AETIOLOGYANDMECHANISMOFINJURYOFMIDFACIALFRACTURES:A PROSPECTIVESTUDYOFTHEJOHANNESBURGREGION.

YusufFaroukSuleman

AresearchreportsubmittedtotheFacultyofHealthSciences,Universityofthe Witwatersrand,Johannesburg,inpartialfulfillmentoftherequirementsforthedegree ofMasterofDentistryinMaxillofacialandOralSurgery.

Johannesburg2008

Candidatesdeclaration

I,YusufFaroukSuleman,declarethatthisresearchreportismyownwork.Itisbeing submittedforthedegreeofMasterofDentistryinthebranchofMaxillofacialandOral Surgery,intheUniversityoftheWitwatersrand,Johannesburg.Ithasnotbeen submittedbeforeforanydegreeorexaminationatthisoranyotheruniversity.

______________dayof_____________________200__.

 Dedication

Bismillahhirrahmaanirraheem

Tomyparentswhonurturedandguidedme

Tomybeautifulwife,Yasmeen,forherundyinglove,dedicationandsupport.

TomychildrenfromwhomIdrawstrengthandhappiness.

ABSTRACT

Objective:Todeterminetheaetiology,biomechanicsanddemographicsofpatients withfracturesofthemidface.

MaterialsandMethods:Patientswithmidfacefractures(whoconsentedtoparticipate inthestudy)whopresentedtotheDivisionofMaxillofacialandOralSurgeryovera12 monthperiodfromDecember2005toDecember2006wereincludedinthestudy.Data wasrecordedonage,race,gender,dateandcauseofinjury,associatedinjuriesanduse ofalcoholatthetimeofinjury.ThefracturesweregroupedintoLeFort,zygomatico maxillary,dentoalveolarandpanfacialfractures.

Results:Thesamplecomprised94patients;78(82.98%)malesand16(17.02%)females withanagerangeof3to67years.Blacksaccountedfor77.66%ofthetotalsample, followedbyWhites(12.77%),Coloureds(6.38%)andAsians(3.19%).Blunttraumadue tointerpersonalviolence,motorvehicleaccidents,gunshotwoundsandfalls contributedto40.5%,26.6%,13.8%and5.3%ofthefracturesrespectively.LeFort fractureswerelesscommonlyobservedthanzygomaticomaxillarycomplexmidface fractures.

Conclusion:Arelationshipexistsbetweenfacialtrauma,povertyandalcohol consumption.Blunttraumaduetointerpersonalviolenceisthemostcommoncauseof midfaceinjuries.Majorityofinjuriesaresustainedduringweekends. Zygomaticomaxillarycomplexfracturesarethemostcommonmidfacefractures.

ACKNOWLEDGEMENTS

Iwishtoexpressmysinceregratitudetothefollowingpersons:

ProfessorJ.LownieBDS,MDENT(MFOS),FCMFOS(SA),PhD,DrE.RikhotsoBDS,MDENT
(MFOS),FCMFOS(SA)andDr.N.DayaBDS,FCMFOS(SA)fortheirsupervision.

ProfessorP.E.CleatonJonesBDS(WITS),MBCHB,DA(SA),PhD,DTM&H,DPH,DSC.forhis expertise,enthusiasmandstatisticalanalyses.

DrE.Rikhotsoforallhisencouragement,patience,wisdomandguidance. Dr.E.Muthrayforhissupportandassistance. Tomyfellowregistrarswithoutwhomthisresearchwouldnotbepossible.

TABLEOFCONTENTS

TITLEPAGE DECLARATION DEDICATION ABSTRACT ACKNOWLEDGEMENTS TABLEOFCONTENTS LISTOFFIGURES LISTOFTABLES NOMENCLATURE CHAPTER1:INTRODUCTION 1.1Appliedanatomy 1.1.1Zygoma 1.1.2Maxilla 1.1.3Nasalbones 1.1.4LacrimalBones 1.2Historyofmidfacialfracturesandtheirmanagement 1.3Classification 1.3.1Zygomaticfractures 1.3.2Maxillaryfractures

1 2 3 4 5 6 9 10 11 12 12 13 14 15 15 16 18 18 20

1.3.3Nasoorbitoethmoid(NOE)fractures 1.4SignsandSymptoms 1.4.1NOE 1.4.2Maxilla 1.4.3Zygoma 1.5LiteratureReview 1.6AimsandObjectives CHAPTER2:MATERIALSANDMETHODS 2.1Ethicalclearance 2.2InclusionCriteria 2.3ExclusionCriteria 2.4ClinicalStudy 2.5DataAnalysis CHAPTER3:RESULTS 3.1Age,genderandracedistribution 3.2Natureofinjuryandsocialhabits 3.3SpecialInvestigations 3.4Typeoffracturessustained 3.5Analyses 3.6Hardwarecosts CHAPTER4:DISCUSSION CHAPTER5:CONCLUSION

22 25 25 26 26 27 31 32 32 32 32 33 36 37 37 39 42 43 44 50 51 57
7

REFERENCES APPENDIX AppendixAEthicalClearance AppendixBPatientinformationsheetandconsent AppendixCParticipationinformationdatasheet

58 63 63 64 66

LISTOFFIGURES

Figure1.1A&Bfacialbuttressofthemidfaceandarchitecturalmodelrespectively. 13 Figure1.2LefortI,II&IIIfracturelinesfrontal&threequarterview Figure1.3NOEtypeIfractureunilateralandbilateral Figure1.4NOEtypeIIfractureunilateralandbilateral Figure1.5NOEtypeIIIfractureunilateralandbilateral Figure2.1Occipitomentalviewindicatingmultiplefacialfractures Figure2.2SMVusedtoassessfracturesofthezygomaticarch. Figure2.3ThreedimensionalCTscanindicatingmultiplefacialfractures. 21 23 23 24 34 34 35

LISTOFTABLES

Table3.1Frequencydistributionbyageindecades Table3.2Frequencydistributionbygender Table3.3Frequencydistributionbyrace Table3.4Frequencydistributionbynatureofinjury Table3.5Frequencydistributionbyalcoholconsumption Table3.6Frequencydistributionbylossofconsciousness Table3.7Frequencydistributionbyassociatedinjuries Table3.8Frequencydistributionbydayoftheweek Table3.9Frequencydistributionbyradiographicinvestigations Table3.10Frequencydistributionbyfracturespattern Table3.11Analysisofalcoholconsumptionbymechanismofinjury Table3.12Analysisofalcoholconsumptionbygender Table3.13Analysisofgenderbymechanismofinjury Table3.14Analysisofdecadebygenderandalcoholconsumption Table3.15Analysisoffracturetypebyalcoholconsumption&mechanismofinjury Table3.16Analysisoffracturetypebytreatment

37 38 38 39 40 40 41 42 43 44 45 45 46 47 48 49

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NOMENCLATURE

ComputerTomography Dentoalveolar

=CT =DA =HIV =NOE =OM =OPG =ORIF =SMV =ZMC

HumanImmunodeficiencyvirus Nasoorbitoethmoid Occipitomental

Orthopantomograph

OpenReductionInternalFixation Submentovertex

Zygomaticomaxillarycomplex

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Chapter1Introduction
1.1AppliedAnatomyofthemidfacialbones

Themidfaceiscomposedofthenasal,zygoma,maxilla,ethmoidanditsconchae, palatine,inferiorconchaandvomerwhicharecollectivelyreferredtoasthemiddle thirdofthefacialskeleton.Thesefacialbonesinisolationarecomparativelyfragilebut gainstrengthandsupportastheyarticulatewitheachother.1,2

Itisthisstrengthgainedfromeachotherthathasoftenbeendescribedasthefacial buttresseswhichManson3alludedtowhendescribingtheverticalandhorizontalstruts thatsupportthefacialskeleton(Figure1.1).Thehorizontalpillarsareformedbythe frontalbar(composedofthesupraorbitalrimsandnasalprocessofthefrontalbone), thezygomaticarch,infraorbitalrims,andthenasalbridgeandfinallythealveolar processofthemaxilla.

Theverticalpillarsareformedfirstlymediallybythepiriformrimswhichcontinue superiorlyasthefrontalprocessofthemaxilla.Secondlythezygomaticbuttresseswhich continuesuperiorlywiththelateralorbitalrimsformthelateralpillarsandfinallythe mostcaudalpillarsarethepterygoidplates.

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 Figure1.1A&Bindicatingfacialbuttressofthemidfaceandarchitecturalmodel respectively.4

1.1.1 Zygoma

Thenamezygomaisderivedfromthewordmeaningayoke(i.e.astructurethat connectsvariouspartstogether),whereitarticulateswiththetemporal,maxillary, frontalandsphenoidbones.Itisoftendescribedasadiamondorpyramidalshaped boneofwhichthelateralsurfaceisconvexformingtheprominenceofthecheek.The posteriorsurfacecontributestothetemporalfossa.

Projectingsuperiorlyisthefrontalprocesswhicharticulateswiththezygomaticprocess ofthefrontalboneinfrontandgreaterwingofsphenoidbehindtoformthelateralwall

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andrimoftheorbit.Posterolaterallythetemporalprocessarticulateswiththe zygomaticprocessofthetemporalbonetoformthezygomaticarch.Inferiorlyand mediallyitbroadlyarticulateswiththemaxillatoformtheinferiororbitalrimand contributestotheorbitalflooraswellasthezygomaticomaxillarybuttresswhichforms oneofthestrutsmentionedabove.5

1.1.2Maxilla

Themaxillaconsistsofacentralbodyandfourprocessesnamelythefrontal,zygomatic, alveolarandpalatineprocess.Thebodyishollowedoutandcontainsthemaxillary sinus.Itispyramidalshapedwiththebasebeingthemedialsurfacefacingthenasal cavityandtheapexbeingelongatedintothezygomaticprocess.Ithasanorbitalor superiorsurfacewhichformsthefloorandrimoftheorbit,amalaroranterolateral surfacewhichformspartofthecheekandaposterolateralorinfratemporalsurface whichcontributestotheinfratemporalfossa.Thebaseisrimmedinferiorlybythe alveolarprocess.

Thealveolarprocesshousesthedentalarchwiththesocketsvaryinginsizeaccordingto theteeth.Thepalatineprocessisahorizontalprocessfromthebodytothealveolar processandmediallyarticulateswiththepalatineprocessoftheoppositemaxillawhilst posteriorlyitarticulateswiththehorizontalplateofthepalatinebone.Thezygomatic processisanextensionoftheanterolateralsurfaceofthebodywhichcontributestothe zygomaticomaxillarysuture.5

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Thefrontalprocessprojectsupwardtoarticulatewiththemaxillaryprocessofthe frontalboneaswellasthenasalboneanteriorlyandthelacrimalboneposteriorly.Itis thissegmentofbonethatincludesthelacrimalcrestintowhichthemedialcanthus attachesthatMarkowitzcalledthecentralfragmentindefiningnasoorbitethmoid (NOE)fractures.6

1.1.3Nasalbones

Thepairedquadrilateralbonesformtheupperpartofthebridgeofthenoseand articulatewiththefrontalprocessofthemaxillalaterallyandwitheachotherinthe midline.Superiorlytheyarticulatewiththefrontalbone.

1.1.4Lacrimalbones

Eachlacrimalboneisirregularlyrectangularformingpartofthemedialwalloftheorbit. Theyarticulateposteriorlywiththepaperthin(laminapapyracea)partoftheethmoid, superiorlywiththefrontalboneandinferiorlywiththebodyofthemaxilla.Thesharp orbitalverticallacrimalcrestcontinuesinferiorlytoformthelacrimalhamulus,withits concaveportionhousingthelacrimalsac.Thelargeranteriorlimbofthemedialcanthus attachestotheanteriorlacrimalcrestandadjacentfrontalprocessofmaxilla.5

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1.2 Historyofmidfacialfracturesandtheirmanagement

TheearliestknownwritingsofmaxillofacialfractureswererecordedintheEdwinSmith Papyrusin1650BCwhichwerepurchasedbySmithin1862andtranslatedby Breasted.7,8Traditionally,healingandreligionwerecloselyintertwinedasillustratedin theHellenicperiodatthetemplesofAsklepios,whereassistantstothepriestsprovided medicalcare.Tooneoftheseassistantsasonwasbornin460BCnamedHippocrates. Hippocrateswhoisoftenportrayedasthefatherofmedicinedescribedamyriadof facialinjuriesinaround400BCandhisinsightprovidedthebasisforbandagesand singlejawinterdentalwiringasmethodsoffixationandstabilisationoffacialfractures.9

OverthesubsequentcenturiesfollowingHippocratesthereappearedmanytechniques whichinessencewerevariationsofhismethods.InthenineteenthcenturyCharles FredrickReiche8providedthefirstdetailedtreatiseofmaxillaryfractures.Carlvan Graefe8reportedontheuseofanelastictubeplacedintothenosetomaintainpatency oftheairwayandalsodescribedtheuseofaheadframetotreatamaxillaryfracture.It wasalsointhesamecenturythatGarretsonandBlair8advocatedmandibularmaxillary fixationwiththeaidofsplintstoprimarilytreatmaxillaryfractures.

16

In1901aFrenchsurgeon,RenLeFort,10publishedhisclassicalpaperonmidfacial fracturepatterns.Heinflictedbluntfacialtraumaon35cadaversthensubsequently removedthesofttissueandexaminedfracturepatternsofthefacialskeleton.Thisstudy haseversincebeenthebasisforthedescriptionofmaxillaryfractures.

FracturesofthezygomawerenotadequatelymentionedsincethetimeofHippocrates, howeverin1906Lothrop11wasthefirsttodescribetheuseofanantrostomyapproach toreduceamediallyandinferiorlydisplacedzygoma.In1909Keen11describedan intraoralapproachtothezygomaticarch.In1927Gillies11describedatechniqueto reduceazygomaticarchaswellasmanipulateafracturedzygoma. In1942Adam12utiliseddirectwiringtoobtainbetterstabilityofzygomaticfractures. Foryearshisprotocolappearedtobethemainstayoftreatmentatmanyinstitutions.In the1970sosteosynthesisbecamearealityforfacialfractureswiththeSwiss ArbeitsgemeinschaftfrOsteosynthesefragen(AssociationfortheStudyofInternal FixationorAO)developingminiplatefixation.Todaytheuseofminiplatesprovidesthe principalmodalityoftreatmentforreductionandfixationofdisplacedmidfacial fractures.

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1.3 Classification

Thereisnouniversalconsensusontheclassificationofmidfacefractures.Several classificationshavebeenproposedformidfacefracturesduetoamyriadoffracture patternsobtainedwhichreflectthecomplexnatureofconstructionofthesebones.The objectivesoftheseclassificationsweretohelpformulateclinicalguidelinesforpatient management.

1.3.1Zygomaticfractures TheearliestclassificationofzygomaticfractureswasproposedbySchjelderup13who classifiedzygomafracturesdependantonwhichregionitwasstillattachedtoe.g.Type IIIfractureoccurredwhenthezygomawashingedatthefrontalbone. In1961KnightandNorth13classifiedzygomafracturepatternsintothefollowing6 typesaccordingtothelevelofdisplacementnotedradiographically: TypeI TypeII TypeIII TypeIV TypeV TypeVI

:undisplacedfracture :isolatedarchfractures :posteriorlydisplaced :mediallyrotated :laterallyrotatedatthebuttress :multipleorcomminutedfractureincludingthebody

18

In1968RoweandKilley13utilisedtheprincipleofverticalandhorizontalaxialrotations andenblocdisplacementtoclassifyzygomaticfractures.Theyutilisedthe frontozygomatictofirstmolarplaneastheverticalaxisandtheinfraorbitalforamento zygomaticarchplaneasthehorizontalaxis.Theauthorsclassifiedthefracturepatterns into8groupsandsuggestedwhichonesrequiredfixation. LarsenandThomsen13attemptedtoclassifyzygomaticfracturesaccordingtotheir treatmentguidelines.TheysuggestedgroupAwhichincludednoorminimallydisplaced fractures,groupBwhichencompassedfracturesthatrequiredreductionandfixation (thisgroupincludedcomminutedanddisplacedfractures)andgroupCwhichincluded allotherfracturesthatrequiredreductionbutnofixation.

Withtheadventofcomputertomographyandrigidfixationsomeauthorsclassified zygomaticfracturesbasedontheamountofkineticenergyorseverityoftheblowtothe bone.AmongstthesewereMansonandMarkowitz14whoin1990classifiedfracturesas low,middleandhighenergyfracturesandwhoadvocatedwhichgrouphadaroleto playinopenreductionandfixation.Lowenergyinjuriesarecharacterisedbynoor minimaldisplacementincludingincompleteseparationwhichareeasilyreducedand tendtostayinpositionwithnoorminimalstabilisation.Thesefracturesaccountfor18% ofinjuries.Middleenergyinjuriesaccountforthebulkofinjuriessustained(77%)with displacementrangingfrommildtomarkedwithcompleteseparationatallfoursutures. Theyrequirevariableamountofrigidfixationdependingonthedegreeofdisplacement. Highenergyinjuriesareassociatedwithcomminution,significantdisplacementand

19

telescoping.Duetotheinherentinstabilityofthesefractureswideexposurefor adequatereductionandrigidfixationisrequired.Onoccasiongraftingmayberequired toaddressthebuttressesduetoextensivebonydefects.

1.3.2Maxillaryfractures

ThemostwidelyquotedclassificationofmaxillaryfracturesistheLeFortsystemof classification.8,16HeclassifiedfracturepatternsintoLeFortI,IIandIII(Figure1.2).

TheLeFortIorlowlevelsupraapicalfractureextendshorizontallyfromthepiriform rimlaterallyalongthealveolarprocessabovetheapicesoftheteethcontinuingbelow thezygomaticbuttresstoinvolvethelowerthirdofthepterygoidplates.Thisresultsin disarticulationoftheocclusalunitfromthemidface.

TheLeFortIIorpyramidalfractureextendsfromthenasalbonestoinvolvethemedial andinfraorbitalrim,theanteriorwallofthemaxilla,thezygomaticbuttressand pterygoidplates.Thisfractureresultsincentralmobilityofthemidfacefromthecranial basewiththeconsequenceoflengtheningoftheface.

TheLeFortIIIorsuprazygomaticfractureextendsfromthefrontonasalregioninthe midline,involvingthemedial,floorandlateralwallsoftheorbit,thefrontozygomatic suture,maxillaandcontinuestotheupperthirdofthepterygoidplates.Thisresultsin disarticulationofthefacialbonesfromthecranialbase.

20

Today,howeverfracturepatternsarerecognisedasfarmorecomplexthanthose producedinLeFortslaboratory.Injuriescausedbypenetratingtraumaaswellashigh velocityblunttraumaintroduceaspectrumoffracturesnotdescribedbyLeForts classification.LeFortdidhoweverstatethatcomminutioncanoccurinconjunctionwith theabovelistedfractures.Healludedtotheconceptofthesuperiorfractureasthelevel ofclassificationandthatcomminutionoccursbelowitaccordingtothelinesof weaknessinherentinthemidface.17Todaytheintroductionofthemidpalatalsplitas wellasexpansionoftheoriginalLeFortclassificationasproposedbyMarciani18isoften theclassificationquoted.

Figure1.2LeFortI,II&IIIfracturelinesfrontal&threequarterview.4

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1.3.3Nasoorbitoethmoid(NOE)fractures

Thesefracturesareamongstthemostcomplexfracturesbothdiagnosticallyand therapeuticallyduetotheintricateanatomyanddifficultyinfracturefixation.Gruss19 statedthatduetothecomplexnatureofNOEfracturesnumerousclassificationswere proposed.TheyclassifiedNOEfracturesintoisolatedorassociatedwithothermidfacial fractures.Furthersubdivisionsweremadeintounilateralorbilateralfractures.

Theaboveclassificationshoweverfailedtoidentifythemedialcanthalattachmentand itsrelationshiptothefracturepatterns.Aclassificationandtreatmentprotocol proposedbyMarkowitzetal6hasbeenadoptedasthemostrelevantclassificationof NOEfractures(Figures1.3,1.4and1.5).

Theydefinedtheareaofattachmentofthemedialcanthustotheboneasthecentral fragmentwhichiscriticalforthediagnosisandtreatmentofNOEfractures.TypeI fracturesproducesasinglesegmentfractureofthecentralfragment.TypeIIinjuryhasa comminutedcentralfragmentwiththefracturesremainingexternaltothemedial canthalinsertionandfinallytypeIIIhasacomminutedcentralfragmentwith involvementofthecanthalinsertion.Theyalsodefinedthefracturesasunilateralor bilateralaswellasisolatedorextendedintotheadjacentstructures.

22

Figure1.3NOEtypeIfractureunilateralandbilateral.6

Figure1.4NOEtypeIIfractureunilateralandbilateral.6

23

Figure1.5NOEtypeIIIfractureunilateralandbilateral.6

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1.4Signsandsymptoms

AllpatientswhosustainmidfacialfracturesareinitiallyattendedtointheAccidentand Emergencyunitsattherelevanthospitalsandaremanagedaccordingtotheadvanced traumaandlifesupport(ATLS)protocolasadvocatedbytheAmericanCollegeof Surgeons.Oncethepatientisstabilisedthesecondarysurveyincludesadetailed maxillofacialexamination.Thisexaminationwouldincludeinspectionandpalpationof thefractures.Numerousfunctionalandaestheticdisordersaccompanymidfacial fracturesandthefollowingaresomeofthepresentingsignsandsymptomsthatmay occurinthedifferentfracturetypes.

1.4.1NOE

Uponinspectionanylacerations,abrasions,ecchymosis,facialoedemaandperiorbital ecchymosismayindicateaNOEfracture.Ocularchangessuchastelecanthus,mongoloid slantofthemedialcanthus,epicanthalfold,shorteningofthepalpebralfissure, decreaseocularmobility,andenopthalmusarestronglysuggestiveofaNOEfracture.A depressednasalbridge,epistaxis,binoculardiplopiaandepiphoraarefurthersignsofa NOEfracture.6Clinicalevaluationinvolvingabowstring,Furnesstestandbimanual palpationofthecentralfragmentaswellasanystepsinthatregioncanalsoalertthe cliniciantothisfracture.

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1.4.2Maxilla

Extraoralevaluationmayrevealadishfaceappearance,elongatedface,depressed nasalbridge,neurologicalfalloutinthedistributionoftheinfraorbitalnervesaswellas stepdeformityatthebuttressandinfraorbitalrim.MobilityofthemaxillaattheLeFort I,IIorIIIlevelcouldalsobenoted.Intraorallymalocclusion(inparticularananterior openbite),mobilityofdentoalveolar(DA)segmentsortheentiremaxillacanbeelicited aswellasstepsinthebuttressmaybepalpated.Otherintraoralsignsarestepsin occlusion,malocclusion,diastemaformationaswellasecchymosisalongthebuttress andthepalate.

1.4.3Zygoma

Periorbitaloedemaandecchymosisisacommonsignoforbitozygomaticcomplex fractures.Othersignsincludesubconjunctivalhaemorrhagewithorwithoutlaterallimit inallplanes,depressionofthemalareminence(lossofprojection)andneurological falloutindistributionofinfraorbitalnerves.Dystopia,decreasedocularmovement, binoculardiplopia,enophthalmus,antimongoloidslantoflateralcanthusaswellas palpablestepsaroundtheorbitalrimandbuttressarefurtherindicationofzygomatic fractures.Limitedmouthopeningmaybepresentwhenthearchisfracturedimpeding onthecoronoidprocessorasaresultofmuscleinjury.14

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1.5LiteratureReview

Facialtraumaisoftenassociatedwithseveremorbiditywithrespecttolossoffunction anddisfigurementaswellastheimpactofincreasedfinancialcoststoboththestate andtheaffectedindividual.Ofthe1500facialfracturesanalysedbyRoweandKilley2 629(41.9%)involvedfracturesofthemiddlethird.KellyandHarrigan2analysed4317 facialfracturesofwhich594(13.76%)involvedthemiddlethirdofthefacialskeleton.

Ananalysisoftheassociationbetweentheepidemiologyandassociatedinjuriesisthus importantinordertoimprovetreatmentandprevention.Beaumontetal20undertooka studyof389patientswithfacialfracturesinthreepopulationgroups.Theyfoundthat themaletofemaleratiowasabout4:1.Inallethnicgroupsthepeakprevalenceof fractureswasinthethirdandfourthdecades.Themeanageforblacks,asiansand whiteswerenotedasbeing32,30and27yearsrespectively.Blacksweremainlyvictims ofinterpersonalviolence,whilstinthewhitegroupmidfacialfractureswere predominantlycausedbymotorvehicleaccidents.Inallthegroupsthemandiblewas mostcommonlyfracturedfollowedbythemidfaceandthencombinedfracturesof mandibleandmidface.

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 TheaboveresultsweresimilartothefindingsbySnijman21andDuvenage22,published in1963and1979respectively,whosestudieswereconductedintheTshwanedistrictof theGautengprovince.Theyalsofoundthatathirddecadepeakwasnotedwithasimilar malepredominance.Snijmanalsonotedthatassaultwasthemostcommoncauseof facialfracturesamongstblacks.Hesimilarlynotedthatmotorvehiclesaccidents accountedforahigherpercentageoffacialfracturesamongstthewhitegroup. Mandibularfractureswerealsothemostcommonlyrecordedfacialfracturebyboth authorsinagreementwithBeaumont.

Theseresultsareincontrasttothosepublishedinotherregions.Bataineh23undertook aretrospectivestudyoftheincidenceofmaxillofacialfracturesinJordanandnotedthat ofthe563patientsthatpresentedfortreatmentovera5yearperiod,themandiblewas mostfrequentlyfractured(74.4%)followedbythemaxilla,zygomaticarchandfinally thedentoalveolarprocess.Themostcommoncausewasroadtrafficaccidents(55.2%) followedbyaccidentalfalls(19.7%)andassault(16.9%).Amaletofemaleratioof3:1 wasnotedandthemeandecadeforinjurywasthethirddecade.Asimilar epidemiologicalpatternwasnotedintheUnitedArabEmirates.24

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Balakrishnan25reviewed313casesinTrivandrum,Indiaintheearly1980sandfounda markedmalepreponderance(93.3%).Thereasongivenwasthatwomenwerehardly everinvolvedinroadtrafficaccidents.Theydonothoweversubstantiateorclarify theirremarkwhethertherewerefewerwomenoccupantsanddriversinmotorvehicle accidentsorwhetherwomenwerebetterdrivers.Onceagaintheinjurieswere sustainedmostcommonlybyindividualsinthethirddecade.Heretrafficaccidents followedbyassaultwerenotedtobethemostcommoncausesofmaxillofacial fractures.InterestinglytwodecadeslaterinanotherdistrictinIndiathemaletofemale ratiodecreasedto3.7:1.26 IntheNetherlandsvanBeek27foundastrikingreductioninroadtrafficaccidentsand anincreasinginfluenceofviolenceandsportresultinginachangingpatternof maxillofacialfractures.TheseresultswereinstarkcontrasttoinjuriesinAustriaas reportedbyGassner28whofoundthatactivityofdailylifeandplayaccidentswasthe maincausefollowedbysport,interpersonalviolenceandtrafficaccidents.Gassneralso notedanincreaseinfemalepatientswithanoverallmaletofemaleratioof2.1:1. Greene29notedthatthedistributionofthemidfacefracturesinvolvingthe zygomaticomaxillarycomplexwasthehighestfollowedbyorbitalblowout,nasal, zygomaticarch,LeFortandfinallyNOEfractures.ThedistributioninGreecewas somewhatdifferentwithzygomafracturespredominatingfollowedbyLeFortII,NOE,Le FortIII,nasal,LeFortI,palatalsplitandfinallydentoalveolarfractures.30

29

AlKhateeb31analysedcraniofacialfracturesinUnitedArabEmirates.Healsofound thatamongmidfacialinjuriestheincidencewerehighestforzygomaticcomplex fracturesfollowedbyNOE,isolatedorbitalfloorandLeFortfracturesrespectively. Beaumont20alsonotedthatthezygomaticomaxillarycomplexhadthehighest distribution. Ferreiraetal32undertookastudytodeterminethedistributionofmidfacialfracturesin childrenandadolescence.Theyfoundthatthedistributionsinprevalenceaccordingto siteswere:zygoma,alveolar,Lefort,orbitalfloorandfinallyhardpalate. Kontio33interestinglyfoundinhisepidemiologicalstudyinFinlandthatthespectrumof maxillofacialinjurieschangedsomewhat.Thedecademostaffectedwithfracturesin 1981wasthefourthwhilstin1997itwasthefifthdecade.Healsonotedadecreasein motorvehicleincidentswithanincreaseininterpersonalviolencewhichhadbecome moresevereinnature.

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1.6AimsandObjectives

Althoughtherearenumerousstudiesofmaxillofacialinjuriesintheliterature,onlya fewhavecontainedmeaningfulinformationrelatingtolocaldemographicfactors.In ordertoimproveservicedeliveryinthetreatmentofmidfacialfracturesitisparamount toanalysecurrentdataonitsbiomechanicsandincidence.Thisstudyintendsto:

1. Providecurrentlocaldataontheaetiology,biomechanicsanddemographicsof patientspresentingfortreatmentoffracturesofthemidface. 2. Toassesstheassociation,ifany,betweenfracturepatternsandmechanismof injury,thusprovidinginsightintolocalbehaviouralpatterns. 3. Tosupplydataofthefinancialresourcesprovidedbythedepartmentofhealth requiredtomeetpatientneeds.

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Chapter2Materialsandmethods
2.1Ethicalclearance

AnapplicationforethicsclearancewassoughtwiththeCommitteeforResearchon HumanSubjects(Medical)oftheUniversityoftheWitwatersrand.TheClearance certificate,protocolnumberM050812wasgranted(AppendixA).Verbalandwritten explanationsofthestudyweregiventopatientswhofulfilledtheinclusioncriteriaof thestudyandawrittenconsentwasobtainedfromeverysubject.(AppendixB)

2.2InclusionCriteria

PatientswhopresentedtotheMaxillofacialandOralSurgeryDepartmentofthe UniversityofWitwatersrandwithmidfacialfracturesandwhogaveconsentwere admittedtothestudy.Midfacialfracturesweredefinedasfracturesinanareaboundby thefrontozygomaticandfrontonasalsuturessuperiorly,theocclusalplaneinferiorly, posteriorlytothepterygoidplatesandlaterallytilltherootofthezygomaticarchas describedbyFrost1.

2.3ExclusionCriteria

Anypatientwhodidnotpresentwithmidfacialfractures,declinedtogiveconsentor withdrewfromthestudy.

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2.4ClinicalStudy

ThiswasaprospectiveauditundertakenintheDivisionofMaxillofacialandOral Surgery,DepartmentofSurgery,UniversityoftheWitwatersrandattheChrisHani BaragwanathHospitalandtheJohannesburgAcademicHospitalunits.

Atotalof94patientsrecordswerecollectedbymaxillofacialregistrarsatbothunits overa12monthperiodfrom(December2005toDecember2006).Allpatientswere consultedonanoutpatientbasisoradmittedtotheabovehospitals.

Thedatarecorded(AppendixC)reflectedadetailedclinicalexaminationwhichincluded ademographicprofile,medicalhistory,pastsurgicalhistory,aetiologyofthefracture andassociatedinjuries.Ageneralevaluationfollowedbyamorespecificmaxillofacial examinationwasundertaken.Themaxillofacialexaminationincludedsofttissue, skeletalandaneurologicalexamination.Anintraoralexaminationfollowedwhich assessedocclusion,dentition,alveolus,oralmucosa,palate,tongueandfloorofthe mouth.

Specialinvestigationsinparticularradiographicexaminationswereundertakento complimentclinicalexaminationandarriveatafinaldiagnosis.Theradiographs routinelyutilizedincludedOccipitomental(OM)viewstakenat0o,15o,30o, Submentovertex(SMV),Orthopantomograph(OPG),andComputertomography(CT) scans.Figures2.1to2.3illustratesomeexamplesoftheseradiographs.Interpretations

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oftheOccipitomentalviewsweredonefollowingtheprinciplesofMcGrigorand Campbell.34

Figure2.1Occipitomentalviewindicatingmultiplefacialfractures.

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 Figure2.2SMVusedtoassessfracturesofthezygomaticarch.

Figure2.3ThreedimensionalCTscanindicatingmultiplefacialfractures.

Thetreatmentofferedwasnotedincludinganyplatingsystemandotheralloplastic materialsusedforopenreductionandinternalfixation(ORIF)sothatacostingofthe hardwarecouldbeobtained.

35

2.5DataAnalysis

DatawasanalysedwithSASforWindows(Version9.1,SASInstituteInc.USA)

36

Chapter3Results
Recordswereobtainedfromatotalof94patientswhosustainedmidfacialfractures.

3.1Age,genderandracedistribution

Thepatientsagesrangedfromthreeto67yearsold.Theagesweredefinedperdecade foreaseofuseandforcomparativestudiesaslistedinTable3.1below.Gender distributionrevealedamalepredominanceinaratioof4:1(Table3.2).

Table3.1Frequencydistributionbyageindecades(N=94)

Decade

Agerange

Numberofpatients (N)

Percentage(%)

1 2 3 4 5 6 7

09 1019 2029 3039 4049 5059 6069

1 2 37 25 20 6 3

1.1 2.1 39.4 26.6 21.3 6.3 3.2

37

Table3.2Frequencydistributionbygender(N=94)

Gender Male Female

N 78 16

% 82.98 17.02

Blackpatientsaccountedforthelargestracialgroup(77.66%)followedbywhites, colouredsandasiansrespectively(Table3.3).

Table3.3Frequencydistributionbyrace(N=94)

Race Black Coloured Asian White

N 73 6 3 12

% 77.66 6.38 3.19 12.77

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3.2Natureofinjuryandsocialhabits

ThedistributionofthecausesofthefracturesisshowninTable3.4.Themostcommon causeofmidfacialfractureswasblunttraumaduetointerpersonalviolence(40.5%), followedbymotorvehicleaccidents(26.6%),gunshotwounds(13.8%)andfalls(5.3%). 13.8%ofpatientscouldnotrecollecthowtheywereinjuredasindicatedintable3.4.Of thosepersonsinjuredwithaweapononly2werestabwoundswiththeremaining18 injuredwithbricksorrod/pipe.

Table3.4Frequencydistributionbynatureofinjury(N=94)

Mechanismofinjury Injurywithweapon(otherthan firearm) Fist/s Gunshotwound/s Fall Motorvehicleaccident Unknown

N 20

% 21.3

18 13 5 25 13

19.2 13.8 5.3 26.6 13.8

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Ifoneconsidersallocatingthenatureofinjuryashighvelocity(gunshotandmotor vehicleaccidents)andlowvelocityinjuries(theremainingcausesofmidfacialfractures) thenthepercentagesare46.91%and53.09%respectively.Thisexcludesthe13patients whocouldnotprovideinformationaboutthemechanismofinjury.

Socialhabitsinvolvingalcoholconsumptionwasalsonotedin58.51%ofthepatients (Table3.5).Approximatelytwothirdsofpatientshadreportedsomedegreeoflossof consciousnessasillustratedinTable3.6.

Table3.5Frequencydistributionbyalcoholconsumption(N=94)

Alcoholconsumption No Yes

N 39 55

% 41.49 58.51

Table3.6Frequencydistributionbylossofconsciousness(N=94)

Lossofconsciousness No Yes

N 31 63

% 32.98 67.02

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Thecharacteristicsoftheinjuriessustainedindicatedthesiteofimpactasroughlyequal intermsofleftandmidline(26.6%right,30.9%left,31.9%midlineand10.6% unknown).Themostcommonlyassociatedinjurysustainedwithmidfacialfractureswas afracturedmandible(32.9%)followedbychesttrauma(5.3%)asindicatedinTable3.7. Sundayappearedtobethedayonwhichmostoftheinjuriesoccurredasillustratedin Table3.8.

Table3.7Frequencydistributionbyassociatedinjuries(N=94)

Associatedinjury None Mandible Chest other

N 49 31 5 9

% 52.2 32.9 5.3 9.6

41

Table3.8Frequencydistributionbydayoftheweek(N=94)

Day Monday* Tuesday Wednesday Thursday Friday Saturday Sunday Unknown

N 8 7 8 13 16 15 24 3

% 8.5 7.4 8.5 13.9 17 16 25.5 3.2

*TwopatientswereinjuredonaMondaywhichcoincidedwithapublicholiday.

3.3SpecialInvestigations

Fromthisstudy(asshowninTable3.9)themostprevalentradiographicinvestigations formidfacialfracturesweretheOM&SMVviews(61.7%).ThesewerefollowedbyCT scans,OPGandotherviews.Itshouldalsobenotedthatcertainradiographswerealso takenincombinationinclinicallyindicatedsituations.(e.g.takingofanOPGwithOM viewsfordentoalveolarfracturewithzygomaticbonefracture).

42

Table3.9Frequencydistributionbyradiographicinvestigations(N=94)

Radiology Occipitomental&SMV CTscans OPG Other

N 58 32 3 1

% 61.7 34 3.2 1.1

3.4Typeoffracturessustained

Thefracturessustainedvariedconsiderablyfromisolatedorbitalfloorblowoutfracture ornasalbonefracturetomultiplefracturesinvolvingacombinationofmidfacialbones. Inordertoavoidgreaterthan5%ofcellsinacontingencybeingemptyacombinationof fracturetypesweremade.ThefracturesweregroupedintoLeForttypefractures(I,II orIII),dentoalveolar(DA)fractures,zygomaticomaxillarycomplex(ZMC)fractures, panfacialfractures(involvingmultiplebones)andother(suchasNOEandBlowout fractures).ThesearelistedinTable3.10below.

43

Table3.10Frequencydistributionbyfracturepattern(N=94)

Typeoffracture Dentoalveolar Lefort(I,II,III) Panfacial Zygomaticcomplex Other

N 16 13 16 43 6

% 17.02 13.83 17.02 45.74 6.38

3.5Analyses

Inordertogaininsightintobehaviouralpatterns,analysisofthecircumstancesofthe injurywasdone.Ananalysisofalcoholconsumptiontothemechanismofinjurywas alsodonetodetermineifanystatisticalsignificancecouldbeelicited.Othercriteria werealsoassessedasreflectedinTable3.11toTable3.16below.Itwasalsorecorded thattheaverageperiodfromthetimeofinjurytomanagementwas13.9dayswitha rangeof1to151dayspriortotreatment.

44

Table3.11Analysisofalcoholconsumptionbymechanismofinjury(N=81)

Alcoholconsumption No(N) % Yes(N) % Total(N) %

Mechanismofinjury HighVelocity 27 33.33 11 13.58 38 46.91 LowVelocity 11 13.58 32 39.51 43 53.09

Total 38 46.91 43 53.09 81 100.00

TheChisquaretestindicatedaPvalue<0.0001.

Table3.12Analysisofalcoholconsumptionbygender(N=94)

Alcoholconsumption No(N) % Yes(N) % Total(N) % Female 7 7.45 9 9.57 16 17.02

Gender Male 32 34.04 46 48.94 78 82.98

Total 39 41.49 55 58.51 94 100.00

TheChisquaretestindicatedaPvalueof0.8403.

45

Table3.13Analysisofgenderbymechanismofinjury(N=81)

Gender Female(N) % Male(N) % Total(N) %

Mechanismofinjury HighVelocity 11 13.58 27 33.33 38 46.91 LowVelocity 4 4.94 39 48.15 43 53.09

Total 15 18.52 66 81.48 81 100.00

TheChisquareindicatesaPvalueof.0231

46

Table3.14Analysisofdecadebygenderandalcoholconsumption(N=93).

Decade 1&2(N) % 3(N) % 4(N) % 5(N) % 6(N) % Total(N) %

Alcoholconsumption No 1 1.08 17 18.28 10 10.75 9 9.68 1 1.08 38 40.86 Yes 2 2.15 20 21.51 15 16.13 11 11.83 7 7.53 55 59.14

Total 3 3.23 37 39.78 25 26.88 20 21.51 8 8.60 93 100

Gender Female 2 2.15 6 6.45 2 2.15 4 4.3 2 2.15 16 17.20 Male 1 1.08 31 33.33 23 24.73 16 17.20 6 6.45 77 82.8

Total 3 3.3 37 39.78 25 26.88 20 21.51 8 8.6 93 100

ChisquareindicatesaPvalueof0.5123

ChisquareindicatesaPvalueof0.1299

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Table3.15Analysisoffracturetypebyalcoholconsumptionandmechanismofinjury.

Fracture

Alcohol consumption

Total

Mechanismofinjury

Total

DA(N) % LeFort(N) % Other(N) % Panfacial(N) % Zygoma(N) % Total(N) %

No 11 11.7 5 5.32 3 3.19 3 3.19 17 18.09 39 41.49

Yes 5 5.32 8 8.51 3 13.83 13 13.83 26 27.66 55 58.51

16 17.02 13 13.83 6 17.02 16 17.02 43 45.74 94 100.00

Highvelocity 11 13.58 5 6.17 1 1.23 7 8.64 14 17.28 38 46.91

LowVelocity 3 3.7 5 6.17 4 4.94 8 9.88 23 28.40 43 53.09

14 17.28 10 12.35 5 6.17 15 18.52 37 45.68 81 100.00

ChisquareindicatesaPvalueof0.0719

ChisquareindicatesaPvalueof0.0796

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Table3.16Analysisoffracturetypebytreatment.

Fracture DA(N) % LeFort(N) % Other(N) % Panfacial(N) % Zygoma(N) % Total(N) %

C 9 9.57 2 2.13 1 1.06 0 0.00 5 5.32 12 18.08

ED 6 6.38 1 1.06 1 1.06 0 0.00 0 0.00 8 8.51

N 1 1.06 1 1.06 1 1.06 0 0.00 8 8.51 11 11.70

O 0 0.00 8 8.51 0 0.00 16 17.02 30 31.91 54 57.45

X 0 0.00 1 1.06 3 3.19 0 0.00 0 0.00 9 4.25

Total(N) 16 17.02 13 13.83 6 6.38 16 17.02 43 45.74 94 100.00

ChisquareindicatesaPvalueof<0.0001however,76%ofthecellshaveexpected countsoflessthan5.

C=Closedreduction

N=Notreatment

ED=Extraction/sanddebridement

X=Othermethods

O=OpenReductioninternalFixation(ORIF)
49

3.6Hardwarecosts

Atotalofthreecompaniesprovidedtheplatingsystemsforinternalfixation.The averagepriceforascrewfromthesecompanieswasR182.45andtheaveragepricefor aminiplatewasR509.63.

Anaverageoftwominiplateswitheight1.5mmor1.3mm(dependingonwhich companysystemwasused)screwswasusedforplatingafracturedzygoma.The averagecostperpatientforanORIFofafracturedzygomawasR2479.12(2x509.63+ 8x182.45).Forpanfacialfracturesanaverageof6miniplatesand32screwswere utilizedperpatient.ThusacostofR7438.69(6x509.63+24x182.54)perpatientfor ORIFofpanfacialfractureswasnoted.LeFortfracturesonaveragerequired4mini platesand16screws,resultinginacostofR4959.16(4x509.63+16x182.54)per patientforORIFLeFortfracture.

CollatingtheabovedatawiththatofTable3.16forthenumberofORIFforeachofthe fracturetypes,atotalofR287090.28wasobtainedastheaveragecostofhardware utilizedinthisreport.ThisequatestoUS$35886.29perannumforthisstudy(rateof R8.00=US$1).

50

Chapter4Discussion
TheDepartmentofMaxillofacialandOralSurgeryoftheUniversityofthe Witwatersrandprovidesservicestovirtuallytheentirecentral,southern,easternand westernareaoftheGautengProvinceviatheJohannesburgAcademicandChrisHani BaragwanathHospitals.Thesetwotertiaryinstitutionsalsoacceptreferralsfromparts oftheNorthWest,FreeStateandNorthernCapeProvinces.Theservicesrendered includeallaspectsofmaxillofacialsurgerywithtraumaformingthebulkofthecaseload.

Theaetiologyofmidfacialfracturesinthisstudyvariedconsiderablywithblunttrauma duetointerpersonalviolenceaccountingfor40.5%ofallinjuriessustained.Ofthose patientswhosustainedfracturesasaresultofaweapon,18(19.2%)wereinjuredwith bluntforcetraumawithabrickorrod/pipe,2(2.1%)withknifewoundsand13(13.8%) werevictimsofbulletwounds.ThisfindingissimilartootherstudiesconductedinSouth Africawhichindicatedviolenceastheprincipalmodalityofmaxillofacialinjuries.21,22,35 Greeneetal29alsonotedthatmostfacialinjuriesresultedfromnonpenetratinginjury.

Inthisstudyroadtrafficaccidentsaccountedfor26.6%ofallthefractures.Thisisin contrasttoZachariadesetal30andvanBeeketal27whonotedthatroadtraffic accidentsaccountedformorethanhalfofmaxillofacialinjuriesinGreeceand Netherlandsrespectively.VanBeeketal27didhowevernoticeasharpdecreaseinroad trafficaccidentswithaconcomitantincreaseinviolenceasacauseofmaxillofacial

51

injuriesovera27yearperiod.Falls(5.3%)weretheleastcontributorstomidfacial fracturesinthisstudy.Onceagainsimilarepidemiologicdatawerenotedinprevious SouthAfricanstudies.21,22,35

Fromthisstudyitwasnotedthatthemaletofemaleratiois4:1.Thismarkedmale predominanceissimilartothoseepidemiologicalstudiesconductedinIrbid,Jordan23 andNjimegen,Netherlands.27Thisalsocomparefavourablywithpreviousstudies conductedinSouthAfrica.20,21,22,35Thesefindingsarehoweverincontrasttothose foundinInnsbruck,Austria27andinChennai,India26wheretheauthorsreportahigher femaleincidencebutstillamalepredominance.

77.6%ofpatientswhosoughttreatmentinourhospitalswereblack,followedbywhites, colouredsandasiansindescendingorderoffrequency.Possibleexplanationsforthis trendincludethefactthatblacksconstitutethehighestpopulationinSouthAfrica.36 Secondlythehighestunemploymentrateinourcountyisamongstblacks.36These indigentpatientswithoutanyformofmedicalinsurancewouldthereforetendtoseek treatmentinpublicinstitutionslikeours.Thesmallerpopulationgroups,withfewer ratesofunemployment,tendtoseekmedicaltreatmentintheprivatesector.Previous studiesinourcountrycorroboratethistrend.20,21,22,35

Ifoneconsiderstheagerangeitwasnotedthat67.0%ofindividualsthatsustained midfacialinjurieswerereportedtobeinthethirdandfourthdecadewiththehighest incidencenotedinthethirddecade(39.4%).Desai35describedthisgroupas representingtheunskilledlabourforcethatareusuallypaidweeklyandtraditionally

52

frequentdrinkingestablishments(colloquiallyknownasShebeens)overtheweekends. Duetoinebriationatthetimethisleadstoamarkedincreaseininterpersonalviolence withrobberyoftenbeingthemotive.

Ofthosepersonswhosustainedmidfacialfractures,58.51%wereintoxicatedatthe timeofinjury.Somepatients(13.8%)weresoinebriatedatthetimeofinjurythatthey hadnorecollectionofhowtheywereinjured.3.8%oftheintoxicatedpatientshadno recollectionofwhichdaytheywereinjuredduetointoxicationortheirstateof consciousness. Kontioetal33reportedintheirstudyofmaxillofacialinjuriesthatthelevelofviolence hadbecomemoresevereinnature.Thisisborneoutinthat67.02%ofindividualsinthis studyreportedlossofconsciousnesswhicheveniftransientisdefinedasamildhead injuryaccordingtoATLS. Kontioetal33alsoreportedthatmaxillofacialinjuriesoccurredmostoftenoverthe weekendsandcorrelateditwithFinnishdrinkinghabits.Anecdotalevidenceinourunit haslongsupportedthehypothesisthatmostmaxillofacialinjuriesoccurredduring weekends.Thisstudyconfirmsoursuspicioninthat58.5%ofthe94patientswere injuredovertheweekend,withSunday(25.5%)beingthedaywhenmostinjurieswere sustained.AsfarasIamawarethisisthefirstSouthAfricanstudytorecordinjuries takingintoaccountdaysoftheweekinordertoprovideinsightintobehavioural patterns.ItsthusfairtoconcludethatSouthAfricanshavesimilarsocialhabitstothe Finnish.
53

Ifoneanalysesthedataastatisticallysignificant(ChisquaretestindicatedaPvalue <0.0001)correlationoflowvelocitytraumaandalcoholconsumptionisnoted,thus providingcredibilitythatsubstanceabuseiscloselyrelatetotrauma(Table3.11). Surprisinglythereseemstobeneitherstatisticalsignificancebetweengenderand alcoholconsumptionnoranysignificancebetweengenderandmechanismofinjury, thussuggestingthatfemalepatientswereequallyaffectedasmalesbyalcoholand mechanismofinjuryalbeitinlowernumbers.

Thecharacteristicsofinjuriessustainedindicatethatmajorityofthevictimsare assaultedmoreontheleftsuggestingthattheassailantsaremainlyrighthanded.Also themostcommonlyassociatedinjurywithmidfacefracturesisafracturedmandible (32.9%). Beaumontetal20reportedintheirstudythatwhenconsideringmidfacefractures,ZMC fracturespredominatefollowedbyLeFortandDAfracturesrespectively.Twentyone yearslaterthisstudyonceagainconfirmsthatZMCarethemostcommonmidface fractures(45.74%).Inthisstudyhoweverpanfacialfractures(17.02%)werethesecond mostfracturesfollowedbyDA(17.02%)andLeFort(13.83%).FracturessuchasNOE andisolatedblowoutfracturesonlyaccountedforlessthan7%ofthefractures.Other authorshavealsoreportedthataZMCfracturehasthehighestincidencealthough thereisvariabilityinthefrequencyoftheothermidfacialbones.29,30,31,32Onereason forthehighrateintheZMCfracturesisthatitisinstinctivetoturntheheadwhen anticipatingablowtothemidfaceinordertoprotecttheglobe.

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Intermsoftreatment,the16patientswithpanfacialfractures,30(31.9%)ZMCand8 (8.5%)LeFortfracturesweretreatedwithopenreductionandinternalfixationwhich allowedforimprovedrigidityoftheseunstablefractures.Inthisstudy5(11.63%)of ZMCfracturesweretreatedbyclosedreduction.8(8.5%)patientswithundisplaced zygomafracturesweretreatedconservatively(i.e.observationonly)asisadvocatedin theliterature.13TheChisquareresultsreflectedinTable3.16indicatesaPvalueof <0.0001however,76%ofthecellshaveexpectedcountsoflessthan5thusrendering thestatisticalanalysesvoid.Theresultsdohoweversuggestatrendinthetreatment offeredtothevariousfracturetypes.Althoughthesizeisnotsufficienttheclinical importanceisstillpresent.ToillustratethisitisnotedthattheneedforORIFofZMC fracturesishighwhichsuggeststhatthemajorityofthereviewedpatientshave displaced,comminutedandunstableZMCfracturesattestingtotheviolentnatureof thetrauma.

Thetimeintervalfromthedateofinjurytodateofsurgeryrangedfrom0to151days withameanof13.9days.Thedelayintreatingpatientsisattributabletotwomain factors:

(1)Delayedpresentation:Themajorityofpatientsthataretreatedarereferredfrom peripheralhospitalsasfaras400kilometresfromChrisHaniBaragwanathand JohannesburgHospitals.Thesepatientseitherdependonscheduledhospitaltransport toferrythemtoourhospitaloroftenhavetoseekscarcefinancialresourcestoarrange fortransporttoourunits.

55

(2)Patientoverload:Thehighprevalenceofinterpersonalviolenceinourcountryoften resultsintraumaoverload.Combinedwithabroaderlackofresourcessuchasalackof theatretimeitinevitablyresultsinlongerwaitingperiods.

Bythetimethesepatientsgettotheatreinappropriatehealing(intheformoffibrous union,malunionandsepsishastakenplace)thusoftennecessitatingosteotomisingthe fractureswithsubsequentprolongationoftheatretimeandincreasingcosts.Also treatmentoftheolderfracturesoftenyieldssuboptimalclinicaloutcomes.

Fromthisstudyitisnotedthatonaveragethehardwarecostsforapatientwitha ZMCfractureequatestoR2479.12whilstthatofapanfacialwasR7438.69. InterestinglythecostsprovidedbyDuvenage22in1979reportedatotalhospitalcost formaxillofacialinjuries(inclusiveofanaesthetic,wardandhardwarecosts)ofR295.75 forORIFingeneral. Desai35in2006reportedatotalcostforhardwareonlyforORIFoffractured mandibletothestateperannumofR158305.Thisstudyrevealsthetotalhardware costformidfacialfracturestobeR287090.28perannum.Thesecostsdonotinclude ward,anaestheticandtheatrefees.

56

Chapter5Conclusion
Thisstudyhasshownthatthemajorityofpatientspresentingwithmidfacialfractures werethoseoflowersocioeconomicstatus(i.e.blacks).Themajorityofthesepatients wereinjuredoverweekendsandwereinebriatedatthetimeofinjury.Blunttraumadue tointerpersonalviolencewasthemostcommoncauseoffacialfractures.Thezygomatic complexfracturewasthemostcommonlyobservedmidfacefracture.Thisstudy suggeststhatarelationshipexistsbetweenfacialtrauma,povertyandalcohol consumption.Itisalsonotedthatfacialtrauma(mainlyduetointerpersonalviolencein ourcountry)placesenormousfinancialburdenonthestate.

Futurestudiesshouldseektounderstandtheepidemiologicalfactorsinfluencingfacial traumainanefforttoimprovepreventionandmanagementoftheseinjuries.

Inadditionitisclearthattrendsareobservedwhenanalysingthedatacollated, howeverthelimitednumbersofpatientsdonotreflectstatisticalsignificance.Again, furtherresearchisrequiredtoencompassalargersamplesizewithadequatefollowup ofclinicaloutcomesastoobtainmoremeaningfuldatawithothercriteriasuchas complicationrates,sepsisratesandtotalhospitalisationcostsbeingincorporated.This wouldenhanceabetterunderstandingofinfluencingpatternsonfacialtraumawitha viewtoprovidinganeffectiveresponsetothisepidemic.

57

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8. CunninghamLL,HaugRH.Managementofmaxillaryfractures.In:MiloroM., GhaliGE,LarsonP,WaiteP,editors.PetersonsPrinciplesofOraland MaxillofacialSurgery.BCDeckerInc.Canada.2004:chapter23.1:434438. 9. MukerjiR,MukerjiM,McGurkM.Mandibularfractures:historicalperspective. BrJOralMaxillofacSurg2006;44:222228. 10. BagheriSC,HolmgrenE,KademaniD,HommerL,BryanBellR,PotterB,etal. ComparisonoftheseverityofbilateralLeFortinjuriesinisolatedmidface trauma.JOralMaxillofacSurg2005;63:11231129. 11. GilliesHD,KilnerTP,StoneD.Fracturesofthemalarzygomaticcompound:with adescriptionofanewxrayposition.BrJSurg1927;14:651656. 12. MansonP.Transcutaneousreductionandexternalfixationforthetreatmentof noncomminutedzygomafractures.JOralMaxillofacSurg1998;56,13871389. 13. EllisEIII.Fracturesofthezygomaticcomplexandarch.In:FonsecaRJ,Walker RV,editors.OralandMaxillofacialTrauma.WBSaundersCompany. Philadelphia.1991:chapter18:440460. 14. BaileyJS,GoldwasserMS.Managementofzygomaticcomplexfractures.In: MiloroM.,GhaliGE,LarsonP,WaiteP,editors.PetersonsPrinciplesofOraland MaxillofacialSurgery.BCDeckerInc.Canada.2004:chapter23.2:445455. 15. ZinggM,LaedrachK,ChenJ,etal.Classificationandtreatmentofzygomatic fractures:areviewof1025cases.JOralMaxillofacSurg1992;50:778.

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25. BalakrishnanNandPaulG.Incidenceandaetiologyoffractureofthefacio maxillaryskeletoninTrivanadrum:aretrospectivestudy.BrJOralMaxillofac Surg1986;24:4043. 26. SubhashrajK,NandakumarN,RavindranC.Reviewofmaxillofacialinjuriesin Chennai,India:Astudyof2748cases.BrJOralMaxillofacSurg2007;45:637639. 27. VanBeek.MerckxCA.Changesinthepatternoffracturesofthemaxillofacial skeleton.IntJOralMaxillofacSurg1999;28:424428. 28. GassnerR,TuliT,HachlO,RudischAandUlmerH.Craniomaxillofacialtrauma:a 10yearreviewof9543caseswith21067injuries.JCranioMaxillofacialSurg 2003;31:5161. 29. GreeneD,RavenR,CarvalhoGandMaasCS.Epidemiologyoffacialinjuryin bluntassault.ArchOtolaryngolHeadNeckSurg1997;123:923928. 30. ZachariadesN.Papavassiliou.ThePatternandaetiologyofmaxillofacialinjuries inGreece.JCranioMaxillofacialSurg1990;18:251254. 31. AlKhateebT,AbdullahFM.CraniomaxillofacialinjuriesintheUnitedArab Emirates:aretrospectivestudy.JOralMaxillofacSurg2007;65:10941101. 32. FerreiraP,MarisaM,PhinoC,RodriguesJ,ReisJ,ArmanteJ.Midfacialfractures inchildrenandadolescents:areviewof492cases.BrJOralMaxillofacSurg 2004;42:501505. 33. KontioR,SuuronenR,PonkkonenH,LindqvistC.,LaineP.Havethecausesof maxillofacialfractureschangedoverthelast16yearsinFinland?An epidemiologicalstudyof725fractures.DentalTraumatology2005;21:1419.
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34. WhaitesE.Essentialsofdentalradiographyandradiology.ChurchillLivingstone. Edinburgh2002:402406. 35. DesaiJ.Mandibularfracturepatternsasrelatedtomechanismofinjurya prospectiveauditofJohannesburgpatients.UniversityoftheWitwatersrand. Johannesburg.2006:24. 36. LehohlaP.Censusinbrief.StatisticsSouthAfrica.1998. http://www.statsa.gov.za/censu01/Census98/HTML/default.htm(accessed25th March2008).

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APPENDIX

AppendixA

63

 AppendixB
PARTICIPANTINFORMATIONSHEETANDCONSENT. Dearpatient

MynameisDr.YusufFSulemanandIamaregistrarintheDivisionofMaxillofacial&Oral Surgery.Aspartofmytraining,Iamconductingastudyaboutmidfacialfractures(brokenbones ofthefacefromtheeyebrow,nose,thebonesaroundthecheekandupperjawincludingupper teethbutnotincludingthelowerjaw).

Asyourinjuriesareconsistentwiththosedescribedabove,Irequireyourhelpbyallowingmeto useyourclinicalrecords;thesewouldincludeaphysicalexaminationofyourselfaswellas analysisofyourxraysforthepurposesofthisstudy.Itishopedthatthisstudywillhelpour departmentbetterunderstandthisinjury,andimproveonourservicetoallofourpatients.

Yourparticipationinthisstudyispurelyvoluntaryifyousowishatanytimeandthatwhether youparticipateornotwillnotaffecttheoutcomeofyourtreatmentandsuchyoumaychoose whetheryouwouldliketoparticipateinthisstudyornot.Ifyouopttoparticipateafew questionswillbeaskedaboutthecircumstancessurroundinghowyougotinjuredaswellasan examinationoftheextentofyourinjuries.Acopyoftheinformationsheetisattachedforyour perusal.

Pleasenotethatitisyourrighttowithdrawfromthisstudyifyouwishatanytimeandthat whetheryouparticipateornotwillnotaffecttheoutcomeofyourtreatment.

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Youwillnoticethatthedatainformationsheetdoesnotreflectyournameandassuchyouwill remainanonymousandallinformationgatheredisstrictlyconfidentialandwillbeusedfor researchpurposesonly.

Ifyouhaveanyquestionsrelatingtothisstudyorfeelthatyoumayrequiremoreinformation aboutthestudy,youmaycontactmeon0119338107(ChrisHaniBaragwanathHospital,Ward H4).

THEDOCTORHASEXPLAINEDHISINTENTIONSTOMEANDIAGREETOPARTICIPATEINTHIS STUDY.IDOSOFREELYANDUNDERSTANDTHATIMAYWITHDRAWATANYTIME,WITHOUT COMPROMISINGANYTREATMENTDUETOME.

PATIENTSIGNATURE

DATE..

OR

PARENT/LEGALGUARDIAN..

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AppendixC
MIDFACE FRACTURE PATTERNS PATICIPANT INFORMATION DATA SHEET. DateofBirth: Race: DateofConsultation: Intoxicatedatthetime: Y/N Lossofconsciousness: patent/compromised/obstructed Airway : Neurologicalstatus:GCSscore/15/10 Relevantmedicalhistory: Relevantsurgicalhistory: Mechanismofinjury (Tickappropriate) Motor vehicle accident Occupant Pedestrian Motorcyclist Cyclist

Gender: M/F DateofInjury: DateofAdmission: Hospitalno.:

Assault Fist Foot Pipe Brick Bottle Firearm

Sport Industrial IncludingBat/Stick Other Fall Miscellaneous BluntTrauma highvelocity:(mva/other) lowvelocity:(fists/fall) highvelocity:(bullet/blastshrapnel/other) PenetratingTrauma lowvelocity:(knife/other) stateentranceandexitwound(ifapplicable) left/right/midline Siteofimpact : : lacerations/abrasions/avulsive Softtissue Associated/Otherinjuries: SpecialInvestigations:

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Midfacial Fracture/s Orbit Zygoma

: (Tick and illustrate on diagram below) Blowout Frontal process LeFortI NOE Maxillary process LeFortII Arch Other

Buttress

Maxilla LeFortIII Dentoalveolar Nasal Palate SignsandSymptoms: :Y/N Displacedfracture :ORIF/CRFM/NONE(indicatetreatmentontableanddiagrambelow) Treatment Plating Y X DoubleY L Curved Straight Wires Gillies MMF Arch Bars Wires DurationofMMF:

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