A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India

Abstract: Background: The Department of Oral and Maxillofacial Surgery, D.A.V [C] Dental College and Hospital, Yamuna Nagar, Haryana, India conducted a study on patients with maxillofacial fractures in a time span of seven years (2003-2010). The purpose of this study was to evaluate their aetiology, incidence, patterns and different modalities employed for management. Methods: In this study, 740 patients with 1054 fractures were evaluated clinically and radiographically, based on which closed reduction and open reduction was undertaken. Review of patient records included: Age, sex, time, mechanism and etiology of injury, history of bleeding, unconsciousness and prior first aid, type of vehicle and use of preventive measures, type of fracture and treatment modalities. Results: Road traffic accidents accounted for highest number of fractures predominantly occurring in the age group of 21-30 years (38.3%)1,2. Males incurred more fractures with a male female ratio of 4.2: 1.Mandible was the most commonly fractured bone with parasymphysis being the commonest affected site.76.66% patients had associated head injury and 15.68 % had history of unconsciousness. Open reduction and internal fixation was the preferred modality for mandible whereas the mid face fractures were treated more often by closed methods. Conclusions: Injuries occurred more commonly in 20 – 40 age range with road traffic accident being the major etiological factor. Majority of the patients were driving two wheelers and most were under the effect of alcohol. Most of the injuries occurred during night and road traffic accidents (71.89%) were found to be the major etiological factor. Out of 532 road traffic accidents, 490 patients (66.2%) were on two wheelers, among whom 49(10%) were wearing helmet. In the mandible, fractures occurred most commonly in the parasymphyseal region (224, 30.2%), and out of the 314 fractures of the middle third showed, 155 (49.4%) ZMC. OPG was the most commonly advised X-ray. With regard to treatment modalities, 36.8% of all the mandibular fractures (740) were treated by closed reduction, 62.6% were treated using open reduction and 0.5% was under observation only.


Introduction
axillofacial region (MFR) involves soft and hard tissues forming the face extending from frontal bone superiorly to the mandible inferiorly. The face be-heavy reliance on road transportation and the increasing socioeconomic activities of the population. [1][2][3] Every 30 seconds someone dies on the world's roads. Annually over 1 million people die and over 25 million are injured or permanently disabled from road traffic injuries. 4 The primary cause of maxillofacial fractures throughout the world is road traffic accidents and assaults. 5 Telfer MR et al (1991) 6 conducted a study in United Kingdom, and reported that total number of patients with facial bone fractures had risen from 79 per annum in 1977 to 94 per annum in 1987, an increase of 20% which was highly significant, statistically. Number of patients injured in RTA had decreased by 34% while number of patients injured in assaults had increased by 47%. Other causes of maxillofacial fractures include falls, hit by animal, work related and sports related injuries.
In India inspite of the great impact of maxillofacial traumatic injuries on the patient's quality of life, there is inadequate information about the epidemiological characteristic of this problem. In this backdrop, the present study has been undertaken to evaluate (i) the etiology of trauma and incidence of fractures according to the cause and establish relationship between the cause and fracture pattern. (ii) The increase in incidence of trauma due to alcohol intake. (iii) The incidence of fractures with respect to two wheelers and four wheelers. (iv) The pattern of maxillofacial injuries sustained by helmet and nonhelmeted motorcyclists in cases of two wheelers and in those wearing seat belts in case of four wheelers. (v) To identify anatomical site of fracture and associated injuries, and (vi) to evaluate different modalities of treatment rendered.

Methods
The patients with maxillofacial fractures managed in the Department of Oral and Maxillofacial Surgery, D.A.V [C] Dental College and Hospital, Yamuna Nagar, Haryana, India in a time span of seven years (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010) were selected for the study. All patients were treated irrespective of age, sex, caste, religion and socioeconomic status. Patients were evaluated for any maxillofacial fracture by assessing clinically the displacement of fractured fragments, functional and cosmetic deficits, patient's age and patient's medical status. Exact determination of the site and pattern of bony injury was determined by correlating it radiographically using any of the following radiographs and CT scan as per indication the parameters on which patients were evaluated included.     Most of the injuries occurred at night (48.1%). Injuries occurred at mid day and morning with almost equal frequency (26.75%) and (25.13%) respectively. (Table 5) Based on statistical analysis (Chi-Square Tests) it was concluded that majority of the injuries occurred during night (48.1%), and based on Lindahl's classification of mechanism of injury, 7 9.3% patients were static individuals, 49.9% patients were moving and 40.8% patients were under combination group. (Table 6) Among the various etiological factors responsible for maxillofacial fractures, road traffic accidents (71.89%) were found to be the major etiological factor. (Table 7) Out of 532 road traffic accidents, 490 patients (66.2%) were on two wheelers, 28 patients (3.8%) on four wheelers and 14 (1.9%) were pedestrians. Out of these 490 patients on two wheelers, 374 patients (76.3%) were drivers and 116 (23.7%) were pillion riders. Out of 28 patients on four wheelers, 15 patients (53.6%) were drivers, 4 (14.3%) were front seaters and 9 (32.1%) were rear seaters. Out of 490 patients driving two wheelers, 49(10%) were wearing helmet. (Table  8) None of the pillion rider was wearing helmet. Out of 28 patients driving four wheelers, 9 (32.14%) were wearing seat belts. None of the front seater or rear seater passengers was wearing seat belts. (Table 9) Among the 740 patients, 26 (3.5%) were under the effect of alcohol. (Table 10) 664 patients reported history of oral bleed (89.7%), 59 patients (7.9%) reported nasal bleed and 14 (1.9%) had ear bleed. 0.4% patients (3) had no history of oral, nasal or ear bleed. (Table 11) Out of total 740 patients, 116 patients (15.68%) reported history of unconsciousness. (Table 12) Among 740 patients of maxillofacial fractures, total 1054 fractures occurred including 117 dentoalveolar fractures (11.1%), average 1.4 fractures per patient. The site distribution of the fractures showed 740 fractures in the mandible (70.2%) including dentoalveolar fractures. Rest 314 (29.8%) fractures were distributed in rest of the maxillofacial skeleton. (Table 13) In the mandible, fractures occurred most commonly in the parasymphyseal region (224, 30.2%), followed by condylar region (213, 28.78%). Among the condylar fractures 6.2% (46), were bilateral whereas 16.4% (121) were unilateral condylar fractures. Third most common site for the fractures was angle (147, 19.9%), followed by body (72, 9.7%), dentoalveolar (34, 4.5%) and symphysis (12, 1.6%). Least common fractures reported were ramal fractures (6, 0.8%) and coronoid fractures (6, 0.8%). (Table 14)    (4) Rear seater (9) 53.6% 14.3%     Data with regard to associated injuries in patients with maxillofacial fractures demonstrated that patients had associated injuries. Of these 115 patients (76.66%) had head injuries and 35 patients (23.33%) had orthopedic injuries. (Table 17) X -rays were advised to confirm the diagnosis of the fractures. OPG was commonly advised (71.3%) followed by IOPA (10.4%). SMV and PNS were done in 8.4% and 6.6% patients respectively. CT scan was done in 2.2 % patients and PA mandible in 1%. (Table 18) With regard to treatment modalities, 36.8% of all the mandibular fractures (740) were treated by closed reduction, 62.6% were treated using open reduction and 0.5% was under observation only. Among closed reduction group, 35.5% were treated using arch bars and other forms of interdental wiring while splints with circummandibular wiring were used in1.35%. (Table 19) Of the 314 middle third fractures, 48.4% were treated using closed reduction, 39.5% using open reduction, 12.1% using observation only. Among closed reduction group, arch bars and other forms of interdental wiring were used in 37.9%, splints in 1.2%, internal skeletal suspension in 3.8% and Gillie's temporal approach in 5.4%. (Table 20)

Statistical analysis
Pearson Chi-Square test was used to evaluate the association/significance between the different variables/parameters.
The association between the time of injury and incidence of trauma was highly significant (P=0.019; p<0.01) and between incidence of trauma and mechanism of injury was very highly significant (p<0.001).
The association between incidence of trauma and alcohol consumption was also significant (p=0.048; p<0.05).     Very high significance was observed when age was associated to mechanism of injury, type of passenger, alcohol consumption and incidence of trauma (p<0.001).
No significant association was found between the incidence of trauma to the type of vehicle or (p>0.05) and the mechanism of injury to helmet use (p>0.05).

Discussion
This study showed that the maxillofacial fractures predominantly occurred in the age group of 21-30 years (38.3%), followed by 31-40 years (20.2%) and 11-20 years (19.7%). These findings being similar with the previous studies. 8,9,10,11,12 The high incidence in 3rd decade of life might be due to the facts that people belonging to this decade are more active, energetic, take active participation in dangerous exercises and sports activities and mostly involved in violence. Men aged 21-40 years represent a group with intense social interaction and higher rates of morbidity, making them more susceptible to transport accidents and interpersonal violence. 13 In the age group 0-10 years, incidence of the maxillofacial fractures was 6% in the present study. This finding was close to some previous studies, one of which showed an incidence of 9%, 14 and 12% incidence 15 was reported in the other. The low incidence has been explained by the high elasticity of children's bones, the smaller face relative to head size and a decreased exposure to major trauma. 16 An incidence of 1.3% was noted for geriatric (>60 years) maxillofacial fractures in this study, probably as this age group is less active and less involved in outdoor activities. Similar incidence was found by Kadkhodaie MH in Iran 17 and Mahmeed BEA in Kuwait. 18 In men as compared to women the incidence of maxillofacial fractures had a ratio of 4.2: 1. This can be explained by the fact that men are more involved in outdoor activities and are also exposed to violent interactions as compared to females who are less exposed due to social and religious limitations. Male vehicle drivers also far outnumber females. 15 Similar ratio of 4:1 has been found in Finland by Salonem EM in 2010. 19 The analysis of the data on patients in the present study in reference to the time of the day exhibited that the most of accidents occurred at night (48.1%). Active nightlife and increasing number of clubs and pubs result in increase in traffic during night. Other reasons may be headlights glare at night and people are more drowsy and sleepy while returning late night from their jobs.
In our study considering the mechanism of injury, 49.9% of patients were moving at the time of injury and head on collision attributed to 40.8% of road traffic accidents, which was in accordance with a study conducted in Nigeria. 20 Head-on collision is at its greatest on roads with narrow lanes, sharp curves, and no separation of lanes of opposing traffic and high volumes of traffic.
According to this study, 71.89% maxillofacial fractures were caused by road traffic accidents followed by falls (16.2%) and assaults (5.6%). Road traffic accidents are the main cause of maxillofacial trauma. 21,22,23 The reasons for higher frequency of RTA in developing countries are inadequate road safety awareness, unsuitable road conditions without expansion of the motorway network, violation of speed limit, old vehicles without safety features, not wearing seat belts or helmets, violation of highway code and use of alcohol or other intoxicating agents. 22   Two wheelers were responsible for the majority of road traffic accidents in the present study (66.2% of road crashes), probably because two wheelers are very popular as a mode of transport due to their fuel efficiency and ease of use in congested traffic. 24 Only 10% people riding on two wheelers were wearing helmets in our study. In developing countries people avoid using safety measures. The frequency of wearing helmet in Tehran is 8.6%, 25 Vietnam 29.94% 26 and in Greece 20.02%. 27 In the present study, most of the patients injured in RTA are in Group III i.e. 21-30 years. These findings being similar with the previous studies. 28,10 This is due to the reason that people of this age group are inexperienced drivers; they are most likely to exceed speed limits and do not use proper safety measures. Of the total number of patients included in the study there were 464 male patients and 72 female patients, who reported with a history of RTA.
Fall from height was the second most common cause of maxillofacial trauma in this study, found in 16.2 % cases. This is similar to the study by Taiseer Al-Khateeb 8 who reported 20% incidence of maxillofacial injuries due to fall. Out of the total 119 patients who underwent trauma because of fall from height, 63 were females.
Sports related maxillofacial fractures occurred in 2.8% cases in this series. All the patients in this group belonged to 1st to 4th decade of life. This can be attributed to higher interest in sports in early childhood and young age. 29 According to the site of fracture, in 70.2% cases mandible was involved as compared with 29.8% of middle third of facial skeleton fractures in this series. These results are similar to the previous studies in Jordan, 8 UAE, 15 Bulgaria 30 and Tanzania 23 where mandible was more involved than the middle third. (Fig 1,2, 3,4) Mandibular fractures (68.7%) accounted for highest number of fractures due to RTA followed by middle third fractures (31.3%) in our study. Similarly in sports related injuries , mandibular fractures (87.5%) were more common than the middle third fractures (12.5%)Mandible, being the most prominent bone in face, is often fractured more than the strongly supported middle third of the face. 16 (Fig 5,6) In the present series, among the mandibular fracture sites, parasymphysis (30.2%) was the most common fracture site followed by the condyle (28.78%). The location of fracture site appears to be directly related to the cause of injury in some instances and probably reflects the direction from which force was applied to the mandible. 15   In our study, in middle third fractures, ZMC (49.4%) was most commonly involved. This is because of the prominent positions; zygomatic bone and nasal bone are more vulnerable to trauma. However in our study, there was less involvement of nasal fractures (1.3%). This was may be due to the reason that patients with nasal fractures often seek advice from ENT specialist rather than maxillofacial surgeons.
The incidence of associated injuries in the present study was 20.3%. Most common associated injury noted in our study was head injury (76.66%). This was similar to UAE studies in which associated injuries were 22.2% and with Nigerian series which reported 23% of associated injuries. 32,23 However more associated injuries recorded by Al-Khateeb et al in UAE (41%) 10 and Schaftenaar E et al in Netherland (51.5%) 23 were attributed to the severity of trauma.
Out of 740 patients, 116 (15.68%) patients gave history of loss of consciousness and CT scan was done in 2.2% of patients in the present series.
Before reporting to our institute, 79.5% patients in our study took first aid from a local practioner or civil hospital. In our study most of the patients (99.6%) having maxillofacial trauma had history of bleeding (oral-89.7%, nasal-7.9% and ear-1.9%). Patients have a tendency to rush to a nearest doctor to get the bleeding arrested.
Several methods of closed reduction were used in the treatment of mandibular fractures such as Ehrich's arch bar, other interdental wirings and splints. Out of 740 mandibular fractures, 273 (36.8%) and out of 314 midface fractures, 152 (48.4%) were treated with closed reduction in our study. No complications concerning occlusion and mouth opening were encountered in these patients. In developing countries people prefer closed reduction than open reduction. 15 In the past 15 years, plate osteosynthesis has become popular in the management of facial fractures and in the treatment of mandibular fractures. 33 Surgeons prefer it because it offers stable and precise anatomical reduction of fragments, allows immediate recovery of function as it has no IMF, shortens the period of bone healing and decreases the recovery period. Despite the obvious advantages, it has not become popular in many developing countries mainly because of cost factors. However, 55.7% of all maxillofacial fractures in our series were treated with open reduction and internal fixation. A higher proportion of fractured mandibles were treated surgically (62.6%) than were middle third (39.5%). Routinely, patients treated with ORIF were placed in inter maxillary fixation only intra-operatively. IMF was then released in all except for the cases which had concomi-tant condylar fractures, planned to treat conservatively with arch bars and IMF.
In our institute, open reduction and internal fixation using miniplates is the most preferred treatment plan for maxillofacial fractures. The technical and functional advantages of miniplate osteosynthesis over maxillomandibular fixation including the ease of use, precise anatomical reduction, limited or complete avoidance of maxillomandibular fixation, functional stability and improved mouth opening have made it more preferable.

Conclusion
Unlike in most developed countries where assaults have replaced road traffic crashes as the major cause of the injuries, in India no apparent shift from road traffic crashes as the leading cause of maxillofacial injuries was observed. Injuries have causes; they do not simply befall us from fate or bad luck. Since no magic pill is envisaged for the prevention of road traffic crashes, we need to take good stock of all the tools at our disposal, and to get down to what the developed nations have done to reduce road traffic crashes. Therefore, an awareness campaign to educate the public about the importance of restraints and protective seatbelts in cars and motorcycles should be championed. These findings should also alert the authorities, particularly the government and the