Trauma is a leading cause of morbidity and mortality worldwide.1,2 Faciomaxillary injures are common among such admissions, although their epidemiology and aetiology can vary across various geographical areas.3,4. These are the most common life-threatening emergency situation in both developing and developed nations, representing 7.4–8.7% of the emergency medical care.5 Faciomaxillary injures affects both the skeletal and soft tissue structures of the facial region and can pose considerable long-term functional, aesthetic, and psychological complication.6 It is most prone to fractures because of its prominent position. The means of injury and direction of impact determine the pattern and location of such fractures7. Understanding maxillofacial trauma helps to assess the behaviour patterns of people in different countries and helps to establish effective measures through which injuries can be managed and prevented12. Trauma to the faciomaxillary region mandates special attention as important sensory systems are contained within the face (e.g. vision, auditory, somatic sensation, gustatory, olfaction and vestibular), also, vital structures in the head and neck region are intimately associated (airway, blood vessels, nerves and gastrointestinal tracts). Lastly, the psychological impact of disfigurement can be devastating. Socioeconomic ramifications of maxillofacial trauma are the cost of treatment and admission to hospital, hospital resources, and macroeconomic loss of revenue. For individual patients consequences may comprise functional problems, physical discomfort, aesthetic problems, emotional or psychological distress, an intensive treatment regimen (often in hospital), frequent visits to the outpatient department after discharge, and loss of revenue. Epidemiological studies of maxillofacial trauma are important to help develop more efficient ways to deliver care, to assess and improve the quality of care, and to advise on tactics for the prevention of injury. The present study was done to determine the pattern and aetiology of the maxillofacial fractures, most common affected age, sex, fracture type, manifestations and treatment modality. Also, the possible preventive measures that could be taken to prevent such fractures were discussed.

The present study is an observational study conducted on patients who presented with features of faciomaxillary trauma to the department of ENT and department of Plastic Surgery at Krishna Rajendra Hospital, Mysore attached to the Mysore Medial College and Research Institute during the period from January 2020 to June 2021. SAMPLE SIZE AND SAMPLING METHOD SAMPLE SIZE: Sample size, n is calculated using the formula: n=z2pq/d2, where p is the prevalence of faciomaxillary trauma. According to the hospital records of previous years, p=52.1% q=1-p i.e., 47.9% d=level of precision in terms of absolute error i.e. 10% z=standard normal variate for 5% alpha error i.e. 1.94 Therefore, n=95 SAMPLING METHOD: Convenience sampling METHOD OF COLLECTION OF DATA The study is a cross sectional, observational study done in patients presenting with features of faciomaxillary trauma presenting to E.N.T OPD and emergency department of Plastic Surgery at Krishna Rajendra Hospital, Mysore from January 2020- June 2021. COLLECTION OF DATA AND ANALYSIS All cases underwent a thorough history taking and detailed examination after obtaining informed consent. Once suspected, the cases were examined and subjected to relevant investigations like OPG, CT scan head with facial cuts. Thorough clinical evaluation was performed. Management results were be analysed appropriately. Data obtained analysed using appropriate statistical test. Based on epidemiological data, clinical and imaging findings, treatment modalities and outcome of patients were analysed. INCLUSION CRITERIA a) Patients giving consent b) Patients with nose bleed/oral bleed/ any facial swelling on preliminary examination/deformity of face and confirmed with imaging study c) All patients aged from 18 years to 65 years of age and either sex with clinical manifestations of faciomaxillary trauma. d) Patients with radiologically confirmed faciomaxillary fractures. EXCLUSION CRITERIA a) Patients not willing for the study b) Unconscious patient who had no relatives to give consent on behalf of the patient c) Head injury patients (parenchymal involvement) d) Patient record with incomplete data e) Age <18 years f) Patients who died before initial assessment g) Patients with no history of trauma

Table 1: Age and Sex distribution of study participants Age in Categories Frequency (N) Percentage (%) 18-25 years 34 35.8 26-35 years 27 28.4 36-45 years 23 24.2 46-55 years 7 7.4 55-65 years 4 4.2 Total 95 100.0% The mean age of the participants in the study was 31.77 years with a standard deviation of around ±10.90 years. The minimum age and maximum age of the study participants were 18 years and 60 years, respectively. In the study, majority of the participants were males i.e., around 87.4%. Remaining 12.6% of them were females. Male to female ratio was 6.9:1 Table 2: Distribution of participants based on the aetiology Etiology Frequency (N) Percentage (%) Road Traffic Accidents 57 60.0 Physical Assault 20 21.1 Accidental Fall 12 12.6 Others 6 6.3 Total 95 100.0% Majority of the participants in the study suffered faciomaxillary injury as a result of road traffic accidents i.e., around 60.0%. The next common cause was physical assault followed by accidental fall. In only 6.3% cases, the causes were regarded as others. Table 3: Distribution of participants based on the clinical manifestations Site of fracture Number of fractures Nasal bones • Deformity of nose 15 • Laceration of skin over the bridge 5 • Epistaxis 13 • Septal deviation 11 • Crepitus over nasal bones 15 • Tenderness 17 Naso orbito ethmoidal • Telecanthus 2 • Depressed nasal dorsum 6 • Ecchymosis/swelling 8 • Subjective diplopia 8 • Upgaze limitation 5 • Enophthalmos/depression 7 • V2 para/anaesthesia 3 • Subconjunctival haemorrhage 8 Maxilla • Elongated/retuded midface 10 • Mobile midface 5 • Ecchymosis/swelling 23 Zygoma • Cheek flatness 20 • Antimongoloid slant 8 • Palpable step 8 • Ecchymosis/swelling 11 • Tenderness 15 Mandible • Dental malocclusion 40 • Intraoral/gingival laceration 35 • V3 para/anaesthesia 15 • Tenderness 50 • Ecchymosis/swelling 43 • Palpable step 2 40 Frontal Depressed fracture 1 Based on examination findings, the clinical manifestations were categorized as per the site of the fracture. Accordingly, tenderness was the most common finding, followed by swelling. As per the site, mandible was the structure which resulted in more clinical manifestations. Among the clinical manifestations of nasoethmoidal area fracture, ecchymosis and subjective diplopia was the most commonest manifestation followed by enophthalmos. Among the clinical manifestations of maxillary fracture, Ecchymosis and swelling were the most common manifestations followed by elongated mid face. Among the clinical manifestations of Zygoma fracture, cheek flatness was the most common finding followed by tenderness and swelling. Among the clinical manifestations of Mandibular fracture, majority had tenderness as the most common symptom followed by ecchymosis and swelling. 40 patients were found to have dental malocclusion and palpable step. 35 patients had laceration intra orally.V3 paraesthesia was the least common manifestation in mandibular fracture in our study Table 4: Distribution of fractures based on anatomical site Fracture type Number of fractures Central third of maxillofacial skeleton • Nasal bones 17 • Naso-orbito-ethmoid 8 • Lefort I 14 • Lefort II 8 • Lefort III 2 • Palate 3 • Dentoalveolar 8 Lateral third of faciomaxillary skeleton • Zygomatic body 8 • Zygomatic arch 3 • Zygomatic body + Arch 20 Mandible fractures (lower third) • Condyle 25 • Ramus 1 • Coronoid 1 • Angle 13 • Body 11 • Para symphysis 8 • Symphysis 6 • Dento alveolar 1 Frontal bone 1 In the study, on analysing the anatomical distribution of fractures among the participants, mandible was the most common site i.e., around 42.03%. The next common site was central third of facial skeleton which accounts for about 38.2%.. The lateral third of facial skeleton was involved in only 19% case. In our study, condyle was the commonest site of fracture in mandible followed by angle of the mandible. Body of the mandible fracture was found in 11 cases. Ramus, coronoid and dento alveolar area was affected least in mandibular fracture in our study. On studying distribution of fractures in Central third of maxillofacial skeleton, nasal bone fracture was found as the commonest one followed by Lefort I fractures. Lefort III was the least common fracture in central third of maxilla facial skeleton in our study. On studying distribution of fractures in lateral third of maxillofacial skeleton, combined fracture body and arch of zygoma was found to be commonest compared to isolated body or arch fractures. Fracture of frontal bone was found in one patient. Table 5: Distribution of participants based on the mode of treatment Mode of treatment Frequency (N) Percentage (%) Open Reduction Internal Fixation 59 62.1 Closed Reduction 22 23.31 Conservative 14 14.73 Total 95 100.0% In our study 62.1% patients underwent open reduction and internal fixation,23.3% underwent closed reduction and 14.73% was given conservative management.

The present clinical study was conducted for a period of 18 months on 95 patients with faciomaxillary trauma who visited either casualty or outpatient department of Ear, Nose and Throat of Krishna Rajendra Hospital attached to Mysore Medical College and Research Institute, to understand the distribution of faciomaxillary trauma with respect to age group, gender and anatomy, to evaluate the aetiology and manifestations of these injuries, and to study the mainstay of management. 95 patients with 157 fractures are analysed in this study. Fractures over the face always remain a challenge to the operating surgeon as it is associated with the intimate structures nearby, and any mistake in the procedure could worsen the situation. Thus understanding the types of facial fractures is most important in developing a sound treatment plan. This provides the best opportunity in restoring the structural relationship which is the most important outcome overall. In the present study, the age group of 18-25 years (35.8%) was predominantly affected followed by the age group 26-35 years. This is almost closer to the findings from the study by Dutta SRB1 et al where around 67.1% of the participants aged between 18 and 40 years. These findings being similar to previous studies too7,8,9,. This portrays that the young adults are more prone for road traffic accidents and assaults due to the aggressive behaviour which may lead them to end up with facial trauma. Men aged 21-40 years represent a group with intense social interaction and higher rates of morbidity making them more susceptible to traffic accidents and interpersonal violence10. Majority of the participants in the present study were males i.e., around 87.4%. Remaining 12.6% of them were females. The high male to female ratio (6.91%) was similar to other international studies,11,12. In the study, majority of the participants suffered faciomaxillary injury as a result of road traffic accidents i.e., around 60.0%. The next common cause was physical assault followed by accidental fall. On reviewing the most of the previous studies, it has made obvious that motor accidents contribute the most in sustaining facial trauma. In the studies by Von Haut et al7, Kamath RAD et al6, and Garkoti PD et al13, the causes for injury were in an order completely similar to the present study. Some studies even tried to understand further the reason for facial trauma in specific post road traffic accidents. Accordingly, the study by Bali R et al found that accidents were common during night due to low vision, and extensively in case of 2 wheeled vehicles due to more exposure14. Based on the examination findings, the clinical manifestations were categorized as per the site of the fracture. Accordingly, ecchymosis or swelling was the most common finding, followed by tenderness. As per the site, mandible was the structure which resulted in more clinical manifestations. Among the clinical manifestations of nasal bone fracture, tenderness was the commonest finding followed by crepitus over nasal bones and external deformity. Among the clinical manifestations of nasoethmoidal area fracture, ecchymosis and subjective diplopia was the commonest manifestation followed by enophthalmos. Ansari MH et al had even analysed the injuries to ocular and orbital structures associated with the facial trauma and found the increased risk which could lead to complete or partial loss of vision as a result of either optic nerve lesion or eyeball destruction15. On analysing the anatomical distribution of fracture among the participants in the study, mandible was the most common site i.e., around 42% condyle being the most commonly involved followed by angle of mandible. The next common site was central third of facial skeleton which accounts for about 38.2%. In around 67.9% cases, the fracture was seen in multiple sites. The lateral third of facial skeleton was involved in only 19% cases. The mode of treatment in the study was open reduction and internal fixation in majority cases i.e., around 62.1%. The next common mode was closed reduction (23.31%) followed by conservative management (14.73%).In study conducted by Kamath et al7, it was found that facial bones chiefly imparts an esthetically appealing contour to the face, apart from protecting the globe of the eye. Intact sensory perception over the cheek is also necessary. Occlusion is of considerable importance as it influences not only lower facial height and appearance but also speech and deglutition. Mastication is an important consideration in addressing these fractures as it could affect general nutrition and well-being.

Reliable epidemiological information on faciomaxillary trauma is crucial for decision making in emergency care unit, for identifying factors that increase the risk of injury and for providing measures for prevention. Ideally, such information improves the quality of treatment and helps to achieve measures to prevent injuries and morbidity like in our study. We use epidemiological methods to determine the various significant epidemiological factors like age, sex, mode of injury which potentially help in planning regarding preventive measures, management & rehabilitation of patients. This study results will help clinicians to better understand maxillofacial trauma. It is helpful to implement various new laws which will protect facio maxillary skeleton. An awareness campaign to educate public about importance of restraints and protective seatbelts in cars and helmet in motorcycles should be encouraged. This results should also alert government and Road Safety Commission for the provision of good roads and traffic guidance. Enforcement of traffic laws regarding mandatory use of helmets or seat belt and drink-driving legislations should be done. In developed countries, lane discipline, high tech protective devices like shatter proof glass, collapsible steering dramatically reduced the incidence of these injuries. Efforts should be made to reduce mortality and morbidity from these so as to reduce domestic disruption and psychological stress. Reluctance to use helmets, exceeding speed limits and increasing competition among young men could explain the increased incidence of facial injuries.

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