With demands for an evidence-based approach to patient care, the management of facial fractures will come under increasing scrutiny because there is an overall deficiency in higher level clinical evidence. This article reviews the management of facial fractures, focusing on an evidence-based approach. It focuses on select areas of facial trauma in which there is controversy and presents randomized studies and meta-analysis to help define best practice. The article notes the many areas where the evidenced-based literature is weak and looks at the future of evidence-based facial trauma care.
Key points
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The facial trauma literature primarily consists of lower-level evidence, including retrospective case series and case reports.
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There is strong clinical evidence from meta-analysis to guide antibiotic use in facial trauma.
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There is solid clinical evidence from meta-analysis of clinical trials supporting the use of general anesthesia for closed nasal reduction.
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There is no consensus from the literature on the best method of treating mandible fractures.
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Systematic review of the literature suggests improved patient outcomes with open reduction for displaced fractures of the mandibular condyle.
Introduction
The demand for safe, cost-effective health care is increasing from the public, physicians, and third-party payers. Evidence-based practice is becoming an essential component of twenty-first century medicine and, increasingly, doctors must justify their work based on clinical effectiveness and cost. Physicians are being asked to show, using higher level clinical research, the clinical benefits of accepted treatments. However, many of these treatments developed through technical advances or surgical pioneering and were not vetted through the rigorous process of clinical trials.
Facial fracture management, like most aspects of facial plastic and reconstructive surgery, has evolved through the collective experiences of its surgeons. The current surgical trends and techniques have been shaped through advances in diagnostics, instrumentation, and hardware. In facial trauma, most current practices did not result from rigorous randomized clinical trials (RCTs). Instead, surgeons adopted new techniques and approaches when they believed them to be better than what had been done. There certainly was no requirement to prove the superiority of a new technique or instrument before adopting it. Innovators were not compelled to prove what they thought was inherently obvious.
It is not surprising that the literature concerning facial fracture treatment is limited both in its quality and level of evidence. The predominant article types are retrospective case series and nonrandomized trials. There is a scarcity of RCTs in all of facial plastic surgery; however, it is very glaring in facial trauma. This is not surprising given the obstacles inherent in conducting clinical studies in fracture treatment. Cost, ethical constraints, and subject recruitment all deter randomized studies. There are also challenges in conducting surgical trials given the significant variability in facial fractures, the range of surgical procedures to address the injuries, and the skills of surgeons performing those operations.
Recognizing that facial fracture management has evolved over decades mostly devoid of any evidence-based research, and further recognizing the persistent challenges in conducting quality studies, it is easy to view evidenced-based facial fracture care as unattainable. However, some recent studies in facial fracture treatment have included higher level randomized trials as well as organized meta-analysis. As specialists, facial plastic surgeons must continue to adapt evidence-based approaches to both clinical practice and research. Doing so validates what we are doing well and highlights areas needing improvement. Both the public and organized medicine demands this research and our specialty needs to provide it.
This article reviews relevant issues in facial fracture management, emphasizing the evidence-based methodology. It highlights the few areas of facial trauma in which randomized studies and meta-analysis are available. It also points out the many other areas for which the evidenced-based literature is poor or altogether absent. Finally, the article examines the future of facial trauma care in which clinical registries and health databases may be better able to answer clinical questions too complex to be addressed by clinical trials.
Introduction
The demand for safe, cost-effective health care is increasing from the public, physicians, and third-party payers. Evidence-based practice is becoming an essential component of twenty-first century medicine and, increasingly, doctors must justify their work based on clinical effectiveness and cost. Physicians are being asked to show, using higher level clinical research, the clinical benefits of accepted treatments. However, many of these treatments developed through technical advances or surgical pioneering and were not vetted through the rigorous process of clinical trials.
Facial fracture management, like most aspects of facial plastic and reconstructive surgery, has evolved through the collective experiences of its surgeons. The current surgical trends and techniques have been shaped through advances in diagnostics, instrumentation, and hardware. In facial trauma, most current practices did not result from rigorous randomized clinical trials (RCTs). Instead, surgeons adopted new techniques and approaches when they believed them to be better than what had been done. There certainly was no requirement to prove the superiority of a new technique or instrument before adopting it. Innovators were not compelled to prove what they thought was inherently obvious.
It is not surprising that the literature concerning facial fracture treatment is limited both in its quality and level of evidence. The predominant article types are retrospective case series and nonrandomized trials. There is a scarcity of RCTs in all of facial plastic surgery; however, it is very glaring in facial trauma. This is not surprising given the obstacles inherent in conducting clinical studies in fracture treatment. Cost, ethical constraints, and subject recruitment all deter randomized studies. There are also challenges in conducting surgical trials given the significant variability in facial fractures, the range of surgical procedures to address the injuries, and the skills of surgeons performing those operations.
Recognizing that facial fracture management has evolved over decades mostly devoid of any evidence-based research, and further recognizing the persistent challenges in conducting quality studies, it is easy to view evidenced-based facial fracture care as unattainable. However, some recent studies in facial fracture treatment have included higher level randomized trials as well as organized meta-analysis. As specialists, facial plastic surgeons must continue to adapt evidence-based approaches to both clinical practice and research. Doing so validates what we are doing well and highlights areas needing improvement. Both the public and organized medicine demands this research and our specialty needs to provide it.
This article reviews relevant issues in facial fracture management, emphasizing the evidence-based methodology. It highlights the few areas of facial trauma in which randomized studies and meta-analysis are available. It also points out the many other areas for which the evidenced-based literature is poor or altogether absent. Finally, the article examines the future of facial trauma care in which clinical registries and health databases may be better able to answer clinical questions too complex to be addressed by clinical trials.
Antibiotics and facial fractures
The role of antibiotics in facial fracture treatment remains unsettled and controversial. With injuries varying widely in fracture location, severity, and wound contamination, the clinical benefits of antibiotics use is not easily determined. The literature on this topic is complex and at times conflicting. With the increasing rates of antibiotic resistance and calls for an evidence-based approach to patient care, clarifying the role for antibiotic use in facial trauma is important. The literature has tried to distinguish between antibiotic use in mandible fractures and antibiotics with other facial fractures, including those isolated mandibular condyle fractures. Surgeons agree on the need for antibiotics with infected wounds and most routinely administer antibiotics in the perioperative setting. The literature supporting preoperative antibiotic use is not clear-cut and the use of postoperative antibiotics is even more controversial.
In 2006, Andreasen and colleagues conducted a systematic review to identify the potential benefit of prophylactic antibiotics in the maxillofacial fractures. The reviewers sought to address 3 important questions: does antibiotic prophylaxis decrease infections in jaw fracture treatment, are there situations when antibiotic prophylaxis is not indicated, and which is the antibiotic prescription of choice? They identified 4 RCTs that met the search criteria. Collectively, the studies showed a 3-fold decrease in infection rates for mandibular fractures in the antibiotic-treated groups compared with the no-antibiotic control groups. The review identified a wide variety of antibiotics that seemed to have a uniform effect in reducing infections. The review further noted that the reduction in infections was seen regardless of antibiotic duration. However, there was no benefit to giving postoperative antibiotics beyond 24 to 48 hours. Only 1 of the 4 studies actually looked at antibiotics in facial fractures other than the mandible. This trial found no infections with repairs of maxillary, zygoma, or condyle fractures. The reviewers concluded that prophylactic antibiotics are beneficial in the treatment of mandible fractures but, because of a low risk of postoperative infection, prophylactic antibiotics were not indicated for other facial fracture sites.
In 2011, Kyzas published another comprehensive systematic review of antibiotics and mandible fractures with slightly different conclusions. Challenging the notion that antibiotic use in mandible fractures was mandatory, and spurred by the weak literature previously highlighted, Kyzas sought to more clearly define the role for antibiotics. This review included 9 randomized trials and 22 nonrandomized retrospective case series. He found the literature to be of poor quality with variable data that prohibited making any quantitative assessments. The reviewed studies had infection rates ranging from 4.5% to 62% without antibiotics and from 1.9% to 29.4% with antibiotics. He concluded that the support for prophylactic antibiotic use was limited and of weak quality. Based on his analysis, any recommendation for routine antibiotic use was weak and not reliably supported by the literature.
To determine the benefit of postoperative antibiotics after mandible fracture repair, Miles and colleagues conducted a prospective RCT. All subjects received preoperative and intraoperative antibiotics. Eighty-one subjects also received postoperative antibiotics and 100 had no postoperative antibiotics. There were no differences in postoperative infection rates. There were infections in 8 out of 81 subjects who received postoperative antibiotics and 14 out of 100 who did not receive postoperative antibiotics. The investigators were unable to show a benefit of using postoperative antibiotics for mandible fracture repair.
A 2014 systematic review by Shridharani and colleagues also looked at the potential benefit of antibiotics after mandible fracture repair. Their review found 73 potential articles with only 5 meeting defined criteria. They noted that, although several studies addressed the antibiotic question, there was wide variability in antibiotics, subjects, and treatment protocols. They suggested there was a trend toward not needing antibiotics beyond 24 hours after fracture repair. They cautioned that this lower degree of evidence with its limited number of level 1 studies did not provide a gold standard for management. To highlight what are clear differences between actual clinical practice and the prevailing literature, the reviewers also presented results from a surgeon survey in which more than 50% of respondents routinely used postoperative antibiotics despite the lack of supporting evidence.
The literature examining the role of antibiotic prophylaxis in nonmandibular facial fractures is even sparser. In a multi-institutional prospective cohort study, Knepil and Loukota studied prophylactic antibiotics in 134 subjects who had surgery for zygoma fractures. They found a postoperative infection rate of only 1.5%, which was seen only after transoral surgical approach.
Summarizing the available literature, Morris and Kellman recommend that antibiotics be given for mandible fractures only from injury until completion of the perioperative course but not postoperatively. There are insufficient data to assess prophylactic antibiotics in nonmandible fractures and isolated condyle fractures but evidence that did exist suggested no benefit to postoperative antibiotics ( Table 1 ).
| Antibiotics Before Surgery | Perioperative Antibiotics (within 2 h of surgery) | Prophylactic Antibiotics After Surgery | |
|---|---|---|---|
| Mandible fractures (not isolated condyle) | Yes | Yes | No benefit to antibiotics beyond 24–48 h |
| Isolated mandibular condyle fractures | No benefit | Yes | No benefit |
| Midface and frontal sinus fracture | No benefit | Yes | No benefit |
| Skull base fractures | No role for prophylactic antibiotics with or without cerebrospinal fluid leak Role for antibiotics with skull base fracture repair not defined | ||
Having highlighted the indications for antibiotics in facial fracture repair, comment on the role of antibiotics in skull base trauma is necessary. There is controversy about whether antibiotics should be routinely given to patients with skull base fractures in an effort to prevent infectious complications, including meningitis. Previous publications have both called for and recommended against this practice. In 2011, Ratilal and colleagues published a Cochrane review of RCTs as well as non-RCTS concerning antibiotics and skull base fracture. The review identified 5 RCTs involving 208 subjects. Analysis showed no reduction in meningitis rates, overall mortality, meningitis-related mortality, and the need for surgery from cerebrospinal fluid leak in subjects receiving prophylactic antibiotics. No complications from antibiotic use were seen; however, 1 study did find a change in the microbial flora toward organisms more likely to be resistant to antibiotics. In addition, the review examined 17 nonrandomized studies, which included more than 2100 subjects. The analysis produced results in line with those seen in the randomized data. Most of studies lacked sufficient details on methodology, which limited their quality. The conclusion of this analysis was that there was insufficient evidence for prophylactic antibiotic use in patients with skull base fractures with or without a cerebrospinal fluid leak. Until better evidence becomes available, the routine use of antibiotics in these cases should be avoided.
Nasal fractures
No facial injury is more common than the nasal fracture. Despite a frequency of injury that should lend to clinical investigation, there are only a handful of randomized trials examining nasal trauma management. Although closed reduction for a nasal fracture is common practice and, in some locations, the standard of care, the efficacy of this procedure is still debated. Although many surgeons advocate for closed nasal reduction, others encourage more extensive open techniques to address nasal injuries. Extensive-fracture dislocation of the nasal bone and septum, dramatic deviation of the nasal pyramid, dislocation or open fractures of the septum, and persistent deformity after an attempt at closed reduction are directing surgeons to an consider an open approach. Some recent publications have even advocated for a more formal rhinoplasty approach with nearly all of these injuries. Despite the ongoing controversy, no prospective RCT has been conducted to directly compare open and closed techniques and help answer this clinical question.
In assessing the efficacy of nasal injury treatment, a 2002 publication by Staffel deserves comment. He reported on the effectiveness of closed nasal reduction by reviewing several studies in the literature and proposing a treatment algorithm to improve outcomes. He also highlighted a dichotomy between high patient satisfaction with the clinical outcomes (79%) and the low surgeon satisfaction (37%) with those same results. This demonstrates that patient and surgeon expectations can be quite different and suggests that, if patient satisfaction is a primary goal of treatment, closed nasal reduction is likely the appropriate initial approach.
There is also no consensus on the best method of anesthesia for reducing a nasal fracture. Previous studies have shown that general anesthesia, sedation, and local anesthesia can all be effective and are well tolerated by subjects undergoing nasal reduction. Anesthesia selection is often guided by surgeon preference, operating room availability, and hospital protocol. Advocates for general anesthesia have suggested that reduction can be performed with better outcomes and less pain, whereas others showed equivalent outcomes at a lower cost using local anesthesia
To address choice of anesthesia for closed nasal reduction Al-Moraissi and Ellis conducted a systematic review of the literature with a meta-analysis. The review identified 8 studies with 846 subjects. Of these studies, 3 were RCTs, 2 were clinical cohort studies, and 3 were retrospective series. The analysis showed subject satisfaction with anesthesia and subject satisfaction with nasal function were both slightly higher, but not statistically higher, under general anesthesia. The subject satisfaction with nasal appearance was statistically higher with general anesthesia ( Table 2 ). These subjects were also less likely to later require a secondary nasal procedure. These results support improved outcomes when nasal reduction is performed under general anesthesia; however, this must be balanced against other factors, including procedure cost and convenience. Regardless of the anesthesia use in nasal reduction, other clinical factors, including septal and nasal tip deviation, are predictors of a persistent deformity and must be considered in selecting the method of treatment.
| Patient Satisfaction with Anesthesia | Patient Satisfaction with Nasal Function | Patient Satisfaction with Nasal Appearance | |
|---|---|---|---|
| General anesthesia | Slightly higher | Slightly higher | Significantly higher |
| Local anesthesia | Slightly lower | Slightly lower | Significantly lower |
Mandible fractures
Mandible fractures are common fractures that encompass a variety of different injuries with an extensive range of treatment options. This diverse group of fractures can be treated with either open or closed reduction, followed by external or internal fixation, or both. Given the variety of fractures and the plethora of treatment options, it is not surprising that there is little consensus about which treatment is best for a specific fracture pattern.
Advancements in plating systems and a better understanding of the biomechanics of the mandible have led to a gradual evolution in fracture management. Closed reduction with mandibular-maxillary fixation (MMF) is increasingly being replaced by open approaches with application of various fixation hardware. As with most of facial trauma, there is limited high-level evidence to support such a clinical change. Most of the thousands of publications on mandible fracture repair are retrospective studies of suboptimal quality. Only recently have quality randomized trials looking at various aspects of mandible fracture repair appeared in the literature. These RCTs have examined many different variables, including the use of single miniplates, locking plates, 3-dimensional plates, resorbable plates, and lag screws to treat adult mandible fractures.
Angle Fractures
Patients sustaining mandible trauma usually present with defined anatomic fracture patterns. Each anatomic fracture pattern offers several options for repair with internal fixation. The presence of third molars and thin cortices of bone make the mandibular angle among the most common sites of fracture. The fractures of the angle have been investigated with several RCTs ( Table 3 ) attempting to determine the ideal method of fixation. Danda conducted 1 such trial by comparing postoperative complications between angle fractures repaired with a standard Champy plate and fractures repaired with a Champy plate plus a second plate on lateral aspect of the mandible. In this study, with 27 subjects in each group, there was no difference in complication rates. He concluded that there is no benefit to using a second plate for noncomminuted angle fractures. Siddiqui and colleagues also compared plating requirements for angle fractures. This RCT again compared using 1 miniplate (n = 36) to using 2 miniplates (n = 26) for noncomminuted angle fractures. There was no difference in total morbidity or complications between the techniques. The investigators concluded that 2 miniplates offered no additional benefit and increased costs.
| Study | Question | Result | Conclusion |
|---|---|---|---|
| Danda, 2010 | 1 vs 2 miniplates for noncomminuted fracture | No difference in complication | No benefit to second plate |
| Siddiqui et al, 2007 | 1 vs 2 miniplates for noncomminuted fracture | No differences in total morbidity or complications | No benefit and increased cost with second plate |
| Laverick et al, 2012 | Traditional Champy plate vs lateral plate via transbuccal | Much lower complications with lateral plate | Lateral plate favored over Champy |
| Sugar et al, 2009 | Traditional Champy plate vs lateral via transbuccal | Fewer complications with lateral plate | Lateral plate favored over Champy and preferred by surgeons |
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