Pain management and anesthesia considerations for pediatric oral and maxillofacial surgery: a narrative review

Introduction

Background

Pediatric oral and maxillofacial (OMF) surgery is a subspecialty of clinical dentistry and typically encompasses a wide range of procedures, including dental surgery, maxillofacial trauma management, excision of cysts and tumors in the oral cavity and buccal region, cleft lip and palate repair, corrective surgery for Pierre Robin sequence and other congenital anomalies, as well as orthognathic surgery (1). Although many surgical techniques are similar to those used in adults, the unique physiological, anatomical, and psychological characteristics of children, along with the distinct spectrum of common procedures, increase the complexity of anesthesia management and postoperative analgesia in pediatric OMF surgery. Children undergoing OMF procedures often present with more challenging airway management and pain that is more difficult to assess accurately (2,3). This presents a greater challenge for anesthesiologists.

Rationale and knowledge gap

Previous reviews have primarily focused on the anesthetic risks associated with pediatric OMF surgery, while few have comprehensively addressed pharmacological, non-pharmacological, and multimodal analgesic strategies (3).

Objective

This review aims to summarize current evidence on anesthesia and pain management in children undergoing OMF surgery. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-30/rc).

Methods

We conducted a narrative review on anesthesia and pain management for pediatric OMF surgery, with the search methodology summarized in Table 1.

Based on the results of a comprehensive literature review, we will systematically outline the core aspects of anesthesia and pain management in pediatric OMF surgery. The key topics include: anesthesia-related risks, anesthetic and sedative agents, and multimodal pain management strategies that combine pharmacological and non-pharmacological interventions.

Anesthesia risks and management in pediatric OMF surgery

Preschool-aged children, especially those under 6 years old, represent the primary group undergoing OMF surgery under general anesthesia (2). Their anatomical structure, physiology, and psychological development differ significantly from that of adults. Therefore, a more specialized approach to anesthesia management is required to ensure the child’s safety and achieve optimal therapeutic outcomes.

Airway management

Compared to adults, preschool-aged children have a larger tongue, a higher laryngeal position, an omega-shaped epiglottis, and smaller airway diameters with a funnel-like shape. These anatomical factors make them more prone to edema. Additionally, in the supine position, the short neck and prominent occiput make it difficult to align the oral cavity, larynx, and trachea, leading to a higher risk of rapid hypoxia during anesthesia (4,5). Moreover, children aged 5–7 years often have a larger number of submucosal glands and rapidly growing lymphoid tissue, with common hypertrophy of the tonsils and adenoids. This enlargement of lymphoid tissue increases the risk of upper airway obstruction in this age group (6). According to existing data, respiratory events account for approximately 60% of anesthesia-related complications (7,8), and are one of the leading causes of anesthesia-related mortality in children (9). Among these, laryngospasm, hypoxemia, and bronchospasm are the most common anesthesia-related respiratory complications (10).

Compared to other pediatric surgeries, OMF surgery requires a higher level of airway management due to the nature of the procedure, which involves the oral cavity and facial bone operations. This often necessitates endotracheal intubation via the nasal route to provide adequate surgical access. Bleeding from the surgery, combined with increased nasal secretions or nasal bleeding resulting from nasal intubation, can persist even after extubation, increasing the risk of laryngospasm and aspiration (11). Studies have shown that the incidence of laryngospasm in pediatric dental sedations can be as high as 7.9 per 1,000 procedures (12). Additionally, many children with autism, neurodevelopmental disorders, genetic diseases, and other special conditions require OMF surgery under general anesthesia (13). Due to their anatomical, physiological, and psychological abnormalities, these children are more likely to present with difficult airways, thus complicating the surgery and increasing anesthesia risks.

Therefore, for airway management in pediatric OMF surgery, in addition to routine preoperative assessments and adjunctive investigations, appropriate airway equipment and close perioperative monitoring are essential (14). According to the American Society of Anesthesiologists (ASA) guidelines, it is recommended that medical facilities be equipped with age-appropriate specialized equipment, including:

• Standard airway equipment: masks, oropharyngeal and nasopharyngeal airways, laryngeal mask airways, straight and curved laryngoscope blades, endotracheal tubes, guidewires, etc.
• Positive pressure ventilation systems suitable for various age groups, warming devices, and intravenous infusion devices.
• Resuscitation equipment: pediatric defibrillators, appropriately concentrated vasoactive drugs, and dantrolene.
• Specialized equipment for managing pediatric difficult airways: including, but not limited to, dedicated endotracheal intubation devices, emergency cricothyroid membrane puncture kits, etc.

Additionally, as per ASA standards, it is essential to monitor the child’s blood pressure, oxygen saturation, end-tidal carbon dioxide, anesthetic gas concentration, oxygen concentration, electrocardiogram, and blood pressure perioperatively. A stethoscope should also be available for immediate assessment of airway conditions. These monitoring tools are vital for early detection and management of potential airway emergencies (15,16).

For children with anticipated difficult airways undergoing OMF surgery, video laryngoscopy may be used for intubation. For children known to have upper airway obstruction or anatomical abnormalities, intubation can be performed under deep sedation with preserved spontaneous breathing, guided by a flexible bronchoscope. In the event of unexpected or emergency difficult airways, immediate assistance should be sought, and oxygenation should be maintained. For patients who cannot be ventilated or intubated, an emergency invasive airway should be established. Furthermore, for children with difficult airways, preparation for extracorporeal membrane oxygenation (ECMO) should be considered (15,17).

Physiological and psychological development

In addition to anatomical factors, children’s physiological and psychological development is also immature. Besides smaller lung capacity and underdeveloped intercostal muscles, children have a higher metabolic rate and oxygen consumption, making them more susceptible to hypoxia. Furthermore, due to the incomplete development of the cardiovascular system, children have weaker cardiac reserve, and cardiac output relies primarily on heart rate, which increases the risk of bradycardia and hypotension during anesthesia (18). The immature liver and kidney functions in children affect drug metabolism, and their immature thermoregulation function may prolong the duration of drug effects (19,20).

Due to differences in psychological development and cognitive abilities, children of different ages may experience anxiety, fear, and other emotions preoperatively. These emotions can lead to delayed awakening from anesthesia, postoperative behavioral disturbances, and other issues (21). More than two-thirds of children experience postoperative complications such as nausea, vomiting, pain, and drowsiness within 24 hours after surgery, and about 24% of children may experience anxiety and fear on the first postoperative day, which may even lead to sleep disturbances and negatively impact their growth and development (22).

Long-term neurocognitive outcomes

Children with oral and facial deformities (such as cleft lip and palate) often require multiple surgeries during infancy, childhood, and adolescence, thus facing repeated anesthesia exposures (23). Neurotoxicity of anesthetic agents has been confirmed in animal studies (24), and subsequent research has shown that children exposed to multiple anesthetic episodes during infancy exhibit impairments in fine motor skills, response speed, and non-verbal reasoning abilities, compared to those with single or no anesthesia exposure. Repeated exposure may even increase the risk of developing attention deficit hyperactivity disorder (ADHD) and other disorders (25,26). Although most studies rely on follow-up data and scales for statistical inference, with many factors potentially influencing outcomes, it is undeniable that multiple surgeries and anesthetic exposures can impact neurodevelopment in children with oral and facial deformities (23). Therefore, it is necessary to alleviate preoperative anxiety, reduce the use of anesthetic agents, and optimize the anesthesia process.

Sedation and anesthesia

Sedation, as part of a comprehensive anesthesia plan, serves to alleviate anxiety and induce a mild hypnotic effect, facilitating progression to the next stage of anesthesia (14). This section will explore emerging sedative agents in pediatric OMF surgery, with a focus on the roles of dexmedetomidine (DEX), midazolam, and remimazolam.

DEX

DEX is a highly selective α2-adrenergic receptor agonist known for its sedative, analgesic, and anxiolytic properties (Figure 1). The sedative state induced by DEX closely resembles natural sleep, it is easily reversible with minimal respiratory depression, and has been proven to be safe for pediatric sedation (35). In addition to intravenous administration, DEX can be delivered via various routes, including oral, intranasal, buccal mucosa, and intramuscular injection, with corresponding bioavailability rates of approximately 16%, 65%, 82%, and 104%, respectively—each achieving satisfactory sedative effects (36,37).

Figure 1 Mechanism of sedative and analgesic action of DEX (27-34). DEX, dexmedetomidine.

In neonates, the clearance rate of DEX is lower than in adults, likely due to immature metabolic pathways. However, by one year of age, DEX clearance approaches adult levels (38). A meta-analysis on the effects of DEX and midazolam in pediatric oral surgery showed that, when administered orally or intranasally, DEX was superior to midazolam in terms of its anxiolytic effect during separation from parents. Additionally, DEX was also effective in preventing postoperative delirium in children undergoing oral surgery. However, in terms of mask acceptance, DEX did not demonstrate superiority over midazolam (39).

Further studies have shown that preoperative oral administration of DEX at 2 µg/kg can achieve sedation comparable to oral midazolam at 0.5 mg/kg, with similarly acceptable levels of cooperation during mask induction (40). Nevertheless, high doses of DEX may lead to hemodynamic fluctuations and bradycardia in children. Therefore, dosing must be carefully managed, and continuous monitoring of hemodynamic parameters is essential. In cases of significant bradycardia, administration of atropine or other supportive medications may be required (41).

Overall, DEX is considered more effective as an adjunct rather than a sole agent. When combined with other sedatives such as midazolam or ketamine, DEX can enhance sedative efficacy while reducing the total drug dosage and mitigating adverse effects (42,43).

Benzodiazepines

Commonly used benzodiazepines in pediatric OMF surgery include diazepam and midazolam. Due to its short duration of action, good sedative effect, and safety profile, midazolam has gradually become the preferred choice among anesthesiologists (44). In recent years, the novel benzodiazepine remimazolam, known for its rapid metabolism, fewer side effects, and superior sedative properties, has garnered increasing attention.

Midazolam

Midazolam remains one of the most commonly used benzodiazepines in pediatric OMF surgery for procedural sedation and anesthesia. It acts primarily by enhancing the activity of gamma-aminobutyric acid (GABA) at GABA-A receptors, resulting in sedation, anxiolysis, and anterograde amnesia (45). Besides intravenous injection, midazolam can also be effectively administered via oral or intranasal routes (44,46).

Common adverse effects of midazolam include paradoxical agitation and excessive sedation in pediatric patients. It may also cause mild respiratory depression and reductions in heart rate and blood pressure, although these changes typically remain within safe clinical limits (47,48). Importantly, adverse reactions related to midazolam can be reversed by the administration of flumazenil.

Remimazolam

Remimazolam is a novel ultra-short-acting benzodiazepine with rapid onset and offset, minimal respiratory depression, limited cardiovascular effects, and notable anxiolytic properties. It is rapidly hydrolyzed by tissue esterases into an inactive carboxylic acid metabolite, enabling its safe use in patients with normal hepatic and renal function as well as those with hepatic or renal impairment. Given that hepatic and renal functions in pediatric patients are not yet fully developed, the organ-independent metabolism of remimazolam supports similar pharmacokinetic profiles between children and adults (49,50).

The common adverse effects of remimazolam include respiratory and circulatory depression (51). However, these are generally mild and can be reversed by flumazenil. Remimazolam has been shown to be safe for pediatric sedation, induction and maintenance of anesthesia, and sedation in pediatric intensive care units (PICUs) (52). Studies have shown that 0.2 mg/kg of remimazolam can be safely and effectively used for anesthesia in pediatric procedures such as gastroscopy, bronchoscopy, and outpatient root canal treatment (53,54). Furthermore, remimazolam has been found to reduce the incidence of postoperative delirium in pediatric ear, nose, and throat surgeries (55).

In adult OMF surgery, remimazolam has demonstrated efficacy comparable to propofol and midazolam, with a more favorable safety profile and faster postoperative recovery (56,57). Nevertheless, its application in pediatric OMF surgery remains underexplored and warrants further investigation. Additionally, there have been isolated reports of anaphylactic shock related to remimazolam administration. Additionally, some studies have indicated that remimazolam may cause anaphylactic shock, with its allergens differing from those of midazolam. This could be related to immunoglobulin E (IgE)-mediated immune responses (58). Given that the immune system in children is still developing, close monitoring is required during the use of remimazolam.

We compared DEX, midazolam, and remimazolam in Table 2 (37,59,60).

Analgesia

Improper or excessive use of opioid analgesics can adversely affect children’s respiratory function and postoperative recovery, potentially leading to neurodevelopmental impairment (61). Therefore, we aim to minimize the use of opioids through multimodal analgesia, achieving effective sedation and analgesia while reducing the incidence of adverse perioperative events (62) and promoting rapid postoperative recovery in pediatric patients.

Opioid-sparing multimodal analgesia

In pediatric outpatient dental procedures, effective analgesia can often be achieved through rectal administration of acetaminophen at the onset of surgery combined with local infiltration anesthesia (63,64). However, for more invasive surgeries such as cleft lip and palate repair, this analgesic approach is often inadequate.

Several studies have demonstrated that regional nerve blocks, such as infraorbital nerve blocks and suprazygomatic maxillary nerve blocks, provide effective perioperative analgesia for children undergoing cleft lip and palate surgeries. Additionally, DEX can be used as an adjunct in regional anesthesia or as an intravenous infusion to enhance analgesic effects.

Postoperative, patient-controlled analgesia (PCA) pumps and non-opioid drugs such as acetaminophen, gabapentin, and non-steroidal anti-inflammatory drugs (NSAIDs) can be used as part of multimodal analgesia strategy has been shown to reduce the need for opioids. This approach not only mitigates the negative impact of opioids on neurodevelopment but also decreases the incidence of postoperative nausea, vomiting, and other opioid-related adverse effects in pediatric patients (65-67).

Non-pharmacological analgesia

Due to the incomplete physiological development in children, drug metabolism and its adverse effects may still place a burden on their development. Furthermore, assessing pain in children is challenging, which can easily lead to either overdose or insufficient dosing of analgesics. Additionally, children with oral and facial deformities require multiple surgeries and anesthesia exposures, and studies have shown that their risk of developing long-term anxiety and depression may increase (23). Therefore, non-pharmacological analgesia measures are also crucial in pediatric OMF surgeries.

Psychological interventions

Hypnosis, as a psychological therapy, has been demonstrated to effectively alleviate anxiety and pain in adult OMF surgeries. In pediatric clinical procedures, hypnosis has also been shown to reduce procedural anxiety and pain, thereby improving cooperation (68,69).

A study by Díaz-Rodríguez et al. involving children aged 5–12 years undergoing dental surgery found that hypnosis significantly alleviated fear and injection-related pain during local anesthesia, allowing for smoother procedural completion (70). Another child-centered psychological intervention, therapeutic play, includes activities such as bubble blowing and play-dough modeling. These have been proven effective in alleviating preoperative anxiety in children aged 6–14 years. However, the evidence regarding their efficacy in reducing postoperative pain remains inconsistent, and further research is needed to clarify their role in pediatric OMF surgery (71-73).

Audiovisual (AV) interventions

AV interventions are among the most extensively studied non-pharmacological therapies in pediatric care. These interventions have evolved from simple music therapy and audio storytelling to more sophisticated methods involving animated videos and entertainment clips that provide simultaneous visual and auditory distraction. AV interventions are believed to reduce sympathetic nervous system activity and activate the parasympathetic nervous system, thereby helping to lower heart rate and blood pressure while diverting attention from painful stimuli (74).

The majority of studies support the efficacy of AV interventions in alleviating preoperative anxiety, intraoperative distress, and reducing postoperative analgesic requirements in children. However, some research indicates that the effectiveness of AV therapies can vary significantly between individuals, which may be attributed to differences in personal preferences and interests. These interventions appear to be most effective in children aged 3 to 14 years. It has also been suggested that allowing children to actively select their preferred AV content leads to better outcomes compared to passive assignment of materials (75-77).

In recent years, with the advancement of virtual reality (VR) technology, immersive VR has increasingly been incorporated into clinical settings. Unlike traditional AV interventions, VR offers a fully immersive sensory experience that further dampens the perception of nociceptive stimuli. Several studies have demonstrated that VR is effective in reducing anxiety and perceived pain in children aged 4 to 12 years undergoing dental or oral procedures (78-80). Notably, younger children seem to benefit more from VR, possibly due to their higher baseline anxiety levels and stronger engagement with immersive environments (81,82). Future studies are warranted to optimize VR integration into pediatric perioperative care and to further validate its efficacy across various age groups and surgical contexts.

Other non-pharmacological analgesic measures

Additional non-pharmacological approaches to pediatric analgesia include sweet solutions, non-nutritive sucking, and swaddling—interventions primarily designed for neonates and infants. These techniques have been well-documented to reduce procedural pain in this age group by leveraging innate soothing responses.

Physical modalities such as antimicrobial photodynamic therapy and low-level laser therapy have been explored in adult OMF surgery for postoperative pain control, showing promising results. However, the application of these techniques in pediatric OMF settings remains limited and under-investigated. More research is needed to assess the safety, feasibility, and effectiveness of these modalities in younger populations (83-85).

Due to the potential adverse effects of opioids, such as respiratory depression, nausea and vomiting, pruritus, and addictive properties, which can impact children’s growth and development, the use of opioids should be minimized in OMF surgeries (61). For minor procedures, such as dental caries restoration and primary tooth extraction, especially in pediatric outpatient oral surgery, preoperative non-pharmacological analgesia, combined with deep sedation and local infiltration anesthesia during the procedure, and postoperative non-opioid analgesia can provide a comfortable treatment experience. For more extensive surgeries, such as cleft lip and palate repair or trauma surgery, opioid analgesics can be used in conjunction with regional nerve block anesthesia to reduce opioid consumption, prolong the duration of analgesia, and prevent the negative impact of pain on the child’s physiological and psychological development, while promoting postoperative recovery of oral function.

We have summarized a concise perioperative multimodal management flowchart for pediatric OMF surgery patients (Figure 2).

Figure 2 A concise perioperative multimodal management flowchart for pediatric OMF surgery patients. NSAIDs, non-steroidal anti-inflammatory drugs; OMF, oral and maxillofacial.

Limitations of this article

This article provides an overview of anesthesia and pain management in pediatric OMF surgery, but it has some limitations. The content is based on a synthesis of the literature, and the range of sedative, analgesic, and analgesic drugs available for pediatric OMF surgery is vast. This article only summarizes some commonly used and newer drugs, and cannot capture all the nuances or the latest evidence, thus limiting its comprehensiveness and synthesis capabilities. Furthermore, high-quality randomized studies on ordinary and complex pediatric OMF patients remain limited. Therefore, this article references some literature on small observational studies in adult populations, but this may mean that the findings are not universally applicable to different pediatric populations.

Conclusions

Due to the unique physiological, anatomical, and psychological characteristics of children, pediatric OMF surgery presents distinctive challenges in anesthesia and analgesia. Effective and safe multimodal analgesia is required to minimize drug-related adverse effects and promote postoperative recovery.

Pharmacological sedation and analgesia remain the cornerstone of anesthetic management. Agents such as DEX and benzodiazepines can provide satisfactory sedation, while regional nerve blocks serve as valuable adjuncts. Postoperatively, the use of rescue analgesics including acetaminophen and NSAIDs allows for effective pain control while reducing the reliance on opioids.

Non-pharmacological analgesia, such as psychological interventions, AV interventions, VR, and other physical interventions, plays an important auxiliary role in alleviating perioperative anxiety and reducing postoperative pain in children, especially those undergoing OMF surgery requiring multiple procedures. Reducing preoperative anxiety and smoothly transitioning into the surgical state is particularly important for them. These methods can also improve cooperation in other children who are more sensitive or have difficulty verbally expressing discomfort.

The rational combination of pharmacological and non-pharmacological analgesia methods can improve the safety, comfort, and satisfaction of pediatric patients undergoing OMF surgery. However, research on pediatric OMF surgery is limited, with most studies focusing on dental or non-surgical procedures. For children with OMF requiring multiple procedures (such as cleft lip and palate, craniofacial syndromes), research on reducing preoperative anxiety through non-pharmacological analgesia is limited, and standardized anesthesia protocols are lacking. Furthermore, high-quality, large-scale randomized controlled trials of combined pharmacological and non-pharmacological analgesia remain limited.

Future research should focus on the standardization of intervention protocols, age-specific strategies, and the optimization of dosing and timing, in order to validate efficacy, refine multimodal regimens, and further improve analgesia, sedation, and postoperative recovery outcomes in this vulnerable population.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-30/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-2025-30/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2025-30/coif). H.M. serves as an unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from February 2024 to January 2026. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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