| Abstract|| |
Background: Maxillofacial fractures are common following trauma and show varying epidemiology and demographics. Aims: To describe the pattern of maxillofacial fractures outlining the etiological spectrum, fracture characteristics and treatment outcomes in our local setting. Settings and Design: This descriptive retrospective study was conducted at the Plastic Surgery Department, of our Institute in Pondicherry from January 1, 2007 to December 31, 2013. Materials and Methods: All adult and pediatric patients presenting with confirmed maxillofacial fractures were included. Results: A total number of 432 patients with 656 facial fractures presented during the study period. Male to female ratio was 10:1. Road traffic accidents (87.9%) were the most common mode of injury with Orbitozygomatic fractures predominating (55.7%). Associated injuries were observed in 30.3% of patient's. 66.2% of patients were operated, and 33.8% were treated conservatively. Conclusion: Increasing awareness and improved legislation are required to combat the trend of increased maxillofacial fractures.
Keywords: Fractures, maxillofacial, trauma
|How to cite this article:|
Ramdas S, Lingam PP, Sateesh S. Review of Maxillofacial Fractures in a Tertiary Care Centre in Puducherry, South East India. Ann Trop Med Public Health 2014;7:100-4
|How to cite this URL:|
Ramdas S, Lingam PP, Sateesh S. Review of Maxillofacial Fractures in a Tertiary Care Centre in Puducherry, South East India. Ann Trop Med Public Health [serial online] 2014 [cited 2021 Apr 14];7:100-4. Available from: https://www.atmph.org/text.asp?2014/7/2/100/146388
| Introduction|| |
Maxillofacial fractures are a common presentation following trauma either in isolation or as part of multiple injuries. The management of fractures of the human face is therapeutically challenging and usually involves different specialties. In addition, these injuries may cause serious functional, psychological, and cosmetic disabilities. 
The pattern and etiology of maxillofacial trauma differ from one country to another and even within the same region depending on the prevailing socioeconomic and cultural factors.  Various studies have been carried out in different countries including different parts of India to understand the demographics and epidemiology so as to improve management and have an impact in creating public awareness and strengthening legislation to prevent such fractures. ,,,,
Puducherry, on India's South East coast, has become a tourist hub due to its proximity to cities like Chennai and Bengaluru. This has inadvertently lead to an increase in the number of trauma cases related to road traffic accidents (RTAs) particularly along the East Coast Road (ECR), which is a scenic highway leading from Chennai. Our hospital is situated near the ECR and manages a number of maxillofacial fractures related particularly to RTAs.
This study was carried out to determine the demographic profile, etiology, and injury characteristics of maxillofacial injuries at our teaching hospital. Studies from Puducherry analyzing maxillofacial fractures are few.
Aim and objectives
The aim of this study was to describe our own experiences in the management of maxillofacial injuries outlining the etiological spectrum and injury characteristics of these injuries in our local setting.
The study may provide the basis for the establishment of treatment guidelines and planning for preventive strategies.
| Materials and Methods|| |
This descriptive retrospective study was conducted at the Plastic Surgery Department, of our Institute, from 1 st January 2007 to 31 st December 2013. All the adult and pediatric patients presenting with confirmed maxillofacial fractures were included. The confirmed diagnosis of maxillofacial fractures was based on clinical examination correlated with relevant radiographic examination. Age, sex, presentation, etiology, associated injuries and treatment modalities undertaken in these patients were recorded.
| Results|| |
The total number of patients who presented with facial fractures during the period 2007-2013 was 432 with a total number of 656 facial fractures. Complete data was available for 429 patients and was considered for analysis [Figure 1].
There were 393 male patients and 39 female patients.
The proportion of males and females were 91.1%, 8.9%, respectively with a male to female ratio of 10:1.
The maximum number of patients were in the age group of 21-30 years (40.7% n = 175) whereas only 8 patients were <12 years of age [Figure 2].
The most common mode of injury for facial fractures was RTAs (87.9%, n = 377), followed by falls (5.4%), assault (3.5%), and occupational injury (1.4%). Sport injury constituted only 0.7% of the facial fractures.
Road traffic accident was the most common cause (72-96%) for facial fractures every year during the period of 2007-2013 with an average of 87.9% [Figure 3].
The incidence of facial fractures has increased over the years, and the proportion of RTA specific facial fractures has also increased over the years (72-96%). Among those with RTA specific facial fractures, the most common vehicle used for transportation by majority of them was a motorized two-wheeler (81.9%). The other modes of transport used were car/lorry (8.5%), and bicycles (3.7%). Pedestrians with facial fractures were only 5.9%.
Motorized two-wheeler had been the most common mode of transport among those with facial fractures every year (71-88%) during the period of 2007-2013 [Figure 4].
|Figure 4: Type of vehicle involved in facial fractures associated with road traffic accidents|
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Among those who had been riding two-wheeler and with a history of RTA (n = 290), no second vehicle was involved in 35.2%, two-wheeler in 40.7%, four-wheeler in 17.9%, and others were 6.2%. The others included were animals such as dog and cow, (2.8%), non-living things such as tree, etc. (2.1%), cycle (0.7%), and bullock cart (0.7%).
Among those with no second vehicle involvement (n = 102), skid and fall were reported by 94.1% of the patients.
None of the patients who had facial fractures on two wheelers due to RTA reported of helmet use at the time of an accident.
Associated injuries were observed in 30.3% of patients and were related to neurosurgery (62.3%), orthopedics (26.9%), ophthalmology (6.2%), and general surgery (4.6%).
Majority of the facial fractures were orbitozygomatic fractures 55.7% followed by mandibular fractures (41.2%), maxillary fractures (28.6%), nasal fractures (15.3%), and frontal (11.8%) fractures.
Two-thirds (66.7%) of the patients had single fractures and one-third (33.3%) had multiple fractures. Among males, 65.7% had single fractures, and 34.2% had multiple fractures, whereas among females, it was 76.3%, and 23.7%, respectively.
Of the total facial fractures, 66.2% were operated, and 33.8% were treated conservatively for fracture management. Facial fractures that required surgical intervention had increased over the last 4 years.
| Discussion|| |
The present study was conducted to retrospectively assess the pattern of maxillofacial fractures in a tertiary care center close to the ECR in Puducherry. Various epidemiologic factors and the type of maxillofacial fractures were assessed.
The age distribution pattern in maxillofacial fractures showed that although people of all ages were affected; the peak incidence of 40.7% was observed in the age group of 21-30 years. Individuals in the extremes of life were found to be least affected. These findings are in accordance with a number of previous studies in other parts of the world , as well as in different regions in India. ,,,, It has been postulated that the age group of young adults have an active lifestyle and are the predominant users of vehicles making them vulnerable to vehicular accidents as well as falls and assault-related injuries. An additional contributing factor especially in fractures due to RTAs was not using helmets. None of the patients who had facial fractures on two wheelers due to RTA reported of helmet use at the time of an accident.
The gender distribution revealed a male preponderance in all the age groups. The male:female ratio in our study (10:1) was similar to that reported by Kamath et al.  and Al Ahmed et al.  however, higher than what has been reported by Jerius,  and El-Sheikh et al.,  and other authors from India like Bali et al.  and Gandhi et al.  This may be due to the fact that there are more male drivers then female drivers in Puducherry. The association of alcohol with vehicular accidents is also seen predominantly in males. Positive history of alcohol consumption was present in one-fifth of the injured patients (20.5%), of which 94.3% had a history of RTA. 22.02% of those who had RTA specific facial fracture gave a positive history of alcohol consumption at the time of an accident.
Regarding the etiology of maxillofacial fractures we found the commonest mode of injury was RTAs (87.9%, n = 377). In fact, road traffic accident was the most common cause for facial fractures every year during the period of 2007-2013 with an increasing incidence from 72% to 96% over the years. In developing countries, such as ours, road traffic accident is generally believed to be the most common cause of facial trauma and this has been confirmed by some of the previous studies. ,,,, However Luce et al.  from United States reported association of RTA in 65% cases of facial fractures. Lida et al.  from Japan also reported similar findings regarding etiology of facial fractures.
In a recent study from East Delhi Kapoor and Kalra however reported interpersonal assault as the most common etiology behind maxillofacial injuries. This may be indicative of a changing trend in some parts of India. They postulated that two factors have been consistently associated with facial injury due to alleged assaults, namely alcohol and unemployment.  Arslan et al. reported that the most common cause of maxillofacial injuries in Ankara, Turkey was violence, accounting for 39.7% of the sample, followed by falls 27.9% and RTAs 27.2%. 
The other etiological factors in the present study included falls (5.4%), assault (3.5%), and occupational injury (1.4%). Sport injury constituted only 0.7% of the facial fractures in the present study. Gassner et al.  from Innsbruck found that 31% of cranio maxillofacial trauma cases were related to sports injury. This is indicative of a lifestyle not common in Indian cities so far.
Among those with RTA specific facial fractures, the most common vehicle used for transportation by majority of them was a motorized two-wheeler (81.9%). Motorized two-wheeler had been the most common mode of transport among those with facial fractures every year (71-88%) during the period of 2007-2013.
This is similar to the findings from Chennai by Subhasraj et al.  who reported that motorcycles were involved in 62% cases of RTA causing facial trauma. As the vehicular traffic in our city roads increase, more people are relying on smaller vehicles particularly two wheelers to go about. Public transport measures need to be improved to overcome this. The other modes of transport used were car/lorry (8.5%), and bicycles (3.7%). Pedestrians with facial fractures were only 5.9%.
Among those who had been riding two-wheeler and with a history of RTA (n = 290), no second vehicle was involved in 35.2%, two-wheeler in 40.7%, four-wheeler in 17.9%, and others were 6.2%. The others included were animals like dog, cow, etc. (2.8%), non-living things such as tree, etc. (2.1%), cycle (0.7%), and bullock cart (0.7%). Among those with no second vehicle involvement (n = 102), skid and fall were reported by 94.1% of the patients.
None of the patients who had facial fractures on two wheelers due to RTA reported of helmet use at the time of an accident. Another study from Yamunanagar, India reported that only 10% use of helmets.
Although legislative measures are in place to helmet use, implementation of such rules needs to be stringent, and awareness regarding the use of helmets as protective gear should be spread among schools and colleges targeting the vulnerable age group in their 2 nd and third decades.
A majority of the facial fractures in this study were orbitozygomatic fractures (55.7%) with most presenting as isolated single bone fractures, followed by mandibular fractures (41.2%), maxillary fractures (28.6%), nasal fractures (15.3%), and frontal (11.8%) fractures. Kamath et al.  had similar findings in their study as did Gandhi et al.  and Subhasraj  from Chennai. The study by Al Khateeb et al.,  have found zygomatic complex as the most common site of middle face injury, which is coinciding, with the results of this study.
According to Vetter et al.  the cheekbone is susceptible to injury when an impact is directed laterally upon the upper face whereas the mandible, owing to its prominent size and position, is more often affected when the impact is directed to the lower face. Le et al.  believed that the midfacial skeleton, especially the nasal bone stands a high risk of fracture following trauma due to its relative structural weakness and prominent location on the face.
Among bony fractures, the mandible has been reported to be the most frequently fractured bone in most studies like of Lida et al.  in Japan, Motamedi  in Iran, and of Erol et al. in Turkey. Various Indian authors have documented similar findings. Sandhu et al.  reported an incidence of 64.3% mandibular fractures and Shenoi et al.  58%. The high incidence of isolated mandibular fractures in studies all across the world may be attributed to the prominence of the lower jaw and to its exposed anatomical position on the face. The mandibular condyle is a relatively weak anatomic area, which often gets fractured following a blow to the chin as the force of the blow is transferred through the mandibular body onto the condyle. Furthermore, the abrupt change in direction in the region of the angle of the mandible (from a relatively thicker body to a comparably thin ramus) also increases the chances of mandibular fracture following facial trauma.
In our study, 66.2% of the total fractures were operated, and 33.8% were treated conservatively. Facial fractures that required surgical intervention had increased over the last 4 years. Operative modality commonly used in our setup is both open reduction with plate fixation and closed reduction with intermaxillary fixation using either arch bars or screws.
This is consistent with the studies conducted by Erol et al.  and Ansari et al.  Plating with intermaxillary fixation was the most commonly opted treatment procedure in the study by Al Khateeb et al. The treatment selected may differ as there are many factors like cost of treatment, affordability by the patient, feasibility in the hospital, doctor's decision and skill, patient's willingness to avail the treatment advised-all of which may vary from one country to another.
Associated injuries were observed in 30.3% of patients by and were related to neurosurgery (62.3%), orthopedics (26.9%), ophthalmology (6.2%), and general surgery (4.6%). Concomitant ophthalmic injuries occurred in 30.52% of cases in the study by Kamath et al.  The incidence of associated injuries in a study by Bali et al.  was 20.3%. Most common associated injury noted in their study was the head injury (76.66%) similar to our findings.
Various epidemiologic and demographic characteristics of facial injuries have been highlighted in this study. This is perhaps the first study in Puducherry, which assesses the profile of maxillofacial fractures in this region. More elaborate prospective surveys may further corroborate the findings of our study and help prepare more reliable preventive and health care measures against maxillofacial trauma.
| Conclusion|| |
Road traffic accidents are the main etiological factor for facial fractures in our center. Males in the second decade are particularly affected and alcohol as well as not wearing helmets seems to be contributory factors. It is also interesting to note that most of the vehicles involved were two wheelers. Increase in the number of cases of maxillofacial fractures indicates an alarming trend and unless awareness is created, and legislation imposed strictly the trend will remain.
| Acknowledgment|| |
Dr. Bridgette Akila, Tutor, Department of Biostatistics, Pondicherry Institute of Medical Sciences for help with statistical analysis.
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Department of Plastic, Reconstructive and Microsurgery, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry - 605 014
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]