Research Report Final- Aetiology & Mechanism of Midfacial Fractures

7/28/2019 Research Report Final- Aetiology & Mechanism of Midfacial Fractures

1/67

AETIOLOGY AND MECHANISM OF INJURY OF MIDFACIAL FRACTURES: A

PROSPECTIVE STUDY OF THE JOHANNESBURG REGION.

YusufFaroukSuleman

AresearchreportsubmittedtotheFacultyofHealthSciences,Universityofthe

Witwatersrand,Johannesburg,inpartialfulfillmentoftherequirementsforthedegree

ofMasterofDentistryinMaxillofacialandOralSurgery.

Johannesburg2008


2/67

2

Candidatesdeclaration

I,YusufFaroukSuleman,declarethatthisresearchreportismyownwork.Itisbeing

submittedforthedegreeofMasterofDentistryinthebranchofMaxillofacialandOral

Surgery,intheUniversityoftheWitwatersrand,Johannesburg.Ithasnotbeen

submittedbeforeforanydegreeorexaminationatthisoranyotheruniversity.

______________dayof_____________________200__.


3/67

3

Dedication

Bismillahhirrahmaanirraheem

Tomyparentswhonurturedandguidedme

Tomybeautifulwife,Yasmeen,forherundyinglove,dedicationandsupport.

Tomy

children

from

whom

Idraw

strength

and

happiness.


4/67

4

ABSTRACT

Objective: Todeterminetheaetiology,biomechanicsanddemographicsofpatients

withfractures

of

the

midface.

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

fractureswere lesscommonlyobservedthanzygomaticomaxillarycomplexmidface

fractures.

Conclusion:Arelationshipexistsbetweenfacialtrauma,povertyandalcohol

consumption.Blunttraumaduetointerpersonalviolenceisthemostcommoncauseof

midfaceinjuries.Majorityofinjuriesaresustainedduringweekends.

Zygomaticomaxillarycomplexfracturesarethemostcommonmidfacefractures.


5/67

5

ACKNOWLEDGEMENTS

Iwishtoexpressmysinceregratitudetothefollowingpersons:

ProfessorJ.Lownie BDS,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.forhisexpertise,enthusiasmandstatisticalanalyses.

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


6/67

6

TABLEOFCONTENTS

TITLEPAGE 1

DECLARATION 2

DEDICATION 3

ABSTRACT 4

ACKNOWLEDGEMENTS 5

TABLEOFCONTENTS 6

LISTOFFIGURES 9

LISTOFTABLES 10

NOMENCLATURE 11

CHAPTER1:INTRODUCTION 12

1.1Applied

anatomy

12

1.1.1Zygoma 13

1.1.2Maxilla 14

1.1.3Nasalbones 15

1.1.4LacrimalBones 15

1.2

History

of

midfacial

fractures

and

their

management

16

1.3Classification 18

1.3.1Zygomaticfractures 18

1.3.2Maxillaryfractures 20


7/67

7

1.3.3Nasoorbitoethmoid(NOE)fractures 22

1.4SignsandSymptoms 25

1.4.1NOE 25

1.4.2Maxilla 26

1.4.3Zygoma 26

1.5LiteratureReview 27

1.6AimsandObjectives 31

CHAPTER2:MATERIALSANDMETHODS 32

2.1Ethicalclearance 32

2.2InclusionCriteria 32

2.3ExclusionCriteria 32

2.4ClinicalStudy 33

2.5DataAnalysis 36

CHAPTER3:

RESULTS

37

3.1Age,genderandracedistribution 37

3.2Natureofinjuryandsocialhabits 39

3.3SpecialInvestigations 42

3.4Typeoffracturessustained 43

3.5

Analyses

44

3.6Hardwarecosts 50

CHAPTER4:DISCUSSION 51

CHAPTER5:CONCLUSION 57


8/67

8

REFERENCES 58

APPENDIX 63

AppendixA EthicalClearance 63

AppendixB Patientinformationsheetandconsent 64

AppendixC Participationinformationdatasheet 66


9/67

9

LISTOFFIGURES

Figure1.1A&Bfacialbuttressofthemidfaceandarchitecturalmodelrespectively. 13

Figure1.2

Le

fort

I,II

&

III

fracture

lines

frontal

&

three

quarter

view

21

Figure1.3NOEtypeIfractureunilateralandbilateral 23

Figure1.4NOEtypeIIfractureunilateralandbilateral 23

Figure1.5NOEtypeIIIfractureunilateralandbilateral 24

Figure2.1Occipitomentalviewindicatingmultiplefacialfractures 34

Figure2.2SMVusedtoassessfracturesofthezygomaticarch. 34

Figure2.3ThreedimensionalCTscanindicatingmultiplefacialfractures. 35


10/67

10

LISTOFTABLES

Table3.1Frequencydistributionbyageindecades 37

Table3.2

Frequency

distribution

by

gender

38

Table3.3Frequencydistributionbyrace 38

Table3.4Frequencydistributionbynatureofinjury 39

Table3.5Frequencydistributionbyalcoholconsumption 40

Table3.6Frequencydistributionbylossofconsciousness 40

Table3.7Frequencydistributionbyassociatedinjuries 41

Table3.8Frequencydistributionbydayoftheweek 42

Table3.9Frequencydistributionbyradiographicinvestigations 43

Table3.10Frequencydistributionbyfracturespattern 44

Table3.11Analysisofalcoholconsumptionbymechanismofinjury 45

Table3.12Analysisofalcoholconsumptionbygender 45

Table3.13Analysisofgenderbymechanismofinjury 46

Table3.14Analysisofdecadebygenderandalcoholconsumption 47

Table3.15Analysisoffracturetypebyalcoholconsumption&mechanismofinjury 48

Table3.16Analysisoffracturetypebytreatment 49


11/67

11

NOMENCLATURE

ComputerTomography =CT Dentoalveolar =DA HumanImmunodeficiencyvirus =HIV Nasoorbitoethmoid =NOE Occipitomental =OM Orthopantomograph =OPG OpenReductionInternalFixation =ORIF Submentovertex =SMV Zygomaticomaxillarycomplex =ZMC


12/67

12

Chapter1Introduction

1.1AppliedAnatomyofthemidfacialbones

Themidfaceiscomposedofthenasal,zygoma,maxilla,ethmoidanditsconchae,

palatine,inferiorconchaandvomerwhicharecollectivelyreferredtoasthemiddle

thirdofthefacialskeleton.Thesefacialbonesinisolationarecomparativelyfragilebut

gainstrength

and

support

as

they

articulate

with

each

other.

1,

2

Itisthisstrengthgainedfromeachotherthathasoftenbeendescribedasthefacial

buttresseswhichManson3alludedtowhendescribingtheverticalandhorizontalstruts

thatsupportthefacialskeleton(Figure1.1).Thehorizontalpillarsareformedbythe

frontalbar(composedofthesupraorbitalrimsandnasalprocessofthefrontalbone),

thezygomaticarch,infraorbitalrims,andthenasalbridgeandfinallythealveolar

processofthemaxilla.

Theverticalpillarsareformedfirstlymediallybythepiriformrimswhichcontinue

superiorlyasthefrontalprocessofthemaxilla.Secondlythezygomaticbuttresseswhich

continuesuperiorlywiththelateralorbitalrimsformthelateralpillarsandfinallythe

mostcaudalpillarsarethepterygoidplates.


13/67

13

Figure1.1A&Bindicatingfacialbuttressofthemidfaceandarchitecturalmodel

respectively.4

1.1.1 ZygomaThenamezygomaisderivedfromthewordmeaningayoke(i.e.astructurethat

connectsvariouspartstogether),whereitarticulateswiththetemporal,maxillary,

frontalandsphenoidbones.Itisoftendescribedasadiamondorpyramidalshaped

boneofwhichthelateralsurfaceisconvexformingtheprominenceofthecheek.The

posteriorsurface

contributes

to

the

temporal

fossa.

Projectingsuperiorlyisthefrontalprocesswhicharticulateswiththezygomaticprocess

ofthefrontalboneinfrontandgreaterwingofsphenoidbehindtoformthelateralwall


14/67

14

andrimoftheorbit.Posterolaterallythetemporalprocessarticulateswiththe

zygomaticprocessofthetemporalbonetoformthezygomaticarch.Inferiorlyand

mediallyitbroadlyarticulateswiththemaxillatoformtheinferiororbitalrimand

contributestotheorbitalflooraswellasthezygomaticomaxillarybuttresswhichforms

oneofthestrutsmentionedabove.5

1.1.2Maxilla

Themaxillaconsistsofacentralbodyandfourprocessesnamelythefrontal,zygomatic,

alveolarandpalatineprocess.Thebodyishollowedoutandcontainsthemaxillary

sinus.Itispyramidalshapedwiththebasebeingthemedialsurfacefacingthenasal

cavityandtheapexbeingelongatedintothezygomaticprocess.Ithasanorbitalor

superiorsurfacewhichformsthefloorandrimoftheorbit,amalaroranterolateral

surfacewhichformspartofthecheekandaposterolateralorinfratemporalsurface

whichcontributes

to

the

infratemporal

fossa.

The

base

is

rimmed

inferiorly

by

the

alveolarprocess.

Thealveolarprocesshousesthedentalarchwiththesocketsvaryinginsizeaccordingto

theteeth.Thepalatineprocessisahorizontalprocessfromthebodytothealveolar

processandmediallyarticulateswiththepalatineprocessoftheoppositemaxillawhilst

posteriorlyitarticulateswiththehorizontalplateofthepalatinebone.Thezygomatic

processisanextensionoftheanterolateralsurfaceofthebodywhichcontributestothe

zygomaticomaxillarysuture.5


15/67

15

Thefrontalprocessprojectsupwardtoarticulatewiththemaxillaryprocessofthe

frontalboneaswellasthenasalboneanteriorlyandthelacrimalboneposteriorly.Itis

thissegmentofbonethatincludesthelacrimalcrestintowhichthemedialcanthus

attachesthatMarkowitzcalledthecentralfragmentindefiningnasoorbitethmoid

(NOE)fractures.6

1.1.3Nasalbones

Thepairedquadrilateralbonesformtheupperpartofthebridgeofthenoseand

articulatewiththefrontalprocessofthemaxillalaterallyandwitheachotherinthe

midline.Superiorlytheyarticulatewiththefrontalbone.

1.1.4Lacrimalbones

Eachlacrimalboneisirregularlyrectangularformingpartofthemedialwalloftheorbit.

Theyarticulate

posteriorly

with

the

paper

thin

(lamina

papyracea)

part

of

the

ethmoid,

superiorlywiththefrontalboneandinferiorlywiththebodyofthemaxilla.Thesharp

orbitalverticallacrimalcrestcontinuesinferiorlytoformthelacrimalhamulus,withits

concaveportionhousingthelacrimalsac.Thelargeranteriorlimbofthemedialcanthus

attachestotheanteriorlacrimalcrestandadjacentfrontalprocessofmaxilla.5


16/67

16

1.2 Historyofmidfacialfracturesandtheirmanagement

TheearliestknownwritingsofmaxillofacialfractureswererecordedintheEdwinSmith

Papyrusin1650BCwhichwerepurchasedbySmithin1862andtranslatedby

Breasted.7,8Traditionally,healingandreligionwerecloselyintertwinedasillustratedin

theHellenicperiodatthetemplesofAsklepios,whereassistantstothepriestsprovided

medicalcare.Tooneoftheseassistantsasonwasbornin460BCnamedHippocrates.

Hippocrateswhoisoftenportrayedasthefatherofmedicinedescribedamyriadof

facialinjuriesinaround400BCandhisinsightprovidedthebasisforbandagesand

singlejawinterdentalwiringasmethodsoffixationandstabilisationoffacialfractures.9

Overthe

subsequent

centuries

following

Hippocrates

there

appeared

many

techniques

whichinessencewerevariationsofhismethods.InthenineteenthcenturyCharles

FredrickReiche8

providedthefirstdetailedtreatiseofmaxillaryfractures.Carlvan

Graefe8reportedontheuseofanelastictubeplacedintothenosetomaintainpatency

oftheairwayandalsodescribedtheuseofaheadframetotreatamaxillaryfracture.It

wasalsointhesamecenturythatGarretsonandBlair8advocatedmandibularmaxillary

fixationwiththeaidofsplintstoprimarilytreatmaxillaryfractures.


17/67

17

In1901aFrenchsurgeon,RenLeFort,10

publishedhisclassicalpaperonmidfacial

fracturepatterns.Heinflictedbluntfacialtraumaon35cadaversthensubsequently

removedthesofttissueandexaminedfracturepatternsofthefacialskeleton.Thisstudy

haseversincebeenthebasisforthedescriptionofmaxillaryfractures.

FracturesofthezygomawerenotadequatelymentionedsincethetimeofHippocrates,

howeverin1906Lothrop11

wasthefirsttodescribetheuseofanantrostomyapproach

toreduceamediallyandinferiorlydisplacedzygoma.In1909Keen11

describedan

intraoralapproachtothezygomaticarch.In1927Gillies11

describedatechniqueto

reduceazygomaticarchaswellasmanipulateafracturedzygoma.

In1942Adam12

utiliseddirectwiringtoobtainbetterstabilityofzygomaticfractures.

Foryearshisprotocolappearedtobethemainstayoftreatmentatmanyinstitutions.In

the1970sosteosynthesisbecamearealityforfacialfractureswiththeSwiss

Arbeitsgemeinschaftfr

Osteosynthesefragen

(Association

for

the

Study

of

Internal

FixationorAO)developingminiplatefixation.Todaytheuseofminiplatesprovidesthe

principalmodalityoftreatmentforreductionandfixationofdisplacedmidfacial

fractures.


18/67

18

1.3 Classification

Thereisnouniversalconsensusontheclassificationofmidfacefractures.Several

classificationshave

been

proposed

for

midface

fractures

due

to

amyriad

of

fracture

patternsobtainedwhichreflectthecomplexnatureofconstructionofthesebones.The

objectivesoftheseclassificationsweretohelpformulateclinicalguidelinesforpatient

management.

1.3.1Zygomaticfractures

TheearliestclassificationofzygomaticfractureswasproposedbySchjelderup13

who

classifiedzygomafracturesdependantonwhichregionitwasstillattachedtoe.g.Type

IIIfractureoccurredwhenthezygomawashingedatthefrontalbone.

In1961KnightandNorth13

classifiedzygomafracturepatternsintothefollowing6

typesaccording

to

the

level

of

displacement

noted

radiographically:

TypeI :undisplacedfracture TypeII :isolatedarchfractures TypeIII :posteriorlydisplaced TypeIV :mediallyrotated TypeV :laterallyrotatedatthebuttress TypeVI :multipleorcomminutedfractureincludingthebody


19/67

19

In1968RoweandKilley13utilisedtheprincipleofverticalandhorizontalaxialrotations

andenblocdisplacementtoclassifyzygomaticfractures.Theyutilisedthe

frontozygomatictofirstmolarplaneastheverticalaxisandtheinfraorbitalforamento

zygomaticarchplaneasthehorizontalaxis.Theauthorsclassifiedthefracturepatterns

into8groupsandsuggestedwhichonesrequiredfixation.

LarsenandThomsen13

attemptedtoclassifyzygomaticfracturesaccordingtotheir

treatmentguidelines.TheysuggestedgroupAwhichincludednoorminimallydisplaced

fractures,groupBwhichencompassedfracturesthatrequiredreductionandfixation

(thisgroupincludedcomminutedanddisplacedfractures)andgroupCwhichincluded

allotherfracturesthatrequiredreductionbutnofixation.

Withtheadventofcomputertomographyandrigidfixationsomeauthorsclassified

zygomaticfracturesbasedontheamountofkineticenergyorseverityoftheblowtothe

bone.Amongst

these

were

Manson

and

Markowitz

14who

in

1990

classified

fractures

as

low,middleandhighenergyfracturesandwhoadvocatedwhichgrouphadaroleto

playinopenreductionandfixation.Lowenergyinjuriesarecharacterisedbynoor

minimaldisplacementincludingincompleteseparationwhichareeasilyreducedand

tendtostayinpositionwithnoorminimalstabilisation.Thesefracturesaccountfor18%

of

injuries.

Middle

energy

injuries

account

for

the

bulk

of

injuries

sustained

(77%)

with

displacementrangingfrommildtomarkedwithcompleteseparationatallfoursutures.

Theyrequirevariableamountofrigidfixationdependingonthedegreeofdisplacement.

Highenergyinjuriesareassociatedwithcomminution,significantdisplacementand


20/67

20

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.


21/67

21

Today,howeverfracturepatternsarerecognisedasfarmorecomplexthanthose

producedinLeFortslaboratory.Injuriescausedbypenetratingtraumaaswellashigh

velocityblunttraumaintroduceaspectrumoffracturesnotdescribedbyLeForts

classification.LeFortdidhoweverstatethatcomminutioncanoccurinconjunctionwith

theabovelistedfractures.Healludedtotheconceptofthesuperiorfractureasthelevel

ofclassificationandthatcomminutionoccursbelowitaccordingtothelinesof

weaknessinherentinthemidface.17

Todaytheintroductionofthemidpalatalsplitas

wellasexpansionoftheoriginalLeFortclassificationasproposedbyMarciani18

isoften

theclassificationquoted.

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


22/67

22

1.3.3Nasoorbitoethmoid(NOE)fractures

Thesefracturesareamongstthemostcomplexfracturesbothdiagnosticallyand

therapeuticallydue

to

the

intricate

anatomy

and

difficulty

in

fracture

fixation.

Gruss

19

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.


23/67

23

Figure1.3NOEtypeIfractureunilateralandbilateral.6

Figure1.4NOEtypeIIfractureunilateralandbilateral.6


24/67

24

Figure1.5NOEtypeIIIfractureunilateralandbilateral.6


25/67

25

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.


26/67

26

1.4.2Maxilla

Extraoralevaluationmayrevealadishfaceappearance,elongatedface,depressed

nasalbridge,neurologicalfalloutinthedistributionoftheinfraorbitalnervesaswellas

stepdeformityatthebuttressand infraorbitalrim.MobilityofthemaxillaattheLeFort

I,IIorIIIlevelcouldalsobenoted.Intraorallymalocclusion(inparticularananterior

openbite),mobilityofdentoalveolar(DA)segmentsortheentiremaxillacanbeelicited

aswellasstepsinthebuttressmaybepalpated.Otherintraoralsignsarestepsin

occlusion,malocclusion,diastemaformationaswellasecchymosisalongthebuttress

andthepalate.

1.4.3Zygoma

Periorbitaloedema

and

ecchymosis

is

acommon

sign

of

orbitozygomatic

complex

fractures.Othersignsincludesubconjunctivalhaemorrhagewithorwithoutlaterallimit

inallplanes,depressionofthemalareminence(lossofprojection)andneurological

falloutindistributionofinfraorbitalnerves.Dystopia,decreasedocularmovement,

binoculardiplopia, enophthalmus,antimongoloidslantoflateralcanthusaswellas

palpablestepsaroundtheorbitalrimandbuttressarefurtherindicationofzygomatic

fractures.Limitedmouthopeningmaybepresentwhenthearchisfracturedimpeding

onthecoronoidprocessorasaresultofmuscleinjury.14


27/67

27

1.5LiteratureReview

Facialtraumaisoftenassociatedwithseveremorbiditywithrespecttolossoffunction

anddisfigurementaswellastheimpactofincreasedfinancialcoststoboththestate

andtheaffectedindividual.Ofthe1500facialfracturesanalysedbyRoweandKilley2

629(41.9%)involvedfracturesofthemiddlethird.KellyandHarrigan2analysed4317

facialfracturesofwhich594(13.76%)involvedthemiddlethirdofthefacialskeleton.

Ananalysisoftheassociationbetweentheepidemiologyandassociatedinjuriesisthus

importantinordertoimprovetreatmentandprevention.Beaumontetal20

undertooka

studyof389patientswithfacialfracturesinthreepopulationgroups.Theyfoundthat

themaletofemaleratiowasabout4:1.Inallethnicgroupsthepeakprevalenceof

fractureswasinthethirdandfourthdecades.Themeanageforblacks,asiansand

whiteswerenotedasbeing32,30and27yearsrespectively.Blacksweremainlyvictims

ofinterpersonalviolence,whilstinthewhitegroupmidfacialfractureswere

predominantlycausedbymotorvehicleaccidents.Inallthegroupsthemandiblewas

mostcommonlyfracturedfollowedbythemidfaceandthencombinedfracturesof

mandibleandmidface.


28/67

28

TheaboveresultsweresimilartothefindingsbySnijman21

andDuvenage22

,published

in1963

and

1979

respectively,

whose

studies

were

conducted

in

the

Tshwane

district

of

theGautengprovince.Theyalsofoundthatathirddecadepeakwasnotedwithasimilar

malepredominance.Snijmanalsonotedthatassaultwasthemostcommoncauseof

facialfracturesamongstblacks.Hesimilarlynotedthatmotorvehiclesaccidents

accountedforahigherpercentageoffacialfracturesamongstthewhitegroup.

Mandibularfractureswerealsothemostcommonlyrecordedfacialfracturebyboth

authorsinagreementwithBeaumont.

Theseresultsareincontrasttothosepublishedinotherregions.Bataineh23

undertook

aretrospectivestudyoftheincidenceofmaxillofacialfracturesin Jordanandnotedthat

ofthe563patientsthatpresentedfortreatmentovera5yearperiod,themandiblewas

mostfrequentlyfractured(74.4%)followedbythemaxilla,zygomaticarchandfinally

thedentoalveolarprocess.Themostcommoncausewasroadtrafficaccidents(55.2%)

followedbyaccidentalfalls(19.7%)andassault(16.9%).Amaletofemaleratioof3:1

wasnotedandthemeandecadeforinjurywasthethirddecade.Asimilar

epidemiologicalpatternwasnotedintheUnitedArabEmirates.24


29/67

29

Balakrishnan25

reviewed313casesinTrivandrum,Indiaintheearly1980sandfounda

markedmalepreponderance(93.3%).Thereasongivenwasthatwomenwerehardly

everinvolvedinroadtrafficaccidents.Theydonothoweversubstantiateorclarify

theirremarkwhethertherewerefewerwomenoccupantsanddrivers inmotorvehicle

accidentsorwhetherwomenwerebetterdrivers.Onceagaintheinjurieswere

sustainedmostcommonlybyindividualsinthethirddecade.Heretrafficaccidents

followedbyassaultwerenotedtobethemostcommoncausesofmaxillofacial

fractures.InterestinglytwodecadeslaterinanotherdistrictinIndiathemaletofemale

ratiodecreasedto3.7:1.26

IntheNetherlandsvanBeek27

foundastrikingreductioninroadtrafficaccidentsand

anincreasinginfluenceofviolenceandsportresultinginachangingpatternof

maxillofacialfractures.TheseresultswereinstarkcontrasttoinjuriesinAustriaas

reportedbyGassner28

whofoundthatactivityofdailylifeandplayaccidentswasthe

maincausefollowedbysport,interpersonalviolenceandtrafficaccidents.Gassneralso

notedanincreaseinfemalepatientswithanoverallmaletofemaleratioof2.1:1.

Greene29

notedthatthedistributionofthemidfacefracturesinvolvingthe

zygomaticomaxillarycomplexwasthehighestfollowedbyorbitalblowout,nasal,

zygomatic

arch,

Le

Fort

and

finally

NOE

fractures.

The

distribution

in

Greece

was

somewhatdifferentwithzygomafracturespredominatingfollowedbyLeFortII,NOE,Le

FortIII,nasal,LeFortI,palatalsplitandfinallydentoalveolarfractures.30


30/67

30

AlKhateeb31

analysedcraniofacialfracturesinUnitedArabEmirates.Healsofound

thatamongmidfacialinjuriestheincidencewerehighestforzygomaticcomplex

fracturesfollowedbyNOE,isolatedorbitalfloorandLeFortfracturesrespectively.

Beaumont20

alsonotedthatthezygomaticomaxillarycomplexhadthehighest

distribution.

Ferreiraetal32

undertookastudytodeterminethedistributionofmidfacialfracturesin

childrenandadolescence.Theyfoundthatthedistributionsinprevalenceaccordingto

siteswere:zygoma,alveolar,Lefort,orbitalfloorandfinallyhardpalate.

Kontio33

interestinglyfoundinhisepidemiologicalstudyinFinlandthatthespectrumof

maxillofacialinjurieschangedsomewhat.Thedecademostaffectedwithfracturesin

1981wasthefourthwhilstin1997itwasthefifthdecade.Healsonotedadecreasein

motorvehicleincidentswithanincreaseininterpersonalviolencewhichhadbecome

moresevere

in

nature.


31/67

31

1.6AimsandObjectives

Althoughtherearenumerousstudiesofmaxillofacialinjuriesintheliterature,onlya

fewhavecontainedmeaningfulinformationrelatingtolocaldemographicfactors.In

ordertoimproveservicedeliveryinthetreatmentofmidfacialfracturesitisparamount

toanalysecurrentdataonitsbiomechanicsandincidence.Thisstudyintendsto:

1. Providecurrentlocaldataontheaetiology,biomechanicsanddemographicsofpatientspresentingfortreatmentoffracturesofthemidface.

2. Toassesstheassociation,ifany,betweenfracturepatternsandmechanismofinjury,thusprovidinginsightintolocalbehaviouralpatterns.

3. Tosupplydataofthefinancialresourcesprovidedbythedepartmentofhealthrequired

to

meet

patient

needs.


32/67

32

Chapter2Materialsandmethods2.1Ethicalclearance

AnapplicationforethicsclearancewassoughtwiththeCommitteeforResearchon

HumanSubjects(Medical)oftheUniversityoftheWitwatersrand.TheClearance

certificate,protocolnumberM050812wasgranted(AppendixA).Verbalandwritten

explanationsofthestudyweregiventopatientswhofulfilledtheinclusioncriteriaof

thestudyandawrittenconsentwasobtainedfromeverysubject.(AppendixB)

2.2InclusionCriteria

PatientswhopresentedtotheMaxillofacialandOralSurgeryDepartmentofthe

UniversityofWitwatersrandwithmidfacialfracturesandwhogaveconsentwere

admittedtothestudy.Midfacialfracturesweredefinedasfracturesinanareaboundby

thefrontozygomatic

and

frontonasal

sutures

superiorly,

the

occlusal

plane

inferiorly,

posteriorlytothepterygoidplatesandlaterallytilltherootofthezygomaticarchas

describedbyFrost1.

2.3ExclusionCriteria

Anypatient

who

did

not

present

with

midfacial

fractures,

declined

to

give

consent

or

withdrewfromthestudy.


33/67

33

2.4ClinicalStudy

ThiswasaprospectiveauditundertakenintheDivisionofMaxillofacialandOral

Surgery,Department

of

Surgery,

University

of

the

Witwatersrand

at

the

Chris

Hani

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,30

o,

Submentovertex(SMV),Orthopantomograph(OPG),andComputertomography(CT)

scans.Figures2.1to2.3illustratesomeexamplesoftheseradiographs.Interpretations


34/67

34

oftheOccipitomentalviewsweredonefollowingtheprinciplesof McGrigorand

Campbell.34

Figure2.1Occipitomentalviewindicatingmultiplefacialfractures.


35/67

35

Figure2.2SMVusedtoassessfracturesofthezygomaticarch.

Figure2.3ThreedimensionalCTscanindicatingmultiplefacialfractures.

Thetreatmentofferedwasnotedincludinganyplatingsystemandotheralloplastic

materialsusedforopenreductionandinternalfixation(ORIF)sothatacostingofthe

hardwarecouldbeobtained.


36/67

36

2.5DataAnalysis

DatawasanalysedwithSASforWindows(Version9.1,SASInstituteInc.USA)


37/67

37

Chapter3ResultsRecordswereobtainedfromatotalof94patientswhosustainedmidfacialfractures.

3.1Age,genderandracedistribution

Thepatientsagesrangedfromthreeto67yearsold.Theagesweredefinedperdecade

foreaseofuseandforcomparativestudiesaslistedinTable3.1below.Gender

distributionrevealedamalepredominanceinaratioof4:1(Table3.2).

Table3.1Frequencydistributionbyageindecades(N=94)

Decade Agerange Numberofpatients

(N)

Percentage(%)

1

09

1

1.1

2 1019 2 2.1

3 2029 37 39.4

4 3039 25 26.6

5 4049 20 21.3

6

5059

6

6.3

7 6069 3 3.2


38/67

38

Table3.2Frequencydistributionbygender(N=94)

Gender N %

Male 78 82.98

Female 16 17.02

Blackpatientsaccountedforthelargestracialgroup(77.66%)followedbywhites,

colouredsandasiansrespectively(Table3.3).

Table3.3

Frequency

distribution

by

race

(N=94)

Race N %

Black 73 77.66

Coloured 6 6.38

Asian 3 3.19

White 12 12.77


39/67

39

3.2 Natureofinjuryandsocialhabits

ThedistributionofthecausesofthefracturesisshowninTable3.4.Themostcommon

causeof

midfacial

fractures

was

blunt

trauma

due

to

interpersonal

violence

(40.5%),

followedbymotorvehicleaccidents(26.6%),gunshotwounds(13.8%)andfalls(5.3%).

13.8%ofpatientscouldnotrecollecthowtheywereinjuredasindicatedintable3.4.Of

thosepersonsinjuredwithaweapononly2werestabwoundswiththeremaining18

injuredwithbricksorrod/pipe.

Table3.4Frequencydistributionbynatureofinjury(N=94)

Mechanismofinjury N %

Injurywithweapon(otherthan

firearm)

20 21.3

Fist/s 18 19.2

Gunshotwound/s 13 13.8

Fall 5 5.3

Motorvehicleaccident 25 26.6

Unknown

13

13.8


40/67

40

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 N %

No 39 41.49

Yes

55

58.51

Table3.6Frequencydistributionbylossofconsciousness(N=94)

Lossofconsciousness N %

No 31 32.98

Yes 63 67.02


41/67

41

Thecharacteristicsoftheinjuriessustainedindicatedthesiteofimpactasroughlyequal

interms

of

left

and

midline

(26.6

%

right,

30.9%

left,

31.9

%

midline

and

10.6%

unknown).Themostcommonlyassociatedinjurysustainedwithmidfacialfractureswas

afracturedmandible(32.9%)followedbychesttrauma(5.3%)asindicatedinTable3.7.

Sundayappearedtobethedayonwhichmostoftheinjuriesoccurredasillustratedin

Table3.8.

Table3.7Frequencydistributionbyassociatedinjuries(N=94)

Associatedinjury N %

None 49 52.2

Mandible 31 32.9

Chest 5 5.3

other 9 9.6


42/67

42

Table3.8Frequencydistributionbydayoftheweek(N=94)

Day N %

Monday*

8

8.5

Tuesday 7 7.4

Wednesday 8 8.5

Thursday 13 13.9

Friday 16 17

Saturday 15 16

Sunday 24 25.5

Unknown 3 3.2

*TwopatientswereinjuredonaMondaywhichcoincidedwithapublicholiday.

3.3SpecialInvestigations

Fromthisstudy(asshowninTable3.9)themostprevalentradiographicinvestigations

formidfacialfracturesweretheOM&SMVviews(61.7%).ThesewerefollowedbyCT

scans,

OPG

and

other

views.

It

should

also

be

noted

that

certain

radiographs

were

also

takenincombinationinclinicallyindicatedsituations.(e.g.takingofanOPGwithOM

viewsfordentoalveolarfracturewithzygomaticbonefracture).


43/67

43

Table3.9Frequencydistributionbyradiographicinvestigations(N=94)

Radiology N %

Occipitomental&SMV 58 61.7

CTscans 32 34

OPG 3 3.2

Other 1 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.


44/67

44

Table3.10Frequencydistributionbyfracturepattern(N=94)

Typeoffracture N %

Dentoalveolar 16 17.02

Lefort (I,II,III) 13 13.83

Panfacial 16 17.02

Zygomaticcomplex 43 45.74

Other 6 6.38

3.5Analyses

Inordertogaininsightintobehaviouralpatterns,analysisofthecircumstancesofthe

injurywasdone.Ananalysisofalcoholconsumptiontothemechanismofinjurywas

alsodonetodetermineifanystatisticalsignificancecouldbeelicited.Othercriteria

werealsoassessedasreflectedinTable3.11toTable3.16below.Itwasalsorecorded

thattheaverageperiodfromthetimeofinjurytomanagementwas13.9dayswitha

rangeof1to151dayspriortotreatment.


45/67

45

Table3.11Analysisofalcoholconsumptionbymechanismofinjury(N=81)

Alcoholconsumption Mechanismofinjury Total

HighVelocity

Low

Velocity

No(N) 27 11 38

% 33.33 13.58 46.91

Yes(N) 11 32 43

% 13.58 39.51 53.09

Total(N)

38

43

81

% 46.91 53.09 100.00

TheChisquaretestindicatedaPvalue


46/67

46

Table3.13Analysisofgenderbymechanismofinjury(N=81)

Gender Mechanismofinjury Total

HighVelocity LowVelocity

Female(N) 11 4 15

% 13.58 4.94 18.52

Male(N) 27 39 66

% 33.33 48.15 81.48

Total(N) 38 43 81

%

46.91

53.09

100.00

TheChisquareindicatesaPvalueof.0231


47/67

47

Table3.14Analysisofdecadebygenderandalcoholconsumption(N=93).

Decade Alcoholconsumption Total Gender Total

No Yes Female Male

1&2(N) 1 2 3 2 1 3

% 1.08 2.15 3.23 2.15 1.08 3.3

3(N) 17 20 37 6 31 37

% 18.28 21.51 39.78 6.45 33.33 39.78

4(N)

10

15

25

2

23

25

% 10.75 16.13 26.88 2.15 24.73 26.88

5(N) 9 11 20 4 16 20

% 9.68 11.83 21.51 4.3 17.20 21.51

6(N) 1 7 8 2 6 8

%

1.08

7.53

8.60

2.15

6.45

8.6

Total(N) 38 55 93 16 77 93

% 40.86 59.14 100 17.20 82.8 100

ChisquareindicatesaPvalueof0.5123 ChisquareindicatesaPvalueof0.1299


48/67

48

Table3.15Analysisoffracturetypebyalcoholconsumptionandmechanismofinjury.

Fracture Alcohol

consumption

Total Mechanismofinjury Total

No Yes Highvelocity LowVelocity

DA(N) 11 5 16 11 3 14

% 11.7 5.32 17.02 13.58 3.7 17.28

LeFort(N) 5 8 13 5 5 10

% 5.32 8.51 13.83 6.17 6.17 12.35

Other(N) 3 3 6 1 4 5

% 3.19 13.83 17.02 1.23 4.94 6.17

Panfacial(N) 3 13 16 7 8 15

% 3.19 13.83 17.02 8.64 9.88 18.52

Zygoma(N) 17 26 43 14 23 37

% 18.09 27.66 45.74 17.28 28.40 45.68

Total(N) 39 55 94 38 43 81

% 41.49 58.51 100.00 46.91 53.09 100.00

ChisquareindicatesaPvalueof0.0719 ChisquareindicatesaPvalueof0.0796


49/67

49

Table3.16Analysisoffracturetypebytreatment.

Fracture C ED N O X Total(N)

DA(N) 9 6 1 0 0 16

% 9.57 6.38 1.06 0.00 0.00 17.02

LeFort(N) 2 1 1 8 1 13

% 2.13 1.06 1.06 8.51 1.06 13.83

Other(N) 1 1 1 0 3 6

% 1.06 1.06 1.06 0.00 3.19 6.38

Panfacial(N) 0 0 0 16 0 16

% 0.00 0.00 0.00 17.02 0.00 17.02

Zygoma(N) 5 0 8 30 0 43

% 5.32 0.00 8.51 31.91 0.00 45.74

Total(N) 12 8 11 54 9 94

% 18.08 8.51 11.70 57.45 4.25 100.00

ChisquareindicatesaPvalueof


50/67

50

3.6Hardwarecosts

Atotalofthreecompaniesprovidedtheplatingsystemsforinternalfixation.The

averageprice

for

ascrew

from

these

companies

was

R

182.45

and

the

average

price

for

aminiplatewasR509.63.

Anaverageoftwominiplateswitheight1.5mmor1.3mm(dependingonwhich

companysystemwasused)screwswasusedforplatingafracturedzygoma.The

averagecostperpatientforanORIFofafracturedzygomawasR2479.12(2x509.63+8x182.45).Forpanfacialfracturesanaverageof6miniplatesand32screwswereutilizedperpatient.ThusacostofR7438.69(6x509.63+24x182.54)perpatientforORIFofpanfacialfractureswasnoted.LeFortfracturesonaveragerequired4mini

platesand16screws,resultinginacostofR4959.16(4x509.63+16x182.54)perpatientforORIFLeFortfracture.

CollatingtheabovedatawiththatofTable3.16forthenumberofORIFforeachofthe

fracturetypes,atotalofR287090.28wasobtainedastheaveragecostofhardware

utilizedinthisreport.ThisequatestoUS$35886.29perannumforthisstudy(rateof

R8.00=US$1).


51/67


52/67

52

injuriesovera27yearperiod.Falls(5.3%)weretheleastcontributorstomidfacial

fracturesinthisstudy.Onceagainsimilarepidemiologicdatawerenotedinprevious

SouthAfricanstudies.21,22,35

Fromthisstudyitwasnotedthatthemaletofemaleratiois4:1.Thismarkedmale

predominanceissimilartothoseepidemiologicalstudiesconductedinIrbid,Jordan23

andNjimegen,Netherlands.27

Thisalsocomparefavourablywithpreviousstudies

conductedinSouthAfrica.20,21,22,35

Thesefindingsarehoweverincontrasttothose

foundinInnsbruck,Austria27

andinChennai,India26

wheretheauthorsreportahigher

femaleincidencebutstillamalepredominance.

77.6%ofpatientswhosoughttreatmentinourhospitalswereblack,followedbywhites,

colouredsandasiansindescendingorderoffrequency.Possibleexplanationsforthis

trendincludethefactthatblacksconstitutethehighestpopulationinSouthAfrica.36

Secondlythe

highest

unemployment

rate

in

our

county

is

amongst

blacks.36

These

indigentpatientswithoutanyformofmedicalinsurancewouldthereforetendtoseek

treatmentinpublicinstitutionslikeours.Thesmallerpopulationgroups,withfewer

ratesofunemployment,tendtoseekmedicaltreatmentintheprivatesector.Previous

studiesinourcountrycorroboratethistrend.20,21,22,35

Ifoneconsiderstheagerangeitwasnotedthat67.0%ofindividualsthatsustained

midfacialinjurieswerereportedtobeinthethirdandfourthdecadewiththehighest

incidencenotedinthethirddecade(39.4%).Desai35

describedthisgroupas

representingtheunskilledlabourforcethatareusuallypaidweeklyandtraditionally


53/67


54/67

54

Ifoneanalysesthedataastatisticallysignificant(ChisquaretestindicatedaPvalue


55/67

55

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.13

TheChisquareresultsreflectedinTable3.16indicatesaPvalueof


56/67

56

(2)Patientoverload:Thehighprevalenceofinterpersonalviolenceinourcountryoften

resultsintraumaoverload.Combinedwithabroaderlackofresourcessuchasalackof

theatretimeitinevitablyresultsinlongerwaitingperiods.

Bythetimethesepatientsgettotheatreinappropriatehealing(intheformoffibrous

union,malunionandsepsishastakenplace)thusoftennecessitatingosteotomisingthe

fractureswithsubsequentprolongationoftheatretimeandincreasingcosts.Also

treatmentoftheolderfracturesoftenyieldssuboptimalclinicaloutcomes.

Fromthisstudyitisnotedthatonaveragethehardwarecostsforapatientwitha

ZMCfractureequatestoR2479.12whilstthatofapanfacialwasR7438.69.

InterestinglythecostsprovidedbyDuvenage22

in1979reportedatotalhospitalcost

formaxillofacialinjuries(inclusiveofanaesthetic,wardandhardwarecosts)ofR295.75

forORIFingeneral.

Desai35

in2006reportedatotalcostforhardwareonlyforORIFoffractured

mandibletothestateperannumofR158305.Thisstudyrevealsthetotalhardware

costformidfacialfracturestobeR287090.28perannum.Thesecostsdonotinclude

ward,anaestheticandtheatrefees.


57/67

57

Chapter5ConclusionThisstudyhasshownthatthemajorityofpatientspresentingwithmidfacialfractures

werethose

of

lower

socio

economic

status

(i.e.

blacks).

The

majority

of

these

patients

wereinjuredoverweekendsandwereinebriatedatthetimeofinjury.Blunttraumadue

tointerpersonalviolencewasthemostcommoncauseoffacialfractures.Thezygomatic

complexfracturewasthemostcommonlyobservedmidfacefracture.Thisstudy

suggeststhatarelationshipexistsbetweenfacialtrauma,povertyandalcohol

consumption.It

is

also

noted

that

facial

trauma

(mainly

due

to

interpersonal

violence

in

ourcountry)placesenormousfinancialburdenonthestate.

Futurestudiesshouldseektounderstandtheepidemiologicalfactorsinfluencingfacial

traumainanefforttoimprovepreventionandmanagementoftheseinjuries.

Inadditionitisclearthattrendsareobservedwhenanalysingthedatacollated,

howeverthelimitednumbersofpatientsdonotreflectstatisticalsignificance.Again,

furtherresearchisrequiredtoencompassalargersamplesizewithadequatefollowup

ofclinicaloutcomesastoobtainmoremeaningfuldatawithothercriteriasuchas

complicationrates,sepsisratesandtotalhospitalisationcostsbeingincorporated.This

wouldenhanceabetterunderstandingofinfluencingpatternsonfacialtraumawitha

viewtoprovidinganeffectiveresponsetothisepidemic.


58/67


59/67

59

8. CunninghamLL,HaugRH.Managementofmaxillaryfractures.In:MiloroM.,GhaliGE,LarsonP,WaiteP,editors.PetersonsPrinciplesofOraland

MaxillofacialSurgery.BCDeckerInc.Canada.2004:chapter23.1:434438.

9. Mukerji R, Mukerji M,McGurkM.Mandibularfractures:historicalperspective.BrJOralMaxillofacSurg2006;44:222228.

10.BagheriSC, HolmgrenE,KademaniD,HommerL,BryanBellR,PotterB,etal.ComparisonoftheseverityofbilateralLeFortinjuriesinisolatedmidface

trauma.JOralMaxillofacSurg2005;63:11231129.

11.GilliesHD,KilnerTP,StoneD.Fracturesofthemalarzygomaticcompound:withadescriptionofanewxrayposition.BrJSurg1927;14:651656.

12.MansonP.Transcutaneousreductionandexternalfixationforthetreatmentofnoncomminutedzygomafractures. J OralMaxillofacSurg1998;56,13871389.

13.EllisEIII.Fracturesofthezygomaticcomplexandarch.In:FonsecaRJ,WalkerRV,

editors.

Oral

and

Maxillofacial

Trauma.

W

B

Saunders

Company.

Philadelphia.1991:chapter18:440460.

14.BaileyJS,GoldwasserMS.Managementofzygomaticcomplexfractures.In:MiloroM.,GhaliGE,LarsonP,WaiteP,editors.PetersonsPrinciplesofOraland

MaxillofacialSurgery.BCDeckerInc.Canada.2004:chapter23.2:445455.

15.Zingg

M,

Laedrach

K,

Chen

J,

et

al.

Classification

and

treatment

of

zygomatic

fractures:areviewof1025cases.JOralMaxillofacSurg1992;50:778.


60/67

60

16.LewD,SinnD.Diagnosisandtreatmentofmidfacefractures.In:FonsecaRJ,WalkerRV,editors.OralandMaxillofacialTrauma.WBSaundersCompany.

Philadelphia.1991:chapter19:515544.

17.MansonP.SomethoughtsontheclassificationandtreatmentofLeFortfractures.AnnPlastSurg1986;17:356363.

18.MarcianiRD.Managementofmidfacefractures:Fiftyyearslater.JOralMaxillofacSurg1993;51:960968.

19.GrussJS.Complexnasoethmoidorbitalandmidfacialfractures:roleofcraniofacialsurgicaltechniquesandimmediatebonegrafting.AnnPlastSurg

1986;17:377390.

20.BeaumontER. FracturesofthefacialskeletoninthreeethnicgroupsinthegreaterJohannesburg.UniversityoftheWitwatersrand.Johannesburg.1981:24

47.

21.SnijmanPC.Fracturesofthebantufacialskeleton.JournalofDentAssocofSAfr1963;18:570575.

22.Duvenage.EpidemiologyofmaxillofacialandoraltraumainSouthAfrica.JournalofDentAssocofSAfr1979;33:691693.

23.BatainehA.EtiologyandincidenceofmaxillofacialfracturesinnorthofJordan.Oral

Surg

Oral

Med

Oral

Pathol

Oral

Radio

Endod

1988;

86:31

35.

24.KlenkGandKovacsA.EtiologyandpatternsoffacialfracturesintheUnitedArabEmirates.JCraniofacSurg2003;14:7884.


61/67

61

25.BalakrishnanNandPaulG.IncidenceandaetiologyoffractureofthefaciomaxillaryskeletoninTrivanadrum:aretrospectivestudy.BrJOralMaxillofac

Surg1986;24:4043.

26.SubhashrajK,NandakumarN,RavindranC.ReviewofmaxillofacialinjuriesinChennai,India:Astudyof2748cases.BrJOralMaxillofacSurg2007;45:637639.

27.VanBeek.MerckxCA.Changesinthepatternoffracturesofthemaxillofacialskeleton.IntJOralMaxillofacSurg1999;28:424428.

28.GassnerR,TuliT,HachlO,RudischAandUlmerH.Craniomaxillofacialtrauma:a10yearreviewof9543caseswith21067injuries.JCranioMaxillofacialSurg

2003;31:5161.

29.GreeneD,RavenR,CarvalhoGandMaasCS.Epidemiologyoffacialinjuryinbluntassault.ArchOtolaryngolHeadNeckSurg1997;123:923928.

30.ZachariadesN.Papavassiliou.ThePatternandaetiologyofmaxillofacialinjuriesin

Greece.

JCranio

Maxillofacial

Surg

1990;

18:251

254.

31.AlKhateebT,AbdullahFM.CraniomaxillofacialinjuriesintheUnitedArabEmirates:aretrospectivestudy.JOralMaxillofacSurg2007;65:10941101.

32.FerreiraP,MarisaM,PhinoC,RodriguesJ,ReisJ,ArmanteJ.Midfacialfracturesinchildrenandadolescents:areviewof492cases.BrJOralMaxillofacSurg

2004;

42:501

505.

33.KontioR,SuuronenR,PonkkonenH,LindqvistC.,LaineP.Havethecausesofmaxillofacialfractureschangedoverthelast16yearsinFinland?An

epidemiologicalstudyof725fractures.DentalTraumatology2005;21:1419.


62/67

62

34.WhaitesE.Essentialsofdentalradiographyandradiology.ChurchillLivingstone.Edinburgh2002:402406.

35.DesaiJ.MandibularfracturepatternsasrelatedtomechanismofinjuryaprospectiveauditofJohannesburgpatients.UniversityoftheWitwatersrand.

Johannesburg.2006:24.

36.LehohlaP.Censusinbrief.StatisticsSouthAfrica.1998.http://www.statsa.gov.za/censu01/Census98/HTML/default.htm(accessed25th

March2008).


63/67


64/67

64

AppendixBPARTICIPANT INFORMATIONSHEETANDCONSENT.Dearpatient

MynameisDr.YusufFSulemanandIamaregistrarintheDivisionofMaxillofacial&Oral

Surgery.Aspartofmytraining,Iamconductingastudyaboutmidfacialfractures(brokenbones

ofthefacefromtheeyebrow,nose,thebonesaroundthecheekandupperjawincludingupper

teethbutnotincludingthelowerjaw).

Asyourinjuriesareconsistentwiththosedescribedabove,Irequireyourhelpbyallowingmeto

useyourclinicalrecords;thesewouldincludeaphysicalexaminationofyourselfaswellas

analysisofyourxraysforthepurposesofthisstudy.Itishopedthatthisstudywillhelpour

departmentbetterunderstandthisinjury,andimproveonourservicetoallofourpatients.

Your

participation

in

this

study

is

purely

voluntary

if

you

so

wish

at

any

time

and

that

whether

youparticipateornotwillnotaffecttheoutcomeofyourtreatmentandsuchyoumaychoosewhetheryouwouldliketoparticipateinthisstudyornot.Ifyouopttoparticipateafew

questionswillbeaskedaboutthecircumstancessurroundinghowyougotinjuredaswellasan

examinationoftheextentofyourinjuries.Acopyoftheinformationsheetisattachedforyour

perusal.

Pleasenotethatitisyourrighttowithdrawfromthisstudyifyouwishatanytimeandthat

whetheryouparticipateornotwillnotaffecttheoutcomeofyourtreatment.


65/67

65

Youwillnoticethatthedatainformationsheetdoesnotreflectyournameandassuchyouwill

remainanonymousandallinformationgatheredisstrictlyconfidentialandwillbeusedforresearchpurposesonly.

Ifyouhaveanyquestionsrelatingtothisstudyorfeelthatyoumayrequiremoreinformation

aboutthestudy,youmaycontactmeon0119338107(ChrisHaniBaragwanathHospital,Ward

H4).

THEDOCTORHASEXPLAINEDHISINTENTIONSTOMEANDIAGREETOPARTICIPATEINTHIS

STUDY.IDOSOFREELYANDUNDERSTANDTHATIMAYWITHDRAWATANYTIME,WITHOUT

COMPROMISINGANYTREATMENTDUETOME.

PATIENTSIGNATURE DATE..

OR

PARENT/LEGALGUARDIAN..


66/67

66

AppendixCMIDFACE FRACTURE PATTERNS PATICIPANT INFORMATION DATA SHEET.

DateofBirth: Gender: M/F

Race: DateofInjury:DateofConsultation: DateofAdmission:

Intoxicatedatthetime:

Lossofconsciousness: Y/N Hospitalno.:

Airway : patent/compromised/obstructed

Neurologicalstatus:GCSscore /15 /10

Relevantmedicalhistory:

Relevantsurgicalhistory:

Mechanismof

injury

(Tickappropriate)

Motor vehicle accident Assault

Occupant Fist

Pedestrian Foot

Motorcyclist Pipe

Cyclist Brick

Bottle

Firearm

Sport Industrial

IncludingBat/Stick

Other

Fall Miscellaneous

BluntTrauma highvelocity:(mva/other)

lowvelocity:(fists/fall)

PenetratingTrauma highvelocity:(bullet/blastshrapnel/other)

lowvelocity:(knife/other)

stateentranceandexitwound(ifapplicable)

Site

of

impact

:

left/right/midline

Softtissue : lacerations/abrasions/avulsive

Associated/Otherinjuries :

SpecialInvestigations:


67/67

Documents

Research Report Final- Aetiology & Mechanism of Midfacial Fractures