Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 183e189

Epidemiology and management of

maxillofacial fractures in an Australian
trauma centre
Miguel S. Cabalag a, Jason Wasiak b, Nadine E. Andrew c,
Jason Tang a, Julia C. Kirby a, David J. Morgan a,*
a

Plastic, Hand & Faciomaxillary Surgery Unit, The Alfred Hospital, Melbourne, VIC, Australia
Victorian Adult Burns Service and School of Public Health and Preventive Medicine, Monash
University, The Alfred Hospital, Melbourne, VIC, Australia
c
Translational Public Health Unit, Stroke and Ageing Research Centre, Southern Clinical School,
Monash University, Melbourne, VIC, Australia
b

Received 15 September 2013; accepted 14 October 2013

KEYWORDS
Maxillofacial
fractures;
Epidemiology;
Management;
Complications;
Risk factors;
Australia

Summary Background and aim: Trauma is a leading cause of morbidity and mortality, with a
considerable proportion of trauma patients sustaining concomitant maxillofacial (MF) injuries.
The purpose of this study was to review and analyse the epidemiology, management and complications of patients with MF fractures managed by the Faciomaxillary Surgery Unit at the
Alfred Trauma Hospital in Melbourne.
The secondary objective of the study was to determine the risk factors for developing postoperative complications.
Methods: A retrospective records review was performed for 980 patients who were treated for
MF fracture(s) from January 2009 to December 2011. Descriptive statistics were used and independent demographic and injury-related factors assessed for association with outcome using
multivariate logistic regression.
Results: A total of 1949 MF fractures from 980 patients were treated over the study period.
Males (n Z 785, 80.10%) and patients aged 15e24 years (n Z 541, 55.20%) were the most
frequently affected (mean age (standard deviation, SD) 27.69 (19.22)). The most common aetiology was assault (n Z 293, 29.90%). The majority presented with fractures of the orbit
(n Z 359, 36.33%). In total, 803 fractures from 500 patients were treated operatively. Mandibular fractures were most commonly treated surgically (79.82%). Postoperative complications
occurred in 69 of 500 patients treated surgically (13.8%), most commonly due to infected
metalware (n Z 16, 3.20%). Multiple fractures were associated with a higher probability of

* Corresponding author. Faciomaxillary Surgery Unit, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia. Tel.: 61
03 9076 3626; fax: 61 03 9347 8799.
E-mail address: D.Morgan@alfred.org.au (D.J. Morgan).
1748-6815/$ - see front matter 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2013.10.022

184

M.S. Cabalag et al.

requiring surgery (p < 0.001) and developing postoperative complications (p < 0.001)
compared to isolated fractures.
Conclusion: MF fractures most commonly affected young males, often as a result of an assault.
Per bony injury, mandibular fractures had the greatest proportion that was managed operatively. High-energy injuries were associated with an increased risk of sustaining multiple MF
fractures and developing postoperative complications.
2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Trauma is a leading cause of mortality and morbidity in

Australia, with an estimated 5e33% of major trauma patients suffering concomitant maxillofacial (MF) injuries.1e3
It has been estimated that MF injuries contribute to 28% of
the total cost of treating trauma patients, ranging from
$793 to $20,678 per patient.4,5 In New South Wales,
Australia, the acute care costs of managing MF trauma was
reported to be over $30 million annually.4 Few published
Australian data are available analysing the epidemiology
and management of MF fractures in general, with most
being bone-specific.6e8
The purpose of this study was to review and analyse the
epidemiology, treatment and complications of MF fractures
managed by the Faciomaxillary Surgery Unit at Alfred
Hospital in Melbourne, one of the busiest tertiary trauma
centres in Australasia. The secondary objective was to
determine the risk factors for developing postoperative
complications.

Methods
A retrospective review of prospectively collected data was
conducted for 980 patients with MF fractures managed by
the Faciomaxillary Surgery Unit at the Alfred Hospital
(Melbourne, VIC, Australia) from January 2009 to December
2011. Patients with MF fractures were identified using the
units audit database (created in January 2009, Figure 1)
and were confirmed with hospital records. Those patients
with isolated dentoalveolar trauma were excluded, as they
were treated by dentists.
Demographic variables extracted from the medical records included age, gender and injury variables (Table 1).
Motor vehicle accidents (MVAs) included motorbike injuries,
and sporting injuries included cycling. The group classified
as other included events such as explosions, home or work
accidents and medical complications or conditions. For the
regression analyses, pedestrians were included in the group
other due to small subgroup numbers. The frequency and
pattern of facial fractures, their management and associated postoperative complications were also recorded. The
psychological complications of MF trauma were not studied
(e.g., posttraumatic stress disorder).
Anatomically, MF fractures were subdivided by bony
regions as shown in Table 2. All the paired bones (zygoma,
orbit, nasoorbitoethmoid (NOE) complex, hemimaxilla,
hemimandible and condyle) were considered to be single
unilateral units. Fractures of the zygoma, orbit, NOE complex and maxilla were not mutually exclusive. With regard
to the mandible, intracapsular fractures were defined as

fractures of the condylar head, which were not amenable

to open reduction and internal fixation (ORIF). Extracapsular fractures involved the condylar neck and subcondylar region and could undergo ORIF.
Data were presented using descriptive analyses. Multiple
logistic regression analyses were used to identify demographic and injury-related factors associated with
outcome. Outcome variables included the need for and
type of surgical management and the occurrence of postoperative complications. Stata (StatCorp. 2011. Stata
Statistical Software: Release 12; College Station, TX, USA:
StatCorp LP) was used for all analyses and a p value of 0.05
was considered statistically significant.
Ethics approval was obtained from the Hospital Research
Ethics Committee prior to data collection.

Results
A total of 980 patients sustained 1949 MF fractures over the
3-year study period (n Z 197, 414 and 369, respectively).

Demographics of MF fractures
Males were affected more than females with a ratio of
approximately 4:1 (n Z 785, 80.10% vs. n Z 195, 19.90%)
and the mean (standard deviation, SD) age was 27.69
(19.22) (range 18e99). In both genders, the 15e24-yearold age group had the highest frequency of MF fractures
(n Z 541, 55.20%). There was a progressive decline in
the frequency of MF fractures with increasing age
(Figure 2).

Mechanism of injury
Data variables in reference to mechanism of injury are
summarised in Table 1. Assault was the most common
mechanism of injury (n Z 293, 29.90%), followed by MVA
(n Z 234, 23.88%). In the 15e44-year-old age group, the
most common mechanism of injury was assault followed by
MVA. However, in the 45e84-year-old age group, the most
common cause was falls followed by MVA (Figure 2). Assault
was the most frequent cause in males (n Z 267, 34.01%)
and falls was the most common in females (n Z 77,
39.49%). A history of preceding alcohol use was present in
142 patients (14.49%), of whom 70 were assault cases.
After other injures, patients who suffered sporting injuries most commonly sustained an isolated fracture
(n Z 91, 60.26%) and they were most likely to undergo

Epidemiology and management of MF

185

Figure 1

Screenshot of audit program.

surgical intervention (n Z 90, 59.60%). Half of the MVA

patients underwent ORIF (n Z 118, 50.43%). Figure 3 depicts the distribution of aetiologies over the 3-year study
period.

Site and pattern of MF fractures

Patients (total n Z 980) most commonly presented with
fractures in the region of the orbit (n Z 359, 36.63%),
followed by fractures of the maxilla (n Z 326, 32.96%),
zygoma (n Z 315, 31.85%), nasal bone (n Z 306, 31.22%),
mandible (n Z 166, 16.94%), frontal bone (n Z 84, 8.57%),
condyle (n Z 82, 8.37%) and the NOE complex (n Z 51,
5.20%). However, when analysing by individual fractures
(total n Z 1949), the maxilla accounted for the majority
of the total MF fractures managed by the unit (413,
21.19%) as these were more commonly fractured bilaterally (Table 2).
Approximately half of the patients (n Z 509, 51.94%)
suffered an isolated fracture, with the nasal bone being the
most common isolated fracture site (160 of 306 patients
with nasal bone fractures, 52.29%), followed by fractures of
the mandible (59 of 166 patients with mandibular fractures,
35.54%). A total of 239 patients had two fractures (24.39%)
and 116 patients (11.84%) had three, or four or more fractures respectively. In the majority of patients sustaining
four or more fractures (n Z 45, 19.23%), the cause was MVA
(Table 1). The median number of fractures per person was 1
with a range of 1e12.

Management
Approximately half of the patients (n Z 500, 51.02%), with
a total of 803 fractures, were treated surgically. As many as
387 patients (39.49%) underwent an ORIF.
When analysing per bony injury, mandibular fractures had
the greatest proportion that were treated surgically (178 out
of 223 fractures, 79.82%) (Table 2). The majority of extracapsular condylar fractures underwent an intervention (22 and
16 out of a total of 62 extracapsular condylar fractures underwent an ORIF and placement of arch bars, respectively),
whilst most intracapsular condylar fractures were managed
conservatively (three and nine out of a total of 37 fractures
underwent an ORIF and placement of arch bars, respectively).
Most orbital wall fractures were managed conservatively
(294 of 403 fractures, 72.95%) and approximately half of
the maxillary fractures underwent an ORIF (208 fractures,
50.36%).

Complications
A total of 71 postoperative complications occurred in 69 out of
500 patients treated operatively (13.80%). The most common
complication was infected metalware (n Z 16 out of 500 patients, 3.20%), followed by malocclusion (n Z 14, 2.80%),
malunion (n Z 8, 1.60%), plate exposure (n Z 8, 1.60%),
palpable plate (n Z 7, 1.40%), wound infection (n Z 5, 1.00%),
abnormal facial contour requiring recontouring (n Z 4, 0.08%)
and nonunion (n Z 1, 0.02%). Enophthalmos occurred in eight

186

M.S. Cabalag et al.

Table 1

Summary of patient data with reference to mechanism of injury (n[%]).

Assault

MVA

Fall

Sport (inc cycling)

Pedestrian

Other

Total

17
7
3
3
5
5
0
0

21
14
10
6
1
1
0
0

541
146
104
81
43
44
23
1

Age
15e24
200 (68.26)
151 (64.53)
25e34
49 (16.72)
29 (12.39)
35e44
29 (9.90)
25 (10.68)
45e54
12 (4.10)
15 (6.41)
55e64
2 (0.68)
8 (3.42)
65e74
0 (0.00)
4 (1.71)
75e84
0 (0.00)
2 (0.85)
85
1 (0.34)
0 (0.00)
Gender
Male
267 (91.13)
187 (79.91)
Female
26 (8.87)
47 (20.09)
ETOH
Yes
70 (23.89)
21 (8.97)
No
223 (76.11)
213 (91.03)
Isolated fracture
Yes
160 (54.61)
92 (39.32)
No
132 (45.05)
142 (60.68)
Surgery
Yes
170 (58.02)
131 (55.98)
No
123 (41.98)
103 (44.02)
ORIFa
Yes
121 (41.30)
118 (50.43)
No
172 (58.70)
116 (49.57)
Number of fractures per patient
1
160 (54.61)
92 (39.32)
2
79 (26.96)
67 (28.63)
3
35 (11.95)
30 (12.82)
4
19 (6.48)
45 (19.23)
Total
293 (29.90)
234 (23.88)
a

56
20
16
36
26
34
21
0

(26.79)
(12.39)
(7.66)
(17.22)
(12.44)
(16.27)
(10.05)
(0.00)

96
27
18
9
1
0
0
0

(63.58)
(17.88)
(11.92)
(5.96)
(0.66)
(0.00)
(0.00)
(0.00)

(42.50)
(17.50)
(7.50)
(7.50)
(12.50)
(12.50)
(0.00)
(0.00)

(39.62)
(26.42)
(18.87)
(11.32)
(1.89)
(1.89)
(0.00)
(0.00)

(55.20)
(14.90)
(10.31)
(8.30)
(4.39)
(4.49)
(2.35)
(0.10)

132 (63.16)
77 (36.84)

130 (86.09)
21 (13.91)

27 (67.50)
13 (32.50)

42 (79.25)
11 (20.75)

785 (80.10)
195 (19.90)

41 (19.62)
168 (80.38)

7 (4.64)
144 (95.36)

3 (7.50)
37 (92.50)

0 (0.00)
57 (100.00)

142 (14.49)
838 (85.51)

113 (54.07)
96 (45.93)

91 (60.26)
60 (39.74)

19 (47.50)
21 (52.50)

34 (64.15)
19 (35.85)

509 (51.94)
471 (48.06)

68 (32.54)
141 (67.46)

90 (59.60)
61 (40.40)

13 (32.50)
27 (67.50)

28 (52.83)
25 (47.17)

500 (51.02)
480 (48.98)

47 (22.49)
162 (77.51)

61 (40.40)
90 (59.60)

13 (32.50)
27 (67.50)

27 (50.94)
26 (49.06)

387 (39.49)
593 (60.51)

19
11
4
6
40

34
7
5
7
53

509
239
116
116
980

113
42
33
21
209

(54.07)
(20.10)
(15.79)
(10.05)
(21.33)

91
33
9
18
151

(60.26)
(21.85)
(5.96)
(11.92)
(15.41)

(47.50)
(27.50)
(10.00)
(15.00)
(4.08)

(64.15)
(13.21)
(9.43)
(13.21)
(5.41)

(51.94)
(24.39)
(11.84)
(11.84)
(100.00)

ORIF: open reduction internal fixation.

out of 109 cases of orbital fractures treated operatively.

There were no postoperative cases of blindness. One patient
had three complications (malocclusion, palpable plate and
abnormal facial contour). Of the 16 postoperative metalware
infections, 13 cases had two fractures per patient. Nine out of
128 patients with operatively treated mandibular fractures
developed metalware infection (7.03%). Of the nine cases,
five (55.56%) had an ORIF of the mandibular angle. There were
no documented cases of facial dysaesthesia, temporomandibular joint (TMJ) dysfunction nor any dentoalveolar, lachrymal, sinonasal or airway pathologies. For operatively
managed frontal bone fractures, there were no documented
central nervous system (CNS) complications (e.g., cerebrospinal fluid (CSF) leak, meningitis, cerebral bleed or abscess).
As many as 58 (84.06%) of the 69 patients with postoperative complications required further intervention (reoperation, n Z 47; oral antibiotics only, n Z 7; oral
antibiotics and re-operation, n Z 2; and admission for
intravenous antibiotics only, n Z 2). The majority of reoperations were for removal of metalware.

Logistic regression analyses: results

Table 3 demonstrates the multiple logistic regression
analyses results. Age, number of fractures and injury

mechanism were independently associated with whether or

not a patient had surgical management of their fracture.
Younger patients and those with more than one fracture
were significantly more likely to undergo surgery. Those
with four or more fractures were six times more likely to
have surgery than those with only a single fracture (odds
ratio (OR): 5.56, confidence interval 95% (CI 95%)
3.89e9.13). Injury mechanism was also significantly associated with having surgery. Those who sustained their
fracture as a result of a fall were half as likely to have
surgery as compared to the reference group (assaults) (OR
0.49, CI 95% 0.32e0.75).
Of those patients who underwent surgery, those injured
as a result of a MVA were twice as likely to require ORIF as
compared to those injured from an assault (OR 2.09, CI 95%
1.05e4.15). The odds of requiring ORIF was greater for
those patients with multiple fractures, with those with four
or more fractures being 23 times more likely to require ORIF
(OR 23.34, CI 95% 6.98e78.06).
The number of fractures sustained, and injury mechanism, were independently associated with developing
postoperative complications. Patients who underwent surgery and had four or more fractures were approximately
eight times more likely to have a complication compared to
those who sustained one fracture (OR 8.03, CI 95%

Epidemiology and management of MF

187

Table 2 Frequency distribution of 1949 MF fractures and

their specific management.
Fracture
Frontal bone
Ant table e Cons Mx
Ant table e ORIF
Ant table e delayed reconstruction
Ant table e cranialization
Ant/Post table Cons Mx
Ant/Post table e ORIF
Ant/Post table e cranialization
Ant/Post table e obliteration
Total
NOE
Conservative
External nasal wiring
ORIF
ORIF canthoplasty
ORIF/bone graft canthoplasty
Total
Orbit
Conservative
Repair e floor
Repair e wall
Repair e floor wall
Repair e delayed enophthalmos
Total
Maxilla
Conservative
ORIF
ORIF palatal split
ORIF bone graft
Total
Zygoma
Conservative
Gilles elevation
ORIF e simple #s
ORIF e comminuted #s
Total
Nasal Bone
Conservative Mx
GAMP
GAMP/osteotomy
Bone graft/ORIF
Total
Mandible
Cons Mx e angle
Cons Mx e body
Cons Mx e parasymphysis
Cons Mx e ramus
ORIF e angle
ORIF e body
ORIF e parasymphysis
ORIF e ramus
ORIF e multisegment
Total
Condyle
Cons Mx e intracapsular
ORIF - intracapsular
Arch bars e intracapsular

N (%)
40
15
2
1
11
5
8
2
84

(47.62)
(17.86)
(2.38)
(1.19)
(13.10)
(5.95)
(9.52)
(2.38)
(100.00)

39
2
33
3
2
79

(49.37)
(2.53)
(41.77)
(3.80)
(2.53)
(100.00)

294
48
21
12
28
403

(72.95)
(11.91)
(5.21)
(2.98)
(6.95)
(100.00)

205
205
1
2
413

(49.64)
(49.64)
(0.24)
(0.48)
(100.00)

139
54
135
14
342

(40.64)
(15.79)
(39.47)
(4.09)
(100.00)

156
122
3
25
306

(50.98)
(39.87)
(0.98)
(8.17)
(100.00)

8
16
2
19
48
51
46
17
16
223

(3.59)
(7.17)
(0.90)
(8.52)
(21.52)
(22.87)
(20.63)
(7.62)
(7.17)
(100.00)

25 (25.25)
3 (3.03)
9 (9.09)

Table 2 (continued )
Fracture

N (%)

Cons Mx e extracapsular
ORIF e extracapsular
Arch bars e extracapsular
Total
Total

24
22
16
99
1949

(24.24)
(22.22)
(16.16)
(100.00)
(100.00)

3.95e16.30). Those who sustained a sporting injury were

twice as likely to have a complication (OR 2.31, CI 95%
1.06e5.02).

Discussion
To the best of our knowledge, this is one of only a few
studies investigating the risk factors for requiring surgical
intervention and developing postoperative complications in
a large cohort of patients with MF fractures.
The results of this study support previously published
data, that young males in the 20s are the most commonly
affected patient group.2,9,10 The majority of the patients
sustained a fracture in the region of the orbit, consistent
with an earlier study illustrating that patients with severe
trauma (Injury Severity Score >12) were more likely to have
an orbital floor fracture.11 However, when analysing fractures individually, the most common site was the maxilla,
consistent with earlier local3 and international studies.5,12
The maxilla occupies a relatively larger exposed area in
the facial skeleton and it is most commonly injured bilaterally in high-velocity, blunt traumas. Other reported
common MF fracture sites include the zygoma,12 nasal
bones9,13 and the mandible.9,10,14
MVAs, assaults and falls are the leading causes of MF
fractures worldwide, with their relative frequencies
differing both within and between countries, depending
upon the regions socioeconomic, cultural and environmental factors.6,8,10,13e15 Assault was the most common
aetiological factor in this series (29.90%), in concordance
with numerous international and local studies.9,13,16,17
Interestingly, in 2006 a previous Melbourne study demonstrated MVA to be the most common cause (69%) of MF

Figure 2 Distribution of aetiology according to age of patients with MF fractures.

188

M.S. Cabalag et al.

Figure 3

Table 3

which concluded that the only statistically significant risk

factor was treatment modality.22 Interestingly, sporting
injuries and other mechanisms of injury (i.e., pedestrian
vs. car, explosions, home or work accidents and medical
complications or conditions) were independently associated with developing postoperative complications. The
association of sporting injuries and developing postoperative complications may be a direct result of the higher
operative rate for this subgroup of patients (59.60%). The
high velocity and complex mechanisms of injury in the
other group may also explain its association with developing complications.
Limitations of the study include the fact that the patient population was obtained from the Faciomaxillary

Distribution of aetiology by year.

Logistic regression analyses.

Variable

Surgery yes/no
Odds ratio
(95%CI)

p-value

ORIFb yes/noa
Odds ratio
(95%CI)

p-value

Complications
yes/noa Odds
ratio (95%CI)

p-value

Age (per year)

0.98 (0.97, 0.99)

<0.001

1.00 (0.98, 1.01)

0.75

0.99 (0.97, 1.01)

0.30

0.85 (0.60, 1.21)

0.37

0.55 (0.29, 1.03)

0.06

1.51 (0.76, 3.00)

0.24

1.12 (0.75, 1.66)

0.58
0.006

0.62 (0.33, 1.18)

0.15
0.015

1.31 (0.62, 2.76)

0.48
0.018

Sex
Alcohol
Injury
Mechanism

Fracture
number

a
b
c

Male (ref)
Female
No (ref)
Yes
Assault (ref)
Fall
MVAc
Sport
Other
One (ref)
Two
Three
Four plus

0.49
0.80
1.13
0.66

(0.32,
(0.55,
(0.74,
(0.40,

0.75)
1.16)
1.72)
1.09)

0.92
2.09
0.75
3.08

(0.44,
(1.05,
(0.40,
(1.08,

1.95)
4.15)
1.40)
8.81)

<0.001
1.55 (1.12, 2.14)
2.64 (1.70, 4.10)
5.56 (3.89, 9.13)

0.76
1.48
2.31
3.71

(0.28,
(0.72,
(1.06,
(1.45,

2.04)
3.05)
5.02)
9.52)

<0.001
6.92 (3.69, 13.00)
4.36 (2.13, 8.96)
23.34 (6.98, 78.06)

<0.001
2.47 (1.22, 5.02)
2.59 (1.12, 6.02)
8.03 (3.95, 16.30)

Only includes patients that underwent surgery.

ORIF: Open reduction internal fixation.
MVA: Motor vehicle accident.

fractures with only 10% of cases due to assault, suggesting a

rise in the citys rate of interpersonal violence in recent
years.3 The decline in MVAs (in part due to compulsory seat
belts, progressive introduction of airbags and legislation
against drunk driving) and rise in assaults causing facial
fractures have also been demonstrated in The Netherlands,
United States and U.K.10,18,19 Of note, falls remains an
important aetiology, as it was the most common mechanism
in the older age group (45e84 years old), consistent with
previously published literature.20
Previous studies have reported variable postoperative
infection rates (1.1e45.65%).9,14,21,22 In our study, the most
common postoperative complication was infected metalware (3.20%). This may be attributed to the larger proportion of patients who suffered high-energy mechanisms
of injury, resulting in more complex, diffuse and thus mobile facial fractures. Logistic regression analyses confirmed
that patients with two or more fractures were more likely
to develop postoperative complications. This is in contrast
to an earlier study that analysed the risk factors for
developing postoperative infection in mandibular fractures,

Units audit database in a single trauma centre and would

not necessarily reflect the experience at centres with a
different mix of presentations. Additionally, the data
in the units database is dependent upon residents
classifying and entering the fracture data correctly.
Consequently, minor differences in the frequencies of
zygomatic, orbital, maxillary and nasal bone fractures
may be negligible.

Conclusion
Males, aged 15e24 years, were the most commonly
affected and assault was the most common aetiology of MF
fractures. The majority of patients sustained orbital fractures and approximately half sustained a fracture to more
than one bony region. Per bony injury, mandibular fractures had the highest percentage treated surgically. Highenergy mechanisms of injury were associated with an
increased risk of sustaining multiple fractures and developing postoperative complications. The data presented

Epidemiology and management of MF

189

carry potential implications for the development of new

injury prevention strategies and the identification of patients at risk of developing postoperative complications.

11.

Conflict of interest

12.

None.
13.

Funding
None.

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