Management of Maxillofacial Trauma in Road Traffic Accident (RTA) at Tertiary Care Center

Abstract

Road traffic accidents (RTA) are the major cause of maxillofacial injuries (MFIs) in developing countries (Akama et al. 2007). Road traffic accidents were reported to be the 9th most common cause of death and morbidity in the world and are expected to rise to 3rd position by 2020 (Peden et al. 2002). Maxillofacial injuries remain a serious clinical problem because of the involvement of complex anatomic region. Facial fractures occur most commonly in males in the third decade of life (Motamedi et al. 2014). The goal of treatment in facial fractures is to achieve anatomic reduction and restore function while increasing patient comfort and making postoperative care easier (Lachner et al. 1991). The aim of the study was to evaluate the cases of Maxillofacial injuries with the existing literature on its different presentation and management. An observational study was done from the patients of RTA with Maxillofacial injuries in ENT department and trauma centre of Sir T General hospital and Government Medical College, Bhavnagar for a period of 2 year. A total of 315 patients were included. Males are more commonly affected than females. The main etiological factor for RTA was motorcycle accidents. The trend of MFIs especially due to MCAs was on the rise after the age of 20 year. Anatomically the lower 1/3 section of the face was the most affected. Mandibular fractures were most common isolated fracture in MFIs. Open reduction and internal fixation (ORIF) by plating and screw was the treatment of choice for displaced, comminuted and multiple fractures of face. Facial trauma remains a major source of injury in all parts of the world. Its management involves many disciplines in the hospital setting, but knowledge of occlusion, the masticatory apparatus and anatomy is important for the best outcomes. This study was an analysis of demographic variables and outcome of the management adopted in patients presented to our department.

Introduction

Maxillofacial trauma is classified into injuries involving the lower, middle and upper thirds of the face. It includes the soft tissues and bones of the face. Road traffic accidents (RTA) are the major cause of maxillofacial injuries (MFIs) in developing countries [1]. Road traffic accidents were reported to be the 9th most common cause of death and morbidity in the world and are expected to rise to 3rd position by 2020 [2]. Maxillofacial injuries remain a serious clinical problem because of the involvement of complex anatomic region. The anatomical position of the region makes it relatively more exposed than other part of body so more prone to injury. Those injuries may result in a loss of function, disfiguration, psychological problems or even disability and death [3]. Facial fractures occur most commonly in males in the third decade of life [4]. The incidence, patterns, and aetiology of maxillofacial fractures vary from one country to another and even within the same country, influenced by geographic location, socioeconomic status of the cohort, cultural factors, and the period of investigation [5, 6]. Maxillofacial Injuries are associated with other injuries like Brain, airway and cervical spine. Severity of injury, emergency and definitive treatment decide the outcome. Definitive treatment varies from simple suturing of wound to fracture reduction like for nasal bone fracture close reduction, for mandible fracture by intermaxillary fixation by arch-bar or wiring with or without plating, for zygoma and maxilla fracture includes conservative and platting by ORIF [7]. The goal of treatment in facial fractures is to achieve anatomic reduction and restore function while increasing patient comfort and making postoperative care easier [8].

Aims and Objectives

The aim and objective of the study was to evaluate the clinical presentation, relevant investigations, appropriate treatment and prevention of complications in the cases of Maxillofacial injuries by RTA and compare it with the existing literature on its different presentation and management.

Materials and Methods

An observational study was done from the 315 patients of RTA with Maxillofacial injuries who give informed and written consent in ENT department and trauma centre of Sir T General hospital and Government Medical College, Bhavnagar, Gujarat over a period of 2 year from August 2018 to July 2020. Patients who did not give consent and patients requiring neurosurgical intervention were excluded. The study includes patients of all age and gender. It includes skin, soft tissue and skeletal injury. In all the patient’s number, site of trauma, size of trauma and type of wound were noted. In all the patients apart from general and local ENT examination, radiological investigations like x-ray (Both Nasal bone lateral view, PNS, Mandible AP-Lateral and Orthopantogram (OPG)) were done depending upon type and site of fracture. CT scan of facial bone with 3D reconstruction and CT scan PNS was done as and when required. An accurate assessment of the fractures was performed including the site and type of fracture, amount of displacement, paresthesia in the distribution of nerve, status of dental occlusion or any other functional deficits. All the selected patients were informed about the surgical procedure including prognosis and complications. They gave their approval to participate in a written informed consent. In every case immediate emergency management was done as per ATLS. Definitive management was done depending upon case like in nasal bone fracture; fracture reduction will be done under local or general anaesthesia (Figs. 1, 2, 3). In mandibular fracture intermaxillary fixation with or without plating was done (Figs. 4, 5). In maxilla and zygomatic fracture plating was done as and when required (Figs. 6, 7). Skin and soft tissue injuries were repaired in layers in local or general anaesthesia.

Fig. 1.

X-Ray both nasal bone lateral view showing nasal bone fracture

Fig. 2.

Preoperative nasal bone fracture

Fig. 3.

Immediate Postoperative after reduction of nasal bone fracture

Fig. 4.

Right Parasymphysis fracture of mandible

Fig. 5.

Right Parasymphysis fracture Intra op fracture reduction by plating

Fig. 6.

A 3Dimentional CT face showing Panfacial fractures (left sided Parasymphysis, right body, right infraorbital rim, right lateral orbital rim fracture)

Fig. 7.

Immediate postoperative X-ray

Pre and post treatment status of patient’s was evaluated. Maxillofacial fractures treatment success was established according to criteria including face outline, occlusion, mouth opening and local deformity. Excellent when all four criteria were met, good when three criteria were met, Fair when two criteria were met and Poor when one or none were met.

Results and Observations

A total of 463 patients presented with Maxillofacial trauma out of which 148 (32%) had involvement of brain which were referred to neurosurgeon. The number of patients that met the inclusion criteria were 315 (68%), Males 80% (n = 252), females 20% (n = 63). The ratio of male to female was 4:1. The age range of the victims was 1 to 70 years. The population mean age was 30.29, the mean age for males was 28.33, whereas the mean age for females was 38.14. This infers that males were more prone to MFIs in this study. Out of 315 patients 40 (12.69%) patients presented with bleeding, 20 (6.35%) had nasal bleeding, 15 (4.76%) had oral bleeding and 5 (1.58%) had both oral and nasal bleeding. Figure 8 shows the age-group that was most affected by MFIs was the 21 to 30-year olds followed by the 31–40 and 11–20-year olds respectively. The other age groups were much less affected and the trend dwindled with advancement in age-groups. Table 1 Shows that for every aetiological factor male were more prevalent victims of MFIs. The main aetiological factor was Motorcycle accidents (MCAs) and Motorcar accidents respectively. The motorcycle was responsible for the highest number of RTI- related injuries 195/315 (61.90%) and the motorcyclist were most affected by the RTI-related injuries. The motorcycle was also responsible for the highest number of passengers that suffered MFIs. Out of 315 patients 140 had isolated facial skeleton injuries, 105 had isolated soft tissue injuries and 70 patients had both soft tissue and skeletal injuries. There were total 55.56% (175/315) MFIs victims sustained soft tissue injuries. 65% (114) of the total number of MFIs victims sustained soft tissue lacerations. This was numerically followed by abrasions 23% (40), the least pattern of soft tissue injury being avulsions 12% (21). Anatomically the lower section of the face was the most affected 62% (195/315) by MFIs followed by mid face 28% (88/315) while the upper face 10% (32/315) was least affected. More MFI victims sustained isolated mid face fractures 53.48% (112/210) followed by mandibular fractures 39.52% (83/210).

Fig. 8.

Distribution of MFIs according to age-groups

Table 1.

Distribution of injury according to gender and aetiological agent (n = 315)

Aetiology	Male	Female	Total	Percentage (%)
Motor car	88	16	104	33.01
Motor cycle	151	44	195	61.90
Other RTA	13	3	16	5.07

A total 210 facial fractures were studied out of which 39.52% (83/210) were mandible followed by nasal bone fractures 20.95% (44/210), zygoma fractures 15.23% (32/210), maxilla fractures 12.38% (26/210), NOE fractures 4.76% (10/210) and 7.14% (15/210) was panfacial fractures Fig. 9. The fractures of the mandible mostly presented a multiple pattern 42.85% (36/83), with two or more different parts of the mandible being involved. Single isolated fractures mainly involved the Parasymphysis 23.80% (20/83). Out of all the patients 45.45% (175) underwent soft tissue repairs. For skeletal fractures 16.11% (62) underwent closed reduction whereas 21.81% (84) underwent open reduction and internal fixation (ORIF). About 16.63% (n = 64) underwent ORIF with intermaxillary fixation with eyelets or arch bars. Outcome of Panfacial fracture treatment were excellent in 66.67% (10/15), good in (20%) 3/15 and fair in (13.33%) 2/15. From the analysis of patients, it can be said that the rate of complication was highest in Open reduction and internal fixation 19.05% (16/84) followed by Open reduction and internal fixation with intermaxillary fixation 17.18% (11/64), closed reduction 8.06% (5/62) and Soft tissue repair 4% (7/175).

Fig. 9.

Percentage of facial fractures by individual bones

Discussion

The maxillofacial region is the most exposed part of the body and is more vulnerable to trauma. Facial fractures occur most commonly in males in the third decade of life [4]. Reports reveal that 20 to 60% of all road traffic injuries involve some form of maxillofacial injury, and 62% involve motorcycles [6]. The prevalence of maxillofacial injuries varies from 17 to 69%, and this large difference might be due to various environmental factors, socioeconomic conditions, cultural reasons, and traffic rules. This might be due to differences in the proportion of vehicles registered in India and three highly motorized countries (HMC), the USA, China, and Brazil. The car population as a proportion of total motor vehicles is only 13% in India compared to HMCs (56–80%). On the contrary, the proportion of motorcycles is much higher (70%) in India compared to HMCs. This high proportion of MCAs has a large effect on traffic and crash patterns. Pedestrians, bicyclists, and MCA riders are very vulnerable to injury and constitute 60% to 80% of all traffic injuries in India [9]. In our study, the major cause of maxillofacial injury was MCAs (61.91%). In the present study 32% patients had head injuries which was similar to Rajendra et al. 33% [10] and Sandhya et al. 30% [11]. The higher frequency of maxillofacial injuries among males compared to females is a universal finding of previous studies. [6, 12] In the present study, 80% were males and 20% were females, with a male to female ratio of 4:1. This male predominance may be due to the greater mobility of the male and their aggressive behavior. In our study we found that the age group between 21 and 30 years was the most commonly involved. This was supported by Septa D et al. [12] and Singaram M et al. [13]. Studies had reported zygomatic fractures as the most common subtype among midfacial fractures in both children and adults. [6, 14] In some studies, the most common facial fractures were the mandible (61%), followed by the maxilla (46%), the zygoma (27%) and the nasal bones (19.5%). [15, 16] In our study, the most common facial fractures were mandible fractures (26.35%), 18.71% of fractures involved the malar bone and the maxillary bone, nasal bone fractures (17.14%), and soft tissue injuries (56.45%). Parasymphyseal fractures of mandible were the most common fractures in our study. Ajmal et al. [17] also reported Parasymphyseal fractures were the most frequently involved. This was also supported by Mittal et al. [18] study. The incidence of facial fractures in children in India was 5.5% [19]. Accidental fall is the leading cause of maxillofacial injuries in children, accounting for 43% to 71.42% of injuries [19]. In our study, 3.8% (12/315) of reported injuries were in the 0 to 10 age group, which were mostly due to accidental fall from a bicycle. The peak incidence (47%) of mid-face fracture was in the age group of 21 to 30 years [12]. The most common fracture was ZMC fracture, ranging from 36% to 62.5% [6, 12]. In our report, 18.71% of fractures (58/315) involved the malar bone and maxillary bone, 26.35% (83/315) were mandible fractures, 17.14% (54/315) were nasal bone and NOE fractures. Final treatment outcome in Panfacial fracture treatment was excellent in 10/15 (66.67%), good in 3/15 (20%) and fair in 2/15 (13.33%) due to several factors including malocclusion, facial asymmetry and nasal deformity. Which was similar to Saikrishna Degala et al. [20]. Management of maxillofacial injuries is a real challenge for surgeons, and demands both skill and expertise. Treatment of maxillofacial fractures varies from surgeon to surgeon and also depends on available instruments. However, treatment should relate more to the type of injury than to the desire of an individual surgeon to practice a particular technique [21]. Open reduction and internal fixation (ORIF) were the major types of management performed for our patients. Condyle fractures without displacement or dislocation or occlusal derangement were treated by close reduction and indirect fixation by intermaxillary fixation. Isolated fractures of the nasal bone in our study were treated by closed reduction 37/44 (84%) Which was similar to Sinha et al. [22]

All panfacial fractures, multiple fractures with occlusal derangement, and displaced fractures that were not reduced by close reduction and unstable ZMC fracture after elevation were treated by open reduction and direct fixation by miniplate osteosynthesis. This is in contrast to the previous studies by Ansari [21], and Erol et al. [5] in which closed reduction was more frequently used. In our study, undisplaced fractures, condylar and subcondylar mandibular fractures were treated with Maxillomandibular fixation (IMF) with good functional results as comparable with Ghodke et al. [23] and Benjamin et al. [24] study from Nigeria have also reported the usage of arch bars and eyelets with same results.

The average recommended period of immobilization of fractured mandible is 4–6 weeks. [25] Although this is only empirical, it is usually influenced by several factors such as age of patient, type, number and severity of fracture, presence or otherwise of retained teeth in fracture line, and presence or absence of infection amongst others [18]. Two patient (3.26%) had malocclusion in the closed reduction group of mandible fracture, which was noticed in the first review and they were subjected to open reduction. There was malocclusion in three patients (2.02%) who were treated surgically which were less when compared with the Benjamin et al. [24] study. All maloccluded patients were subjected to redo and occlusion was achieved. There were sixteen cases of infection (4.95%) in the operated group which were treated with higher antibiotics and the implant was retained till the fracture union. Implant removal was done in patient after the fracture union. The infection rate was near to when compared to Ugboko et al. [15] who had 8.1%. The neurological deficit in the operated group was 2 (1.36%) which was comparable to the study done by Okoturo and Benjamin et al. [24] (7.1%) and Cawood [26] (8%) which improved in 6–8-week time. This deficit was not due to the surgical procedure but related to the nature of injury.

Conclusions

According to this study MFIs affected mostly young males between 20 and 30 years of age. The main aetiological factors for RTA was motorcycle accidents. The trend of MFIs especially due to MCAs was on the rise after the age of 20 year. Anatomically the lower 1/3 section of the face was the most affected. Mandibular fractures were most common isolated fracture in MFIs and Parasymphysis was the most frequently affected site. Computed tomography with 3D reconstruction was the mainstay of investigation. Laceration was the most common soft tissue injury in patients with RTA. Open reduction and internal fixation (ORIF) by plating and screw was the treatment of choice for displaced, comminuted and multiple fractures of face. This study was not comparing the result of different modalities of MFIs management. It was an analysis of demographic variables and outcome of the management adopted in patients presented to our department. The results of patients treated were same as reported in the literature. The continuing trend in facial fracture repair is toward rigid osteosynthesis with miniplates and screws. The advantage of this technique is that a higher degree of stability is gained, allowing for earlier removal of MMF and return to mastication.

Funding

Nil

Compliance with Ethical Standards

Conflict of interest

The authors declared that they have no conflict of interest.