Home | About us | Editorial board | Ahead of print | Current issue | Archives | Search | Submit article | Instructions | Subscribe | Advertise | Contact us |  Login 
National Journal of Maxillofacial Surgery
 
Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 428
 


 
Table of Contents
ORIGINAL ARTICLE
Year : 2012  |  Volume : 3  |  Issue : 2  |  Page : 166-171  

The maxillofacial injuries: A study


1 Department of Oral and Maxillofacial Surgery, K.G. Medical University, Lucknow, India
2 Department of Anaesthesia, K.G. Medical University, Lucknow, India

Date of Web Publication4-May-2013

Correspondence Address:
Vibha Singh
A-43, Krishna Nagar, Lucknow
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.111372

Rights and Permissions
   Abstract 

Objectives: The aim of this study was to evaluate the incidence and etiology of maxillofacial fractures and also to evaluate different treatment modalities. Study design: The sample consisted of 1,038 patients, with maxillofacial injuries treated at our center from June 2006 to June 2011. Cause, type, site of injury, gender, age and treatment given to them, all these parameter are evaluated. Conclusion: The results of this study exhibit that road traffic accidents is the main reason for maxilla facial injuries followed by fall from height.Maxillofacial injuries are more frequent in male than in female. The mandible was most frequently involved facial bone. The miniplate osteosynthesis was the most widespread of the fixation technique but conservative management of the fractured bone also has a significance importance in treatment modalities.

Keywords: Close reduction, maxillofacial injuries, road traffic accidents


How to cite this article:
Singh V, Malkunje L, Mohammad S, Singh N, Dhasmana S, Das SK. The maxillofacial injuries: A study. Natl J Maxillofac Surg 2012;3:166-71

How to cite this URL:
Singh V, Malkunje L, Mohammad S, Singh N, Dhasmana S, Das SK. The maxillofacial injuries: A study. Natl J Maxillofac Surg [serial online] 2012 [cited 2019 Nov 20];3:166-71. Available from: http://www.njms.in/text.asp?2012/3/2/166/111372


   Introduction Top


Hippocrates described an array of facial injuries as long ago as 400 BC. The injuries to the facial regions are clinically highly significant for number of reasons. Facial region provides anterior protection for the cranium and plays significant role in appearance. Maxillofacial region is associated with a number of important functions of the daily life sight, smell, eating, breathing, and talking. These functions are severely affected and ultimately result in poor quality of life.

Facial injuries occur in significant proportion in trauma patients requiring prompt diagnosis and management. Maxillofacial injuries are common both in war and peace. The number of maxillofacial injuries is continuously increasing due to rise in traffic, and failure to take preventive measures in the traffic leads to road traffic accidents, which is the main etiological factor in maxillofacial fractures.

The aim of this study was to find out the incidence and pattern of maxillofacial injuries resulting from various etiological factors and treatment modalities and their complications. The maxillofacial injuries remain serious clinical problems because of its anatomical significance, i.e., important organs are located in this area and digestive and respiratory systems start from this area. Due to anatomical proximity together with maxillofacial injuries, the damage to the central nervous system may occur and injuries in this region can result in serious dysfunction. This descriptive analytical study assesses the etiology, type, demographic, and treatment data of maxillofacial fractures managed at our center in the last 5 years.


   Materials and Methods Top


The sample consisted of 1,038 patients, with maxillofacial injuries treated at our center from June 2006 to June 2011. Around 350 patients who were not admitted in the department and were treated as the outdoor patients were not included in this study, as it was not possible to obtain their complete data. Most of them were treated by conservative management. They were put on the intermaxillary fixation. The diagnosis was made on the basis of history, clinical examinations, and other investigations. Radiographs, orthopantomogram, occipitomental view, submentovertex view, posterio-anterior (P.A.) view mandible, lateral oblique view mandible, were the main tools to confirm clinical diagnosis. CT scans, 3D CT, and dentascan were used according to indications.

The parameters assessed included age, sex, etiology, fractured bones, and treatment modalities and complications. The treatment modalities were close reduction, open reduction, and fixation. Different approaches for reduction and fixation of fractures were used according to indications either intra-oral approach or extra-oral approach.


   Results Top


The most common site of fracture maxilla was found to be leforte 2 fracture. In our study, gender distribution was 9:1 [Table 1], but in other studies, it was 2:1. Males are more prone for trauma because of outdoor works, rash driving, and alcoholism. [1],[2],[3] The most common involved age group was 21-30 (37.66%) years [Table 2], followed by 31-40 years (19.36%). [4],[5],[6] The road traffic accident (97.10%) was the most common etiological factor [Table 3].
Table 1: Gender (N=1,038)

Click here to view
Table 2: Age group (N=1,038)

Click here to view
Table 3: Etiology

Click here to view


The commonest fractured bone is mandible (47.87%). Most of the patients had multiple bone fractures including mandible, maxilla, and zygomatic complex fracture (62.42%) [Table 4]. Adeyemo stated that road traffic crashes remain the major cause of maxillofacial injuries, unlike in most developed countries where assaults/interpersonal violence has replaced road traffic crashes as the major cause of the injuries. [6]
Table 4: Fracture involving different bones (N=1,038)

Click here to view


The most commonly involved site was body of the mandible (51.50%) followed by parasymphysis (45.25%). Coronoid fracture was reported [6],[7],[8] to be least common (1.08%) [Table 5]. Among maxillary fractures, the most common fracture was leforte 2 fracture (84.00%) followed by leforte 1 and then leforte 3 [Table 6]. Motamedi [7] also reported leforte 2 was the commonest fracture in his study.
Table 5: Mandible fracture sites

Click here to view
Table 6: Maxilla fractures

Click here to view


In the study of Motamedi et al., [7] they found there were (72.9%) mandibular, (13.9%) maxillary, (13.5%) zygomatic, (24.0%) zygomatico-orbital, (2.1%) cranial, (2.1%) nasal, and (1.6%) frontal injuries. Car accidents (30.8%), motorcycle accidents (23.2%), altercations (9.7%), sports (6.3%), and warfare (9.7%) caused the maxillofacial injuries. Regarding distribution of mandibular fractures, 32% were seen in the condylar region, 29.3% in the symphyseal-parasymphyseal regions, 20% in the angle region, 12.5% in the body, 3.1% in the ramus, 1.9% in the dentoalveolar, and 1.2% in the coronoid region. The distribution of maxillary fractures was Le Fort II (54.6%), Le Fort I (24.2%), Le Fort III (12.1%), and alveolar (9.1%). Of the all mandibular fractures, 56.9% were treated by closed reduction, 39.8% by open reduction, and 3.5% by observation only. Of all maxillary fractures, 54.6% were treated using closed reduction, 40.9% using open reduction, and 4.5% with observation only. Approximately, 52.1% of the patients were treated under general anesthesia and 47.9% were treated under local anesthesia and sedation.

Regarding treatment modalities we used, most of the patients were treated by open reduction and fixation (72.83%) and conservative management (22.73%), and 2.50% patients were treated by circum-mandibular wiring mostly in pediatric patients and edentulous patients [Table 7].
Table 7: Treatment modalities

Click here to view


According to Ajmal, et al., [8] open reduction and internal fixation has proven to be the most effective method for treatment of mandibular fractures. In most of the patients, Open reduction & internal fixation (ORIF) was done under general anesthesia, rest of them under local anesthesia and conscious sedation. All the patients of circum-mandibular wiring were treated under General anaesthesia (GA). The close reduction was done under local anesthesia.

According to study of Back, et al., [1] most patients were males (76%), the average age was 38 years, and drugs or alcohol were a significant aspect of the history in 30% of the cases. The most common mechanism of injury was assault (47%), followed by falls and sporting injuries. Fifty percent of the fractures involved the orbital or orbito-zygomatic complex, and 55% had associated injuries. Average follow-up was for 6 weeks (range: 0-44 weeks). Most patients were managed conservatively based on our current criteria of un-displaced/minimally displaced fracture (57%) or minimal/no symptoms (24%). At final review, a number had residual symptoms, but only three required corrective surgery. The other reasons for conservative management included patient non-compliance (11%) and medical contraindications (8%).

Being a developing country, the socioeconomic status of the majority is low and the patients coming to our center are from remote areas of the state and from neighboring states with the poor background, so choice of plating systems are limited.

Different systems of plating were used according to indications and affordability. Miniplates (stainless steel or titanium), 3D plates, locking plates, reconstruction plates, lag screws, and biodegradable systems were used. Reconstruction of orbital floor was done with autogenous bone graft and in few cases with medpore. In most of the patients, stainless steel plates were used [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8] and [Figure 9].
Figure 1: Pre-operative photograph of patient

Click here to view
Figure 2: Pre-operative photograph of patient

Click here to view
Figure 3: Pre-operative CT scan

Click here to view
Figure 4: Pre-operative CT scan

Click here to view
Figure 5: Intra-operative photograph of patient

Click here to view
Figure 6: Intra-operative photograph of patient

Click here to view
Figure 7: Post-operative CT scan

Click here to view
Figure 8: Post-operative CT scan

Click here to view
Figure 9: Post-operative photograph of patient

Click here to view


In patients with only mandibular fractures (497), 21% patients were treated with intermaxillary fixation and 84.78% with open reduction and fixation with different systems [Table 8].
Table 8: Treatment modalities used for mandible fractures (N=497)

Click here to view


Danda, et al. [9] concluded from their study that the results of this study have shown that no significant clinical difference exists between patients undergoing closed treatment and rigid maxillomandibular fixation or open reduction and internal fixation. However, a radiographically better anatomic reduction of the condylar process was seen in the patients treated with open reduction and internal fixation.

Out of patients who received ORIF (64.78%), in 25.19% cases plates were removed within 6 months to 2 years because of secondary infection, sinus formation, or pus discharge from the site. There was no single case of delayed union or non-union reported [Table 6] and [Table 9].
Table 9: Need of second surgery for removal of plates in 1,038 patients

Click here to view



   Discussion Top


World Health Organization has estimated that nearly 25% of all injuries fatalities worldwide are a result of road traffic crashes with 90% of the fatalities occurring in low- and middle-income countries. [10]

Road traffic accidents have been steadily falling in the developed countries; they continue to rise with the horrifying speed in the low- and middle-income countries of Africa and Asia. It is the major cause of death in India. The majority of the accidents results due to speeding and legislation. Alcoholism is associated with road traffic accidents internationally. Fatigue is another important factor especially in commercial vehicle drivers who drives very long distances. Bad road conditions also play an important role in RTA but some studies reported more RTAs on well paved and broad roads. [4]

The reason for the accidents in our country is due to violation of traffic rules, whereas in developed countries, accidents are most commonly due to alcoholic intoxications.

This study shows that the most common cause of facial injuries was road traffic accidents, which is consistent with observation in other studies in India and other countries. [8],[3],[4],[5],[11] Mandible fracture was the most common fracture observed in this study because it is the most prominent bone in the face and is often fractured more than strongly supported middle third of face.

Fractures have been treated by a series of methods including close reductions, internal fixation, and circum-mandibular wiring. Coletti [10] stated that the IMF self-drilling/tapping screws has been shown to be a useful modality to establish maxillomandibular fixation. It is a safe and time-sparing technique; however, it is not without limitations or potential consequences which the surgeon must be aware of in order to provide safe and effective treatment.

Pediatric patients were treated by circum-mandibular wiring and few cases with bioresorbable plates under general anesthesia. Pediatric patients benefit from the advantage of bioresorbable plates as it results in faster mobilization and the avoidance of secondary surgery for removal of implants. [12]

The old age successful management of these injuries using close reduction technique should be considered. [13],[9] Patients with edentulous atrophic mandible were all so treated with circum-mandibular wiring and results were satisfactory.

The minimally displaced fractures can be treated with conservative methods like close reduction to avoid hospitalization, cost factor, and significantly low risk of infections.

In our study, there was no infection, non-union, mal union, or any functional disability reported in the patients who received inter maxillary fixation for 4-6 weeks. Mouth opening was normal in all patients. Temporomandibular joint stiffness was reported during first week of after releasing IMF which comes normal after a week with physiotherapy.

However despite the professional and commercial interest in open reduction and semi-rigid fixation, we should think about patient's interest affordability and well-being. Conservative management should not be overlooked when indicated. Sometimes, patients' general condition, neurosurgical conditions, spinal injuries, medically compromised patients should be treated with conservative treatment. It is very cost effective, reduces hospital stay, or even no need for hospitalization.

Only dietary restrictions due to mouth closure and patient compliance are limitations. In few patients like epileptic, we cannot use inter maxillary fixation for the management of maxillofacial trauma in minimally displaced fractures.

Other studies also did not show a clear overall benefits of the open reduction and fixation over conventional Maxillo mandibular fixation (MMF) treatment. [6],[14],[15] Marker, etal. [14] found non-surgical treatment of fracture of condoyle is non-traumatic, safe, and predictable and also support the conservative management of mandibular fractures. The fractures with little displacement can be treated with close reduction. The cases with extensive displacement, associated fractures of mid-face, open reduction and fixation are indicated. [1],[15],[16],[17]

According to Worsaae and Thorn [18] in the study of open versus closed reduction of unilaterally dislocated low subcondylar fractures, they concluded that complications such as malocclusion, mandibular asymmetry, impaired masticatory function, and pain located to the affected joint or masticatory muscles were seen significantly more frequent in patients treated with closed reduction compared with those treated surgically ( P = 0.005). Neither the degree of dislocation of the proximal fragment, concomitant mandibular fractures nor the absence of posterior occlusal support seemed to influence the results.


   Conclusions Top


The results of this study exhibit that road traffic accidents is the main reason for maxilla facial injuries followed by fall from height. Maxillofacial injuries are more frequent in male than in female. The mandible was most frequently involved facial bone. The miniplate osteosynthesis was the most widespread of the fixation technique but conservative management of the fractured bone also has a significance importance in treatment modalities.

 
   References Top

1.Back CP, McLean NR, Anderson PJ, David DJ. The conservative management of facial fractures: Indications and outcomes. J Plast Reconstr Aesthet Surg 2007;60:146-51.  Back to cited text no. 1
    
2.Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51-61.  Back to cited text no. 2
    
3.Gupta R, Suryanarayan S, Sharma A, Pandya V, Sathaye S. Traumatic mandibular fractures: Pendulum towards closed reduction. The World Articles in Ear, Nose and Throat 2010;3:1-3.  Back to cited text no. 3
    
4.Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:166-70.  Back to cited text no. 4
    
5.Malara P, Malara B, Drugacz J. Characteristics of maxillofacial injuries resulting from road traffic accidents-A 5 year review of the case records from Department of Maxillofacial Surgery in Katowice, Poland. Head Face Med 2006;2:27.  Back to cited text no. 5
    
6.Adeyemo WL, Ladeinde AL, Ogunlewe MO, James O. Trends and characteristics of oral and maxillofacial injuries in Nigeria: A review of the literature. Head Face Med 2005;1:7.  Back to cited text no. 6
    
7.Motamedi MH. An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61:61-4.  Back to cited text no. 7
    
8.Ajmal S, Khan MA, Jadoon H, Malik SA. Management protocol of mandibular fractures at Pakistan Institute of Medical Sciences, Islamabad, Pakistan. J Ayub Med Coll Abbottabad 2007;19:51-5.  Back to cited text no. 8
    
9.Danda AK, Muthusekhar MR, Narayanan V, Baig MF, Siddareddi A. Open versus closed treatment of unilateral subcondylar and condylar neck fractures: A prospective, randomized clinical study. J Oral Maxillofac Surg 2010;68:1238-41.  Back to cited text no. 9
    
10.Adeyemo WL, Ladeinde AL, Ogunlewe MO, James O. Trends and characteristics of oral and maxillofacial injuries in Nigeria: A review of the literature. Head Face Med 2005;1:7.  Back to cited text no. 10
    
11.El-Degwi A, Mathog RH. Mandible fractures-Medical and economic considerations. Otolaryngol Head Neck Surg 1993;108:213-9.  Back to cited text no. 11
    
12.Lawoyin DO, Lawoyin JO, Lawoyin TO. Fractures of the facial skeleton in Tabuk North West Armed Forces Hospital: A five year review. Afr J Med Med Sci 1996;25:385-7.  Back to cited text no. 12
    
13.Blitz M, Notarnicola K. Closed reduction of the mandibular fracture. Atlas Oral Maxillofac Surg Clin North Am 2009;17:1-13.  Back to cited text no. 13
    
14.Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 2: Results of treatment of 348 patients. Br J Oral Maxillofac Surg 2000;38:422-6.  Back to cited text no. 14
    
15.Abreu ME, Viegas VN, Ibrahim D, Valiati R, Heitz C, Pagnoncelli RM, et al. Treatment of comminuted mandibular fractures: A critical review. Med Oral Patol Oral Cir Bucal 2009;14:E247-51.  Back to cited text no. 15
    
16.Fordyce AM, Lalani Z, Songra AK, Hildreth AJ, Carton AT, Hawkesford JE. Intermaxillary fixation is not usually necessary to reduce mandibular fractures. Br J Oral Maxillofac Surg 1999;37:52-7.  Back to cited text no. 16
    
17.Peter W, Stephen A, Schendel, Jag-Erich H. Maxillo Facial Surgery. Vol. 1, 2 nd ed. Churchill Living Stone Elsevier Ltd.; 2007.  Back to cited text no. 17
    
18.Worsaae N, Thorn JJ. Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: A clinical study of 52 cases. J Oral Maxillofac Surg 1994;52:353-60.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


This article has been cited by
1 The Impact of Blast Implosions and Bullet Injury on Maxillary Air Sinus
Ahmed Fadhel Al-Quisi,Auday M. Al-Anee,Abbas Sabah Mohammed
Journal of Craniofacial Surgery. 2019; 30(5): 1441
[Pubmed] | [DOI]
2 Incidence and Severity of Maxillofacial Injuries During the Syrian Civil War in Syrian Soldiers and Civilians
Murat Ucak
Journal of Craniofacial Surgery. 2019; 30(4): 992
[Pubmed] | [DOI]
3 Mandibular war injuries caused by bullets and shell fragments: a comparative study
Auday M. AL-Anee,Ahmed Fadhel Al-Quisi,Hassanien A. Al-jumaily
Oral and Maxillofacial Surgery. 2018;
[Pubmed] | [DOI]
4 Imaging modalities for midfacial fractures
Chaya M David,Ramya K Kastala,Namitha Jayapal,Shanila A Majid
Trauma. 2017; 19(3): 175
[Pubmed] | [DOI]
5 Analysis of Traffic Accident-Related Facial Trauma
Su Hyun Choi,Ja Hea Gu,Dong Hee Kang
Journal of Craniofacial Surgery. 2016; 27(7): 1682
[Pubmed] | [DOI]
6 Epidemiology and Risk Factors of Maxillofacial Injuries in Brazil, a 5-year Retrospective Study
Luciana Domingues Conceição,Isadora Augusta da Silveira,Gustavo Giacomelli Nascimento,Rafael Guerra Lund,Ricardo Henrique Alves da Silva,Fábio Renato Manzolli Leite
Journal of Maxillofacial and Oral Surgery. 2016;
[Pubmed] | [DOI]
7 Effect of 2100 MHz mobile phone radiation on healing of mandibular fractures: an experimental study in rabbits
Mustafa Durgun,Suleyman Dasdag,Serkan Erbatur,Korkut Yegin,Suna Ogucu Durgun,Cosar Uzun,Golge Ogucu,Ulas Alabalik,Mehmet Zulkuf Akdag
Biotechnology & Biotechnological Equipment. 2016; 30(1): 112
[Pubmed] | [DOI]
8 Timing of maxillofacial-oral injuries in an individual of the ancient city of Herculaneum (79 AD, Naples, Italy): a case report
Joan Viciano,Ruggero DæAnastasio,Luigi Capasso
Dental Traumatology. 2015; 31(3): 215
[Pubmed] | [DOI]
9 A ten year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology
Erik G. Salentijn,Saskia M. Peerdeman,Paolo Boffano,Bart van den Bergh,Tymour Forouzanfar
Journal of Cranio-Maxillofacial Surgery. 2014;
[Pubmed] | [DOI]
10 Aetiology of maxillofacial fractures: a review of published studies during the last 30 years
Paolo Boffano,Sofie C. Kommers,K. Hakki Karagozoglu,Tymour Forouzanfar
British Journal of Oral and Maxillofacial Surgery. 2014;
[Pubmed] | [DOI]
11 Development plates for stable internal fixation: Study of mechanical resistance in simulated fractures of the mandibular condyle
Tóride Sebastião Celegatti Filho,Danillo Costa Rodrigues,Andrezza Lauria,Roger William Fernandes Moreira,Simonides Consani
Journal of Cranio-Maxillofacial Surgery. 2014;
[Pubmed] | [DOI]
12 Maxillary Chronic Osteomyelitis Caused by Domestic Violence: A Diagnostic Challenge
Tamyris Inácio Oliveira,Marina Lara de Carli,Noé Vital Ribeiro Junior,Alessandro Antônio Costa Pereira,Dimitris N. Tatakis,João Adolfo Costa Hanemann
Case Reports in Dentistry. 2014; 2014: 1
[Pubmed] | [DOI]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed2647    
    Printed81    
    Emailed2    
    PDF Downloaded618    
    Comments [Add]    
    Cited by others 12    

Recommend this journal