Introduction

Trauma is defined as the injury of tissues and organs from acute or chronic transmission of energy¹. Maxillofacial trauma corresponds to all traumatic injuries affecting the bones of the face, determined by the upper, middle and lower thirds of the face. Nowdays, it represents one of the main healthcare issues worldwide. Because of these injuries are extremely serious and complex, they are often associated with high morbidity, loss of function and high cosmetic, social and economic costs^2-4. The basic principles of fracture treatment include reduction of bone fragments and fixation and monitoring of postoperative complications⁵. The goals are to obtain complete and stable fixation, protect the organs of the face, preserve craniofacial contours and prominences, and restore dental occlusion and pre-injury joint function⁶. The aim of this study is to analyze the experience of the interventions performed in patients with maxillofacial fractures and the subsequent management of their complications.

Material and methods

We conducted a retrospective and observational study. Data from 205 patients admitted in the area of general surgery of Hospital Militar Central de Buenos Aires due to head and neck surgery between 2011 and 2019 was retrieved from the electronic clinical records. The variables analyzed were demographics, year of intervention, mechanisms of trauma, type of fractures, type of procedure and postoperative complications according to the modified Clavien-Dindo classification⁷. Readmissions were defined as a new hospitalization within 30 days after hospital discharge. In accordance with our surgical technique, the approaches most used were coronal and external ciliary for upper-third fractures; subciliary for orbital floor fractures; superior vestibular for middle-third fractures and inferior vestibular for mandibular body fractures. The Risdon approach was used for fractures of the mandible body, angle and ramus. Data were analyzed using a Microsoft Office Excel^© spreadsheet.

Results

Of the 205 patients with maxillofacial fractures, 81.46% were men (n = 167). Figure 1 shows the incidence by age ranges; the highest incidence was in the age range between 21 and 30 years (38.54%; n = 79), followed by the age range < 20 years, (14.15%; n = 29).

The types of facial fractures and their frequency are detailed in Table 1, subdivided into panfacial bone fractures (12.2%; n = 25) (Fig. 2f (involving > 1 third of the face); upper-third fractures (1.46%; n = 3), middle-third fractures (72.2%; n = 148) and lower-third fractures (14,15%; n = 29).

In the upper third of the face, 66.67% (n = 2) corresponded to frontal sinus fractures associated with the frontal bone (Fig. 2e). The most common fractures of the middle third of the face were combined (54.73%; n = 81), followed by isolated fractures of the floor of the orbit (27.7%; n = 41) (Fig. 2b). In the lower third of the face, complex fractures were most common (34.48%; n = 10) (Fig. 2c), followed by multiple fractures (24.14%; n = 1) and mandible ramus fractures, (17.24%; n = 5) The mechanisms of trauma by order of frequency were traffic collision (56.1%; n = 115), blunt trauma (27.32%; n = 56), ground level fall 15.12% (n = 31) and gunshot injury 1.46% (n = 3). Table 2 shows the association found between the type of facial fracture and its mechanism of trauma.

Non-surgical management was decided in only 6 patients (2.92%). In 199 patients (97.07%), surgical treatment consisted of reconstruction with titanium mini-plates and screws in 95.48%, reconstruction with titanium mesh and screws and use of osteoconductive material in 80.9% (Fig. 3).

Post-operative complications occurred in 11.56% of the cases (n = 3), and according to the modified Clavien-Dindo classification were as follows: grade I (seroma in 2 cases, edema in 4, pain in 3, temporary diplopia in 1, temporary paresthesia in 4, and ectropion in 3) in 8.54% (n = 17); grade II (corresponding to 1 case of fistula with spontaneous closure) in 0.5% (n =1) and grade IIIb (persistent fistula in 2 and rejection of prosthetic material in 3) in 2.52% (n = 5). No complications grade IV or V were reported.

Discussion

The results obtained in this study show that most maxillofacial trauma occurred in men and the age range most affected was between 21 and 30 years, followed by those < 20 years and those between 31 and 40 years. Then, the incidence of facial fractures decreases as age increases. These age ranges and gender distribution are similar to the results of other publications^8-12,4,13.

Nowadays, computed tomography scan is the gold standard for the evaluation of facial fractures, while the extension of lesions to other tissues allows characterization by different criteria and identification of possible causes of complications¹⁴. The epidemiology of facial fractures varies by type, severity and cause depending on the study population^9,12.

In our study, middle-third bone face fractures were most common, in accordance with previous studies^9,11,15. We found that combined fractures had the highest prevalence, followed by isolated fractures of the orbital floor; this is due to the fact that, in general, they are commonly associated with maxillary, zygomatic or nasal fractures due to the anatomy of the region¹⁶. One of the first mechanisms of orbital fracture was described in 1943 by Pfeiffer (blow out), who stated that the force of the blow received by the eyeball is transmitted by it to the walls of the orbit, fracturing the most delicate bones, such as the floor of the orbit. In the less severe cases the posterior portion is fractured, and in the more severe injuries the entire floor is broken through¹⁷. The presence of an air-fluid level or complete opacification of the maxillary sinus and fat herniation (teardrop sign) is common, which may also involve the inferior rectus muscle and the inferior oblique muscle and be associated with diplopia. Rarely fragments from an orbital floor fracture buckle up into the orbit, an injury referred to as a “blow-in” fracture¹⁶.

Lower-third fractures occurred in second place; this result differs from that of other publications in which the lower third was the most commonly affected^13,18-23. Finally, upper-third fractures accounted for 1.46% of cases (n = 3). In our study, traffic collisions were the most common cause of fractures across all fracture categories, mainly in the age groups 21-30 years and <20 years. This can be explained by the fact that these groups are involved in high-risk activities, use mainly car transportation, and participate mostly in nocturnal activities. These statistical data were similar to those reported by other publications^{18,8,9,24,11,16,13}. A recent international original research paper concludes that the cause of injury varies by geographic region and sex; the most common causes are ground level falls and blunt force trauma due to physical violence²⁵.

Titanium mini-plates or meshes with screws, or both elements with or without osteoconductive material, were used in the patients who underwent surgery. Titanium-based material for osteosynthesis is insoluble in the body, has excellent corrosion and mechanical resistance and biocompatibility, and is biologically inert⁶. In our series only 23 patients (11.56%) developed complications; the highest percentage (8.54%, n = 17) were mild (grade I), followed by 2.52% (n = %) grade IIIb complications (fistula and rejection of prosthetic material), which required further surgeries. Within this last category, the mechanism of trauma was traffic collision in 4 patients in the age range between 21 and 50 years, while in the remaining patient, the mechanism of trauma was blunt trauma in the age range of 71-80 years. Among the different complications that can occur in the treatment of fractures, the most common were infections in the site of the fracture and their consequent progression to fistula and rejection of the prosthetic material²⁶. This supports the aforementioned statement that traffic collisions were the most prevalent cause and can be considered as contaminated wounds; thus, their treatment and postoperative outcome are more complex. We did not observe serious complications, deaths or readmissions.

Conclusion

In our series, most patients were young men, traffic collisions were the most common cause of trauma, and the middle third of the face was the most affected region. Surgical management, mostly by open reduction and fixation with titanium osteosynthesis material, is an effective, safe and reliable procedure, which allows the restoration of pre-trauma function in most patients, with very low rate of postoperative complications and repeated surgeries.