Aetiology, prevalence, fracture site and management of maxillofacial trauma

Abstract

Introduction

Maxillofacial fractures are often associated with severe morbidity, functional deficit, disfigurement and significant financial implications. The aim of this review was to investigate whether the aetiology, prevalence and management modalities of facial trauma can identify the common causes of facial trauma with a view to recommending measures to the appropriate governing bodies to change the current practice wherever possible.

Methods

The records of 1,112 patients referred to our oral and maxillofacial unit in Andhra Pradesh, India, between February 2008 and October 2017 were analysed retrospectively. Data including age, sex, aetiology, fracture site and treatment were evaluated.

Results

Men aged 20–40 years were the most common victims of facial trauma. Road traffic accidents (RTAs) were responsible in 70% of cases. Mandibular fractures constituted 47% of the overall fractures, and 55% of the total fractures were treated with open reduction and internal fixation.

Conclusions

The main cause of maxillofacial injury among patients reporting to our hospital was RTAs. Mandibular fractures were the most common, accounting for almost half of the cases. Over half (55%) of all maxillofacial fractures were treated with open reduction and internal fixation. Reasons for this high frequency may include the large number of poorly maintained, overloaded vehicles on unsuitable roads, violation of traffic regulations (particularly by inexperienced young drivers), abuse of alcohol or other intoxicating agents and the sociocultural behaviours of some drivers.

Introduction

In surgical terms, trauma is defined as a physical force that results in injury. Maxillofacial injuries are one of the most common injuries and road traffic accidents (RTAs) are a major cause of maxillofacial injuries in developing countries.¹ Facial fractures occur frequently as the face is anatomically exposed and its bones are fragile. An understanding of the frequency and case distribution of facial fractures can assist in establishing research priorities for effective treatment and prevention of these injuries. The main aim of this study was to evaluate the aetiology, prevalence and site of maxillofacial injuries as well as treatment modalities.

Methods

The records of maxillofacial injury patients who reported to the Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Vijayawada, India, between February 2008 and October 2017 were retrieved and analysed retrospectively. Those who had facial soft tissue injuries were also included. Data including age, sex, aetiology, anatomical fracture site and treatment were assessed.

Aetiology of injury was grouped into four main categories:

1. RTA involving automobiles, motorcycles or bicycles (including drivers, passengers or pedestrians);

2. falls from a height or while playing or due to systemic illness;

3. assault or interpersonal violence;

4. sports and other injuries.

Fractures were assessed according to six anatomical regions:

1. fractures of the mandible (subdivided into parasymphysis, symphysis, body, angle, ramus, coronoid process and condyle);

2. zygomatic complex fractures (including zygomatic bone with or without zygomatic arch);

3. fractures of the maxilla (including Le Fort I, Le Fort II, Le Fort III and any combination of these);

4. fractures of the nasal bone;

5. orbital and cranial bone fractures (including temporal, frontal and orbit fractures);

6. other injuries (including soft tissue lacerations, dentoalveolar injuries, avulsion and fracture of teeth).

The prevalence of injury in a particular age group as well as the sex distribution, aetiology, type of fracture and management were analysed. The existing literature relating to maxillofacial injuries was reviewed for comparison.

Results

The data of 1,112 patients (988 male [89%], 124 female [11%]) were evaluated. The male-to-female ratio was approximately 8:1. A significantly higher proportion of males were involved in accidents and sustained injuries. The mean patient age was 32 years (range: 4–81 years). The peak incidence (41%) of maxillofacial fractures occurred in patients aged 21–30 years (Fig 1).

Figure 1. Age distribution of patients.

Aetiology of maxillofacial trauma

The most common cause of maxillofacial injury was RTA, accounting for 70% of cases. Trauma due to falls accounted for 19% of injuries. This mostly involved self-falls or skids on two-wheeled vehicles, children who fell while playing, elderly people who fell owing to systemic illness or men who were under the influence of alcohol. Assault by a known person constituted 9% of injuries. Seventeen cases of sports/other injuries (2%) were reported (Fig 2).

Figure 2. Aetiology of trauma.

Site and type of fracture

A total of 1,399 fractures were diagnosed in 1,112 patients. Mandibular fractures constituted almost half (47%) of the total cases while cranial and orbital bones made up only 1%. A breakdown of the other sites for maxillofacial fractures is given in Table 1.

Table 1. Site of maxillofacial fractures (n=1,399).

Fracture site	Frequency
Mandible	660 (47.2%)
Zygomatic complex	243 (17.4%)
Maxilla	173 (12.4%)
Nasal	25 (1.8%)
Cranial and orbital	18 (1.3%)
Panfacial	16 (1.1%)
Dental and soft tissues	264 (18.9%)

The distribution of the anatomical site of fractures of the mandible is shown in Figure 3. Parasymphysis fractures were the most common, accounting for 28% of cases, and the least common were coronoid fractures (0.6%).

Figure 3. Anatomical site of fractures of the mandible.

Management

Almost a third of the total patients (319/1,112, 29%) were treated conservatively, with splinting for dentoalveolar fractures, and suturing and wound care for soft tissue injuries. Closed reduction with intermaxillary fixation using Erich arch bars or eyelet wires was performed for 17% of patients (184/1,112). Open reduction and internal fixation (ORIF) was employed in 55% of cases (609/1,112). The indications for ORIF included displaced fractures that were not suitable for closed reduction, gross malocclusion from the injury, patients in whom intermaxillary fixation was contraindicated, and availability of miniplates and screws.

Discussion

The maxillofacial region includes organs executing essential functions of the body such as respiration, speech, mastication, vision and smell. Special attention must therefore be paid in cases of facial trauma. Advanced Trauma Life Support^® principles must be applied in the initial assessment of all maxillofacial injury victims, as in any trauma patient. The epidemiology of maxillofacial trauma can provide information on how people are injured as well as showing how the geographic area, socioeconomic status, traffic and social behaviour can influence this type of trauma.¹ Maxillofacial fractures have been reported to represent 7.4–8.7% of the medical care provided in emergency centres.²

The higher frequency of maxillofacial injuries among men is a universal finding in all previous studies.^1–7 The age distribution of patients with facial trauma in the present study corresponds to the data in the literature. Injury was most prevalent in those aged 20–40 years in both sexes. Young adults usually have greater physical skills and mobility; furthermore, they expose themselves more often to risky situations and they are likely to drink more alcohol.^8–14

Aetiology of maxillofacial trauma

Many factors are considered responsible for maxillofacial trauma. With the recent growth in the Indian economy, traffic density on the roads has greatly increased. According to the Society of Indian Automobile Manufacturers, the number of automobiles sold each year in India has more than doubled during the last ten years,¹⁵ This has led to a significant increase in the number of vehicles on the road and therefore accidents, which often result in oral and maxillofacial injuries. RTAs were by far the leading cause of maxillofacial fracture in our study, accounting for 70% of the total cases. This is in keeping with results from other studies, which also reported RTA as the leading cause of maxillofacial fractures in the developing world.^16,17 Within the category of RTAs, motorcycle accidents, bicycle accidents, and collisions of light and heavy vehicles are important aetiological factors.

The second most common cause of maxillofacial fractures in our cohort was falls, which accounted for 19% of cases. Injuries sustained from falls are different from other facial injuries because they are nearly always caused by impact against a static object of variable size and density. Fall injuries show a bimodal age distribution, being more common in the first 10 years of life and then again in patients aged over 60 years. In the younger age group, it is predominantly boys who are affected whereas in the older population, women have a higher incidence of fractures.

Interpersonal violence accounted for 9% of cases resulting in trauma in our study. Assault is the threat of attack. An act of physical violence is better termed ‘battery’ although the word ‘assault’ has become synonymous with the act of violence itself and assault is reported as the most frequent cause of maxillofacial fractures in the developed world.^13,18–20

Our findings on the aetiology of maxillofacial trauma are similar to those in other studies from India by Singh and Arunkumar (RTAs 75%, assault 15%, falls 10%),²¹ and Gandi et al (RTAs 75%, assault 15%, other aetiologies 20%).²² This can likely be attributed to the overpopulation of cities, bad road conditions, risky driving behaviour and poor traffic discipline in our country. Conversely, the aetiology varied greatly when compared with a developed country. In a US study, Guimond et al found that assault was the main aetiology (81%), followed by falls (11%) and finally, RTAs (8%).²³

Site and type of fracture

Other authors have reported zygomatic fractures as the most common subtype among midfacial fractures in both children and adults.^6,19,20 In our study, 17% of fractures involved the zygomatic complex and the maxillary bone constituted 12%. The mandible was the most common site of the facial skeleton to be prone to fracture (47%). This is in accordance with multiple previous studies.^5,13,24,25 The vulnerability of this bone can be explained by its anatomically prominent position in the facial skeleton. Few studies support the midface as the most common fracture site.^11,26

Unlike the study by Adebayo et al, in which body fractures were most common (51%),⁸ our study had the highest frequency of fractures in the parasymphysis region. Similar findings were noted in the study by Gaddipati et al.¹² Young adults wearing a half helmet (leaving the anterior mandible unprotected) appears to be one of the main reasons for the high incidence of symphysis/parasymphysis fractures caused by RTAs on Indian roads. Force per unit area appears to be greater at the site of maximum convexity (ie the mandibular symphysis/parasymphysis), resulting in increased concentration of tensile strength, which leads to fracture.²⁷

Management

Over the past 15 years, plate osteosynthesis has become popular in the management of facial fractures and in the treatment of mandibular fractures.²⁸ Despite the obvious advantages, ORIF is used sparingly in many developing countries owing to the necessity of general anaesthesia in most cases, resulting in financial implications. Over half (55%) of the maxillofacial fractures in our series were treated with ORIF. These patients were routinely placed in intermaxillary fixation only intraoperatively. The intermaxillary fixation was then released in all cases except those with concomitant condylar fractures that were planned to be treated conservatively with arch bars and intermaxillary fixation.

In our institution, ORIF using miniplates is the preferred treatment for maxillofacial fractures. This is because of the technical and functional advantages of miniplate osteosynthesis over maxillomandibular fixation (including ease of use, precise anatomical reduction, limited or complete avoidance of maxillomandibular fixation, functional stability and improved mouth opening).²⁹

Conclusions

This study has revealed that the main cause of maxillofacial injury in patients admitted to our institution is RTAs. Men aged 20–40 years were the group most likely to sustain maxillofacial injury. Fractures of the mandible are most common in the maxillofacial region, constituting 47% of our overall fractures. Over half (55%) of all maxillofacial fractures in our series were treated with ORIF and 29% were treated conservatively. Reasons for this high frequency are difficult to postulate but may include the large number of poorly maintained and overloaded vehicles without safety features on unsuitable road conditions, inadequate road safety awareness (failure to wear seatbelts and helmets) and violation of the highway code (particularly by inexperienced young drivers), abuse of alcohol or other intoxicating agents and the sociocultural behaviours of some drivers.