A face is a unique component of an individual and helps in his/her identification. The upper third of the Facial skeleton is formed prominently by the frontal bone, followed by the middle third, which commences just below the frontal bone and terminates at the level of the upper teeth. The mandible is dictated by the lower third. Maxillofacial trauma includes injuries to the hard and soft tissues and bony injuries of the head and face, which can be closed or open. Trauma to these regions may be in the form of abrasion, laceration, contusion, hematoma, avulsion, burn, and bone fractures [1]. Road traffic fatalities have been increasing at approximately 8% annually for the last ten years and are the leading cause of morbidity and mortality worldwide. [2] With over one million people dying and over 25 million injured or permanently disabled from road traffic injuries [3]. The primary cause of maxillofacial fractures throughout the world is road traffic accidents [4]. Among the injuries caused by Road traffic accidents, head injury can lead to morbidity and mortality as compared to other injuries and most of these have associated Facial fractures [5]. The maxillofacial region involves soft tissues and facial bones extending from the frontal bone superiorly to the mandible inferiorly. Maxillofacial trauma refers to injuries of the facial skeleton, soft tissues, and viscera injuries of the face. It is also known as facial orthopedics. The incidence of maxillofacial fractures varies widely among countries. The large variability in reported incidence and etiology is due to a variety of contributing factors, including environmental, cultural, and socioeconomic factors [6]. If not properly managed, maxillofacial fractures can result in complications such as malunion, infection, non-union, CSF leak, malocclusion, chronic sinusitis, TMJ ankylosis, facial asymmetry, and disfigurement. The management of facial fractures is widespread across the disciplines of oral surgery, plastic surgery, and otolaryngology [7]. Because of the comprehensive training in head and neck anatomy and physiology, plastic surgeons are uniquely equipped to best deal with these injuries. 5 Hence, this study aimed to investigate various patterns of maxillofacial injuries and their complications. The current study aimed to determine the clinical presentation, management, and outcome of maxillofacial injuries.

This prospective study was done in the Department of Plastic and Reconstructive Surgery, Gandhi Medical College and Hospital, Secunderabad, Telangana from May 2022 to October 2024. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants included in the study after explaining the nature of the study in vernacular language.

One hundred and fifty patients with maxillofacial injuries following road traffic accidents, industrial accidents, sports injuries, falls from height, assault, animal/human bite presenting to the Emergency Room or outpatient or referred by a neurosurgeon after attending head injury or ruling out brain parenchymal injury and managed in the department of Plastic and reconstructive surgery of Gandhi medical college were included in the study.

 Inclusion criteria

All patients with maxillofacial injuries were admitted to the Department of Plastic and Reconstructive Surgery of Gandhi Hospital, during the study period.

Exclusion criteria

1. Facial injuries secondary to burns.

Method of Collection of Data: All patients presenting to the Emergency Room or outpatient or referred by a neurosurgeon and Department of Plastic and Reconstructive Surgery with suspected maxillofacial fractures, were stabilized and after obtaining consent, were included in the study and were assessed on the following parameters. Mode of injury was enquired into road traffic accidents, assault, and fall from height. Clinical history was taken about symptoms of maxillofacial injuries. Altered bite Inability to open the mouth Double vision Nasal or oral bleed Paresthesia over the face

 Clinical Examination: All patients then were thoroughly examined to rule out associated injuries after the preliminary survey. A detailed examination for any facial soft tissue injury, of eyelids, ears, nose, tongue, facial nerve, or loss of soft tissues, was performed. The facial skeletal framework was examined for any deformity, bony crepitus including occlusion. Oral and nasal cavities were examined in detail and all positive findings were documented. All patients underwent radiographic evaluation either by plain radiograph AP view, Water's view, lateral oblique view, or computerized tomography scan of the Head and Face axial cuts to r/o brain injury, coronal cuts to rule out facial injuries 3D reconstructions to rule out or to study the patterns of maxillofacial fractures or Orthopantogram to look for mandible.

 CT Technique: The fracture detected on CT examination was classified according to the region involved.

All patients received were resuscitated and stabilized in airway, breathing, and circulation. A compromised airway in patients is secured by endotracheal intubation or tracheostomy. Bleeding was controlled and volume expansion was accomplished by blood transfusion, blood substitutes, or intravenous fluids as indicated. Tetanus toxoid (TT), Antibiotics and analgesics were administered to all patients. All contaminated wounds were thoroughly irrigated and cleaned with antiseptic solutions. Soft tissue injuries were managed appropriately by simple wound dressings or suturing. Epistaxis, which could not be managed conservatively, was treated by anterior or posterior nasal packing depending on the site of the bleed. Anterior nasal packing was done using tobramycin-impregnated ribbon gauze packs. Posterior nasal bleeds were controlled using a Foley catheter. The packs were removed after a period of 48 hrs. Frontal bone fractures are elevated by a bi-coronal approach or through the scar and managed with ORIF with or without mini plates.

Nasal bone and septal fractures were reduced using Walsham's forceps and Asch's forceps under local or general anesthesia after the patient got worked up. The nasal splint was used to immobilize the reduced fragments. Depressed Zygoma fractures managed by gillies’ elevation or keens approach, comminuted fractures managed by ORIF with mini plates. Interdental wiring /Inter maxillary fixation was used as a temporary stabilization technique in unstable maxillary and mandibular fractures. General anesthesia with nasal intubation was done for fractures of the maxilla and mandible oral intubation for zygoma and nasal bone fractures oral intubation was converted to submental intubation in pan-facial fractures.

Displaced fractures of the maxilla and mandible were managed by open reduction and internal fixation with Stainless steel mini plates and screws depending on the location and severity of the fractures. Fractures were exposed with gingivobuccal incision or with an external skin incision. Followed by IMF application for three weeks then eyelets/arch bar removal after two weeks.

Following discharge, all patients were evaluated regularly for a period of two months. The first week is for wound inspection, the second week is for suture removal, and to third week is for checking the position of occlusion/IMF application for IMF removal. After six weeks for arch bar/eyelet removal. Patients were evaluated clinically and radiologically or both for complications such as Secondary wound infection, Malocclusion, Non-union, Implant exposure, and Discharging sinuses. Patients with complications managed accordingly with admission again addressed infected implant for removal of the implant, malocclusion for reapplication of IMF, or redo ORIF.

In our study, the maximum number of patients were adults in the age group of 21-30 years (38%). The Mean age of the cohort was 31.4 ± 8.6 years. Our study included 138 males and 12 females. The male-to-female ratio is 9: 1. In our study population 16 patients had soft tissue injuries out of the 16 patients 7 patients had associated facial bone fractures which were operated with ORIF. 7 patients out of the 9 with soft tissue injuries alone were treated with suturing of the wounds 2 patients required flap cover. One patient with superiorly based nasolabial flap+ SSG for loss of middle 3rd of the upper lip and another patient with Mustarde flap for 50% loss of right lower eyelid.

Radiological Evaluation: All patients included in our study were evaluated by CT scan of the head and facial skeleton and the pattern of fractures of maxillofacial fractures was studied. In addition to the CT scan, plain radiographic evaluation was used in patients for the patient's post-op follow-up for suspected malocclusion with OPG and x-ray skull lateral oblique, x-ray skull lateral view for nasal bones, X-ray PNS with AP view, and Water’s view.

N=143 patients out of 150 have facial bone fractures of the 143 patients 36 patients have isolated fractures in one zone of facial bones. 31 patients have more than one fracture in one zone. N=76 patients have one or more fractures in more than one zone The commonest facial bone fracture was the mandible 91 patients (60.6%) in 143 patients, followed by nasal bone and orbit (Table 1).

Table 1: Pattern of facial fractures

Frontal bone fractures 3 patients had frontal bone fractures. The anterior table alone was fractured in 3 patients. Two patients with depressed frontal bone fractures were managed with bone grafts. One patient with iliac crest bone graft another with rib graft. Patients with rib grafts got infected later needed removal and cover with a paramedian forehead flap cover Orbital wall fractures 41 patients had orbital wall fractures (Figure 1).

Figure 1: Pattern of facial fractures

N=21 patients in our study had infraorbital margin fractures they were managed with ORIF 1 patient needed orbital floor reconstruction with titanium mesh another patient floor reconstruction was done with an iliac crest bone graft. Displaced fractures involving the roof, medial wall, and lateral wall were managed with ORIF (Table 2).

Table 2: Orbital wall fractures

Nasal bone and Naso-orbito-ethmoid (NOE) fractures 16 patients had nasal bone fractures; 2 patients had NOE fractures. Nasal bone fractures required closed reduction and nasal packing with external nasal splint NOE fractures one patient with type 3 was managed with ORIF and transnasal wiring another patient with bilateral type 3 was managed with bilateral canthonasal suturing (Figure 2).

Figure 2: Nose and NOE Fractures

N=44 patients had a zygoma fracture. These included 7 fractures of the zygomatic arch 38 fractures of the body of zygoma and comminuted fractures in patients. The zygoma tripod fractures are present in 13 patients. Fractures having open wounds, diplopia, associated with other facial bone fractures, and enophthalmos were operated on (Table 3).

Table 3: Showing the pattern of Zygoma fractures

Five patients with zygoma fracture required Gillie’s elevation approach for closed reduction and Others required an ORIF approach with gingivobuccal incision or external skin incision. Single fractures managed with single point fixation comminuted fractures needed two. Three-point fixation was done for zygoma tripod fractures (Table 4).

Table 4: Zygoma Fracture Management

In this study, Maxilla is fractured in our study (47 patients). Among patients, 28 patients had unilateral maxillary fractures and 9 had bilateral fractures. Central split fracture present in 2 patients. Comminuted fracture maxilla was present in 8 patients. N=45 patients with maxilla fractures managed with an arch bar or eyelets application followed by ORIF with Gb sulcus approach and fixation with mini plates followed by intermaxillary fixation. One patient with left zygoma tripod fracture, right maxilla Fracture, and right nasal bone Fracture managed with eyelets and IMF application, and another patient with maxilla central split fracture managed with eyelets and IMF application (Table 5).

Table 5: Maxilla fractures management

Mandible Fractures occurred in 91 patients. Most common in our study. Parasymphysis fractures were commonly encountered (42 cases).  24 patients had a single fracture of the mandible. N=29 patients had more than one fracture in the mandible (Figure 2).

Figure 2: Location of mandible fractures

Except for condylar and sub-condylar fractures of the mandible, all others required open reduction and internal fixation with plates and screws. 86 patients managed with Arch bar/eyelets application followed by ORIF with Gb sulcus approach or external skin/sutured wound exploration. One pediatric patient managed with a cap splint application. One patient with Parasymphyseal and another patient with Symphysis fracture managed with eyelet application with interosseous wiring. One patient with PS and body fracture, one with condyle fracture, another with angle of mandible fracture managed with Arch bar +IMF application (Table 6)

Table 6: Mandible fractures management

Facial nerve Palsy: One patient in our study developed post-traumatic facial palsy of lower motor neuron type and was managed by exploration and sural nerve grafting. Fourteen patients were treated with suturing of the wounds. Four patients required split-thickness skin grafting. 3 patients required flap cover for the soft tissue defects. Seven patients with nasal bone fractures underwent closed reduction. 116 patients underwent Open reduction and internal fixation with various sizes of mini plates. Interosseus wiring was done for six cases Conservative management with arch bar/eyelets + IMF application was done for 4 patients.

Figure 3: Overall interventions used in the cases of the study

Complications: 5 patients in our study developed complications following maxillofacial injury during the three-month follow-up period. Infection was the most common complication in our study (3 patients). Two patients with mandible implant infections were managed with implant removal and one patient with a frontal bone fracture implant was managed with implant removal and a paramedian forehead flap cover. Malocclusion was documented in 2 cases of mandible fractures. One case was managed with redo ORIF another patient was managed with IMF application.

Maxillofacial injuries are diverse in nature due to socioeconomic, cultural, and environmental factors. Road traffic accidents, however, remain one of the predominant causes of facial trauma in both developed as well as developing countries which has been reported by several studies [8-11].  In the current study, we found that RTAs were the common cause of maxillofacial injuries it was found to occur in males with 91% prevalence. The male-to-female ratio of maxillofacial injuries in this study was 9:1, in concordance with findings by Kapoor et al. [12] and Singh et al. [10] The mean age of the cohort in our study was 31.4 years with a peak incidence of 21 – 30 years of age group similar trends have been reported by other studies [13-15]. The mean age was 31.4 years, with the peak incidence in the 21–30 age group, a trend seen across multiple studies in this field [16-18]. In this study, we found that soft tissue injuries were less frequent (10%) compared to other studies [13-19]. N=16 patients had soft tissue injuries, and N=7 also had associated facial bone fractures. These injuries required plastic surgical intervention. We evaluated all 150 cases with CT scans and plain radiographs (X-ray PNS or OPG) in 141 patients.  CT scan with 3D reconstruction was preferred for complex mid-face fractures associated with head injuries.  Whereas the plain radiographs were more suitable for isolated fractures but may have limitations due to soft tissue edema [20]. In a similar study by Hwang et al. [21], they reported that only 82% of nasal fractures were identified using standard radiographs. Frontal bone fractures involving the anterior table were found in 3 patients of this study which is in contrast with findings of other studies where they reported 63% of cases with anterior table and 33% bi-table involvement and 3% of cases with posterior table fractures [22]. In this study, we managed the frontal sinus fractures with native bone adjustments or iliac bone grafts. One case of graft-related infection occurred which required debridement. In the current study, we found orbital wall fractures in 26.6% of cases. The orbital floor was involved in 61.85 of these cases. These results are in contrast with other similar studies where they reported that the most frequent involvement was by a medial wall of the orbit [23]. Zygoma fractures occurred with a frequency of 29.3% of our cases. The fracture of the body of the zygoma and comminuted fractures were commonly involved. Similar findings have been reported by Menon et al. [17] and Obuekwe et al. [24] in their studies respectively.

In this study, maxillary fractures were reported in 31.3% of cases. Most of the cases were unilateral and showed signs of occlusal disturbances. They were commonly managed with open reduction and internal fixation (ORIF) using 1.5 mm L-plates. Nasal bone fractures occurred in this study with a frequency of 10.6% mostly presenting with nasal deformity and breathing issues. Management of these cases was done with closed reduction and splinting and in one case septorhinoplasty was done. In this study, we found Naso-orbito-ethmoid (NOE) fractures were found in two cases. Mandibular fractures were common in 60.6% of cases this is in agreement with the findings of Kapoor et al. [12] and parasymphysis was the site commonly involved in mandibular fractures in 46.1% of cases. Similar findings were also reported by Singh et al. [10] and other studies where RTA was the primary cause of mandibular fractures. Most of the cases of this study were treated with arch bars/eyelets and ORIF with few patients requiring conservative management and splints. Postoperative complications included infections in two cases and malocclusion in two patients. The complication rate was 5%, lower than the 7–29% range reported in other studies [12, 13] Malocclusion (2%) was the most common complication, consistent with Ozkaya et al. [8] Infections (2.5%) were managed effectively with antibiotics, with no cases of osteomyelitis. Ahmed et al. [25] reported a 5.6% infection rate. Prophylactic antibiotics likely contributed to better outcomes. Zallen et al. [26] observed a 6.25% complication rate with antibiotics compared to 50.3% without. Malocclusion was managed with either redo ORIF or conservative IMF. Brasileiro et al. [27] found a 19% malocclusion rate in maxillofacial trauma patients. Pediatric fractures were managed conservatively with dental impressions and IMF using circummandibular/ circumzygomatic wiring. Surgical protocols included nasotracheal intubation, gingivobuccal or skin incisions, and fixation with stainless steel mini plates (2 mm for mandible, 1.5 mm for zygoma/maxilla).

Within the confines of this study, we found that maxillofacial trauma commonly occurs in young adult males and is frequently caused by RTAs. Mandibular fractures are most commonly involved, followed by maxillary bone, zygomatic bone, and orbital wall fractures. CT is the best and most accurate diagnostic tool for maxillofacial complex injuries. Most cases are managed with open reduction and internal fixation (ORIF). The complication rate in the present study was relatively low. Early intervention with a tailored treatment plan contributes to effective management. This study reinforces the importance of a structured and multidisciplinary approach to managing maxillofacial injuries

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