British Journal of Oral and Maxillofacial Surgery (1988) 26, 430-434

0 1988 The British Association of Oral and Maxillofacial Surgeons

FACIOMAXILLARY FRACTURES IN NORTH INDIA

A STATISTICAL ANALYSIS AND REVIEW OF MANAGEMENT

C. P. SAWHNEY and R. B. AHUJA*

Department of Plastic Surgery, Postgraduate Institute of Medical Education and
Research, Chandigarh, India

Summary. An analysis of the incidence of facial fractures and their combinations is presented along with
an evaluation of our techniques of fracture reduction and fixation. Two hundred and sixty two patients
with facial fractures treated between January 1982 and December 1983 at the Postgraduate Institute of
Medical Education and Research, Chandigarh, form the basis of this study. Simple methods have been
used for reduction and fixation for the last 20 years without any major modification, as they have
provided satisfactory results. Road traffic accidents are the leading aetiological factor in both sexes.
More than 75% of the cases were in the 16-45 year age group. The mandible was the most frequently
fractured bone. Contrary to previous reports we found that the parasymphseal region was more
commonly fractured than the subcondylar region. More than 50% of the maxillary and zygomatic
fractures were a part of the panfacial group. Orbital and nasoethmoidal fractures were relatively
uncommon.

Introduction
The changing socio-economic status of our country and the increasing number of
faciomaxillary fractures coming to our emergency service prompted us to review
our cases; to analyse the incidence of facial fractures and their combinations; and to
evaluate our techniques of reduction and fixation. A 2-year-period from January
1982-December 1983 provided us retrospectively with our data.

Patients and methods

Two hundred and sixty two patients with facial fractures admitted to the
Department of Plastic and Maxillofacial Surgery of the Postgraduate Institute of
Medical Education and Research, Chandigarh between January 1982 and
December 1983 form the basis of this study. This Institute, in addition to receiving
local patients, also has patients referred from several neighbouring States. All
patients who expired before a proper clinical examination were excluded. Alveolar
fractures of the mandible and maxilla were also excluded, because most of these
fractures are treated in the dental department.
Simple methods of reduction and fixation were used for treatment. These
techniques have been immensely successful and have been employed for the last
20 years without any modifications. In addition, they are easily mastered. In the
16-45 year age group in which facial fractures are most common, wiring is easily
accomplished without any anaesthesia in the majority of cases. Mandibular frac-
tures are treated by eyelet wiring or arch bar fixation. Open reduction and interos-
seous wiring procedures are carried out at the lower border for an edentulous
patient, an unfavourable fracture at the angle, for multiple fractures difficult to
maintain with an arch bar, and for cornminuted fractures. Le Fort fractures of the
(Received 25 October 1986; accepted 1 January 1987)
*Present address: Plastic Surgeon, Loknayak Jai Prakash Narain Hospital, New Delhi, India.
430
 FACIOMAXILLARY FRACTURES IN NORTH INDIA 431

maxilla are treated by crania-mandibulo-maxillary fixation using an external fixa-

tion device (Fig. 1). Interosseous wiring has been a supplementary procedure for
comminuted fractures and for some Le Fort III fractures. Zygoma fractures are
routinely reduced by Gillies’ temporal approach. Interosseous wiring is used for
comminuted fractures or where reduction has been difficult to maintain by simple
elevation.

Fig. 1
Figure 1-A patient with a Le Fort II fracture of the maxilla treated by crania-mandibular-maxillary
fixation.

146

o-ISY 16-3OY 3C45Y 46-6OY 61-75Y > 76~

AGE GROUPS
Fig. 2
Figure 2-Age distribution of facial fractures.
432 BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY

Results
Age and sex. The patients’ ages in this study ranged from 2-80 years (Fig. 2). Two
hundred and eight patients were males and 54 were females (approximately a ratio
of 4: 1). Seventy-seven per cent of facial fractures occurred between 16 and 45 years
of age, and only 9% of patients were less than 15 years.

Aetiology. Interestingly, 40% of facial fractures in females resulted from accidents

at home and another 40% from travel accidents. In males 53% of cases were a
result of travel accidents, 14% from fights, 13% from accidents at home and 9%
from sports (Table I).

Mandibularfractures. The incidence of different facial fractures is shown in Figure 3.

There were 123 patients with fractures of the mandible and 24.4% of these were in
the panfacial group. Thirty six patients (30%) had more than one fracture line. The
most common site of mandibular fracture was the parasymphyseal region (Fig. 4).

Table I
An analysis of aetiological factors

Cause of Fracture % of cases

A) Road traffic accidents 50

1. Motorcycle 19.85
2. Light motor vehicle 9.92
3. Heavy motor vehicle 8.78
4. Pedestrian hit by vehicle 9.54
5. Cyclist 1.14
6. Train 0.77
B) Accidents at home 18.32
C) Fights, assaults 12.97
D) Miscellaneous 18.71
1. Sports 6.87
2. Falls from height 5.72
3. Industrial accidents 3.05
4. Agricultural accidents 2.68
5. Hit by animals 0.39

ZYGDMA 8% OFtBITAL AN0

NASOETH~lO 2%
MAXILLA9.5
NASAL BONES 28%

MANDIBLE 35 5%

PANFACIAL 17 %
Fig. 3

Figure 3-Incidence of various facial fractures. Total number of patients=262.

 PACIOMAXILLARY FRACTURES IN NORTH INDIA

Fig. 4

Figure 4-Incidence of regional fractures of the mandible. Total number of patients=123. Patients with
isolated fracture=93. Patients in panfacial group=30.

Fig. 5

Figure 5-Incidence of various maxillary fractures. Total patients=54. Patients with isolated
fracture=25. Patients in panfacial group=29.

Nasal fractures. There were 118 patients with fractured nasal bones; 38% (45
patients) were associated with Le Fort II or Le Fort III fractures or formed a part of
the panfacial group of fractures.

Maxillary fractures. Fifty four patients had a fracture of the maxilla; 54% (29
patients) were in the panfacial group of fractures. The most common maxillary
fracture was the Le Fort II type (Fig. 5).

Zygomatic fractures. Fifty five patients had a zygomatic fracture, with 53% (29
patients) in the panfacial group and 9% (five patients) being a part of a Le Fort III
type of injury.
434 BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY

Orbital and nasoethmoidal fractures. Orbital and nasoethmoidal fractures are

uncommon and of the seven patients seen, two were part of panfacial fractures.
Four cases had nasoethmoidal fractures and one patient with an orbital fracture
(not of the ‘blow-out’ type) sustained damage to the globe.
Discussion
Comparing the results of this study with similar reviews carried out previously,
we have come across some interesting variations. Road traffic accidents caused
50% of fractures in this study as compared to 35.2% reported by Rowe and Killey
(1955). However, in 1968 Rowe and Killey reported that the incidence had
increased to 46.8%. Similar higher incidence of facial fractures resulting from road
traffic accidents has been reported by Turvey in 1977; 46%, and by Khalil and
Shaladi in 1981; 60.4%. This indicates that the global increase in vehicular traffic is
resulting in higher incidence of facial fractures.
All studies report a low incidence of facial fractures in females. The male:female
ratio reported range from 5:2 (Gwyn et al., 1971) to 5.4:1 (Khalil & Shaladi, 1981).
A low incidence of facial fractures in females in India may be due to a large
percentage of them moving only infrequently out of their house. Different
classifications have been used in other studies of facial injuries, making it difficult
to compare the results. Nevertheless, an overall view of several studies shows little
consistency of results (Gwyn et al., 1971; Rowe & Killey, 1968; Shultz, 1967). In
the present series, the most frequently fractured bone was the mandible, closely
followed by the nasal bones. About 50% of the fractures of maxilla and zygoma
belonged to the panfacial group. Orbital and nasoethmoid fractures are seen
infrequently; this is fortunate, because their treatment is tedious and not always
satisfactory.
One thing which is very striking in the literature is the difference in the incidence
of various fractures of the mandible. Whereas Rowe and Killey (1955) and
Dingman and Natvig (1964) report an incidence of about 36% for condylar
fractures, we have observed an incidence of 22% for condylar fractures and 33%
for fractures around the symphyseal region. Similar to our study, Nakamura and
Gross (1973) also report a lower incidence for condylar fractures (20%). It is
difficult to attribute a reason for this discrepancy and perhaps a study on the
aetiology of the regional fractures of the mandible would be more informative. The
incidence of fractures of the angle and body of the mandible is essentially the same
in all the series.
References
Dingman, R. 0. Pr Natvig. P. (1964). Surgery of Facial Fractures. Philadelphia, Toronto, London:
W. B. Saunders.
Gwyn, P. P., Carraway, J. H., Horton C. E. Adamson, J. E. & Mladick, R. A. (1971). Facial
fractures-associated injuries and complications. Plastic and Reconstructive Surgery, 47, 225.
Khalil, A. F. & Shaladi, 0. A. (1981). Fractures of the facial bones in eastern region of Libya. British
Journal of Oral Surgery, 19, 300.
Nakamura, T. & Gross, C. W. (1973). Facial fractures. Analysis of five years of experience. Archives of
Otolaryngology, 97, 288.
Rowe, N. L. & Killey, H. C. (1955). Fractures of the Facial Skeleton, 1st Ed., Edinburgh & London:
Churchill Livingstone.
Rowe, N. L. & Killey, H. C. (1968). Fracfures of the Facial Skeleton, 2nd Ed., Edinburgh & London:
Churchill Livingstone.
Schultz, R. C. (1967). Facial injuries from automobile accidents: a study of 400 consecutive cases.
Plastic and Reconstructive Surgery, 40, 415.
Turvey, T. A. (1977). Midfacial fractures: a retrospective analysis of 593 cases. Journal of Oral Surgery,
35, 887.