CURRENT THERAPY

J Oral Maxillofac Surg

64:1664-1668, 2006

A Systematic Review of Prophylactic

Antibiotics in the Surgical Treatment of
Maxillofacial Fractures
Jens O. Andreasen, DDS, Odont Drhc,* Simon S. Jensen, DDS,†
Ole Schwartz, DDS, LDS,‡ and Yören Hillerup, DDS, Dr Odont§

Purpose: A systematic review was performed to find evidence for prophylactic administration of
antibiotics in relation to treatment of maxillofacial fractures.
Methods: Four studies were retrieved that fulfilled most of the requirements of being randomized
controlled clinical trials.
Results: An analysis of these studies showed a 3-fold decrease in the infection rate of mandibular
fractures in the antibiotic treated groups compared with the control groups. A variety of antibiotics had
been used with an apparently uniform effect. A “1-shot” regimen or a 1-day treatment course had a similar
or perhaps even better effect than 7 days of treatment. No infections were related to condylar, maxillary,
or zygoma fractures.
Conclusion: A 1-shot or 1-day administration of prophylactic antibiotics seem to be the best docu-
mented to reduce infections in the management of mandibular fractures not involving the condylar
region.
© 2006 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 64:1664-1668, 2006

Evidence-based treatment strategies depend on applica-
tion of the best knowledge a discipline can offer. Sys-
tematic reviews should aim at extracting the current
best evidence within a well-defined area, and thereby
give the clinician an intended unbiased tool in keeping
up with an exponentially growing knowledge base.
*Consultant, Department of Oral and Maxillofacial Surgery, Uni-
versity Hospital (Rigshospitalet), Copenhagen, Denmark.
†Assistant Professor, Department of Oral and Maxillofacial Sur-
gery, University Hospital (Glostrup), Copenhagen, Denmark; and
the Department of Oral Surgery and Stomatology, School of Dental
Medicine, University of Berne, Switzerland.
‡Department Chairman, Department of Oral and Maxillofacial
Surgery, University Hospital (Rigshospitalet), Copenhagen, Den-
mark.
§Professor, Department of Oral and Maxillofacial Surgery, Uni-
versity Hospital (Rigshospitalet), Copenhagen, Denmark.
Address correspondence and reprint requests to Dr Andreasen:
Department of Oral and Maxillofacial Surgery, University Hospital
(Rigshospitalet), Blegdamsvej 9, DK-2100 Copenhagen, Denmark;
e-mail: RH11323@RH.dk
© 2006 American Association of Oral and Maxillofacial Surgeons
0278-2391/06/6411-0014$32.00/0
doi:10.1016/j.joms.2006.02.032
For many years, prophylactic antibiotic treatment
has been considered a must in the surgical treatment
of jaw fractures.1 The evidence for this preventive
intervention, however, has been weak in a series of
other surgical disciplines.2-5 For many indications,
prophylactic antibiotics have been shown to have no
positive and sometimes even a negative effect (ie, a
higher infection rate in antibiotic treated situations).6
The latter event being explained by the fact that no
single antibiotic can eliminate all kinds of invading
bacteria and thereby may give an advantage to oppor-
tunistic infection.7
Several factors with a known impact on the incidence
of infections in relation to maxillofacial trauma must be
taken into consideration before the specific role of a
prophylactic antibiotic regimen can be evaluated.
Two different situations exist in relation to the
invasion of bacterias into the fracture site, namely a
closed fracture (eg, mandibular condyle or ramus frac-
tures and maxillary Le Fort I–III fractures) on 1 side
and open fractures with direct communication to the
oral cavity and/or the skin surface on the other. No
study has so far evaluated the actual invasion of bac-
teria in a healing fracture site; but the importance of
this differentiation is apparent by the fact that healing
of fractures located in the condylar region is never

1664
ANDREASEN ET AL 1665

Table 1. SURVEY OF STUDIES INCLUDED

Zallen and Aderhold et Gerlach and Chole and Heit et al,15 Abubaker et
Curry,12 1975 al,13 1983 Pape,14 1988 Yee,8 1987 1997 al,16 2001

Randomization ⫹ ⫹* ⫹* ⫹ ⫹* ⫹*
Patient blinded to treatment ⫺ ⫺ ⫺ ⫺ ? ⫹
Assessor blinded to treatment ⫺ ⫺ ⫺ ⫺ ⫹ ⫹
Drop-outs accounted for ⫺ ⫺ ⫺ ⫺ ⫺ ⫺
Outcome measures clearly defined ⫺ ⫹ ⫹ ⫹ ⫺ ⫹
Statistical method ⫺ ⫹ ⫹ ⫹ ⫺ ⫹
*Claimed, but the method is not provided.
Andreasen et al. Antibiotics for Maxillofacial Fractures. J Oral Maxillofac Surg 2006.

followed by infection compared with the more fre-
quent occurrence of infections in the mandibular an-
gle, body, and symphysis regions.8
Another factor to be analyzed is the treatment pro-
cedure used (ie, open versus closed reduction of the
fracture). From a previous analysis, it became appar-
ent that an open procedure may lead to a 4-fold
higher rate of infection.9 The type of treatment pro-
cedure (open or closed) should therefore also be
included in an analysis of the effect of antibiotics.
Mandibular fractures are more prone to infection
than maxillary fractures8; and within the mandible,
the location of the fracture in the dental arch also
seems to be of importance with the third molar region
showing the highest frequency of infections.8 Thus,
the topography of the jaw fractures is another factor
to be considered.
Concerning the administration of antibiotics, a
number of factors have to be taken into account. First,
the type of antibiotics administered; the dose, dura-
tion, and route of administration, and finally the tim-
ing of administration in relation to injury and surgical
treatment. All of these factors have been shown to
have significant influence on the chance of avoiding
infection.5
The term prophylaxis implies preventive use of
antibiotics. In the present review, antibiotic prophy-
laxis is interpreted as given, when no clinical signs of
infection are present at the time of surgery, although
it may be argued that any fracture open to the skin or
oral cavity should be considered contaminated, and
that antibiotics thereby are indicated as a part of
treatment rather than prophylactic.
Finally, an analysis of the literature should concen-
trate on randomized studies, and in this regard whether
the studies meet the requirements for a reliable study
design, proper randomization, limited number of drop-
outs, sufficient number of patients included, and utiliza-
tion of relevant statistical methods.10
It was the purpose of the present systematic review
to evaluate available randomized clinical trials to an-
swer the following questions:
1) Does antibiotic prophylaxis decrease the inci-
dence of post-trauma infections in jaw fracture
treatment?
2) Are there situations where an antibiotic prophy-
laxis is not indicated?
3) Which antibiotic is the drug of choice? In what
dose? And for how long?
Material and Methods
ANALYSIS OF THE LITERATURE
The databases MEDLINE and Cochrane were
searched for relevant studies, using the following key
words: jaw fractures, mandibular fractures, maxillary
fractures, antibiotic treatment, infection, and random-
ized studies. This search was supplemented by a hand
search of relevant German journals not electronically
listed and by a review of reference lists of potentially
eligible studies.
For each retrieved study, the following questions
were asked (Table 1):
1) Were the patients randomly allocated to the
treatment groups?
2) Were the patients blind to treatment allocation?
3) Were the treatment outcomes assessed blind?
4) Were all dropouts to follow-up accounted for?
5) Were the clinical outcome variables clearly de-
fined?
6) Were details given of the statistical evaluation
method?
Based on this, each individual study was character-
ized as a randomized controlled trial or a controlled
clinical trial. To meet the criteria of a randomized
controlled trial, the study should involve at least 1 test
treatment and 1 control treatment and concurrent
enrollment and follow-up of the test- and control-
treated groups, in which the treatments to be admin-
istered are selected by a random process such as a
random number table. Studies where the patients are
appointed to the different treatment groups using
1666
quasi- or pseudo-randomization techniques such as
coin flips, social security numbers, or days of the
week, are considered controlled clinical trials.11
Results
Four randomized studies8,12-14 were retrieved con-
cerning the possible benefit of prophylactic antibiot-
ics in the treatment of maxillofacial fractures. Two
clinical randomized studies were found that com-
pared different antibiotic regimens without including
a control group.15,16 A critical analysis of these
showed that none of them fulfilled all the require-
ments for a randomized controlled trial. The short-
comings of the studies are presented in Table 1.
However, as these studies represent the best knowl-
edge available at the present time, the results are
summarized below.
The first randomized study on the effect of prophy-
lactic antibiotics in the treatment of compound man-
dibular fractures was published by Zallen and Curry in
1975.12 The material consisted of 32 patients with
compound mandibular fractures who received antibi-
otics (a wide variety of different antibiotics), and 30
patients treated without antibiotics. A control of the
stratification was made and shown to be effective.
The administration of antibiotics was in 20 cases par-
enterally and in 10 cases orally. A highly significant
difference in complication rates was found as 6%
developed infection complications in the antibiotic-
treated group, whereas 53% developed infection in
the nontreated group (P ⫽ .0001) (Table 2).
In 1983, Aderhold et al13 published a study on the
effect of antibiotic treatment of 120 mandibular frac-
tures. All fractures had communication to the oral
cavity and were treated with miniplate osteosynthe-
sis. Forty cases were treated without antibiotics, 40
cases with antibiotic coverage up to 48 hours, and 40
cases with treatment for more than 48 hours. Type
and dosage of the prescribed antibiotics are not pre-
sented. Proper stratification was checked and found
to be reliable, and the numbers of open and closed
reductions in the 2 groups are comparable. An almost
significantly higher infection rate was found in the
nontreated group (20%), whereas cases treated with
short-term antibiotics showed a frequency of 5% and
beyond 48 hours of 10% (n ⫽ .06). It was concluded
that short-term antibiotic prophylaxis was effective in
reducing infection; furthermore, that long-term treat-
ment did not significantly reduce the risk of infections
as compared with the control group (Table 2).
In 1987, Chole and Yee8 reported a prospective
clinical trial of 101 patients with facial fractures. The
patients were randomly assigned to either no antibi-
otic treatment or a short-term prophylaxis with an
intravenous administration of cefazolin 1 g (a cepha-
ANTIBIOTICS FOR MAXILLOFACIAL FRACTURES
losporin) 1 hour before surgery and 8 hours after. A
total of 150 fractures were diagnosed in the 101
patients (6 maxillary, 24 zygomatic, and 120 mandib-
ular fractures). None of the maxillary, zygomatic, and
subcondylar mandibular fractures got infected, irre-
spective of antibiotic prophylaxis given or not. In the
79 patients with mandibular fractures, the 37 who
received antibiotics experienced an infection rate of
14%, whereas 42 patients in the control group devel-
oped infections in 43% (P ⫽ .01) of the cases.
In a separate nonrandomized analysis, it was con-
firmed whether the infection rate in relation to closed or
open reduction of the mandibular fractures was influ-
enced by the administration of antibiotics. It turned out
that antibiotic prophylaxis had virtually no influence on
the infection rate when the fractures were treated with
closed reduction (23% infections with administered an-
tibiotics/28% infections with no antibiotics). In the open
reduction group, however, 62% developed infections
when no antibiotics were used compared with 8% in the
antibiotic group (Table 2).
It was concluded that antibiotic prophylaxis is in-
dicated for mandibular fractures.
In 1988, Gerlach and Pape14 examined the influ-
ence of antibiotic treatment on infection rates in 200
mandibular fractures all treated with open reduction
and miniplate osteosynthesis through an intraoral ap-
proach. In group I (n ⫽ 50), a 1-day antibiotic treat-
ment was given, starting immediately before surgery.
In group II (n ⫽ 50), a 1-shot prophylaxis of antibiot-
ics was administered immediately before surgery. In
group III (n ⫽ 51), a 3-day course was used. Finally, a
control group (n ⫽ 49) received no prophylactic
antibiotics. The control group showed a significantly
higher infection rate (22%) compared with the 3 pro-
phylactic groups (2%, 6%, and 8%, respectively) (P ⫽
.001). It was concluded that a “1-shot administration”
of antibiotics in relation to intraoral osteosynthesis in
the mandible is sufficient to protect the patient from
wound infection (Table 2).
Two different antibiotic prophylactic regimens were
compared in a prospective and nonrandomized clinical
study by Heit et al15 in 1997. A total of 90 patients with
compound mandibular fractures were divided into 2
groups of 45 patients. In group I, the prophylaxis con-
sisted of ceftriaxone (a cephalosporin) 1 g daily pre- and
perioperatively until the intravenously administration
was discontinued and thereafter penicillin VK 500 mg
every sixth hour orally 1 week postoperatively. Group II
received an intravenous administration of penicillin G 2
million U every fourth hour pre- and perioperatively
until the intravenously administration was discontinued
and thereafter the same orally administered doses of
penicillin VK as for group I. Two patients in each group
developed an infection and thus there could not be a
ANDREASEN ET AL 1667

Table 2. COMPARISON OF POSTOPERATIVE INFECTION RATES RELATED TO THE USE OR NOT OF ANTIBIOTICS

Control Group Test Group

No Antibiotics Antibiotics
Study Administration No. x % No. x % Probability Level

Zallen and Curry,12

1975 30 16 53 32 2 6 0.001
13
Aderhold et al, Control 40 8 20
1983 ⱕ48hours 40 2 5 0.06
⬎48hours 40 4 10
Gerlach and Pape,14 Control 49 11 22
1988 1 day 50 1 2
1 shot 50 3 6 0.001
3 days 51 4 8
Chole and Yee,8
1987 42 18 62 37 5 14 0.01
Abbreviation: x, Number of infections.
Andreasen et al. Antibiotics for Maxillofacial Fractures. J Oral Maxillofac Surg 2006.

demonstrated significant difference between the 2 reg-
imens.
Abubaker and Rollert16 reported in 2001 preliminary
results of a comparative, double-blind, placebo-con-
trolled study of a 1-day prophylaxis versus a 5-day treat-
ment with penicillin. In a limited number of patients
(n ⫽ 30), no benefit of a prolonged administration of
antibiotics could be seen. However, the results should
be interpreted with caution because of the small num-
ber of patients and that both open and closed reductions
were mixed in the material.
Discussion
In maxillofacial fracture treatment a multitude of
external sources exist for contamination of the
wound. In this aspect the fracture can, in most cases,
be considered contaminated, implying an elevated
risk of infection.17
From this perusal of the literature, it appears strongly
indicated to use a short-term antibiotic coverage to de-
crease the infection rate in relation to the treatment of
compound mandibular fractures. Approximately a 4-fold
reduction in the number of infections was found. It is
also of interest to observe that open reduction was
highly influenced by the use of antibiotics. This seems to
indicate that the cause of infection could be related to
the surgical approach itself, namely damaging the prin-
cipal blood supply to perform an osteosynthesis and
thereby additionally exposing an injured area to bacteria
from the oral cavity or external environment.
An interesting analogue to the surgical treatment of
jaw fractures appears in orthognathic surgery where
the infection rate is normally very low, and in 3
studies has been shown not to be related to the
administration of antibiotics.18-20 Only 1 study has
shown a positive effect on infection rates.21 It might
be expected that the same exposure to all bacteria
may occur in orthognathic surgery.
However, in jaw fracture treatment a multitude of
external sources exist for contamination of the
wound. In this aspect the fracture can, in most cases,
be considered contaminated,17 with the known ele-
vation in infection risk and that was also the general
finding in this survey.
However, the difference might be that the injured
tissue had a short exposure to oral bacteria in com-
parison to jaw fractures where bacteria might have
invaded the tissues for days (although it was shown
that the time delay until treatment did not influence
the infection rate).8
Combining the evidence from all 4 studies, the
following can be concluded about infection rates: It
appears that there is a significant reduction in the
number of post injury infections. As a whole, a 3-fold
decrease in the infection rate took place by the ad-
ministration of antibiotics.
INFECTION RATES IN DIFFERENT LOCATIONS
All studies had their analysis primarily confined to
the dentate part of the mandible (ie, excluding the
condylar region). In 1 study, the infection rate was
compared between various locations (Table 3). It ap-
pears that infection was not found in the maxilla, the
condylar region, or the zygoma, irrespective of admin-
istration of antibiotics.8
INFECTION RATES RELATED TO ANTIBIOTIC
ADMINISTRATION
There appears to be no difference in the reduction
rate of infection in the 4 studies.
1668
Table 3. COMPARISON OF POSTOPERATIVE
INFECTION RATES ACCORDING TO FRACTURE
LOCATION
Infection
n (%)
Zygoma 18 0 (0)
Maxilla 6 0 (0)
Condyle 23 0 (0)
Mandible 79 23 (29)
Data from Chole and Yee 1987.8
Andreasen et al. Antibiotics for Maxillofacial Fractures. J Oral
Maxillofac Surg 2006.
INFECTION RATE RELATED TO THE LENGTH OF
ANTIBIOTIC ADMINISTRATION
Three studies analyzed this parameter.13,14,16 It ap-
pears that a “1-shot” or 1-day administration worked
equally, or maybe even better (however, not signifi-
cantly), than a 7-day course. A similar finding has been
made for other approaches in oral and maxillofacial
surgery22 and in orthopedic surgery.3,23
The present study based on 4 quasi-randomized
studies appeared to show a significant decrease in
wound infection (4-fold when antibiotics were admin-
istered). This finding can be compared with similar
effects in the treatment of bone fractures of the ex-
tremities.24 This effect can be explained in the way
that antibiotic treatment will reduce or eliminate bac-
teria that have entered the wound before treatment.
The first event seems to be the most obvious expla-
nation, as prophylactic administration of antibiotics
has not resulted in a significant reduction in wound
infection after orthognathic surgery. In this situation,
presurgical bacteria contamination is not present.
An analysis of the bacteria flora infections related to
jaw fractures is very sparse. In 1 study, a mixed
infection with aerobic and anaerobic flora and a pre-
dominance of staphylococcus aureus seems to indi-
cate that specific antibiotics may be indicated.25
The great variety of antibiotics used in the cited
studies with varying specificity against the presumed
bacteria flora gives no significant clue concerning the
selection of proper antibiotic.
The specific preference of wound infection to the
angular region does support a dental origin (pulp
canal or periodontal flora related to the molar may
play a role). This phenomenon will be further ana-
lyzed in a subsequent study.
In conclusion, a short-term antibiotic therapy (less
than 48 hours), possibly a 1-shot administration, ap-
pears to be effective in protecting compound man-
dibular fractures from infection, especially open re-
duction. Because of the very low infection rate in
maxillary fractures, zygoma fractures, and the non-
ANTIBIOTICS FOR MAXILLOFACIAL FRACTURES
existence of infection complications in condylar frac-
tures, antibiotic treatment in the latter types of frac-
tures does not seem indicated.
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