RISK FACTOR FOR

HYPESTHESIA AFTER REPAIR

OF FACIAL FRACTURE

Yuana Dianis Eka Putri (1995031)

Pembimbing: drg. Franky Oscar

Maxillofacial trauma accounts
for a substantial percentage of
traumatic injuries.
In most cases of facial fractures,
This is because the facial bones
surgical treatment is necessary
protrude and are more likely to
for restoration of morphology
be damaged by external forces.
and function.

Surgical procedures for facial

bone fractures may cause
complications, such as
Hypesthesia is one of the most
asymmetry, neurologic
common complications.
hypesthesia, disturbed wound
healing, infection,malocclusion,
nonunion, and malar depression
Because the face has a high
density of peripheral
receptors, the prevalence of
sensory deterioration
caused by trauma ranges
from 70% to 81%.

Posttraumatic hypesthesia is
caused by direct nerve
injury resulting from the
fracture and indirectly by
soft tissue edema.
 The purpose of this study was to
Although trauma characteristics
analyze the general and fracture-
are not limited to the site of
related characteristics of facial
facial bone fracture, previous
bone fractures and to investigate
studies were limited by small
the relationships between risk
sample sizes and the relevant
factors and posttraumatic
factors investigated.
hypesthesia.
 MATERIALS AND METHOD
Study Design
The study included 557 patients
who had suffered facial bone
This was a single-center, fractures and had undergone The exclusion criteria were as
retrospective cohort study. treatment between July 2010
and December 2016 at Pusan
follows:
National University Hospital.
• Those who underwent
nonsurgical treatment
In cases where 2 or more • Pathologic fractures
fractures were diagnosed, only • Incomplete computed
the more displaced fracture was
included, making up a total of tomography data and chart
437 patients included in the data
study. • Those who were not followed
up for at least 6 months
 Surgical procedure was carried out
The endpoint was completed less according to Association for Internal fixation of the metal plate or
than 6 months after surgery. Osteosynthesis/Association for the absorbent plate was performed
Study of Internal Fixation guidelines.

Hypesthesia was examined

Surgical procedure was performed
with an open reduction through an immediately after the trauma and at
by the same oral and maxillofacial
extraoral/intraoral approach. 1 week, 1 month, and 6 months after
surgeon.
surgery.

A neurologic examination was used

to assess the degree of hypesthesia,
utilizing questionnaires and a
Statement of Clinical Relevance
visual analogue scale (VAS), which
was graded from 0 (no sensitivity) to
100 (completely normal sensitivity).
 The study patients were
divided into 2 groups: The control group included
Patient information and
those with VAS scores of
data collection were
100 based on
• Yes group: patients with neurosensory
performed in a double-
blinded manner.
hypesthesia (those with measurements

VAS scores less than 100

based on neurosensory Additionally, medical
records were reviewed,
measurements); and and radiographic
measurements were
• No group: patients with performed.
normal sensation.
To increase measurement
accuracy, 2 measurements
were taken with a 2-week
interval, and the mean
value was calculated.

The intraclass correlation

coefficient was 0.95.
Fracture sites were categorized into 4
types:
• orbital bone fractures, which
included orbital floor, roof, medial,
and lateral bone fractures;
• nasal bone fractures, which included
nasal and septal bone fractures;
• maxillary bone fractures, which
included zygomatic bone,
zygomaticomaxillary complex, and
Le Fort I, II, and III bonefractures;
and
• mandibular bone fractures, which
were divided according to 3
locations (Figure 1)
Study Variable
Details of the characteristics
mentioned above, as well as Patient-related factors Fracture-related
the demographic included sex, age, body mass characteristics included
characteristics of the index, past medical history, occlusion, fracture type, and
included patients, are listed and smoking status. cause of trauma.
in Table I.

Surgery-related factors
included the
maxillomandibular fixation
period, duration between
the injury and operation, and
fixation materials.
Analysis Data
Data were analyzed by using the
SPSS statistical software (SPSS Inc.,
Chicago, IL).
General and fracture-related
characteristics for risk factors were
used in logistic regression analyses.
The Kolmogorov-Smirnov test was
used to test for normality.Median,
interquartile range, and frequency
are presented, and the differences Ethical Consideration
between the 2 groups were
compared by using the Mann-
Whitney U test and the x2 test.
This study was
approved by the
hospital’s Ethics Review
Results of the statistical analysis Committee (No. H-
with P values less than .05 were 1712-005-062).
considered statistically significant.
Result

In the posttrauma evaluation of

the degree of hypesthesia after
facial bone fracture, the
There was no hypesthesia in the
mandibular fracture group had
nasal bone fracture group.
the lowest score (87.69 points),
followed by the maxillary
fracture group (90.11 points).

The degree of hypesthesia after

All patients except those with
trauma differed according to the
nasal bone fractures had lower
traumatized region, but
scores (78.28100.00 points) 1
eventually, 97.3% had recovered
week after surgery than in the
6 months postoperatively (Figure
immediate posttrauma period.
2).
Pemulihan cedera saraf berdasarkan jenis fraktur.
According to the site, mandibular
fractures showed the highest
incidence of hypesthesia after
trauma, whereas that of
maxillary fractures was highest
after surgery (see Table I).

In Table II, we present the general and
fracturerelated characteristics of patients
with facial bone fractures.
With regard to occlusion, posttraumatic
unstable occlusion was present in 40.7%
in the hypesthesia group and in 28.8% in
the control group
When the hypesthesia group and the
control group were compared, there
were significant differences in occlusion
(P = .048), fracture type (P < .001), direct
nerve injury (P < .001), distance between
the fracture line and nerve foramen (P
< .001), and amount of bony
displacement (P < .001).
With regard to the fracture site, there
was no hypesthesia in the nasal bone
fracture group.
 In contrast, 42.6% of the
In the hypesthesia group, control group demonstrated
mandibular fracture was the a difference in the ratios
most frequent (64.4%). between fracture sites.

When the distance between

Moreover, when the
the fracture line and the
amount of bony
nerve foramen was greater
displacement exceeded 9.1
than 10 mm, the incidence
mm, it was 4.62 times
of hypesthesia was 4.65
higher (P = .035).
times higher.
In maxillary fractures, the
ratios in the hypesthesia
and control groups were
similar in cases where the
nerve was damaged
directly.
In the mandible, the
hypesthesia group showed
a higher rate compared
with the control group.

Moreover, 24.2% of
patients did not show
symptoms even if it was
related directly to the nerve
(Table III).
 Therefore, the effect of the
The measurements showed
distance between the nerve
In orbital fractures, direct that hypesthesia occurred
foramen and the fracture
nerve injury was thought to at a distance of less than 10
line on hypesthesia was
be the cause of hypesthesia. mm in both the maxilla and
measured in the maxilla and
the mandible (Table IV).
the mandible.
 Table V shows that there
was a significant difference
between the 2 groups when
the displacement of the
fracture exceeded 9.1 mm.
When the displacement was
analyzed according to the
fracture site, a significant
difference was observed in
the location 2 (L2) group.
This suggests that
hypesthesia is more likely to
occur as the amount of
displacement increases in
the mandibular body area.
DISCUSSION
In this study, we investigated
hypesthesia incidence and healing
Hypesthesia was present in 13.50%
progression after facial bone trauma
of the 437 patients, and symptoms
and analyzed general and fracture-
had resolved in 97.3% of these
related characteristics between
patients 6 months postoperatively.
patients with hypesthesia and the
control group.

The prevalence rates of hypesthesia

ranged from 46.5% to 53.84% among
The prognosis of hypesthesia after
orbital fractures16,17 and from
facial fracture in the present study is
27.90% to 79.90% among maxillary
similar to those reported in previous
and mandibular fractures 18; the
studies.
prevalence of hypesthesia among
nasal bone fractures was 3.47%

Postoperative hypesthesia was
more severe in the remaining
fracture types except for those of
the nasal bone.
In this study, only 8 patients
(1.83%) presented hypesthesia
after 6 months (data not shown).
This resulted from surgical
trauma, such as incision,
perineural dissection, and
traction from instruments, which
was reported to occur in 50% to
90% of patients.
In this study, occlusion was more
unstable in the hypesthesia
group.
Hypesthesia caused by surgical
trauma is known to resolve most
rapidly within 2 weeks of surgery.
Causes of posttraumatic
occlusion after facial bone
fracture include hematoma,
edema, a displaced fracture
fragment, and the restriction of
muscle movement from a
displaced fracture fragment
 This finding can be interpreted as a
Displaced fractures of the facial bones Furthermore, care should be exercised
result of fractures of the
can increase the possibility of damage in predicting this situation and to
zygomaticomaxillary complex;
to the trigeminal nerve, which can be avoid exacerbating it with surgical
occlusal disturbances were found only
linked directly to hypesthesia. trauma.
in patients with displaced fractures.

These characteristics of facial bone

fractures were reported to be highly
Risk factors were age, direct nerve
In relation to age, facial trauma and prevalent among patients 21 to 30
injury, distance between the fracture
fractures are generally known to years of age. In this study, the
and nerve, and displacement of the
occur in the 30s or younger age group. hypesthesia group showed a
fracture.
significant difference in the ratio of
patients younger than 30 years of age.
 In the present study, hypesthesia was
observed in about 60% of patients, and
40% of patients had no symptoms. In
Direct nerve injury was shown to be a
addition, hypesthesia was observed in
risk factor for hypesthesia after facial
about 30% of cases where the nerve
bone fracture in many studies.
was not involved, and it was thought
that hypesthesia occurred because of
other indirect factors.

The reason is that the trigeminal nerve, The large layer of soft tissue covering
which is the sensory nerve for the facial the emergences of the inferior alveolar
bones, extends to the periphery nerve and the infraorbital nerve offers
through relatively long bony canals. protection from direct trauma
 This finding is similar to those of
previous studies, whichshowed Hypesthesia becomes worse as
In the present study, a fracture
that a mandibular fracture with a displacements become larger
with a maximal displacement
displacement greater than 5 mm when nerve involvement is
greater than 9.1 mm was
conveyed a 7-fold higher risk of inevitable, such as in the
identified as a risk factor.
damage to the inferior alveolar mandibular body area.
nerve.

However, it is known that a large

displacement does not delay
recovery from hypesthesia.26 The
results showed that recovery was
observed after 6 months in all
patients with a displacement
greater than 9.1 mm.
Recovery from hypesthesia is
known to be influenced by
various factors, such as age,
medical history, infection, and
smoking status
In the present study, 11 patients
had persistent hypesthesia even
In addition, 8 patients presented
after 6 months. Three patients
hypesthesia, which persisted for
presented hypesthesia after
6 months postoperatively.
trauma that lasted up to 6
months postoperatively.

All these cases showed common

features of a fracture line and
nerve superposition, suggesting
that direct nerve injury has a
significant impact on the
prognosis of hypesthesia.
Conclusion
In the present study, 11 patients
had persistent hypesthesia even
In addition, 8 patients presented
after 6 months. Three patients
hypesthesia, which persisted for
presented hypesthesia after
6 months postoperatively.
trauma that lasted up to 6
months postoperatively.

All these cases showed common

features of a fracture line and
nerve superposition, suggesting
that direct nerve injury has a
significant impact on the
prognosis of hypesthesia.
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