after midfacial fractures

35

surgically treated patients. This indicates a

relative risk of 1.539 (1.3391.769) for
surgical treatment and 0.160 (0.024
1.069) for non-surgical therapy. The additional recorded parameters, pain (2%
operative and 0.7% non-surgical) and disturbing scars (0.88% operative and 0.35%
non-surgical) showed no statistical significant difference in either treatment group.
Diplopia was persistent after 6 months in 2
patients after non-surgical treatment and
in 5 patients after surgical treatment
(Fig. 4a and b).
After 12 months, few complications
were present (6%). There is a statistically
significant difference (p < 0.001) in the
persistence of complications in the surgically treated (9%) and non-surgically treated (0.35%) patients. This means the
remaining relative risk for complications
is 1.411 (1.2311.681) after surgical procedures and 0.381 (0.1920.759) when
otherwise treated. A persisting nerve disturbance was significantly more likely
following operative treatment (5%; relative risk 1.44 (1.2251.694)) compared
with non-surgical therapies (0.7% having
complications; relative risk 0.319 (0.110
0.922)). There was no significant difference in suffering from meteorosensitivity,
which was mentioned by 2% of the
patients. Similar to the results after 6
months, there was no statistically significant difference in the treatment groups
comparing the presentation of pain
(0.95%) and disturbing scars (0.54%)
(Fig. 4a and b).
Discussion

Fig. 3. (a) Treatment depends on the complexity of the fracture. Multiple fractures were more
often treated surgically. (b) There is no statistically significant difference in the treatment of
fractures between young and old patients. (c) Referring to multiple fractures, women are
subjected significantly more often to non-surgical treatment compared with men.

No statistically significant association

between patient age and treatment was
observed (Fig. 3b). There is a statistically
significant difference (p = 0.018) in the
treatment decision making between men
and women. Only 55% of the female
patients (112 patients) underwent operative treatment, while 64% of the male
patients were surgically treated (Fig. 3c).
Complications

Complications were evaluated after 6

months (overall: 17%; 129 patients) and
after 12 months (overall: 6%; 46 patients).
6 months after non-surgical therapy,
patients had a statistically significant

minor complication rate (p < 0.001) and

a reduced relative risk for complications
(0.264 (0.1630.429)) when compared
with operatively treated patients (relative
risk of 1.579 (1.4371.735)). Twenty-five
percent of the surgically treated patients
had complications and 5% of the nonsurgically treated patients. This was
highly statistically significant for ION disturbances (p < 0.001) and meteorosensitivity (p = 0.007). The relative risk
for neurosensory changes were 1.544
(1.4011.702) when operations were performed compared with a relative risk of
0.257 (0.1420.465) in otherwise treated
patients. Meteorosensitivity was found in
3% of the surgically and 0.35% of the non-

Midfacial fractures are a common injury

in oral and maxillofacial surgery. At the
authors institution in Innsbruck, near the
Alps, the cause is mainly related to sports
activities8. Sport-related injuries tend to
lead to midfacial fractures6. Midfacial
fractures affect a variety of neighbouring
anatomical structures that are likely to be
involved in the patho-mechanism of concomitant injuries. Treatment depends on
the seriousness of the injury. The indication for surgical intervention is evident
when large dislocations are present. BACK
et al. claimed as criteria for non-surgical
therapy an undisplaced or minimally displaced fracture, or the refusal of treatment
or medically unfit patients1.
Particularly in elderly patients, who
often suffer from multiple systemic diseases, the decision to carry out surgical
treatment has to be made critically. GOLDSCHMIDT et al. found a higher incidence for
non-surgical treatment in patients older
than 60 years suffering from cranio-max-

36
[(Fig._4)TD$IG]

Kloss et al.

Fig. 4. (a) Complications before the accident, after 6 and 12 months related to surgical
treatment. (b) Complications before the accident, after 6 and 12 months related to non-surgical
treatment.

illofacial trauma; 50% of the patients did

not receive any surgical correction9.
Although elderly patients have a higher
incidence of concomitant injuries12, the
authors did not find any statistically significant association between the age of the
patients and the treatment regimen. However, displacement is not the only criterion
for operative treatment. Several authors
emphasize that the aspect of functionality
should be of major importance when
deciding whether to operate3,4,13. In contrast to the present study group, 177 of 201
patients underwent surgical treatment in a
study by PALUDETTI et al.13. In the present
patient cohort, the authors distinguished
between single or isolated fractures and
multiple or complex fractures. This
revealed a statistically significant higher
rate for the non-surgical treatment regimen in single fracture patients. In the more
complex fractures, the authors observed a
statistically significant higher percentage
of surgical treatment. At least 25% of
patients with complex fractures were treated non-surgically. One reason for nonsurgical treatment is the delay of any
treatment due to the severity of the injury
or the initial non-recognition of the midfacial fracture. This delay might range
from 0 to 24 days15. The decision to use
surgical treatment is not only correlated to
the extent of the injury. It is also correlated
with the patients sex patient. Even in

complex fractures, males underwent surgical treatment significantly more frequently than female patients.
To analyse treatment-specific complications the authors recorded concomitant
injuries before treatment. They found statistically significant differences in the presence of ION disturbances and the
prevalence of contusions of the eyeball
between isolated and multiple fractures.
There was no statistically significant difference in the presence of diplopia, which
confirms the need for a routine ophthalmological examination before any treatment after a midfacial trauma.
Results of non-surgical treatment of
midfacial fractures are rare in the literature1,5,16. Most articles concentrate on
investigations comparing different surgical procedures and operative techniques.
Systematic investigations, comparing the
complications of non-surgical and surgical
treatment with long term follow-up are
missing. BACK et al. investigated the outcome of non-surgically treated patients
with an average follow-up of 6 weeks
and surveyed abnormal diagnostic findings in 17% of patients. Most of these
patients suffered from ION disturbances
and at least 5 patients had an enophthalmus1. The authors found an overall complication rate after non-surgical treatment
of 5% after 6 months and 0.38% after 12
months. In accordance with the study

mentioned above, neurosensory disturbances are the most prominent complications in this group. The different values for
nerve disturbances might be related to the
different time points of evaluation. The
ION recovers quickly and can be influenced directly after operation by haematoma or oedema. The sensitivity and
sensibility of the experimental settings
used to evaluate the nerve damage differ
in various articles, so data for ION recovery has to be compared carefully.
Iatrogenic provocation of neurosensory
complications after surgical manipulation
in the midfacial area is well known after
orthognathic surgery17,20. Analysing the
different Le Fort I osteotomy lines, a
temporary ION dysaesthesia was provoked in 60% postoperatively and in
103% of patients after 6 months20. A
temporary impairment of the ION after
Le Fort I osteotomy has been reported
in 81% of surgically treated patients18.
The patho-mechanism of complex fractures and the iatrogenic component of
surgical fracture treatment probably contribute to the increased rate of ION disturbances. Surgically treated patients have
a 6 times higher prevalence of dysaesthesia of the second trigeminal branch after 6
months and a 4.5 times higher risk for ION
disturbances after 1 year compared with
non-surgically treated patients.
There is also a considerable difference
in meteorosensitivity between non-surgical and surgical treatments. Meteorosensitivity often occurs as headache,
discomfort and pain. There is no direct
pathophysiological explanation for this
phenomenon, but the authors documented
15 surgically and 1 non-surgically treated
patients reporting meteorosensitivity after
1 year. Possible explanations might be the
presence of metal plates or screws and the
high amount of scar tissue resulting from a
more severe initial injury.
It is doubtful, whether patients who
underwent non-surgical treatment can be
directly compared with surgically treated
patients. Too many factors influence the
decision making for an adequate treatment
option, resulting in heterogeneous patient
cohorts. PELTOMAA et al. tried to compare
patients with blow out fractures with intact
infraorbital rim and zygomatico-maxillary
complex fractures. They found that the
sensorial disturbed area was preoperatively smaller in the non-surgical treated
group (44%) and the reported return to
normal sensitivity was found in 74%. This
is significantly more often the case in the
non-surgically than in the surgically treated group, with a sensory recovery rate of
53%. This study refers to a defined popu-

Complications after midfacial fractures

lation and has a follow-up of about 2
years14. VRIENS and MOOS described the
influence of treatment on ION disturbances in patients with orbito-zygomatic
complex fractures. Non-surgically treated
patients had about 10% abnormal sensory
function. Higher disturbances were
found in the surgical treated group21.
These findings are consistent with the
present results showing a significantly
reduced sensory disturbance in non-surgical treated patients.
The large patient cohort evaluated in
this investigation reveals an increased risk
for complications and concomitant iatrogenic impairments for injuries that
required surgical treatment. Statistically
significantly fewer women underwent surgical treatment. As the review of the literature demonstrates, prospective clinical
investigations are needed to optimize
decision making in trauma patients. Currently, no uniform standards are available
in trauma surgery and especially in oral
maxillofacial surgery, to fulfil the criteria
for evidence based medicine19.

3.

4.

5.

6.

7.

8.

9.

Funding

None.

10.

Competing interests

None declared.

11.

Ethical approval

Not required.
References
1. Back CP, McLean NR, Anderson PJ,
David DJ. The conservative management
of facial fractures: indications and outcomes. J Plast Reconstr Aesthet Surg
2007: 60: 146151.
2. Ceallaigh PO, Ekanaykaee K, Beirne
CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in
the emergency department. Part 4. Orbital

12.

13.

floor and midface fractures. Emerg Med J

2007: 24: 292293.
De Man K. Fractures of the orbital floor:
indications for exploration and for the use
of a floor implant. J Maxillofac Surg
1984: 12: 7377.
Dortzbach RK, Elner VM. Which
orbital floor blowout fractures need surgery? Adv Ophthalmic Plast Reconstr
Surg 1987: 6: 287289.
Dulley B, Fells P. Long-term followup of orbital blow-out fractures with and
without surgery. Mod Probl Ophthalmol
1975: 14: 467470.
Erdmann D, Follmar KE, Debruijn
M, Bruno AD, Jung SH, Edelman D,
Mukundan S, Marcus JR. A retrospective analysis of facial fracture etiologies.
Ann Plast Surg 2008: 60: 398403.
Follmar KE, Debruijn M, Baccarani
A, Bruno AD, Mukundan S, Erdmann
D, Marcus JR. Concomitant injuries in
patients with panfacial fractures. J
Trauma 2007: 63: 831835.
Gassner R, Tuli T, Hachl O, Rudisch
A, Ulmer H. Cranio-maxillofacial
trauma: a 10 year review of 9,543 cases
with 21,067 injuries. J Craniomaxillofac
Surg 2003: 31: 5161.
Goldschmidt MJ, Castiglione CL,
Assael LA, Litt MD. Craniomaxillofacial trauma in the elderly. J Oral Maxillofac Surg 1995: 53: 11451149.
Hollier LH, Thornton J, Pazmino P,
Stal S. The management of orbitozygomatic fractures. Plast Reconstr Surg 2003:
111: 23862392 quiz..
Kloss F, Laimer K, Hohlrieder M,
Ulmer H, Hackl W, Benzer A,
Schmutzhard E, Gassner R. Traumatic
intracranial haemorrhage in conscious
patients with facial fracturesa review
of [1959] cases. J Craniomaxillofac Surg
2008: 36: 372377.
Kloss FR, Tuli T, Hachl O, Laimer K,
Jank S, Stempfl K, Rasse M, Gassner
R. The impact of ageing on cranio-maxillofacial trauma-a comparative investigation. Int J Oral Maxillofac Surg
2007: 36: 11581163.
Paludetti G, Almadori G, Corina L,
Parrilla C, Rigante M, Ottaviani F.
Midfacial fractures: our experience.
ActaOtorhinolaryngol Ital 2003: 23:
265273.

37

14. Peltomaa J, Rihkanen H. Infraorbital

nerve recovery after minimally dislocated
facial fractures. Eur Arch Otorhinolaryngol 2000: 257: 449452.
15. Press BH, Boies Jr LR, Shons AR.
Facial fractures in trauma victims: the
influence of treatment delay on ultimate
outcome. Ann Plast Surg 1983: 11: 121
124.
16. Putterman AM, Stevens T, Urist MJ.
Nonsurgical management of blow-out
fractures of the orbital floor. Am J
Ophthalmol 1974: 77: 232239.
17. Rosenberg A, Sailer HF. A prospective study on changes in the sensibility of
the oral mucosa and the mucosa of the
upper lip after Le Fort I osteotomy. J
Craniomaxillofac Surg 1994: 22: 286
293.
18. Schultze-Mosgau S, Krems H, Ott R,
Neukam FW. A prospective electromyographic and computer-aided thermal sensitivity assessment of nerve lesions after
sagittal split osteotomy and Le Fort I
osteotomy. J Oral Maxillofac Surg
2001: 59: 128138.
19. Trentzsch H, Piltz S, Tager G, Berger F, Steinhausen E, Neugebauer
EA, Rixen D. Randomized clinical trials
in trauma surgery: decision-making in an
area of conflict between eminence and
evidence. Unfallchirurg 2009: 112:
742748.
20. Ueki K, Hashiba Y, Marukawa K,
Nakagawa K, Alam S, Yamamoto E.
The evaluation of surgical factors related
to recovery period of upper lip
hypoaesthesia after Le Fort I osteotomy.
J Craniomaxillofac Surg 2008: 36: 390
394.
21. Vriens JP, Moos KF. Morbidity of the
infraorbital nerve following orbitozygomatic complex fractures. J Craniomaxillofac Surg 1995: 23: 363368.
Address:
Frank R. Kloss
Dept. of Cranio-Maxillofacial and Oral
Surgery
Innsbruck Medical University
Anichstr. 35
A-6020 Innsbruck
Austria
Tel.: +43 512 504 81144.
E-mail: frank.kloss@i-med.ac.at