Modern Management of Maxillofacial Injuries

  • Gabriele CanziEmail author
  • Davide Sozzi
  • Alberto Bozzetti


Maxillofacial involvement in patients with multiple trauma injuries is usually frequent and noticeable, but it is mainly dangerous for ATLS priorities, meaning that it can compromise airway protection (A) and circulation (C) and it can often be associated with brain and cervical spine injuries. Facial hemorrhages are rarely one of the main causes of hemodynamic instability, but their early detection and prompt local control must be supported by each emergency surgeon. In very few, selected and complex cases, when local measures fail, endovascular treatment is today the best option available to achieve definitive control of refractory bleeding.

Once the lifesaving priorities are successfully managed, clinicians have to preserve patients’ eyesight as well as limbs; timely clinical diagnosis and appropriate treatment work-up are essential to preserve visual function. On the other hand, we have a few, easy, damage control surgical procedures to save time, thus managing visual-threatening injuries, for instance, anterior orbitotomy is more effective, having a better aesthetic outcome.

Being more confident with facial trauma emergency issues allows clinicians to be better able to deal with the comprehensive care of acutely injured patients.


Maxillofacial trauma Facial bleeding Facial embolization Orbital compartment syndrome Retrobulbar hematoma 


  1. 1.
    Boffano P, Roccia F, Zavattero E, Dediol E, Uglešić V, Kovačič Ž, Vesnaver A, Konstantinović VS, Petrović M, Stephens J, Kanzaria A, Bhatti N, Holmes S, Pechalova PF, Bakardjiev AG, Malanchuk VA, Kopchak AV, Galteland P, Mjøen E, Skjelbred P, Koudougou C, Mouallem G, Corre P, Løes S, Lekven N, Laverick S, Gordon P, Tamme T, Akermann S, Karagozoglu KH, Kommers SC, Forouzanfar T. European Maxillofacial Trauma (EURMAT) project: a multicentre and prospective study. J Craniomaxillofac Surg. 2015;43:62–70.PubMedGoogle Scholar
  2. 2.
    Hutchinson I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. Br Med J. 1990;301:595–9.Google Scholar
  3. 3.
    Perry M, Morris C. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg. 2008;37:309–20.PubMedGoogle Scholar
  4. 4.
    Jose A, Nagori SA, Agarwal B, Bhutia O, Roychoudhury A. Management of maxillofacial trauma in emergency: an update of challenges and controversies. J Emerg Trauma Shock. 2016;9:73–80.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Ardekian L, Samet N, Shoshani Y, Taicher S. Life-threatening bleeding following maxillofacial trauma. J Craniomaxillofac Surg. 1993;21:336–8.PubMedGoogle Scholar
  6. 6.
    Perry M, O’Hare J, Porter G. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: hypovolaemia and facial injuries in the multiply injured patient. Int J Oral Maxillofac Surg. 2008;37:405–14.PubMedGoogle Scholar
  7. 7.
    Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: advanced trauma life support. Emerg Med J. 2006;23:796–7.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Veeravagu A, Joseph R, Jiang B, Lober RM, Ludwig C, Torres R, Singh H. Traumatic epistaxis: skull base defects, intracranial complications and neurosurgical considerations. Int J Surg Case Rep. 2013;4:656–61.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Khanna S, Dagum AB. A critical review of the literature and an evidence-based approach for life-threatening hemorrhage in maxillofacial surgery. Ann Plast Surg. 2012;69:474–8.PubMedGoogle Scholar
  10. 10.
    Bynoe RP, Kerwin AJ, Parker HH 3rd, Nottingham JM, Bell RM, Yost MJ, Close TC, Hudson ER, Sheridan DJ, Wade MD. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma. 2003;55:74–9.PubMedGoogle Scholar
  11. 11.
    Tung TC, Tseng WS, Chen CT, Lai JP, Chen YR. Acute life-threatening injuries in facial fracture patients: a review of 1,025 patients. J Trauma. 2000;49:420–4.PubMedGoogle Scholar
  12. 12.
    Perry M, Dancey A, Mireskandari K, Oakley P, Davies S, Cameron M. Emergency care in facial trauma—a maxillofacial and ophthalmic perspective. Injury. 2005;36:875–96.PubMedGoogle Scholar
  13. 13.
    Ho K, Hutter JJ, Eskridge J, Khan U, Boorer CJ, Hopper RA, Deva AK. The management of life-threatening haemorrhage following blunt facial trauma. J Plast Reconstr Aesthet Surg. 2006;59:1257–62.PubMedGoogle Scholar
  14. 14.
    Gwyn PP, Carraway JH, Horton CE, Adamson JE, Mladick RA. Facial fractures—associated injuries and complications. Plast Reconstr Surg. 1971;47:225–30.PubMedGoogle Scholar
  15. 15.
    Shimoyama T, Kaneko T, Horie N. Initial management of massive oral bleeding after midfacial fracture. J Trauma. 2003;54:332–6; discussion 336.PubMedGoogle Scholar
  16. 16.
    Singam P, Thanabalan J, Mohammed Z. Superselective embolisation for control of intractable epistaxis from maxillary artery injury. Biomed Imaging Interv J. 2011;7:1–3.Google Scholar
  17. 17.
    Al-Jehani HM, Alwadaani HA, Almolani FM. Traumatic intracranial internal carotid artery pseudoaneurysm presenting as epistaxis treated by endovascular coiling. Neurosciences (Riyadh). 2016;21:60–3.Google Scholar
  18. 18.
    Cogbill TH, Cothren CC, Ahearn MK, Cullinane DC, Kaups KL, Scalea TM, Maggio L, Brasel KJ, Harrison PB, Patel NY, Moore EE, Jurkovich GJ, Ross SE. Management of maxillofacial injuries with severe oronasal hemorrhage: a multicenter perspective. J Trauma. 2008;65:994–9.PubMedGoogle Scholar
  19. 19.
    Waldron J, Stafford N. Ligation of the external carotid artery for severe epistaxis. J Otolaryngol. 1992;21:249–51.PubMedGoogle Scholar
  20. 20.
    Zachariades N, Rallis G, Papademetriou G, Papakosta V, Spanomichos G, Souelem M. Embolization for the treatment of pseudoaneurysm and transection of facial vessels. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:491–4.PubMedGoogle Scholar
  21. 21.
    Lynham AJ, Hirst JP, Cosson JA, Chapman PJ, McEniery P. Emergency department management of maxillofacial trauma. Emerg Med Australas. 2004;16:7–12.PubMedGoogle Scholar
  22. 22.
    Sakamoto T, Yagi K, Hiraide A, Takasu A, Kinoshita Y, Iwai A, Yoshioka T, Sugimoto T. Transcatheter embolization in the treatment of massive bleeding due to maxillofacial injury. J Trauma. 1988;28(6):840–3.PubMedGoogle Scholar
  23. 23.
    Gamanagatti S, Prasad TV, Kumar A, Singhal M, Sagar S. Angioembolisation in maxillofacial trauma: an initial experience in a tertiary care center. J Maxillofac Oral Surg. 2016;15:59–66.PubMedGoogle Scholar
  24. 24.
    Buchanan RT, Holtmann B. Severe epistaxis in facial fractures. Plast Reconstr Surg. 1983;71:768–71.PubMedGoogle Scholar
  25. 25.
    Rockey JG, Anand R. A critical audit of the surgical management of intractable epistaxis using sphenopalatine artery ligation/diathermy. Rhinology. 2002;40:147–9.PubMedGoogle Scholar
  26. 26.
    Srinivasan V, Sherman IW, O’Sullivan G. Surgical management of intractable epistaxis: audit of results. J Laryngol Otol. 2000;114:697–700.PubMedGoogle Scholar
  27. 27.
    Baqain ZH, Thakkar C, Kalavrezos N. Superselective embolization for control of facial haemorrhage. Injury. 2004;35:435–8.PubMedGoogle Scholar
  28. 28.
    Goddard JC, Reiter ER. Inpatient management of epistaxis: outcomes and cost. Otolaryngol Head Neck Surg. 2005;132:707–12.PubMedGoogle Scholar
  29. 29.
    Zhang C, Xie X, You C, Mao B, Wang C, He M, Sun H. Endovascular treatment of traumatic pseudoaneurysm presenting as intractable epistaxis. Korean J Radiol. 2010;11:603–11.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Radvany MG, Gailloud P. Endovascular management of neurovascular arterial injuries in the face and neck. Semin Intervent Radiol. 2010;27:44–54.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Sokoloff J, Wickbom I, McDonald D, Brahme F, Goergen TC, Goldberger LE. Therapeutic percutaneous embolization in intractable epistaxis. Radiology. 1974;111:285–7.PubMedGoogle Scholar
  32. 32.
    Liao CC, Hsu YP, Chen CT, Tseng YY. Transarterial embolization for intractable oronasal hemorrhage associated with craniofacial trauma: evaluation of prognostic factors. J Trauma. 2007;63:827–30.PubMedGoogle Scholar
  33. 33.
    Scaramuzzi N, Walsh RM, Brennan P, Walsh M. Treatment of intractable epistaxis using arterial embolization. Clin Otolaryngol Allied Sci. 2001;26:307–9.PubMedGoogle Scholar
  34. 34.
    Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral Maxillofac Surg. 2008;37:209–14.PubMedGoogle Scholar
  35. 35.
    Perry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 4: ‘can the patient see?’ Timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg. 2008;37:505–14.PubMedGoogle Scholar
  36. 36.
    McClenaghan FC, Ezra DG, Holmes SB. Mechanisms and management of vision loss following orbital and facial trauma. Curr Opin Ophthalmol. 2011;22:426–31.PubMedGoogle Scholar
  37. 37.
    Steinsapir KD, Goldberg RA. Traumatic optic neuropathy: an evolving understanding. Am J Ophthalmol. 2011;151:928–33.PubMedGoogle Scholar
  38. 38.
    Winterton JV, Patel K, Mizen KD. Review of management options for a retrobulbar hemorrhage. J Oral Maxillofac Surg. 2007;65:296–9.PubMedGoogle Scholar
  39. 39.
    Allen M, Perry M, Burns F. When is a retrobulbar haemorrhage not a retrobulbar haemorrhage? Int J Oral Maxillofac Surg. 2010;39:1045–9.PubMedGoogle Scholar
  40. 40.
    Popat H, Doyle PT, Davies SJ. Blindness following retrobulbar haemorrhage—it can be prevented. Br J Oral Maxillofac Surg. 2007;45:163–4.PubMedGoogle Scholar
  41. 41.
    Hislop WS, Dutton GN, Douglas PS. Treatment of retrobulbar haemorrhage in accident and emergency departments. Br J Oral Maxillofac Surg. 1996;34:289–92.PubMedGoogle Scholar
  42. 42.
    Perry M. Acute proptosis in trauma: retrobulbar hemorrhage or orbital compartment syndrome—does it really matter? J Oral Maxillofac Surg. 2008;66(9):1913–20.PubMedGoogle Scholar
  43. 43.
    Soare S, Foletti JM, Gallucci A, Collet C, Guyot L, Chossegros C. Update on orbital decompression as emergency treatment of traumatic blindness. J Craniomaxillofac Surg. 2015;43:1000–3.PubMedGoogle Scholar
  44. 44.
    Mohammadi F, Rashan A, Psaltis A, Janisewicz A, Li P, El-Sawy T, Nayak JV. Intraocular pressure changes in emergent surgical decompression of orbital compartment syndrome. JAMA Otolaryngol Head Neck Surg. 2015;141:562–5.PubMedGoogle Scholar
  45. 45.
    Kulkarni AR, Aggarwal SP, Kulkarni RR, Deshpande MD, Walimbe PB, Labhsetwar AS. Ocular manifestations of head injury: a clinical study. Eye (Lond). 2005;19:1257–63.Google Scholar
  46. 46.
    Linberg JV. Orbital compartment syndromes following trauma. Adv Ophthalmic Plast Reconstr Surg. 1987;6:51–62.PubMedGoogle Scholar
  47. 47.
    Fattahi T, Brewer K, Retana A, Ogledzki M. Incidence of retrobulbar hemorrhage in the emergency department. J Oral Maxillofac Surg. 2014;72:2500–2.PubMedGoogle Scholar
  48. 48.
    Chen YA, Singhal D, Chen YR, Chen CT. Management of acute traumatic retrobulbar haematomas: a 10-year retrospective review. J Plast Reconstr Aesthet Surg. 2012;65:1325–30.PubMedGoogle Scholar
  49. 49.
    Schumann P, Kokemüller H, Tavassol F, Lindhorst D, Lemound J, Essig H, Rücker M, Gellrich NC. Optic nerve monitoring. Craniomaxillofac Trauma Reconstr. 2013;6:75–86.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Kniess CK, Fong TC, Reilly AJ, Laoteppitaks C. Early detection of traumatic retrobulbar hemorrhage using bedside ocular ultrasound. J Emerg Med. 2015;49:58–60.PubMedGoogle Scholar
  51. 51.
    Cornelius CP, Altenmüller E, Ehrenfeld M. The use of flash visual evoked potentials in the early diagnosis of suspected optic nerve lesions due to craniofacial trauma. J Craniomaxillofac Surg. 1996;24:1–11.PubMedGoogle Scholar
  52. 52.
    Zoumalan CI, Bullock JD, Warwar RE, McCulley TJ. Evaluation of intraocular and orbital pressure in the management of orbital hemorrhage: an experimental model. Arch Ophthalmol. 2008;126:1257–60.PubMedGoogle Scholar
  53. 53.
    Goodall KL, Brahma A, Bates A, Leatherbarrow B. Lateral canthotomy and inferior cantholysis: an effective method of urgent orbital decompression for sight threatening acute retrobulbar haemorrhage. Injury. 1999;30:485–90.PubMedGoogle Scholar
  54. 54.
    Ikejiri M, Adachi-Usami E, Mizota A, Tsuyama Y, Miyauchi O, Suehiro S. Pattern visual evoked potentials in traumatic optic neuropathy. Ophthalmologica. 2002;216:415–9.PubMedGoogle Scholar
  55. 55.
    Steinsapir KD, Goldberg RA. Traumatic optic neuropathy: a critical update. Comp Ophtalmol Update. 2005;6:11–21.Google Scholar
  56. 56.
    Warner N, Eggenberger E. Traumatic optic neuropathy: a review of the current literature. Curr Opin Ophthalmol. 2010;21:459–62.PubMedGoogle Scholar
  57. 57.
    Sun MT, Chan WO, Selva D. Traumatic orbital compartment syndrome: importance of the lateral canthomy and cantholysis. Emerg Med Australas. 2014;26:274–8.PubMedGoogle Scholar
  58. 58.
    Oester AE Jr, Fowler BT, Fleming JC. Inferior orbital septum release compared with lateral canthotomy and cantholysis in the management of orbital compartment syndrome. Ophthal Plast Reconstr Surg. 2012;28:40–3.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Haubner F, Jägle H, Nunes DP, Schleder S, Cvetkova N, Kühnel T, Gassner HG. Orbital compartment: effects of emergent canthotomy and cantholysis. Eur Arch Otorhinolaryngol. 2015;272:479–83.PubMedGoogle Scholar
  60. 60.
    Ghufoor K, Sandhu G, Sutcliffe J. Delayed onset of retrobulbar haemorrhage following severe head injury: a case report and review. Injury. 1998;29:139–41.PubMedGoogle Scholar
  61. 61.
    Hayter JP, Sugar AW. An orbital observation chart. Br J Oral Maxillofac Surg. 1991;29:77–9.PubMedGoogle Scholar
  62. 62.
    Steinsapir KD. Treatment of traumatic optic neuropathy with high-dose corticosteroid. J Neuroophthalmol. 2006;26:65–7.PubMedGoogle Scholar
  63. 63.
    Yu-Wai-Man P, Griffiths PG. Steroids for traumatic optic neuropathy.Cochrane Database Syst Rev. 2011;(19):CD006032.
  64. 64.
    Levin LA, Beck RW, Joseph MP, Seiff S, Kraker R. The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study. Ophthalmology. 1999;106:1268–77.PubMedGoogle Scholar
  65. 65.
    Lee V, Ford RL, Xing W, Bunce C, Foot B. Surveillance of traumatic optic neuropathy in the UK. Eye (Lond). 2010;24:240–50.Google Scholar
  66. 66.
    Edwards P, Arango M, Balica L, Cottingham R, El-Sayed H, Farrell B, Fernandes J, Gogichaisvili T, Golden N, Hartzenberg B, Husain M, Ulloa MI, Jerbi Z, Khamis H, Komolafe E, Laloë V, Lomas G, Ludwig S, Mazairac G, Muñoz Sanchéz Mde L, Nasi L, Olldashi F, Plunkett P, Roberts I, Sandercock P, Shakur H, Soler C, Stocker R, Svoboda P, Trenkler S, Venkataramana NK, Wasserberg J, Yates D, Yutthakasemsunt S, CRASH trial collaborators. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005;365:1957–9.PubMedGoogle Scholar
  67. 67.
    Sires BS, Stanley RB Jr, Levine LM. Oculocardiac reflex caused by orbital floor trapdoor fracture: an indication for urgent repair. Arch Ophthalmol. 1998;116:955–6.PubMedGoogle Scholar
  68. 68.
    Gerbino G, Roccia F, Bianchi FA, Zavattero E. Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg. 2010;68:1310–6.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Gabriele Canzi
    • 1
    Email author
  • Davide Sozzi
    • 2
  • Alberto Bozzetti
    • 1
    • 2
  1. 1.Maxillofacial Departmental Structure, the Emergency DepartmentASST Grande Ospedale Metropolitano NiguardaMilanItaly
  2. 2.ASST Monza San Gerardo Hospital, and the Department of Medicine and Surgery, School of MedicineUniversity of Milano-BicoccaMilanItaly

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