Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 27-31

Panfacial fractures: Prevalence, sociodemographics, and pattern of presentation in a major referral hospital in the Southern province of the Kingdom of Saudi Arabia


1 Department of Oral and Maxillofacial Surgery, King Khalid Hospital, Najran, Kingdom of Saudi Arabia
2 Department of Oral and Maxillofacial Surgery, Specialty Regional, Dental Center, Najran, Kingdom of Saudi Arabia
3 Department of Oral and Maxillofacial Surgery, Sharorah General Hospital, Sharurah, Kingdom of Saudi Arabia

Date of Submission08-Sep-2019
Date of Acceptance03-Dec-2019
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Ramat Oyebunmi Braimah
Department of Oral and Maxillofacial Surgery, Specialty Regional Dental Center, Najran
Kingdom of Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_35_19

Rights and Permissions
  Abstract 

Background: Panfacial fractures are defined as fractures of the craniomaxillofacial complex involving bones in the lower, middle, and upper thirds of the facial skeleton. The aim of the current study is to report the prevalence, sociodemographics, and pattern of panfacial fractures in Najran, Kingdom of Saudi Arabia.
Materials and Methods: This was a retrospective study of panfacial fractures seen and managed in a major referral hospital in the southern province of the Kingdom of Saudi Arabia over a 10-year period from 2008 to 2018. Data collected include demographics such as age, gender, etiological factor, and pattern of bone fracture involved in the panfacial fracture. Data were stored and analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY, USA: IBM Corp.). Results were presented as simple frequencies and descriptive statistics. Statistical significance was set at P ≤ 0.05.
Results: A total of 1057 patients presented with maxillofacial injuries, of which 43 male patients suffered from panfacial fractures during the study period giving a prevalence rate of 4.1%. The age ranged from 16 to 45 years with mean ± standard deviation (26.6 ± 8.3) years. The age group of 21–30 years had the highest frequency of panfacial fracture, whereas the age group of 41–50 years had the least occurrence with a statistically significant difference. Most of the mandibular fractures involved the symphysis and parasymphysis (27.9% and 23.3%), respectively. In the midface, Le Fort I and II were the most common maxillary fractures.
Conclusion: Inquiry into the prevalence, sociodemographics, and pattern of panfacial fractures is essential in decision-making by the attending clinicians for the patients' overall management. This study has reported a prevalence rate of 4.1% with only male preponderance.

Keywords: Fracture, mandible, maxilla, panfacial, zygoma


How to cite this article:
Daniels JS, Albakry I, Braimah RO, Samara MI, Albalasi RA, Begum F, Al-Kalib MA. Panfacial fractures: Prevalence, sociodemographics, and pattern of presentation in a major referral hospital in the Southern province of the Kingdom of Saudi Arabia. Saudi Surg J 2020;8:27-31

How to cite this URL:
Daniels JS, Albakry I, Braimah RO, Samara MI, Albalasi RA, Begum F, Al-Kalib MA. Panfacial fractures: Prevalence, sociodemographics, and pattern of presentation in a major referral hospital in the Southern province of the Kingdom of Saudi Arabia. Saudi Surg J [serial online] 2020 [cited 2021 Feb 28];8:27-31. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/27/307419


  Introduction Top


Craniofacial injuries, in the past two decades, have witnessed a significant improvement in the repair because of the advancement in rigid internal fixation techniques and improvement in the techniques of exposure of the entire anterior craniofacial skeleton.[1] Panfacial fractures are defined as fractures of the craniomaxillofacial complex involving bones in the lower, middle, and upper thirds of the facial skeleton.[2] Follmar et al.,[3] however, defined panfacial fractures as those that involve at least three of the four axial segments of the facial skeleton, namely frontal, upper midface, lower midface, and mandible [Table 1].
Table 1: Maxillofacial bone components in panfacial fracture[26]

Click here to view


The etiology of panfacial fractures is usually a result of high-energy forces directed to the craniomaxillofacial complex.[4] Such high forces result in contrecoup forces that fracture other bones not directly involved in the impact.[4] Examples of such high-energy mechanisms include road traffic crashes, gunshot/ballistic missile injuries, sports injuries, injuries caused by animals such as camels and horses, and occasionally as a result of assault.[5]

Panfacial fractures account for 4%–10% of all facial fractures.[6] In Korea, the incidence was reported to account for 6.59% of all facial bone fractures.[7] Evaluation of such complex fractures will involve computerized tomographic scans with three-dimensional reconstructed images and magnetic resonance imaging to evaluate other vital soft tissues in the region such as brain and eyes.

There has been no report yet on panfacial fractures from either the southern province or any part of the Kingdom of Saudi Arabia. Therefore, our main objective was to report the prevalence, sociodemographics, and pattern of presentation of panfacial fractures seen and managed at King Khalid Hospital, Najran, the main referral hospital in Najran region, and a major referral hospital in the southern province of the Kingdom of Saudi Arabia.


  Materials and Methods Top


This was a retrospective study of panfacial fractures seen and managed in a major referral hospital in the southern province of the Kingdom of Saudi Arabia over a 10-year period from 2008 to 2018. The southern province has a huge catchment area including the neighboring Yemen. Data collected include demographics such as age and gender of patients and pattern of bone fracture involved in the panfacial fracture. We have adopted the definition of panfacial fracture to involve the upper, middle, and lower thirds of the facial skeleton [Figure 1]a, [Figure 1]b, [Figure 1]c. Ethical clearance was obtained from the Ethics and Research Committee of King Khalid Hospital, Najran, Kingdom of Saudi Arabia, with IRB number H-11-N-081.
Figure 1: (a) Three-dimensional reconstructed computerized tomographic scan showing right lateral view of fractures involving lower, middle, and upper thirds of the facial skeleton. (b) Three-dimensional reconstructed computerized tomographic scan showing frontal view of fractures involving lower, middle, and upper thirds of the facial skeleton. (c) Three-dimensional reconstructed computerized tomographic scan showing left lateral view of fractures involving lower, middle, and upper thirds of the facial skeleton

Click here to view


Data were stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY, USA: IBM Corp). Results were presented as simple frequencies and descriptive statistics. Statistical significance was set at P ≤ 0.05.


  Results Top


A total of 1057 patients presented with maxillofacial injuries, of which 43 male patients suffered from panfacial fractures during the study period, giving a prevalence rate of 4.1%. The age ranged from 16 to 45 years with mean ± standard deviation (26.6 ± 8.3) years. The age group from 21 to 30 years had the highest frequency of panfacial fracture with 23 cases representing 53.5%, whereas the age group from 41 to 50 years had the least occurrence with three cases representing 6.9% with a statistically significant difference (P = 0.05) [Table 2]. Thirty-seven (86.0%) victims were Saudi nationals, whereas 6 (14%) were non-Saudis. All cases were due to road traffic accidents.
Table 2: Distribution of fractured bones in patients with panfacial fracture

Click here to view


Most of the mandibular components of the panfacial fractures involved the symphysis and parasymphysis, representing 27.9% and 23.3%, respectively. In the midface, Le Fort I and II were the most common maxillary fractures. The distribution of mandibular and maxillary fractures is shown in [Table 3]. The pattern of distribution of orbital, frontal, zygomatic, and naso-ethmoidal bone fractures is as shown in [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]. All the cases were managed by open reduction and internal fixation using titanium miniplates and screws as required [Figure 7]a, [Figure 7]b and [Figure 8]a, [Figure 8]b and [Figure 9]a and [Figure 9]b.
Table 3: Distribution of fractured bones in patients with panfacial fracture

Click here to view
Figure 2: Bar chart showing the distribution of patients with panfacial fractures according to age groups

Click here to view
Figure 3: Bar chart showing the distribution of patients with orbital component of the panfacial fracture

Click here to view
Figure 4: Bar chart showing the distribution of patients with frontal bone component of the panfacial fracture

Click here to view
Figure 5: Bar chart showing the distribution of patients with zygomatic bone component of the panfacial fracture

Click here to view
Figure 6: Bar chart showing the distribution of patients with naso-orbito-ethmoidal bone component of the panfacial fracture

Click here to view
Figure 7: (a) Three-dimensional reconstructed computerized tomographic scan showing combination of fractured mandible/maxilla/naso-ethmoidal complex/zygoma. (b) Three-dimensional reconstructed computerized tomographic scan showing reconstructed fractured mandible/maxilla/naso-ethmoidal complex/zygoma

Click here to view
Figure 8: (a) Three-dimensional reconstructed computerized tomographic scan showing combination of fractured mandible/maxilla/frontal bone. (b) Three-dimensional reconstructed computerized tomographic scan showing reconstructed fractured mandible/maxilla/frontal bone

Click here to view
Figure 9: (a) Three.dimensional reconstructed computerized tomographic scan showing combination of fractured mandible/maxilla/nose. (b) Three-dimensional reconstructed computerized tomographic scan showing reconstructed fractured mandible/maxilla/nose

Click here to view



  Discussion Top


There has not been a consensus on the exact definition of panfacial fractures. While some authors have defined panfacial fractures to involve the upper, middle, and lower thirds of the facial skeleton,[3] others have defined them to involve only the middle and lower thirds of the facial skeleton.[8] For the purpose of this study, the authors have defined panfacial fractures to involve the upper, middle, and lower thirds of the facial skeleton. The incidence of maxillofacial trauma is rising at an alarming rate worldwide. In the UK, it has been reported that an increase of 28% was observed in 2011 as compared to 2010.[9]

Panfacial fractures account for 4%–10% of all facial fractures.[6] In Korea, the incidence was reported to account for 6.59% of all facial bone fractures.[7] We have reported an incidence of 4.1%, which falls within the reported range of panfacial fractures worldwide. Literature search has not revealed any study on panfacial fractures in the Kingdom of Saudi Arabia. Therefore, this current study will serve as a reference point for panfacial fractures in the Kingdom. Males are generally reported to be more susceptible to trauma, and the group comprising the 2nd–3rd decade of age is the most exposed due to high activities in this age bracket.[10],[11],[12] Our findings are in support of this position as all of the patients with panfacial fractures were male and in the 2nd–3rd decade of life. The Saudis represent the main people affected as compared to non-Saudis. This is in sharp contrast to the results of a study in the United Arab Emirates (UAE) where the non-Emirati patients were higher than the Emiratis.[13] In the current study, 86% were Saudis, whereas 14% were Yemenis.

In general, motor vehicular accidents, sports injuries, and occasional violent assaults, especially from animals such as camels and horses, may result in panfacial fractures, usually involving the lower, middle, and upper parts of the face.[14] Furthermore, it has also been documented that when maxillofacial injury occurs as a result of road traffic accident, the facial fractures are mostly bilateral.[15] All our cases resulted from high-velocity road traffic accidents. In first world countries, there has been a decrease in motor vehicular accidents due to strict traffic regulations and safety improvements such as airbags and seat belts; however, interpersonal violence continues to upswing.[16],[17] In Saudi Arabia, UAE, and some African countries, road traffic accidents still remain the main etiology of maxillofacial injuries.[10],[18],[19],[20],[21],[22] Currently, revamped stringent traffic control regulations have been instituted in the Kingdom to improve the current paradigm. In a recent report of maxillofacial injuries in Riyadh, Ali-Alsuliman et al.[23] found interpersonal violent as an etiological factor in 17.6% of cases.

The mandible, which forms the lower third of the facial skeleton, is an essential component of panfacial fractures. Literature search has revealed that the most common site of mandibular fracture in panfacial fractures is the symphysis (33.5%), followed by the condyle (31.1%) and body (17.1%).[2] Our study also found that mandibular symphysis was the most common site with 27.9% closely followed by parasymphysis of the mandible with 23.3% of cases. On the contrary, our study has identified angle fracture to be more common than body fracture of the mandible. Different mechanisms of injuries may account for these variations.

In the midface, the maxillary fractures were recorded according to the Le Fort classifications of maxillary fractures.[23] The most common maxillary fractures were at Le Fort 1 level with 34.9% followed by Le Fort II level with 30.2% and Le Fort III with 25.6%. Four cases, representing 9.3%, were combination of all the Le Fort fracture levels. Similar findings have been reported by Abouchadi et al.[8] in Moroccan population.

The naso-orbito-ethmoidal (NOE) complex represents the convergence of the nasal, lacrimal, ethmoid, maxillary, and frontal bones. This confluence of bones makes the region a high risk for fractures. The NOE fracture classification in this present study was based on the work of Markowitz et al.[24] in which they devised a classification system that is based on the degree of central fragment injury. Each fracture type is further subclassified as either unilateral or bilateral. The classifications include Type I fractures (a single noncomminuted central fragment without medial canthal tendon disruption), Type II fractures (comminution of the central fragment, but the medial canthal tendon remains firmly attached to a definable segment of bone), and Type III fractures (severe central fragment comminution with disruption of the medial canthal tendon insertion). Most of the cases in the current study were Type 1 fracture and bilateral.

Cases were managed following the principle of combination of bottom-up and outside-in and bottom-up and inside-out. These approaches have been discussed extensively in the treatment of panfacial fractures.[4],[25] The ultimate goal in the management of panfacial fracture is to follow a systematic sequence focusing on the occlusion as the foundation for proper alignment of other fractured facial bones.[26]


  Conclusion Top


Inquiry into the prevalence, sociodemographics, and pattern of panfacial fractures is essential in decision-making by the attending clinicians for the patients' overall management. This study from Najran, the capital city of Najran region in the southern province in the Kingdom of Saudi Arabia, has reported a prevalence rate of 4.1% with only male preponderance. In the mandible, the symphyseal fractures were dominant, but the angle fractures were more common than the body, whereas in the maxilla, fractures at Le Fort I level were the most common. Zygomatic fractures, orbital floor and inferior rims, frontal bone only, and Type I NOE fractures were also very common in this study. Focusing on occlusion as the basis for proper bony alignment is the ultimate goal in the reconstruction of these categories of maxillofacial bone fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Fritz MA, Koltai PJ. Sequencing and organization of the repair of panfacial fractures. Oper Tech Otolaryngol 2002;13:261-64.  Back to cited text no. 1
    
2.
Yang R, Zhang C, Liu Y, Li Z, Li Z. Why should we start from mandibular fractures in the treatment of panfacial fractures? J Oral Maxillofac Surg 2012;70:1386-92.  Back to cited text no. 2
    
3.
Follmar KE, Debruijn M, Baccarani A, Bruno AD, Mukundan S, Erdmann D, et al. Concomitant injuries in patients with panfacial fractures. J Trauma Acute Care Surg 2007;63:831-5.  Back to cited text no. 3
    
4.
Curtis W, Horswell BB. Panfacial fractures: An approach to management. Oral Maxillofac Surg Clin North Am 2013;25:649-60.  Back to cited text no. 4
    
5.
Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60:398-403.  Back to cited text no. 5
    
6.
Kim J, Choi JH, Chung YK, Kim SW. Panfacial bone fracture and medial to lateral approach. Arch Craniofac Surg 2016;17:181-5.  Back to cited text no. 6
    
7.
Kim JH, Youn CY, Park ES, Tark MS, Lee YM. A clinical experience and treatment of panfacial fracture. J Korean Cleft Palate Craniofac Assoc 2003;4:1-8.  Back to cited text no. 7
    
8.
Abouchadi A, Taoufik H, Nacir O, Arrob A. Pan-facial fractures: A retrospective study and review of literature. Open J Stomatol 2018;8:110-19.  Back to cited text no. 8
    
9.
Borgna S. Maxillofacial Trauma Presentations to the Royal Brisbane Hospital; 2011.  Back to cited text no. 9
    
10.
Obuekwe O, Owotade F, Osaiyuwu O. Etiology and pattern of zygomatic complex fractures: A retrospective study. J Natl Med Assoc 2005;97:992-6.  Back to cited text no. 10
    
11.
Subhashraj K, Nandakumar N, Ravindran C. Review of maxillofacial injuries in Chennai, India: A study of 2748 cases. Br J Oral Maxillofac Surg 2007;45:637-9.  Back to cited text no. 11
    
12.
Menon S, Sinha R, Thapliyal G, Bandyopadhyay T. Management of zygomatic complex fractures in a tertiary hospital: A retrospective study. J Maxillofac Oral Surg 2011;10:138-41.  Back to cited text no. 12
    
13.
Al-Khateeb T, Abdullah FM. Craniomaxillofacial injuries in the United Arab Emirates: A retrospective study. J Oral Maxillofac Surg 2007;65:1094-101.  Back to cited text no. 13
    
14.
Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers, 1980-2000. Otolaryngol Head Neck Surg 2004;130:164-70.  Back to cited text no. 14
    
15.
Obuekwe ON, Ojo MA, Akpata O, Etetafia M. Maxillofacial trauma due to road traffic accidents in Benin City, Nigeria: A prospective study. Ann Afr Med 2003;2:58-63.  Back to cited text no. 15
    
16.
Oikarinen K, Ignatius E, Silvennoinen U. Treatment of mandibular fractures in the 1980s. J Craniomaxillofac Surg 1993;21:245-50.  Back to cited text no. 16
    
17.
Ström C, Nordenram A, Fischer K. Jaw fractures in the county of Kopparberg and Stockholm 1979-1988. A retrospective comparative study of frequency and cause with special reference to assault. Swed Dent J 1991;15:285-9.  Back to cited text no. 17
    
18.
Abdullah WA, Al-Mutairi K, Al-Ali Y, Al-Soghier A, Al-Shnwani A. Patterns and etiology of maxillofacial fractures in Riyadh City, Saudi Arabia. Saudi Dent J 2013;25:33-8.  Back to cited text no. 18
    
19.
Adeyemo WL, Ladeinde AL, Ogunlewe MO, James O. Trends and characteristics of oral and maxillofacial injuries in Nigeria: A review of the literature. Head Face Med 2005;1:7.  Back to cited text no. 19
    
20.
Olasoji HO, Tahir A, Arotiba GT. Changing picture of facial fractures in Northern Nigeria. Br J Oral Maxillofac Surg 2002;40:140-3.  Back to cited text no. 20
    
21.
Ugboko V, Udoye C, Ndukwe K, Amole A, Aregbesola S. Zygomatic complex fractures in a suburban Nigerian population. Dent Traumatol 2005;21:70-5.  Back to cited text no. 21
    
22.
Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:166-70.  Back to cited text no. 22
    
23.
Ali-Alsuliman D, Braimah RO, Ibrahim A. Associated maxillofacial bone fractures with zygomatic complex fracture: Experience from a tertiary referral hospital in Riyadh, Kingdom of Saudi Arabia. Egypt J Surgery 2018;37:244-7.  Back to cited text no. 23
    
24.
Markowitz BL, Manson PN, Sargent L, Vander Kolk CA, Yaremchuk M, Glassman D, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: The importance of the central fragment in classification and treatment. Plast Reconstr Surg 1991;87:843-53.  Back to cited text no. 24
    
25.
Nastri AL, Gurney B. Current concepts in midface fracture management. Curr Opin Otolaryngol Head Neck Surg 2016;24:368-75.  Back to cited text no. 25
    
26.
Ali K, Lettieri SC. Management of panfacial fracture. Semin Plast Surg 2017;31:108-17.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed350    
    Printed4    
    Emailed0    
    PDF Downloaded26    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]