Abstract
Objective
To examine the pattern of maxillofacial fractures in patients treated at the SMS Hospital in Jaipur, India, over a two-year period.
Methods
A retrospective study was conducted from October 2019 to September 2021, which recorded various data of patients with maxillofacial fractures, including age, sex, site distribution, cause of injury, type of facial bone fractures, soft tissue injuries, dentoalveolar trauma, and type of treatment. The days spent in the hospital before and after surgery were also recorded.
Results
The study included 1674 patients, with a male-to-female ratio of 4.07:1 and males being the most affected at 80.3%. The most common cause of injury was road traffic accidents (53.5%), followed by falls (18.6%) and assaults (16.1%). Mandibular fractures accounted for 38% of all fractures, with the parasymphysis being the most common site for fractures. Open reduction and internal fixation (ORIF) and intermaxillary fixation (IMF) were the most common treatment options for mandibular fractures.
Conclusion
The study highlights the need for strict enforcement of traffic rules and road safety laws, along with education and preventive measures to reduce the incidence of maxillofacial trauma. The pattern of maxillofacial injuries can provide useful information for designing programs towards the prevention and management of maxillofacial trauma.
Keywords: Road traffic accidents, Mandible fracture, Maxillofacial trauma, Management
Introduction
Trauma is the largest cause of mortality in people under the age of 40, and traumatic injuries are the biggest source of lost productivity, accounting for more lost working years than heart disease and cancer combined [1]. Facial injuries are included in the category of human body injuries and may be simply described as any damage to the face, including severe and small injuries to the soft tissues, bones, blood vessels, nerves, and other facial tissues. Maxillofacial injuries occur as a result of trauma to the face, head, and jaws, and maxillofacial injuries occur in 51% of road traffic accidents (RTAs). Road traffic accidents, assaults and interpersonal violence, fall from height and sports injuries are common causes of facial bone fractures. The frequency of mandible, zygomatic complex, and maxilla fractures has been recorded in a 6:2:1 ratio [2]. Interpersonal violence, such as fights, assaults, and gunshot injuries, is more likely to induce maxillofacial injuries in more economically developed countries. Road accidents are the leading cause of maxillofacial trauma, according to studies from most developing countries [3]. The goal of this retrospective study was to examine maxillofacial injuries with a focus on age, incidence, fracture pattern, seasonal and daily fluctuations, and compare the findings to those of other studies conducted in India and throughout the world.
Materials and Methods
Study Design
From October 2019 to September 2021, 1860 patients with maxillofacial trauma were treated at SMS Hospital Jaipur. Name, sex, medical history, patient symptoms, clinical signs, radiological findings, date of admission, operation, discharge, aetiology and type of fracture were obtained directly from hospital medical records. Only 1674 (90%) of 1860 interventions were studied. The remaining 186 patients (10%) were excluded because they did not meet the inclusion criteria. Injuries were analysed based on their aetiology, concomitant injuries, and pre and post-operative care period. Comparisons were made using chi2 and Fisher’s exact tests. Patients were divided into eight age groups: 0–14, 15–24, 25–34, 35–44, 45–54, 55–64, over 65. Road traffic collisions, assaults, sports accidents, occupational accidents and domestic mishaps were categorized as five main causes of facial injuries. Fractures were grouped into frontal bone, zygomatic complex (body, arc), maxilla, isolated fractures of the nasal bones, orbit (blow-out, medial wall), mandible (condyle, coronoid process, ramus, body and symphysis) and panfacial fractures.
Unilateral or bilateral condylar fractures were classified using Spiessl and Schroll (Spiessl and Schroll, 1972) classification. Mandibular height loss and functional limitation were surgical indications for this type of fracture. We used a combination of brow, lower eyelid, and maxillary vestibular incision for zygomatic fractures. The orbital lateral pillar and margin were treated with 1.5 mm plates and screws, whereas the maxillary pillar was treated with 1.5 mm or 2.0 mm plates and screws. In cases of comminuted fractures or significant bone defects, a transconjunctival or lower eyelid incision was performed to expose the orbital floor fracture.
A temporal external approach was used for reduction with a zygoma elevator without fixation in cases of single zygomatic arch fractures with displacement. Intermaxillary fixation and a maxillary vestibular approach were required for LeFort I fractures. These were fixed with plates and 2.0 mm screws. After the surgery, the intermaxillary fixation was removed. LeFort II and mid-facial fractures were treated with 2.0 plates and screws using a maxillary vestibular and lower eyelid approach followed by intermaxillary fixation. We used a mandibular vestibular technique to treat mandibular fractures after naso-tracheal intubation and intermaxillary fixation. The intermaxillary fixation was then removed.
Inclusion and Exclusion Criteria
All patients who were presented within 24 hours of the incidence were included in the study. The study enrolled patients of all ages and genders. Patients who had received treatment at another trauma centre, those who presented with secondary problems, and those who presented after 24 hours were excluded from the study.
Results
A total of 1674 patients were examined during the study period. The age varied from 2 to 70 years. Most afflicted age group was 25–34, whereas the least impacted was 1–14 as they are more likely to be protected from traumatic injuries due to parental supervision. Only 11% of fractures occurred among children aged 1–14 as their facial skeleton being more elastic and less brittle than adults (Table 1). With a male-to-female ratio of 4.07:1, male inclination was 80.3%. Males, regardless of age, were frequently more involved. RTA (53.5%) was the most common cause of injury, followed by falls (18.6%) and assault (16.1%) (Fig. 3). There were 536(32%) single mandibular fractures, 318 (19%) isolated middle third fractures, and 67(4%) combined middle third and mandibular fractures among the 1674 patients. There were 636 mandibular fractures (38%) and 418 middle third fractures (25%). The parasymphysis (19%) was the most common site for mandibular fractures, followed by the symphysis (17%), condyles (16%), Angle (13.1%), body (7.0%), and coronoid (0.4%) (Fig. 1), whereas the zygomatic bone (41.9 %) was the most common in the middle third, followed by Lefort I (21.8 %), nasal bone (11.7 %), Lefort II (10.1%), and dentoalveolar (3.1%) (Table 2). Open reduction and internal fixation (ORIF) and IMF (78.2%) and closed reduction with intermaxillary fixation (21.8%) were the most common treatment options for mandibular fractures (Table 3).
Table 1.
Age groups and fracture distribution
| Age (years) | Male | Female | Total |
|---|---|---|---|
| 0–14 | 148 | 36 | 184 (11%) |
| 15–24 | 283 | 69 | 352 (21%) |
| 25–34 | 363 | 89 | 452 (27%) |
| 35–44 | 255 | 63 | 318 (19%) |
| 45–54 | 175 | 43 | 218 (13%) |
| 55–64 | 94 | 23 | 117 (7%) |
| 65 and above | 27 | 6 | 33 (2%) |
| 1345 | 329 | 1674 |
Fig. 3.
Distribution of mandibular fractures
Fig. 1.
Aetiology of accidents
Table 2.
Frequency of maxillofacial fractures
| Site | Total |
|---|---|
| Frontal bone | 67 (4%) |
| Zygomatic bone | 419 (25%) |
| Medial orbital wall | 17 (1%) |
| Blowout | 100 (6%) |
| Le fort 1 | 218 (13%) |
| Le fort 2 | 100 (6%) |
| Panfacial | 67 (4%) |
| Dentoalveolar bone | 33 (2%) |
| Nasal bone | 117 (7%) |
| Mandible | 536 (32%) |
Table 3.
Treatment
| Treatment done | No of patients | Percentage (n = 1674) |
|---|---|---|
| Conservatively managed | 396 | 23.7 |
| Intermaxillary fixation | 89 | 5.3 |
| IMF + closed reduction | 45 | 2.7 |
| ORIF | 455 | 27.2 |
| IMF + ORIF | 689 | 41.1 |
Discussion
Trauma is the largest cause of mortality in people under the age of 40, and traumatic injuries are the biggest source of lost productivity, accounting for more lost working years than heart disease and cancer combined [1].
Males are more likely to sustain maxillofacial injuries than females. The male to female ratio in this study was 4.07:1 (Fig. 2), which is consistent to most studies except in Pakistan where it was 32:1 [4]. Most afflicted age group was 25–34, whereas the least impacted was 1–14, due to their facial skeleton being more elastic and less brittle than adults. Only 11% of fractures occurred among children aged 1–14, as they are more likely to be protected from traumatic injuries due to parental supervision. Adult anatomical and social characteristics (late night outings, beginning of professional life, interpersonal conflicts, and legal authority to drive automobiles beyond the age of 18) make them more prone to facial injuries as they age [5].
Fig. 2.
Sex distribution
Road traffic accidents were the most common cause of injury in this study. Traffic accidents caused 53.6% of maxillofacial injuries, followed by falls from height (18.6%) and assault (17.6%). In other regions of India, the incidences were 62% in Chennai [6], 68.3% in Mysore [7], 87% in Pune [8] and 80.31% in Odisha [9].
In developed countries, assault and daily activities are known to be the leading causes of maxillofacial trauma [10, 11]. The use of seat belts, traffic calming measures, and traffic law enforcement have all reduced road traffic accidents in developed countries [5]. Alcohol is widely acknowledged as a causative factor in fights and traffic accidents [9].
In both males and females, the mandible was the most fractured anatomical region, accounting for 32% of all injuries, followed by zygoma (25%) and Le Fort 1 (13%). These results are in line with other international literature reports, which indicated the mandible as more exposed to traumatic events, reserving zygoma, which is the commonest site for mid-third fractures as the second commonest fracture site (Fig. 3).
This may be because the mandible is the most prominent and only mobile facial bone, and hence more prone to fracture than the well-articulated mid-facial bones [12]. Mandibular fractures were increasingly common in several countries, with road traffic accidents being the leading cause. However, one study found mid-face fractures to be more predominant [1]. In these studies, the primary etiologic variables were activities of daily living and falls, which explains the variation in the distribution of maxillofacial fractures based on aetiology.
The most prevalent location of mandibular fractures was the parasymphysis region (19%), followed by symphysis (17%) and condylar fractures (16%).
Except for one study [7] where sub condylar fractures were more prevalent, these results are in accordance with other Indian studies [6, 8, 9]. The studies where road traffic accidents is found to be the main aetiology for maxillofacial fractures have reported parasymphysis and condyle to be the common site. The maximum combinations of fractures were para symphysis with condyle (7.0%) followed by parasymphysis and angle (6%).
Mandibular fractures were lower than mid-face fractures. This low incidence is attributed to the mandible and cranium’s protection, as well as the mid-facial bones’ elasticity The most prevalent mid-facial fractures were zygomatic complex fractures (25%) followed by Le Fort I fractures (13%). These results are similar to other studies except for one, where nasal bone fractures were more prevalent than zygomatic complex fractures [7].
A total of 67 fractures that involved both maxilla and the mandible were found in this study, accounting for 4% of all fractures. Another study [8] in India found 4.7% pan facial fractures.
Most of the patients with nasal, zygomatic arch, and paediatric condylar fractures were treated conservatively (23.7%). ORIF + IMF remains the major (41.1) mode of treatment followed by ORIF (27.2%). Only IMF was done in 5.3% patients. Treatment of maxillofacial fractures varies from surgeon to surgeon and depends on available facilities (Table 3). Before rendering close or open method of treatment for maxillofacial injuries important consideration should be made regarding age of the patient, type of the fracture, involvement of neighbouring vital structures and associated injuries. The management of severe maxillofacial trauma is challenging and to optimise patient care and outcome, an interdisciplinary approach by different specialties is required.
Conclusion
The aetiology and pattern of maxillofacial injuries reflect the trauma patterns within the community and can thus provide a guide to help design programs towards prevention and management of maxillofacial trauma. It can be concluded that strict traffic rules, road safety laws and preventive measures need to be enforced along with educating the masses.
Declarations
Conflict of interest
No funding was received for conducting this study. No funding was received to assist with the preparation of this manuscript.
Research Involving Human Participants, Their Data or Biological Material
Ethical approval was waived as per the standards of the local Ethics Committee of SMS Medical College and Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.
Informed Consent and Consent to Participate
Informed consent was obtained from all individual participants included in the study.
Consent to Publish
Patients signed informed consent regarding publishing their data.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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