Study of Patterns of Maxillofacial Injuries: An Institution-based Observational Study.

Maxillofacial fractures are one of the common presentations in an emergency department. They are considered to be one of the significant and dominant conditions that requires treatment as the fractures can result in morbidity, mortality, psychological, functional disability, and facial mutilation. The incidence, patterns, and etiology of maxillofacial fractures vary from one country to another due to the geographical, cultural, social, and economic differences. The present study included 176 patients from January 2019 to September 2020 that aimed to evaluate the pattern of maxillofacial fractures and to learn the etiology for the same. Copyright:

INTRODUCTION

Maxillofacial skeleton is a complex system that protects the cranium. It is formed by 14 bones out of which six are paired and two are unpaired. Maxillofacial region is important as it is associated with functions such as sight, smell, eating, breathing, and speech. Any deterioration of these functions can affect the patient's quality of life both functionally and esthetically. Injuries in the maxillofacial region have been found to instill a sense of anxiety or depressive disorder in patients.[1]

Maxillofacial fractures are the common type of injuries in trauma. They occur in about 40% to 60% of victims encountered with trauma.[2] The type of fractures encountered mostly hinge on the impact of the external forces over the maxillofacial region.[3]

Hackl et al., in a study, inferred that cervical spine injuries occur in 19.5% of the patients with maxillofacial fractures.[4] The chances of head injury increase by 1.5 times in a patient with maxillofacial fracture.[4]

Maxillofacial fractures are principally classified based on its anatomical site. The etiology for maxillofacial fractures are broadly categorized as road traffic accidents (RTAs), falls, assaults, sports, industrial injuries, and war injuries.[5] The main cause for maxillofacial fractures in developed countries has been due to assault and in developing countries has been due to RTAs.[6] According to the WHO, 1.35 million people die and 15–30 million people get injured due to RTAs every year. Computed tomography (CT) is the paramount diagnostic modality for the evaluation of maxillofacial fractures. CT has to be analyzed in multiple planes with coronal, sagittal planes, and virtual reality for better assessment.[7]

Maxillofacial fractures are treated based on certain factors such as the site of the fracture, degree of displacement and functional disabilities, age, and medical condition of the patient.

Perinthalmanna is a town in the district of Malappuram with an area of 34.41 km2. According to the 2011 India census, Perinthalmanna has a population of 49,723.

As MES Medical College and Hospital is one of the first tertiary centers in Malappuram, most of the trauma cases get referred to our hospital. There are insufficient data and studies on the analysis of maxillofacial fractures in Kerala. Such studies help in determining the different causes and preventive measures that can be taken to reduce the incidence of maxillofacial fractures by conducting various public education programs and implementing strict laws. Thus, this study was conducted to evaluate the patterns and the etiology of maxillofacial fractures reporting at MES Academy of Medical Sciences. A prospective observational study was conducted from January 2019 to September 2020. A sample of 146 patients included in the study was representative of the cases in the entire district of Malappuram.

METHODOLOGY

All patients reporting at MES Medical and Dental College and Hospital with maxillofacial fractures along with other injuries within the study period of January 2019 to September 2020 were included in the study. The following parameters such as the etiology, age, sex, types of fracture, subtypes of various fractures, associated injuries, and the treatment modality rendered were recorded. Diagnosis of maxillofacial fractures was achieved through clinical and radiological evaluation. The radiologic evaluation was achieved through CT, magnetic resonance imaging, and conventional radiography like orthopantomography, paranasal sinuses (PNS) view, submentovertex view, and posterior–anterior (PA) view of the skull.

RESULTS

Age distribution

The highest incidence of maxillofacial fractures was encountered in the age group of 21–30 years (32.19%). The second largest with maxillofacial fractures was in the age group of 31–40 years (24.66%). The mean age group who presented with maxillofacial fractures in our study was 29.5 ± 12.68.

Sex distribution

Males accounted for 80.14% (n− =117) and females about 19.86% (n = 29) of all the maxillofacial fractures. There was a male predominance with a male: female ratio of 4:1.

Etiology

The majority of patients with maxillofacial injuries reported were as a consequence of RTAs (71.23%). The second popular is falls, comprising 23.29% (n = 34). Assault and worksite were the least, accounting for just 1.37%. Other etiologies accounted for 2.74% (n = 4), of which two were airplane crashes and two were patients with maxillofacial fracture in a fitness club during weight exercise. Around 14.42% of the RTAs were made up of pillion riders. About 8% (n = 8) of the RTAs were by another vehicle (auto). Car and pedestrian injuries, which accounted for just around 3.8%, were the least.

Helmet use

Helmet use was assessed in riders and pillion riders. About 65.9% (n = 56) of riders did not wear helmets, whereas the rest 34.1% were helmet users. None of the pillion riders were helmet users.

Fracture sites

The middle third fractures (47.9%) were the most frequent fracture site observed in the study, followed by the lower third fractures (39.73 percent). Dentoalveolar fractures are the least experienced (2.74%). About 9.6% (n = 14) of the cases had both middle and lower third fractures.

The most frequently observed mandibular fracture was the condylar fractures that accounted for 37.93% (n = 44), followed by parasymphysis region with 24.14% (n = 28).

The most often noticed middle third fracture was the zygomaticomaxillary complex (ZMC) fractures that contributed to about 27.45% (n = 28), followed by isolated maxillary sinus wall fractures with 21.57% (n = 22). None of the patients in our study had presented with Le fort II and Le fort III fractures.

Side of fracture

Most of the patients in this study mostly identified with left side maxillofacial fractures, which led to approximately 53.66% (n = 72), while the right side contributed to approximately 40 percent (n = 48).

Associated injuries

The most repeatedly noticed concomitant injury was the cut lacerated wound that accounted for 56.84% (n = 83). Only 5.5% of the patients presented with head injury.

Alcohol use

About 9.59% of the people with maxillofacial fractures were found to be under the influence of alcohol, whereas the rest 90.4% were not under the effect of alcohol.

Treatment done

Majority of the patients with maxillofacial fractures were treated by open reduction and internal fixation (ORIF) under general anesthesia (GA) (42.36%). About 38.8% (n = 56) of the maxillofacial fractures were treated conservatively. 15.97% of the patients were treated by closed reduction under LA, whereas only 1.39% were treated by ORIF under LA and closed reduction under GA.

DISCUSSION

The facial skeleton is a diverse and complex region that protects the brain and cervical spine. The lower and midportion of the face is associated with breathing, eating, and speech and also is essential for social well-being and self-identity.

Maxillofacial fractures refer to the fractures of the facial skeleton, dentoalveolar segment, and the bone associated with the head and neck region. The anatomical eminence and layout of the facial bones makes the maxillofacial region more prone to fractures.[8] The facial fractures develop as a result of the impact of the forces. The force can be a blunt one or a penetrating one. The tolerance to maxillofacial fractures is dependent on the force impacted the direction of the forces, the velocity, and the thickness of the bone. The facial bones have areas of strength (buttresses) and areas of weakness and the buttress region are the perfect areas for plate fixation during fracture reduction and repair.[9]

Radiographs such as standard plain radiographs, panoramic radiography, and CT help in assessing and diagnosing the maxillofacial fractures. PA view of the skull, submentovertex view, and Waters, Caldwell, and Towne's view are some of the skull radiographs used to assess midfacial fractures.[10] Mandibular and condylar fractures can be assessed using a combination of lateral oblique, transcranial, occlusal, and PA radiographs.[11]

Due to differences in geographical, cultural, and socioeconomic position, the etiology of maxillofacial fractures varies from one nation to another. In the present study, RTA was the common etiology for maxillofacial fractures consistent with the study conducted by R Balakrishnan et al. in Trivandrum. The study conducted by Adekeye,[10] Ravidran,[6] Hussain,[12] and Tan and Lim[13] also concluded that RTAs are the most prevalent reason for maxillofacial fractures in developing countries.[146] Despite the strict regulations put out by the government, the explanation for increased RTAs in Kerala is attributed to weak road infrastructure, negligence to traffic, and safety laws.

It was found in this study that about 34% of the two-wheeler riders were not helmet users and none of the pillion riders had used helmets, thereby increasing their incidence of facial fractures. It was also noticed that no brain injury resulted in patients who wore helmets.

The frequency of facial fractures in males was found to be greater. The male: female ratio was 4.03:1, which is considerably more than other studies probably due to the existing social system of the geographic area where males are more commonly involved in driving vehicles and outdoor activities compared to women. However, in another study by Adekeye conducted in Nigeria, a male: female ratio is found to be 16.9:1.

The age group between 21 and 30 years was more affected compared to the other age groups that were in concordance with other studies conducted by Melmed,[14] Rowe NL,[15] and Timoney.[1617] The younger age group was more affected due to the active energetic life style, more outdoor activities, and probably as they are more involved in reckless driving without the use of safety measures such as helmets. The number of fractures encountered in children is significantly less as the bones are highly elastic with a reduced volume of the PNS.

The most prevalent type of fracture noted in our study was the middle third fractures, followed by the lower third that was consistent with the study conducted by Ravindran and Ravindran Nair in Northern region of Kerala.[6] Midface region has the capacity of absorbing forces and acts as a cushion for any force transmitted to the cranium that is analogous to a “matchbox,” thereby protecting the brain and spinal cord. About 9.6% of the patients presented with both middle and lower third fractures. Among the middle third fractures, zygomaticomaxillary fractures were commonly observed followed by isolated maxillary sinus wall fractures as these areas absorb the forces transmitted and prevent it from being transmitted to the brain and other vital stricture; hence, these areas are termed as “crumble zone.” ZMC fractures were found to be common in a study conducted by Dibaie et al.[18] kindred to our study [Graph 1]. Among the mandibular fractures, condyle was most frequently affected followed by the parasymphysis region [Graph 2]. Any force or impact directed to the chin results in the transmission of the forces toward the condyle, making it more vulnerable for fractures.[19]

Graph 1

Percentage distribution of the sample according to type of fracture of Lower third (Mandible) fractures

Graph 2

Percentage distribution of the sample according to type of fracture of middle third fractures

Fractures were found to be more common on the left side than on the right side similar to studies by Ki-Su Jin et al.,[20] as most of our patients were right hand dominant and have a tendency to defend their dominant side, thereby resulting in more fractures on the left side.

The use of drugs and alcohol consumption was found to play a vital role in causing maxillofacial fractures. In our study, about 9.6% of the people with maxillofacial fractures were under the influence of alcohol that was considerably less compared to other studies by Lee et al.[21] O'Meara C et al,[22] Van Hout et al.[23] and Lee et al.[24] Owing to religious convictions and their ban on drinking, alcohol intake is perceived to be comparatively lower in the district of Malappuram. The reason for increased risk for fractures in alcoholics is alcohol impairs the mind and thinking capacity and delays the response time, making them defiant to traffic rules and the use of safety measures like seat belts and helmets.

CONCLUSION

The study has led to the conclusion that in the abovementioned geographical region, RTA posed to be the common etiological factor for maxillofacial fractures in which middle third fractures were predominant. Nonhelmet users (particularly pillion-riders) suffered more injuries compared to the helmet-clad riders. Males were affected more and a significant correlation of alcohol use and maxillofacial fractures were also observed. It can be concluded from this study that enforcement of traffic rules and legislation are required to decrease the incidence of RTAs, thereby reducing the risks of maxillofacial fractures. In Kerala, better infrastructure of the roads, stringent use of safety measures especially helmets even for pillion users, and educational programs should be implemented to reduce the incidence and severity of maxillofacial fractures. Especially among young people, public awareness and prevention campaigns should be carried out to educate them and thereby reduce the occurrence of maxillofacial fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.